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Vestibular Rehabilitation Therapy - Helping Patients with Dizziness&Imbalance

Online Health Chat with Amy Cassady, PT, and Kay Cherian, PT, MPT, Cert. MDT

February 15, 2011


Introduction

Cleveland_Clinic_Host: The vestibular system includes the inner ear and parts of the brain that control balance and eye movement. This system can be compromised by disease, injury, or aging. Symptoms and their severity can vary considerably from patient to patient and are often difficult to describe.

Each year, more than 10 million patients seek medical treatment for issues with dizziness and imbalance. These patients are often diagnosed with a vestibular disorder. While there are a variety of treatment options, vestibular rehabilitation therapy has shown to increase balance and strength, decrease fall risk, and return patients to prior levels of function.

Both Amy Cassady, PT, and Kay Cherian, PT, MPT, Cert. MDT, are licensed physical therapists with certification in vestibular rehabilitation therapy who have more than 20 years of combined therapy experience.

To make an appointment with Amy Cassady, Kay Cherian, or any of the other vestibular rehabilitation specialists in the Department of Physical Medicine & Rehabilitation at Cleveland Clinic, please call 216.445.8000 or toll-free at 800.223.2273 ext. 58000. You can also visit us online at clevelandclinic.org/vestibular.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with physical therapists Kay Cherian and Amy Cassady. We are thrilled to have them here today for this chat. Let’s begin with the questions.


Understanding Vestibular Disorders

donald: If you have a vestibular problem, is it normal to experience extreme tenseness and dizziness when trying to read?

Amy_Cassady_PT: That is not out of the realm of potential symptoms a person may experience. Your brain receives information from your visual system, the vestibular system, and somatosensory system, which communicates information about touch, pressures, joint position, etc. If any of these sensory systems is dysfunctional, over-stimulating it may result in a feeling of dizziness. Reading involves a great deal of visual stimulation. Also, consider the position your head and neck are in. The neck contributes a lot of sensory information about head position. Any dysfunction or strain in this area may also contribute to a feeling of dizziness or tension in the neck.

continued: What can cause the dizziness of a vestibular disorder?

Amy_Cassady_PT: The vestibular system is responsible for sensing head movement and telling your brain about that movement. Dizziness can occur if the brain does not receive the information it expects or if there is a "mismatch" of sensory information.

Alma: Can you please address the issue of extreme fatigue that occurs with vestibular disorders, and give suggestions to help minimize or combat the fatigue.

Kay_Cherian_PT_MPT_Cert__MDT: Fatigue is a common symptom with vestibular disorders. Your system is likely working hard to keep you balanced, and it is recruiting other systems to help out. Oftentimes, with a vestibular problem, your neck -- along with the other muscles of the spine -- is asked to do more work to keep you balanced. This extra muscle activity is only one area that is contributing to the fatigue. There are many others as well.

frankth: I have a vestibular disorder in the right ear. Are there instances when visual sensory overload will not respond to PT?

Amy_Cassady_PT: We sometimes see this when a person also has migraines.

weeble: I have had imbalance issues for six months. It started with walking like a drunken sailor. Now I can walk without staggering, but I still feel the imbalance when I walk. What can I do to not feel this way anymore? Will it every go away?

Kay_Cherian_PT_MPT_Cert__MDT: I would suggest that you get a full vestibular assessment by a qualified PT to gain more information about the cause of your symptoms. This can assist you in gaining better control of your current symptoms, and preventing you from falls or further injury in the future.


Symptoms

MaryMary: What are some symptoms of vestibular disorders?

Amy_Cassady_PT: Symptoms can vary, but in general include dizziness and imbalance. Some people also complain of visual changes. Dizziness symptoms are sometimes described as spinning, lightheadedness/wooziness, heavy headedness, or a sense of imbalance. These can be constant or intermittent. People may be unsteady on their feet. Visual changes may include jumpy vision, blurred vision, or a sense that head and eye movements aren't coordinated.

Millie: What symptoms make vestibular testing appropriate?

Amy_Cassady_PT: In general, the symptoms are dizziness or imbalance, which are determined by a physician to be related to the vestibular system. There are several factors that influence this decision: the onset of symptoms (sudden versus gradual), the duration of symptoms, the response to conservative treatments -- such as medication or specialized physical therapy -- and other signs or symptoms that may be present (i.e., hearing loss).


Vestibular Therapy

donald: Is vestibular therapy effective 1.5 years after onset of symptoms?

Amy_Cassady_PT: Vestibular therapy can be effective at any time after the onset of symptoms. The amount of progress is dependent on the type of disorder, other medical issues the person may have, and the person’s compliance with his or her exercise program.

JanB: I haven’t been officially diagnosed by a physician with a vestibular disorder, but I do have intermittent balance issues. Can vestibular therapy help me?

Kay_Cherian_PT_MPT_Cert__MDT: Likely, but it is difficult to say without a full evaluation. That would consist of getting a full history of your symptoms and obtaining a baseline of your balance and walking. We would also do a complete assessment of your upper quarter -- which consists of your neck, jaw, and shoulders. If problems are present in these areas, it can also contribute to your symptoms. If needed, we can also do inner ear/positional testing to determine if the ear is involved.

beekmanhill: How long is typical vestibular therapy at Cleveland Clinic?

Kay_Cherian_PT_MPT_Cert__MDT: It is hard to answer that, but in general, treatment varies by your symptoms and your progress. Our sessions are from 45 to 60 minutes each.

pat_stevens: Does this therapy help with all degrees of vestibular disorders? Is it more helpful with mild or severe symptoms?

Amy_Cassady_PT: Therapy can be beneficial for all types of vestibular disorders. The amount of improvement is affected by the source of the symptoms, any other medical conditions the person has, and compliance with the recommended exercise program.

glorybe: Is vestibular therapy an inpatient program or can it be done as an office visit?

Kay_Cherian_PT_MPT_Cert__MDT: Oftentimes it is outpatient. At times, it can also be inpatient when the situation is an acute problem.


Vertigo -- Epley Maneuver

weeble: Is it possible to have had BPPV, which has been resolved through the Epley maneuver, but still be struggling with imbalance issues. My ear, nose and throat doctor said BPPV is no longer present, but I still experience imbalance when walking?

Amy_Cassady_PT: Yes! In some cases, a person may have also experienced a partial loss of function, called vestibular hypofunction. The other consideration is that neck muscles may have tightened up and are still contributing to remaining symptoms.

tanker: What is the Epley maneuver?

Kay_Cherian_PT_MPT_Cert__MDT: The Epley maneuver is a specific treatment for BPPV- positional vertigo.

beekmanhill: Do you have success with the Epley maneuver?

Amy_Cassady_PT: Yes.

beekmanhill: What does Cleveland Clinic's course of therapy for vertigo consist of? I've had therapy at Rusk Institute.

Amy_Cassady_PT: An evaluation is done first to determine what a person's symptoms are. The plan of care is determined based on the symptoms and findings of that evaluation. Based on the source of the symptoms, people may only come a few visits or for a number of visits over weeks or a few months. We re-assess on a regular basis to determine the need for continuing PT or discontinuing it.

beekmanhill: Are there any known effects/causations between alcohol - wine specifically - and vertigo episodes?

Kay_Cherian_PT_MPT_Cert__MDT: Alcohol dehydrates you and decreases the function of the vestibular system by altering the pH balance. Simply, it affects how the brain perceives the signals from the vestibular system.


Medication

beekmanhill: I've been prescribed both Meclizine and Valium. They seem to provide no benefit. Do you have any data on their effectiveness?

Kay_Cherian_PT_MPT_Cert__MDT: You should discuss this with your doctor. These medications suppress your vestibular system. It is possible that the medications are not addressing the source or origin of the problem.

turner98: Does vestibular therapy include medication or is it only physical therapy?

Amy_Cassady_PT: Physical therapy is a large part of treatment for vestibular disorders. Sometimes medication is used, but this is determined by your physician.


General Questions

tanker: Please comment on the effect of Reiki treatments.

Kay_Cherian_PT_MPT_Cert__MDT: I am unfamiliar with Reiki and its effects on vestibular disorders. We do use massage of the neck and jaw, when indicated, on our dizzy patients.

sunsetorange: I have tinnitus. Is there a relation between the two? [VESTIBULAR DISORDER?]

Kay_Cherian_PT_MPT_Cert__MDT: What a good question! We do see a connection but this is yet to be supported with research. A common finding in the two disorders is often the cervical spine. We see cervical spine loss of motion, sometimes pain and headaches in both disorders. With treatment of the neck and any deficits identified, the symptoms decline.

gadapea: Is vestibular rehab offered at most hospitals or rehab centers? Where do you find out about vestibular rehab in various parts of the country?

Amy_Cassady_PT: Vestibular rehab is offered at many facilities, typically in outpatient departments, which may or may not be associated with a hospital. To find a provider in your area, you may want to call your local hospital to see if this is a service they offer. The other option is to look at the Vestibular Disorders Association Web site (vestibular.org). They have a tab to help locate a provider.

gogreen: Is this type of specialized therapy normally covered by insurance?

Kay_Cherian_PT_MPT_Cert__MDT: Typically yes, but you need to review your insurance plan for physical therapy coverage. When scheduling, make sure to ask the office; they usually will also check into your benefits.

gadapea: What medical doctor would do the best evaluation, ear, nose and throat (ENT), internal medicine, neurologist, or cardiologist?

Kay_Cherian_PT_MPT_Cert__MDT: An ENT and/or a Neurologist would be your best options. When calling to schedule with either of these specialists, you should request a doctor who specializes in dizziness.

JL75: Are there any new equipment or techniques that are available to treat vestibular issues?

Kay_Cherian_PT_MPT_Cert__MDT: Oftentimes we need to use our video system to assess patients with disorders. The system consists of a set of goggles and an infrared camera. We use this to monitor the movements of the eye. The eye movements help us to diagnose the problem and, if needed, treat the problem.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with physical therapists Kay Cherian and Amy Cassady is now over. Thank you both, again, for taking the time to answer our questions about vestibular disorders.

Kay_Cherian_PT_MPT_Cert__MDT: This was a great experience. Thank you for all the questions and I hope that our responses were beneficial.

Amy_Cassady_PT: Thank you for all the questions and interest in this topic!


More Information
  • To make an appointment with Amy Cassady, Kay Cherian or any of the other vestibular rehabilitation specialists in the Department of Physical Medicine & Rehabilitation at Cleveland Clinic, please call 216.445.8000 or toll-free at 800.223.2273 ext. 58000. You can also visit us online at clevelandclinic.org/vestibular.
  • A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult.
  • If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!
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