Vestibular Treatment done more gently for Physical Therapists

The Vestibular treatment thoughts below are of Brian Scherff PT's formation.

When I started my first vestibular evaluations, I had a 90 minute evaluation to gather all types of information to help do differential diagnosis. This 90 minute evaluation was very difficult for my patients and may have caused unnecessary suffering. After years of experience I realized, much of that testing was unnecessary on the first visit. I didn’t know this at the time as I wanted to gather a great volume of information to guide treatment.

After a few decades of experience I have reduced my evaluations to 5 to 10 minutes of the most important tests, and then focus on the patient’s symptom relief.

By way of explanation, there are three semicircular canals in each ear: the superior canal, the inferior canal, and the horizontal canal. Each canal is oriented at a different angle in the head, and they are responsible for detecting different types of head movement. Benign paroxysmal positional vertigo (BPPV) is a condition that occurs when otoconia, or small calcium carbonate crystals, dislodge from their normal location in the inner ear and enter one of the semicircular canals. BPPV may cause nausea, dizziness, nystagmus, or vomiting when the head is moved to certain positions. The most common maneuver is the Epley maneuver. The Epley maneuver is used to treat posterior canal BPPV. It involves moving the patient’s head into a series of positions to allow the otoconia to fall back into the utricle.

During my vestibular evaluations, the first thing I do is ask more key questions so I can avoid some symptom-provoking tests. The first questions I ask are: The type of dizziness, as spinning is typical for BPPV. The duration of symptoms. For BPPV it averages 20 seconds (max of 3 minutes for stuck otoconia). When do symptoms occur? When symptoms occur while changing positions, especially when getting in and out of bed, that is a vital clue for BPPV. I prefer to have patients describe their symptoms in their own words. I will give patients choices when they are unable to describe symptoms such as, “Do you feel like you’re rocking on a boat, or do you feel like you are spinning?” Spinning is indicative of some type of BPPV. General unease, rocking, or feeling “off” is associated with central symptoms. I am not saying this provides an absolute diagnosis. I’m saying it helps eliminate some initial testing (and thereby, patient suffering) and focuses on the most likely cause of dizziness. Then, during the first visit, I work to begin improving the symptoms. If the most likely scenario is not the case, and the symptoms are not alleviated, I can do more testing specific to other possibilities at the next visit. After a short subjective assessment, I then play the odds with differential diagnosing. By this I mean I pick the most likely possible positive treatment outcome.

Posterior canal BPPV is by far the most common, depending on which research you read. If I am unsure, I start with the most likely causes of BPPV. The most likely causes of BPPV canal percentages are as follows Posterior 70 to 94% of the time Horizontal (Lateral) 5 to 25% of the time Anterior less than 3% of the time In 12 previous studies, with dysfunction in the posterior canal, it was determined that 70 to 94% of the time BPPV is posterior canal based. With this in mind, you could skip all evaluation, treat for posterior canal BPPV, and likely produce symptom relief. So, that means, if positive signs are present after doing both L and R tests, a Dix-Hallpike or possible Epley maneuver could be indicated to provide symptom relief. It could be that simple.

I have begun treating BPPV differently; looking for the most like cause early on and helping relieve the symptoms as soon as the first visit. To make my work with BPPV easier, I have invented and am selling the Multiple Applications Table which has great functionality with vestibular treatment. Unlike any other table, the MAT Table tilts in positive and negative degrees, and has a built-in 30 in. head cradle. For example, if someone has a stiff neck, the ability to tilt the table rather than rotate the head, could reduce the potential for pain while still facilitating the correct orientation of the semicircular canals relative to gravity – the most important contributor to BPPV. You can learn more about my product and see the MAT Table on our website: https://multipleapplicationstable.com/.

Brian Scherff has been a physical therapist in Michigan for 28 years during which I treated vestibular patients frequently. For eight of those years I was senior PT at a balance center and did thousands of evaluations with vestibular/balance disorder patients. During this time, I had the support of one to two PTAs who did habituation follow-up treatments as needed.