Balance therapy is a generalized category of physical therapy exercises to help an individual improve their balance. The ultimate goals of balance therapy are to prevent falls and increase a person’s functional abilities and independence, both at home and in the community.
These goals are driven by the following 4 main factors:
1. Lifestyle. Is the person sedentary with hobbies such as reading, playing bridge, or watching TV? Is the person active with hobbies such as golf, tennis, boating, or gardening?
2. Location. Where does the person live, and what are the obstacles they encounter in their home or community? For instance, my balance therapy practice is located in Sarasota, Florida. In order for my patients to function safely in the community, they need to be able to walk on uneven parking lots or sidewalks, and walk up and down the periodic ramp or curb. Most of the homes in Sarasota are condos or single story homes with only one step to enter the building. The only reason a person might walk on the grass would be if they are a golfer, enjoy gardening, or enjoy walking on uneven surfaces at the beach or local parks. However, if they are a snowbird and only come to Florida in the winter, when they return to their home up north they may live in a 2-story home with 5 steps to enter. The bedroom and bathroom may be upstairs, and the washing machine down in the basement, and they may have a cobblestone driveway. I think you get the idea…
3. Personal choice. What does the person want to achieve or be able to do that they cannot currently do because of poor balance? This is different for every person. Some people just want to be able to walk around their home without falling, and to go to the grocery story or doctor’s office on their own. Some people want to improve their balance so that they do not need to use a cane or walker. Some people have given up a sport they used to love because of their poor balance, and their goal is to return to playing golf or tennis again with their friends.
4. Health Status. A person’s underlying health status plays a factor in setting reasonable goals. For instance, if the person has terrible arthritis in their knees, a reasonable goal is probably not that they would be able to run a marathon or climb Kilimanjaro. However, it may be reasonable that they should be able to climb a flight of stairs safely, or be able to walk their dog each morning with good balance.
I want to encourage you to think about your personal goals and discuss these things with your balance therapist. Having good goals with motivate you to do your home exercise program, and allow you to chart your progress.
Included image: Balance, a painting by Norval Morrisseau
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?
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.
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
Crystal, 1921 Watercolor by Paul Klee
My physical therapy clinic in Sarasota, Florida sees many patients who are surprised to learn that they have crystals in their ears, and yes, they are supposed to be there! The crystals are made of calcium carbonate, and are called otoconia. Under an electron microscope they look like little grains of rice.
The crystals sit on top of the nerve cells in the ear. The purpose of these crystals is to help stimulate the nerve when the inner ear fluid whooshes over the nerve in response to movement. However, if these crystals come loose and start floating in the ear canals where they don’t belong, this can trigger vertigo.
Vertigo is a sensation that the world is spinning around you, or that the world is still but you are spinning. The name of the condition is Benign Paroxysmal Positional Vertigo (BPPV). The vertigo sensation is triggered by motion, and it usually lasts just a few seconds. Treatment for this problem consists of maneuvers to guide the crystals back into the part of the ear where they belong.
Once there, we want the crystals to sink back into a jelly-like matrix on top of the nerve cells, so that they stick in place and stay where they belong. Once back in place, life returns to normal, and the vertigo episodes cease.
My Eyes in the Time of Apparition, 1913. By August Natterer
This is one on the most frequent questions that my patients in Sarasota, Florida ask me, “Will my vertigo come back?” It is the question they usually ask right after I tell them that their BPPV (Benign Paroxysmal Positional Vertigo) was successfully treated, and is now gone. Research tells us that in about 40% of cases, the condition will come back. Sometimes it can come back within a year, other times the person can go for many years before the condition returns.
The next question is usually, “Is there anything I should avoid doing so that the vertigo doesn’t return?” There is nothing that the person does that makes it come back, it just does. So in that case, I tell my Sarasota BPPV patients that they should go back to life as normal. That means sleeping flat like they normally did before all this started, and to resume all their normal every day activities. This includes bending over, for example to pick something up off the ground, or tipping their head back as they would to reach over head.
If the condition does return, the person will just need to call and come back to therapy to have treatments to put the crystals back in place again. Knowing that they have a plan of what to do if the BPPV returns, usually takes the fear away, and allows the person to go on with their lives- which is the goal after all…
This is a frequent question that many of my patients ask me. Antivert, Meclizine, Bonine, and Dramamine are all drugs that can be bought over the counter to treat dizziness. But the question is, when should a person take these drugs?
To answer this question, one must first understand how these medications work. These drugs decrease or prevent dizziness, by blocking signals FROM the inner ear TO the brain. If a person is having a full blown vertigo attack, these drugs may be necessary, and may be prescribed by your doctor. However, once the attack is over, continuing to take these medications can interfere with one’s recovery.
For instance, when a person comes to physical therapy to treat an inner ear disorder, the purpose of the therapy is to teach the brain how to respond better to inner ear signals in order to improve one’s balance and decrease one’s dizziness. In other words, we want the inner ear to be able to send signals to the brain, so that the brain can learn how to adjust and use inner ear information again.
If a person is taking one of these drugs, then the medication is actually blocking the very signals that the brain needs in order for the person to get better. Therefore, in most cases, it is not advised to take these medications. In fact when used chronically, these medications can actually prevent or delay recovery.
*Disclaimer: The above recommendations reflect basic treatment philosophy when working with patients with inner ear disorders. Since physical therapists do not dispense medications, further specific questions about your medication regimen should be directed to your personal physician.
We know that people use information from other senses to help them balance. For instance, we use our vision to help us balance. When we walk outside today, and see that the sidewalk is sloping, we will automatically adjust our steps and our balance based on this information.
But how does one’s hearing affect their balance? A study appeared in the Archives of Internal Medicine Feb 28, 2012 about research out of Johns Hopkins Medical Institution. They studied 2,000 people between the ages of 40 to 69. The people had their hearing tested and were asked questions about if they had fallen in the past year.
(Pictured: an antique ear trumpet for the hard of hearing.)
The results confirmed the contribution that hearing makes to balance. In this study, the researchers found that even people with a mild hearing loss (25 decibels) were nearly 3 times more likely to have a history of falls than those without a hearing loss! They were also able to measure how as the hearing decreased, the risk of falls increased. For instance with every 10 decibels of hearing loss, the risk of falling increased by 1.4 fold!
Many people don’t want to wear their hearing aids, for many various reasons. But when they understand that wearing the hearing aids will decrease their risk of falls and injury, they are usually much more willing to put them on…
So, what should be the first topic for my Blog? That’s easy BPPV! Why BPPV? I am choosing this topic because it is the most common type of inner ear disease. Of all inner ear disease, it takes up about 25% of all inner ear conditions. Also, it is the easiest to treat! BPPV stands for Benign Paroxysmal Positional Vertigo. BENIGN, meaning it is not life threatening and will not kill you. PAROXYSMAL, meaning the symptoms come and go. POSITIONAL, meaning the symptoms are triggered by a change in head or body position. And VERTIGO, meaning the person complains of a spinning sensation.
So many times people come to me and say, “they told me I have something wrong with the “crystals” in my ear”. Yes, that really sounds strange and like voodoo, but it’s not. There are crystals in our ears and they are supposed to be there! They are called “otoconia” and they are made up of calcium carbonate. They have to be seen with and electron microscope, because they are too tiny to see with the naked eye. Some people call them “ear rocks” because of their appearance. These tiny crystals can cause a heap of trouble when they become dislodged and start floating in the parts of the ear where they don’t belong. This will be better understood once you learn a bit about basic ear anatomy.
Art is inspirational, and when I see these rocks, I can’t help myself! They make me think of otoconia!
Understanding the inner ear anatomy and BPPV
Lets start with the outer ear and work our way inward. Sound travels from the outer ear, down the ear canal, to the ear drum. It crosses the eardrum and is conducted by 3 little bones called the malleus, incus, and stapes to the cochlea. The cochlea is in the inner ear and is incased in the temporal bone of your skull. Sound information is processed in the cochlea, and then transmitted by the cochlear nerve to your brain, which then translates the information into what we know as sound. If you really want to be technical about it, we hear with our brains!
The other half of the inner ear is the balance part, and it is called the vestibular system. In the vestibular system, we have 3 canals that are filled with fluid. When we move, the fluid moves, and it stimulates the little nerve fibers, which look like tiny hairs. These 3 canals converge into a central area where there are nerve cells that sense gravitational forces. These structures are called the saccule and utricle. They have a gelatinous matrix on top, which is where the otoconia, (or crystals), are found. The function of these crystals is to help stimulate the nerve when our head changes position. The information then travels down the vestibular nerves to the brain and our brain uses this information to help us balance and coordinate head and eye movements. However, if these crystals break free and start floating in the canals of the ear where they don’t belong, then when a person moves in the plane of that canal, for instance, when bending over or tipping their head back, it causes an abnormal woosh of fluid across the nerve cell and triggers vertigo or a spinning sensation.
With BPPV, the vertigo, or actual spinning sensation last for seconds, usually less than a minute. Once the crystals float to the bottom of the canal, the spinning stops. But if you move your head again, you can get the spinning all over again. Gradually this symptom will fatigue.
So how is BPPV treated?
Well, many times is goes away on its own in a day or two. Other times, it can last for a long time and not go away unless it is treated.
To treat this, it first has to be diagnosed properly. There is a lot of information out there on the internet, and sometimes people try to treat themselves with varying degrees of success or failure. Diagnosing which canal the crystals are floating in takes knowledge and a clear understanding of the condition and it’s various presentations. For instance, a doctor or therapist will test to determine if the crystals are loose in your right ear, your left ear, or both ears. Once that is determined, the next thing to figure out is which of the 3 canals are the crystals loose in? This is very important because the treatment is different for each canal! With both ears combined, there are 6 canals that need checking in order to come up with the correct diagnosis. Therapists or doctors look at the pattern of eye movements that create the sensation of vertigo while in the test positions in order to determine which canal is affected.
Research tells us that the most common canal for BPPV is the posterior canal, which is affected in 80-85% of most cases. But the horizontal canal, or the anterior canal, are also possibilities. The test for BPPV is called the Hallpike Dix test (also called the Dix-Hallpike Test depending on who you ask). It is used to diagnose BPPV if the posterior or anterior canal is the culprit. Testing for the horizontal canal is done by the roll test.
Treatment for the posterior canal is done by the Epley Maneuver. It is a treatment named after a famous ear doctor named Dr. John Epley who was the first to present this treatment for this condition. He is a great guy, and I have met him on several occasions. He is getting older now, and is no longer in practice, but his techniques have helped so many people and have become the standard of care for posterior canal BPPV. There is another technique called the Semont Maneuver. This can be effective, and I will use this when a client is not responding to the Epley Maneuver. Brandt Darroff exercises are also used when the above techniques are not working for a client. The Brandt Darroff exercise is not a corrective treatment like the Epley or Semont. It works on the theory of habituation, which means with repeated exposure to the position that is provoking the vertigo, our brain will learn to become desensitized to the motion, and disregard the stimuli so that one can move in and out of positions that usually trigger vertigo and dizziness.
If you need to find a doctor or therapist near you who is familiar with treating BPPV, I recommend going to the Vestibular Disorders Association website. There, you can enter your area code and find a doctor or therapist in your area.