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Old 13-12-2011, 03:10 PM   #1
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Default Vestibular exercises

Theoretically, if "vestibular exercises" were ordered for a patient you were ostensibly in charge of, what would you do?

Theoretically, of course.

Thanks.
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Old 13-12-2011, 03:36 PM   #2
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ahhhh something I'm finally comfortable with here

what would I do? (what *DO* I do since I do this everyday)

vestibular therapy basically boils down to 4 things:

1)-Repositioning for BPPV. BPPV is estimated to occur in 50% in the over 70 population so it's better to assume it's there until evaluated and proven otherwise. An excellent overview of BPPV eval/treatment is here: http://www.dizziness-and-balance.com...bppv/bppv.html This site is updated a few times a year as new literature comes out.

2)-Vestibular adaptation exercises. These are designed to help the balance system basically reprogram itself after a deficit (unilateral or bilateral impairment or loss) Adaptation exercises seek to fine tune the performance of two reflexes involving the vestibular system, the VOR (vestibuloocular reflex-for gaze stability which allows effective use of vision for balance) and the VSR (vestibulospinal reflex for postural stability).

Adaptation exercises involve challenging these reflexes at a level that causes an "error" in their performance. For example, for the VOR, focusing the eyes on a target and moving the head at a frequency that creates a very mild blurring and maintaining this for 1-2 minutes. With a healthy CNS, the vestibular system will recalibrate to become better at maintaining stable vision with increased speed of head movement. A test to see if this is indicated is the dynamic visual acuity test. This test involves having a pt read the lowest line possible on an eye chart, then comparing this with the lowest line possible when the head is passively moved by the therapist (horizontally) at 2Hz. If the vision with head movement is more than 2 lines worse than with the head still, there is likely an impairment in VOR function.

For the VSR this is where generalized standing balance exercises apply. The "error signal" sought here is a mild to moderate sway while attempting to maintain balance. The exercises most likely to directly target use of vestibular input would be those on a compliant surface (foam) with vision reduced or eliminated (eyes closed, sunglasses, head moving). Of course many people have to start much more simply than this (solid ground>compliant, feet apart>together, eyes open>closed, head still > moving) As with VOR exercises, 1-2 minutes at a time is the typical suggestion. Home exercises for both VOR and VSR are encouraged typically 3-5x/day.

3)-Habituation exercises. These are for movement provoked dizziness not due to BPPV (although they can be used for BPPV as well, particularly if unresponsive to repositioning maneuvers). These involve identifying movements that provoke dizziness either through patient history or through a more standardized test called a Motion Sensitivity Quotient. Once provoking movements are identified, exercises are designed based on those movements with the intention of causing habituation (ie desensitization). Habituation occurs in response to repetition of provoking movements. For example, if rolling in bed caused dizziness, the exercise would involve rolling in bed at a speed that provoked mild to moderate symptoms, then remaining in the position until the provoked symptoms subsided, then returning to the start position and repeating. Typically up to 3 movements are used, doing 3-5 repetitions at a time. While recovering from provoked symptoms in any exercise, the person is encouraged to use visual and somatosensory information (feeling the supporting surface, focusing eyes on clear visual target) to speed the recovery.

4)-Substitution exercises. For people with a complete loss of vestibular information (primarily for bilateral impairments)exercises emphasizing use of somatosensation or stable vision are encouraged. Examples would include balance exercises on solid ground with the eyes closed to promote use of somatosensation, and balance or vision exericses where the person learns to use voluntary eye movements to fixate on stable visual targets prior to/instead of moving the head.

Hope this helps, happy to elaborate further if needed!!!
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Old 13-12-2011, 07:46 PM   #3
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I just went through a course of treatment for motion sickness, and it WORKED! I drove all the way up into the mountains last weekend with nary a barf bag. We did a few of the things Tony mentioned above. Tony, do you ever target motion sickness?
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Old 13-12-2011, 07:51 PM   #4
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Quote:
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Tony, do you ever target motion sickness?
Occasionally I do, mainly when the person has motion provoked symptoms that aren't BPPV-this especially seems to occur with migraine associated vertigo. I recently had habituation exercises work well for a pt with this, but the key there is the migraine process has to be well controlled medically for motion sensitivity, visual motion sensitivity and balance to respond to rehab with MAV.

One thing with motion sickness is sensory re-weighting. These people will often be overly dependent on vision for their sense of balance and treatment often needs to include increasing attentiveness to somatosensory cues.

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Old 13-12-2011, 07:56 PM   #5
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For the last couple years I've become dizzy rolling onto my left side, sitting up after sleeping, or laying down. It goes away in a couple seconds. I thought it was just the aging process. Anyway, thanks for the info Tony.
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Old 13-12-2011, 08:02 PM   #6
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Do you use the CTSIB to evaluate what system the patient is relying on?
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Old 13-12-2011, 08:05 PM   #7
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Quote:
Originally Posted by Diane View Post
For the last couple years I've become dizzy rolling onto my left side, sitting up after sleeping, or laying down. It goes away in a couple seconds. I thought it was just the aging process. Anyway, thanks for the info Tony.

glad to help!

and Diane, sounds like you have BPPV! If you come to WI to teach I'll fix it for ya! (or you can try to self treat w/ the maneuver in the attachment-try the one for the L side first )

EDIT: should make known I obtained that handout from an excellent vestibular website run by Jeff Walter, DPT at www.vestibularseminars.com
Attached Files
File Type: pdf Home_CRT_instruction_sheets_B_W_R_L.pdf (80.0 KB, 88 views)
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Old 13-12-2011, 08:13 PM   #8
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Quote:
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Do you use the CTSIB to evaluate what system the patient is relying on?
I sure do, either that or posturography...depends on the pt/circumstances but will do one or the other the vast majority of the time...

The CTSIB I use is the modified one, testing only 4 conditions vs 6 in the original (those 4 being balance on floor eyes open and closed and balance on foam eyes open and closed-never really did the lampshade thing )
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Old 13-12-2011, 09:06 PM   #9
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Quote:
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One thing with motion sickness is sensory re-weighting. These people will often be overly dependent on vision for their sense of balance and treatment often needs to include increasing attentiveness to somatosensory cues.

Tony
This was definitely the case for me, I was very visually dominant. One thing we discussed in lecture was the use of Dramamine and other drugs in children, and if it's possible that over time this leads to a lack of the ability to reconcile the systems. This is said to be true of patients with vertigo and is why they should not use meclizine or other dizziness drugs during their recovery.
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Old 13-12-2011, 09:12 PM   #10
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One thing we discussed in lecture was the use of Dramamine and other drugs in children, and if it's possible that over time this leads to a lack of the ability to reconcile the systems. This is said to be true of patients with vertigo and is why they should not use meclizine or other dizziness drugs during their recovery.

I hadn't heard about that (don't do much w/ pediatric vestibular as of now) but it makes sense-the vestibular system has been referred to by some course instructors I've listened to as the "quarterback" amongst the various balance senses. I'd imagine Dramamine has similar vestibular suppresant effects to meclizine etc making it hard to achieve desired sensory integration.
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Old 13-12-2011, 09:17 PM   #11
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Total side note, Jeff Walters graduated 1 year after me from Wisconsin. D1 collegiate heavyweight wrestler.

I sent him an e-mail encouraging him to get involved here at SS. Amazingly small world!!

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Old 13-12-2011, 09:20 PM   #12
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That'd be awesome! I've narrowed down my course choices for vestibular for next year to RICs (Dr Hain & Janet Helminski) in March and Jeff Walter's in May in Milwaukee...
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Old 14-12-2011, 05:23 AM   #13
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Thanks for the post, Tony.

The vestibular apparatus, extra-ocular eye muscles, and vision (peripheral) sub-serve proprioceptive information and, in large part, make up the body schema (BS) or postural frame of reference. I’ve found that emphasizing the function of any of the 3 components of the BS can make an immediate and significant difference in how someone moves and feels. To be clear, this is not choreographed motor learning in the traditional sense and the goal isn’t to necessarily improve at the actual exercises, but rather “un-smudge” the BS and allow for movement possibilities to reemerge on their own. At which point the formerly inhibited or suppressed movements are consciously perceived and thus, begin to alter the body image (perception, attitude, and beliefs about your body).

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Old 14-12-2011, 11:40 AM   #14
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Tony,

This is the sort of help that will only appear freely, immediately and competently on Soma Simple. This thread is an astounding advertisement for the site.

Thank you.
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Old 23-02-2012, 06:53 PM   #15
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Well well...what a site.

Tony,

Last Thursday I was on the floor doing situps and when I went to get up....the room started to spin and I literally had to lay down to make it stop.

I have felt lightheaded and a bit "floaty" at times ever since (so one week).

I am 42 years old. Otherwise fit and healthy. This is troubling to me obviously but I really have not been impaired in any way. I can run on a treadmill for 30 minutes, work etc etc. Just with a general feeling of dizziness or floatiness at times.

The other day I was demosnstrating to a patient the Thomas test postion and as I lay there...the room started spinning again. Patient had to help me up.

I looked a few things up and became suspicious that I might have BPPV.

Had a colleague perform Dix-Halpike test today and when I turned to the left (once extended) within 5 seconds, the room started to spin. Colleague said no nystagmus however.

No symptoms going the the right.

Right now, as I type....I feel lightheaded and kinda dizzy if I change my eye gaze too rapidly. Have a slight headache. This about 90 minutes after being tested.

My questions:

1) Can you Dx BPPV in abcsence of nystagmus?

2) Is it normal to feel lightheaded/dizzy even when not in the position that brings on the "big" spins? So basically a residual after effect of giving yourself vertigo?

3) Is it typical in an under 50 age category?

4) What is the typical prognosis for BPPV?

I knew I was getting old but cripes!

Thanks for any input. I also think Advantage1 may be able to chime in on this....
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Old 23-02-2012, 07:07 PM   #16
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Hi Proud! Sounds like you may have it! For your ?s:

Quote:
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My questions:

1) Can you Dx BPPV in abcsence of nystagmus?

Sort of. Technically you need both vertigo + nystagmus to = BPPV. Did your colleague use goggles to test you? Nystagmus, especially if brief, can be hard to see w/o them. Otherwise, for people like yourself who fit the description fully except for nystagmus, experts such as Sue Whitney will advocate doing repositioning a couple of tries for "subjective BPPV". It's a harmless enough maneuver, so trying 2-3 cycles over a couple days may very well take care of it.

2) Is it normal to feel lightheaded/dizzy even when not in the position that brings on the "big" spins? So basically a residual after effect of giving yourself vertigo?

Yup. Residual lightheadedness & imbalance very common with BPPV

3) Is it typical in an under 50 age category?

other than young childhood ( < 9 y.o) sure is...one estimated statistic I've seen is 40% of people over 40 get it. I know I've treated many people in your/our age group.

4) What is the typical prognosis for BPPV?

Any individual episode considered very responsive to repositioning manuevers (roughly 80% effective in 1 or 2 treatments), BUT fairly high recurrence rate ( estimated 25% in 1 yr, 44% in 2 yrs). Treatment has no effect on future occurences, only fixes what's present at the moment and so far no proven preventive methods-they even tried daily self-repositioning when symptom-free which failed to prevent recurrences.


Hope this helps!

Tony
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Old 23-02-2012, 08:46 PM   #17
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Really helpful.

Do you often see people complain of a headache after testing?
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Old 23-02-2012, 09:00 PM   #18
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Do you often see people complain of a headache after testing?

I'd say occasionally, especially if they have neck issues that makes the Dix-Hallpike position uncomfortable, or if they are guarded or if they're anxious (esp if they don't know what's wrong with them etc) but mostly if their neck is touchy.

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Old 24-02-2012, 03:40 AM   #19
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Tony,
How do you treat visual vertigo? I went to Marousa Pavlou's seminar at CSM about the use of optokinetics, and I wondered how commonly you see it in clinic and if you use optokinetics of any sort. We are working up to our vestibular section in neuro this semester, I'm getting excited!
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Old 24-02-2012, 11:19 AM   #20
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Hi Lauren,

Visual vertigo unfortunately is a weak area in my knowledge in VR. They didn't go into it much at my competency course in '06, and it was briefly covered in one of my advanced courses a couple years ago.

At that time, mention was made about optokinetic stimulation using disco balls, either as a habituation technique of its own or in combination with balance exercises. I've only really tried it once, and the patient didn't follow through long enough for me to know if it helped.

Otherwise the only other thing I've really done in that arena are VOR cancellation type exercises such as holding an object at arms length and maintaining visual fixation on it while moving object and body at the same time (ie: holding a ball and looking at it while bending over, returning to stand, reaching overhead, etc)

Sorry I don't have more on that one...if you get anything more in your VR unit in school I'd love to hear it!

Tony
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Old 24-02-2012, 11:24 AM   #21
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This is a great find.

What about a feeling of nausea when taking the head back?
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Old 24-02-2012, 02:26 PM   #22
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Quote:
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What about a feeling of nausea when taking the head back?

Hi CDano,

are you asking if that can be characteristic of BPPV? if so, then yes it can but it can also go with other things as well...
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Old 24-02-2012, 02:43 PM   #23
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Thanks for your reply tonyf315

I was asking for two reasons -

I personally do some backward bending movements - e.g. from standing bending backwards. When i was young i could put my hands all the way to the floor. Some years ago, doing these types of movements that weren't standard for me i would get very nauseous. It was always from the head tilting back.

I do also get occasional motion sickness.

Due to my gymnastic involvement it can happen similarly with tumbling, rolling over forward or backward on a mat, rolling backwards on rings etc. I've seen some students get very green in the face and nearly vomit.

I guess i'm wondering 1)Is this something that is naturally improved via gradual acclimation. (seems to be the case) 2)If a person is 'hard case' is there anything that can be done to help the acclimatization. 3) Why it seems so specific. In other words I might get used to one type of rolling motion, but trying another, that seems almost the same will provoke a greater response.
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Old 25-02-2012, 07:32 PM   #24
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those are good questions, CDano!

I guess if I were assessing you, I'd first check for BPPV as it is so common. If that were absent, it could simply be motion intolerance and could be treated as you mentioned by acclimation, or as we call it in vestibular rehab, "habituation"-where we have you intentionally, repeatedly expose yourself to the provoking movement(s) in controlled doses in order to desensitize to them.

As to why one motion may become less bothersome while another similar motion remains bothersome could be several factors: different somatosensory inputs in the different circumstances, same for visual inputs, different speed, slight change in angle of motion...

as to how to go about this habituation/acclimation process-for a mildly to moderatly provocative movement pattern, do the motion at a speed that provokes the familiar symptoms to a tolerable degree then rest. Rest long enough for the provoked symptoms to FULLY subside (usually plus an additional half minute just to be sure). While recovering take advantage of sensory cues from your support surface and/or visual environment to facilitate the process. Once recovered, repeat. A single session usually consists of 3-5 reps of 2-3 sensitive motions done twice daily.

Does that answer somewhat? If not I'll try to clarify further...

Tony
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Old 26-02-2012, 12:42 PM   #25
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Tony, I really appreciate you getting back to me on this.

How would having BPBV affect your recommendation? Is it difficult to assess? Is it something i could learn to do?

What you suggest is pretty much what i do, although it's easy to not wait long enough, now that i know that's important, i'll make sure that happens in the future. Next time i see my sensitive athlete i'll give her the full Rx (3-5 reps of 2-3 sensitive motions done twice daily) and see how she does.
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Old 26-02-2012, 01:10 PM   #26
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if BPPV is the reason, the fix is a lot quicker and easier!

this is the test: http://en.wikipedia.org/wiki/Dix-Hallpike_test

and here's a video (cute one!) of the test and treatment of the most common variation of the condition (posterior canal) http://www.youtube.com/watch?v=eOuzUi5ckrk&feature=fvst
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Old 26-02-2012, 10:30 PM   #27
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Thanks Tony! I had no idea this was all so well understood.

I'm quite curious, the eye movements, how did anyone work that out and find that they correspond to different conditions.
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Old 02-07-2012, 11:58 PM   #28
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I had someone ask me recently about bppv and realised my depth/loss of knowledge about it. Thanks for everyone who contributed to this thread as it is an excellent quick refresher.
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Old 03-07-2012, 02:16 PM   #29
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This may sound strange, but my Scottish terrier has this. He fell over, unable to get up and stand, and he had nystagmus. Not being familiar with this I rushed him to the emergency vet and was very relieved to find out he didn't have a stroke or paralyzed limbs (He fell to one side and his back legs collapsed). He was diagnosed with a vestibular disorder.

His symptoms were gone within the day and have not come back so far. If they come back, does anyone know if there is anything that could be done to help him? The vet said to take him home and wait it out hoping it would resolve on its own, but if there are movements or anything I could do with him that would be great.

Thanks,
Dawn

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Old 03-07-2012, 07:17 PM   #30
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Default Vertigo

Sorry to Hijack the thread, my mother has been suffering from vertigo for the last four years on and off. The latest bout has lasted over a month, she has been doing the epley manouvre and it is not as effective as it once was.

If anyone has any suggestions, and also knows of any specialist clinics in midlands/north of england/wales (uk)

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Old 03-07-2012, 11:47 PM   #31
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@ DDH: I would say just keep him moving! if it's a problem with vestibular hypofunction, head and body motion will help the recalibration process. If it's BPPV it will likely resolve on it's own w/ continued head motion (dissolving the displaced particles) Otherwise you could try performing "human" repositioning maneuvers if your pup will go along with them. Seriously though, something simple like playing ball may be helpful by promoting head movement and visual tracking.

@chris: try looking here- http://vestibular.org/finding-help-s...ider-directory
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Old 04-07-2012, 01:57 AM   #32
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Thank you very much, Tony!
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Old 09-07-2012, 12:42 PM   #33
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If you want to read more from Tony on this subject, he has written a 2 part series of posts for my blog: http://forwardthinkingpt.com/2012/07...rapist-part-1/
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Old 09-07-2012, 12:46 PM   #34
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My first blog post!
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Old 09-07-2012, 01:20 PM   #35
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Nicely done, Tony!
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Old 09-07-2012, 01:42 PM   #36
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Very nice blog post (and blog)!
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Old 09-07-2012, 04:29 PM   #37
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Thanks Tony will check out the link.

Regards

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Old 10-07-2012, 07:16 PM   #38
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That is a vary nice blog post about a specialty dearly lacking in publicity.
Thanks Tony!
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Old 10-07-2012, 07:19 PM   #39
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part 2 is tomorrow (I think) with focus on treatment, basically much of what is in my first reply in this thread with a significant expansion of the info on BPPV. As always, I'm happy to elaborate on any questions that may arise!
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Old 10-07-2012, 08:09 PM   #40
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Tony, do you work in a large rehab setting or in a smaller clinic?

Do you treat vestibular patients only or also other conditions?

I hope you don't mind me asking, but I really enjoy vestibular therapy as well, and was wondering about the working conditions of someone specialized in such therapy.
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Old 10-07-2012, 09:50 PM   #41
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Great Job Tony - thanks for sharing this info, I must be a huge geek, because I find the subject fascinating.
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Old 11-07-2012, 12:42 AM   #42
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Quote:
Originally Posted by MaxG View Post
Tony, do you work in a large rehab setting or in a smaller clinic?

Do you treat vestibular patients only or also other conditions?

I hope you don't mind me asking, but I really enjoy vestibular therapy as well, and was wondering about the working conditions of someone specialized in such therapy.
I am one of two PTs in a department in an ENT clinic where I've been now for two years. Prior to this, I was in a hospital-based outpatient clinic seeing everything typically seen in that setting with a minor concentration on vestibular (probably 25% of my caseload at most) Where I am now, I'm the only one of the two of us doing vestibular and vestibular/balance evals make up about 2/3 to 3/4 of my new evaluations, the rest being persistent pain problems, post op ortho and so forth. So I guess you could say I'm specialized now but I'm far away from where the gurus that teach courses are as far as experience and as far as the variety of vestibular related things I've worked with. I see a TON of BPPV (which I love treating), followed by unilateral vestibular problems and "general" (ie multifactorial) balance. I've seen very little in the way of post op rehab (acoustic neuroma or meneire's), or bilateral loss patients.

Thanks for the feedback so far everyone, I'm hoping part 2 is worthwhile!
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Old 11-07-2012, 12:52 PM   #43
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part 2 courtesy of Joe!

http://forwardthinkingpt.com/2012/07...rapist-part-2/
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Old 06-08-2013, 01:54 AM   #44
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Thanks Tony

Is BPPV hereditary or has genetic cause. I know you mentioned different causes but was curious.
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Old 06-08-2013, 02:45 AM   #45
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this is a little old, but here's one study specific to BPPV:

http://www.ncbi.nlm.nih.gov/pubmed/9870618


Additionally, people with Meneire's disease and Migraine, both of which are known to run in families, are also known to have a higher incidence of BPPV than the general population.

Hope that helps?
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Old 07-08-2013, 12:22 AM   #46
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Thanks Tony.
Is Dix - hallpike test positive if only nystagmus is reproduced during test?

Well I saw 2 patient today with complain of light headedness and dizziness. It's interesting, as both cases were total contrast.

A mid 30 female patient with complain of dizziness with bending forward to lift laundry, rotating side to side suddenly and sometimes with windy weather. MRI brain Normal, ENT findings normal , EYE specialist findings normal. Symptoms persistent for last 6 years, increased frequency in last 3-4 months. Per patient, she has motion sickness for many years. No other medical conditions.

My findings, Dix hallpike negative ( I am novice in treating vestibular conditions, so I did test twice. There was no symptoms of dizziness but I SAW nystagmus with left rotation?????, not exactly sure).

But, with gaze examination, there was aha!! moments. Everytime when see tried to fixate gaze on moving object, she felt dizzy. So I came with conclusion of having weak VOR reflex.

So, Tony I need your expert advise. What's your opinion? What should be the treatment protocol?
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Old 07-08-2013, 02:51 AM   #47
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Is Dix - hallpike test positive if only nystagmus is reproduced during test?

positive is if both vertigo and nystagmus are provoked, in a direction and duration consistent with BPPV

Well I saw 2 patient today with complain of light headedness and dizziness. It's interesting, as both cases were total contrast.

A mid 30 female patient with complain of dizziness with bending forward to lift laundry, rotating side to side suddenly and sometimes with windy weather. MRI brain Normal, ENT findings normal , EYE specialist findings normal. Symptoms persistent for last 6 years, increased frequency in last 3-4 months. Per patient, she has motion sickness for many years. No other medical conditions.

My findings, Dix hallpike negative ( I am novice in treating vestibular conditions, so I did test twice. There was no symptoms of dizziness but I SAW nystagmus with left rotation?????, not exactly sure).

But, with gaze examination, there was aha!! moments. Everytime when see tried to fixate gaze on moving object, she felt dizzy. So I came with conclusion of having weak VOR reflex.

So, Tony I need your expert advise. What's your opinion? What should be the treatment protocol?

with this case, there's really not enough to go on to give a well reasoned opinion on what may be going on. From what info you have provided on exam findings (nystagmus in Dix-Hallpike w/o vertigo, symptoms provoked during visual tracking of a moving object) I guess I'd have some suspicion of a problem of central origin as opposed to BPPV or other peripheral. Does your patient have a migraine history perhaps?
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Old 07-08-2013, 03:30 AM   #48
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No complains of migraine, but she did mention that some perfumes and certain smell triggers her dizziness.
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Old 07-08-2013, 03:40 AM   #49
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How timely I find this thread after finishing up the final for my Vestibular Rehab course. Please take anything I say with a grain of salt as I am by no means proficient in this area.

kpshah-- Initially when reading your post I was thinking some sort of anterior canal involvement (with the complaints during bending down to lift laundry) which you could be assessed with a Straight Head Hanging Test or the Dix-Hallpike. I think the rest of your post leads away from a BPPV diagnosis, as Tony has mentioned.

Was there any abnormal eye pursuit movements evident when focusing on the moving target? History of migraines/headaches, head trauma, loss of hearing/tinnitus, recent falls?
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Old 07-08-2013, 09:57 PM   #50
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Hi Venerek,

No history of head trauma or fall

I forgot to mention that, her symptoms started after pregnancy ( is there any co-relation ?)

No abnormal eye pursuit movement with moving target, however her symptoms of dizziness worsen.

She will be coming next week for follow-up.

@ Venerek : Are you thinking in any direction ?
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