Therapy and Treatment

 

The elderly who have imbalance can have many problems that add to their dizziness/imbalance problems.  Some of these can include Parkinson's, MS, arthritis, diabetes, stroke, BPPV, spine disorders and Macular Degeneration.  It is easy to see why some would feel that they cannot be helped.  Age is not a reason for a lack of effort to improve.  It is true that complicating factors can limit progress but most people, at any age, have areas of balance that can be improved.

 

As balance specialists, we assess many factors and develop a treatment plan that address specific problems.  There is significant evidence that balance training will help poor balance if the rehabilitation program is specific to the problems found in good evaluation performed by a qualified clinician (Medical Management of Balance and Mobility Disorders, Nashner, L., Advance for Directors in Rehabilitation, July 1999).

Factors that are test and treated:

  • Amount of sway in standing

  • How you sense posture

  • Ability to reach and lean

  • How you sense balance (with eyes, inner ear, and feet)

  • Ability to balance on uneven ground

  • Leg strength and joint health

  • Foot and ankle movements

  • Endurance of trunk muscles

  • Confidence

  • Inner ear

  • Neck

What is important in recovery?

Dizziness can be very band and can cause additional problems such as stress, depression and poor confidence.  Usually, people will stop moving to make the dizziness better.  Although holding steady helps the dizziness feel better it does not help in recovering from it and returning to normal activities.   There are two facts of dizziness:  holding the head still prevents recovery, and movement of the head speeds up recovery.  The exercises for dizziness are well-researched and have had over 20 years of clinical success and a 90 percent success rate for those that don't give up.  Yes, they can increase dizziness and nausea in the beginning but if done within tolerance, dizziness can improve.  The hardest thing to convince people of is that if they stick to the program they will improve with very few exceptions.  Stay motivated and don't give up.

  • Dizziness occurs when signals going to the brain are bad.

  • The brain will stop the dizziness when it detects the bad signals and corrects them.

  • When the head is moved the bad signals momentarily make the dizziness worse but it also helps the brain to compare and correct the signals that are causing the problem.

  • Head movement equals improvement.  Pace yourself and don't give up!

We are here to help in any way we can and wish everyone the very best.  Best positive, maintain hope, and face your challenges head on.

The Four Conditions of Recovery (Adaptation)

In the 1940's, Dr. Cawthorne (Otolaryngologist) and Cooksey (Physical Therapist) observed that people with dizziness recovered faster when they remained active versus the people that limited their movement.  As a result, they developed a set of exercises known as the Cawthorne-Cooksey exercises.  1  These exercises speed up adaptation.  Adaptation is when the brain corrects bad inner ear signals.  Over the years, researchers have begun to understand how the brain recovers from dizziness (adaptation).  There are four conditions of adaptation that guide treatment:

  •  Adaptation is frequency dependent.  The brain adapts only at the speeds that it is trained.  Therefore, a patient needs to train with head movements in a variety of speeds to adapt to the different demands of daily life.  2

  • Adaptation requires time.  3  Once the signals are calibrated, symptoms should improve.

  • Adaptation requires concentration to focus the brain's attention on adapting.  4  Exercises should cause some dizziness.

  • Adaptation requires multiple system stresses.  5  Since there are three systems that interact (vestibular, visual and somatosensory) exercises should vary to emphasize each system.

The inner ear exercises are designed to speed up adaptation and improve dizziness.  Assessment and treatment should be performed only by one trained in balance and vestibular disorders.

Dedication to Scientific Based Treatments

There is a great concern in rising medical costs.  Insurance premiums are going up at alarming rates.  One way to fight raising medical costs is to be efficient by using proven scientifically-based treatment models.

The majority of the patients we see have spent months or years suffering with dizziness or balance problems going from doctor to doctor and having a borage of expensive tests that often result in normal results.  How can a physician treat a problem if there is no positive findings?  It is difficult.

It is common to see a patient who has been dizzy with poor balance to stop their normal activities and fall into depression.  Sometimes the dizziness has lasted for 10, 20, or 30 years only to be completely resolved in one to three treatments.  Of course, not all balance and dizziness problems are so quickly reversed but there is a specific order of tests that can identify many dizziness problems.

Why should assessment and treatment be performed only by one trained in balance and vestibular disorders?

  • Patients get the right treatment

  • Less cost and better recovery

  • Complete assessment and treatment

  • Patients are well-educated

  • Limits prolonged suffering and improves the quality of life

  • Understanding dizziness reduces fear and anxiety

The Dizziness/Balance Management Model

  • Pathology Diagnosis:  The diagnosis given by a physician that is supported by patient history, exam, and diagnostic tests.

  • Impairment Diagnosis:  Impairments of specific systems that limit functional activities, (i.e. impairment in the integration of vestibular input for maintaining balance).  The functional problems associated with this may be imbalance, limits in independent walking or falls. 

The primary tests to determine impairments are:

Postural Integration Tests:

  • Modified Control Test for sensory integration for balance

  • Posturography

Vestibular Testing:  ENG/VNG

  • Care Plan:  a written outline of the actions that will most efficiently resolve functional limits, symptoms and maximize the quality of life.

  • Surgical/Pharmacological Intervention

  • Balance/Vestibular Rehabilitation:  training of impaired systems for balance with emphasis in regaining independent quality function and reduction of symptoms.

  • Progression Indicators:  specific objective pre-determined tests such as functional tests, balance tests, Posturography, dizziness scale scores, and gait assessment.

  • Lifestyle Modification:  changes a person makes in a variety of areas that will best control symptoms (i.e. low salt diet or avoidance of poorly lit environments).

   

Lower Extremity Neuropathy and Balance

  • When Neuropathy is the cause of poor balance:

    • It is a misconception that imbalance cannot be improved if lower extremity neuropathy is a coexisting problem.  I have often heard my patients say, my imbalance is because of my neuropathy.  They make the inference that if their neuropathy cannot be helped then their balance cannot be helped.  The problem with this assumption is that the patient has a false preconceived negative outcome to any treatment with no hope for improvement.

  • Lower extremity neuropathy can reduce balance because it is one of the sensory systems that is involved in balance and body orientation.  The most important realization that once can have is that there are two more sensory systems of balance that can be trained to compensate for lower extremity neuropathy.  Permanent balance problems can exist with neuropathy but the extent of the imbalance depends on the condition of the vestibular system and the ability of the CNS to use visual stimuli for balance.  These are the two systems that can compensate for neuropathy.

  • The best way to determine the functional condition of balance systems are to assess each system through an ENG/VNG and Posturography.  Only with this information can a decisive and accurate conclusion be made as to the prognosis of balance.

    • 1.  Dix MR:  The rational and technique of head exercises in the treatment of vertigo.  Acta Oto rhino Laryngol B. 1979; 33:370-384.

    2.  Lisberger SG, Miles FA, Optican LM:  Frequency-selective adaptation:  evidence for channels in the vestibulo-ocular reflex.  J Neurosci 1983; 3:1234-1244.

    3.  Pfaltz CR:  Vestibular compensation.  Acta Otolaryngol 1983; 95:402-406.

    4.  Jones GM, Guitton D, Berthoz A:  Adaptive modification of the vestibulo-ocular reflex by mental effort in darkness.  Exp Brain Res 1984; 56: 149-153.

    5.  Collewijn H, Martins AJ, Steinman RM:  Compensatory eye movements during active and passive head movements:  Fast adaptation to changes in visual magnification.  J. Physiol 1983; 340: 259-286.