Effective Patient Education Strategies on Vestibular Conditions

Raising Vestibular Awareness: Discussing Specific Vestibular Pathologies

Dr. Esmonde:

Now, we’re going to get into some individual explanations of pathologies to build vestibular awareness. We’ve alluded to some of them already, but I think that’s okay. Never hurts to reinforce, in my book.

I want to start with Danielle, and she’s going to give us her two cents on how she likes to explain the pathology of BPPV, which is, of course, the most common condition that causes positional vertigo.

Dr. Tolman:

I strive to accommodate all types of learners in my practice: those who prefer reading, those who learn best by watching and listening, and those who benefit from a hands-on approach. I highly recommend a poster from anatomywarehouse.com, which I have Velcroed to my wall. It allows me to easily pull it down and show patients the location of the inner ear or vestibular system, differentiating it from the outer and middle ears. I emphasize that the inner ear is encased in bone, reassuring them that they cannot damage it with a Q-tip.

I also use a GIF from Dr. Timothy Hain’s website, dizzinessandbalance.com, in my PowerPoint presentations. It helps illustrate how tiny crystals can dislodge, causing benign paroxysmal positional vertigo (BPPV), which isn’t life-threatening but can cause sudden dizziness with changes in head position. Symptoms vary widely, including feelings of the room spinning or general disorientation, which can lead to initial misdiagnosis.

In discussing ear anatomy, I focus on the otolith organs and their role. These jellybean-like organs are coated in a gel and crystals, which we have from birth and cannot regenerate or strengthen. They are similar to bones or limestone, which become more brittle as we age. Under the microscope, these crystals in younger individuals are intact, but they become brittle and may detach with age, settling into fluid-filled tubes in the ear that act like a gyroscope, helping to indicate head movement and orientation.

When these crystals displace, they can cause the tubes to signal incorrect movements, leading to miscommunication between the inner ear and the eyes—this results in symptoms like nystagmus, which I demonstrate in another slide to show patients why it appears as if the room is spinning.

At the onset of COVID, I filmed a maneuver for patients to safely treat themselves at home, illustrating how movements like lying back or turning can trigger dizziness. This helps patients understand their symptoms and the treatment process, reducing anxiety during evaluations. I also provide handouts and a video link for home exercises, encouraging self-management.

Regarding post-maneuver precautions, recent guidelines suggest they are not always necessary. Originally, patients were restricted significantly after treatment, but we now know that it’s better for recovery to maintain normal activities to help the brain adjust and avoid fear-based behaviors. However, in cases with a history of inner ear issues, precautions may be necessary to prevent recurrence, and I assess this on a case-by-case basis, using clinical judgment to decide the best approach for each patient.

Dr. Esmonde:

Definitely.

Dr. Tolman:

These are examples of both YouTube videos and resources. I’m surprised at how much attention one of my videos has received. It’s a 10-minute piece aimed at patients, covering all the BPPV education, tips, and tricks. It’s a bit outdated, and I should probably film a new version in a better setting than my old apartment in Bluffton. However, it has been useful for patients who go home and attempt to Google the procedures themselves, thinking, “That was easy, I can do it myself.” Unfortunately, there are many incorrect versions online. This raises the debate about whether patients should attempt these maneuvers at home. My stance is that they will seek out the information regardless, so I’d rather provide them with accurate and reliable guidance that I advocate in the clinic.

Additionally, I’ve created two brief videos focusing on just the left- or right-side maneuvers for those who prefer direct information without extra discussion. When discussing other common types of vestibular dysfunction like vestibular neuritis, which causes hypofunction, I explain that it may be triggered by a dormant virus on the nerve that connects the vestibular organ to the brain. Often, it’s activated following an upper respiratory infection or GI distress, which stirs the immune response. I use the analogy of stepping on a garden hose to describe how inflammation can pinch the nerve, disrupting the flow of information and causing a loss of function, which can be quite disorienting. However, we can perform exercises to help compensate and improve the situation.

Vestibular neuritis typically doesn’t involve hearing loss. There’s an imbalance in the signals from the vestibular organs, which are supposed to fire at the same rate on both sides. When one side underperforms, it feels like you’re constantly on a tilt. The brain remarkably tries to compensate, and with time, exercises, and consistency, you might regain balance and stability.

Regarding Meniere’s disease, it affects about 0.2% of the U.S. population, typically those over forty, and can progressively affect both ears. Interestingly, it has an equal prevalence among males and females, though slightly more common in women. Meniere’s disease has specific diagnostic criteria, which I use to educate patients about their condition. If a patient is diagnosed after a single consultation, we approach it with caution, discussing symptoms and criteria to better understand and confirm the diagnosis. This includes identifying classic symptoms like severe spontaneous vertigo attacks lasting from twenty minutes to twenty-four hours, documented low-frequency hearing loss through audiograms, symptom fluctuation like ear fullness or pressure, and ruling out other possible conditions.

This approach helps patients make informed decisions about their health, potentially exploring other causes and immediate treatment options during our sessions.

Dr. Esmonde:

Absolutely. Adding to that, it’s unfortunate that BPPV can occur alongside Meniere’s disease, especially on the affected side. I often encounter patients who thought we had ruled out all other possibilities. I explain that, unfortunately, it’s possible to have multiple issues within the same system. I use the analogy of having a heart valve problem and an arterial blockage simultaneously to help clarify this because it can be quite confusing, especially since diagnosing issues like vestibular migraines often involves ruling out other conditions. They can, indeed, coexist, making it challenging.

Regarding BPPV, we no longer sell certain treatments, but I still use the analogy of navigating a maze with plastic balls to explain repositioning the crystals in the inner ear. This visualization helps patients understand the treatment process. I always try to use multiple tools and analogies to aid understanding whenever possible.

Dr. Tolman:

Exactly, and when discussing Meniere’s disease, it’s crucial to acknowledge the overlap with other conditions. For instance, about 50% of individuals with Meniere’s experience migraines or similar symptoms, and this percentage rises to about 85% among those with bilateral Meniere’s. Additionally, there’s a higher likelihood of developing BPPV, especially among females. There’s also a genetic component, as it often runs in families. I have twin uncles who both exhibited signs of Meniere’s simultaneously and developed BPPV as well. This genetic link is commonly echoed by patients who mention family members with similar issues.

Furthermore, there’s a notable association with autoimmune thyroid diseases. Many of my patients have thyroid-related treatments or conditions, like Hashimoto’s, listed in their medical history. This all ties into the complexity of diagnosing dizziness in Meniere’s, as it typically involves unraveling multiple underlying issues.

Dr. Esmonde:

That’s a great point. I need to address a specific question we received via email about bilateral loss, where both sides of the inner ear are affected, possibly by Meniere’s, neuritis, or even chemotherapies. This can lead to discrepancies in the information each side sends to the brain, often resulting in dizziness. If both sides are completely damaged, which is rare, we discuss different compensatory mechanisms the brain might adopt. This distinction is important in understanding our approach to treatment and compensation.

Dr. Tolman:

I recently evaluated a patient who nearly died from sepsis caused by a severe UTI. The strong antibiotics used were ototoxic and resulted in complete loss of function in both ears. I explained that while I cannot restore the function of her vestibular system, we can still work to improve her quality of life through other means. We focus on enhancing her balance using the visual and somatosensory systems and employing assistive devices to aid mobility. These strategies are vital for helping her navigate her environment more effectively.

Dr. Esmonde:

Exactly, the approach is to “work with what you’ve got.” We focus on enhancing aspects like hip strength, which can significantly aid balance. These strategies help fill in the gaps where functionality may be limited. I completely agree with your methods, Danielle.

Alright, let’s switch gears a bit. DeJ’a will now take the stage. When patients come in with a vestibular schwannoma, they might opt for surgery or choose to simply monitor it.

We’ve discussed neuritis-type hypofunction and Meniere’s disease, which also causes hypofunction, albeit in a fluctuating manner, typically damaging at least one side. Now, let’s consider another scenario—a different kind of hypofunction caused by its own unique pathology. How would you briefly explain vestibular schwannoma to a patient who needs more information than what their doctor provided?

Dr. Crippen:

Vestibular schwannoma, also known as acoustic neuroma or even acoustic neurofibroma, is a benign, slow-growing tumor. It develops from the balance and hearing nerves in our ear, specifically the vestibular and cochlear nerves. The tumor arises from an overproduction of Schwann cells, which normally wrap around and support nerve fibers.

Clinically, as the tumor grows, it may cause unilateral hearing loss, tinnitus, dizziness, and balance issues. If it continues to grow, it can affect facial sensation and nerves, leading to numbness and sometimes muscle weakness or paralysis, depending on its size.

Dr. Esmonde:

When patients hear the word “tumor,” they often get anxious, despite it being benign.

Dr. Crippen:

Yes, it’s benign—meaning it’s not malignant. It doesn’t spread like cancer but does cause some issues due to cell overgrowth.

Dr. Esmonde:

Indeed, and managing patient anxiety is crucial, right DeJ’a?

Dr. Crippen:

Absolutely, it’s not life-threatening.

Dr. Esmonde:

We’ve touched on treating hypofunction, regardless of its cause. You’ve mentioned gaze stability exercises on this slide. How would you explain to a patient the need to perform exercises that might make them feel dizzier?

Dr. Crippen:

These adaptation exercises are designed to compensate for the deficiencies in your vestibular system. By repeatedly moving your head, we aim to reduce your initial symptoms and eventually normalize your gaze and postural stability while focusing on a specific target.

Dr. Esmonde:

Absolutely.

Dr. Crippen:

Regarding gaze stability, moving on to balance training, we might alter your visual inputs, like asking you to close your eyes to isolate the vestibular system. We might also use a foam piece to modify the sensory inputs and improve your vestibular strength by changing your base of support.

Many of my patients worry about failing sobriety tests because they feel unsteady, but these exercises are crucial for strengthening the vestibular system. We also encourage walking around the house and engaging in outdoor aerobic activities, which are beneficial for these patients.

Dr. Esmonde:

We must keep moving, and as physical therapists, we are naturally biased towards physical exercise. The scientific literature supports this because both our brains and bodies require blood flow. For instance, inner ear structures, including those affected by conditions like tumors, require proper blood flow for nutrient delivery and waste removal to maintain or improve their health. For highly symptomatic individuals, I start them with simple exercises like leg lifts while lying down to promote blood flow.

Dr. Crippen:

Absolutely, and transitioning to central vestibular disorders like strokes, which typically result in one-sided body weakness. However, a stroke affecting the cerebellum can have different consequences. A stroke in the anterior inferior cerebellar artery, which supplies blood to the back of the brain, impacts balance, coordination, facial and body sensations, and body position. Symptoms may include dizziness, vertigo, nausea, imbalance, hearing loss, tinnitus, and walking difficulties. Blocking blood flow in these vessels can lead to severe central disorders.

Dr. Esmonde:

Absolutely. Blood flow issues can also arise from blockages or clots and, in stroke cases, from excessive bleeding from a ruptured vessel. These issues often explain symptoms like ear ringing, which though appearing to be an ear issue, actually originates from the brain, a concept vital for patient understanding.

Dr. Crippen:

Indeed.

Dr. Esmonde:

Alright, excellent. Could you also touch briefly on vertebrobasilar insufficiency?

Dr. Crippen:

Vertebrobasilar insufficiency involves reduced blood flow to the brain’s rear, affecting two arteries that converge to supply this area. This condition affects balance and can cause the earlier mentioned symptoms.

Dr. Esmonde:

Perfect. We have a table here outlining generalized symptoms of peripheral and central origins. Is there a particular point you’d like to emphasize for patient education?

Dr. Crippen:

This table is an excellent guide for clinicians to differentiate between the signs and symptoms of peripheral and central vestibular issues. It helps us in diagnosing and treating our patients more effectively.

Dr. Esmonde:

Fantastic. I’ll make sure to highlight that as well. Great summary.

Alright, it looks like we’re ready to move on to another brain problem, one that’s even more complicated in some ways. Although people are somewhat familiar with strokes, we’re now discussing vestibular migraine, which instead of affecting physical movement, impacts spatial orientation. This is essentially a processing issue for that particular function. Madison, please lead us into this topic.

Dr. Oak:

I really liked that chart you presented, DeJ’a. It featured excellent signs and symptoms charts.

I want to address central vestibular issues because it’s important to distinguish whether central signs are due to migraines or strokes, which can be confusing and frustrating for many. Often, when we think of migraines, we picture someone we know—perhaps a friend of our mom—who suffered headaches so severe that they had to retreat to their room, leaving us with a babysitter or another caregiver. Many people equate migraine to just a headache, but it’s much more than that, and I am passionate about this topic. Vestibular migraine is the most common cause of recurrent spontaneous vertigo. Just before this discussion, I read an email from someone unknown to me, describing symptoms of dizziness and panic attacks, fearing a brain tumor or stroke. While I never offer medical advice to non-patients, statistically, these symptoms often point to vestibular migraine, particularly when accompanied by a headache.

It’s vital to refer patients who may have a brain tumor or stroke for imaging. Yet, vestibular migraine is incredibly common, affecting 7% of patients in dizziness clinics and 9% in migraine clinics. It’s also severely underdiagnosed; about 50% of those with migraines are unaware or undiagnosed, often because they minimize their symptoms as just a headache. However, it should be treated.

In discussing migraine, it’s crucial to differentiate it from peripheral dysfunctions. Our initial discussion touched on various peripheral vestibular disorders like neuritis or Meniere’s disease. I start by explaining the entire vestibular system, educating patients that their symptoms can stem from central, not just peripheral, dysfunctions and may closely mimic other diagnoses. People with vestibular migraine experience symptoms similar to those of BPPV or vestibular neuritis but in frequent, unusual attacks.

Patients often undergo testing that shows no abnormalities, leading them to fear undetected brain tumors. Here, I emphasize the need to understand the migraine cascade. For anyone dealing with vestibular migraine—whether as a patient or a healthcare provider—I recommend “Victory Over Vestibular Migraine” by Dr. Beh for valuable insights.

Migraine is a spectrum disorder in terms of intensity and frequency, and it can manifest without headache. This is crucial as we shift towards more precise language, referring to it as migraine disease or disorder, not merely migraines. Symptoms vary widely, from head pain to dizziness and even transient blindness in cases of ocular migraine.

Clinically, a migraine diagnosis may involve a personal or familial history, sensitivity to light and sound, and potential head or neck pain, though these are not universal. Dizziness and balance issues are common, as are certain central signs on vestibular tests that do not respond to typical treatments like the Epley maneuver.

Patients may describe their sensations as internal rocking or walking on a trampoline, often exacerbated by stress or poor sleep. It’s essential to consider vestibular migraine in differential diagnoses, especially given its prevalence and the commonality of being overlooked or misunderstood in medical settings.

Every patient is different, and unusual symptoms may still be indicative of a vestibular disorder. Always consider further imaging or testing if necessary, but remember how widespread and often misinterpreted vestibular migraine is.

Dr. Esmonde:

This is perfect. Let’s revisit DeJ’a’s slides because there might be confusion with symptoms like slurring speech in patients diagnosed with vestibular migraine. DeJ’a, could you remind us of the key symptoms, the ‘D’s, to keep in mind?

Dr. Crippen:

I apologize, could you repeat that?

Dr. Esmonde:

I believe one of the symptoms is dizziness.

Dr. Crippen:

Yes, dizziness, and drop attacks…

Dr. Esmonde:

Danielle, could you help here? Is double vision, or Diplopia, one of them? Are we missing any others?

Dr. Oak:

Dysarthria.

Dr. Esmonde:

Which refers to slurred speech, correct.

Dr. Oak:

Correct, along with diplopia, dysarthria, dysphagia, dysmetria, and dizziness.

Dr. Esmonde:

Perfect.

Dr. Oak:

Each of these can occur with vestibular migraine. Symptoms might include inability to walk for periods ranging from 45 minutes to a day. It’s crucial to differentiate these from stroke symptoms, so appropriate imaging and treatments for red flags are necessary. After ruling out other causes, consider vestibular migraine in your diagnosis.

Dr. Esmonde:

Absolutely.

Dr. Oak:

This leads us to another important topic.

Dr. Esmonde:

Yes, everyone’s second favorite topic: persistent postural perceptual dizziness.

Dr. Oak:

Persistent postural perceptual dizziness, often abbreviated as 3PD, is the leading cause of chronic dizziness. It typically manifests as a cycle of anxiety and dizziness exacerbating each other. Patients with 3PD are usually very anxious or frustrated, which compounds their symptoms.

Many referrals mistakenly assume a diagnosis of just 3PD, but it’s vital to consider other potential underlying conditions, such as panic disorders. Treating 3PD involves understanding its root causes. Clinically, it’s characterized by worsening symptoms with visual stimuli or motion, and patients often feel better while lying or sitting down, though some may report worsening symptoms when lying flat.

Patients might also experience stiffness, neck pain, heightened body awareness, and a non-spinning type of vertigo that progressively worsens, severely impacting their daily activities. Exploring these persistent symptoms is key to addressing the underlying issues.

In terms of treatment, the approach varies widely. Vestibular rehabilitation therapy (VRT) is recommended for acute cases, like vestibular neuritis, but not for unresolved migraine symptoms. Cognitive behavioral therapy, SSRIs or SNRIs, and VRT might all be used concurrently to treat 3PD effectively. Encouraging patients to exercise can also be beneficial, regardless of their initial skepticism.

Dr. Esmonde:

Absolutely. Regarding 3PD, when explaining it to my patients, I sometimes mention anxiety, but more commonly I describe it as a learned dizziness. I emphasize their experience of dizziness, and from the tests I perform, I might detect signs of an old hypofunction. Patients appreciate having something tangible to understand, even if the diagnosis isn’t certain. I explain it by saying, “Your brain now associates movement with dizziness, and we need to unlearn that.” This is the analogy I use.

Dr. Oak:

I agree. I once learned an excellent analogy from a vestibular psychologist about creating a new path through the woods. You tend to take the paved path because it’s easier, but intentionally choosing the more challenging path can help you unlearn the dizziness. I fully support this approach.

Dr. Esmonde:

Understood. I wanted to offer the chance to speak on this, especially since vestibular migraine and 3PD are common in my practice. Patients often think they have the same issue a neighbor resolved, but it turns out to be something else. Danielle or DeJ’a, if you have anything to add on this topic, please do so before we proceed.

Dr. Tolman:

This topic could easily fill an entire Journal Club episode. Madison did an excellent job summarizing and introducing the complexities of vestibular migraine, which can be quite overwhelming for both clinicians and patients.

Dr. Crippen:

Yes, as a new physical therapist, I find that understanding the diagnoses and patient presentations discussed here is enlightening. It makes me want to reevaluate some cases to explore deeper possibilities. This discussion has been very beneficial.

Dr. Tolman:

Absolutely, you never stop learning. The resources and research on migraines are continuously evolving. The way I treat migraines now is drastically different from how I did a few years ago. I still consult with a patient who started with me not long after I graduated. We keep updating our strategies based on the latest research, demonstrating how much can change over time. Always stay informed and be prepared for consistent changes in the field.