Vestibular Rehabilitation: Las Vegas, NV

1. Vestibular Rehabilitation:Las Vegas, NV Presenter: Brian K. Werner, PT, MPT Werner Institute of Balance and Dizziness, Inc. www.nomorevertigo.com

2. Presentation Overview • Statistics of Dizziness in the Community • Current problems with dizziness management… • Basic Anatomy and Physiology review of Balance • The vestibular system specifically • What is dizziness? • What is vestibular rehabilitation? • Is There a need for specialized centers that work exclusively with dizziness? • When to make a cross referral to the Werner Institute? • What is new to the Werner Institute? • Questions and Answers

3. Brian Werner, PT, MPT • B.S. – Exercise Physiology • Summa Cum Laude Graduate • Northern Arizona University (NAU) • Master’s Degree – Physical Therapy • With Honors from NAU • National Certification of Competency – Vestibular Disorders - 2000 • University of Miami School of Medicine • Started – Balance Center of Las Vegas and Henderson – 2001 & 2003 • Left BCLV in 2005 • Own and operate – Werner Institute of Balance and Dizziness, Inc. • Opened the Henderson location in 2008.

4. Statistics • By the age of 40, 40% of the population goes to their PCP for complaints of dizziness – this is 90 million people on average annually • Less than 1% ever get therapy for dizziness • By the age of 65, the 3rd leading PCP visit is imbalance/dizziness • By 75, it is the number one reason for a visit!!!

5. Current Problems with Dizziness Management • We are seeing an over-medication of our patients with vestibular suppressants • 70% of all patients coming into a PCP office with c/o dizziness get Meclizine (Burke, 1994) regardless of history of dysfunction. • Barber, 1994 study found chronic use of Meclizine equals a blood alcohol level of 0.04 to 0.06 • You wonder why it would be prescribed – especially in seniors • Known to inhibit natural CNS compensation • If patient with dysequilibrium, you may be doing more harm as Meclizine causes lethargy/fatigue and may increase fall risk.

6. Current Problems with Dizziness Mgmt • We are under-utilizing physical therapy services, especially balance retraining physical therapy. • Why? • We don’t understand the therapy and how it works • VRT has been used since the 1940’s with Cawthorne-Cooksey Exercises • Military started use of exercises in WWII for Concussion Injuries • Most patients get better over time with a vestibular disorder is the assumption • Yardley, et al. 1993 reported 20% of patients had full recovery of symptoms after a one year review • At two years, 60% of population had recurrent symptoms

7. Basic Anatomy of the Balance System Postural Stability Integration Gaze Stability

8. Over 80% of Classic Dizziness Originates from a Vestibular Disorder • Two Primary Sensors • Semicircular Canals • Function: Angular accelerometer • Roll over in bed • Turn head up/down • Three pairs of canals • Work with the opposite • Sensors act like a sail in the wind • Push/Pull on the sensor due to flow of fluid • Pattern of movement is what brain recognizes as motion

9. Vestibular System:Sensors • Primary Sensors • Otolithic System • Controls linear stability • Forward/backward in car • Up/Down in elevator • Sensitive to gravity through Otoliths (crystals) bending hair cells • Abnormal Function can create dizziness and disorientation

10. What is Dizziness? • Non-specific symptom in the treatment of balance disorders. • Categorized in five types: • Vertigo • Objective and Subjective • Tilting; whirling • Lightheadedness • Pre-syncope • Motion Sickness • Self or surroundings • Dysequilibrium • Imbalance to severe gait ataxia • Floating (Psychogenic) • Fear (provoking) and/or anxiety

11. Nothing “learn to live with it” “It will go away over time” Medicate Suppressive Inhibition of vestibular signal Meclizine – antihistamine Valium/Klonapin – CNS suppressant Reduction of fluid volume in the body Diuretics for Meniere’s disease Surgeries Ablative – Meniere’s disease Repairs – Perilymphatic Fistula; Superior Canal Dehiscence Removals – Acoustic Neuromas Extremely rare in general to surgically treat dizziness Therapies Allopathic Evidence Based Medicine Naturopathic Herbal Homeopathic Remedies Chiropractic CVR Spinal Manipulation Other What Can Be Done for the Dizzy Patient Medically?

12. When to Send to Specialized Physical Therapy for Dizziness • Severe fall risk patients • Use ceiling full-body harness systems • Complex Balance Disorders • Use NASA and Navy based technology to determine origin of dizziness • Will have the Epley OMNIAX chair to assess and treat complex BPPV • When patients are just not improving • We work closely with local specialist ENTs that understand vestibular disorders

13. Need for Specialized Centers for Dizziness Management • “I know as a PT clinician we all want to be able to treat whatever comes through the door – the generalist.” • Not always set-up for every disorder in clinic • Sub-specialization within the field of PT is common • Seen in most medical practices across all disciplines • APTA - Neurological Section • Vestibular and Balance special interest groups (SIG)

14. Specialized Testing in a Balance Center – Audiology Testing • Videonystagmography (VNG): • Allows the clinician to visualize the function of the vestibular system through the eyes • Uses infrared video technology to see eyes in the dark • Visualizing eye movement = front-end out of alignment on car • Helps to determine if the balance disorder is PNS or CNS in origin Normal VNG

15. Abnormal VNG Brainstem Vestibular Injury Left-sided Vestibulopathy BPPV – Posterior Canal Horizontal BPPV - Cupulolithiasis

16. Vestibular Rehabilitation - Historical Review • Started in WWII in the 1940’s • Observed by two physicians - Cawthorne and Cooksey • Post-concussion injuries in soldiers • Those who got up and moved early on got over their dizziness and imbalance faster than those who were medicated or stayed bed bound. • Mid 50’s to 70’s • Brandt-Daroff and Habituation Norré Exercises • Mid- 1980’s to Late 1990’s • Shepard, AuD and Telian, MD • Review Paper: Programmatic Vestibular Rehabilitation • Shepard, AuD and Solomon, MD • Review Paper: Chronic Dizziness • Susan Herdman, PT, PhD and Susan Whitney, PT, ATC, PhD • Started Competency Based Course for: • PT, OT, AuD, and MD/DO • Who Else is getting involved in VR 

17. Vestibular Rehabilitation • The Old Turf Battle Again (remember ATCs)  • AUDIOLOGIST!!! • Practice Act from AAA states that audiologists are able to perform vestibular therapy – billing 97112. • CHIROPRACTORS!!! • Trademarked: Chiropractic Vestibular Therapy (CVR): • Most fall prevention programs are central to a non-pharmaceutical approach that is in concert with the practice of chiropractic. • Would seem more in concert with PT? • “Chiropractors who are trained in Vestibular Rehabilitation will have the tools necessary to establish themselves as experts in the discipline in their community.” • A review of the literature identifies chiropractic care as an appropriate intervention for the patient with Meniere’s disease, vertigo and abnormal nystagmus; all which are symptoms of vestibular brainstem imbalances.

18. Sediment from Utricle loosens in the semicircular canal makes them responsive to gravity Assessed with the Hallpike-Dix Test Treatment of choice: Epley Maneuver Canalith Repositioning Maneuver Omniax Chair (80-90% improvement in vertigo in 1-4 visits) NOTE: BPPV+ (VRT + Epley) in 70% of patients Most Common Vestibular Dysfunction in your Clinic: BPPV

19. Canaliths Moving Through Posterior Canal…

20. What’s Coming to Las Vegas • OMNIAX is almost here!!! • Designed by the doctor who determined the treatment for BPPV • John Epley, MD • Only Seven (7) Systems in the world • Werner Institute is going the have the 8th system. • Will be available to see during open house during CSM 2009 at Summerlin clinic

21. Questions and Answers