1. Balance Retraining Physical Therapy for the Physical Therapy Assistant CSN PTA Program - 2009 Brian Werner, PT, MPT President – Werner Institute

2. Brian K. Werner, PT, 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. Is There a Need Over 65, third leading MD visit –Number one cause of injury death in seniors 2% of all physician visits are due to dizziness Last year, over 350,000 hip fractures due to falls –Costing Medicare over $32 billion Largest population needing service is seniors

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/annually –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. We normally don’t think about our balance systems…but Vincent van Gogh committed suicide This self portrait was completed in 1889, after he cut off his ear We think he suffered from Meniere’s disease

6. Anatomy of the Balance System

7. It is Not Just Your Inner Ear Balance control is made of several systems Sensory –Vision –Somatosensory –Vestibular Integrators –Brainstem/Brain –Past Experience Motor Systems –Muscles –Motor Nerves

8. Balance System Anatomy - Vision Signals position and movement of the head with respect to surrounding objects Good for slow movements or static tilts of the head Control through the Oculomotor reflexes

9. Visual System Orientation and balance are maintained via several visual properties: –Saccades –Smooth pursuit –Optokinetic reflex –Depth perception –Visual cortex centers specially designed to respond to vertical and horizontal stimuli Rehabilitation of these “responses” is available

10. Balance System Anatomy - Somatosensory The largest sensory system The primary input for balance control with respect to surface

11. Balance System Anatomy - Vestibular Although anatomically developed and responsive at birth, the vestibular system matures along with other senses in the first 7 to 10 years of life. Provides information about the head with respect to gravity and inertial forces. Cannot work alone but acts as a judge for the other two sensory systems. In most cases of dizziness (over 80%), the vestibular system is the cause.

12. Anatomy - Vestibular Bony Labyrinth –Located in the temporal portion of the skull Membranous Labyrinth –Inner tube like structure housing fluid and sensors Endolymph –Fluid that baths sensors, helps with transmission of impulses, acts as an inertial drag Perilymph –Outside fluid from membrane, acts as a cushion like CSF for brain, helps with nerve transmission

13. Vestibular System - Specific Semicircular Canals –Ampulla Bulbous bony opening that houses the cupula –Cupula Sensor/Sail that houses hair cells –Canals (Orthogonal) Anterior Posterior Lateral

14. Anatomy of Vestibular System Otolith Organs –Otolithic Membrane Where calcium stones, crystals, otoconia sit to act as an inertial mass –Hair Cells Project into the membrane –Two Organs Utricle Saccule

15. Otolith Organs, Continued Utricle –Linear Accelerations –Sits horizontal Saccule –Linear Accelerations –Sits vertical

16. Physiology of the Balance System

17. Key is the Inner Ear for Balance Inner ear functions as a plum line for which the somatosensory and visual system cue off for stability Without vestibular function we can still maintain balance but at a cost –Surface dependent Loss of vision/vest –Visual diseases –Visual dependent Loss of surf/vest –Diabetics

18. The Hair Cell is the Structure You Need to Understand This is a really small system –Size of thumbnail –20,000 haircells/inner ear Stereocilia Kinocilium –Toward  Excitation –Away  Inhibition

19. Hair Cell Continue… Semicircular Canals –Hair cells act like a sail in the wind on cupula –Deflection of the hair cell by the inner ear fluid causes the cilia to bend –The direction and “pattern” of the bending is the message of motion YAW, PITCH, ROLL –Head on Neck  VCR –Gaze Stability  VOR –Postural Stability (Stand, transfers, gait)  VSR

20. Hair Cell Continued… Otolithic Organs –Orientation of hair cells in the otolith organs help to determine movement of the head –Unlike SSC, the inertial push on the hair cells is GRAVITY!

21. How We Measure Balance… We DON’T Measure Structure – Must Measure FUNCTION All the PTAs Learn How to Both Test and Assess at the Werner Institute

22. Types of Technology You Work With In a Vestibular/Balance Clinic

23. Types of Technology…VNG Video- Nystagmography (VNG) –Allows visualization of the eyes in the dark –Like taking your hands off the steering wheel of your car Helps determine origin of imbalance –PNS/CNS (Mixed)

24. Types of Technology…VAT Vestibular Auto- rotational Test –Measure gaze stability from 2 Hz to 6 Hz –Determines if balance disorder is PNS/CNS –Helps determine type of therapy Hypo  Stimulate –VOR x 1/ x 2 Hyper  Suppress –Oculomotor

25. Types of Technology…CDP Computerized Dynamic Posturography –Gold standard in postural standing testing –Helps determine impairments causing imbalance Vision, vestibular, touch –Quantitative

26. Common Pathologies of the Balance System

27. First Principle: YOU Must Know the Dizziness You are Treating Dizziness is a non-specific term – it can mean several things: –Vertigo –Motion Sickness –Lightheadedness –Dysequilibrium –Behavior Overlay –Compilation of one or more above

28. Vertigo Illusion of motion Rotational in nature Two types: –Subjective: You feel the motion –Objective: You see the motion Commonly associated with inner ear disorder

29. Motion Sickness This is a mismatch between the visual and vestibular system Commonly occurs with: –Cars, boats, airplanes –Usually associated with vestibular injury

30. Lightheadedness Pre-sycope (impending sensation of passing out) Patient complain of wooziness or increased symptoms with exertion Many times indicative of cardiovascular disease or origin disorder

31. Dysequilibrium Wobbling on your feet Feeling of unsteadiness Commonly seen in our geriatric and senior populations Vestibular ataxia

32. Behavioral Conversion –Small Pathology –Exaggeration of symptoms –Convert/Hysterical overlay making symptoms worse –Most common patient we see in clinic Factitious Disorder –No pathology –Volitional exaggeration of symptoms –Functional overlay Somatoform Disorder –No pathology –Diagnosed DSM IV psychiatric disorder Depression Anxiety Panic Attacks Malingering –No pathology –Volitional exaggeration of symptoms –Secondary gain

33. BREAK

34. Three Most Common Patients Seen in a Balance Program BPPV Vestibular Neuritis with consequential vertigo, imbalance, and Fatigue/Disuse Non-specific Dysequilibrium

35. Common Pathologies of the Balance System - BPPV Benign Paroxysmal Positional Vertigo (BPPV) –Most Common form of vertigo –Calcium loosens in the inner ear canals Creates an illusion of movement (vertigo) –Can linger for weeks to years –Relatively easy to treat with a repositioning maneuver…as long as you know which canal Screw it up and vomit is sure to follow

36. Common Pathologies of the Balance System – Vestibular System Inflammation Vestibular Neuritis - Labyrinthitis –Inner ear infection –Can occur at any age – including children –Commonly caused by URI –Sends most patients to the ER as they think they are having a stroke Some may be so it is good they go –Peripheral injury to the inner ear or to the peripheral nerves

37. How Do You Treat…Vestibular Neuritis Treatment is based on symptoms –Blurred vision  Gaze Stability Exercises VOR x 1/VOR x 2 –Dysequilibrium  Static/Dynamic Balance EO/C; PR/SR; HT/N/R –Positioning Dizziness  Habituation Repetition in symptomatic position –Fear  Conditioning and positive education Pavlov’s dog You must challenge the symptoms

38. Dysequilibrium Wobbling on your feet Feeling of unsteadiness Commonly seen in our geriatric and senior populations Vestibular ataxia Usually a multisensory disorder –Example: Diabetes Visual loss due to retinopathies Sensory loss due to neuropathies Inner ear loss due to vestibulopathies

39. Let’s Finish With Treatment

40. 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

41. Gentile’s Taxonomy of Tasks Body Stable  Body Transport –Romberg  walking Without Manipulation  With Manipulation –Holding cup –Using AD –Eyes Open/Closed –Head Turns/Nods Closed versus Open Environment –In parallel bars –Over the ground with/without AD No Intertrial Variability  Intertrial Variability –Same activities –Variable between each activity

42. Types of Treatments Available in VRT/BRT Strengthening/Conditioning Static/Dynamic Balance Retraining Gait Training Adaptation Training Habituation Training Repositioning Maneuvers Manual Therapies w/ and w/o modalities and physical agents Education/HEPs

43. How Do You Treat…Dysequilibrium Visual Loss –Not much we can do Teach use lights at home at night Refer to MD for treatment Glasses adjusted Somatosensory Loss –Proper shoes –Assistive device –Infrared Light Therapy for DPN Vestibular Loss –Re-charge the batteries –Substitution of other senses Assistive Device Also –Disuse  Strengthening –Deconditioning  Aerobic retraining –Fear  Conditioning Therapy or Psych. Consult

44. CASE I Patient is a 78 yo male with a insidious onset of “dizziness” for the past three years. He reports a history of DDD/DJD of the cervical to lumbar spine, diabetes type II, and macular degeneration. MMT demonstrated FAIR PLUS bilaterally in lower extremities.

45. CASE I

46. Multisensory Dysfunction Pattern

47. How To Treat…BPPV The key is identifying the affected canal –Dix-Hallpike TestDix-Hallpike Test Treatment –Epley maneuverEpley maneuver The key is vertigo in the head down position… –Semont maneuverSemont maneuver The key is vertigo in the head down position…

48. CASE II Patient is a 35 year old Cirque du Soleil artist that missed a protection mat during a show and hit her head. She reports every time she looks up or rolls over in bed she has a robust spinning sensation. MRI, CAT scan, X-rays are all negative for neurological or bony injury.

49. CASE II

50. Always Looking For PTAs… We Do Rotations in Balance – please call Jim Schiemer, PT at 880-1515.