Balance

"Balance Testing needs to be part of basic primary care…all physicians need to be monitoring and screening their patients for vestibular dysfunction so that we can take preventative measures to guard against falls”     -Johns Hopkins University Gazette, 2009

Most patients that suffer from vestibular dysfunction are asymptomatic. Inner ear disorders are the leading cause of falls. Effective treatments exist for balance and dizziness issues…when correctly diagnosed.

The role of the primary care physician in treating patients with dizziness or vertigo has increased over the last decade.

Dizziness and vertigo are among the most common symptoms causing patients to visit a physician (as common as back pain and headaches). The incidence of falling is greater then 35% in patients older than 65 years. Falling can be a direct consequence of dizziness in this population.

There are many causes of dizziness and only your physician can determine the cause and recommend proper treatment options. Here is a brief summary of the some of the conditions that may cause balance problems:

BPPV (benign paroxysmal positional vertigo)

BPPV is the most common cause of vertigo. It is due to disturbances within the inner ear. The inner ear has fluid filled tubes called semicircular canals. These canals contain tiny cilia that are covered with crystals. The way the crystals sit on the cilia tells your brain that you are upright. When the crystals are moved off the cilia your brain becomes confused and can not tell what is upright. Symptoms include a feeling of spinning with change in positions such as rolling in bed; nausea, vomiting, hearing loss, and loss of balance. Treatment includes vestibular therapy including the "Eply maneuver" to help realign the crystals and habituation exercises.

Vestibular Neuritis:

In Vestibular neuritis, dizziness is attributed to a viral infection of the vestibular nerve. In older patients, this can be secondary to ischemic damage to the inner ear or vestibular nerve. If hearing loss also is associated with the dizziness, the problem is called "labyrinthitis."  The symptoms of both vestibular neuritis and labyrinthitis typically include dizziness or vertigo, disequilibrium or imbalance, and nausea. For the first several days, dizziness and nausea can be treated with suppressive medications. Long-term use of medications, however, can actually impede full recovery. Vestibular rehabilitation is the definitive treatment for the symptoms associated with this vestibular neuritis.

Acoustic Neuroma:

Acoustic neuromas, also known as vestibular schwannomas, are non-malignant tumors of the eighth cranial nerve. These cells provide the insulation of the nerves, much like the insulation around an electrical wire. Acoustic neuromas usually cause hearing loss, but may not cause dizziness or imbalance. Acoustic neuromas are relatively rare as only about 10 tumors are newly diagnosed each year per million persons in the United States. Diagnosis is made with MRI after changes are detected on audiometry and brain stem auditory evoked responses.

Treatment options for acoustic neuromas include surgery and radiation.

Migraine-Associated Dizziness:

Although most think of migraine as a terrible headache and nothing more, migraine is actually a complex disorder of the brain that affects 12% of all people. About 20% of people with migraine have migraine with aura. An "aura" is a symptom that can be localized to a specific brain region. Visual changes (flickering lights, dark spots, etc.) are the most common auras associated with migraine. Although visual changes are the most common auras, dizziness also can be a symptom caused by migraine aura if decreased brain cell activity occurs in the vestibular system.

Nevertheless, the phenomenon of migraine aura does not explain all cases of dizziness in migraine patients. In fact, studies have shown that the prevalence of vertigo in migraine may be as high as 42% (Kurizky et al, 1981). Vertigo secondary to migraine can be very difficult to diagnose, especially in patients without head pain. [Yes. It is possible to suffer from migraine without having headaches!] 

Perilymph Fistula:

A perilymph fistula is a tear or defect in the oval window or round window (the thin membranes between the middle and inner ears). When a fistula is present, changes in middle ear pressure will directly affect the inner ear, stimulating the balance and/or hearing structures and causing several symptoms. These include dizziness, vertigo, imbalance, nausea, and vomiting. Some people experience ringing or fullness in the ears, and many notice a hearing loss. Most people with fistulas find that their symptoms get worse with changes in altitude (elevators, airplanes, or travel over mountains). Additionally strenuous activity or straining can trigger symptoms. Head trauma is the most common cause of perilymph fistula, however, other activities such as weight lifting or scuba diving can cause this problem. Often fistula can be diagnosed by applying pressure to the ear while measuring eye movements. Often, perilymph fistulas will heal spontaneously with rest, but sometimes surgery is required.

Transient Ischemic Attack (TIA) and Stroke:

TIAs and stroke are caused by low blood flow to the brain. When the areas of the brain that control balance (brain stem and cerebellum) suffer from low or absent blood flow, dizziness and imbalance can occur. Sometimes dizziness can occur if the vertebral arteries in the neck become narrow (vertebral stenosis). When a patient with vertebral stenosis turns his or her head in certain directions, the arteries can be pinched off and blood flow to the brain can be diminished. Dizziness or vertigo is much more often caused by inner ear problems, however,TIA and stroke are frequent causes of imbalance.

Orthostatic Hypotension:

This is a very common cause of dizziness, especially in the elderly. Orthostatic hypotension is a decrease in blood pressure that occurs when an individual stands up after sitting or laying down. The drop in blood pressure is caused by pooling of blood in the legs. If blood pools in the legs, less blood is pumped by the heart to the brain and dizziness or lightheadedness occurs.  Orthostatic hypotension is generally treated with hydration, elastic stockings, and sometimes with medications. The diagnosis is made by measuring the blood pressure and heart rate in the recumbent and standing positions while the patient's symptoms are documented. 

Cardiac Arrhythmias:

An arrhythmia is an electrical conduction abnormality of the heart. An arrhythmia can lead to an irregular heartbeat that causes less blood to be pumped to the brain and this can lead to dizziness. In general, cardiac arrhythmias can be treated with medications, but sometimes a pacemaker may be required.

Falls:

The most common fall is a simple fall in which the patient trips and has no ominous underlying peripheral or central disorder. Hazards in the environment ( rugs, electrical wires, poor lighting), polypharmacy (multiple drug use), and orthopedic factors often contribute to fall.
 
Because of the substantial risk of injury and the resultant decline in independence and/or quality of life after a fall, a well-directed evaluation is indicated. Balance is not a single physiologic function. The sensory inputs are vision, vestibular, and proprioceptive. While a person is walking, the CNS must instantaneously integrate this information and execute appropriate motor plan and output. This function must be supported by an adequate musculoskeletal system. All of these factors change with age. Any further disease related decline in any of these systems further impairs balance. Bilateral vestibular failure is a contributor in one fourth of elderly patients with disequilibrium.

At Kaizen Total Wellness we are pleased to offer balance therapy/rehabilitation in addition to balance testing/screening in our office with state of the art computerized vestibular testing. 

Our physical therapist, Dr. Jill Rose is certified in vestibular disorders and supervises the entire program which consists of physical therapy and exercise fitness training utilizing the Power Plate and bioDensity machines.

Vestibular Rehabilitation Therapy

Definition : Vestibular rehabilitation therapy (VRT) is a specific form of physical therapy designed to habituate symptoms, and promote adaptation to and substitution for various aspects of deficits related to a wide variety of balance disorders.[3] VRT is effective in improving the functional deficits and subjective symptoms resulting from unilateral and bilateral peripheral vestibular hypo function as well as from central balance disorders.[4]
 
Goals : By improving vestibular function and promoting mechanisms of central adaptation and compensation, VRT aims to do the following: 

- Improve balance
- Minimize falls
- Decrease subjective sensations of dizziness
- Improve stability during locomotion
- Reduce over dependency on visual and somatosensory inputs
- Improve neuromuscular coordination
- Decrease anxiety and somatization due to vestibular disorientation

Our VATplus Computerized Balance Testing System is quick and easy to perform and does not cause any side effects. This service is covered by most insurance plans including Medicare.

Our unique balance program is also covered by most insurance plans.
For more information, please call 941-556-7788