Levanna Doing ExerciseLevanna 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.  

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Vestibular RehabilitationDo 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!

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VertigoProspective 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.

 

 

 

Published in Blog
Monday, 13 July 2015 19:02

Vertigo- What’s it like?

Flying PeopleFlying 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.

Published in Blog
Wednesday, 03 June 2015 14:41

How to Fix Vertigo at Home

Carpenter Oil PaintingCarpenter, Oil Painting by Kazimir Malevich, 1927 
 
If you search the Internet, you will see many articles and videos about how to treat yourself at home. Some are good, some aren’t. There is really only one type of vertigo that you can fix at home, and it is called BPPV (Benign Paroxysmal Positional Vertigo).  With this type of vertigo, the spinning sensation lasts for only seconds, and is caused by changes in position such as bending over, getting in or out of bed, or tipping one’s head back.  If a person is experiencing vertigo lasting for minutes to hours, then it is not BPPV but another type of vertigo.  If that’s the case, the person needs to go and see their doctor because doing the maneuvers will not help a bit. 
 
When it comes to the repositioning maneuvers, there are a few.  The most commonly used is the Epley Maneuver, because this treats the posterior canal, which is where the crystals are usually dislodged to in about 75-80% of cases. There is also the anterior canal or the horizontal canal, where BPPV occurs about 10-15% of the time.  Each canal has a different treatment.  For a person looking on the Internet to treat this problem, it is a bit of a crapshoot because first they have to first figure out which ear has the problem, and then which canal has the problem.  
 
Sometimes people have a sense of which ear is affected. If a person gets 
dizzy when tipping their head back and to the side, sometimes they can figure out which ear it is.  For instance, if my dizziness only happens when I look up and to the right, then it is probably the right ear. It is also possible, but less common, to have BPPV in both ears.
 
This week I had a patient who had BPPV over the holiday weekend. She didn’t want to go to the ER, and she didn’t know what to do. She started surfing the Internet, saw some maneuvers on the Internet, and decided that she could do it with the help of her husband. She did not improve, and came to me.  After examining her, I could see that she was doing the wrong maneuver. She had BPPV in the posterior canal, and she was doing treatments for the anterior canal. Needless to say, it didn’t work. Here are some questions my dizzy patients in Sarasota, Florida ask me about doing vertigo treatments at home. I hope the questions help you decide if trying to fix your vertigo at home is right for you.
 
1. Should I try to fix my vertigo at home?  
It’s up to you. Perhaps you will get lucky, and figure out which ear it is and which canal it is. 
 
2.  Can it make it worse?
Yes, there is the chance that what you are doing at home may make it worse.  For instance, if the crystals then move into more than one canal instead of going back where they belong, the person may be even more sensitive to movement than before.    
 
3. Will it hurt me to try the maneuvers on my own at home?  
Doing the maneuvers incorrectly will not cure your problem, but it is not dangerous per se.  BPPV is not the kind of health problem that will kill you, that’s why it is called “Benign”.  If you have a neck problem, you may want to have a professional do the treatment so that you don’t injure you neck accidently.
 
Published in Blog
Wednesday, 22 April 2015 13:45

Fall Alert Buttons

IcarusWho 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.

 

Published in Blog
Thursday, 05 March 2015 15:25

What is Orthostatic Hypotension?

orthostatic hypotensionThis 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?
Dehydration
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

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Man with His Head Full of Clouds by Salvador DaliVOR 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

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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.

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Cliff near Dieppe 1985 Paul Gauguin

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!

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Dr. Laura Wazen

DSC 1920

Listen. Listening is the most important step in understanding a patient’s concern. It is the most basic beginning, and in health care today, so often undervalued. It directs understanding, direction of testing, and formulation of a plan. It is the most important step in paving the road to treatment and recovery.

Learn. My role is not only to learn from my patients, but to guide them in how to learn from me, what they should do to take back their lives and create positive change.

Live. Life is a gift. The purpose of all treatment at Equinox Physical Therapy is to restore function, independence, and freedom to clients recovering from or living with an illness.

Vertigo

Dizziness

BPPV

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