Vestibular Rehabilitation: Examination and Treatment

Vestibular
Rehabilitation:
Examination
and Treatment
of BPPV
Kathy Joy, PT, MBA
Braintree Rehabilitation Hospital
(781) 348-2500, ext. 312802
Program Overview
 Anatomy and Physiology
 Roles of the vestibular system
 Categories of vestibular disorders
-BPPV, spontaneous, chronic
 Treatment options for BPPV
 Vestibular injury s/p traumatic head and neck injuries
(Treatment considerations)
Incidence of Dizziness (VEDA)
www.vestibular.org
 8 million PCP visits annually (2.5%)
 2nd leading cause for PCP visit in adults
 #1 for people over age of 65
 40-50%
40 50% caused by vestibular system disorder
 Etiology for 80% of above is inner ear pathology
 42% of the population (90 million) will complain of dizziness
at least once in their lifetime (NIH)
1
Causes of Vertigo
 Vestibular
 Neurological
 Orthostatic Hypotension
 Migraine / Vascular Disease
 Cervicogenic
 Anxiety / Phobic Disorders
 Other
Vestibular injury following posttraumatic head and neck injuries
 Incidence of vertigo sx :
50-78%
 Difficult to treat due to
combination of deficits
 Lack of clear guidelines
for return to work
Roles of the Vestibular
System
 Inertial guidance system: detecting gravity
 Detects head position in space
 Promotes gaze stability through VOR
 Resolution of sensory conflict
 Influences muscle tone for postural control
2
Review of Vestibular System
 Peripheral Vestibular System:
 semicircular canals, otoliths and the eighth cranial nerve
Membranous Labyrinth
Herdman; Vestibular Rehabilitation,
2007
Labyrinth
3
Physiology of the Labyrinth
 Push - Pull arrangement
 Resting vestibular tone (resting discharge frequency) is
modulated, up or down, according to the direction of
head rotation.
Semicircular Canals
Specific gravity relationship
Herdman; Vestibular Rehabilitation, 2007
Otolithic Macula
Herdman; Vestibular Rehabilitation, 2007
4
Sensory End Organs
 OTOLITHS
 Low frequency receptors
 Directionally specific
 Responds to linear
accelerations/ GRAVITY
 Does not respond to constant
velocity motion
 Otoconia in macula serve as
inertial mass
 Pathology: static postural
problems; difficulty
detecting vertical
 SEMICIRCULAR CANALS
 Medium-high frequency
receptors
 3° of rotational freedom
 Responds to angular head
motions, not to gravity
 Responds to movement along
a curve
 Pathology: results in a sense
of spinning; head
movement-related
symptoms
Review of Vestibular System
 Central Vestibular
System:
 Vestibular nuclei and
th i projections
their
j ti
iinto
t
the brainstem, pons,
midbrain, cerebellum,
cortex and spinal cord
Vestibulo-Ocular Reflex (VOR)
5
Categories of Vestibular
Disorders
 Paroxysmal Positional Disorders
 Acute Paroxysmal Spontaneous Disorders
 Acute Onset-Gradual Resolution/Chronic Disorders
Symptom Presentation
•
•
•
•
•
•
•
•
•
*Positional Vertigo : BPPV
Movement-provoked spatial disorientation
Visual flow deficits
Distorted vision
*Dysequilibrium/Ataxia
*Neck restriction
Headache
*Nausea
*Anxiety
Clinical Examination of the
Vertiginous Patient
 Thorough History
 PMH/DHI
 Nature of initial episode/
duration
 Activities being performed
 Functional limitations
 Provocation/reduction
factors
 Describe symptoms
 Vertigo versus spatial
disorientation
 Intermittent versus
continuous
 associated symptoms of
nausea, vomiting
 Changes during the day
6
Benign Paroxysmal
Positional Vertigo
 Brief Paroxysms of positional vertigo
 Duration: less than one minute
 Initial imbalance following an episode
 ?Spatial disorientation
 Autonomic symptoms: nausea, diaphoresis
Neuro-Otologic Examination
Nystagmus
 Non-voluntary rhythmic oscillations of the eyes
• described by the direction of the fast phase
• describe latency
latency, intensity
intensity, direction
direction, duration
Neuro-Otologic Examination
Nystagmus
 Physiologic versus Pathologic
• Physiologic nystagmus induced with natural or external
st ul .
stimuli.
7
Rotational Chair
Nystagmus
 Physiologic versus Pathologic
 Pathological nystagmus can be spontaneous, gaze-evoked,
positional
Positional Nystagmus
 Positional nystagmus
 Traditional classifications: lesions of the otoliths,
vestibular nuclei and cerebellum.
 More recent concept: alteration in the specific gravity of
the semicircular canal endolymph or cupula
8
Positional Nystagmus
 Paroxysmal positional nystagmus
provocative movement is in the plane of the canal
 benign paroxysmal positional nystagmus
 central positional nystagmus
BPPV
Distorted Function:
 Benign Paroxysmal
Positional Vertigo
– Cupulolithiasis
– Canalithiasis
Cupulolithiasis
9
Canalithiasis
Otoconia
Furman JNEJM,341(21)1999
Paroxysmal Positional Vestibular
Disorders
 ETIOLOGIES
 Idiopathic
 Degenerative
 Post-traumatic
 TBI, mild head injury, whiplash
 Post-acute vestibulopathy (viral)
 Prolonged bedrest or post-surgical
10
Clinical Examination
 History
 Vestibulo-ocular exam
 Vestibulospinal exam
 Postural control
 Other systems
 musculoskeletal, cognitive, behavior
Clinical Examination
 Vestibulo-ocular function:




Ocular alignment
Smooth pursuit
Saccades
VOR/Gaze stability
Clinical Examination
Vestibulo-ocular reflex:




VOR: Head thrust, Head shaking nystagmus
VOR: x1 viewing
VOR: Dynamic visual acuity (Snellen Chart,
Chart LogMar)
VOR cancellation
11
Clinical Examination
BPPV
 Positional provocation testing
 Dix-Hallpike: “Gold Standard”
 Sidelying test
 Roll test/ lateral canal test
 Cohen, HS, Otology & Neurology 25a; 130-134, 2004
Positional Provocation Testing
 Purpose
 Identify the involved canal(s)
 Lateralize
 Identify type (cupulo/canal)
Comparison of BPPV by canal
type
(neurology,May 2008Fife etal)
Posterior
Horizontal
Anterior
Estimated
frequency
81-89%
8-17%
1-3%
Provocative
maneuver
Dix-Hallpike
p
Supine
p Roll Test
(Pagnini-McClure)
Dix-Hallpike
p
Nystagmus
Upbeat, torsional
Horizontal
Direction Changing
Downbeat, torsional
12
Clinical Examination
Positional Testing
 Dix-Hallpike Test
 Seated VA test
Sidelying Test
Describing Nystagmus
 Latency
 Direction
 Duration
 Reversal
 (Fatigability)
13
Positional Nystagmus
 Peripheral
 Central

1-40 second latency

No latency

Torsional component
component*

V i d nystagmus
Varied

Crescendo / decrescendo

Lasts as long as positioned

Fatigues with repetition

Does not fatigue with

Vertigo symptoms

Geotropic vs. Ageotropic
repetition

(horizontal canal)
No symptoms
Duration of Nystagmus
 <60 seconds: canalithiasis
 Crescendo / decrescendo:
 >60 seconds/persistent: cupulolithiasis or central
 No change in intensity with central
Direction of Nystagmus
 Torsional
 Posterior or anterior canal
 No torsional component : horizontal canal
 Upbeating
p
g / Downbeating
g
 Torsional upbeating: posterior
 Torsional downbeating: anterior
 Right-beating / Left-beating
 (Counterclockwise versus clockwise)
14
Right posterior canalithiasis
Left posterior canalithiasis
Left posterior canalithiasis
15
Reversal of Nystagmus
 Nystagmus often reverses direction with return to
sitting (BPPV)
Fatigability
 Fatigues with repetition: canalithiasis
 Decrease in intensity but persistent: cupulo
 Does not fatigue: central
Intervention
 Canal Involvement
 Repositioning Maneuvers
 Canalith Repositioning Maneuvers
 CRT,
CRT CRM
CRM, PRM
PRM, Epley; use of vibration
 Liberatory/Semont
 Horizontal canal maneuvers
 Brandt-Daroff
16
Repositioning Maneuvers –
Canalith-Repositioning /Epley
Furman J NEJM, 341(21), 1999
Repositioning Maneuvers Liberatory
Considerations for
Anterior Canal BPPV
Difficulty lies in determining which side to treat
Right Dix Hallpike test:
downbeat and torsional to left = Left anterior
downbeat and torsional to right = Right anterior
17
Canal Involvement based on
Direction of Nystagmus: ( R) DixHallpike
(Herdman, Vestibular Rehabiitation, 2007)
CANAL
Right Dix-Hallpike
Reversal Phase
Right posterior
Upbeat, torsional
right
g
Downbeat, torsional Downbeat, torsional
left
left
Return to Sitting
Right anterior
Downbeat, torsional Upbeat, torsional
right
left
Upbeat, torsional
left
Left anterior
Downbeat, torsional Upbeat, torsional
left
right
Upbeat, torsional
right
Roll Test
Horizontal Canal BPPV
 Brief nystagmus that fatigues and is geotrophic:
canalithiasis
 Prolonged nystagmus and is ageotrophic: cupulolithiasis
18
Horizontal canal nystagmus
Geotropic
Ageotropic
Left horizontal canalithiasis
Right horizontal canalithiasis
19
Determining the Side with
H i
Horizontal
t l Canal
C
l BPPV
Bow and Lean Test
Choung YH et al, Laryngoscope 116, 2006
Repositioning Maneuvers
Horizontal Canal Involvement
Repositioning Maneuvers
Horizontal Canal Involvement
360 degree barrel roll
270 degree roll
20
Repositioning Maneuvers
Horizontal Canal Involvement
-Cassani et al in Laryngoscope 2002
-Appiani et al in Otology and Neurol 2001
-Vannuchi et al in Jvest Res 1997
(Forced Proglonged Position: FPP)
Subjective BPPV
How much time in each position?
 Varies in the literature
 Clinically have seen no difference between 2 minutes
and 30 seconds
 Epley’s rule: onset + duration = length of time in each
position
 Clendaniel: double length of nystagmus
21
Home Guidelines
 Remain upright for 24-48 hours
 Do not lie on affected side
 Avoid extreme flexion and extension of the head and
trunk.
trunk
 Avoid lateral tilt for horizontal canal
 Soft collar, towel
 Start head movement exercises after 48 hours
 Resistance to Treatment??
Brandt-Daroff
22
Prognosis
 85 -95% remission of symptoms
 Course of Treatment: 2-6 visits
 Recurrence rate: 20-30%
 Co-morbidity considerations
 Head/Neck pain
 Fatigue
Complications
 Conversion to a different canal
 Nausea and vomiting during or after treatment
E l Omniax
Epley
O i
http://www.arrigg.com/epley-omniax
23
ANXIETY
Alternative Treatments
 Canal Plugging
 Singular nerve section
24
250 Pond Street, Braintree MA 02184
(781) 348-4012 Fax (781) 356-4222
DIZZINESS & BALANCE DISORDERS
Diagnostic & Therapy Services
Almost half of the adult population, in the United States reports episodes of dizziness, vertigo and balance
problems to their doctors every year. Dizziness or imbalance is the second most common reason for visits to the
doctor’s office, second only to back problems. People in all age groups can experience episode of poor balance,
dizziness and frequent falls.
The vestibular system, or balance system, is the sensory system that provides the dominant input about
movement and our sense of balance. It is one of the physiological senses related to balance. Other senses play
roles as well, for instance our visual system and proprioception. Fifty percent of community-dwelling adults who
see their physician with symptoms of dizziness or vertigo have a problem somewhere in the vestibular system and
80% of those folks have inner ear or peripheral vestibular deficits. Between 33% and 50 % of the general elderly
population fall at least once a year. As a result, they often become afraid to venture out of their own homes.
Everyone experiences dizziness differently. For many, dizziness is experienced as a sensation of
lightheadedness or faintness. Many experience dizziness as the feeling of motion even if they are not moving.
Others report a sensation of spinning in which they are moving or their environment is spinning around them
(vertigo). Describing exactly what you experience when you feel dizzy will help your doctor determine the cause.
Nausea and anxiety may also accompany your dizziness. Dizziness can occur along side other symptoms such as
pressure or fullness in the head or ears and ringing in the ears (tinnitus). It is important to report these
symptoms to your doctor.
Who is at risk?
People with one of the following diagnosis can have balance and gait disorders.
•
BPPV (Benign Paroxysmal Positional
Vertigo)
• Peripheral or Central Vestibular Deficits
• Head Injury
•
•
Brainstem or Cerebellar CVA
Extrapyramidal Disorders. i.e. Parkinson’s
Disease
• Peripheral Neuropathy
Possible causes of these symptoms include:
•
•
Inner ear infection and / or disease
• Sports Injury or Cervical whiplash injuries
Stroke
• General muscle weakness or inflexibility
● Head injury as a result of falls, blows to the head or motor vehicle accidents
Over → → →
Why am I dizzy?
Although there are many causes of dizziness, for 85% of the people who experience this symptom, the
problem is due to changes in the “Vestibular System.” The Vestibular system is the part of the inner ear that
helps to control balance and body orientation. Your vertigo may be due to a mechanical problem in the inner
ear. Dizziness may also be related to a loss of balance control.
Balance control also comes from input from the eyes, muscles and joints. When you have an inner ear
disorder, your brain cannot rely on the information received from your Vestibular system. As a result, your body
becomes dependent on your systems, such as vision and your muscles and joints to maintain steady balance.
Lifestyle changes because of your dizziness
You have probably already adjusted the way you carry out your daily activities to prevent an increase in
your symptoms. For example, by limiting head movements, you may have found that you don’t get dizzy. Or,
you may feel more secure walking if you stay close to the wall or hold on to furniture. All of these changes,
which may seem helpful, are actually very stressful to your system and will decrease your ability to adjust to your
Vestibular problem.
Our Team of Professionals Consists of:
•
•
Otoneurology: Dr. Gregory Whitman, from the Mass, Eye & Ear Infirmary
Specialized Physical Therapists (therapy services are available at various locations)
•
Vestibular Laboratory Technicians
Your doctor may recommend you see one of our Physical Therapists first for an evaluation or a
Consultation at Braintree Rehabilitation Hospital with Dr. Gregory Whitman: (617) 573-6700
Physical Therapy: Dizziness & Balance Treatment Services
Although dizziness is a common symptom, living with this problem can significantly impact a person's
lifestyle and function. Traditionally, dizziness has been treated with medication. Many balance problems, on the
other hand, have been addressed with adaptive equipment such as straight canes or walkers. Today, a variety of
new treatment opportunities exist for people with balance and dizziness disorders.
Balance is a multifactorial neurological function. Disorders of balance invariably involve several
components of balance function. We identify the critical factors that are impaired in a balance disorder.
Treatment is directed specifically toward the identified balance deficits and utilizes newly devised clinical
protocols.
Vestibular Physical Therapy utilizes specialized exercises to address specific areas of the individual's
vestibular/balance disorder. The individual goals of vestibular rehabilitation vary, depending upon the type,
cause and duration of vertigo/disequilibrium. Your physical therapist will work with you to develop a program
to meet your specific needs.
A referral from your doctor is required to be evaluated in Physical Therapy
We can help you obtain one if necessary
What is Vestibular Therapy?
Vestibular therapy is an exercise-based approach with an emphasis on teaching the body to compensate
for inner ear deficits. With therapy, patients ultimately experience a decrease in dizziness, improved balance
function and an overall increase in activity level. Secondary symptoms of decreased range-of-motion and strength
(especially in the neck and shoulder region of the body) often leads to headaches and increased muscle tension.
Physical therapy also alleviates these symptoms.
What Happens During Therapy?
A thorough evaluation will be done at your first therapy appointment. Your physical therapist will
carefully assess your dizziness balance control, strength, flexibility, walking and safety during certain functional
activities. A specific program will be designed for you, based on your individual needs. This may include
specific head positioning maneuvers to decrease symptoms of vertigo, and / or balance retraining exercises to be
performed both with your physical therapist and at home. You will also be provided with educational information
to help you become more aware of the correct ways to move and maintain your balance. With time and consistent
work, therapy will teach you how to gain control of your balance system and, in a majority of cases, dramatically
reduce your symptoms of dizziness, vertigo and nausea.
Therapy Treatment Outpatient Locations:
Abington: (781) 871-6918
Braintree: (781) 348-4012
Brockton: (508) 586-6391
Milford: (508) 478-5775
Plymouth: (508) 747-4720
Taunton: (508) 880-8721
Otoneurology & Diagnostic Services
The Vestibular and Balance Disorders Services offered at Braintree Rehabilitation Hospital uses both the
clinical expertise of an Neurotologist, Dr. Steven D. Rauch, specially trained therapists and the most advanced
computerized technology to provide a complete evaluation, diagnosis and treatment recommendations for
dizziness and balance disorders. The outcome of treatment can be specifically reevaluated using these devices.
At present, the computerized devices available for diagnostic evaluation and rehabilitation are a computerized
rotary chair system, dynamic posturography and balance master.
Dynamic Posturography (Equilibrium Platform Test)
These are a series of tests that measure how well you are able to maintain your balance under different conditions.
You will be asked to stand as steadily as possible on a platform inside a booth. The platform will have sensors
that measure how well you maintain your balance as the walls of the booth move around you and the surface you
are standing on moves under your feet. The tests will be conducted with your eyes open and with your eyes
closed. You will be supported by a safety harness in case you become unsteady. Some of the tests are designed to
mimic different conditions you encounter in every day life. Other tests are designed to determine the source of
your balance problem. The computerized tests are able to isolate the different sensory information you rely on to
maintain your balance.
The test results provide a better understanding of your balance problem and can point to possible causes.
This allows your doctor to focus on the abnormal system. Six test conditions will be performed using three 20second trials for each. This test takes between 20 to 30 minutes.
Rotary Chair System
You will be seated on a rotating chair placed in a darkened room with electrodes on your eyes to measure
their movements. The chair will rotate back and forth at different speeds to see how your eyes move in response
to rotations when you cannot see anything. You will also be asked to keep your eyes on a small light while the
chair rotates. You will be given mental tasks during these tests to keep you alert, because your eyes will not move
as accurately if you get drowsy. Some laboratories also test your responses to rotation with your eyes open and
viewing visual patterns.
Vestibular Function Test: This test measures the vestibular-occular reflex. During head movements the
vestibular system (located in the inner ear) sends signals to your occular (eye) muscles to stabilize your
vision. This test will assess this reflex. You will be fitted with a headpiece that houses two small cameras
to record eye movements. Afterwards, you will be seated in a chair within a six-foot enclosure. The chair
will move slowly back and forth to stimulate the reflex while the mounted cameras record eye movements.
The test is made up of 8 parts, the longest lasting 3 minutes. Breaks can be taken between tests as needed.
The entire test time should not exceed 30 minutes.
Visual-Vestibular Integration Test: Test preparation is described above. Testing determines your ability
to either enhance or suppress your vestibular reflex. During testing you will be instructed to follow certain
target with your eyes without the chair moving. Test time is 15 minutes.
Balance Master
Computerized Balance Training: This system uses forceplate technology to allow for objective
measurement of the patient's center of mass/gravity and limits of stability. The patient utilizes visual biofeedback
to help facilitate the development of static and dynamic balance skills.
Electronystagmography (ENG) Call our Audiology Department: 781-348-2209
This three-part test assesses your balance system under varying conditions and is performed by an
audiologist in our Audiology Department here at Braintree Hospital. Due to the interconnected nature of your
vestibular (balance) system and your visual (occulomotor) reflex, measuring eye movement can provide
important information with regard to balance system functioning. ENG detects and records rapid eye movements,
called nystagmus, through the use of electrodes or goggles. The first part of the test involves following visual
targets with your eyes. In the second part, eye movement is recorded as you lie in different positions. The final
component of this test involves irrigating each ear with cool and warm air. By irrigating each ear separately, the
balance mechanism on each side can be stimulated and measured independently.
Neurotology consultation with Dr. Steven D. Rauch and our Diagnostic Center: (781) 348-3801
We accept all major insurances including Medicare, Mass Health,
All BCBS plans, BMC Healthnet, Fallon, Workers Compensation & MVA's
DIZZINESS & BALANCE DISORDERS
www.braintreerehabhospital.com
Almost half of the adult population in the United
balance problems to their doctors every year.
disorders can be devastating. Living with these
person’s lifestyle and function. Between 33% and
fall at least once a year.
States reports episodes of vertigo and
The impact of dizziness and balance
symptoms can significantly impact a
50% of the general elderly population
Equilibrium and balance control depends upon multiple systems working together, ie:
vestibular, visual, somatosensory. Impairments in one or more of these systems can
lead to vertigo, dizziness and/or imbalance. Our experts work to identify the critical
factors contributing to a patient’s symptoms. Treatment is directed specifically toward
the identified deficits and utilizes current clinical protocols.
Patients can be referred to us if they have had a pattern of clinical findings as well as a
collection of symptoms and complaints in the following categories:
Vestibular loss/BPPV, Disequilibrium or Balance Disorders
Assessment Battery: Includes a thorough medical history, vestibular function tests, if
indicated assessment of; balance, gaze stabilization, strength, endurance, range of
motion, safety and overall function in daily activities. This examination and assessment
provides a more efficacious evaluation of each patient’s condition, allowing for
appropriate treatment intervention.
Indications for a referral:
♦ History of disequilibrium and imbalance
♦ Vertigo, dizziness or movement-provoked spatial disorientation
♦ History of falls
Possible causes of symptoms include:
♦ Vestibular Disorder: post-labyrinthitis, neuronitis, BPPV, ototoxicity, degeneration,
post-surgery
♦ Parkinson’s Disease / Multiple
♦ Stroke (brainstem or cerebellar)
Sclerosis
♦ Head Injury
♦ Cervical whiplash injuries
♦ General muscle weakness, inflexibility
♦ Peripheral Neuropathy
Outpatient Locations for Therapy Services
Abington: (781) 871Milford:
Brockton: (508) 5866918
5775
6391
Braintree: (781) 3484012
(508) 478-
Plymouth:
747-4720
(508)
Taunton: (508) 8808721
OTONEUROLOGY CONSULTATIONS: with Dr. G. Whitman from:
Located Braintree Rehabilitation Hospital (617) 573-6700
Braintree Rehabilitation Hospital Outpatient Vestibular Physical Therapy
Your doctor has referred you to Vestibular Physical Therapy because of dizziness,
vertigo or imbalance. You may be experiencing a spinning sensation (vertigo)
with head movements, a sense of “wooziness” when walking, or unsteadiness on
your feet in certain environments. The best way to determine your treatment
options is to specifically evaluate your symptoms.
WHY AM I DIZZY?
Although there are many causes of dizziness, for 85% of the people who experience this
symptom, the problem is due to changes in the “Vestibular System.” The Vestibular system is
the part of the inner ear that helps to control balance and body orientation. Your vertigo may
be due to a mechanical problem in the inner ear. Dizziness may also be related to a loss of
balance control.
Balance control also comes from input from the eyes, muscles and joints. When you have an
inner ear disorder, your brain cannot rely on the information received from your Vestibular
system. As a result, your body becomes dependent on your systems, such as vision and your
muscles and joints to maintain steady balance.
LIFESTYLE CHANGES
You have probably already adjusted the way you carry out your daily activities to prevent an
increase in your symptoms. For example, by limiting head movements, you may have found
that you don’t get dizzy. Or, you may feel more secure walking if you stay close to the wall or
hold on to furniture. All of these changes, which may seem helpful, are actually very stressful
to your system and will decrease your ability to adjust to your Vestibular problem.
WHAT IS VESTIBULAR THERAPY?
Vestibular therapy is an exercise-based approach with an emphasis on teaching the body to
compensate for inner ear deficits. With therapy, patients ultimately experience a decrease in
dizziness, improved balance function and an overall increase in activity level.
Secondary symptoms of decreased range-of-motion and strength (especially in the neck and
shoulder region of the body) often leads to headaches and increased muscle tension.
Physical therapy also alleviates these symptoms.
WHAT HAPPENS DURING VESTIBULAR THERAPY?
A thorough evaluation will be done at your first therapy appointment. Your physical
therapist will carefully assess your dizziness balance control, strength, flexibility, walking
and safety during certain functional activities.
A specific program will be designed for you, based on your individual needs. This may
include specific head positioning maneuvers to decrease symptoms of vertigo, and / or
balance retraining exercises to be performed both with your physical therapist and at home.
You will also be provided with educational information to help you become more aware of
the correct ways to move and maintain your balance.
With time and consistent work, therapy will teach you how to gain control of your balance
system and, in a majority of cases, dramatically reduce your symptoms of dizziness, vertigo
and nausea.
Braintree Rehabilitation Hospital Outpatient Locations for Therapy
Services
Abington: (781) 8716918
Braintree: (781) 3484012
Brockton: (508) 5866391
Milford: (508) 4785775
Plymouth: (508) 7474720
Taunton: (508) 8808721
OTONEUROLOGY CONSULTATIONS: with Dr. G. Whitman from
6700
Located Braintree Rehabilitation Hospital (617) 573-
2010
Brain Injury Association of Massachusetts
Vestibular Providers
This list is not an endorsement by BIA-MA but a potential resource of
available providers in the state.
Please contact them for more information.
Support Groups
(Online) www.facebook.com/vestibulardisorders
(in person) Massachusetts
• Metro Boston
Claire Haddad
Boston-Area Vestibular Disorders Support Group
10 Heritage Ln.
Cohasset, MA 02025
(781) 383-0253 (please call between 9am and 8pm)
e-mail
meeting location: Newton-Wellesley Hospital
Newton, MA
Professionals (see next page)
Professionals
1) Fred G. Arrigg, Jr., MD
ENT/Otolaryngologist
Otologist
Otoneurologist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
Arrigg Eye & Ear Associates
439 S. Union St., Bldg. 1, Ste. 101
Lawrence, MA 01843 U.S.A.
(978) 686-2983
(978) 686-0684 (fax)
2) Susan Barros, PT
Physical Therapist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
Braintree Rehabilitation Clinic at Sharon
778 S Main St.
Sharon, MA 02067 U.S.A.
(781) 784-0920
(781) 784-0925 (fax)
3) Maureen Murphy Billotte, PT
Physical Therapist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
Jordan Hospital Rehab
10 Cordage Park Circle
Suite 225
Plymouth, MA 02571 U.S.A.
(508) 830-2182
(508) 830-2172 (fax)
4) Lisa G. Blain, OTR/L
Occupational Therapist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
Weldon Rehabilitation Hospital
233 Carew St.
Springfield, MA 01104 U.S.A.
(413) 748-6955
(413) 748-6939 (fax)
5) Nancy Cohen, AuD, CCC-A
Audiologist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
Lahey Clinic Medical Center
41 Mall Road
Burlington, MA 01805 U.S.A.
(781) 744-2528
(781) 744-7540 (fax)
6) Kathleen Gill-Body, DPT, MS, NCS
Physical Therapist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
Newton Wellesley Hospital
2015 Washington Street
Newton, MA 02462 U.S.A.
(617) 243-6172
7) Beth Shane Grill, PT
Physical Therapist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
Spaulding Framingham Outpatient Center
570 Worcester Road
Framingham, MA 01702 U.S.A.
(508) 872-2200
8) Craig A. Jones, MD
ENT/Otolaryngologist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinics
Cape Cod Ear, Nose, & Throat Specialists
800 Falmouth Rd., Ste. 102A
Mashpee, MA 02649 U.S.A.
(508) 539-2444
(508) 539-9923 (fax)
9) Patricia Jung, PT
Physical Therapist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
Cooley Dickinson Hospital
30 Locust Street
Northampton, MA 01060 U.S.A.
(413) 582-2113
10 ) Theresa O'Neil, DPT, MS, OCS
Physical Therapist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
Winchester Hospital Orthopaedics Plus
Choate Medical Center
23 Warren Ave.
Woburn, MA 01801 U.S.A.
(781) 932-8866
11) Dennis S. Poe, MD
ENT/Otolaryngologist
Neurotologist
Otologist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
Department of Otolaryngology
Children’s Hospital
300 Longwood Ave.
Boston, MA 02115 U.S.A.
(617) 355-6462
12) Pam Proulx, PT
Physical Therapist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
Baystate Rehabilitation Care
360 Birnie Ave.
Springfield, MA 01199 U.S.A.
(413) 794-1600, ext. prompt 1
13) Steven D. Rauch, MD
ENT/Otolaryngologist
Otologist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
Massachusetts Eye & Ear Infirmary
243 Charles St.
Boston, MA 02114 U.S.A.
(617) 573-3644
14) Kristen Schimley, MSPT, CSCS
Physical Therapist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
NovaCare Rehabilitation
9 Pond Lane
Damonmill Square
Concord, MA 01742 U.S.A.
(978) 369-9996
15) Susan Mercure Slysz, PT
Physical Therapist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
AEEA Center for Balance Hearing & Dizziness
439 S Union St., Ste. 101
Lawrence, MA 01843 U.S.A.
(978) 686-2983
16) Gary Stanton, MD
Neurologist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
131 Ornac, Ste. 600
Concord, MA 01742 U.S.A.
(978) 371-8935
17) Susan Teehan, PT
Physical Therapist
This provider indicates that he/she is trained to perform in-office BPPV Maneuvers (e.g.,
Epley).
Clinic
Caritas Norwood Hospital Rehab Services
800 Washington St.
Norwood, MA 02062 U.S.A.
(781) 769-4000
Dizziness (Vestibular) and Balance Disorders
Almost half of the adult population, in the United States reports episodes of dizziness, vertigo
and balance problems to their doctors every year. Dizziness or imbalance is the second most
common reason for visits to the doctor's office, second only to back problems. People in all age
groups can experience episode of poor balance, dizziness and frequent falls.
The vestibular system, or balance system, is the sensory system that provides the dominant input
about movement and our sense of balance. It is one of the physiological senses related to
balance. Other senses play roles as well, for instance our visual system and proprioception. Fifty
percent of community-dwelling adults who see their physician with symptoms of dizziness or
vertigo have a problem somewhere in the vestibular system and 80% of those folks have inner
ear or peripheral vestibular deficits. Between 33% and 50 % of the general elderly population
fall at least once a year. As a result, they often become afraid to venture out of their own homes.
Everyone experiences dizziness differently. For many, dizziness is experienced as a sensation of
lightheadedness or faintness. Many experience dizziness as the feeling of motion even if they are
not moving. Others report a sensation of spinning in which they are moving or their environment
is spinning around them (vertigo). Describing exactly what you experience when you feel dizzy
will help your doctor determine the cause. Nausea and anxiety may also accompany your
dizziness. Dizziness can occur along side other symptoms such as pressure or fullness in the
head or ears and ringing in the ears (tinnitus). It is important to report these symptoms to your
doctor.
Who is at risk?
Patients with one of the following diagnosis can have balance and gait disorders.
•
BPPV (Benign Paroxysmal Positional Vertigo)
•
Peripheral or Central Vestibular Deficits
•
Head Injury
•
Brainstem or Cerebellar CVA
•
Extrapyramidal Disorders
•
Peripheral Neuropathy
Possible causes of these symptoms include:
•
Inner ear infection and / or disease
•
Stroke
•
Sports Injury
•
General muscle weakness or inflexibility
•
Head injury as a result of falls, blows to the head or motor vehicle accidents
The Vestibular and Balance Disorders Services offered at Braintree Rehabilitation Hospital uses
both clinical expertise and the most advanced computerized technology to provide a complete
evaluation, diagnosis and treatment recommendations for dizziness and balance disorders. The
outcome of treatment can be specifically reevaluated using these devices. At present, the
technology for diagnostic evaluation and rehabilitation are a computerized rotary chair system,
dynamic posturography and static forceplate postural feedback rehabilitation device. We also
offer Electronystagmography (ENG) through our Audiology Department.
Our team of professionals consists of:
•
Otoneurologist
•
Specialized Physical Therapists
•
Vestibular Laboratory Technicians
The Vestibular and Balance Disorders Services are a regional diagnostic center providing
specialized testing to help determine the cause of each person's symptoms. A network of
community-based treatment centers carry out the prescribed therapy services.
Treatment Services: Physical Therapy
Although dizziness is a common symptom, living with this problem can significantly impact a
person's lifestyle and function. Traditionally, dizziness has been treated with medication. Many
balance problems, on the other hand, have been addressed with adaptive equipment such as
straight canes or walkers. Today, a variety of new treatment opportunities exist for people with
balance and dizziness disorders.
Balance is a multi-factorial neurological function. Disorders of balance invariably involve several
components of balance function. We identify the critical factors that are impaired in a balance
disorder. Treatment is directed specifically toward the identified balance deficits and utilizes
newly devised clinical protocols
Vestibular Physical Therapy utilizes specialized exercises to address specific areas of the
individual's vestibular/balance disorder. The individual goals of vestibular rehabilitation vary,
depending upon the type, cause and duration of vertigo/disequilibrium. Your physical therapist
will work with you to develop a program to meet your specific needs.
Why Am I Dizzy?
Although there are many causes of dizziness, for 85% of the people who experience this
symptom, the problem is due to changes in the "Vestibular System." The Vestibular system is the
part of the inner ear that helps to control balance and body orientation. Your vertigo may be due
to a mechanical problem in the inner ear. Dizziness may also be related to a loss of balance
control. Balance control also comes from input from the eyes, muscles and joints. When you have
an inner ear disorder, your brain cannot rely on the information received from your Vestibular
system. As a result, your body becomes dependent on your systems, such as vision and your
muscles and joints to maintain steady balance.
Lifestyle Changes
You have probably already adjusted the way you carry out your daily activities to prevent an
increase in your symptoms. For example, by limiting head movements, you may have found that
you don't get dizzy. Or, you may feel more secure walking if you stay close to the wall or hold on
to furniture. All of these changes, which may seem helpful, are actually very stressful to your
system and will decrease your ability to adjust to your Vestibular problem.
What Is Vestibular Therapy?
Vestibular therapy is an exercise-based approach with an emphasis on teaching the body to
compensate for inner ear deficits. With therapy, patients ultimately experience a decrease in
dizziness, improved balance function and an overall increase in activity level. Secondary
symptoms of decreased range-of-motion and strength (especially in the neck and shoulder region
of the body) often leads to headaches and increased muscle tension. Physical therapy also
alleviates these symptoms.
What Happens During Vestibular Therapy?
A thorough evaluation will be done at your first therapy appointment. Your physical therapist will
carefully assess your dizziness balance control, strength, flexibility, walking and safety during
certain functional activities. A specific program will be designed for you, based on your
individual needs. This may include specific head positioning maneuvers to decrease symptoms of
vertigo, and / or balance retraining exercises to be performed both with your physical therapist
and at home. You will also be provided with educational information to help you become more
aware of the correct ways to move and maintain your balance. With time and consistent work,
therapy will teach you how to gain control of your balance system and, in a majority of cases,
dramatically reduce your symptoms of dizziness, vertigo and nausea.