Vestibular Rehabilitation: Examination and Treatment
Vestibular Rehabilitation: Examination and Treatment of BPPV Kathy Joy, PT, MBA Braintree Rehabilitation Hospital (781) 348-2500, ext. 312802 Program Overview Anatomy and Physiology Roles of the vestibular system Categories of vestibular disorders -BPPV, spontaneous, chronic Treatment options for BPPV Vestibular injury s/p traumatic head and neck injuries (Treatment considerations) Incidence of Dizziness (VEDA) www.vestibular.org 8 million PCP visits annually (2.5%) 2nd leading cause for PCP visit in adults #1 for people over age of 65 40-50% 40 50% caused by vestibular system disorder Etiology for 80% of above is inner ear pathology 42% of the population (90 million) will complain of dizziness at least once in their lifetime (NIH) 1 Causes of Vertigo Vestibular Neurological Orthostatic Hypotension Migraine / Vascular Disease Cervicogenic Anxiety / Phobic Disorders Other Vestibular injury following posttraumatic head and neck injuries Incidence of vertigo sx : 50-78% Difficult to treat due to combination of deficits Lack of clear guidelines for return to work Roles of the Vestibular System Inertial guidance system: detecting gravity Detects head position in space Promotes gaze stability through VOR Resolution of sensory conflict Influences muscle tone for postural control 2 Review of Vestibular System Peripheral Vestibular System: semicircular canals, otoliths and the eighth cranial nerve Membranous Labyrinth Herdman; Vestibular Rehabilitation, 2007 Labyrinth 3 Physiology of the Labyrinth Push - Pull arrangement Resting vestibular tone (resting discharge frequency) is modulated, up or down, according to the direction of head rotation. Semicircular Canals Specific gravity relationship Herdman; Vestibular Rehabilitation, 2007 Otolithic Macula Herdman; Vestibular Rehabilitation, 2007 4 Sensory End Organs OTOLITHS Low frequency receptors Directionally specific Responds to linear accelerations/ GRAVITY Does not respond to constant velocity motion Otoconia in macula serve as inertial mass Pathology: static postural problems; difficulty detecting vertical SEMICIRCULAR CANALS Medium-high frequency receptors 3° of rotational freedom Responds to angular head motions, not to gravity Responds to movement along a curve Pathology: results in a sense of spinning; head movement-related symptoms Review of Vestibular System Central Vestibular System: Vestibular nuclei and th i projections their j ti iinto t the brainstem, pons, midbrain, cerebellum, cortex and spinal cord Vestibulo-Ocular Reflex (VOR) 5 Categories of Vestibular Disorders Paroxysmal Positional Disorders Acute Paroxysmal Spontaneous Disorders Acute Onset-Gradual Resolution/Chronic Disorders Symptom Presentation • • • • • • • • • *Positional Vertigo : BPPV Movement-provoked spatial disorientation Visual flow deficits Distorted vision *Dysequilibrium/Ataxia *Neck restriction Headache *Nausea *Anxiety Clinical Examination of the Vertiginous Patient Thorough History PMH/DHI Nature of initial episode/ duration Activities being performed Functional limitations Provocation/reduction factors Describe symptoms Vertigo versus spatial disorientation Intermittent versus continuous associated symptoms of nausea, vomiting Changes during the day 6 Benign Paroxysmal Positional Vertigo Brief Paroxysms of positional vertigo Duration: less than one minute Initial imbalance following an episode ?Spatial disorientation Autonomic symptoms: nausea, diaphoresis Neuro-Otologic Examination Nystagmus Non-voluntary rhythmic oscillations of the eyes • described by the direction of the fast phase • describe latency latency, intensity intensity, direction direction, duration Neuro-Otologic Examination Nystagmus Physiologic versus Pathologic • Physiologic nystagmus induced with natural or external st ul . stimuli. 7 Rotational Chair Nystagmus Physiologic versus Pathologic Pathological nystagmus can be spontaneous, gaze-evoked, positional Positional Nystagmus Positional nystagmus Traditional classifications: lesions of the otoliths, vestibular nuclei and cerebellum. More recent concept: alteration in the specific gravity of the semicircular canal endolymph or cupula 8 Positional Nystagmus Paroxysmal positional nystagmus provocative movement is in the plane of the canal benign paroxysmal positional nystagmus central positional nystagmus BPPV Distorted Function: Benign Paroxysmal Positional Vertigo – Cupulolithiasis – Canalithiasis Cupulolithiasis 9 Canalithiasis Otoconia Furman JNEJM,341(21)1999 Paroxysmal Positional Vestibular Disorders ETIOLOGIES Idiopathic Degenerative Post-traumatic TBI, mild head injury, whiplash Post-acute vestibulopathy (viral) Prolonged bedrest or post-surgical 10 Clinical Examination History Vestibulo-ocular exam Vestibulospinal exam Postural control Other systems musculoskeletal, cognitive, behavior Clinical Examination Vestibulo-ocular function: Ocular alignment Smooth pursuit Saccades VOR/Gaze stability Clinical Examination Vestibulo-ocular reflex: VOR: Head thrust, Head shaking nystagmus VOR: x1 viewing VOR: Dynamic visual acuity (Snellen Chart, Chart LogMar) VOR cancellation 11 Clinical Examination BPPV Positional provocation testing Dix-Hallpike: “Gold Standard” Sidelying test Roll test/ lateral canal test Cohen, HS, Otology & Neurology 25a; 130-134, 2004 Positional Provocation Testing Purpose Identify the involved canal(s) Lateralize Identify type (cupulo/canal) Comparison of BPPV by canal type (neurology,May 2008Fife etal) Posterior Horizontal Anterior Estimated frequency 81-89% 8-17% 1-3% Provocative maneuver Dix-Hallpike p Supine p Roll Test (Pagnini-McClure) Dix-Hallpike p Nystagmus Upbeat, torsional Horizontal Direction Changing Downbeat, torsional 12 Clinical Examination Positional Testing Dix-Hallpike Test Seated VA test Sidelying Test Describing Nystagmus Latency Direction Duration Reversal (Fatigability) 13 Positional Nystagmus Peripheral Central 1-40 second latency No latency Torsional component component* V i d nystagmus Varied Crescendo / decrescendo Lasts as long as positioned Fatigues with repetition Does not fatigue with Vertigo symptoms Geotropic vs. Ageotropic repetition (horizontal canal) No symptoms Duration of Nystagmus <60 seconds: canalithiasis Crescendo / decrescendo: >60 seconds/persistent: cupulolithiasis or central No change in intensity with central Direction of Nystagmus Torsional Posterior or anterior canal No torsional component : horizontal canal Upbeating p g / Downbeating g Torsional upbeating: posterior Torsional downbeating: anterior Right-beating / Left-beating (Counterclockwise versus clockwise) 14 Right posterior canalithiasis Left posterior canalithiasis Left posterior canalithiasis 15 Reversal of Nystagmus Nystagmus often reverses direction with return to sitting (BPPV) Fatigability Fatigues with repetition: canalithiasis Decrease in intensity but persistent: cupulo Does not fatigue: central Intervention Canal Involvement Repositioning Maneuvers Canalith Repositioning Maneuvers CRT, CRT CRM CRM, PRM PRM, Epley; use of vibration Liberatory/Semont Horizontal canal maneuvers Brandt-Daroff 16 Repositioning Maneuvers – Canalith-Repositioning /Epley Furman J NEJM, 341(21), 1999 Repositioning Maneuvers Liberatory Considerations for Anterior Canal BPPV Difficulty lies in determining which side to treat Right Dix Hallpike test: downbeat and torsional to left = Left anterior downbeat and torsional to right = Right anterior 17 Canal Involvement based on Direction of Nystagmus: ( R) DixHallpike (Herdman, Vestibular Rehabiitation, 2007) CANAL Right Dix-Hallpike Reversal Phase Right posterior Upbeat, torsional right g Downbeat, torsional Downbeat, torsional left left Return to Sitting Right anterior Downbeat, torsional Upbeat, torsional right left Upbeat, torsional left Left anterior Downbeat, torsional Upbeat, torsional left right Upbeat, torsional right Roll Test Horizontal Canal BPPV Brief nystagmus that fatigues and is geotrophic: canalithiasis Prolonged nystagmus and is ageotrophic: cupulolithiasis 18 Horizontal canal nystagmus Geotropic Ageotropic Left horizontal canalithiasis Right horizontal canalithiasis 19 Determining the Side with H i Horizontal t l Canal C l BPPV Bow and Lean Test Choung YH et al, Laryngoscope 116, 2006 Repositioning Maneuvers Horizontal Canal Involvement Repositioning Maneuvers Horizontal Canal Involvement 360 degree barrel roll 270 degree roll 20 Repositioning Maneuvers Horizontal Canal Involvement -Cassani et al in Laryngoscope 2002 -Appiani et al in Otology and Neurol 2001 -Vannuchi et al in Jvest Res 1997 (Forced Proglonged Position: FPP) Subjective BPPV How much time in each position? Varies in the literature Clinically have seen no difference between 2 minutes and 30 seconds Epley’s rule: onset + duration = length of time in each position Clendaniel: double length of nystagmus 21 Home Guidelines Remain upright for 24-48 hours Do not lie on affected side Avoid extreme flexion and extension of the head and trunk. trunk Avoid lateral tilt for horizontal canal Soft collar, towel Start head movement exercises after 48 hours Resistance to Treatment?? Brandt-Daroff 22 Prognosis 85 -95% remission of symptoms Course of Treatment: 2-6 visits Recurrence rate: 20-30% Co-morbidity considerations Head/Neck pain Fatigue Complications Conversion to a different canal Nausea and vomiting during or after treatment E l Omniax Epley O i http://www.arrigg.com/epley-omniax 23 ANXIETY Alternative Treatments Canal Plugging Singular nerve section 24 250 Pond Street, Braintree MA 02184 (781) 348-4012 Fax (781) 356-4222 DIZZINESS & BALANCE DISORDERS Diagnostic & Therapy Services Almost half of the adult population, in the United States reports episodes of dizziness, vertigo and balance problems to their doctors every year. Dizziness or imbalance is the second most common reason for visits to the doctor’s office, second only to back problems. People in all age groups can experience episode of poor balance, dizziness and frequent falls. The vestibular system, or balance system, is the sensory system that provides the dominant input about movement and our sense of balance. It is one of the physiological senses related to balance. Other senses play roles as well, for instance our visual system and proprioception. Fifty percent of community-dwelling adults who see their physician with symptoms of dizziness or vertigo have a problem somewhere in the vestibular system and 80% of those folks have inner ear or peripheral vestibular deficits. Between 33% and 50 % of the general elderly population fall at least once a year. As a result, they often become afraid to venture out of their own homes. Everyone experiences dizziness differently. For many, dizziness is experienced as a sensation of lightheadedness or faintness. Many experience dizziness as the feeling of motion even if they are not moving. Others report a sensation of spinning in which they are moving or their environment is spinning around them (vertigo). Describing exactly what you experience when you feel dizzy will help your doctor determine the cause. Nausea and anxiety may also accompany your dizziness. Dizziness can occur along side other symptoms such as pressure or fullness in the head or ears and ringing in the ears (tinnitus). It is important to report these symptoms to your doctor. Who is at risk? People with one of the following diagnosis can have balance and gait disorders. • BPPV (Benign Paroxysmal Positional Vertigo) • Peripheral or Central Vestibular Deficits • Head Injury • • Brainstem or Cerebellar CVA Extrapyramidal Disorders. i.e. Parkinson’s Disease • Peripheral Neuropathy Possible causes of these symptoms include: • • Inner ear infection and / or disease • Sports Injury or Cervical whiplash injuries Stroke • General muscle weakness or inflexibility ● Head injury as a result of falls, blows to the head or motor vehicle accidents Over → → → Why am I dizzy? Although there are many causes of dizziness, for 85% of the people who experience this symptom, the problem is due to changes in the “Vestibular System.” The Vestibular system is the part of the inner ear that helps to control balance and body orientation. Your vertigo may be due to a mechanical problem in the inner ear. Dizziness may also be related to a loss of balance control. Balance control also comes from input from the eyes, muscles and joints. When you have an inner ear disorder, your brain cannot rely on the information received from your Vestibular system. As a result, your body becomes dependent on your systems, such as vision and your muscles and joints to maintain steady balance. Lifestyle changes because of your dizziness You have probably already adjusted the way you carry out your daily activities to prevent an increase in your symptoms. For example, by limiting head movements, you may have found that you don’t get dizzy. Or, you may feel more secure walking if you stay close to the wall or hold on to furniture. All of these changes, which may seem helpful, are actually very stressful to your system and will decrease your ability to adjust to your Vestibular problem. Our Team of Professionals Consists of: • • Otoneurology: Dr. Gregory Whitman, from the Mass, Eye & Ear Infirmary Specialized Physical Therapists (therapy services are available at various locations) • Vestibular Laboratory Technicians Your doctor may recommend you see one of our Physical Therapists first for an evaluation or a Consultation at Braintree Rehabilitation Hospital with Dr. Gregory Whitman: (617) 573-6700 Physical Therapy: Dizziness & Balance Treatment Services Although dizziness is a common symptom, living with this problem can significantly impact a person's lifestyle and function. Traditionally, dizziness has been treated with medication. Many balance problems, on the other hand, have been addressed with adaptive equipment such as straight canes or walkers. Today, a variety of new treatment opportunities exist for people with balance and dizziness disorders. Balance is a multifactorial neurological function. Disorders of balance invariably involve several components of balance function. We identify the critical factors that are impaired in a balance disorder. Treatment is directed specifically toward the identified balance deficits and utilizes newly devised clinical protocols. Vestibular Physical Therapy utilizes specialized exercises to address specific areas of the individual's vestibular/balance disorder. The individual goals of vestibular rehabilitation vary, depending upon the type, cause and duration of vertigo/disequilibrium. Your physical therapist will work with you to develop a program to meet your specific needs. A referral from your doctor is required to be evaluated in Physical Therapy We can help you obtain one if necessary What is Vestibular Therapy? Vestibular therapy is an exercise-based approach with an emphasis on teaching the body to compensate for inner ear deficits. With therapy, patients ultimately experience a decrease in dizziness, improved balance function and an overall increase in activity level. Secondary symptoms of decreased range-of-motion and strength (especially in the neck and shoulder region of the body) often leads to headaches and increased muscle tension. Physical therapy also alleviates these symptoms. What Happens During Therapy? A thorough evaluation will be done at your first therapy appointment. Your physical therapist will carefully assess your dizziness balance control, strength, flexibility, walking and safety during certain functional activities. A specific program will be designed for you, based on your individual needs. This may include specific head positioning maneuvers to decrease symptoms of vertigo, and / or balance retraining exercises to be performed both with your physical therapist and at home. You will also be provided with educational information to help you become more aware of the correct ways to move and maintain your balance. With time and consistent work, therapy will teach you how to gain control of your balance system and, in a majority of cases, dramatically reduce your symptoms of dizziness, vertigo and nausea. Therapy Treatment Outpatient Locations: Abington: (781) 871-6918 Braintree: (781) 348-4012 Brockton: (508) 586-6391 Milford: (508) 478-5775 Plymouth: (508) 747-4720 Taunton: (508) 880-8721 Otoneurology & Diagnostic Services The Vestibular and Balance Disorders Services offered at Braintree Rehabilitation Hospital uses both the clinical expertise of an Neurotologist, Dr. Steven D. Rauch, specially trained therapists and the most advanced computerized technology to provide a complete evaluation, diagnosis and treatment recommendations for dizziness and balance disorders. The outcome of treatment can be specifically reevaluated using these devices. At present, the computerized devices available for diagnostic evaluation and rehabilitation are a computerized rotary chair system, dynamic posturography and balance master. Dynamic Posturography (Equilibrium Platform Test) These are a series of tests that measure how well you are able to maintain your balance under different conditions. You will be asked to stand as steadily as possible on a platform inside a booth. The platform will have sensors that measure how well you maintain your balance as the walls of the booth move around you and the surface you are standing on moves under your feet. The tests will be conducted with your eyes open and with your eyes closed. You will be supported by a safety harness in case you become unsteady. Some of the tests are designed to mimic different conditions you encounter in every day life. Other tests are designed to determine the source of your balance problem. The computerized tests are able to isolate the different sensory information you rely on to maintain your balance. The test results provide a better understanding of your balance problem and can point to possible causes. This allows your doctor to focus on the abnormal system. Six test conditions will be performed using three 20second trials for each. This test takes between 20 to 30 minutes. Rotary Chair System You will be seated on a rotating chair placed in a darkened room with electrodes on your eyes to measure their movements. The chair will rotate back and forth at different speeds to see how your eyes move in response to rotations when you cannot see anything. You will also be asked to keep your eyes on a small light while the chair rotates. You will be given mental tasks during these tests to keep you alert, because your eyes will not move as accurately if you get drowsy. Some laboratories also test your responses to rotation with your eyes open and viewing visual patterns. Vestibular Function Test: This test measures the vestibular-occular reflex. During head movements the vestibular system (located in the inner ear) sends signals to your occular (eye) muscles to stabilize your vision. This test will assess this reflex. You will be fitted with a headpiece that houses two small cameras to record eye movements. Afterwards, you will be seated in a chair within a six-foot enclosure. The chair will move slowly back and forth to stimulate the reflex while the mounted cameras record eye movements. The test is made up of 8 parts, the longest lasting 3 minutes. Breaks can be taken between tests as needed. The entire test time should not exceed 30 minutes. Visual-Vestibular Integration Test: Test preparation is described above. Testing determines your ability to either enhance or suppress your vestibular reflex. During testing you will be instructed to follow certain target with your eyes without the chair moving. Test time is 15 minutes. Balance Master Computerized Balance Training: This system uses forceplate technology to allow for objective measurement of the patient's center of mass/gravity and limits of stability. The patient utilizes visual biofeedback to help facilitate the development of static and dynamic balance skills. Electronystagmography (ENG) Call our Audiology Department: 781-348-2209 This three-part test assesses your balance system under varying conditions and is performed by an audiologist in our Audiology Department here at Braintree Hospital. Due to the interconnected nature of your vestibular (balance) system and your visual (occulomotor) reflex, measuring eye movement can provide important information with regard to balance system functioning. ENG detects and records rapid eye movements, called nystagmus, through the use of electrodes or goggles. The first part of the test involves following visual targets with your eyes. In the second part, eye movement is recorded as you lie in different positions. The final component of this test involves irrigating each ear with cool and warm air. By irrigating each ear separately, the balance mechanism on each side can be stimulated and measured independently. Neurotology consultation with Dr. Steven D. Rauch and our Diagnostic Center: (781) 348-3801 We accept all major insurances including Medicare, Mass Health, All BCBS plans, BMC Healthnet, Fallon, Workers Compensation & MVA's DIZZINESS & BALANCE DISORDERS www.braintreerehabhospital.com Almost half of the adult population in the United balance problems to their doctors every year. disorders can be devastating. Living with these person’s lifestyle and function. Between 33% and fall at least once a year. States reports episodes of vertigo and The impact of dizziness and balance symptoms can significantly impact a 50% of the general elderly population Equilibrium and balance control depends upon multiple systems working together, ie: vestibular, visual, somatosensory. Impairments in one or more of these systems can lead to vertigo, dizziness and/or imbalance. Our experts work to identify the critical factors contributing to a patient’s symptoms. Treatment is directed specifically toward the identified deficits and utilizes current clinical protocols. Patients can be referred to us if they have had a pattern of clinical findings as well as a collection of symptoms and complaints in the following categories: Vestibular loss/BPPV, Disequilibrium or Balance Disorders Assessment Battery: Includes a thorough medical history, vestibular function tests, if indicated assessment of; balance, gaze stabilization, strength, endurance, range of motion, safety and overall function in daily activities. This examination and assessment provides a more efficacious evaluation of each patient’s condition, allowing for appropriate treatment intervention. Indications for a referral: ♦ History of disequilibrium and imbalance ♦ Vertigo, dizziness or movement-provoked spatial disorientation ♦ History of falls Possible causes of symptoms include: ♦ Vestibular Disorder: post-labyrinthitis, neuronitis, BPPV, ototoxicity, degeneration, post-surgery ♦ Parkinson’s Disease / Multiple ♦ Stroke (brainstem or cerebellar) Sclerosis ♦ Head Injury ♦ Cervical whiplash injuries ♦ General muscle weakness, inflexibility ♦ Peripheral Neuropathy Outpatient Locations for Therapy Services Abington: (781) 871Milford: Brockton: (508) 5866918 5775 6391 Braintree: (781) 3484012 (508) 478- Plymouth: 747-4720 (508) Taunton: (508) 8808721 OTONEUROLOGY CONSULTATIONS: with Dr. G. Whitman from: Located Braintree Rehabilitation Hospital (617) 573-6700 Braintree Rehabilitation Hospital Outpatient Vestibular Physical Therapy Your doctor has referred you to Vestibular Physical Therapy because of dizziness, vertigo or imbalance. You may be experiencing a spinning sensation (vertigo) with head movements, a sense of “wooziness” when walking, or unsteadiness on your feet in certain environments. The best way to determine your treatment options is to specifically evaluate your symptoms. WHY AM I DIZZY? Although there are many causes of dizziness, for 85% of the people who experience this symptom, the problem is due to changes in the “Vestibular System.” The Vestibular system is the part of the inner ear that helps to control balance and body orientation. Your vertigo may be due to a mechanical problem in the inner ear. Dizziness may also be related to a loss of balance control. Balance control also comes from input from the eyes, muscles and joints. When you have an inner ear disorder, your brain cannot rely on the information received from your Vestibular system. As a result, your body becomes dependent on your systems, such as vision and your muscles and joints to maintain steady balance. LIFESTYLE CHANGES You have probably already adjusted the way you carry out your daily activities to prevent an increase in your symptoms. For example, by limiting head movements, you may have found that you don’t get dizzy. Or, you may feel more secure walking if you stay close to the wall or hold on to furniture. All of these changes, which may seem helpful, are actually very stressful to your system and will decrease your ability to adjust to your Vestibular problem. WHAT IS VESTIBULAR THERAPY? Vestibular therapy is an exercise-based approach with an emphasis on teaching the body to compensate for inner ear deficits. With therapy, patients ultimately experience a decrease in dizziness, improved balance function and an overall increase in activity level. Secondary symptoms of decreased range-of-motion and strength (especially in the neck and shoulder region of the body) often leads to headaches and increased muscle tension. Physical therapy also alleviates these symptoms. WHAT HAPPENS DURING VESTIBULAR THERAPY? A thorough evaluation will be done at your first therapy appointment. Your physical therapist will carefully assess your dizziness balance control, strength, flexibility, walking and safety during certain functional activities. A specific program will be designed for you, based on your individual needs. This may include specific head positioning maneuvers to decrease symptoms of vertigo, and / or balance retraining exercises to be performed both with your physical therapist and at home. You will also be provided with educational information to help you become more aware of the correct ways to move and maintain your balance. With time and consistent work, therapy will teach you how to gain control of your balance system and, in a majority of cases, dramatically reduce your symptoms of dizziness, vertigo and nausea. Braintree Rehabilitation Hospital Outpatient Locations for Therapy Services Abington: (781) 8716918 Braintree: (781) 3484012 Brockton: (508) 5866391 Milford: (508) 4785775 Plymouth: (508) 7474720 Taunton: (508) 8808721 OTONEUROLOGY CONSULTATIONS: with Dr. G. Whitman from 6700 Located Braintree Rehabilitation Hospital (617) 573- 2010 Brain Injury Association of Massachusetts Vestibular Providers This list is not an endorsement by BIA-MA but a potential resource of available providers in the state. Please contact them for more information. Support Groups (Online) www.facebook.com/vestibulardisorders (in person) Massachusetts • Metro Boston Claire Haddad Boston-Area Vestibular Disorders Support Group 10 Heritage Ln. Cohasset, MA 02025 (781) 383-0253 (please call between 9am and 8pm) e-mail meeting location: Newton-Wellesley Hospital Newton, MA Professionals (see next page) Professionals 1) Fred G. Arrigg, Jr., MD ENT/Otolaryngologist Otologist Otoneurologist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic Arrigg Eye & Ear Associates 439 S. Union St., Bldg. 1, Ste. 101 Lawrence, MA 01843 U.S.A. (978) 686-2983 (978) 686-0684 (fax) 2) Susan Barros, PT Physical Therapist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic Braintree Rehabilitation Clinic at Sharon 778 S Main St. Sharon, MA 02067 U.S.A. (781) 784-0920 (781) 784-0925 (fax) 3) Maureen Murphy Billotte, PT Physical Therapist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic Jordan Hospital Rehab 10 Cordage Park Circle Suite 225 Plymouth, MA 02571 U.S.A. (508) 830-2182 (508) 830-2172 (fax) 4) Lisa G. Blain, OTR/L Occupational Therapist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic Weldon Rehabilitation Hospital 233 Carew St. Springfield, MA 01104 U.S.A. (413) 748-6955 (413) 748-6939 (fax) 5) Nancy Cohen, AuD, CCC-A Audiologist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic Lahey Clinic Medical Center 41 Mall Road Burlington, MA 01805 U.S.A. (781) 744-2528 (781) 744-7540 (fax) 6) Kathleen Gill-Body, DPT, MS, NCS Physical Therapist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic Newton Wellesley Hospital 2015 Washington Street Newton, MA 02462 U.S.A. (617) 243-6172 7) Beth Shane Grill, PT Physical Therapist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic Spaulding Framingham Outpatient Center 570 Worcester Road Framingham, MA 01702 U.S.A. (508) 872-2200 8) Craig A. Jones, MD ENT/Otolaryngologist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinics Cape Cod Ear, Nose, & Throat Specialists 800 Falmouth Rd., Ste. 102A Mashpee, MA 02649 U.S.A. (508) 539-2444 (508) 539-9923 (fax) 9) Patricia Jung, PT Physical Therapist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic Cooley Dickinson Hospital 30 Locust Street Northampton, MA 01060 U.S.A. (413) 582-2113 10 ) Theresa O'Neil, DPT, MS, OCS Physical Therapist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic Winchester Hospital Orthopaedics Plus Choate Medical Center 23 Warren Ave. Woburn, MA 01801 U.S.A. (781) 932-8866 11) Dennis S. Poe, MD ENT/Otolaryngologist Neurotologist Otologist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic Department of Otolaryngology Children’s Hospital 300 Longwood Ave. Boston, MA 02115 U.S.A. (617) 355-6462 12) Pam Proulx, PT Physical Therapist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic Baystate Rehabilitation Care 360 Birnie Ave. Springfield, MA 01199 U.S.A. (413) 794-1600, ext. prompt 1 13) Steven D. Rauch, MD ENT/Otolaryngologist Otologist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic Massachusetts Eye & Ear Infirmary 243 Charles St. Boston, MA 02114 U.S.A. (617) 573-3644 14) Kristen Schimley, MSPT, CSCS Physical Therapist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic NovaCare Rehabilitation 9 Pond Lane Damonmill Square Concord, MA 01742 U.S.A. (978) 369-9996 15) Susan Mercure Slysz, PT Physical Therapist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic AEEA Center for Balance Hearing & Dizziness 439 S Union St., Ste. 101 Lawrence, MA 01843 U.S.A. (978) 686-2983 16) Gary Stanton, MD Neurologist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic 131 Ornac, Ste. 600 Concord, MA 01742 U.S.A. (978) 371-8935 17) Susan Teehan, PT Physical Therapist This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g., Epley). Clinic Caritas Norwood Hospital Rehab Services 800 Washington St. Norwood, MA 02062 U.S.A. (781) 769-4000 Dizziness (Vestibular) and Balance Disorders Almost half of the adult population, in the United States reports episodes of dizziness, vertigo and balance problems to their doctors every year. Dizziness or imbalance is the second most common reason for visits to the doctor's office, second only to back problems. People in all age groups can experience episode of poor balance, dizziness and frequent falls. The vestibular system, or balance system, is the sensory system that provides the dominant input about movement and our sense of balance. It is one of the physiological senses related to balance. Other senses play roles as well, for instance our visual system and proprioception. Fifty percent of community-dwelling adults who see their physician with symptoms of dizziness or vertigo have a problem somewhere in the vestibular system and 80% of those folks have inner ear or peripheral vestibular deficits. Between 33% and 50 % of the general elderly population fall at least once a year. As a result, they often become afraid to venture out of their own homes. Everyone experiences dizziness differently. For many, dizziness is experienced as a sensation of lightheadedness or faintness. Many experience dizziness as the feeling of motion even if they are not moving. Others report a sensation of spinning in which they are moving or their environment is spinning around them (vertigo). Describing exactly what you experience when you feel dizzy will help your doctor determine the cause. Nausea and anxiety may also accompany your dizziness. Dizziness can occur along side other symptoms such as pressure or fullness in the head or ears and ringing in the ears (tinnitus). It is important to report these symptoms to your doctor. Who is at risk? Patients with one of the following diagnosis can have balance and gait disorders. • BPPV (Benign Paroxysmal Positional Vertigo) • Peripheral or Central Vestibular Deficits • Head Injury • Brainstem or Cerebellar CVA • Extrapyramidal Disorders • Peripheral Neuropathy Possible causes of these symptoms include: • Inner ear infection and / or disease • Stroke • Sports Injury • General muscle weakness or inflexibility • Head injury as a result of falls, blows to the head or motor vehicle accidents The Vestibular and Balance Disorders Services offered at Braintree Rehabilitation Hospital uses both clinical expertise and the most advanced computerized technology to provide a complete evaluation, diagnosis and treatment recommendations for dizziness and balance disorders. The outcome of treatment can be specifically reevaluated using these devices. At present, the technology for diagnostic evaluation and rehabilitation are a computerized rotary chair system, dynamic posturography and static forceplate postural feedback rehabilitation device. We also offer Electronystagmography (ENG) through our Audiology Department. Our team of professionals consists of: • Otoneurologist • Specialized Physical Therapists • Vestibular Laboratory Technicians The Vestibular and Balance Disorders Services are a regional diagnostic center providing specialized testing to help determine the cause of each person's symptoms. A network of community-based treatment centers carry out the prescribed therapy services. Treatment Services: Physical Therapy Although dizziness is a common symptom, living with this problem can significantly impact a person's lifestyle and function. Traditionally, dizziness has been treated with medication. Many balance problems, on the other hand, have been addressed with adaptive equipment such as straight canes or walkers. Today, a variety of new treatment opportunities exist for people with balance and dizziness disorders. Balance is a multi-factorial neurological function. Disorders of balance invariably involve several components of balance function. We identify the critical factors that are impaired in a balance disorder. Treatment is directed specifically toward the identified balance deficits and utilizes newly devised clinical protocols Vestibular Physical Therapy utilizes specialized exercises to address specific areas of the individual's vestibular/balance disorder. The individual goals of vestibular rehabilitation vary, depending upon the type, cause and duration of vertigo/disequilibrium. Your physical therapist will work with you to develop a program to meet your specific needs. Why Am I Dizzy? Although there are many causes of dizziness, for 85% of the people who experience this symptom, the problem is due to changes in the "Vestibular System." The Vestibular system is the part of the inner ear that helps to control balance and body orientation. Your vertigo may be due to a mechanical problem in the inner ear. Dizziness may also be related to a loss of balance control. Balance control also comes from input from the eyes, muscles and joints. When you have an inner ear disorder, your brain cannot rely on the information received from your Vestibular system. As a result, your body becomes dependent on your systems, such as vision and your muscles and joints to maintain steady balance. Lifestyle Changes You have probably already adjusted the way you carry out your daily activities to prevent an increase in your symptoms. For example, by limiting head movements, you may have found that you don't get dizzy. Or, you may feel more secure walking if you stay close to the wall or hold on to furniture. All of these changes, which may seem helpful, are actually very stressful to your system and will decrease your ability to adjust to your Vestibular problem. What Is Vestibular Therapy? Vestibular therapy is an exercise-based approach with an emphasis on teaching the body to compensate for inner ear deficits. With therapy, patients ultimately experience a decrease in dizziness, improved balance function and an overall increase in activity level. Secondary symptoms of decreased range-of-motion and strength (especially in the neck and shoulder region of the body) often leads to headaches and increased muscle tension. Physical therapy also alleviates these symptoms. What Happens During Vestibular Therapy? A thorough evaluation will be done at your first therapy appointment. Your physical therapist will carefully assess your dizziness balance control, strength, flexibility, walking and safety during certain functional activities. A specific program will be designed for you, based on your individual needs. This may include specific head positioning maneuvers to decrease symptoms of vertigo, and / or balance retraining exercises to be performed both with your physical therapist and at home. You will also be provided with educational information to help you become more aware of the correct ways to move and maintain your balance. With time and consistent work, therapy will teach you how to gain control of your balance system and, in a majority of cases, dramatically reduce your symptoms of dizziness, vertigo and nausea.
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