BalanceMD BPPV - Benign Paroxysmal Positional Vertigo

BalanceMD's Lafayette Office Turns 10 Today!

It was February 12, 2007 when BalanceMD (then known as Indiana Neuro-ophthalmology & Center for Balance) opened it's doors in Lafayette, IN.  We have grown from having an office manager and one front office staff to having an office manager, 4 front office staff, a nurse, 2 audiologists and a physical therapist.  We opened a second office in Indianapolis in 2011.  

We are proud to say that we have been privileged to serve patients from the entire state of Indiana as well as surrounding states, including Michigan, Illinois, Ohio, Kentucky and even Georgia.

We would like to thank our patients and referring doctors and all of those who have contributed to our success over the years.  We plan to continue to provide the highest level of care to patients suffering from vestibular disorders (dizziness, vertigo and imbalance) for many years go come.

Thank you!

Vestibular Rehabilitation Therapy Works Best When Diagnosis is Known

Vestibular rehabilitation therapy (VRT) is a subspecialty of physical therapy (PT), focusing on treating vestibular system disorders causing dizziness and imbalance. Vestibular therapists (VT) have training beyond what is typically received in PT school and this additional training includes recognizing the symptoms and signs of vestibular system disorders, such as Benign Paroxysmal Positional Vertigo (BPPV), vestibular nerve weakness (unilateral or bilateral), cervicogenic (neck-related) dizziness and central (brain) disorders. It is extremely important to recognize the various vestibular system disorders and have an accurate diagnosis because the type of VRTthat would best benefit the patient is dependent on the diagnosis. The ability for even a trained and experienced VT to diagnose a specific vestibular system disorder is limited. While VTs are trained to perform clinical tests to help determine the cause of a patient’s symptoms, the results of vestibular function testing is an invaluable tool in any VTs ability to design and implement the most optimal treatment for patients suffering from a vestibular system disorder.

Imagine, for example, a patient presenting with chest pain. There are questions and some basic clinical tests that could be performed to determine the cause of the chest pain, but laboratory tests, such as an EKG and blood tests would aid in identifying a heart attack, while a chest X-ray would help determine pneumonia or a broken rib as the source. In the same way, dizziness and imbalance may be caused by a variety of medical conditions and vestibular function testing is the best way to evaluate these symptoms when the cause is not obvious.

Results from vestibular function testing allows the skilled VT to begin the correct treatment sooner and treatment is more efficient and successful when the precise cause of dizziness or imbalance is known. Different VRT exercises are prescribed for vestibular nerve weakness (unilateral or bilateral), cervicogenic (neck-related) and central (brain) disorders. Having this knowledge leads to fewer VRT visits, which saves time and cost for the patient. In the same way, the patient with pneumonia as the cause of their chest pain may not improve as much or as quickly without the appropriate treatment with antibiotics. Unfortunately, we see many patients who have been through VRT elsewhere without significant improvement only because the proper vestibular exercises were not administered due to a lack of the correct diagnosis.

Stephanie Ford, PT, is BalanceMD’s vestibular therapist. She has extensive post-graduation training and many years of experience treating patients with vestibular system disorders. She utilizes the results of vestibular function testing in order to obtain maximal improvement in her patients.

BPPV is Over-diagnosed

What is BPPV?

BPPV (Benign Paroxysmal Positional Vertigo) is a common inner ear disorder that causes brief spells of vertigo (spinning sensation) triggered by a change in head position. For example, lying back or rolling over in bed, getting up from bed, looking up or down results in brief, 10-15 seconds of vertigo and usually no dizziness any other time. BPPV is caused by“crystals” normally present in one part of the inner ear, but become detached and displaced into another part of the inner ear where they cause vertigo with changes in head position. However, there are many patients diagnosed with BPPV who do not fit this description of symptoms or have a different cause of positional vertigo, yet are often diagnosed and unsuccessfully treated as though they had BPPV.

Why is BPPV Over-diagnosed?

BPPV has gained popularity as a diagnosis because it is a benign condition that causes vertigo and is readily diagnosed and immediately cured by a skilled healthcare provider. Patients often joke about “having a few loose rocks” in their head. BPPV is a common condition, but there are many more people diagnosed with BPPV than actually have BPPV.

How is BPPV Treated?

BPPV is treated by a “crystal repositioning maneuver” (CRM), which is designed to move the “crystals” by gravity back to where they originated, where they may be dissolved. The type of CRM utilized depends on the type of BPPV. For example, one form of BPPV is treated with a modified Epley or a Semont maneuver and another type with a Lempert roll. There is also a type of BPPV where the “crystals” are actually stuck to a membrane in the inner ear and is treated with a headshake of Gufoni maneuver. BPPV is no longer treated by the old fashioned Brandt-Daroff or Cawthorne-Cooksey exercises, or with medications, such as meclizine (Antivert). We are actually able to cure BPPV in one visit over 90% of the time with the appropriate CRM. Unfortunately, we see many patients incorrectly diagnosed with BPPV undergoing a modified Epley maneuver dozens of times unsuccessfully.

What else causes positional vertigo if it’s not BPPV?

Because migraine is the most common cause of dizziness/vertigo and can cause positional symptoms, the most common correct diagnosis in those mis-diagnosed with BPPV, is vestibular migraine. Other conditions which may cause positional dizziness include inner ear nerve weakness, blood pressure changes and even brain tumors. Obviously, it is very important to be certain of the cause of vertigo, as we don’t want to ineffectively treat for a condition that isn’t present and we don’t want to miss a more sinister cause.

At BalanceMD, we treat all types of BPPV on a daily basis and perform over 400 CRMs each year. We are able to quickly recognize BPPV and differentiate BPPV from other causes of positional vertigo. Patients with BPPV usually need only a single visit for their positional vertigo symptoms to be cured.

To Diagnose and Cure Dizziness Sooner Than Later

After focusing my medical practice on vestibular system disorders over a decade ago and seeing over a thousand new dizzy patients per year for many years, I have noticed that patients ask me one particular question more than any other. The question is:

why couldn't I have found you sooner?

Fortunately, with technologic and diagnostic advances in vestibular medicine, we are now much better able to recognize the cause of dizziness or vertigo and to therefore provide the most appropriate and effective treatment.  As with any symptom in medicine, the correct diagnosis is necessary in order to apply the most effective and appropriate treatment.  Vestibular function testing, when combined with the patient's clinical symptoms and physical examination findings, enhances our ability to arrive at the most likely diagnosis.  We are now able to differentiate brain from inner ear disorders causing dizziness/vertigo and thus know whether a CT or MRI is needed (usually not).  We can quickly identify and instantly cure patients with benign paroxysmal positional vertigo (BPPV), aka the 'crystal' problem.  Based on the diagnosis, we know whether medication or a physical therapy intervention would be most useful.

Unfortunately, many patients go months or years without a correct diagnosis, undergoing unnecessary (and sometimes multiple) MRI or CT scans and/or carotid doppler studies. They are prescribed medications, such as meclizine, which are often ineffective.  They are sent to a physical therapist when the underlying cause of their dizziness or vertigo is something that physical therapy cannot help.  

For the specific case of BPPV, patients are amazed to learn that their vertigo can be cured with a simple head maneuver - they leave our office after their first visit cured of the vertigo they had been suffering with for months or years.  One particular patient who had been suffering with BPPV for many months actually fell and broke her hip as a result of vertigo and certainly wished she had received a diagnosis and treatment sooner.

In neurology, we have a saying:  "time is brain".  Indeed, in vestibular system disorders, timely diagnosis and appropriate treatment can save needless suffering, prevent painful and sometimes deadly falls, and save our healthcare system unnecessary expense.  

For further information or to schedule an appointment, click here to go to our website, www.BalanceMD.net, or call toll free 888-888-DIZZY (3499).

Dizzy? It's Not a Tumor!

Feeling dizzy or having spells of vertigo (an illusory sense of motion usually described as 'spinning') can be quite troubling to most people. Of utmost concern is whether these symptoms represent something serious, such as a brain tumor. Rest assured, isolated symptoms of dizziness or vertigo are an extremely rare presenting sign of a brain tumor. To quote Arnold Schwarzenegger in 'Kindergarten Cop' (using his Austrian accent) "It's not a tumor!"

Despite this, at least in the United States, it is the norm to proceed with a neuro-imaging study, such as CT or MRI, of the brain to "rule out" brain tumor, stroke, or multiple sclerosis (MS). There have been several studies concluding that doing CT and MRI scans for 'dizziness' or 'vertigo' in the absence of other neurologic signs or symptoms and in the absence of asymmetric hearing loss is not cost effective and rarely leads to a diagnosis.

Consider the following quote from Australian neuro-ophthalmologists who specialize in vestibular disorders:

"Balance disorders are common, while brain tumors are rare. An isolated balance disorder is thus rarely the presenting symptom of a brain tumor, and some physicians, particularly in countries infested with lawyers, worry about missing a brain tumor" - Hirose & Halmagyi, 1996 

What country do you think they are referring to ("infested with lawyers")?

On the other hand, vestibular function testing [which includes video-nystagmography (VNG), rotary chair, vestibular evoked myogenic potential (VEMP) and audiogram(hearing test)] assesses for both central (brain) and peripheral (inner ear) causes for dizziness and vertigo and can be quite helpful in localizing 'where', and then 'what' is causing the problem. Vestibular function testing has been demonstrated to be much more accurate and much more cost effective than MRI or laboratory tests in determining the cause of dizziness and vertigo.

'Dizziness' and 'vertigo' are symptoms, not diagnoses. Proper treatment of vestibular disorders is based on first determining the cause of dizziness or vertigo. Determining the cause of symptoms begins with a thorough history and physical examination followed by vestibular function testing in select patients. At BalanceMD, we have developed a targeted, cost-effective approach to the diagnosis and treatment of vestibular disorders, noting that 91% of our patients report either a significant improvement or cure of their symptoms.

For further information or to schedule an appointment, click here to go to our website, www.BalanceMD.net, or call toll free 888-888-DIZZY (3499).

Dizzy Patients Typically See 4-5 Doctors Before Receiving the Correct Diagnosis

In a 2011 survey by the Vestibular Disorders Association (VEDA), it was determined that those suffering from dizziness (the "dizzy" patient) were on average seen by 4-5 doctors before receiving the correct diagnosis.  As is the case with any medical condition, without the correct diagnosis, the most appropriate treatment cannot be administered.  

Symptoms of dizziness are typically subjective and an accurate diagnosis at first may not be straight forward.  Many patients suffering from dizziness typically see several doctors and undergo multiple tests while accumulating large medical bills and no answers.  The time "dizzy" patients spend in this process can be months to years and may result in painful fall-related injuries while seeking help from various healthcare practitioners.

"Dizzy" patients may initially be seen by their primary care physician or go to an urgent care facility or emergency room, then, as the potential underlying cause for dizziness can be diverse, referred to ENT (Ear, Nose and Throat - aka Otolaryngologist), a neurologist and/or cardiologist.  Studies reveal that many undergo brain or sinus CT and/or MRI scans, carotid doppler studies, EEG, EKG, echocardiogram, tilt table testing, and blood tests, all of which have low yield in arriving at the correct diagnosis for most "dizzy" patients.  Vestibular suppressant medications, such as meclizine, diazepam or promethazine, typically offer little relief and the majority of "dizzy" patients do not significantly benefit from PT (physical therapy).

The knowledge and technology we have available today in the diagnosis and treatment of the "dizzy" patient has advanced significantly and is different than what would have been considered standard of care just 20 years ago.  At the initial visit to a physician experienced in vestibular disorders, the "dizzy"patient will be given the most likely diagnosis and a short list of differential diagnoses.  Vestibular function testing and an audiogram (hearing test) are generally the most valuable tests to obtain for the "dizzy" patient, and will help confirm or refute the diagnosis suspected by clinical information obtained in the history and physical exam.

Arriving at the correct diagnosis is vitally important because effective treatment of "dizziness" depends on the diagnosis.  One cause of dizziness requires a specific sequence of head movements which can result in an instant cure, another cause is treated by reducing dietary sodium and/or a diuretic medication, while the most common cause of dizziness improves or resolves with a migraine-preventative medication, and other causes benefit from a specialized form of PT (physical therapy) known as vestibular rehabilitation therapy.

Especially in this age of high deductible health insurance plans, patients are seeking the most expedient and accurate diagnoses and the most effective treatment in a cost-effective manner.  With the advanced diagnostic and treatment capabilities available today, "dizzy" patients should no longer have to see 4-5 doctorsbefore receiving the correct diagnosis.

BalanceMD is a specialty medical clinic designed to help all patients suffering from dizziness, vertigo and imbalance.  For further information or to schedule an appointment, click here to go to our website, www.BalanceMD.net, or call toll free 888-888-DIZZY (3499).

by Scott K Sanders, MD, PhD and Michelle Koley MA, CCC-A