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
I am happy to announce the realization of a dream! I have been traveling to the American University of Beirut Medical Center for several years now. My husband was going to give grand rounds in the Ear, Nose, and Throat (ENT) Department at the hospital a few years back, and I said, “Do you think that they would like to hear from a physical therapist about how to work with patients with vestibular disorders?” When he asked the department, they invited me to speak as well! I talked about vestibular rehabilitation, and how doctors, physical therapists, and audiologists can form the most effective and comprehensive team to treat individuals with inner ear balance problems. The talk was wonderfully well received. Before I knew it, their physical therapy director (who also happened to be the President of the Lebanese Physical Therapy Association), Ms. Claude Maroun, and their ENT physicians began imagining how to bring the first center of its kind to the Middle East. They were committed to making this dream come true. Each time I would return to Beirut, I would meet again with the doctors and therapists, at times just brainstorming, or lecturing, or working with their vestibular therapist in training.
Earlier this year, I got an email from Claude Maroun stating that they were sending a therapist to Florida for 3 weeks of training! Wow! This was huge. Youssef Koaik came in March 2013, attended a course for 1 week, and afterwards spent 2 weeks in training with me at Equinox Physical Therapy and with the team at the Silverstein Institute.
Currently, I am in Turkey at the Politzer Society Meeting. To my great joy, the ENTs from Beirut, (now old friends) are in attendance as well! What a happy reunion! When I saw Dr. George Zaytoun, head of ENT, I couldn’t wait for the update on the vestibular program. He was pleased to inform me that his colleague, Dr. Marc Bassim, has been appointed the medical director of the new Balance Center. For those of you unfamiliar with these two gentlemen, let me fill you in. They have done their training in the USA at two of the finest medical institutions for ENT in the world (Dr. Zaytoun at Massachusetts Eye and Ear Infirmary, and Dr. Bassim at the House Clinic). But the biggest news is that the center will be opening in January 2014, and they have spared no expense in providing their patients with the most sophisticated equipment available. For instance, they have a Rotary Chair Test, Posturography Machine, Otometrics Video Head Impulse Test, VNG machine, VEMP machine, and audiogram. All in all, I am estimating a quarter million US Dollars in equipment alone! There are only a few centers worldwide that have this level of sophisticated technology at their fingertips. This, in addition to their highly trained and accomplished MDs, PTs, and audiologists, make them a formidable team in treating disorders of the inner ear.
Can you imagine, that from one talk a few years ago, they have built this center? They are remarkable and inspiring! I know that they will blaze a trail of excellence in the Middle East, and the world at large. I will definitely keep you posted on their developments, as I feel they are the ones to watch! If you live in the Middle East, you now have someplace closer to home to go when you have inner ear vertigo, dizziness, or imbalance problems. Nushkur alla (thank God).
2009 Physical Therapy Department - Beirut. Claude Maroun, Laura Wazen, Youssef Koaik.
So, what should be the first topic for my Blog? That’s easy BPPV! Why BPPV? I am choosing this topic because it is the most common type of inner ear disease. Of all inner ear disease, it takes up about 25% of all inner ear conditions. Also, it is the easiest to treat! BPPV stands for Benign Paroxysmal Positional Vertigo. BENIGN, meaning it is not life threatening and will not kill you. PAROXYSMAL, meaning the symptoms come and go. POSITIONAL, meaning the symptoms are triggered by a change in head or body position. And VERTIGO, meaning the person complains of a spinning sensation.
So many times people come to me and say, “they told me I have something wrong with the “crystals” in my ear”. Yes, that really sounds strange and like voodoo, but it’s not. There are crystals in our ears and they are supposed to be there! They are called “otoconia” and they are made up of calcium carbonate. They have to be seen with and electron microscope, because they are too tiny to see with the naked eye. Some people call them “ear rocks” because of their appearance. These tiny crystals can cause a heap of trouble when they become dislodged and start floating in the parts of the ear where they don’t belong. This will be better understood once you learn a bit about basic ear anatomy.
Art is inspirational, and when I see these rocks, I can’t help myself! They make me think of otoconia!
Understanding the inner ear anatomy and BPPV
Lets start with the outer ear and work our way inward. Sound travels from the outer ear, down the ear canal, to the ear drum. It crosses the eardrum and is conducted by 3 little bones called the malleus, incus, and stapes to the cochlea. The cochlea is in the inner ear and is incased in the temporal bone of your skull. Sound information is processed in the cochlea, and then transmitted by the cochlear nerve to your brain, which then translates the information into what we know as sound. If you really want to be technical about it, we hear with our brains!
The other half of the inner ear is the balance part, and it is called the vestibular system. In the vestibular system, we have 3 canals that are filled with fluid. When we move, the fluid moves, and it stimulates the little nerve fibers, which look like tiny hairs. These 3 canals converge into a central area where there are nerve cells that sense gravitational forces. These structures are called the saccule and utricle. They have a gelatinous matrix on top, which is where the otoconia, (or crystals), are found. The function of these crystals is to help stimulate the nerve when our head changes position. The information then travels down the vestibular nerves to the brain and our brain uses this information to help us balance and coordinate head and eye movements. However, if these crystals break free and start floating in the canals of the ear where they don’t belong, then when a person moves in the plane of that canal, for instance, when bending over or tipping their head back, it causes an abnormal woosh of fluid across the nerve cell and triggers vertigo or a spinning sensation.
With BPPV, the vertigo, or actual spinning sensation last for seconds, usually less than a minute. Once the crystals float to the bottom of the canal, the spinning stops. But if you move your head again, you can get the spinning all over again. Gradually this symptom will fatigue.
So how is BPPV treated?
Well, many times is goes away on its own in a day or two. Other times, it can last for a long time and not go away unless it is treated.
To treat this, it first has to be diagnosed properly. There is a lot of information out there on the internet, and sometimes people try to treat themselves with varying degrees of success or failure. Diagnosing which canal the crystals are floating in takes knowledge and a clear understanding of the condition and it’s various presentations. For instance, a doctor or therapist will test to determine if the crystals are loose in your right ear, your left ear, or both ears. Once that is determined, the next thing to figure out is which of the 3 canals are the crystals loose in? This is very important because the treatment is different for each canal! With both ears combined, there are 6 canals that need checking in order to come up with the correct diagnosis. Therapists or doctors look at the pattern of eye movements that create the sensation of vertigo while in the test positions in order to determine which canal is affected.
Research tells us that the most common canal for BPPV is the posterior canal, which is affected in 80-85% of most cases. But the horizontal canal, or the anterior canal, are also possibilities. The test for BPPV is called the Hallpike Dix test (also called the Dix-Hallpike Test depending on who you ask). It is used to diagnose BPPV if the posterior or anterior canal is the culprit. Testing for the horizontal canal is done by the roll test.
Treatment for the posterior canal is done by the Epley Maneuver. It is a treatment named after a famous ear doctor named Dr. John Epley who was the first to present this treatment for this condition. He is a great guy, and I have met him on several occasions. He is getting older now, and is no longer in practice, but his techniques have helped so many people and have become the standard of care for posterior canal BPPV. There is another technique called the Semont Maneuver. This can be effective, and I will use this when a client is not responding to the Epley Maneuver. Brandt Darroff exercises are also used when the above techniques are not working for a client. The Brandt Darroff exercise is not a corrective treatment like the Epley or Semont. It works on the theory of habituation, which means with repeated exposure to the position that is provoking the vertigo, our brain will learn to become desensitized to the motion, and disregard the stimuli so that one can move in and out of positions that usually trigger vertigo and dizziness.
If you need to find a doctor or therapist near you who is familiar with treating BPPV, I recommend going to the Vestibular Disorders Association website. There, you can enter your area code and find a doctor or therapist in your area.
If you knew me, you would never in a million years think that I would be writing a blog. Up until 6 months ago, I didn’t even have a smart phone. I hadn’t bought a new cell phone in 15 years. So why blog? Good question. I have been fortunate enough to travel the world learning the latest in treatment and innovation for people with vertigo, dizziness, balance problems, falls, hearing problems, concussion, and facial paralysis. I benefit from this knowledge, because I love to learn! My patients also benefit from these travels, because they get the latest treatments for their issues. However, there are so many people out there that have no access to information that could potentially change their lives and give them hope for a cure. Many times the people who see me in my office say, “Why hasn’t anyone else told me that before?”.
By now, you are probably wondering who I am. I am a physical therapist who works with people with vertigo, dizziness, balance problems, falls, inner ear disorders, concussion, facial paralysis, stroke, and Parkinson’s Disease. I have been a therapist since 1998 and have a Doctorate Degree in Physical Therapy. I have worked in acute care hospitals, out patient facilities, and nursing homes. I opened my own practice, Equinox Physical Therapy in 2011, because I wanted to be in charge of how patients are treated from the moment they seek treatment until the time their therapy is completed. But, I don’t want this blog to be about me. I want it to be about you, that is, if you have any of the conditions I mentioned above…
But still you must be wondering, why blog? So what happened? Well, I was on a vacation to South Africa, and I met a fascinating young, talented woman who has started a blog relating to her business, which is about baking, decorating, and do-it-yourself crafts. If you love these things, you should check out her blog: Alanajonesmann.com. Her name is Alana Jones-Mann. She was sharing with me how many people she could reach with her blog ideas, and it clicked! I thought WOW- this is the answer to my question of how to share my unique experiences with the general public. I had considered starting a support group at my office, but this would only help the local people. Whereas a blog could help people all over the world and be free of charge. Also, when you are dizzy, driving could be a problem… But with a blog, the person can connect and learn right from their own living room! What a great idea! I was hooked!
Two Cheetah brothers seen on Safari- South African inspiration at it’s best!
These are my ideas, and I’m sure that the more I do this, the better I will get at it, so be patient with me…
This is my mission statement: To provide information for free on the latest research, technology, treatment, and support for those living with dizziness, vertigo, balance problems, falls, facial paralysis, concussion, and inner ear disorders.
I want to include updates on meetings I attend. You see, the meetings I go to are for physicians, nurses, occupational therapists, speech language pathologists, physical therapists, and audiologists. I see this new blog as a bridge for the average guy or gal, to learn what is new in health care and how can they learn more to better their lives. I will share with you the latest and greatest in regards to treating the above symptoms, and links to the information.
I hope you find this information helpful, and hopeful. It is not meant to substitute for an evaluation by a doctor or physical therapist, so if you are having a problem, go see a reputable health care professional for guidance… Please feel free to give me your input, as this blog means nothing if it reaches no one… Also, let’s keep the message in focus, which is to help…
You can contact me, and I am interested in your comments.