This week, we are celebrating Balance Awareness Week at my physical therapy practice in Sarasota, Florida. In honor of this recognition, I am happy to share with you a new infographic from the Vestibular Disorders Association. Infographics are pictures boards that help to communicate a concept or idea. I hope this infographic helps you better understand what causes dizziness, and what to do about it!
Bell Palsy is a condition that causes facial paralysis, and was named after Sir Charles Bell (1774-1842) who described the Facial Nerve and cases of facial paralysis in his writings.
Who: 20-30 people per 100,000 people develop Bell Palsy per year. It can occur at any age, but the median age is around 40 years old.
What: by definition, it is defined as idiopathic, acute unilateral peripheral facial palsy.
Where: It usually occurs on one side of the face. Bell Palsy causes weakness or paralysis in all branches of the nerve. In other words, people show signs of weakness or paralysis in the forehead, midface, and lower face with Bell Palsy.
When: It comes on suddenly, usually within 48 hours and reaches its peak within a week. People with Bell Palsy should show some signs of recovery within 6 months of onset. If a person has complete facial paralysis with no signs of recovery at 6 months, they need further work up, because chances are it is not Bell Palsy, and they may have something serious causing their facial paralysis.
Why: When Bell Palsy was defined, it was defined as idiopathic, meaning “we don’t know what causes it”. However, new research is pointing to the herpes simplex virus type 1 as a major cause of Bell Palsy.
What to do: If you have sudden facial paralysis, you need to find out right away what is causing it so that you get the proper treatment. A physician needs to examine you and determine if it is Bells Palsy, or something more serious such as a stroke or brain tumor.
How is it treated: Initially, patients with Bells Palsy may be prescribed an anti viral medication, and/or a steroid medication to help protect the facial nerve and promote healing. If the facial weakness does not completely recover on its own, the patient may be sent to a speach, ocupational or physical therapist who specializes in treating facial paralysis to retrain the facial muscles how to work again.
Reference: The Facial Nerve by Slattery and Azizzadeh, Chapter 9 on Bells Palsy & Ramsey Hunt Syndrome by Shingo Murakami.
Painting: Green Eye Mask by Amadeo de Souza-Cardoso, 1915
Old woman seen from behind, sketch and study in pencil by Van Gogh, 1882
Most people with balance problems want to avoid walking with a cane or rolling walker unless absolutely necessary. Even when necessary, many people refuse to use a cane because they are too proud or embarrassed for others to see them walking with one. The thing is, if a person is at risk for falling, a fall can cause serious injuries, and even death.
The Center for Disease Control estimates that one out of three adults age 65 and older falls each year, but less than half talk to their healthcare providers about it. And among older adults (those 65 or older), falls are the leading cause of injury death! This is a serious issue...
So I tell my clients, “You need, what you need, when you need it”. The purpose of the balance exercises is for the person to improve to the point where they don’t need the cane or walker. But until that time comes, the last thing a person needs is to add to their problems by falling and getting hurt... When my balance patients in Sarasota understand that the cane or walker isn’t meant to be a “forever thing”, they are usually willing to use it temporarily until their condition improves.
If you or someone you love falls into this category, I encourage you to use a cane or walker, and to seek out a physical therapist who specializes in balance disorders, so that you can address your balance problem and regain your safe and independent lifestyle again.
Balance Awareness Week is September 15th-21st, 2014!
Are you having a balance problem? The goal of balance awareness week is to help people recognize if they are having a problem, and to urge them to seek help. Falling is not a normal part of aging. We know that falls can lead to serious injuries and even death. If you have had one fall with serious injury in the last 12 months, or 2 falls without injury, I encourage you to seek out a professional vestibular balance specialist. Something can be done to help your problem!
Facial paralysis occurs when the facial nerve is damaged and unable to send messages to the muscles of the face that create facial expressions. This problem can occur for several different reasons. Some causes include: tumor, trauma, stroke, or genetic disorders.
The most common cause of facial paralysis is due to Bell Palsy. While most of the time, Bell Palsy patients recover fully, research tell us that about 20-30% have lasting weakness or paralysis.
I first started treating people with facial paralysis because I was a vestibular specialist. The vestibular system or inner ear balance system is innervated by cranial nerve 8 (the Vestibular Nerve). The muscles of the face used for facial expression are innervated by cranial nerve 7 (the Facial Nerve). These 2 nerves run side by side on their way to the brain in a tunnel in the bone called the Internal Auditory Canal (IAC). This is a very narrow space, with only enough room for the nerves to travel. If a tumor is growing in this small place, or an infection travels to this area, both nerves can be damaged. We see this with large acoustic neuroma tumors, or with infections such as Ramsey Hunt Syndrome.
When facial paralysis does occur, it can take a lot of time for the nerve to heal. The first signs of movements of the face can be only just a flicker, but as the nerve heals, the movements can become stronger. Working with a physical therapist who has special training in treating facial paralysis can help improve the outcome for patients with this problem. They can teach a person what to expect while they are recovering, how to do stretches to ease pain and tightness in the face, how to retrain the muscles to move in a symmetrical way with the unaffected side of the face, and how to manage a condition called synkinesis (when facial muscles which should not be working when making a certain expression try to “help” anyway).
*Sculpture by Jun Kaneko 2007, Untitled Head in Glazed Ceramic and Steel
U-STEP: A WALKER DESIGNED FOR PARKINSON’S PATIENTS by Laura Wazen and Charlie
Hi. My name is Laura Wazen and this is my friend Charlie. Today we want to show you a very cool walker you may not have seen before, that is especially good for people who are having Parkinson’s Disease. So, one of the things about Parkinson’s Disease, is that sometimes, it can be a little bit hard to control your momentum if you’re walking with a traditional walker- that is in a sense, rolling away from you. So the neat thing about this U-Step walker is that it will only move if you squeeze the handles. So if Charlie wants to take a step, he squeezes the handles, and takes a couple of steps forward. Now the neat thing about this is, if he’s feeling unsteady or needed to stop, all he would have to do is release the handles. And then he could regain his balance, and he can then take a step forward which is a really, really cool thing! Another neat thing about this walker is that if a person is having a problem taking a step forward, (they’re freezing for example), it has a little button, which is right here, that if you push the button, it puts a red laser on the floor that serves as a visual cue, so that you can just look down and see the red line, and then the person initiates a step by stepping over the line. Charlie, could you push the button on the laser? (Charlie demonstrates pushing the button). The laser would project on the ground, and then he could use that red line as a visual cue to take a step, and start walking again. There you go.
Very good, Charlie.
We have moved our office to 950 South Tamiami Trail, Suite 101, Sarasota, FL 32439. It is a great space with lots of windows, ample parking in the shade (which is huge if you live in Florida), and on the 1st floor of the building.
The new office is right on US 41 South, across the street from the old Sarasota High School Building. I am really pleased to be opposite such a great Sarasota landmark, because the old school is now the new home for the Sarasota Museum of Art (SMOA)!
What does this mean for me? Well, I won’t have to go far to see inspiring art. In fact, if you are sitting in my treatment room, you can see a fascinating art installation right on the front lawn of the museum. I thought you might enjoy it as much as I have, so below you can see some of the photos I took with my phone the other day. As you can see by the pictures, this makes giving directions to my clinic very easy…
I have driven by this exhibit hundreds of times, but actually being able to walk in and around the art, and touch the walls of the structure gave me a whole new personal experience to the art work. If you live in Sarasota, I highly recommend you take 5 minutes, and stop and do the same. While you’re at it, stop by my office to say hello!
Generally speaking, balance therapy is a type of physical therapy that is performed to help a person with a balance problem. Different therapists may approach treating a balance problem based on their own background and expertise. For example, a therapist who comes from an orthopedic background and loves treating mainly people with joint and muscle problems, will tend to do what makes their other orthopedic patients better. That is, put the patient on a bike, and give them leg exercises. If the patient’s balance problem is caused by muscle weakness, they will improve.
However, if the problem is not weakness, they will not improve. It is not unusual for me to get a patient for balance therapy in my Sarasota office, and for the patient to say straight out that they don’t think I will be able to help them, because they have had a lot of physical therapy and did not get any better. The next question I ask is, “Well, tell me what you were doing?”, and 9 times out of 10 they will say sitting on a stationary bike and using machines to strengthen their legs. I usually tell that person, well, good, I am glad to hear that the exercises I have in mind you haven’t done before, so there is still a chance that you will get better.
What are these exercises? They include inner ear balance exercises. Our inner ear system is the major organ in our body that powers our balance. It tells our brain when our head or body is moving, so that the brain can tell the joints and muscles how to move to maintain balance. A classic inner ear exercise is to improve the vestibular-ocular reflex, or VOR. This is a reflex between the ears, the eyes, and the brain. Just to explain it a bit… If a person looks at a target and moves their head side to side, they are stimulating their VOR. The inner ear sends messages to the brain to tell the brain how far or how fast the person is turning their head, and the brain uses this information to coordinate the person’s eyes on the target while the head is turning. If the VOR was not working properly, then when the person turns their head, instead of keeping their eyes on the target, they would find that they are looking in the direction of the head turn. If the person’s VOR is not working properly, the patient could have complaints of dizziness, and be unsteady when walking, especially if turning their head to look at something to the side. Another exercises involves keeping the head still, but watching a moving target. If you would like to see this exercise demonstrated, click here to check out the segment on falls and balance that I recently did for ABC News 7.
According to the CDC, one out of three adults age 65 or older suffer falls each year.
These are only a couple of examples of exercises that improve one’s balance. I know it may sound complicated, but it makes perfect sense. If you have a good balance physical therapist, they should know these exercises and include it in your program to make your ability to use inner ear information stronger. This is just one example of how working with a qualified balance and vestibular therapist, and not just someone who went to PT school, can make all the difference.
Related Article: Trips and falls cause millions of injuries a year
Sitting old man waiting in hall, by Abraham van Strij
Medicine and technology are amazing. People who are deaf can get cochlear implants to restore their hearing, while others get corneal implants for their eyes. There are hip and knee replacements for arthritic joints, and the list goes on… If you have in inner ear balance problem, you may be wondering, “When will someone make an implant to restore my balance?"
Well, Dr. Jay Rubinstein from the University of Washington is definitely one of the researchers in the know. A few years ago, I met Dr. Rubinstein at a University of Colorado ENT meeting. At that time, he was reporting on his early results from implanting human subjects with his vestibular device. When I saw him again in February 2014, he was kind enough to give me an update.
His first studies were done on rhesus monkeys that had healthy inner ear systems with intact hearing and balance function. In order to start testing the device on human subjects, the device needed approval from the Food and Drug Administration (FDA), and the study had to pass strict scrutiny by an institutional review board (IRB) to prove that the research was ethical and would not harm the subjects involved. Dr. Rubinstein had to find a population of people who from a hearing and balance point of view had nothing to lose and everything to gain by participating in the study.
The first group of 4 people to be implanted had a condition called Meniere’s Disease. These patients had already lost their hearing and vestibular function (inner ear balance control) due to Meniere’s Disease before they were implanted. He has now been following these initial patients for one to three years. Because the device can be turned on and off, Dr. Rubinstein compared how the device benefits the person’s balance control, and also how the device improves the ability of the person to stabilize their vision and decrease the visual bouncing phenomenon called Oscillopsia. Oscillopsia is kind of like the effect one would get if watching an amateur video that someone took as they were walking down the street. It looks as if the world is bouncing. One goal of the implant is that by restoring inner ear function, the oscillopsia would stop.
So you must be wondering, what did he find? Dr. Rubinstein found that over time, the electrical response from the device declined. Based on these findings, he adapted the vestibular implant to make the responses generated more robust.
Sounds great, right? But not so fast. Because research on human subjects is very, very regulated, Dr. Rubinstein has to go back to the FDA to get the new device approved, and then has to submit a whole new IRB research protocol for approval! Once that hurdle is jumped, the next hurdle is funding. As you can imagine, this type of research is very expensive and takes a lot of money…
So you see, research takes perseverance. Dr. Rubinstein certainly has that! I am very grateful that he took the time to talk with me, and has allowed me to share these things with you! I told him that my patients are always asking me when there will be a cure for their problem, and I tell them – “they’re working on it...” Truly, hope is on the horizon.
Breaking News! Hi, Everyone. I was just interviewed for a segment on Balance by Alix Redmonde from ABC News 7. For those of you who live in the Sarasota/Tampa area, you can check out the segment tonight during the prime time evening news. Alix says the segment should run at 5:40 pm, although sometimes the health segments can be shown at 5:30 pm. If you are around, check it out!
Cliff near Dieppe 1985, Paul Gauguin
Vertigo, Dizziness, and Dysequilibrium. These words mean different things to different people. However, if you are using these words in the medical sense of things, understanding the definition will help you communicate more precisely when talking with your doctor or physical therapist.
VERTIGO is a spinning sensation, either that you are still and the world is spinning, or that the world is still but you are spinning. If things aren’t spinning, then saying you have vertigo is not quite right.
DIZZINESS has to do with a funny feeling in the head, but nothing is spinning.
DYSEQUILIBRIUM has nothing to do with dizziness, or vertigo. People with dyequilibrium have no dizziness or vertigo, but they are unsteady walking.
Hopefully these definitions will help you in explaining your symptoms!
Crystal, 1921 Watercolor by Paul Klee
My physical therapy clinic in Sarasota, Florida sees many patients who are surprised to learn that they have crystals in their ears, and yes, they are supposed to be there! The crystals are made of calcium carbonate, and are called otoconia. Under an electron microscope they look like little grains of rice.
The crystals sit on top of the nerve cells in the ear. The purpose of these crystals is to help stimulate the nerve when the inner ear fluid whooshes over the nerve in response to movement. However, if these crystals come loose and start floating in the ear canals where they don’t belong, this can trigger vertigo.
Vertigo is a sensation that the world is spinning around you, or that the world is still but you are spinning. The name of the condition is Benign Paroxysmal Positional Vertigo (BPPV). The vertigo sensation is triggered by motion, and it usually lasts just a few seconds. Treatment for this problem consists of maneuvers to guide the crystals back into the part of the ear where they belong.
Once there, we want the crystals to sink back into a jelly-like matrix on top of the nerve cells, so that they stick in place and stay where they belong. Once back in place, life returns to normal, and the vertigo episodes cease.
My Eyes in the Time of Apparition, 1913. By August Natterer
This is one on the most frequent questions that my patients in Sarasota, Florida ask me, “Will my vertigo come back?” It is the question they usually ask right after I tell them that their BPPV (Benign Paroxysmal Positional Vertigo) was successfully treated, and is now gone. Research tells us that in about 40% of cases, the condition will come back. Sometimes it can come back within a year, other times the person can go for many years before the condition returns.
The next question is usually, “Is there anything I should avoid doing so that the vertigo doesn’t return?” There is nothing that the person does that makes it come back, it just does. So in that case, I tell my Sarasota BPPV patients that they should go back to life as normal. That means sleeping flat like they normally did before all this started, and to resume all their normal every day activities. This includes bending over, for example to pick something up off the ground, or tipping their head back as they would to reach over head.
If the condition does return, the person will just need to call and come back to therapy to have treatments to put the crystals back in place again. Knowing that they have a plan of what to do if the BPPV returns, usually takes the fear away, and allows the person to go on with their lives- which is the goal after all…
This is a frequent question that many of my patients ask me. Antivert, Meclizine, Bonine, and Dramamine are all drugs that can be bought over the counter to treat dizziness. But the question is, when should a person take these drugs?
To answer this question, one must first understand how these medications work. These drugs decrease or prevent dizziness, by blocking signals FROM the inner ear TO the brain. If a person is having a full blown vertigo attack, these drugs may be necessary, and may be prescribed by your doctor. However, once the attack is over, continuing to take these medications can interfere with one’s recovery.
For instance, when a person comes to physical therapy to treat an inner ear disorder, the purpose of the therapy is to teach the brain how to respond better to inner ear signals in order to improve one’s balance and decrease one’s dizziness. In other words, we want the inner ear to be able to send signals to the brain, so that the brain can learn how to adjust and use inner ear information again.
If a person is taking one of these drugs, then the medication is actually blocking the very signals that the brain needs in order for the person to get better. Therefore, in most cases, it is not advised to take these medications. In fact when used chronically, these medications can actually prevent or delay recovery.
*Disclaimer: The above recommendations reflect basic treatment philosophy when working with patients with inner ear disorders. Since physical therapists do not dispense medications, further specific questions about your medication regimen should be directed to your personal physician.
Hi, everyone. I just wanted to let you know that if you live in Sarasota or Manatee County in Florida, there is a great event going on this weekend. It is the called the 3rd Annual Hearing Tech Expo, held on Saturday, March 8, 2014 from 9am-4pm.
Over 50 vendors who help people with hearing loss will be present. There will also be 14 seminars taking place. I will be giving one of the seminars, and the title of my talk is “Understanding Balance Problems, and what to do about them”. My talk is at 1:30 pm in the main auditorium of the Manatee Technical Institute (located on State Route 70, just west of I-75, and east of route 301).
This is a super event, and I hope you can make it. It is sponsored by the Hearing Loss Association, whose purpose is to educated, support, and advocate for the over 135,000 people who live in Sarasota and Manatee counties. Hope to see you there!
We know that people use information from other senses to help them balance. For instance, we use our vision to help us balance. When we walk outside today, and see that the sidewalk is sloping, we will automatically adjust our steps and our balance based on this information.
But how does one’s hearing affect their balance? A study appeared in the Archives of Internal Medicine Feb 28, 2012 about research out of Johns Hopkins Medical Institution. They studied 2,000 people between the ages of 40 to 69. The people had their hearing tested and were asked questions about if they had fallen in the past year.
(Pictured: an antique ear trumpet for the hard of hearing.)
The results confirmed the contribution that hearing makes to balance. In this study, the researchers found that even people with a mild hearing loss (25 decibels) were nearly 3 times more likely to have a history of falls than those without a hearing loss! They were also able to measure how as the hearing decreased, the risk of falls increased. For instance with every 10 decibels of hearing loss, the risk of falling increased by 1.4 fold!
Many people don’t want to wear their hearing aids, for many various reasons. But when they understand that wearing the hearing aids will decrease their risk of falls and injury, they are usually much more willing to put them on…
Do you need inspiration to improve your balance? Then check this out:
So many times we want to make positive changes, but they seem impossible. This is true when working on improving one’s balance too. When I was in Miami for the Triologic Meeting in January 2013, I was walking down the street, and there on the corner of Lincoln Avenue was balance inspiration at it’s best. What these guys were doing seemed impossible, but they made it possible! I hope watching this video encourages you to never give up, and to keep doing your balance exercises!
In November, 2013, I traveled to Anatalya, Turkey for the 29th Politzer Society Meeting. I was so fortunate when on the bus from the airport to the conference center, I ran into Dr. Anil Lalwani from Columbia Presbyterian Hospital. Dr. Lalwani is an otologist, (an Ear Nose and Throat physician who specializes in the treatment in inner ear problems), and Chief of the Division of Otology, Neurology, and Scull Base Surgery. I was asking him, “So what’s new? Do you know of any exciting new research or treatments on the horizon that might be able to help my patients in the future?” I was so happy to hear him say the word, “YES”! Dr. Lalwani described to me the exciting research that is coming out of his lab at Columbia. He and his team are developing tiny needles that can be used to access the inner ear. One application for these needles is for diagnosing disorders that may be happening in the ear. These needles will be able to collect inner ear tissues and fluids, which can then be analyzed to diagnose signs of disease. Another application of the needles is to deliver medications directly to the inner ear, for example, aspirin. Currently, medications to treat inner ear problems are given systemically by mouth, by IV, or they diffuse into the inner ear when injected into the middle ear. Being able to deliver medication directly to the inner ear cochlea or to the vestibular balance system is indeed an advancement in treatment.
I will keep you posted on Dr. Lalwani’s research developments, and when this new technology will be ready and available for patients. If you live in the New York City area, and need an excellent physician, with the tools at his fingertips to diagnose and treat your problems, I highly recommend Dr. Anil Lalwani. His contact number is 212-305-5820. He will also be able to help you find the right audiologist, or physical therapist to meet your needs.
Turkish coffee break- Politzer Society Meeting 2013, Turkey