March 19, 2021
3 min read
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Biography: Wallace is the founder and president of 360 Balance & Dizziness, a specialty clinic in Austin, Texas, for the evaluation and treatment of dizziness and balance disorders. She is also the cofounder and director of clinical education for 360 Neuro Health, which provides on-demand education and tools to bridge the gap between research and clinical practice while emphasizing multidisciplinary collaboration in the care of patients with brain injury or neurological disorders. She consults locally and nationally on the development of balance centers and medical management of vestibular disorders, including return-to-play protocols for post-concussion athletes.
Disclosures: Wallace reports no relevant financial disclosures.
I like to say that my interest in dizziness started in a trash can.
I was working in a multidisciplinary traumatic brain injury unit and was frustrated at being unable to offer much in the way of answers to a teenage brain cancer patient who was struggling with dizziness and balance problems after surgery. When I saw a brochure in the lunchroom trash can about a seminar that weekend in Houston on positional vertigo, I decided to attend. That was 25 years ago, and I’ve had the privilege of working in the evolving field of dizziness and balance disorders ever since.
Dizziness is one of the most common symptoms after concussion or other forms of brain injury and a significant predictor of delayed recovery. Unfortunately, dizziness is poorly understood and too often dismissed or mistreated by medical professionals. It is very common, for example, for doctors to recommend the motion-sickness drug meclizine, which often doesn’t resolve the problem and can actually slow down the natural recovery process.
The good news is that it is relatively easy to screen patients for the source of their dizziness and refer for appropriate treatment. Here are four things you can do if a patient complains of dizziness.
Ask more questions
Bridgett Wallace
Are the symptoms worse when the patient is still or moving around? Dizziness with activity or head movement could have a visual or vestibular cause (or both).
But if the symptoms occur at rest, they are not coming from the vestibular system, because it is not activated at rest. In this case, a neuro-optometric referral is the best first step.
Compare static to dynamic vision
Anyone with movement-related dizziness needs to have a vestibular-ocular reflex (VOR) test. This is a quick and easy test. If there is a two-line or greater difference between static and dynamic vision or the test results in provocation of symptoms, consider a referral to a vestibular rehabilitation specialist.
The good news is that the VOR responds well to therapy, with improvement typically in 10 to 14 days if the problem is primarily vestibular.
Assess eye movements
Assess eye movements, including smooth pursuits and saccades. I particularly like the vestibular/ocular-motor screening (VOMS) test, which also includes convergence, the VOR and visual motion sensitivity testing. This is an easy-to-administer, 5-minute test that is commonly performed by a wide range of professionals as part of a post-concussion or neurological health screening.
While the VOMS is not sufficient for true diagnosis at the specialty level, it does give primary care practitioners — and even coaches and parents — some insights into key symptoms and pathways for referral.
Assess balance
I’m a strong advocate for testing balance and especially love performing a modified version of the Concussion Balance Test (mCOBALT), which was specifically created to assess balance under higher vestibular and visual demands.
We administer the mCOBALT on the Bertec force plate, but it can be done without technology. The two most sensitive tests of the mCOBALT are: performing head movements at 2 Hz with eyes closed while standing with feet apart on foam and performing the Visual Motion Sensitivity (VOR cancellation test) while standing with feet together on foam. Studies showed that all uninjured athletes were able to complete these two tests, compared with only 55% of concussed athletes (Massingale et al., 2018).
Additionally, we frequently only perform the conditions on foam. Adding the dynamic demands to balance testing can be much more beneficial than static balance testing.
Dizziness and balance problems can have a variety of causes. Taking a few extra minutes to determine next steps and make a referral can have a huge impact on your patient’s quality of life.
To assist individuals who may be experiencing visual dysfunctions contributing to dizziness and balance problems, the Neuro-Optometric Rehabilitation Association and the Vestibular Disorders Association developed The Vestibular-Vision Connection. This patient-education resource can be viewed and downloaded on NORA’s Patient Caregivers Resource page.
Reference:
Massingale S, et al. J Neurol Phys Ther. 2018;doi:10.1097/NPT.0000000000000225.
For more information:
Bridgett Wallace, PT, DPT, is the founder and president of 360 Balance & Dizziness, a specialty clinic in Austin, Texas, for the evaluation and treatment of dizziness and balance disorders. She is also the cofounder and director of clinical education for 360 Neuro Health, which provides on-demand education and tools to bridge the gap between research and clinical practice while emphasizing multidisciplinary collaboration in the care of patients with brain injury or neurological disorders. She consults locally and nationally on the development of balance centers and medical management of vestibular disorders, including return-to-play protocols for post-concussion athletes.
Disclaimer: The views and opinions expressed in this blog are those of the authors and do not necessarily reflect the official policy or position of the Neuro-Optometric Rehabilitation Association unless otherwise noted. This blog is for informational purposes only and is not a substitute for the professional medical advice of a physician. NORA does not recommend or endorse any specific tests, physicians, products or procedures. For more on our website and online content, click here.
The Link LonkMarch 20, 2021 at 01:37AM
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