“Because when you are a vertigo patient, you know the status quo is not good enough.” -My official position on why I am so fired up about this topic
Recently, I was teaching the students at the San Diego State University Doctorate of Physical Therapy program. I was invited as a Guest Lecturer to introduce the students to the vestibular system, which is my clinical specialty within Physical Therapy (PT).
We had so much fun during the two days we spent together that the students said they felt energized as I was packing up to leave.
One student exclaimed, “Wow, Dr. Bell!! You really are presenting a FRESH PERSPECTIVE.”
My Uncle’s wise words were, “If you have a unique point-of-view, then people will find it interesting.”
Anyone who knows me already knows my point-of-view… so for this blog post, I decided to outline my point-of-view. Here goes…
- Dizziness is the third most common complaint to physicians across the lifespan and the #1 complaint from patients over 75 years old.
- Dizziness is usually multifactorial.
- Dizziness involves an inner ear – VESTIBULAR – component about 45-50% of the time.
The most common vestibular cause of dizziness is BPPV, or Benign Paroxysmal Positional Vertigo.
BPPV is a biomechanical condition that simply involves crystal(s) becoming dislodged from where it naturally lives in the inner ear, and traveling in fluid to a place where it is not supposed to be within the inner ear. The crystal(s) rolling around inside the head during head motion causes vertigo in certain positions and with specific head motions, imbalance, falls and difficulty walking.
Some patients with BPPV may not even complain of dizziness or vertigo, especially after they have it for awhile, but they will still likely have persistent imbalance, difficulty with walking, unexplained repeated falls and a brain fog that interferes with their concentration and short term memory.
The average vertigo patient with BPPV sees 4-5 different physicians and spends an average of $2,000 to receive an adequate diagnosis, resulting in increased suffering and delays in care from months to years.
In fact, the first vertigo patient I ever treated with BPPV had imbalance and vertigo for 20 years prior – was constantly bumping into walls – and had seen many healthcare providers with no reduction or resolution in her symptoms.
Together, we were able to cure her vertigo completely in 2-3 sessions.
After her BPPV was completely resolved, we continued to work together to optimize her balance under all conditions and circumstances since she had lost so much strength and mobility from having unresolved vertigo for twenty years and being homebound as a result. When I discharged her, she was driving again and marketing my services all around her retirement community.
Some side effects of having untreated or undiagnosed BPPV, which may even be mistaken for mild cognitive impairment (MCI) in older adults, include:
- Difficulty concentrating
- Decreased short term memory
- Diminished cognitive stamina
- Reduced executive function
- Reduced eye-hand coordination
- Decreased coordination of limbs
- Bumping into walls and stationary objects
- Unexplained repeated falls
- Blurred vision with head turns
Psychological and Social implications of chronic untreated or mismanaged vertigo include:
- the stress and confusion of waiting for a diagnosis,
- the fear of falling for older patients with persistent dizziness,
- the despair and hopelessness that can result from chronic unresolved symptoms,
- the burden on loved ones who have to take off work for medical appointments,
- and reduced quality of life due to reduced physical exercise and daily activity levels,
- as well as suicidal ideation in some extremely devastating cases.
The common pathway for investigating symptoms of dizziness in Western medicine often results in unnecessary diagnostic testing, referral to a series of specialists, increased healthcare costs and potentially inappropriate long term use of vestibular suppressant medications.
The American Academy of Otolaryngology (ENTs) recommends for BPPV to be assessed and treated prior to referring patients to specialty physicians and prior to any diagnostic testing. BPPV may be assessed by any physician, physical therapist, occupational therapist or audiologist, but they must have specialized training in the inner ear, or the vestibular system.
The vestibular suppressant medication commonly prescribed for complaints of dizziness is meclizine, which is now recommended only for the first 24-48 hours of an acute vestibular injury or inner ear infection.
Potential side effects of meclizine include dizziness, drowsiness and blurred vision, which increase the risk of falls in older adult patients.
Potential side effects of long term use of meclizine include developing an irreversible cognitive impairment, or dementia, due to the cumulative anticholinergic burden of such antihistamine medications.
Meclizine may be appropriate for long term use in some cases of patients with a poor prognosis for a complete vestibular recovery, in order to minimize symptoms and improve quality of life.
Vestibular Rehabilitation with a skilled Provider is recommended for a root cause evaluation and potential resolution of root causes before a lifelong course of vestibular suppressant medications is determined to be the optimal approach.
The most common treatment for the most common type of BPPV is called the Epley maneuver and was invented in 1992. Some physicians are familiar with this treatment, some are not.
The Epley maneuver – and other particle repositioning maneuvers for different types of BPPV – can completely resolves the symptoms of dizziness and vertigo in one treatment session about 85-90% of the time.
But instead of receiving appropriate vestibular assessment for root cause identification, and targeted treatment – especially for BPPV which is frequently a quick fix with complete resolution of symptoms in 1-2 sessions – patients are often taking the vestibular suppressant medications long term, which relieves their experience of dizziness or vertigo, but does not improve the chronic imbalance – or dysequilium, gait ataxia, chronic falls, fall-related injuries, preventable hospitalizations or reduce the potential for developing irreversible cognitive impairment from the anticholinergic burden of long term use of meclizine.
Please note: Patients should never alter or discontinue a prescribed medication without consulting with the prescribing doctor.
Since I first trained as a Vestibular Specialist over ten years ago, I have been testing for BPPV and other Vestibular System Dysfunction on all of my older adult patients with unexplained repeated falls – and I have found an extremely high percentage of positive tests.
In patients without BPPV, I have often identified another less common vestibular disorder that had not previously been diagnosed.
In my clinical experience, at least 90% of my patients over 50 years old with unexplained repeated falls presented with an undiagnosed vestibular disorder, EVEN IN THE ABSENCE of complaints of dizziness or vertigo.
BPPV is the most common inner ear cause of vertigo, but certainly not the only vestibular problem related to normal aging.
A typical initial conversation with these frequent fallers sounds like this:
Me during the initial evaluation: “Do you get dizzy at all?”
Them: “No I never feel dizzy but I just feel unstable all the time when I am walking – my knees feel weak – and I fall often. I don’t know why.”
Me: “How do you sleep at night?”
Them: “Well, I have to sleep propped up on two pillows (or I only sleep on a certain side) because if lie down flat I start spinning. I have not lied flat (or slept on the opposite side) for years.”
Me: “Aha! You likely have BPPV and that is why you are avoiding certain sleeping positions and having unexplained repeated falls, but not complaining of dizziness or vertigo. You are never moving into the ‘provoking position’ that would trigger your vertigo symptoms because you have learned to live in a way that avoids those provoking positions. But you are still experiencing the imbalance and difficulty walking caused by undiagnosed and untreated BPPV. The good news though is that we can often cure BPPV very easily if you want relief. Shall we check you for it? If you have the most simple type of BPPV, there is an 85-90% chance we can fix it today.”
The final level of recovery for patients with vestibular disorders is affected by how quickly the individual returns to their normal activities, with a prompt return to normal activities predicting a better outcome.
If the patient reduces their activity level for an extended period of time, they experience reduced muscle strength and decreased cardiovascular fitness as well. Therefore, it is imperative that individuals with vestibular symptoms be assessed and treated in a timely fashion so they can have a swift return to their daily activities and exercise program.
There is a “research gap” regarding the exact impact of vestibular disorders on falls in older adults.
However, it is established that BPPV’s peak incidence is in the 50’s and 60’s, staying high for the rest of the lifespan. The American Academy of Otolaryngology (ENTs) recommends for BPPV to be tested in all patients over 65 due to its prevalence and its impact on falls.
BPPV is not a medical problem, it is a biomechanical problem and physical therapists are the experts in treating biomechanical problems.
So my perspective is that Vestibular-trained physical therapists, should take the leading role in our healthcare system as experts in differential diagnosis and treatment of dizziness, vertigo, and dysequilibrium – or imbalance.
I believe that ultimately all Physical Therapists (PTs) will benefit from basic knowledge of how to screen for BPPV and how to screen for other vestibular disorders, especially those PTs working in geriatrics. I realize that not all PTs will decide to learn how to treat BPPV and other vestibular disorders, but I am prepared to teach and mentor those PTs who are interested.
Beneficial Medical Referrals for a Vertigo Patient may include:
- To Primary Care Physicians for all patients with dizziness to identifying symptoms caused by medications or chronic health conditions
- To Cardiology for patients with cardiovascular disease and disturbances to their heart rhythm
- To Neurology for patients presenting with signs of central nervous system involvement
- To Optometry for vision exam for patients with inappropriate or old prescription lenses
- To Ophthalmology if signs of eye diseases are present
- To Podiatry for peripheral neuropathy, peripheral vascular disease and diabetic shoes
- To a Dentist if Tooth Decay or Infections are suspected
- To a Manual Therapy Expert Physical Therapist who specializes in upper cervical adjustments for dizziness with neck pain, jaw-related dizziness and suspected cervical alignment issues
- To an Orthodontist if the Jaw Alignment is in question or History of Tooth Extraction with Headgear
- To a Biofeedback Therapist and Clinical Nutritionist for the Physiological Causes of Dizziness
- To an Ear Nose and Throat Doctor if Eustachian Tube blockage is suspected… to name a few relevant Specialists
Physical therapists will benefit from taking a more active role in their respective communities by educating the public and the local physicians about the expertise of physical therapists in assessing and treating dizziness, vertigo, imbalance and unexplained repeated falls.
My fresh perspective is empowerment of physical therapists to emerge as the leaders in healthcare for fall prevention for older adults and vestibular (BPPV) assessment and treatment across the lifespan.
My message is one of HOPE for a better day for all those who are suffering with dizziness, vertigo and dysequilibrium, as well as fear of falling and reduced quality of life.
My message is one of EMPOWERMENT for the physical therapy profession – I stand ready to share with you the knowledge, skills and confidence to effectively emerge as a leader in this field within your respective grass roots communities.
My message is one of COLLABORATION between geriatric physical therapists and vestibular physical therapists, between public health service departments and private healthcare providers in our communities, and between patients and their families, so that we can work together to reduce the suffering caused by undiagnosed vestibular disorders across the lifespan and unexplained repeated falls in older adults, along with their devastating impact on individuals, families, communities and our economy.
My vision is to create a community that is informed about these issues and to train an army of healthcare workers with the skills to reduce suffering for this population.
In this blog, I have shared with you my professional point-of-view and helpful tips and insights, along with my personal experience in managing my own vestibular disorder and the secondary symptoms that I have learned to successfully manage as I have embarked on a journey of true, deep investigation and self-discovery with great curiosity.
For more information about the impact BPPV has on the risk of falling and fracturing a bone, click here to read a Newsbrief article that I published in 2015.
“I am standing next to you with love.” -My final thoughts on this topic
This blog is provided for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. The details of the case mentioned in this post represent a typical patient that I might see and do not describe the circumstances of a specific individual.