Observations and suggestions on better managing the dizzy and imbalanced patient.
Shane Smith, MD
Observation: There seems to be a common misconception that if a patient is screened for BPPV with a Dix-Hallpike and the result is negative, than there is nothing that can be done. This is not the case.
Two thoughts:
1) dispersed otoconia in BPPV may be dispersed in the semicircular canals in such a way as to make the patient asymptomatic -- this patient should be referred for vestibular rehabilitation because
2) BPPV, as most experts agree, is a disease process of the utricle -- the disease process being the sloughing off of otoconia from the otolithic membrane as the result of some sort of past or current injury to the macular organs, i.e., vestibular neuritis, Meniere's disease, or concussions to name a few.
Suggestions: Since BPPV is often present but asymptomatic and more than likely a result of a past or present vestibular insult, it is reasonable and prudent to have a patient referred to a competent balance and dizziness center for further evaluation. In debunking the 'no BPPV, no problem' myth, the incidence of patients tested in computerized dynamic posturography (CDP) who present with BPPV symptoms, active or not, show an exceedingly high correlation with vestibular dysfunction.
Recently (Pollack, 2003) documented what they called BPPV+ where patients exhibit underlying vestibular pathologies in addition to their BPPV -- 72% of their patients presenting with BPPV were documented to be in the BPPV+ category.
So, referring the patient for CDP and a vestibular evaluation is wise for the express purpose of better assessing of what, in all likelihood, is a damaged balance system concurrent with BPPV symptoms. In the event of a vestibular or balance problem, a facility such as The Werner Institute for Balance and Dizziness is superbly equipped to perform normal canalith repositioning maneuvers as well as the family of rolling maneuvers in the Epley-gone-bad horizontal canal conversions that occur occasionally with posterior canal CRT.
Properly conducted, a course of balance retraining therapy including vestibular and conventional physical therapy strengthening will holistically bring patients back to higher levels of functioning than they ever expected to recover. Your patients will feel better and they will love you for referring them.
Observation: There seems to be a general over-reliance on meclizine and vestibular suppressants. If your patient is in the throes of a nasty bout of vestibular neuritis or a suspected Meniere's episode, by all means give them some relief. However, in the vast majority of patients, meclizine is over-used. It is not uncommon to see someone who has been on meclizine/Antivert for months and years. This scenario just further suppresses an already weakened vestibular system. When the weakened vestibular system is called upon, such as a gravel or uneven surface, the vestibular system will be inadequate and the patient will fall.
Suggestion: Proper vestibular rehabilitation beats vestibular suppressants every time after the acute phase of an insult has passed. Balance retraining therapy/VRT works as testament to the brain's amazing plasticity. For best results, get rid of the vestibular suppressants and prescribe some BRT/BRT. Simply put, the patients will get better and greatly reduce their fall risk.
Observation: Vestibular rehabilitation for geriatric fall risk and generalized unsteadiness is grossly underused.
Suggestion: If a patient comes in asking for a prescription for a cane or walker, do a little investigating to make sure there is no genuine crisis, but following that refer them to a vestibular rehab facility, like the Werner Institute if you are fortunate enough to have one nearby. The physical therapist will evaluate their physical condition and the audiologist will assist with identifying any vestibular issues.
Going forward, your patient will be assisted in regaining necessary core strength as well as shoring up their vestibular system. For the patient who is suspecting nothing but more disability and decline, patients can feel like they've received a death row reprieve upon completing their therapy. They often and return to levels of functioning that they had not thought were possible and are thrilled with the outcomes. VR is the best way to keep your patients from falling and out of the ER. Furthermore, recent literature has said that patients actually increase their fall risk by getting a walker or a cane.
Observation: Dizzy patients are sent home with a set of exercises that they generally don't perform.
Suggestion: Referring these patients for vestibular rehabilitation is the ideal choice. Without the benefit of diagnostic testing, audio, VNG, CDP, and PT evaluation the patient exercises are better than nothing. The traditional Brandt-Daroff exercises have patients stimulating their vestibular organs but fairly indiscriminately. Plus, we all know the percentage of patients who will actually remember what they are told -- 49% (University of Rochester Medical Center, 2008). Drawing from the group that remembers the exercises, the percentage of patients who actually commit to doing the exercises is disappointingly poor. In studying the efficacy of home exercises versus targeted exercises, it was revealed that targeted exercises were much more effective.
Additionally, targeted exercise programs were much more likely to be completed. My own personal observation is that for a certain percentage of patients, not only does the VR do them well, but they genuinely enjoy the camaraderie, encouragement, support and social interaction with other VR patients they don't get at home on their couch.
Final Thoughts: Aside from patient load prohibiting a good number of physicians the time to complete a thorough dizziness case history, most of us in the medical world would just assume not deal with the dizzy patient. For me and a lot of my ENT colleagues, they don't represent the need for medical management and they aren't surgical cases. After triaging their issues, where the rubber meets the road is that the vast majority of the dizzy patients should be seen by a balance and dizziness clinic equipped with posturography and safety features such a ceiling- suspended harness system for the best outcomes and the freeing up of your schedules.
