When a person is having a balance problem, they are often issued standing balance exercises that they practice at home. A proper evaluation by a physical therapist is needed in order to assess the abilities of the patient, and to determine if the patient needs to start with very easy and basic exercises, or if they are able to begin with something more challenging.On such exercise is called Romberg balance exercises. The patient stands in a corner with a chair in front for safety so that if they lose their balance, the wall is right behind them, and the chair is in front of them for support. The patient is standing 1-2 inches away from the wall, but not leaning on the wall. For clients with very poor balance, the person should start the exercise with their feet shoulders width apart and with their eyes open. The patient should focus on feeling the ground with their feet to try and decrease their sway, and practice keeping their weight centered over the middle of the foot and not back in the heels or too forward in the toes. I ask my patients to do this exercise for 2 minutes, 3 times a day. If the exercise makes the patient very dizzy or nauseated, they should not do it for so long, but should take a break sooner if their symptoms start to increase. As the patient improves in their ability to maintain their balance, gradually the feet can be moved closer together, 1 inch at a time….
If standing with eyes open and feet together is too easy, the person should try the exercise with their eyes closed and try not to sway. It is a good idea to have someone stand next to the patient for added safety when performing exercises eyes closed. The benefit of doing the exercise eyes closed is that it forces the brain to become less reliant on visual information, and forces the brain to practice using balance information that comes from the inner ear system and the sensation that we have in the joints and muscles that let the individual know if they are stable or swaying.
I hope this gives you an idea of exercises that people would be assigned to do at home when working with a vestibular physical therapist on their balance problem. If you are having a balance problem, I cannot recommend enough how important it is to work with a trained professional in this field that can determine the factors that are causing your particular imbalance and the proper exercises to help you improve.
*Portrait of Edith Schiele, the artist’s wife by Egon Schiele 1915
Vertigo is a spinning sensation. The patient usually describes it as the “world spinning”. Sometimes the patient will say the world is still, but they feel like they are spinning. Vertigo is a sensation that for the most part is due to a vestibular problem (inner ear balance problem). When evaluating a new patient with the complaints of vertigo, it is really important to try and get the patient to answer the following question: Does your vertigo last for seconds, minutes, hours or days before the spinning stops? I always try to make it clear that I am talking just about the spinning sensation alone, and not the dizziness, nausea, or imbalance that may follow.
The reason why it matters so much as to how long the spinning sensation lasts is because the duration of the vertigo is different for different diseases of the inner ear system. In the case of Benign Paroxysmal Positional Vertigo, the spinning should last for seconds. In the case of Meniere’s Disease, the spinning can last for hours to days before it stops. The treatment for these two problems is very different.
I just wanted to share this with you so that you can take a minute to really reflect on the pattern of your vertigo, so that when you are talking with your doctor or physical therapist, they are getting the correct information that will help to lead them to the correct diagnosis and treatment for your problem.
Vertigo, painting by Gunther Forg 1988
It is always great to read a blog and learn a little something about your health that you can put to quick use, but sometimes it is also nice to get more in depth on a topic. For those of you that live in the Sarasota area, I would like to invite you to attend a free lecture that I have been asked to give at Alderman Oaks. The topic is understanding and treating inner ear balance disorders. Being able to teach the community about my passion, the balance system, is always a great pleasure. I hope you can join us. If you attend, please make sure to come up and say hello after the lecture!
This has been a busy year for me, as I have been traveling to spending time with other therapists who specialize in treating facial paralysis. I had the pleasure of spending three days at Radboud University Medical Center in the Netherlands with Carien Beurskens, PT. She is such an amazing therapist with years of experience and knowledge, and it was a true honor to spend time with her and her patients. I was so excited to apply what I learned with Carien to treating my patients in Sarasota, Florida when I returned home. Thank you, Carien! A trip to Sidney, Australia allowed me to meet with Susan Coulson, PT and spend a few hours learning more about the interdisciplinary team that she is a part of in Australia. She was very encouraging and supportive. Thank you, Susan! The most intensive experience I had this year was at the 13th International Facial Nerve Symposium, which was a scientific meeting of doctors, therapists, and scientists from around the world who came together for 3 days of intensive meetings in Hollywood, California. The rehabilitation section was headed by Jackie Diels, OT, from Wisconsin, whose expertise was seen not only in the rehabilitation section meetings, but also on the various panels she participated in and in her wonderful talk to the general assembly. Jackie’s knowledge, creativity, and scientific approach in treating and teaching patients how to improve their facial function are unmatched in my opinion. Thank you, Jackie, for all you have shared teaching therapists from around the globe. These wonderful women have helped me grow as a therapist, and I’m grateful to be able to work with patients who have facial paralysis at Equinox Physical Therapy in Sarasota, Florida.
My name is Dr. Hannah Leatherman, and I work with Dr. Laura Wazen at Equinox Physical Therapy in Sarasota, Florida during the winter months. I am a trained vestibular therapist, which is a physical therapist who specializes in treating patients with dizziness and balance problems. Balance is very important to me, because I am also a professional athlete in the sport of disc golf. I am required to have exceptional balance to have success competing on the professional disc golf tour. The sport of disc golf is similar to golf in that you must drive, approach, and putt towards a hole. Instead of hitting a ball with a club, you are throwing a small frisbee or disc. When I throw a shot with my dominant hand, my follow through forces me to stand on my right leg while maintaining good balance.
In sports and in life, we frequently use one side of our body more than the other. It is natural to have imbalances between our left and right sides, as most of us have a dominant arm and leg. If the imbalance becomes too great, it will lead to problems. Repetitive movements, habits, postures, or even injuries and surgeries can lead to abnormal imbalances on your left and right sides. As you age this can lead to serious balance problems. You may begin noticing that you are having trouble walking a straight line, are bumping into things more than you used to, or even losing your balance and falling.
As a physical therapist who specializes in treating balance problems, I have come to understand the importance of using both sides of my body when I am training in order to improve symmetry in my body. Part of my offseason training involves throwing with my non-dominant hand, which allows my left leg to balance me during the same movements I am constantly using for disc golf on my right leg. Strengthening and balance training of my left leg and core are also key elements to my program.
At Equinox Physical Therapy one of the things that we screen for is asymmetry. In addition to other tests, we analyze our patient’s walking pattern and posture, and assess their strength in both legs in order to find out if asymmetry of the body could be contributing to the patient feeling off balance. This allows us to educate our patient regarding these results as well as treatments which will create improved symmetry in the body, improved balance, and decrease risk for falls.
Whether you have been involved with sports, have had an injury or surgery on one side that has thrown off your balance, or just think that you might have asymmetry from any other activities that you have been doing for years, I encourage you to find a trained vestibular therapist and get evaluated. You might be surprised what they will find. Your body will thank you!
Image from PDGA Disc Golf
Falls in the elderly are not normal and should not be accepted as a fact of life. This week, I had a patient who was 90 years old and told me that he was doing pretty well until this last year. In the last 12 months he has fallen 6 times! These falls have happened at home and in the community. Because he is on blood thinners, falls for him are even more dangerous because of the risk of internal bleeding. I am glad he found me, but sad that it took so long to find help. It turns out that he is a retired pediatrician, and his son is an orthopedic surgeon, but neither of them thought of going to physical therapy. I hope that the patient let his primary care doctor know he was falling, but this was not the source of the referral. The person who suggested physical therapy was his audiologist, who thankfully was looking at the big picture when talking with the patient and not just focused on his or her own particular specialty.
You may be wondering, what do we know about falls in the elderly? Here are 3 simple facts from the Center of Disease Control and Prevention website.
1. One out of three adults age 65 and older falls each year, but less than half talk to their healthcare providers about it.
2. Among older adults (those 65 or older), falls are the leading cause of injury death.
3. In 2009, about 20,400 older adults died from unintentional fall injuries.
Now that you know the facts, you could be the person who helps save an elderly person from serious injury or death. If you see an elderly person with bruises on their arms, legs, or face, ask them how did it happen? If you see an elderly person who is walking and touching the walls or furniture for support, ask them if they are falling or having a balance problem. If you see an elderly person who is struggling to rise from a chair, ask them if they are having a balance problem or falling.
If the answer is yes, let the person know that a physical therapist who specializes in treating balance problems could change his or her life. Finding a local vestibular balance specialist is as easy as going to the Vestibular Disorders Association website, and searching under the tab entitled “Finding Help and Support”.
Included image: Fallen Figure, painting by Jean Helion, 1939
Balance therapy is a generalized category of physical therapy exercises to help an individual improve their balance. The ultimate goals of balance therapy are to prevent falls and increase a person’s functional abilities and independence, both at home and in the community.
These goals are driven by the following 4 main factors:
1. Lifestyle. Is the person sedentary with hobbies such as reading, playing bridge, or watching TV? Is the person active with hobbies such as golf, tennis, boating, or gardening?
2. Location. Where does the person live, and what are the obstacles they encounter in their home or community? For instance, my balance therapy practice is located in Sarasota, Florida. In order for my patients to function safely in the community, they need to be able to walk on uneven parking lots or sidewalks, and walk up and down the periodic ramp or curb. Most of the homes in Sarasota are condos or single story homes with only one step to enter the building. The only reason a person might walk on the grass would be if they are a golfer, enjoy gardening, or enjoy walking on uneven surfaces at the beach or local parks. However, if they are a snowbird and only come to Florida in the winter, when they return to their home up north they may live in a 2-story home with 5 steps to enter. The bedroom and bathroom may be upstairs, and the washing machine down in the basement, and they may have a cobblestone driveway. I think you get the idea…
3. Personal choice. What does the person want to achieve or be able to do that they cannot currently do because of poor balance? This is different for every person. Some people just want to be able to walk around their home without falling, and to go to the grocery story or doctor’s office on their own. Some people want to improve their balance so that they do not need to use a cane or walker. Some people have given up a sport they used to love because of their poor balance, and their goal is to return to playing golf or tennis again with their friends.
4. Health Status. A person’s underlying health status plays a factor in setting reasonable goals. For instance, if the person has terrible arthritis in their knees, a reasonable goal is probably not that they would be able to run a marathon or climb Kilimanjaro. However, it may be reasonable that they should be able to climb a flight of stairs safely, or be able to walk their dog each morning with good balance.
I want to encourage you to think about your personal goals and discuss these things with your balance therapist. Having good goals with motivate you to do your home exercise program, and allow you to chart your progress.
Included image: Balance, a painting by Norval Morrisseau
One really cannot understand how much we use our vision to help us balance until it is taken away. That is why a standardized test for balance is to stand with feet together and eyes closed. The test is called the Romberg test, and the goal for most adults regardless of their age is to stand for at least 30 seconds with good balance.
Last week, my patients with balance problems were tested in a more functional way. Equinox Physical Therapy is located in Sarasota, Florida and what became Hurricane Hermine was approaching our shores. It was around 1 pm when the brunt of the storm rolled into Sarasota. The sky became pitch black. Looking outside my office window, one would think it was midnight! The patients who were coming in for afternoon appointments were used to coming in the daylight, not in conditions where the sky was dark as night. This made negotiating the parking lot much more challenging. Then the electric when out, and the hallway was almost completely dark. Everyone could clearly see how much we rely on our vision to help us balance and walk, and we were all grateful when the electric was restored. In the dark, some patients did better than others. The ones that did the best were the patients whose brains had learned how to use inner ear balance information and somatosensory information (the information from our joints and muscles that that tells the brain what position our body is in). The patients with damaged inner ear systems, or the patients that were not good at using their inner ear information, had the greatest trouble in the dark.
Understanding this problem, and why it happens, allows us as physical therapists to create exercises that will force the brain to practice using inner ear information. One such exercise is based on the Romberg test that I described at the beginning of this article. The patient stands in a corner with a chair in front for safety. If they are very unsteady, a family member stands by, ready to assist them if need be. They stand with their feet shoulder width apart, hands at their sides, and they close their eyes and try not to sway. They will stand for 2 minutes, unless they are too dizzy or become tired. As the exercise gets easier over the next few days, they gradually move their feet closer together to make it more challenging. Over time, they become less dependent on their vision, and better able to use their inner ear balance information and somatosensory information to balance. In real life, this helps in conditions where they must walk in a darkened setting or in the case of Hurricane Hermine when the lights went out…
Included image: In The Light Of The Setting Sun, painting by Victor Borisov-Musatov 1904
This week is Balance Awareness Week, Sept 12-18th, 2016. Please join me and others in our fight to stop dizziness in its tracks. If you would like to learn more about your specific type of inner ear balance problem, the Vestibular Disorders Association website has very good patient information. Let’s continue working together to defeat dizziness!!!
VOR stands for the Vestibular Ocular Reflex. This is basically the coordination that one has between head and eye movements. The way it works is this: when a person is moving their head, the ears send information to the brain to tell the brain how the head is moving. The brain then uses this information to coordinate the eye movements so that the person can stabilize their gaze on an object even though their head is in motion. We do this all the time! For instance, if I am talking to someone, and nodding my head yes or no, then I am using my VOR.
When a person has a weakness in one ear following an inner ear infection, for example, the brain that was used to getting the same amount of information from each ear, realizes that the information from the two ears is no longer balanced. The affected side is not sending the same amount of information as the healthy ear anymore. Initially, this can cause dizziness, nausea, and imbalance. To avoid these symptoms, patients will often avoid head motions. While this may seem logical at first, to continue avoiding head motions only makes the problem worse. You see, the brain needs to learn the difference that now exists between the two ears, and the only way the brain can do this is by experiencing the movement! The brain won’t learn how to recalibrate itself if the person continues to avoid moving their head. By doing the VOR exercise, we force the brain to pay attention to the inner ear information when the head is moving, because the brain must in order to coordinate the eye motions and allow the person to keep their eyes fixed on the target without the target looking blurry, double, or as if it is jumping around…
Initially, this exercise may cause dizziness, or increase the person’s baseline dizziness. The patient should first do this exercise at a slow speed, and for a short duration (30 seconds). That way if the exercise causes dizziness, the dizziness should dissipate in a few minutes after stopping the exercise. With practice, the exercise will no longer cause dizziness or nausea. Once this happens, then we work on increasing the duration of the exercise little by little until eventually they can do it for 2 minutes and feel fine afterwards. At that point, we work on increasing the speed of the head motion, so that the brain learns how to process faster and faster head motions, and not feel dizzy. After that, we move on to other variations. You see, there is a progression to the exercise, and a vestibular specialist will be able to teach you how to do the exercise correctly, and guide you in your journey toward recovery.
Man with His Head Full of Clouds- Painting by Salvador Dali, 1936
Levanna Doing Exercise, painting by Maria Primachenko
The Vestibular Ocular Reflex (VOR) is the mechanism that allows a person to keep their eyes on a fixed target while their head is moving, for instance when you are looking at your friend and nodding your head “yes” or “no”. The reason we are able to do this is because our inner ear system acts like little gyroscopes that tells our brain when our head is in motion. Your brain then takes that information, and tells the eye muscles what to do to keep your eyes on the target.
The VOR exercise is especially important when a person has had damage to their inner ear system. The brain, which was used to getting normal inner ear information previously, will have to relearn how to use the information that has lessened due to illness or injury.
I’ll give you a common example. Let’s say that a person has an inner ear infection that affects their Left inner ear system, and decreases responsiveness of the Left vestibular system (the balance part of the ear) to send information during head motions. When the person now moves their head, the left ear is sending less information than the healthy right ear. This difference in input to the brain being sent from the two ears can result in symptoms of dizziness, nausea, or unsteadiness. Ironically, some patients will avoid moving their head so that they don’t get dizzy, but movement is the only way for the brain to learn how to use the inner ear information again!
Vestibular Ocular Reflex exercises help the brain through this retraining process, because the exercise forces the brain to receive inner ear information and practice using it to keep the eyes on a fixed target. Patients start with slow head turns, keeping the eyes on a fixed target placed on the wall at eye level 4 feet away. They start in a seated position and move the head 20 degrees to each side in a back and forth head motion. They also do the exercise in an up and down head motion as if nodding “yes”. As they are able to do the exercise symptom free, we increase the duration of the exercise to 2 minutes.
The next step is to gradually increase the speed of the head motion. If you are doing the exercise correctly, your symptoms will decrease over the next few weeks. If you aren’t doing the exercise correctly, you may think the exercises don’t work! This is why working with a vestibular specialist is so important. If you are not improving, they can figure out what you are doing wrong and help you learn how to perform the exercise correctly, and hence, recover as much inner ear function as your body will allow.
Connoisseurs of Books (Knowledge is Power), by Nikolay Bogdanov-Belsky, 1920
My physical therapy practice in Sarasota, Florida, is devoted to helping people with balance and inner ear problems. So you may be wondering why I am writing about visual problems The reason is: vision is extremely important in maintaining good balance! We use our vision to understand where we are in space, and how to negotiate obstacles in our environment. As adults, we have an idea of what good vision is, and we are likely to notice if our vision changes. But what if the person we are talking about is a small child, maybe even an infant who may not be able to communicate or recognize that he/she is having a visual problem? This child, in addition to a visual problem, could also be experiencing a balance problem, because we know that good vision and good balance are closely connected.
I was lucky to be talking about this problem with my friend and associate Dr. Mohamad S. Jaafar. Dr. Jaafar is Professor of Ophthalmology and Pediatrics at the George Washington University, and Chief of the Division of Ophthalmology at the Children’s National Health System, Washington, DC. He is passionate about training young doctors to be experts in his field and is the Past-Director of Washington’s Pediatric Ophthalmology Fellowship Program, which is the oldest, largest, and most renowned such program in the world.
Dr. Jaafar and I want to help parents recognize visual problems in their children, so that they know when to seek help. Bear in mind that there is an association of eye diseases in some children who have hearing loss (such as retinal dystrophy, cataract and misalignment of the eyes). Dr. Jaafar was kind enough to provide this top 5 list, so that parents know what to look for if they suspect their child may have a visual problem.
TOP 5 Signs of Visual Problems in Children
1. Bumping into things or acting clumsy.
2. Always sitting close to the TV or holding books and I-pads too close to their face.
3. Crossed or wandering eyes.
4. Tilting or turning the head, or assuming a chin-up or chin-down posture (ocular torticollis).
5. Disliking having one eye covered but not the other (may indicate a “lazy eye” – amblyopia).
If your child is showing these signs, was born prematurely, has multiple health problems or a family history of eye diseases in childhood, it is a good idea to consult an eye doctor who is experienced in treating infants/children. Please remember, a TOP 5 list is not all inclusive. If you have questions about your child’s vision, go and see a specialist or ask your Pediatrician. Dr. Jaafar suggests that you could find a qualified doctor in your area by going to the following website: https://aaosso.aapos.org/ebusaapos/FindanEyeMD
Strangled by Growth, by Emily Carr 1931
Acoustic Neuromas are nerve sheath tumors surrounding the vestibular or cochlear nerves. The vestibular nerve is the balance nerve that goes from the inner ear to the brain. The cochlear nerve is the hearing nerve that goes from the cochlea to the brain. When the tumor grows, it can press on the nerves as they travel through a boney canal to reach the brain. This is how the tumor can damage a person’s balance and hearing. Also in this boney canal is the facial nerve. Damage to the facial nerve can result in facial paralysis.
At Equinox Physical Therapy, we specialize in treating people who have balance problems or facial paralysis as a result of acoustic neuromas. The majority of these patients come to see me following surgery, or radiation to the tumor. A few months ago, I had the pleasure of speaking to the members of the Acoustic Neuroma Association in Sarasota, Florida. They had the idea to videotape the talk for the members who were unable to attend the meeting. They were so pleased with the video, that they asked me if they could post it on their national website. The title of the talk was “The Vestibular System and How it is Affected by Acoustic Neuroma”. If you would like to learn more about this topic, you too can watch the video below.
The New Labyrinth with Black Holes by George Saru, 1996.
Last year I wrote an article for my blog about anxiety and inner ear problems based on the research by Dr. P. Ashley Wackym. It turns out that it has been one of my most frequently visited blog posts! Last October 2015, I saw Dr. Wackym again when we were both attending the 7th International Symposium on Meniere’s Disease and Inner Ear Problems in Rome, Italy. During our discussions, I learned of a recent research article of his that was published in the ENT Journal (Ear, Nose and Throat) that studied people with a type of inner ear problem called Superior Semi Circular Canal Dehiscence (SSCD). This is a condition where the bone between the inner ear system and the brain erodes causing symptoms of imbalance, headache, dizziness, tinnitus, cognitive dysfunction, nausea, subjective hearing loss, visual disturbance, aural fullness, objective hearing loss, hyperacusis, and vomiting.
Although I don’t usually post scientific articles on my blog because I want the information to be easy for the average lay person to understand, for those of you with SSCD, you may find the information interesting… If so, feel free to read Dr. Wackym’s research paper!
Do you like to learn by listening and watching? If so, you may enjoy coming to a free lecture that I am giving next week. The title of the talk is “Understanding and Treating Dizziness and Balance Disorders with Vestibular Rehabilitation”. I will be co lecturing with Dr. Jack Wazen, MD. Spaces are limited, so if you would like to attend, please register online here, or call 941-556-4219.
Hope to see you there!
It’s that time a year for the annual trip to the Christmas tree lot. When a person has Benign Paroxysmal Positional Vertigo (BPPV), bending the head down, or tipping the head back, can trigger a vertigo spell. It goes without saying, that if you are standing on a ladder and reaching overhead to hang something on a tree, you definitely don’t want the world to spin!
So this is a tip for those with holiday cheer and vertigo, let someone else do the ladders, and the reaching overhead and bending over! If you have positional vertigo, aim for the ornaments in the middle of the tree where you can keep your head level. This way you won’t have to worry about triggering the vertigo, and potentially falling and getting hurt during the holiday session. Or, if you live alone, you could get a smaller tree this year that is 3 feet tall, and place it on a small table so that you can decorate it without having to tip you head back or bend over too much…
For those of you with balance problems or BPPV, give yourself the present you deserve, and go and see a trained vestibular specialist and get treated for your problem. That would be the best present of all!
Happy Holidays! - Dr. Laura Wazen, Equinox Physical Therapy 941-404-4567
LOCAL SUPPORT GROUP MEETING INVITATION
Please plan to join us at the next meeting of your local Acoustic Neuroma Support Group. We welcome you to learn about the latest treatment options,
network with other acoustic neuroma patients and find encouragement and support.
Saturday, November 7, 2015
1:00 – 3:30 p.m.
Fruitville Public Library - Meeting Room
100 Coburn Road
Sarasota, FL 34240
The Vestibular System and How it is Affected by Acoustic Neuroma
Presented by Dr. Laura J. Wazen, DPT
Equinox Physical Therapy
"Woman Tying Her Shoe", Painting by Pierre-August Renoir, 1918
Do the shoes you are wearing matter when you have a balance problem or a history of falling? The answer to this question is ABSOLUTELY!
I still remember the lady who came to see me for balance therapy in Sarasota, Florida with complaints of falling. She was wearing 5-inch stilettos that didn’t even have an ankle strap! Now I ask you, do you have to be a balance specialist to know that maybe this is not such a good idea?
So what is a good idea?
1. A FLAT shoe is the best, avoid shoes with a high heel if you can tolerate a flatter shoe.
2. A shoe with a flat WIDE HEEL is better than a small pointy heel. The wide heel provides a more stable foundation when shifting your weight.
3. NO FLIP FLOPS or SLIDE style shoes. These loose shoes can cause a trip and fall.
4. A shoe with a SNUG FIT around the HEEL is important.
5. STRAPS or LACES that tighten- Don’t just slide your feet in and out of your shoes. If they have Velcro straps or laces, use them to make your shoe secure. Ankle straps should fit snuggly.
6. For people with peripheral neuropathy, avoid shoes that are too cushioning as they decrease your already limited ability to feel the ground.
7. Make sure that your toes are comfortable in the shoe, as you use your toes to stabilize your balance.