2/8/2017 WHERE ARE WE? East Amherst East Aurora Hamburg West Seneca Williamsville Boulevard

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1 2/8/2017 WHERE ARE WE? East Amherst East Aurora Hamburg West Seneca Williamsville Boulevard 1

2 2/8/2017 MY GOAL TODAY. 1. Provide a quick overview on falls 2. How our balance systems work 3. What treatments are available (rehab) 4. The best methods to improve your balance THE FEAR OF FALLING Rate increases with age At age 50 chance doubles every 5-6 years 50% of who reach age 90 will have suffered a hip fracture from falling who are 5 8 tall are 2x more likely than who are 5 2 tall or less 2

3 2/8/2017 EXPANDING THE FEAR: HIP FRACTURES Only 25% will make a full recovery 40% will require nursing home care 50% will need a cane or walker 24% of those over the age of 50 will die within 12 months of suffering a hip fracture. This costs nearly $30,000 per event WHAT MAKES UP OUR BALANCE? VISUAL VESTIBULAR PROPRIOCEPTION 3

4 2/8/2017 VISION Constant Feedback Gaze Stablization Walking Movement in the environment Smooth pursuit Saccades 4

5 2/8/2017 WHAT MAKES UP OUR BALANCE? VISUAL VESTIBULAR PROPRIOCEPTION 5

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7 2/8/2017 VESTIBULAR SYSTEM Saccule Elevator Utricle Airplane Semi-Circular Canals 360 Head Movement 7

8 2/8/2017 TRAINING THE VESTIBULAR SYSTEM Habituation Exercises Practice what makes you dizzy Findings suggest that 59% of patients will have a dramatic improvement, after which their vestibular symptoms no longer cause any restriction in their lifestyles. An additional 23% of patients note considerable improvement. Epley Maneuver Telian SA, Shepard NT, Smith-Wheelock M, Kemink JL. Habituation Therapy for Chronic Vestibular Dysfunction: Preliminary Results. Otolaryngol Head Neck Surg: 1990;103(1):89-95]. WHAT MAKES UP OUR BALANCE? VISUAL VESTIBULAR PROPRIOCEPTION 8

9 2/8/2017 PROPRIOCEPTION / SENSATION - Muscles, joints, and skin have touch, pressure, and stretch receptors that change mechanical stimuli into nerve signals -When do we use this system? PROPRIOCEPTION / BALANCE Study suggests that there is a relationship between chronic neck pain, somatic dysfunction, muscle atrophy and standing balance. Neck strategies for balance Neck range of motion to stimulate the vestibular system If you don t use it, you lose it. McPartland JM1, Brodeur RR, Hallgren RC. Chronic neck pain, standing balance, and suboccipital muscle atrophy--a pilot study. J Manipulative Physiol Ther Jan;20(1):

10 2/8/2017 WHAT MAKES UP OUR BALANCE? VISUAL VESTIBULAR PROPRIOCEPTION IMPROVING YOUR BALANCE THROUGH EXERCISE What s best to improve your balance? Tai Chi Weight Lifting Aqua Therapy Riding a bike Yoga Doing Nothing McPartland JM1, Brodeur RR, Hallgren RC. Effect of Tai Chi Exercise on Fall Prevention in Older Adults: Systematic Review and Meta-analysis of Randomized Controlled Trials. International Journal of Gerontology Dec;10(4). 10

11 2/8/2017 YOUR FUTURE EXERCISE PROGRAM TAI CHI WEIGHT LIFTING WALKING YOGA OTHER FOCUSES POINTS TO IMPROVE BALANCE Use it or lose it Train the weak systems Glasses External Support Balance Exercises Standing vs. Sitting Exercise Substantial evidence to support the use of strength and balance training for older adults at risk for falls Vestibular rehabilitation therapy resulted in a statistically significant improvement in Berg balance test scores. Referring diagnosis, age, and gender had no impact on outcome. Tofthagen C, Visovsky C, Berry D. Strength and Balance Training for Adults With Peripheral Neuropathy and High Risk of Fall: Current Evidence and Implications for Future Research. Oncology Nursing Society. Sept 2012;39(5):E416-E424. Macias J, Massingale S, Gerkin R. Efficacy of Vestibular Rehabilitation Therapy in Reducing Falls. Otolaryngol Head Neck Surg Sep;133(3):

12 2/8/2017 PUBLIC ENEMY: PROTECT YOURSELF Berg W, Alessio H, Mills E, Tong C. Circumstances and consequences of falls in independent community-dwelling older adults. Age Ageing (1997) 26 (4):

13 Dizziness, Tinnitus & Imbalance Lixin Zhang, MD, PhD Medical Director Dizziness, Balance & Tinnitus Center Dent Neurologic Institute Feb 8rd, 2017 Dizziness is Common, Dangerous, and Expensive 9.6% of general population #3 most common complaint at age 60+ #1 reason for a doctor visit at age 75+ 1/3 of patients age of 65+ may experience falls Fall related injuries cost 20 Billions annually 1

14 Growth of Dizziness Center VNG Tests Consults /1/09-9/30/10 10/1/10-9/30/11 10/1/11-9/30/12 10/1/12-9/30/13 10/1/13-9/30/14 Prior to DENT Visit Average months: 55 mos Consulted 1.37 MDs Had an ER visit 37.5% Meclizine 35.9% Average Imaging Done 1.26 Number of Solutions Found Prior to Dizziness Center Contact: 0 (June Dizzy Patients) 2

15 Dizziness Improved in 90% Patients at Dent Dizziness and Balance Center 11% Improve Non-Improve 27% 89% 8% 65% Improve Non-Improve Not Sure Specific Vertigo needs Specific Tx Diagnosis Benign paroxysmal positional vertigo (BPPV) Phobic postural vertigo (PPV) Central vestibular vertigo Migraine Associated Vertigo Vestibular neuritis Meniere's disease Bilateral vestibular Treatment Repositioning Anti-anxiety meds VT Lamotrigine VT Lamotrigine VT Post-Concussive Dizziness Lamotrigine Vestibular paroxysmia Carbamazepine Perilymph fistula Surgery Superior Canal Dehensence Surgery Unknown etiology 4.2 3

16 What is Dizziness/Vertigo? Etiologies of Dizziness/Vertigo 13% 7% Vestibular Psychiatric 1% 7% 16% 56% Cerebral or cardiovascular Brain tumor Unknown Other 4

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18 Classifications of Vertigo/Dizziness BPPV 18.3% Vestibular Neuritis 7.9% Labrynthitis Bilateral Vestibular Hypofunction 7.8% Peripheral Meniere s disease 7.8% Vestibular Paroxysmia 2.9% Superior Canal Dehiscence Perilymph fistula 0.4% Vestibular schwannoma Central Migraine Associated Vertigo 9.6% Phobic postural vertigo/chronic Subjective Dizziness 19.5% Stroke Tumor Multiple Sclerosis 13.5% Chiari Malformation Degeneration (atrophy due to age or toxic agents) 6

19 CNS Dizziness Threshold Theory 7

20 Rotary Chair Testing 8

21 Computerized Dynamic Posturography Case #1 BPPV 73-year-old female, who started complaining of dizziness 3 months ago. One morning she woke up with room spinning The dizziness usually lasts 20 seconds when she is laying down or getting up; looking up or bending down Dizziness Handicap Index was 26/100 She denies headaches, or nausea 9

22 Left BPPV 10

23 Average Cost Per Patient Delayed Referral BPPV may Cost 6 times More $1,000 $900 $800 $700 $600 $500 $400 $300 $200 $100 $0 Cost of Tests Prior to Consultation $159 $347 $952 Primary Specialist ER BPPV Patient Referral 11

24 85 y/o male Progressive imbalance and lightheadedness over past 5 years (current: 2-3 days bouts of imbalance per week) Denied true vertigo; Denied hx of migraines Denied anxiety or depression although reported some life stressors Denied fluctuation in hearing Uses a cane and/or walker Case #2 MRI results showed no abnormal findings Completed 4-5 weeks of vestibular therapy with no significant improvement Vestibular Pattern on Rotary Chair and CDP 12

25 Age-related neuronal degeneration in the vestibular system YOUNG ADULT > 75 YEARS OLD DECREASES SEMICIRCULAR CANAL % SACCULE 18,800 14,200 25% UTRICLE 33,100 26,100 20% VIII FIBERS 18,000 11,000 40% Tinnitus Insomnia TMJ Neck pain Anxiety/Stress Hearing loss 13

26 DENT Comprehensive Dizziness and Balance Center Research Concussion Falls Gait abnormal Dizziness Vertigo Tinnitus Hyperacusis Posturography Vestibular therapy Audiogram/VNG Rotary Chair CT/MRI Tinnitus Assessment Fall Prevention PT Audiology ENT Dentist Psychiatrist/ Psychologist 14