Wednesday, 28 September 2016 15:04

Dizziness and the Visual System

in the light of the setting sun 1904.jpg 19199One 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

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Screen Shot 2014-09-11 at 5.58.19 PMBell Palsy is a condition that causes facial paralysis, and was named after Sir Charles Bell (1774-1842) who described the Facial Nerve and cases of facial paralysis in his writings. 

Who:  20-30 people per 100,000 people develop Bell Palsy per year.  It can occur at any age, but the median age is around 40 years old.

What: by definition, it is defined as idiopathic, acute unilateral peripheral facial palsy.  

Where:  It usually occurs on one side of the face.  Bell Palsy causes weakness or paralysis in all branches of the nerve.  In other words, people show signs of weakness or paralysis in the forehead, midface, and lower face with Bell Palsy.  

When: It comes on suddenly, usually within 48 hours and reaches its peak within a week.   People with Bell Palsy should show some signs of recovery within 6 months of onset.  If a person has complete facial paralysis with no signs of recovery at 6 months, they need further work up, because chances are it is not Bell Palsy, and they may have something serious causing their facial paralysis.  

Why When Bell Palsy was defined, it was defined as idiopathic, meaning “we don’t know what causes it”.  However, new research is pointing to the herpes simplex virus type 1 as a major cause of Bell Palsy.  

What to do:  If you have sudden facial paralysis, you need to find out right away what is causing it so that you get the proper treatment.  A physician needs to examine you and determine if it is Bells Palsy, or something more serious such as a stroke or brain tumor.   

How is it treated:  Initially, patients with Bells Palsy may be prescribed an anti viral medication, and/or a steroid medication to help protect the facial nerve and promote healing.  If the facial weakness does not completely recover on its own, the patient may be sent to a speach, ocupational or physical therapist who specializes in treating facial paralysis to retrain the facial muscles how to work again. 

Reference:  The Facial Nerve by Slattery and Azizzadeh, Chapter 9 on Bells Palsy & Ramsey Hunt Syndrome by Shingo Murakami.



Painting: Green Eye Mask by Amadeo de Souza-Cardoso, 1915

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Friday, 15 August 2014 18:06

Facial Paralysis and Inner Ear Conditions

Facial paralysis occurs when the facial nerve is damaged and unable to send messages to the muscles of the face that create facial expressions. This problem can occur for several different reasons. Some causes include: tumor, trauma, stroke, or genetic disorders.
Facial Paralysis and Inner Ear Conditions
The most common cause of facial paralysis is due to Bell Palsy. While most of the time, Bell Palsy patients recover fully, research tell us that about 20-30% have lasting weakness or paralysis.

I first started treating people with facial paralysis because I was a vestibular specialist. The vestibular system or inner ear balance system is innervated by cranial nerve 8 (the Vestibular Nerve). The muscles of the face used for facial expression are innervated by cranial nerve 7 (the Facial Nerve). These 2 nerves run side by side on their way to the brain in a tunnel in the bone called the Internal Auditory Canal (IAC). This is a very narrow space, with only enough room for the nerves to travel. If a tumor is growing in this small place, or an infection travels to this area, both nerves can be damaged. We see this with large acoustic neuroma tumors, or with infections such as Ramsey Hunt Syndrome.

When facial paralysis does occur, it can take a lot of time for the nerve to heal. The first signs of movements of the face can be only just a flicker, but as the nerve heals, the movements can become stronger. Working with a physical therapist who has special training in treating facial paralysis can help improve the outcome for patients with this problem. They can teach a person what to expect while they are recovering, how to do stretches to ease pain and tightness in the face, how to retrain the muscles to move in a symmetrical way with the unaffected side of the face, and how to manage a condition called synkinesis (when facial muscles which should not be working when making a certain expression try to “help” anyway).

*Sculpture by Jun Kaneko 2007, Untitled Head in Glazed Ceramic and Steel

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Thursday, 03 July 2014 14:36


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We have moved our office to 950 South Tamiami Trail, Suite 101, Sarasota, FL 32439. It is a great space with lots of windows, ample parking in the shade (which is huge if you live in Florida), and on the 1st floor of the building.

The new office is right on US 41 South, across the street from the old Sarasota High School Building. I am really pleased to be opposite such a great Sarasota landmark, because the old school is now the new home for the Sarasota Museum of Art (SMOA)!

What does this mean for me? Well, I won’t have to go far to see inspiring art. In fact, if you are sitting in my treatment room, you can see a fascinating art installation right on the front lawn of the museum. I thought you might enjoy it as much as I have, so below you can see some of the photos I took with my phone the other day. As you can see by the pictures, this makes giving directions to my clinic very easy…

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I have driven by this exhibit hundreds of times, but actually being able to walk in and around the art, and touch the walls of the structure gave me a whole new personal experience to the art work.  If you live in Sarasota, I highly recommend you take 5 minutes, and stop and do the same.  While you’re at it, stop by my office to say hello!




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Sitting old man waiting in hall by Abraham van Strij

Sitting old man waiting in hall, by Abraham van Strij

 Medicine and technology are amazing. People who are deaf can get cochlear implants to restore their hearing, while others get corneal implants for their eyes. There are hip and knee replacements for arthritic joints, and the list goes on… If you have in inner ear balance problem, you may be wondering, “When will someone make an implant to restore my balance?"

Well, Dr. Jay Rubinstein from the University of Washington is definitely one of the researchers in the know. A few years ago, I met Dr. Rubinstein at a University of Colorado ENT meeting. At that time, he was reporting on his early results from implanting human subjects with his vestibular device. When I saw him again in February 2014, he was kind enough to give me an update.

His first studies were done on rhesus monkeys that had healthy inner ear systems with intact hearing and balance function. In order to start testing the device on human subjects, the device needed approval from the Food and Drug Administration (FDA), and the study had to pass strict scrutiny by an institutional review board (IRB) to prove that the research was ethical and would not harm the subjects involved. Dr. Rubinstein had to find a population of people who from a hearing and balance point of view had nothing to lose and everything to gain by participating in the study.

The first group of 4 people to be implanted had a condition called Meniere’s Disease. These patients had already lost their hearing and vestibular function (inner ear balance control) due to Meniere’s Disease before they were implanted. He has now been following these initial patients for one to three years. Because the device can be turned on and off, Dr. Rubinstein compared how the device benefits the person’s balance control, and also how the device improves the ability of the person to stabilize their vision and decrease the visual bouncing phenomenon called Oscillopsia. Oscillopsia is kind of like the effect one would get if watching an amateur video that someone took as they were walking down the street. It looks as if the world is bouncing. One goal of the implant is that by restoring inner ear function, the oscillopsia would stop.

So you must be wondering, what did he find? Dr. Rubinstein found that over time, the electrical response from the device declined. Based on these findings, he adapted the vestibular implant to make the responses generated more robust.

Sounds great, right? But not so fast. Because research on human subjects is very, very regulated, Dr. Rubinstein has to go back to the FDA to get the new device approved, and then has to submit a whole new IRB research protocol for approval! Once that hurdle is jumped, the next hurdle is funding. As you can imagine, this type of research is very expensive and takes a lot of money…

So you see, research takes perseverance. Dr. Rubinstein certainly has that! I am very grateful that he took the time to talk with me, and has allowed me to share these things with you! I told him that my patients are always asking me when there will be a cure for their problem, and I tell them – “they’re working on it...” Truly, hope is on the horizon.

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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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Thursday, 03 April 2014 15:20

Will my vertigo come back?


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…

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Thursday, 06 March 2014 16:37

Free Balance Lecture in Sarasota 3/8/2014

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!

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Thursday, 12 December 2013 00:00

Why Blog?

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: 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!

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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.

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