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
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!
If you are reading this blog right now, chances are you are an adult. But adults aren’t the only ones with inner ear balance problems! Children are also affected. For example, dizziness may be a sign of an inner ear problem, and it is estimated that up to 15% of children have dizziness at some point in their childhood. If the child has a hearing loss, that number can be as high as 50%! As adults, it may be hard for us to know if a child is having a balance or dizziness problem, especially if they are young and unable to express their feelings.
Lucky for us, there are doctors like Dr. Sharon L. Cushing from Sick Kids The Hospital for Sick Children in Toronto, Canada, who specializes in treating children with inner ear problems. Dr. Cushing and I recently connected at the American Academy of Otolaryngology Meeting last September 2014 in Orlando, Florida. Together, we decided to create this blog to help parents recognize the top 5 signs that their child may be having an inner ear balance problem. This way, parents are better able to help their children get the help they need...
TOP 5 SIGNS of INNER EAR BALANCE PROBLEMS in CHILDREN
1. Delayed Head Control (these children often get labeled as “Having a head that is too big for their body”) Delayed sitting (>9months) and delayed walking (> 18 months).
2. Unable to stand on one foot (a 2 1⁄2 year old should be able to do for 1 second, a 5 year old for 10 seconds).
3. Unable to ride a bike without training wheels.
4. Brief attacks where children stop what they are doing and cling to a parent or object (they may be experiencing vertigo but may not have the vocabulary to articulate it).
5. Jumpy eye movements – the eyes twitch back and forth (this is an entity called nystagmus).
If these symptoms sound like something your child is experiencing, I encourage you to go see an otologist (an Ear, Nose, and Throat doctor who specializes in the treating the inner ear). If you live in the Toronto area, you’re lucky, because help is just around the corner...
Painting: The Infant (The sick child) by Jean-Francois Millet 1858
This week, we are celebrating Balance Awareness Week at my physical therapy practice in Sarasota, Florida. In honor of this recognition, I am happy to share with you a new infographic from the Vestibular Disorders Association. Infographics are pictures boards that help to communicate a concept or idea. I hope this infographic helps you better understand what causes dizziness, and what to do about it!
This is the title of a radio interview I did on July 1st, 2014 with Heidi Godman on her radio program Health Check on WSRQ Sarasota Talk Radio. She interviewed me, and also my husband Dr. Jack Wazen who is an MD, to discuss answers and treatment advice on balance and dizziness problems. During the podcast, I shared with Heidi how physical therapy can treat these problems, and Dr. Jack Wazen talked about the medical side of diagnosing and treating specific balance or dizziness problems. Conditions we discussed included Meniere’s Disease, BPPV, labyrinthitis, and tumors.
Cilck here to go to the Sarasota Talk Radio WSRQ website, where you can find Heidi Godman’s Health Check program, which was recorded on July 1, 2014. I hope you enjoy listening to the program as much as I enjoyed making it.
Cliff near Dieppe 1985, Paul Gauguin
Vertigo, Dizziness, and Dysequilibrium. These words mean different things to different people. However, if you are using these words in the medical sense of things, understanding the definition will help you communicate more precisely when talking with your doctor or physical therapist.
VERTIGO is a spinning sensation, either that you are still and the world is spinning, or that the world is still but you are spinning. If things aren’t spinning, then saying you have vertigo is not quite right.
DIZZINESS has to do with a funny feeling in the head, but nothing is spinning.
DYSEQUILIBRIUM has nothing to do with dizziness, or vertigo. People with dyequilibrium have no dizziness or vertigo, but they are unsteady walking.
Hopefully these definitions will help you in explaining your symptoms!