New Interventions: Physical Therapy: The New “Drug” into the Management of the Dizzy Patient

1. New Interventions:Physical Therapy: The New “Drug” into the Management of the Dizzy Patient Brian K. Werner, MPT December 15, 2006 CME – Sunrise Grand Rounds

2. Brian K. Werner, MPT • Master’s Degree in Physical Therapy • Northern Arizona University – Flagstaff, AZ • National Certification of Competency – Vestibular Assessment and Treatment • Miami School of Medicine: Physical Therapy Department – Miami, Fl (2000) • Service • Founder, Director and Lead Clinician of Balance Centers of America: Las Vegas and Henderson (2001-2005) Branch • Service • Owner and Lead Clinician of the Werner Institute of Balance and Dizziness, Inc. (11/05 to present)

3. What is Physical Therapy? • Form of exercises designed to improve functional independence in patients • Commonly associated with pain management. • Treatment of dizziness and falls is a new modality. • PT’s are licensed clinicians (Masters/Doctorates) that are under a board that certifies licenses annually. • PT’s require 15 CME/CEUs annually.

4. Prevalence of Dizziness • General Population • Nazareth, et. al, 1999 • Reported 4% of patients 18 to 65 who consult with GP reported persistent symptoms of dizziness • 3% considered dizziness “severely incapacitating.” • This is over 15 million Americans • Yardley, et al, 1998 (follow-up study of Nazareth) • One in 10 people of working age experience dizziness with some degree handicap (Yardley, et al, 1998). • 18 months later concluded: • 24% more handicapped • 20% had recurrent dizziness • 20% improved • Kroenke, et al (1992) • Patient with initial complaint of dizziness • Two weeks – 70% no resolution • 3 months – 63% no resolution • 11 months – 47% no resolution • CONCLUSION: simple observation and reassurance are not appropriate in many cases.

5. Prevalence of Dizziness • Older/Aged Population • 1000 Internal Medicine Clinics reported dizziness 3rd most common complaint over age 59 with chest pain and fatigue noted more (Kroenke, 1989). • Over age 75 – number one complaint (Koch & Smith, 1995) • Sloan et al, 1989 reported 18.3% of adults over 60 suffer dizziness significant enough to seek physician, take medication, or interfere with normal activities “a lot” during the past year. • Graying of America (U.S. Census Bureau) • 65 and over will double over the next few decades • 20% of the US population • 85 and over will quadruple

6. Prevalence of Dizziness • Kroenke, et al, 2000 Combined Literature Review of 12 Articles on Etiology of Dizziness: • 44% - Vestibulopathy (PNS) • 11% - Vestibulopathy (CNS) • 16% - Psychiatric • 26% - Other conditions • 13% - Unknown causes • 6% - Cerebrovascular disease • 1.5% - Cardiac Arrhythmia • <1% - Brain Tumor

7. Don’t most people with dizziness recover spontaneously? • 6-8 weeks? • others say 6 months to a year… • 80%/20% • It is part of old age… • It will go away on its own.. • It’s all ‘in your head’”… • Learn to live with it… • What is the consensus? • PT Opinion: Look at how many fallers we have in our seniors…I think we are missing a lot of patients. • 40% of the US Population (40 Million) go to their MDs for handicapping dizziness. • Yesterday I had 38 patients on my schedule with chronic dizziness…I get referrals from less that 1% of the local MDs? • Where are all the people going…

8. Why Are We Seeing So May Patients with Chronic Dizziness? • Population growth • More aging population – baby boomers • Multiple Medications=Increased Risk for Dizziness • More Chronic diseases • With Existing Dizzy Patients – Why aren’t they improving: • MDs not knowing this therapy exists or actually works • See attached article by Tee and Chee, 2005 • Unstable central or peripheral vestibular system • Causes repeated changes in the functional status of the system (e.g., Meniere’s,BPPV) • Maladaptive behaviors of avoidance in movements • Creates a stable locus of the lesion (stalls compensation (e.g.., intermittent symptoms post vestibular neuritis, fear of falling) • A second disease process interferes with compensation (e.g., Anxiety, Migraines, Stroke) • Chronic use of medication initiated at onset not appropriately withdrawn (e.g., Meclizine, Benzodiazepines)

9. The Need for Therapy – Building the Case…EBM is Paramount! • Most patients play no active role in their own health care • Rely totally on the Health Care Practitioner (HCP) to make decisions. • Have overly optimistic view of the effectiveness of medical treatment • Rarely question whether the recommended treatment has proved effective • Onus on the HCP to provide treatment that has undergone rigorous clinical trials and be effective for most patients with a given diagnosis. • Evidence Based Medicine (EBM) means integrating individual clinical expertise with the best available external clinical evidence from systematic research (Sackett, et al., 1996)

10. The Need for VRT – Building the Case… • Historical Perspective – Three Options • Medical Treatment of Symptoms (Medicate) • Surgical Stabilization (Reparative or Ablation) • Observation, Reassurance, and Counseling (Learn to Live with It) ALTERNATIVE – Vestibular Therapy • Cawthorne and Cooksey, 1945 • Patient who remained sedentary recovered slower than those who were more active • Developed Cawthorne-Cooksey (C-C) exercises • McCabe, 1970 • Expanded Cawthorne’s ideas and described “Labyrinthine Exercises” as “our most single tool in the alleviation of protracted recurrent vertigo.” • Hecker, et al, 1974 • Used C-C exercises with vestibular-type patients • 84% improved symptoms – other 16% not improved due to lack of patient compliance or emotional distress • Norre, 1988 • Optimal recovery period in animals following vestibular injury • Suppressant medications and/or forced inactivity reduces natural compensation

11. The Need for VRT – Building the Case… • Horak, et al, 1992 • Three groups of patients with chronic vestibular complaints (VRT, medication, general activity) • Those who used VRT showed the greatest improvement in functional performance • General Activity improved to a lesser degree • Medicated showed the least improvement • Fujino, 1996 • Two groups: Medication and Medication with VRT • 8-weeks – exercise with medication had less symptoms • Shepard, et al, 1990 • Patients taking vestibular suppressants, antidepressant, tranquilizers, and anticonvulsants achieve the same level of compensation as patients not on meds – length of therapy significantly longer on medications • Telian and Shepard, 1995 • General VRT versus Customized Programs • 64% using general therapy had complete resolution • 85% using a customized had complete resolution

12. What is Vestibular Retraining Therapy (VRT)? • A set of physical therapy exercises designed to “re-calibrate” the balance system through specific practice of in-therapy treatment and customized home exercises. These include: • Habituation • Adaptation • Static/Dynamic Balance • Strengthening/Endurance • Manual Therapy (Cervical) • Behavioral Therapy • Repositioning Maneuver

13. Vestibular Therapy – The New Drug – Key Concepts • Referrals • When Should I Refer for VRT? • Specific interventions for BPPV (loose calcium in canal) • Epley/Semont maneuvers • General interventions for vestibular loss • Unilateral loss (Neuritis/ Labyrinthitis) • Bilateral Loss (Ototoxicity/ other) • Persons with fluctuating vestibular loss (help prepare patient for future surgical treatments) • Meniere’s disease (slowly fluctuating) • Perilymphatic Fistula • Experimental treatment where origin of dizziness is unclear • Post-traumatic vertigo, CNS Dysfunction • Multisensory dysfunction of aging • Psychogenic vertigo for desensitization • Phobic Positional Vertigo • Fear of falling/provocation

14. Vestibular Therapy – The New Drug – Key Concepts • Indications/Contraindications • When is this therapy not appropriate for my patient ? • Almost any patient with dizziness associated with an inner ear dysfunction can benefit from the therapy • Not Beneficial • Vertebral Basilar Insufficiency (VBI) • Unless there is a suspicion of BPPV • Postural Hypotension • Reducing/eliminating TIAs or Strokes • Can help after a TIA/Stroke • Extremely unstable Meniere’s disease • Questionable (might help) • Mal De Debarquement • Have seen improvement just not complete resolution • Cerebellar Degenerations • May improve in strength/endurance • Motion Intolerance • Puma Method • Basal Ganglia Syndromes (PSP, PD – may help if slowly progressing)

15. Vestibular Therapy – The New Drug – Key Concepts • Compliance • How Long will my patient attend the course or get home exercises ? • Analogy: Taking full dose of antibiotics • Twice an week typical – some need three depending on severity • 4 to 12 weeks – again depending on severity • All patients get a customized home program.

16. Vestibular Therapy – The New Drug – Key Concepts • Education • How do I convince the patient that they need this therapy versus medication? • Probably the hardest thing to do… • Must convince the patient that medications only suppress the symptoms – not fix the problem. • Horak et al, 1992 – VRT group versus medication reports least symptoms in 6 weeks • VRT re-calibrates and re-organizes the balance system naturally without drugs • Same techniques used by NASA and Military fighter pilots to adapt to environments • Same techniques used to hit a golf ball • Dizziness is the error message your brain needs to learn to overcome your symptoms – suppressing or avoiding your symptoms only worsens the symptoms.

17. Vestibular Therapy – The New Drug – Key Concepts • Duration of Therapy/Refills/Dosing (twice a week) • How will I know when to stop the program? • Stable PNS vestibular disorders: 6 to 8 weeks of therapy • Stable CNS vestibular disorders – 10 to 14 weeks of therapy • Mixed (PNS/CNS) – 14 to 18 weeks of therapy

18. Vestibular Therapy – The New Drug – Key Concepts • Side Effects/Toxicity • How do you know the patient is getting the right therapy? • The key is the diagnosis • Second is proper treatment by a proper provider • Physical therapists with certifications in vestibular disorders are paramount • Not just any therapist should treat your dizzy patient • Cost • Do insurances cover this therapy? YES!!! • The key is diagnosis coding on your part • Dizziness in most cases in not reimbursable (780.4) • Must use a functional diagnosis code – 781.2 (dysequilibrium)

19. Vestibular Therapy – The New Drug – Key Concepts • Functional Balance Testing • What type of testing will you do with my patients? • Computerized Dynamic Posturography • Dynamic Visual Acuity Testing • Functional Balance Testing (Sharpened Romberg) • Vestibular Auto-Rotational Test (VAT) • Infrared-Video Oculography (ENG) • With Calorics

20. Vestibular Therapy – The New Drug – Key Concepts • How do I gauge the effects of the therapy with my patient? • Symptom-mediated • Dizziness questionnaires improved • Reduced symptoms = improved function • ADL questionnaires • Improved balance confidence – improved function • Findings-mediated • Posturography Scores improved • VAT scores improved • Improved gain, phase, asymmetry • Reduced Nystagmus under infrared • Improved static/dynamic balance • Sharpened Romberg • Single Leg Stance

21. How Does Vestibular Therapy Work? • How does a figure-skater spin? • How do NASA astronauts go to space or Nellis pilots tolerate flying a jet? • Adapt and Habituate…to the environment. • VRT focuses on the plasticity of the central nervous system. • Does not repair the damaged inner ear or brainstem. • Works on getting the CNS and brain to adapt to the asymmetrical input from the VOR and VSR. • Analogies for Patients: • Alternator and Battery System • Inner ears – Alternators • Brainstem – Battery • Driving a car with the front end out of alignment • Take your hands off the steering wheel

22. Types of Patients Seen at a Balance Clinic • Patients ages 10 to 103 years (Werner,2006) • The Effect of Age on VRT Outcomes (Whitney, et al, 2003) • Conclusion: Age does not significantly influence the beneficial effects of VRT for persons with vestibular disorders. • Increased time for older populations • Types of Patients • Chronic Mobility Disorders • Dizziness/Dysequilibrium • Fall Risk Identification & Mgmt • Head Injury/Concussions • Neuro-Degenerative Diseases (MS, PD) • Orthopedic (THR/TKR) • Vestibular Disorders (PNS/CNS) • Ototoxicity • Post-Surgical Vestibular • Workers’ Compensation • Medico-Legal • Performance Enhancement

23. Currently no “Gold Standard” test/outcome – key is symptom reduction and improved ADL independence. Cochrane Review BPPV – Epley Maneuver helps reduce vertigo VRT for ULv Currently in protocol Question: How much do you follow the Cochrane review in your pt. mgmt? Efficacy of Vestibular Rehabilitation (Review) (Whitney, et al, 2000) Review of 87 articles on VRT PNS disorders that are stable demonstrate better outcomes than CNS PT intervention works in most cases of vestibular disorders, regardless of age. Efficacy of VRT on Chronic ULV Dysfunction (2003) Purpose: Supervised vs. Home Program (Used DHI and VAS) Prospective Study N=125 Conclusion: Supervised demonstrated improved DHI and VAS scores Regardless of age, gender, or disability level Does Vestibular Therapy Really Work?

24. Questions and Answers

25. References Cawthorne, T. (1944). The physiological basis for head exercises. J Chart Soc Physiother 106-7. El-Kashlan, HK., et al. (1998). Disability from vestibular symptoms after acoustic neuroma. American Journal of Otology 19:101-114. Hain, T. (2006). http://www.dizziness-and-balance.com/treatment/rehab.html Horak, FB., et al. (1992). Effects of Vestibular rehabilitation on dizziness and imbalance. Otolaryngology – Head and Neck Surgery 106: 175-9. Kreb, DE., et al. (2003). Vestibular Rehabilitation: useful but not universally so. Otolaryngology – Head and Neck Surgery. 128: 240-50. Norre, M. (1988). Vestibular habituation training. Archives of Otolaryngology – Head and Neck Surgery 114: 883-86. Solomon, D & Shepard, N. (2002). Chronic Dizziness. Current Treatment Options in Neurology: Ophthalmology and Otology. 281-288. Whitney, et al. (2000). Efficacy of vestibular rehabilitation. Otolaryngologic Clinics of North America. 33,3; 659-673. Whitney, et al (2003). The effect of age on vestibular rehabilitation outcomes. Laryngoscope. 112,10: 1785-90.