Epley Maneuver (modified) Video

The modified Epley maneuver (or canalith repositioning procedure) is the best treatment for the most common form of Benign Paroxysmal Positional Vertigo (BPPV).  For a detailed explanation of what BPPV is, how it causes vertigo, and why this treatment works, click here.

There are many videos on the internet on how to perform this treatment.  Many are done very well, however there are some that are inaccurate.  The technique shown in this video is taken directly from the evidenced based clinical practice guidelines put out by the American Academy of Neurology and the American Academy of Otolaryngology- Head and Neck Surgery and updated based on recent research.

Keep in mind there are many causes of vertigo and over a dozen different presentations of BPPV, many requiring different types of positional maneuvers for successful treatment.  Be sure to get properly evaluated by a healthcare provider with training in this area to make sure that this is the right treatment for the cause of your vertigo.  Since diagnosing and treating BPPV is one of our specialties we can do this for you at NPBTC.  If you or someone you know has vertigo or other forms of dizziness, call us to make an appointment.  

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If There is Nothing Wrong, Why Do I Feel Dizzy?

dj red turnA 42 year old woman named Sue wakes up one morning with a sickening feeling of severe dizziness and nausea.  She tries to get up, but can barely walk, because she feels so unsteady.  A feeling of fear and helplessness also fills her as she sees the world around her spinning whenever she moves.  Her husband calls 911 and she is taken to the hospital.  There she is given intravenous medications and a CT scan of her head is performed along with a bunch of other tests.  Multiple doctors examine her during her two day stay.  By the time she is discharged from the hospital she is still dizzy, but can move around slowly.  She is told that her brain was fine, her heart was fine and that she “probably had vertigo” and is sent home with a prescription for medication and told to follow up with her primary physician.

The following week she sees her primary physician who recommends that she see an ear, nose, throat physician (ENT).  By the time she can see the ENT it is another two weeks later and she is still having daily dizziness.  The medication that was prescribed does nothing to help.  The ENT performs a bunch of tests for her inner ear which causes severe dizziness again, however all of the testing is normal.  She is then referred to a neurologist.  The neurologist also can’t find anything wrong with her and tells her to see a psychiatrist.  “WHAT!?!” she thinks to herself, “I’m not crazy, I’m truly dizzy and wobbly!” she thinks to herself as she still has dizziness every day and holds on to objects as she walks for stability.  She can’t go into large busy stores, lie flat or use the computer much, because all these activities make her symptoms worse.  HOW CAN THERE BE NOTHING WRONG!?!

The answer is that there was something wrong and there continued to be something wrong.  She is an example of someone who had benign paroxysmal positional vertigo (BPPV) which resolved on its own, but subsequently developed chronic subjective dizziness (CSD).  For most people the feeling of spinning uncontrollably, nausea, and being unbalanced are horrible feelings  Anytime there is a problem with the systems of your brain and inner ear (the vestibular system) that control your equilibrium you can have those symptoms and feel those terrible feelings.  When this happens your body finds ways to adapt to help you feel more stable.  This can include changing the way the brain uses balance signals from the body such as relying more on vision for balance.  You may also associate certain activities with the horrible feeling of the dizziness.  Once the disease that caused the dizziness in the first place clears up then the balance pathways in the brain should return to their normal state and the dizziness should go away.  Sometimes, however, they don’t and you are left with persistent dizziness for months or years even though all of the brain scans, blood work, heart tests, and inner ear tests are normal.  That is the CSD.  This condition is more likely to happen in people who are more prone to anxiety, but it could happen to anyone.  In people with a certain degree of depression or anxiety it can even happen without an inner ear disease.

Unfortunately, many healthcare providers including ENT’s, neurologists, and physical therapists aren’t aware of this phenomenon.  The good news is that there are physicians, physical therapists, and other healthcare professionalsmotivational stones  with interest and training in this area that can help you overcome this dizziness.  Once a proper examination is done and it is determined that this is the cause of the dizziness, then the right treatment can begin.  The treatment may consist of specialized vestibular rehabilitation therapy (VRT), a temporary course of psychiatric medications, psychotherapy or a combination of these treatments.  The treatments work to help the brain and mind restore normal interactions between the parts of the brain that deal with balance and fear.  The result is no more dizziness and improved balance allowing you to feel normal doing the things you need to do in life.

If you have been having trouble getting a diagnosis for your dizziness when all of the testing you had was normal or think you have CSD, make an appointment at NPBTC.  We have a neurologist, psychiatrist, and a physical therapist with special interest in this area who will work together with each other and you to help you overcome your dizziness.

Special thanks to Jeffery P. Staab, MD and Michael J. Ruckenstein, MD, for their research and publications on CSD.  Please see their works for more information.

What Is the Treatment for Vertigo?

If you experience vertigo you may have heard about many different treatments and wondered if they work or not.   Here are a couple of tips to guide you in the answer:

The most important step in the treatment of vertigo is to find out the cause.  Keep in mind that vertigo is not a diagnosis*, just like pain is not a diagnosis.  Vertigo is a symptom defined as the illusion of movement when you are still.  Vertigo, like other forms of dizziness, can be caused by many different problems, some serious, while others are very benign.  Here are just some of the causes of vertigo:

  • Benign Paroxysmal Positional Vertigo (BPPV)
  • Vestibular Neuritis
  • Labyrhinthitis
  • Migraines
  • Stroke/Transient Ischemic Attack (TIA)
  • Meniere’s Disease
  • Panic Attacks
  • Multiple Sclerosis
  • Concussion/Traumatic Brain Injury (TBI)
  • Vestibular Paroxismia
  • Sick Sinus Syndrome of the Heart
  • Depression or Anxiety
  • Vestibular Epilepsy
  • Medication Side Effects

When vertigo is caused by a stroke, heart problems, or other problems associated with lack of blood flow to the brain you need to go to the emergency department.

For less emergent causes of vertigo you will want to see someone with an interest and special training in this area such as a neurologist, physical therapist (often referred to as vestibular therapist), or ENT.

For some causes such as medication side effects or non-emergent heart problems you will want to see your primary physician or cardiologist.

Once you have the correct diagnosis for the cause of your vertigo, then the right treatment can be given for successful management of it.   Treatments that have been found to rid people of vertigo include:

  • Positional Maneuvers (Eply’s Maneuver is one example)
  • Head/Eye Movement Exercises
  • Habituation Exercises
  • Balance Exercises
  • Psychotherapy
  • Medication
  • Surgery

Again, which of these treatments is right for you will depend on the cause of your vertigo.  If are doing a great treatment for the wrong diagnosis, you probably won’t get much better.  What worked for your Aunt Betty’s vertigo may not work for yours.  No matter what, no one can tell you what the best treatment is for your vertigo without a complete examination.

A final note: In general, being active and moving around is helpful in improving the symptoms for most causes of vertigo, even if the activity is as  simple as taking short walks within the tolerance of your symptoms.  Staying in bed and in the dark for an extended period can prolong your recovery or even make your symptoms worse.  How much and what type of activity that will give you the most benefit can only be determined after a complete examination by a qualified healthcare professional.

If your have the symptom of vertigo or another form of dizziness and want to get an examination to find out how you can get relief, call us at 215-591-0700 to schedule an appointment.

*While vertigo is not a diagnosis, insurance companies recognize it as one.  Therefore you may get a prescription for testing or to see a specialist that will list vertigo as a diagnosis just to make sure insurance pays for it.  Insurance also recognizes “pain in limb” as a diagnosis even then almost anything can cause pain in one of your limbs.

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4 Quick Exercise Tips to Improve Your Balance

Tip 1: Make Exercises Challenging but Doable

Just like any exercise you have to push yourself a little to get the benefits.  When doing a balance exercise, if you can keep from falling for at least five seconds, but you are wobbling all over the place, it is challenging, but doable and you will improve with practice.  If you can maintain your balance thirty seconds while doing the exercise and you are not too wobbly, then it might be too easy.

Balance Exercise on Bongo Board with Harness
Tip 2: Be Safe

When doing balance exercises you will lose your balance and that’s okay, however you want to make sure you do it in a safe way so that you don’t go crashing down to the ground.  This may be something as simple as standing next to a counter.  One of the best methods is to stand with your back to a corner a place a chair in front of you.  For more complex and challenging exercises you may need to utilize a safety harness. Click the photo to the left for a video demonstration.

Balance Exercise on PillowTip 3: Create Variety
download adobe cs6

The body relies on a lot of different parts to stay balanced (click here to learn more), so you want to challenge your balance in different ways.  Here are a few simple things you can do to make your balance exercise more challenging:

  • Stand with your feet closer together or even on one foot.
  • Close your eyes.
  • Shift your weight forward, backward, or sideways.
  • Stand on something squishy like a pillow or cushion.
  • Move your head side to side or up and down.

Tip 4: Practice, Practice, Practice

When learning a new skill or even reacquiring an old one the amount of practice makes a huge difference.  You may get some benefit by doing one balance exercise once a week, but you will make significant improvements if you practice a couple of exercises for several minutes at a time, two to three times a day, every day.

To learn more about balance exercises and conditions that affect balance such as dizziness and vertigo, or for help with specific balance exercises or conditions, please contact us at Neurology, Psychiatry, and Balance Therapy Center.

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