BPPV (Benign Paroxysmal Positional Vertigo) is the most common type of inner ear problem, comprising approximately 25% of all inner ear problems. It is caused when crystals in the ear that are supposed to sit on top of the nerve fibers in a jelly like matrix, become loose and start floating in the semi-circular canals of the ear. When this happens, the person can experience a spinning sensation (vertigo) that lasts for seconds and is triggered by changes in head or body position. For instance, it happens when getting in/out of bed, bending over, or tipping your head back.
In answer to the question, “Can people have BPPV in both ears?” the answer is YES. About 40% of people can have it in both ears at the same time. The good news is that if the condition does not go away on its own, it can be treated with maneuvers to guide the crystals back into the part of the ear where they belong.
If you think you have BPPV, I encourage you to find a qualified doctor or physical therapist, who can test to see if BPPV is your problem, and if it is in one ear or both ears. The proper testing leads to the proper treatment, and to the proper cure…
Painting entitled, A Serious Question, by Sergey Solomko
Money Matters (Selected Part of Letters from Aunt Evelyn), conceptual art by Barton Lidice Benes, 1982.
This is an article that I thought I would never write. When I first started working as a physical therapist, I worked for a big hospital in Manhattan. I never had to think about insurance, because basically the hospital accepted every type of insurance there was! In fact, these were the days when there was no such thing as a co-payment. When co-pays did come along, for many years the hospital never attempted to collect the 5 to 10 dollars per visit. But that was 17 years ago, and a lot has changed now.
Things really started to change after Obama care. I not saying that I am either for or against Obama care, I am just saying that things are very different now. For example, in order to have insurance, many families are choosing insurance where the deductible is 5 to 6 thousand dollars per year! This means that the patient has to pay the first 5 or 6 thousand dollars in medical services, thus meeting their deductible, before their physical therapy services are covered. In addition, the person usually has a co-pay required at each physical therapy session, which can be as high as 50 to 75 dollars per visit with some plans. Take the time to consider these factors when choosing your insurance needs.
At Equinox Physical Therapy, we check a patient’s insurance benefits before they even arrive for their first visit. I am a standard Medicare Part B provider for out-patient physical therapy services. That means that I accept standard Medicare Part B because I am committed to treating people over 65 years of age who have balance problems, dizziness, vertigo, falls, inner ear problems, concussion, or facial paralysis. I don’t want my Medicare patients to fall and break a hip, when I know that I can help them to enjoy their retirement in sunny Sarasota, Florida, and live a long and healthy life! Medicare pays 80% for out patient physical therapy services, and most people have a secondary insurance that covers all or part of the remaining 20% of the bill.
As far as other types of insurance, I see patients who do not have Medicare, but some other type of insurance, and in these cases I am classified as an “out-of-network” physical therapy provider. Because I am not a major hospital, I cannot accept every insurance under the sun, because it would be too much for my small practice to manage.
Why would someone come to me, an out-of-network provider, when they could see someone in-network instead? That should be your next question. The reasons are probably many. When I see a private insurance patient, they pay me, and then I give them the papers they need to submit their physical therapy bills to their insurance company. Then, their insurance company will reimburse the patient directly for whatever their out-of-network physical therapy benefits are. The patient calls their insurance company to verify their benefits before they even step inside my door. They know exactly the percentage that their insurance company will reimburse them, and the percentage that they will have to pay of the remaining bill.
Again, why would someone come to me instead of going to his or her “in-network” provider? For one thing, many of these patients have BPPV, a condition that causes vertigo and seriously interferes with their ability to work, or function properly. With this condition, it usually goes away if treated properly in 2-6 sessions. So, it is not such a big expense to come see me. If they have a big deductible, they will have to pay either way. At least if they come to see me, they know they are being seen by someone who treats this problem 3-4 times a day, as opposed to someone who has little experience, or only treats this problem occasionally. For patients with conditions that take longer to treat, they come to me because they know that their chances of having a good outcome are enhanced if they have the best possible therapist that their money can buy, because again, they still have to pay the large deductible either way. Other patients come to me because I am a specialist in treating inner ear disorders, concussion, falls, dizziness, and facial paralysis, and their “in-network” therapists are not.
Another point to consider is the co-payment. Because I am out of network, I do not collect a co-payment. For those patients whose co-payments are 50 to 75 dollars per visit, the difference between their co-payment and what they have to pay me may be the same, or not much more.
If you are considering going out of network for your out-patient physical therapy services, here are a list a questions that you should ask your insurance company to help you decide if going out of network is right for you or your loved one. One thing to remember is that you, the patient, have the right to receive services from any physical therapist you choose.
TOP 4 QUESTIONS REGARDING OUT-OF-NETWORK PHYSICAL THERAPY BENEFITS
1. Do I have out-of-network physical therapy benefits? If not, what does that mean?
2. Am I eligible to receive direct reimbursement from the insurance company for my physical therapy visits?
3. What percentage of the money I paid at my physical therapy visit will you, the insurance company, reimburse?
4. Do I have an out-of-network deductible to meet first?
Artwork: Here is a Sign by Forrest Best, 1970
How do you know if you or someone you love, such as an elderly parent, may need balance therapy? Below are 5 signs that balance therapy could be right for you. If it is, contact a physical therapist that specializes in balance therapy so that you can improve your health and decrease your risk of falling.
The bottom line is we want you around for a long time! A fall could cause an injury that would jeopardize your livelihood, and your functional independence. For those older folks, it could mean the difference between living independently on your own, or having to go to a nursing home- so take it seriously!
5 signs that a Person needs Balance Therapy:
1. Any fall that created a serious injury in the last 12 months.
2. Two or more falls without injury in the last 12 months.
3. Needing more that 1 attempt to rise from a chair.
4. Walking touching the walls & furniture for support.
5. Having a fear of falling is a significant risk factor for falls.
If you answered “yes” to any of these 5 signs, don’t wait to do something about it. Find a qualified vestibular specialist who can help you improve your balance. You can use these web sites to look for vestibular specialists in your area.
1. The Vestibular Disorders Association website
2. The American Physical Therapy Association Neurology section has a Vestibular Rehabilitation Section where you can search for vestibular specialists state by state.
Be empowered. Balance therapy CAN change your life!
Prospective Chromatique, Abstract art by Martha Boto 1972
Several years ago I was working at a hospital in Manhattan, and I was trying to get a patient out of bed. They didn’t want to get up, or do their exercises, even though that was what they needed to do to get better. I remember the patient, because I was working on the open heart surgery floor at the time. The patient got really mad, and demanded to know how I could I possibly help them, because I had not had open heart surgery and therefore didn’t know what they were going through.
Thank goodness for all the physical therapists, doctors, and nurses in this world that we do not need to have every disorder there is under the sun before we can help patients! Yet, I understand how the patient feels at the same time. Sometimes it is comforting to know that you are not the only one who knows what it feels like to have a condition. My vertigo patients sometimes ask if I have had vertigo. Luckily, I have not, but I work with people who have vertigo every day. One of my patients offered to tell her story of how vertigo and BPPV was affecting her life. I hope her story helps those of you out there who do not know someone with vertigo, and that it gives you comfort that you are not alone, and that there is hope that things can get better.
Flying People by Karel Appel, 1971
From a medical terminology stand point, vertigo is the sensation that the world is spinning around you, or that the world is still and you are spinning. But what’s it really like?
From a personal standpoint, everyone experiences vertigo differently. I have had many patients who seem to have a mild case, and find it to be mainly an annoyance. In the case of BPPV (Benign Paroxysmal Positional Vertigo), there are some patients who only experience the spinning when getting in and out of bed, and since the spinning only lasts less than a minute, the person finds it to be more of a nuisance than anything else.
I have also had patients who complain of dizziness and imbalance only (not a spinning sensation), and then when I test them for BPPV it turns out they have BPPV after all. There have even been times when the nystagmus (spinning of the eyes) is extremely strong, and the patient denies feeling dizziness or spinning at all!
On the other hand, I have some BPPV patients who have an incredibly strong case of BPPV, and the vertigo sensation feels incredibly violent and awful. Sometimes it causes nausea, and can be very frightening. One of my new BPPV patients last week had such a strong sensation of spinning that she said she would rather get her other hip replaced than have to have vertigo again. She felt like she could control her pain with a hip replacement, but she couldn’t control her vertigo.
I have also had BPPV patients who are so afraid of their vertigo, that they don’t want to do the repositioning maneuver because they might feel the spinning again. Of course, this is not a logical or viable option, because if they don’t get treated they are very likely to have continued vertigo, but if they do get treated they are very likely to make the vertigo stop. What would you choose? So far, no one has refused treatment once they really understand that this is their best alternative.
Luckily for those with BPPV, the vertigo only lasts for seconds. And again, luckily for BPPV, most people respond to the repositioning maneuvers, and we are able to stop their vertigo.
Painting: Le golf by Emilio Grau Sala, 1961
BPPV hit the international stage this last week at the 2015 US Open Golf Tournament in Chambers Bay when Australian golfer Jason Day suffered an attack of vertigo and fell to the ground. It’s not every day that people all over the world are talking about and witnessing the debilitating effects of a vertigo attack...
I have been surfing the net, looking at the video footage, and listening to and reading the various commentaries that people are posting. The bottom line is that BPPV is a real drag, and it is horrible in general, but especially difficult if you are trying to play golf. Why do I say that? It is because we know that head or body motions trigger BPPV. The crystals in the inner ear become out of place, and when we bend over, tip our head down or back, or turn quickly, it can trigger the vertigo. Needless to say, it is pretty difficult to play golf without bending over or turning your head quickly, not to mention playing championship level golf and competing with people who are not having this problem.
The good news is that BPPV can be treated! Living in South Florida, I treat a lot of golfers who have this condition. All they want is for the vertigo to go away so that they can get back on the golf course. My BPPV patients in Sarasota, Florida couldn’t stop talking about Jason Day, because they knew how he felt, and hoped that this international exposure of the condition might help others understand what they are going through.
The most common treatment for BPPV is a repositioning maneuver where the head is moved in a certain way in order to put the crystals back in the part of the ear where they belong so that the person no longer has vertigo. There are several treatments that will do this, including the Epley Maneuver, Semont Maneuver, or the Foster Maneuver. These 3 treatments are for the Posterior canal. (The inner ear has 3 canals and each canal requires a different treatment). If maneuvers do not work, there is a surgery to occlude the canal where the crystals are floating, but this surgery is only done in the worst of cases and for very few people since most people respond to the repositioning maneuvers. Also, sometimes BPPV goes away on it’s own.
If you are having vertigo, you need the proper diagnosis in order to get the proper cure. Some of the people who were commenting on the Internet were talking about other causes of vertigo, such as Meniere’s Disease, and offering advice on what they do to control their vertigo. The treatments for BPPV and Meniere’s Disease are completely different, and what works to help Meniere’s Disease does not work to treat BPPV (and vice versa). I would recommend that if you are having vertigo, do not take antidotal advise from a layman with no medical training. Go and see an Otologist (an ENT physician who specializes in treating inner ear problems), or a vestibular therapist (a physical therapist who specializes in treating inner ear problems) who can test you for this problem and get down to business in helping you find the correct answer to your problem.
A former patient recently came back to see me due to an article he received from the Harvard Health Letter. I thought it was a good article, and wanted to share it with you. Maybe you, or your parent, or loved one, need to think about how using a rolling walker could improve safety and independence. An evaluation by a physical therapist would help in determining if you could benefit from balance therapy, and if using a rolling walker is a good idea. In the case of my patient, he was so happy with the walker because now he is able to walk without assistance of another person, and he can walk for much longer distances than he ever could with his cane alone.
Click here to read the article.
Painting by Edvard Munch, 1943: Self-portrait. Between the Clock and the Bed.
When you live in one part of the country, and your elderly parents live in another, it can cause a lot of concern and worry -especially if your parent starts to have issues with falling. In the last blog, I wrote about fall alert buttons. This is a good idea, but it only helps after the fact, that is, after the person has fallen. This week, I would like to write about 6 simple things that you can change in the home that would lessen the chances of a fall happening in the first place.
1. Remove all throw rugs, these are just things to trip on.
2. Install good lighting in darkened entrances, hallways, and staircases.
3. Install sturdy grab bars in the shower and bath areas.
4. Use night-lights, especially from the bed to the bathroom.
5. Install a banister or railing anywhere there are stairs or steps.
6. Have a phone on the bedside table, so no one needs to run to answer the
phone when half awake.
Hopefully, these simple fall prevention ideas will help your loved one to be safe at home. An ounce of prevention is worth a pound of cure! If your parent needs more help, or is falling despite already having a safe home environment, then they need to go and see a physical therapist who specializes in balance training and fall prevention in the elderly. The therapist will evaluate your parent, and then design an individualized treatment plan to address their specific balance needs.
Who can forget the commercial when fall alert buttons first came out,where the individual is lying on the floor and yells out “HELP! HELP! I’ve fallen and I can’t get up!” I do not want to make light of the situation, because being in such a vulnerable situation is awful. I know, because I once dislocated my kneecap when playing with my dog in the front yard. I didn’t have my cell phone, and I was on the only one home at the time, and I had to lie there for a half hour before some stranger walked by who could get me the help I needed.
Many times when an older person lives alone and has started to have some falls, the kids who lives out of state starts trying to get their mom or dad to get a fall alert button. It is hopefully a back up plan that they will never need to use.
When the emergency call buttons first came out, they worked through your phone. Back in the day, this was what we now call your “land line”. It meant that you had to be within 200-300 feet of the phone in order for it to work. You can still get this kind today, but I don’t recommend them. When one patient of mine from Sarasota, Florida, fell in her yard when gardening, she was too far away from the phone for it to work.
These days, there are fall alert devices that work via GPS. That means you could be anywhere, push the button, and they would find you! One of my “snow bird” patients who went back up to Maine for the summer pushed the button just to see if they would answer, and they did!
Another one of my patients fell when stepping off the curb on the way home from the theatre one night. He is a huge 6-foot tall 250 lb man, with an itsy, bitsy wife, and she was not able to help him up. All she had to do was push the button, and the paramedics knew where to find him. She didn’t have to figure out what address she was at, fiddle in her purse to find her cell phone, or risk hurting herself trying to help him up. She just had to push the button that was hanging around his neck.
So the gist of the message is that even fall alert devices are using GPS technology, and you might as well take advantage of good technology that could really save your life. The best way to compare the different plans is to do a Google search for “GPS Fall Alert Buttons”, and check out what comes up.
Painting: The Fall of Icarus- Marc Chagall, 1975.
Peripheral neuropathy is a condition of the nervous system that causes numbness, tingling, pins and needles sensation, or complaints of pain in the arms and legs. The pattern of the altered sensation starts in the toes or fingertips. If the condition worsens, this feeling gradually climbs up the foot or hand, as if you are putting on a stocking or a glove. In the legs, the condition can go above the ankle, but for most of the patients I have met, it has been less common for it to travel above the knee. This problem can occur when a person has diabetes, or it can occur without any history of diabetes.
Sometimes people have it off and on. Others say that they only notice it at night when they are lying in bed. Others have these altered sensations constantly. Some people say their symptoms are mild, and they basically ignore it, while others have severe symptoms that can be annoying, painful, or debilitating.
If the peripheral neuropathy is severe, it can affect one’s balance. This seems to be the case if a person has peripheral neuropathy, in addition to other problems such as visual or inner ear disorders. The reason for this is that the sensation that we have in our feet sends messages to the brain that tells our brain how we are shifting our weight. Our brain uses this information, in addition to the information it gets from the inner ear balance system and the visual system, to tell our joints and muscles what to do to maintain our balance. Usually our brains can compensate when one of these systems is sending poor information, but it is very tough to balance when two or more of these systems are not sending good information (for example, a person has peripheral neuropathy in addition to an inner ear problem and/or a visual problem).
Medical treatments to decrease the pain and discomfort of peripheral neuropathy need to be discussed with a physician.
Treatments to decrease the imbalance caused by peripheral neuropathy need to be addressed with a physical therapist that specializes in treating complex balance problems. I would recommend a vestibular specialist.
With many of my physical therapy balance patients in Sarasota, Florida, as we work together to evaluate their peripheral neuropathy further, we come to recognize that even though the sensation in the feet is altered, the brain has the ability to re-learn how to use the information even though it is not how it used to be, or “normal”. When the peripheral neuropathy is so severe that the person cannot feel the ground at all, compensations such as walking with trekking poles or a cane can make a big difference, because then the person can learn how to substitute feeling the ground with the cane for the missing sensation in their feet.
If you are having problems like these, there are things that can be done to help.
Painting: The Black Stocking by Felix Vallotton, 1904
This is a condition that causes dizziness when a person changes position, for example when getting out of bed in the morning, or when standing up from a chair.
I test for this condition with my physical therapy patients in Sarasota, Florida who complain of dizziness when changing positions, because not all dizziness is caused by inner ear problems! The symptoms of orthostatic hypotension are similar in some ways to an inner ear condition called Benign Paroxysmal Positional Vertigo that can also cause dizziness with positional changes, however, the treatments for these two problems are very different.
What happens with orthostatic hypotension?
Orthostatic hypotension is not an inner ear problem. It is caused by dropping blood pressure. When the person sits up, or stands up, the blood drops from their head, and until the body readjusts, the person feels lightheaded and dizzy. If the body doesn’t adjust fast enough, the person could pass out.
What are some factors that could cause orthostatic hypotension?
Low sodium in the body
Poor vascular circulation in the legs
Over medication with cardiac meds meant to control high blood pressure
How is it tested?
The person’s blood pressure is taken first when lying on their back in bed.
Then the blood pressure is taken when they first sit up at the edge of the bed.
Then the blood pressure is taken when they first stand up.
If the blood pressure drops more than 20 mm Hg from one position to the next, then the test is positive.
What can be done to correct orthostatic hypotension?
• A physician should review your medications, especially if you are taking cardiac medications, as they may need to be held or adjusted.
• Sometimes this condition is caused by dehydration, so drinking water is very important!
• Sometimes patients are deficient in sodium, and their body is not retaining the fluids it needs to have good fluid volume.
• Sometimes the vascular vessels in the legs loose their elasticity, and wearing compression stockings can help prevent this shift of blood to the legs when changing positions.
Speak to your physician if you suspect orthostatic hypotension could be causing your dizziness. This is a problem that can usually be corrected.
Painting: Getting Up, by Berthe Morisot 1886
Recently, I wrote an article about Labyrinthitis, and mentioned that with this type of inner ear problem, when it affects only one ear, the expectation is for full functional recovery. I received some feedback from some frustrated readers who had this problem but did not recover. They felt that I made it seem like everyone gets 100% better, and they were living proof that this is not always the case!
My training tells me that when a patient is not making progress as expected, it is time to stop and reassess what is going on, and why?
First off, could something have been missed? If so, this is the time to readjust the treatment plan to address the issue. If nothing was missed, then why is the patient not improving?
Here is a list of potential reasons that I have seen with patients over the years:
1. The patient is doing their exercises, but they are not doing the exercises correctly.
2. The patient is not compliant with their home exercises. They know how to do the exercises, but for whatever reason they are not doing the exercises, or not doing them as frequently as they were prescribed.
3. The patient is avoiding exercises that cause dizziness or nausea, and therefore the brain cannot learn how to adjust and recover.
4. The patient has many other health problems that are compounding their problem, and causing them not to fully recover.
5. The patient has memory and cognition problems, and has no social support network to help bridge the gap and assist them with their home exercise program.
6. The patient’s exercise program does not address all of the patient’s issues.
7. The patient has not been given the right exercises, or the right exercise progression.
If you are not improving with your vestibular therapy, it’s time to talk to your therapist. I can tell you, the therapist wants you to get better! Sometimes a good review will allow the patient to get back on track with their recovery.
If recovery is not occurring as expected based on your diagnosis, then you need to go to another professional for a second opinion.
Artwork: Reflection, a pastel by Odilon Redon
This is the time of year when one can reflect on our lives and the things we want to improve on for the upcoming year. Why not make it your goal to improve your balance? One way to decide if your balance needs improving is by having your balance tested. Balance testing can be high tech, or low tech. The low tech testing is something that you could do at home, without fancy equipment, and it is based on a physical performance test. In other words, we ask a patient to perform a balance skill, and then see if they can do it or not. A person with good balance, and no history of inner ear pathology or neurological problems should be able to do the test.
One such test is called the Rhomberg Test. When I do this test with my balance therapy patients in Sarasota, Florida, I have the patient stand in a corner about 2 inches away from the wall, with a chair in front for safety. Then, I am standing by just in case. If you decide to try this test, have a friend or family member stand by to make sure you do not fall and get hurt.
The test is this- the person must stand with their feet together, with no space in between the feet. (If you are knock-kneed and cannot get your feet together, then put your knees as close together as you can). Next, you stand as still as you can, trying not to sway. The goal is to be able to do this for 30 seconds without falling, needing to open your eyes, take a step, or touch the wall or chair for support.
When standing with the eyes open, the person is using their vision, their inner ear system, and their somatosensory system to help them balance. Somatosensation is the sensation that allows your joints and muscles to send information to the brain to tell you if you are steady, or swaying. If a person cannot perform this test for 30 seconds, then they are at high risk for falling.
The second part of the Rhomberg Test is performed with the eyes closed. Again, the goal is to stand for 30 seconds. When the eyes are closed, the brain must rely on information from the inner ear, and feeling the ground in order to maintain balance. If a person falls in this test, they are reliant on their vision to maintain balance. This means that they would be at increased risk of falling if walking in a darkened setting, or on a complaint surface such as grass in the back yard when the sun is setting, for example.
How did you do with the testing? If the answer is “not so good”, make it your 2015 New Year’s Resolution to do something about it before you fall and get hurt. What should you do? Talk to your doctor about your balance, and find a physical therapist who specializes in treating inner ear balance problems. You could find a balance specialist in your area if you go to the Vestibular Disorders Association website. They allow you to search for a physical therapist in your area by entering your zip code. I believe you can achieve the goal of better balance in 2015! Happy New Year!
Painting: Planting the New Year’s Pine by Keisai Eisen, 1830s.
It’s that time a year for the annual trip to the Christmas tree lot. Last week I went with my family to find the perfect tree. We walked around and around each tree, trying to find the one that looked just right. We were tipping our head back to look at the top of the tree, and then looking down to examine the bottom of the tree, searching for the perfect shape and height… We looked at so many trees! When we got home, we had to tip our heads back when we reached overhead to pull the tree off the roof of the SUV. Then we carried the bulky, heavy, awkward tree into the house. Once the tree was set up, which was tricky on it’s own, we climbed up and down ladders putting the star on top, not to mention the lights and the ornaments! Then I had to get down on my hands and knees and crawl under the tree to pour a pitcher of water in the container for the tree to drink.
I couldn’t help but think of my balance therapy patients in Sarasota, Florida, and of my patients with positional vertigo (BPPV). I was praying that they weren’t doing the same thing I was doing, and that I wouldn’t come in to work on Monday morning to find out that someone had fallen and gotten hurt.
Can you imagine doing all these things if you had vertigo? 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…
And also, for those of you with balance problems and BPPV, give yourself the present you deserve, and go and see a trained vestibular specialist and get treated for your problem, so that you can enjoy all the festivities that this time of year brings, but without the vertigo or imbalance! That would be the best present of all!
BPPV is a condition of the inner ear where the crystals in the ear that are supposed to be sitting on top of the nerve fibers become dislodged and start floating in the semi circular canals. When this happens, it can trigger symptoms of vertigo (a spinning sensation), dizziness, or imbalance. Unlike other inner ear symptoms, vertigo caused by BPPV lasts seconds, not for extended minutes, hours or days.
Top 5 Motions that can trigger BPPV listed in no particular order:
1. Vertigo or dizziness when getting in or out of bed.
2. Vertigo or dizziness when rolling over in bed.
3. Vertigo or dizziness when tipping your head back to look overhead.
4. Vertigo or dizziness when bending over.
5. Vertigo or dizziness when moving your head or body quickly.
Motion, 1962 an Abstract Painting by Ernst Wilhelm Nay
Labyrinthitis is a condition that affects the inner ear hearing and balance system. It is caused by an infection to the inner ear that can result in temporary or permanent damage to the inner ear. Symptoms associated with labyrinthitis include complaints of severe and sudden vertigo, dizziness, nausea, imbalance, veering during ambulation, difficulty walking, and sensitivity to head motions. Patients who have had labyrinthitis may be sent to a physical therapist that specializes in treating inner ear problems. This therapy is sometimes referred to as Vestibular Rehabilitation. The therapist is sometimes referred to as a “vestibular therapist”. This therapy is very specialized. Vestibular therapists must go for specialized continuing education after completing their degree and obtaining their license, in order to become competent. My physical therapy practice in Sarasota, Florida specializes in treating people with vestibular inner ear problems.
When it comes to labyrinthitis, the good news is that it is not very common for a labyrinthitis to affect both ears. What does this mean for the brain? It means that the good ear is sending the full amount of information that it always did, but the bad ear is not. Testing by an audiologist can confirm how much information each ear is sending. Patients with labyrinthitis can lose up to 100% of their inner ear balance function, or just a portion. Testing for this is done with video nystagmography (VNG). For there to be considered a clinically significant difference in the two ears, one ear must show a reduced responsiveness to testing of at least 21% to 100%. Even if the bad ear is 100% damaged, with therapy the brain will adjust and learn to depend on the good ear, and whatever amount of information the affected ear is capable of sending. Once the brain recalibrates itself to this difference in information that it is receiving from each ear, the symptoms will stop. The patient will regain their balance, and no longer be dizzy, nauseated, or sensitive to movement. They will be able to turn their head quickly, turn quickly, bend over, walk and look to the side, and basically return to life as normal. For many people, this recovery happens on its own. As the person gets back to life as normal and resumes their normal activities, the brain gradually adjusts. That is why it is really important once you are over the worst of things that you start moving your head again, and become active! The patients that come to see me for physical therapy in Sarasota somehow were unable to make this transition on their own, and need a therapist to guide them in exercises and activities to help them recalibrate their balance system and get back to life as normal. In general, a person suffering from labyrinthitis should get completely better within 8-12 weeks of the proper therapy. If you are having these types of problems, please know that there are treatments that can help!
Clissa Turned Left with her Hand to her Ear, pastel portrait by Mary Cassatt, 1895.
Basically, our brain relies on sensory input that tells it where our body is in space. Then the brain deciphers this information, and tells the joints and muscles what to do to maintain balance.
Where does the brain get its sensory information from? The 3 main sets of information the brain relies on come from our eyes, our ears, and the joints and muscles.
1. The eyes provide visual feedback as to where we are in relationship to our environment. For instance, if I walk outside and have to cross a crooked sidewalk, I see what is coming and subconsciously my brain tells my legs what to do to adjust my steps and maintain my balance.
2. A second set of sensory information comes from the nerve endings in our muscles and joints that tells that brain how we are shifting our weight on our legs, and if we are standing or walking on something firm, or soft, or slanted. We call this proprioception.
3. A third set of information comes from our inner ear system, (we actually have two of these, one in each ear). The ears act like little gyroscopes to tell the brain if we are moving. They tell the brain how far, how fast, and in what plane of motion we are experiencing movement.
The brain takes this sensory information, and then tells the joints and muscles what to do to maintain balance.
If you understand this concept, then watching Nik Wallenda walk a couple weeks ago between the skyscrapers in Chicago, will be even more meaningful to you. As some of you may have figured out, Nik Wallenda and I both live in Sarasota, Florida. A friend said to me, “Hey, Nik Wallenda is practicing for his Chicago walk tonight at 6 pm, do you want to go watch and show our support?”. How could I say no to that?!!! After watching him practice, I knew he could do it, and I was able to watch the Discovery Channel to see his triumph.
Here are some pictures I took of him when he was practicing in Sarasota.
As you can see here, he is walking on the wire up an incline. He is using his vision, his proprioception (feeling the alignment of his body on the wire), and his inner ear system. You could even argue that he is using his hearing too, but that is a topic for another blog. His brain is getting this SENSORY information, and then tells his joints and muscles what to do to maintain balance and walk the wire. At every second, this system is analyzing and reanalyzing, and deciding what to do next. When walking with his eyes open, his vision and inner ear system are sending very reliable information on what is happening, and his proprioceptive system is also sending information, but it is more variable because the wire can move and be unpredictable.
In this picture, Nik is walking blindfolded. WHATTTT!!! He essentially deprived his brain of very reliable information, and now he only has the sensation from a wire that can move, and from his inner ear system. His inner ear system is sending the most reliable information in this condition.
Nik- blindfolded on his way to the tower. Doing what he does, walking the wire blindfolded, with only 2 sets of information for his brain to utilize is astounding. When watching the Discovery program that night, I remember his wife and mother saying that they were most worried about the blindfolded portion. When they said that, I thought to myself, me too!!! Now I hope you can understand from a physiological standpoint why this was so unbelievable. Hopefully one day, Nik will be a guest blogger on my blog, because his mission is to inspire people. I bought one on his signed posters that day to put in my office to help inspire my patients with balance problems. It says at the bottom, NEVER GIVE UP-DARE TO BE GREAT! Thanks, Nik Wallenda for all you give to others.
Time to check my messages…
In this self-portrait of Vincent van Gogh, we can look at it and see that he has his right ear bandaged, and without even knowing him, we can surmise that something is wrong with his ear. He has a bandage on his outer ear, and looking at the painting, one can has some empathy for him. But when a person has an inner ear disorder, there is no bandage one can wear that alerts others that we are having a problem. I think it is fair to say that Inner Ear Disorders are “invisible” to others. What do I mean by that? Well, if you had a broken arm, every one would see the cast on your arm, and they could relate to that. I you had a cold, or the flu, even without a bandage, others can understand that because they know what it feels like themselves to have this type of illness. But with inner ear disorders, for those friends and family members who have never had an inner ear balance problem, it can be hard to understand what if feels like to have vertigo, dizziness, or imbalance. Some patients tell me that they feel as though their family doesn’t understand their problem, because they don’t “look” sick.
For the person with the inner ear problem, this can add to their stress and sometimes cause added depression. Hang in there!!! If it is possible (and you want them to), having a spouse, grown child, or your best friend come with you to your doctor or physical therapy sessions can help that person better understand your condition, and in so doing, be better able to offer you the empathy, support, and understanding you could use. I have also had physical therapy patients in Sarasota, Florida who did not have this support network. They may live alone, or have no children or friends near by. This is not uncommon here, where many people come only for the winter months to escape the cold northern winters. Some of these individuals decided to take the bull by the horns, and go and see a psychologist who helped them learn better coping skills that they could apply on their own. I really admired these patients and their commitment to do whatever it takes to help themselves learn ways to better deal with their “invisible disease”. Whatever the case, don’t be afraid to ask those around you for help. We all need a helping hand at some point in our lives...
Painting by Vincent van Gogh, Self Portrait with Bandaged Ear, 1889
Sculpture by Alice Aycock entitled Hoop-La (2014), Park Avenue Paper Chase, Painted aluminum & steel
You would have to be a person who loves the inner ear, and knows what it looks like anatomically speaking, to see what I see. I was in NYC July 2014 for the Open Forum ENT Meeting. When exiting my hotel to walk to the conference, I had to cross Park Avenue. For those of you familiar with NYC, they usually have sculptures in the median where they feature a new artist every year.
This year, the artist was Alice Aycock. She created a series of huge sculptures made out of metal. This sculpture reminded me of the inner ear with the circular patterns on the bottom right being the cochlea for hearing, and the swirls on the top and left being the vestibular system and its semi-circular canals.
Here is an anatomical drawing of the inner ear system:
This drawing was taken from the NASA website for teachers and educators. Click here to check it out.
I don’t know what Alice Ayock’s inspiration was for this sculpture, but if you ask me, it’s an inner ear...The artist entitled this work Hoop-La, and if you are talking about the inner ear system, I understand what all the Hoop La is about... Do you?