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Strike a Balance
Monday October 31, 2011


When Cindy Allen, OTR/L, noticed her elderly patient losing her balance while helping wash her hair in the shower, Allen's training in vestibular assessment and rehabilitation kicked in immediately.

"She closed her eyes to keep the shampoo out and started to sway," said Allen, who is with Medi-Home Health and Hospice in Roanoke, Va. "I asked her if she was dizzy, and she said yes."

Allen brought her patient out of the shower and assessed her for oscillopsia — a visual disturbance in which objects in the field of vision seem to oscillate — one of several symptoms of damage to the inner ear that affects balance. "I had her gaze to the right and left," Allen said.

After further visual testing, Allen was able to diagnose benign paroxysmal positioning vertigo, a vestibular disorder that affects half of people 70 and older. The patient was put on a therapy protocol for three weeks to reset eye movement with the inner-ear nerve, which eliminated her dizzy symptoms.

No medication or surgery

Allen said she learned these assessment techniques and therapy maneuvers at a weeklong training session at the American Institute of Balance in Largo, Fla., one of the country's largest balance disorders treatment centers. Led by Richard Gans, PhD, an audiologist who has specialized in dizziness and balance disorders for 30 years, the institute has trained about 6,000 therapists worldwide since 1994, Gans said.

"The No. 1 complaint of people 70 and older is dizziness," Gans said. "But dizzy people don't have to live with it."

Vestibular rehabilitation therapy is used by audiologists, physical and occupational therapists and physicians as a treatment and management strategy for patients with a dysfunction caused by a vestibular disease or disorder, Gans said. It has been documented that about 85% of all dizziness or vertigo symptoms are a result of either damage or wear to the inner ear, he said.

These evidence-based techniques to treat vestibular dysfunctions require no medication or surgery, he said. Rather, they are individualized and programmatic therapy protocols and programs involving sequential coordination exercises of the eyes, head and body.

The effects of vestibular dysfunction — dizziness or vertigo — can last for less than a few hours, or for days, weeks and even years. But with proper treatment, symptoms can be alleviated in less than an hour, said Elizabeth Brinegar, OT/BS, director of ancillary services, outpatient rehabilitation clinics and MRI centers for Neuroscience Consultants in Miami. "It's almost like magic," she said. "For positional vertigo if you do the maneuvers correctly, it will go away in 45 minutes to an hour."

As many as a quarter of patients who see the 36 neurologists at Neuroscience Consultants has dizziness or balance issues, Brinegar said. "The neurologists refer these cases to our OTs," she said. "The OTs tie the vestibular rehab into the patient's activities of daily living."

Training in the assessment and maneuvers is critical to be able to conduct VRT properly, Brinegar said. She has taken courses at the Balance Institute and other clinics, and also sent her OT staff out for training. "Anybody treating this type of patient needs training and experience to do it," she said. "The clinical application takes a bit longer to get good at. It's not all that complicated, but you need to get an eye for it."

Assessment and therapy options

Allen said her VRT training has changed the way she assesses patients. "Before, dizziness wasn't a question," she said. "Now to me, it's as important as asking about pain. There are more people out there dizzy than I ever thought before."

Assessment includes asking when a patient is dizzy, such as when he or she is lying down, standing up, or turning his or her head. Based on the patient's answers, a diagnosis can be made, Allen said. According to AIB, common causes of vestibular dysfunction include: autoimmune disorders, cardiovascular issues, diabetes, labyrinthine concussion, labyrinthitis, Meniere's disease, migraine-vestibular, shingles-herpes simplex, stroke, traumatic brain injury and vestibular neuritis.

There are three different therapy approaches based on the cause for dizziness: adaptation, substitution and canalith repositioning, Gans said.

An example of an adaptation maneuver could be having the patient look at two lists of words while moving his or her head right and left while sitting on a balance ball, he said.

A substitution maneuver might have a patient stand on a trampoline and either close his or her eyes, or watch moving stimulus while retaining his or her balance.

Canalith repositioning is used to treat BPPV through a series of specific coordinated maneuvers of the head and body that move the otolith debris from the semicircular canals back to the utricle, where they can dissolve naturally within hours.

Gans, the author of the textbook Vestibular Rehabilitation: Protocols and Programs, said he has spent his professional life working on equilibrium disorders. "My mother had Meniere's disease," he said. "I saw her lose the best years of her adult life because of an equilibrium disorder."

The AIB offers seven different educational workshops for OTs, PTs, and audiologists on dizziness and vestibular assessment and rehabilitation at its Florida location, and also in seminars in the U.S. and around the world, Gans said. The seminars run for two to five days and culminate in a certificate. They are accredited by the American Medical Association.

In March, AIB rolled out an online version of its seminars, which can be found through the American Institute of Continuing Medical Education at or These seminars are available in English, Spanish, and Chinese, and courses begin at $29. A smartphone application also is on the way, Gans said.

"My goal is that everybody should have access to the most current evidence-based education in this," he said. "OTs and PTs, specialists in this area, have an opportunity to help. Old people don't have to fall."

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Teresa McUsic is a freelance writer.

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Monday October 31, 2011
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