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

3PD – Persistent Postural-Perceptual Dizziness

3PD is a new name for conditions formerly known as phobic postural vertigo and chronic subjective dizziness.  As the features, diagnostic criteria and treatment options of 3PD have been refined over the past several years, 3PD will appear for the first time in the next International Classification of Diseases, being released in 2017.

What is 3PD?  3PD is a non-vertiginous, waxing-waning dizziness and/or unsteadiness, persisting for at least 3 months, with symptoms present at least 15 days per month, but typically daily.  3PD often follows a separate triggering event (vestibular neuritis, vestibular migraine, head injury) that caused dizziness, vertigo or unsteadiness.  With the anxiety or worry over an underlying sinister cause (such as a brain tumor) of these symptoms or with the anticipation of having another vestibular event, symptoms of 3PD develop.

What are the symptoms of 3PD?  The symptoms of 3PD include dizziness and /or unsteadiness, worse when upright, head or body in motion, and in visually busy environments, becoming worse later in the day.  Exacerbation of symptoms in grocery or large stores, when reading, scrolling on the computer or cell phone, and with exposure to complex patterns on carpeting, wallpaper or clothing, is common.  The dizziness and/or unsteadiness become intrusive and those affected often report trouble focusing/concentrating or “brain fog”.

How is 3PD treated?  Once other causes are ruled out with appropriate vestibular function and/or other diagnostic testing, a combination of medications, such as benzodiazepines and SSRIs (selective serotonin reuptake inhibitors) and vestibular rehabilitation therapy is often effective.  With significant underlying anxiety, cognitive behavioral therapy may also be helpful.

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).

Custom Ear Molds Provide Superior Protection and Comfort

Protecting your hearing should have a more important role in our day-to-day lives.  Noisy air travel, loud music devices, roaring sporting events, rocking concerts, loud outdoor jobs and even hunting can pose serious risks to hearing health. According to the Centers of Disease Control and Prevention, 17% of adults from ages 20 to 69 (approximately 26 million!) have suffered permanent damage to their hearing from excessive exposure to noise. Custom ear molds can often provide a simple and effective solution.  We can provide a custom ear mold to protect you from hearing loss at our Indianapolis or Lafayette Indiana locations.

All patients have uniquely shaped ears. This means one-size-fits-all headphones, hearing aids and ear plugs don’t always function the way they should. Inexpensive ear molds provide a custom-fitted solution which can be used in a wide variety of ways. Industrial workers, dentists, pilots, musicians and avid hunters could benefit tremendously from a custom noise-suppression mold. These ear molds can also be useful for earbuds, hearing devices, cell phone and Bluetooth accessories, motor sports and even swimmers who deal with frequent swimmer’s ear.

These comfortable and convenient molds can be crafted from a wide range of materials. Acrylic, soft vinyl, silicone and polyethylene are all options you and your audiologist can choose from. Once a material is chosen, your hearing professional will take an impression of your ears with a putty-like silicone that will be used to create your final custom-made mold. This process takes just about 30 minutes. After your impression, the replica of your ear shape is sent to the manufacturer after which you receive your molds in about two or three weeks. Aesthetics, comfort, acoustics and a superior seal are all reasons an ear mold can be advantageous to maintaining your healthy listening lifestyle.

If you have questions or would like to schedule an appointment, please call toll free (888) 888-DIZZY (3499).  At BalanceMD, we can provide a custom ear mold to protect you from hearing loss at our Indianapolis or Lafayette Indiana locations.

Meniere's Disease - A Common Misdiagnosis

Meniere’s disease is a disorder of the inner ear characterized by recurrent spells of vertigo (spinning sensation), hearing loss, tinnitus (ear noise) and a full feeling in the ear. The average age of onset of Meniere’s is around 50 and the underlying cause is unknown. 

The inner ear has fluid-filled chambers and canals, which send information from the inner ear to the brain to interpret your body's position, movement and to maintain balance. A Meniere’s “attack” occurs when the properties of the inner ear fluid become altered. The symptoms (below) begin suddenly and the severity of each spell varies. 

Symptoms

The symptoms of Meniere’s typically include recurrent vertigo spells lasting 20 minutes to several hours, low frequency (pitch) hearing loss, roaring tinnitus and a sense of fullness or pressure in the involved ear. Early on, hearing may improve between attacks but repeat attacks often lead to some degree of permanent hearing loss. Meniere’s generally affects only one ear, but may affect both ears in at least 20% of those affected.

Treatment

There is no cure for Meniere’s disease, but most will do well with some lifestyle changes and medication. Reducing sodium (salt) in the diet and the use of diuretics (water pills) may reduce vertigo symptoms and prevent recurrent attacks. Other factors that may influence Meniere’s attacks include alcohol, caffeine, smoking and stress. If symptoms are not adequately controlled by reduced salt intake, diuretic medication, and lifestyle changes, there are several surgical procedure options that may be effective in controlling symptoms.

Warning

Unfortunately, Meniere’s disease is a condition that is over-diagnosed, meaning that many are diagnosed with Meniere’s disease, but they don’t actually have it. If you or someone you know has been diagnosed with Meniere’s and do not have significant hearing loss in one ear and/or are under the age of 40, consider obtaining a second opinion. Most who are incorrectly diagnosed with Meniere’s are suffering from Vestibular Migraines and there are many effective treatment options available for Vestibular Migraine.

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).

Treating Dizziness Without Medication

Some causes of dizziness, vertigo and imbalance can be treated by physical therapy (PT) alone. This type of PT is called Vestibular Rehabilitation Therapy (VRT), and it has been proven effective through decades of scientific research and positive patient outcomes. However, only a minority of patients with dizziness benefit from VRT, so it is quite important to first determine the underlying cause of dizzinessto assess whether VRT is the most appropriate intervention.

VRT can treat vestibular (balance) system disorders caused by:

• A weak or damaged inner ear nerve
• Cervicogenic (neck-related) dizziness
• Imbalance with risk of falls due to visual motion sensitivity
• Neuropathy (reduced sensation in the feet)
• Age-related imbalance (often with a fear of falling)
• Multiple unrelated factors together causing imbalance

The focus of VRT is not particularly related to your physical strength or endurance, but on the sensory brain and inner ear systems which control your balance. The brain uses vision, vestibular (inner ear) and proprioception (your sense of where your limbs are in space) to allow you to move safely and without falling. 

Vestibular rehabilitation therapy helps the brain adapt to any weaknesses in these three systems and improves the use of these systems to decrease dizziness and improve balance and stability.

Vestibular rehabilitation therapy is a highly specialized area of physical therapy, requiring specific and extensive training in the field beyond physical therapy school. Most non-VRT therapists treat dizziness sporadically or not at all. Vestibular therapists need additional specialized training to understand balance disorders and to stay current in this fast-developing area of PT.

A typical patient is seen once a week for one to two months. After an examination and diagnosis of the cause of dizziness, a home exercise program is designed to help with the specific symptoms. Once VRT is concluded, it is important to continue the program to maintain its benefits.

Stephanie Ford is BalanceMD’s PT specialist in Vestibular Rehabilitation and treats patients in our Indianapolis and Lafayette offices. She has focused her practice exclusively on VRT since 2008, has completed advanced VRT courses at both Emory University and Duke University, and has lectured on VRT techniques to other medical providers.

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).

Meclizine - a Medication to Avoid

Antivert (meclizine) is one of the most popular and commonly prescribed medications for dizziness. However, there is no scientific evidence supporting it’s benefit and in fact, we now have evidence against it’s use, especially long-term use. 

Meclizine is an antihistamine with anticholinergic, central nervous system and labyrinth (inner ear) depressant effects, so meclizine may cause drowsiness, confusion, memory impairment, and slow reaction time.

While migraine is the most common (and most under recognized) cause of dizziness, making up approximately 60% of all dizzy patients, Benign Paroxysmal Positional Vertigo (BPPV - aka the “crystal” problem) is second, making up about 15%. In neither condition is meclizine indicated. Meclizine would have minimal, if any benefit for migraine and may help blunt the vertigo associated with BPPV, but we are now able to instantly cure those suffering from BPPV, so why use meclizine at all?

Meclizine may be helpful short term in acute vestibular disfunction (sudden onset of vertigo), such as in vestibular neuritis (without hearing loss) or labyrinthitis (with hearing loss), an attack of Meniere’s, or to reduce motion sickness during travel. When used for these conditions or situations, only a short course, perhaps 3-7 days, should be prescribed.

Chronic use of meclizine is never indicated. Use of meclizine in the elderly, especially in the setting of peripheral neuropathy and/or vision loss from cataract, glaucoma or macular degeneration, may cause more imbalance and lead to painful falls. Chronic use of meclizine following vestibular nerve damage (such as with vestibular neuritis or labyrinthitis, trauma, or Meniere’s) will actually prevent the brain from adjusting and will reduce the effectiveness of vestibular rehabilitation therapy (a specialized form of physical therapy).

If you know of anyone who takes meclizine on a regular basis, please let them know there likely is a better treatment option available. As we are now better able determine the underlying cause of dizziness and vertigo, we have also developed more effective, targeted treatments.

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).

Hearing Aid Care

Protect Your Investment in Hearing Aids: Five Essential Tips

If you’ve shopped for hearing aids recently or already own a pair, you know that these devices are not cheap, although well worth their cost for the enhanced quality of life that comes with an improved ability to hear.   Our Indianapolis hearing aid and our Lafayette hearing aid locations can help you understand how to best care for your hearing aid purchase.  With the average cost of a hearing aid approaching $2,500, it pays to protect your investment by following these “Must Do” tips:

Tip #1:  Be aware of the temperature.

•          Avoid excessive heat and cold. Do not leave your hearing aids in a hot car in the summer or a cold car in the winter. 
•         Do not dry your hair with a hair dryer while wearing hearing aids. 
•        Humidity and hearing aids do not mix. If you live in a humid environment, purchase a hearing aid dehumidifier.

Tip #2:  Avoid moisture and water.

• While a humid environment can damage hearing aids, moisture from perspiration as well as submersion in water can interfere with the functionality of a hearing aid.
• Do not wear hearing aids while swimming, showering, taking a bath, during strenuous exercise that causes you to perspire or while in the sauna (unless you wear an extended-wear, deep canal device).
• Remove your hearing aids at the hairdresser or barber.
• Use an umbrella or hooded raincoat when it is raining.
• Make sure your hair and ears are completely dry before inserting your hearing aids.
• Remove your hearing aids at night and open the casing door to allow air to ventilate the interior. 

Tip #3:  Avoid shock and vibration.

•         Hold the hearing aid over a cushioned surface when changing the battery.
•         Store your hearing aid in the cushioned case it came in. 
•         To avoid accidents, sit down to insert or remove your hearing aid.

Tip #4: Regularly clean the outer shell of your hearing aid.

•        To clean an in-the-ear hearing aid externally, wipe it off with a dry cloth.  Then brush across the receiver opening with the wax brush that came with your hearing aid.* Do not push anything sharp into the microphone port.  * If you did not receive a wax brush, consult your Audiologist. To clean wax guards, follow the instructions given to you by your Audiologist.
•        To clean behind-the-ear hearing aids externally, wipe off the hearing aid with a dry cloth.   To clean the ear mold, remove it from the ear hook of the hearing aid and wash it in warm, soapy water.  Rinse thoroughly and shake out the excess moisture.  Allow the ear mold to dry overnight.
•        At least every 6 months, take your hearing aids to your Audiologist for a thorough “clean and check” and to change out microphone protectors and BTE tubing that is becoming brittle.

 Tip #5: Use Hair, Shaving and Cosmetic Products carefully

Perfume, hair spray, bath powder, shaving cream, cosmetics and hair gel can all clog the microphone of your hearing aid.

Should you have any questions about hearing aid care, please contact our Indianapolis hearing aid or our Lafayette hearing aid location at 888-888-3499.