2/8/2017
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WHERE ARE WE?
East Amherst
East Aurora
Hamburg
West Seneca
Williamsville
Boulevard
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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
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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
PROPRIOCEPTIONVESTIBULAR
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VISIONConstant Feedback
Gaze Stablization
Walking
Movement in the
environment
Smooth pursuit
Saccades
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WHAT MAKES UP OUR BALANCE?
VISUAL
PROPRIOCEPTIONVESTIBULAR
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VESTIBULAR SYSTEM
Saccule
Elevator
Utricle
Airplane
Semi-Circular Canals
360 Head Movement
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TRAINING THE VESTIBULAR SYSTEM
Habituation Exercises
Practice what makes you dizzy
Findings suggest that 59% of patients willhave 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
PROPRIOCEPTIONVESTIBULAR
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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. 1997 Jan;20(1):24-9.
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WHAT MAKES UP OUR BALANCE?
VISUAL
PROPRIOCEPTIONVESTIBULAR
IMPROVING YOUR BALANCE THROUGH EXERCISE…
What’s best to improve your balance?
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. 2016 Dec;10(4).
Weight Lifting
Tai Chi
Doing NothingRiding a bike
Aqua Therapy Yoga
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YOUR FUTURE EXERCISE PROGRAM
TAI CHIWEIGHT
LIFTINGWALKING 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. 2005 Sep;133(3):323-5.
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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): 261-268.
1
Lixin Zhang, MD, PhD
Medical Director
Dizziness, Balance & Tinnitus Center
Dent Neurologic Institute
Feb 8rd, 2017
Dizziness, Tinnitus & Imbalance
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
2
Growth of Dizziness Center
744
975
1287 12801248
550
786
1127
13281365
0
200
400
600
800
1000
1200
1400
10/1/09-9/30/10 10/1/10-9/30/11 10/1/11-9/30/12 10/1/12-9/30/13 10/1/13-9/30/14
VNG Tests
Consults
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
(June 2010-62 Dizzy Patients)
Number of Solutions Found
Prior to Dizziness Center Contact: 0
3
Dizziness Improved in 90% Patients
at Dent Dizziness and Balance Center
65%8%
27%
Improve
Non-Improve
Not Sure
89%
11%
Improve
Non-Improve
Specific Vertigo needs Specific Tx
Diagnosis TreatmentBenign paroxysmal positional
vertigo (BPPV)
Repositioning
Phobic postural vertigo (PPV) Anti-anxiety meds
Central vestibular vertigo VT
Migraine Associated Vertigo Lamotrigine
Vestibular neuritis VT
Meniere's disease Lamotrigine
Bilateral vestibular VT
Post-Concussive Dizziness Lamotrigine
Vestibular paroxysmia Carbamazepine
Perilymph fistula Surgery
Superior Canal Dehensence Surgery
Unknown etiology 4.2
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What is Dizziness/Vertigo ?
Etiologies of Dizziness/Vertigo
56%
16%
7%
1%
13%
7%Vestibular
Psychiatric
Cerebral or
cardiovascular
Brain tumor
Unknown
Other
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Classifications of Vertigo/Dizziness
BPPV 18.3%Vestibular Neuritis 7.9%LabrynthitisBilateral Vestibular Hypofunction 7.8%
Peripheral Meniere’s disease 7.8%Vestibular Paroxysmia 2.9%Superior Canal DehiscencePerilymph fistula 0.4%Vestibular schwannoma
Migraine Associated Vertigo 9.6%Phobic postural vertigo/Chronic Subjective Dizziness 19.5%Stroke
Central TumorMultiple Sclerosis 13.5%Chiari MalformationDegeneration (atrophy due to age or toxic agents)
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CNS “Dizziness Threshold “ Theory
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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
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$159
$347
$952
$0
$100
$200
$300
$400
$500
$600
$700
$800
$900
$1,000
Primary Specialist ER
Av
era
ge
Co
st P
er
Pa
tie
nt
BPPV Patient Referral
Cost of Tests Prior to Consultation
Delayed Referral BPPV may
Cost 6 times More
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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
MRI results showed no abnormal findings
Completed 4-5 weeks of vestibular therapy with no
significant improvement
Case #2
Vestibular Pattern on Rotary Chair and CDP
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Age-related neuronal degeneration in the vestibular system
YOUNG ADULT > 75 YEARS OLD DECREASES
SEMICIRCULAR
CANAL 7600 4600 40%
SACCULE 18,800 14,200 25%
UTRICLE 33,100 26,100 20%
VIII FIBERS 18,000 11,000 40%
Tinnitus
Hearing lossAnxiety/Stress
TMJNeck painInsomnia
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DENT Comprehensive
Dizziness and Balance Center
Audiogram/VNG
Rotary Chair
CT/MRIPosturography
Audiology ENT Dentist
Diz
zin
ess
Vertig
o
Gait
abnormal
FallsTinnitus
Hyperacusis
Vestibular therapy
Fall
PreventionPT
Concussion
TinnitusAssessment
Research
Psychiatrist/
Psychologist