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BackTable / ENT / Podcast / Transcript #36
Podcast Transcript: Vestibular Rehab: A Physical Therapist's Perspective
with Matthew Johnston, PT
We talk with Vestibular Therapist Matthew Johnston about the workup of dizziness and setting up patients for success with Vestibular Rehab. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) The Path to Practicing in Vestibular Rehabilitation
(2) Patient Evaluation for Vestibular Therapy
(3) Physical Exam in Vestibular Rehab
(4) The Importance of a Subjective Assessment
(5) Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo (BPPV)
(6) The Role of At-Home Physical Therapy Exercises
(7) Combining Therapy and Vertigo Medication
(8) Treating Vestibular Hypofunction with Vestibular Rehab
(9) Treating Ménière’s Disease and Vestibular Migraines with Vestibular Rehab
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[Gopi Shah MD]
Hello everyone. And welcome to the back table ENT podcast, where we discuss all things ENT. We bring you the best and brightest in our field with the hope that you can take something from our show to your practice. My name is Gopi Shaw, and I'm a pediatric otolaryngologist at UT Southwestern in Dallas, Texas.
And I'm here with my lovely cohost, Dr. Ashley Agan..
[Ashley Agan MD]
Hey, y'all I'm also an otolaryngologist. I practice general ENT in Dallas.
[Gopi Shah MD]
We have a very, very exciting topic and I'm going to let you introduce our speaker and topic.
[Ashley Agan MD]
We're very lucky to have Matthew Johnston on the podcast today. He's a physical therapist in Philadelphia, and he has a special focus on the vestibular rehab. Bless his heart. He's taking care of all of our dizzy patients. He obtained his Doctor of Physical Therapy at Temple University in 2016, and he practices at Excel Physical Therapy in Northeast Philadelphia.
He's here today to talk to us about evaluation and treatment for vestibular problems from the rehab perspective. Welcome to the show, Matt.
[Matthew Johnston PT]
Thank you both for having me. I'm extremely excited to be here. I'm looking forward to sharing, you know, the other side of the patient experience on the physical therapy side. And just looking to learn from you guys and share some information.
[Ashley Agan MD]
Yeah. Well, we appreciate you.
[Gopi Shah MD]
Well, we're happy to have you. These are tough patients and it's huge to be able to share patients with you guys. Start off by telling us a little bit about yourself and your practice and maybe how does one decide that I want to spend all day taking care of dizzy patients?
[Matthew Johnston PT] Sure. Yeah. So I’m a physical therapist. I graduated in 2016 from Temple. And just started out in the vestibular therapy setting. I treat orthopedics as well. But there's a really nice kind of like collaboration with both of those specialties. But just started treating. I've been treating this patient population for awhile.
So I see anything, you know, and everything, vestibular: concussions, headaches, dizziness, migraines, vertigo. So kind of you name it, anything that kind of crosses my way, you know, I'm happy to, to treat at least or evaluate, or make sure, you know, they're getting to the right places. But for the most part, anything with the word “dizzy” in it, generally we’ll treat.
(1) The Path to Practicing in Vestibular Rehabilitation
[Gopi Shah MD]
And, is that something that you kind of had to subspecialize in? Or is that something like, oh, I took this elective and physical therapy school and I loved it. How does that work? How'd it happen?
[Matthew Johnston PT]
So for me personally, there was an elective offered when I went to Temple. So it was a 10 week elective. would that just focused on vestibular therapy. For the most part, you know, in physical therapy school, you might see anywhere from like a couple lectures to two weeks of actual information on vestibular therapy.
So we were really lucky at Temple to have a ton of extra time comparatively to focus on this area, deep dive in some topics. And then I was also fortunate to have a three month internship at a clinic where all they saw was vestibular therapy, like a hundred percent of the time. So it was really, you know, to get those reps in was it was super important.
And to see the weird stuff that you don't always get to see, and, you know, eye patterns and movements that, a typical therapist might not see, was really important. And I think that gave me a really good headstart into the profession and to the vestibular therapy world.
But it is something that's kind of growing in terms of its educational offerings. There's a lot of coursework out there. Emory does a week long like competency course. And then there's some like residencies kind of popping up a little bit more like specialization in the field. a lot of it has been kind of lumped in the neuro and the neurological specialty in physical therapy.
But there is, it's kind of like moving away from that a little bit, I think. And just kind of becoming its own sub-specialty because not every vestibular therapist treats neurological patients. So it's kind of forming its own specialty.
[Gopi Shah MD]
That’s cool.
[Ashley Agan MD]
So you feel like maybe just because of all the exposure you were able to have to it, it just kind of, made you say, “Hey, this, this fits for me. I enjoy this. I want to do this.”
[Matthew Johnston PT]
Yeah. Yeah. It was something that I was, I always had a little bit of interest in, you know, I had some family members who had some of these problems and conditions and just kind of like fell into it with my internship and just kind of like fell in love with the patient population and really enjoyed treating them.
And it was something that was different from just like the regular low back pain or shoulder pain that you see on a regular basis.
[Gopi Shah MD]
And at that clinic, was it all physical therapists, was there like neurologists there, ENTs there, eyeologists, like who were all involved in the clinic during your training?
[Matthew Johnston PT]
That's a great question at the clinic that I was at unfortunately it was just physical therapy. But there was a lot of close relationships with ENT colleagues, neuro colleagues, primary care— a lot comes from primary care. And a lot comes from the community. A lot of our patients come from workshops and community talks that we do that just kind of cater to this population.
Maybe the older adult, over 50, and to something that we get out and talk, you know, I taught maybe like two or three times a year to certain groups and a lot of our patients come from there. Just to work on, even if it's just balanced stuff too. So a lot of it just comes from the community. Some comes from specialists and some comes from primary care.
(2) Patient Evaluation for Vestibular Therapy
[Ashley Agan MD]
So maybe we can jump into the evaluation process and kind of what things look like in your clinic. So I sent you a dizzy patient, so maybe I've made the diagnosis of, you know, something like BPPV, benign paroxysmal positional vertigo, or maybe I, you know, we're suspecting some sort of a similar hypofunction or something, but regardless, or, or maybe I'm just like, you're dizzy and your workup is negative. And maybe, maybe, yeah.
[Gopi Shah MD]
It’s that family member!
[Ashley Agan MD]
Maybe this person can help you. What do things look like once they meet you? I usually tell patients that you guys will do an initial evaluation and kind of make a treatment plan. What does that look like?
[Matthew Johnston PT]
That's a great question. And I think the best answer is it kind of looks like a thorough process, and there needs to be a solid framework. And I think the best way to do that is get a lot of reps in treating these patients. First and foremost, a very thorough long history taking, trying to understand when this happened, was it sudden, you know, what their symptom patterns are looking like.
The duration of symptoms can tell you a lot about what type of thing we're dealing with, what provokes it, what makes it better, you know, trying to rule out some red flags in the process. So that subjective history really getting that patient's story is extremely important. Um, it kind of sets up the next part of the exam, which is that physical exam, but the subjective history, we're really kind of talking with the patient, understanding their story.
But also getting something like the psychosocial aspects of their care, you know, are they really nervous about this? Are they like, I haven't gone out, and bike ride, you know, in a year because I was afraid, that's when it all started, you know? So those kinds of things where, it's not just like, this makes it worse and this makes it better.
But some of those other things that are going to kind of nuance our treatment, a lot of that comes from like the history taking and the story that the patients tell. The next part is more of that physical exam, and that might be something the ENT may be more familiar with. a very thorough ocular motor exam, you know, a head impulse test, the dynamic static balance testing, and then the positional tests.
That's probably what we see most often actually. ENTs will put patients on the table, and most of the patients will come back and say, well, they put me on the table and this happened, I got really dizzy. And then they sent me to you. So that's usually like the most kind of common thing that we see or hear, I guess, from patients. But the subjective history is really important to kind of set up the next step.
[Gopi Shah MD]
What are some of the red flags you mentioned?
[Matthew Johnston PT]
A lot actually is blood pressure relief related. More often than not, we send patients away because their blood pressure is inappropriate for us to see. It's sending them back to their primary care for further management. Sometimes in rare occasions, it's like, you need to go to the hospital. We call the primary care and they say, no, send them, send them right over to the emergency department.
That's probably the biggest thing that we kind of stop session for. And then other things, we'll see some vertical eye movements that might be concerning for us. We might see some things that like, everything is negative. We've done maybe some initial treatment and still quite aren't sure it's vestibular oriented.
So that might be something that might warrant at least further imaging or further workup might not be “a red flag,” but something that we need a little more collaboration with. But by and large, at least in my experience with the patients, I see some sort of cardiovascular suspected stroke or blood pressure issue.
And then, rare occasions, we might see some central findings that might indicate some sort of lesion or tumor or some sort of malignancy that, you know, we might be concerned.
[Ashley Agan MD]
Is it usually high blood pressure. Blood pressure that you guys are seeing that's concerning?
[Matthew Johnston PT] Probably 95% of the time, anywhere, 190 or higher, you know, two hundreds. Yeah. Just, you know, something over 120, but things that are… I'm nervous for you to be here, or are you taking, you know, some of those kinds of things like that. Like not just are you not taking your medications, but things that--
[Ashley Agan MD]
Do you feel okay?
[Matthew Johnston PT]
Yeah. And,
[Ashley Agan MD]
Do you have a headache?
[Matthew Johnston PT]
Right, right, right, right. And especially when they come in with complaints of dizziness, you know, that combination kind of gets us a little nervous. But by and large, you know, that's on the rare occasion.
(3) Physical Exam in Vestibular Rehab
[Gopi Shah MD]
So can we get it to the physical exam in a little bit more detail? Like, I don't have Frenzel lenses. Okay. And I see kids, I probably see maybe two dizzy kids a year. and they're usually teenagers, although I've had as young as eight.
That being said, my physical exam, I don't know. I'll do a little, as long as they don't have any neck issues, like head shake, head thrust, you know. I'll make sure they can do tandem walk, check their cerebellar function. I'll do adix hallpike. Is that the kind of stuff or? Go through it with me. Tell me exactly what you're doing.
[Matthew Johnston PT]
What you just said is a lot of what we do. I think the systematic approach is important, obviously screening vitals first, but then a thorough ocular motor exam. Like how does, how well do their eyes track, you know, can they hit one target to the next target to look at saccades?
What is their vestibular ocular reflex look like? Can they maintain that vestibular ocular reflex for 30 seconds? Horizontally, vertically. We're going to do a VOR cancellation test. Pretty much all my patients will get a very thorough ocular motor exam.
[Ashley Agan MD]
Do you use any equipment to help you with your oculomotor exam or is it all just like follow my finger? I'm looking at your eyes kind of thing.
[Matthew Johnston PT]
It's usually a pen. A pen and my hand. We don't have Frenzel lenses or goggles at our office. I've worked with those in the past and they are definitely gold standard. Something that is kind of best practice, something that's going to get us the most accurate answer. And sometimes we do refer patients out for that specific type of testing.
But in a setting or practice that I work at it's really just follow the pan. Now let me cover one eye or the other for, you know, occluding vision or the cross-cover test. That HINTS to infarct test. I don’t know if you guys are familiar with that but that's something we use on a daily basis.
[Gopi Shah MD]
I'm not familiar with it, please explain.
[Matthew Johnston PT]
Sure. Sure. It's so it's a HINTS to infarct.
So it's looking for a stroke in patients that might present with acute onset of dizziness. So it's an acronym that is pretty sensitive for ruling out cerebrovascular or stroke events. And it's something that used, I think it was originally developed in the emergency department. It has become a really good tool.
Not something that, usually by the time they make it to see me, unless they're coming under, what's called direct access or without a prescription, or they're our current patient that we're seeing, you know, “Oh my God, I woke up yesterday and had a horrible dizziness,” and we're seeing them for evaluation, most of the time that ends up being negative.
I don't think I've ever had anyone that's like, “Oh my God, you need to be sent to the emergency department.” But it's a really good exam. It's a really good, thorough thing that you can put into an examination, especially for patients that might be more at risk.
[Ashley Agan MD]
What are some of the items on that?
[Matthew Johnston PT]
Sure. So we're looking at like a head impulse test. If the head impulse test is negative, we are looking at a skew deviation, like, did they have any vertical movement of thr eye? Do they have a head tilt? Thinking about someone who's uncompensated for hypofunction, they might present that way. But if some of the testing is negative, that might be leading us to more a stroke-like condition.
[Ashley Agan MD]
Interesting. What kinds of other things are on your physical exam? Sorry, I interrupted you as you were going through your—
[Matthew Johnston PT]
No, that's okay. So yeah, after the ocular motor exam, most of the time we're going to screen their balance, statically. The modified CTSIB is the test that we follow. So looking at them in, you know, feet together, tandem balance, single leg, eyes open, eyes closed. And then on the foam or compliant surface, especially foam eyes closed can tell us the most about the vestibular system so that— If someone like falls right over with that, okay maybe I'm thinking, is there something more acute happening or is there something that definitely is pointing towards the vestibular system with this type of person.
[Ashley Agan MD]
Do you ever have to modify that? You know, I'm imagining some of these older patients that, you know, are barely just standing on hard ground sometimes, and putting them on foam and seeing what happens.
[Matthew Johnston PT]
Yeah, absolutely. Obviously all of this is patient dependent and what they tolerate, you know, someone who might have some knee pain or some back pain or can't stand for too long. We're going to modify some of these things with, you know, instead of feet together, it might be feet apart. Instead of standing on one leg, we might go for a tandem or a semi tandem. We might skip the foam for that day until they build up some tolerance. So a lot of it is what they come in with and matching, our exam, you know, we're not trying to fit patients into like, here's our box and we have to do everything just because it's what we have to do. There are some important information that we need to get, just to make sure this is like a person that's safe to be here and there's no red flags happening.
But by and large, we can modify these exam points and start where the patient's ready. Like it's all adapted to what they're capable of and what they're kind of bringing with them in terms of past medical history or social history and stuff like.
[Ashley Agan MD]
Yeah, that makes sense.
[Gopi Shah MD]
And the foam test, it's literally, you're getting like one of those egg crate foams, putting it on the ground and having the patient do some of the balance work, tandem, leg ups, standing on the foam. Is that what you're saying with that?
[Matthew Johnston PT]
Essentially. Yeah, we’ve used these like blue AIREX pads, they’re kind of a squishier compliant surface. Most of the time, it's like feet together, eyes open, eyes closed. Kind of a basic screening, for someone like maybe you might see, Gopi, is like a younger person, athlete, we might make them do like single leg or, single leg with head movements or something like more advanced.
But again, it's kind of like adapting what we're doing and scaling it up or scaling it down depending on what the patient's capable of doing. Or what their goals are. You know, if their goal is to be flipping in the air, doing gymnastics, we're going to do something more aggressive and something that might be more challenging to them.
[Ashley Agan MD]
Yeah. And if I remember correctly, way, way back in the day, when we were learning about all of the vestibular tests, when someone is standing on foam and their eyes are closed, they are purely relying on their vestibular system for their balance. Right. Cause they don't have proprioception.
[Matthew Johnston PT]
That's exactly right.
[Ashley Agan MD]
And they don't have visual cues. So you're kind of able to isolate.
[Matthew Johnston PT]
That's it. Good memory.
[Ashley Agan MD]
That's about as far as it goes.
[Gopi Shah MD]
Clearing that cobweb.
[Ashley Agan MD]
Yeah. That's very dusty information.
[Matthew Johnston PT]
Yeah. And that, to me, to me, that's like the most, the one that I want to get to the most, because it's going to give me like pass or fail. Can they make 30 seconds? Can they not? If they, if they can, if they only make one or two seconds and they're right over, okay, that's going to give me a lot of information of like how functioning or how functional this system is.
[Ashley Agan MD]
That makes sense. Any, any other physical exam maneuvers that we missed?
[Matthew Johnston PT]
I think the most important and maybe the things that you guys are most familiar with are positional testing for BPPV, or the positional vertigo. Usually we'll have patients go from sitting to supine first we're assessing eye motion or nystagmus in that position. That's going to tell us about horizontal canal function.
I have a preference for just turning patients on their side, either left or right, for a roll test. Some therapists will just move the head. I've just never had good experience getting patients all the way to the degrees that I want them to. So I generally just have them, just like turn on their side, so it’s usually easier.
So I'm assessing for their geotropic or apogeotropic nystagmus there. And symptom reproduction, of course. And then finally, it's those dix hallpikes positions off the edge of the table, or in a modified position to see if their posterior or anterior canals are involved.
[Ashley Agan MD]
Yeah, I think that can be the challenge for me sometimes because we don't have like a table the way you do, like in a physical therapy gym. So we have, I guess one clinic does, but the other clinic, we just kind of have the chair. So I have to kind of make the chair flat, like a table and then have a, yeah, we kind of, you know, we make it work most of the time. But yeah, we just don't have the same. We don't have a gym the way you guys do. So I think some of the maneuvers can be a little bit trickier depending on the patient.
[Matthew Johnston PT]
Yeah, I totally agree.
(4) The Importance of a Subjective Assessment
[Gopi Shah MD]
How important is the subjective? So you don't see any nystagmus, but you sit him back up and there, the remiss thinning for them. How important is that to you in your evaluation?
[Matthew Johnston PT]
So we're always constantly weighing, the positional tests can be tricky I think. You know, the speed of movement, you know, is the head in the right position. I think the anatomy books, or maybe what people learn in school as the canal system is oriented exactly 45 is not quite right. Because you might have to give that person maybe 55 degrees of rotation or 10 degrees of rotation, or they may can't get into the position.
Sometimes you have to, you might have to do the positional testing more than once, and it kind of depends on what the person's coming into the clinic with in terms of their mobility. And, not only joint wise, like neck, can they move it, but like their body mechanics, can they, do they have hard time going from laying down to sitting up normally? Now you add this dizziness component to it.
So you might get false positives or false negatives. And you might have to kind of think about what's the most likely cause of things. Every time patient says, “Every time I turn to my right and it happens,” I get a left positive. So you have to kind of weigh these factors.
And if someone sits up and I'm seeing no nystagmus throughout the whole process, usually with sitting up symptoms, I'm more thinking towards a hypofunction or something else. Usually I'm looking for that dissent symptoms and that's going to tell me, at least personally, where I'm going to start. Sometimes I'll treat something and send a patient home and say, well, let's see how that goes.
[Ashley Agan MD]
Yeah, I think that makes sense.
[Matthew Johnston PT]
But that's a really good question because they don't always have nystagmus.
[Ashley Agan MD]
They frequently don't. Like when people actually have the perfect, you know, rotary nystagmus, like, I feel like I almost cheer.
[Gopi Shah MD]
I'm excited. I’m like, wow.
[Ashley Agan MD]
I’m like, “Alright!” We definitely, we found it, you know, they're like, whoa, like this is a great type of dizziness to have. We're going to cure you. It's going to be great.
But yeah, a lot of the times, you know, they might feel a little dizzy or it's just, they don't quite have it.
[Gopi Shah MD]
Well, and that's why they're coming to us right?
[Ashley Agan MD]
And then I send them to you guys and I say, “You're going to figure it out.”
[Matthew Johnston PT]
Yeah. And I think it's validated for patients to like, “Oh, my gosh, you're actually seeing it. You know, this is what the ENT saw.” Ur, you know, they couldn't make it happen, but then therapy gets it to happen or vice versa. So I think them knowing that it's actually having the nystagmus is very validating, but on the other side, it can be very tricky to navigate when you put patients down and be like, well, the ENT did this and I was really dizzy.
And then they get to you a week later, or two weeks later, whenever. Nothing happens.
[Gopi Shah MD]
Yeah.
[Matthew Johnston PT]
And so that can become tricky to navigate. And some patients just clear on their own by the time they get to see us, so. And sometimes you can't make it happen, but they still have ongoing dizziness. And then you might have to course correct with that whole different plan of care.
So it's all very, very, very adaptable and very, you know, I won't say complicated cause that's not the right word, but,
[Ashley Agan MD]
I would say it's complicated. It's complicated for me sometimes.
[Gopi Shah MD]
For sure.
[Matthew Johnston PT]
I think once, you know, the rules and that like once you know, the rules and have the framework in place, I think it becomes a little more simple, but there is, there is some nuance, you know, I won't totally discredit my profession, but like there is, there is a lot of nuance happening. And there's a lot of weighing of factors, because it's not always going to look the same and things can fatigue, like nystagmus can fatigue in certain cases. Yeah, it can be totally variable in the day. You might bring them in for an eval on Monday and find nothing. And then second visit on Wednesday is when they have like the worst dizziness all the time.
So it can be surprising sometimes.
(5) Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo (BPPV)
[Gopi Shah MD]
So let's talk about BPPV. Okay. How do you diagnose it from your standpoint? And then what are, are you doing the Epley for them, and then being like, okay.
[Matthew Johnston PT]
Sure. Yeah. I think this is a great question. Cause, like you mentioned before, we're looking for symptom reproduction and we're looking for nystagmus in any of the positional tests. So if someone has, we'll go with the most common one. Someone gets put back in the dix hallpike on the right, and they have that, beating, you know, torsional nystagmus, that's a pretty solid test for posterior canal bound it, you know, and then I'm weighing the timeframe.
So if it's, if it's less than a minute, it's in the canal, it's more than a minute it's stuck on the opening of the ampulla. So, it's a lot of timing. It's a lot of assessing symptoms. You'd kind of get an idea of when the nystagmus starts to like dissipate. And that's going to give you a little bit more information about how intense this person's symptoms might be in like, you know, break times and stuff like that.
So, a lot of it is which positional test is positive. I always tell patients there's 12 possibilities. You have three canals on each side, plus an opening on each side. So there's 12 options for where it could be. Usually the anterior canal is pretty unlikely unless they're in like a rollover car accident, or a gymnast, they were unfortunately involved in some sort of explosion or some sort of major, head trauma, but by and large horizontal canal or posterior canal, you know, we're looking at least four different canals there.
[Ashley Agan MD]
So, explain this to me where the 12 is coming from, because I'm counting like three or four on each side that gives me like eight. Where's the, is it, are we talking about combinations?
[Matthew Johnston PT]
So we're talking about, you have anterior, posterior and horizontal canal on each side. So that's our six. But in each of those options. So each posterior canal, the crystals or the otoconia can be stuck in the canal itself, or they can be stuck in the opening of the canal or the ampulla. So that doubles us to twelve.
[Ashley Agan MD]
Thank you for breaking that down for me.
[Matthew Johnston PT]
No problem, no problem. And I think that's an important thing, to not necessarily on your guys, and to distinguish, like, are we talking about acanalithiasis vs cupulolithiasis. But something that is in the horizontal canal or the posterior canal, and at least having that like framework, if you're gonna put someone in a horizontal canal, nothing happens, but they're really describing this positional room-spinning vertigo. You know, there could be other possibilities too. And it might not show up on that poster here and dix hallpike.
[Ashley Agan MD]
And finding the location is kind of the crux of prescribing the right exercise. Right. Can you talk, kind of a little bit about that?
[Matthew Johnston PT]
Yeah, you got it. That's exactly right. And I think that's where some, either novice therapists or therapists that might not have that exact skills and in vestibular therapy, you know, maybe one of their patients get some vestibular symptoms and they're going to treat it, just to make that patient feel better.
It's really important to identify the correct canal. Because if you're doing an Epley maneuver, for example, on a posterior canal, but the patient has horizontal canal and vomit, it's kind of a mismatch treatment and it's not quite gonna work. It's just something that you need to be aware of and something that you're just gonna speed up the improvement of the patient if you're matching the treatment to the involvement of the canal.
[Gopi Shah MD]
And are these, just a repositioning maneuver, when they come to see you? And then are there things or certain restrictions afterwards or exercises, I guess, do they still do things for that specific, where you think the lesion is or where the crystals are? How does the post-care for that session work?
[Matthew Johnston PT]
It kind of depends. It depends like I'm sure all of these answers, but once I treat a patient, I might treat them with one to three maneuvers, like three different times. Like I'll put them through an Epley maybe one to three times in a session, it depends on what their tolerance is. It depends on how symptomatic they are.
And then post restriction or post maneuver of restrictions in the research hasn't been that confirmatory. So yeah, they used to put people in collars and said, don't move your head for 24 to 48 hours. And just something that hasn't, it's kind of fallen out of fad and the research has kind of really disproven that.
So for me, I usually say just kind of do your normal thing. Don't go crazy and like shake your head around, but otherwise just kind of go through your normal day. And I'm sure you guys won't be surprised, but, I think the average person would be surprised that, you know, patients are going to try to make it happen sometimes.
And it's like, don't go out of your way to put yourself in these positions. If it's not something you need to do during your normal life. But something that, I don't give a lot of restrictions in the rare cases that we clear it and then if it comes back and we're kind of like fighting back and forth and we're seeing them for like multiple, if I'm working on like two weeks worth of, BPPV symptoms, I might give them some restrictions, for example, to like sleep with two pillows or try to avoid looking up or down for a day or two, I might give them some general guidelines. just to see if we can get a little bit more holding of things where they're supposed to be, until I see them again. And that's only in the rare case where I'm like we're fighting for two, three weeks to get something resolved.
[Gopi Shah MD]
How long does PT usually on average, do you tell patients when they first come see you, specifically for BPPV? Is that like a three session and we're good? Or is it like, listen, this might take four to six weeks and two, three times a week type of thing?
[Matthew Johnston PT]
I hate to say, I've tried to avoid this answer, but I try to avoid this answer because the research will say one to three sessions for BPPV and then something like six to eight weeks for a vestibular hypofunction. But in my experience, there's so many factors that can dictate whether someone's getting improvement in one to three sessions for BPPV specifically. If they can't get into the maneuver the way I, we need them to do it, or the modifications not quite working, or they can't tolerate it, that might be someone who needs to do a little bit more troubleshooting and might go beyond three visits.
When I first graduated, I would tell, oh one to three sessions, and then patients undoubtedly would be there more than three sessions. And then, yeah, that's a whole nother can of worms.
[Gopi Shah MD]
It's like ear tubes, you say nine to 15 months, and then maybe they fell out at six months or they're in for three years.
[Matthew Johnston PT]
Yeah. Yeah. There's so many factors outside of our control. So I'm trying to avoid putting an exact timeframe on it and sometimes my colleagues will get people better first visit on eval. They won't even have to come back and then like, I'm struggling with this person for three weeks or four weeks, or vice versa. So it kind of goes in waves. It depends on so many factors of the patient. and it just kind of, it all depends. So the research does say one to three, but I'd have to go back and look at like, is this just like college kids? Or is this like, who is this research on? What was the average age of those people? Comorbidities, those kinds of things.
(6) The Role of At-Home Physical Therapy Exercises
[Ashley Agan MD]
Yeah. What are your thoughts on patients doing the exercises at home on their own?
[Matthew Johnston PT]
That's a great question.
[Ashley Agan MD]
Should we be encouraging them to, you know, if it's going to take a couple of weeks to get into PT, should we be like, okay, here's a handout, like maybe try to do, you know, an Epley on yourself or one of the modifications, you know, there's like the forward roll or forward bend or something like that, right? I don't know. Maybe you can talk more about that.
[Matthew Johnston PT]
Yeah, there is a modified one where people are on their hands and knees and they just kind of like bow their head forward and then they kind of bring it back. I've had a handful of patients come in and be like, well, I tried this thing and it didn't quite work. I have not personally seen a ton of like literature or research coming out about that particular one.
So I just don't have personal experience with it, but we will give patients home maneuvers. And that might be someone I have do it prophylactically. Like I might have say, do this once a day, until I see you again next week, or especially if we're having some trouble getting complete resolution, I tend to give them to that people, do this one to three times a day.
Obviously their mobility factor, you know, can they do it on their own is a big important, caveat to all of this. Some patients just can't get into the position or can't get the speed or they're at risk for converting the symptoms into the horizontal canal, and that's just going to be way more symptomatic.
So it kind of depends on the patient, but I have given patients like do this for homework one to three times a day, or once we get resolution and I've seen them for, every three months for the last year for some people just get recurrent symptoms. Well, maybe this would be a good idea to do this every day.
And just kind of flush the canal and get things moving because your day-to-day activities, aren't doing that on its own and you just need something more specific so you can avoid having these symptoms coming back to see me. but each individual therapist has their own kind of style with, if they give them on day one or they don't, you know, it kind of depends.
[Ashley Agan MD]
Yeah. And I guess since you're seeing them, you can actually evaluate, okay, this person, they can do it on their own. I've watched, you know, you're able to see it and be like, okay, I'm comfortable with them doing it. I think, I've heard in the past, like other colleagues be like, oh, don't send patients home with exercises cause they could convert it to, you know, a different canal and then things are worse. And so, I think it's, it's very patient dependent and specific. Some patients, you know, need something to do, you know, before they get to PT because they're just going crazy. So you need to give them something. But yeah, it's definitely patient specific, I get that.
[Matthew Johnston PT]
Yeah, I think it's appropriate for ENTs to give maneuvers for patients at home if they are confident in which canal it is. Yeah. And location exactly. More often than not, patients will be like, well, I'm doing these exercises. And, then I'll kind of make the motion of like laying on your side and turn your head up.
So they're going to be doing Brandt Daroff exercises. and that's just something that's vague, in my opinion, it's just going to irritate patient's symptoms. There is research that, is it effective? Yes. But in acute stages, the more we can kind of line up canal environment with treatment, the more successful that patient's going to be.
I have prescribed Brandt Daroff exercises in a handful of cases. And those are the people who we just can't get resolution or, the testing is kind of coming up inconsistent. And then I send them to get, testing with like a Frenzel lenses or goggles and they still just haven't quite gotten it.
And I'll just say, well, just get your body moving. And like, maybe we just need to desensitize you. And that's where the Brandt Daroff exercises come into play. But I think if the ENTs are confident and this is, you know, posterior canal especially, go for it, do that, I believe there's no restrictions for the patient.
[Gopi Shah MD]
The balance testing. So the VNG, how helpful is that to you? Cause sometimes, if I'm not sure, right, the patient’s head’s dizzy, they're coming in for dizziness and you know, my physical exam, my audio hearing test is normal. My physical exam is the best, nonspecific. A lot of subjective, you know, I don't, haven't seen too many, nystagmus changes and it's pretty subjective that, you know, “Hey, I feel dizzy.”
I might send them to vestibular testing, just to make sure that we're not missing a peripheral etiology. And if that looks okay and I'm not concerned about an acute lesion, I may or may not get imaging, or I might just send them straight to neurology depending on the patient and the age and all that kind of stuff.
How do you use balance testing? Can they tell you specifically, like right left canal, ampulla, or is that something you kind of look at and decipher on your own? Because, and with balance testing, they can also tell you central, things as well, with the rotary chair and stuff. Do you use a VNG to supplement your evaluation and your treatment?
[Matthew Johnston PT]
More often than not, I don't have patients come into me with testing already done. Usually that's going to be something that we've troubleshooted in the clinic. We've done some, you know, maneuvers, they might have had short term resolution of some things, but it's kind of persistent, it's recurring or the examinations kind of inconclusive.
Maybe we've done like four weeks of habituation training or desensitization training, with some VOR exercises or something, just some kind of general activity and they just haven't gotten improvement. That might be something where we collaborate with the referring physician, ENT, neurology about, “Hey, this might be something that's going to tell us definitively where and what we're dealing with.”
And if it's something that's peripheral, maybe that gives us clearance to continue treatment. But if it's something that shows up maybe at central or no vestibular involvement at all, either we have to look somewhere else like cervical spine or something else as like another nonphysical therapy pathology. But more often than not patients don't always come in with that type of intervention, unless in my opinion, unless they've had symptoms for a long time, maybe they had a course of PT or they been through several different providers and they've gotten that in the work up. And then they're coming to see me as maybe a second opinion or, like another trial of PT depending on their situation. But more often than not, I don't know if that's just the practice pattern in Philadelphia, but, more often than not, these patients are coming without any testing, rare occasions, we'll come in with an MRI at most.
(7) Combining Therapy and Vertigo Medication
[Ashley Agan MD]
So another thing that I think about when I’m sending patients to you guys, sometimes the act of doing the therapy can make you really dizzy, right? Make you, you know, nauseated, maybe even throw up. Is there any reason to, you know, routinely send these patients out with a script, for some sort of anti-medic like Meclizine or Zofran that they can have, you know, to either take before PT or just to have in case they leave your office feeling like—
[Gopi Shah MD]
How taboo is it?
[Ashley Agan MD]
What are your thoughts on that?
[Gopi Shah MD]
Like is it giving a candy bar to a diabetic or, you know, what are we, how bad is it?
[Matthew Johnston PT]
I love this question because I think it is something that there's a lot of debate about, if you asked five different therapists, you might get five different answers. If you asked five different ENTs, you might get five different answers. So like there's a lot of debate. So I think if there's very clear guidelines about how it's being prescribed, and this is obviously just my opinion, and it's like take this only when you get dizzy versus take this three times a day every day, without any guidelines of like when to stop. To me, I think that's an important distinction. I am personally totally fine with patients who take Meclizine. I generally will be able to bring out their symptoms, whether they're taking it or not. So I feel like it doesn't matter to me too much, but some therapists might say that it's masking symptoms or it's masking eye motion or positional testing findings.
But I haven't found that that's the case, you know, whether patients are taking it or not I tend to just kind of do things as normal. I do think it's a great idea for patients who are extremely nauseous or extremely sensitive, extremely prone to throwing up, or have like very bad autonomic symptoms.
When we go through, you know, they feel faint or they can't get back up into a sitting position, like those things happen. And I think having them have some sort of precursory medication to get through the testing could be really beneficial. And I think there's some research on how prolonged use of Meclizine especially can be ototoxic for patients.
So I think definitive timeframes are important, take this for the next four weeks. If it's not helping, or you're not better, maybe we need to stop or look into vestibular therapy or look into some sort of next step or next intervention for the patient. I just think patients rely so heavily on it that guidelines and expectations are really important because if they do get better, trying to wean off of that can be challenging.
[Ashley Agan MD]
Yeah, it's such a good point. I've definitely had the occasional patient that was diagnosed with, you know, just vertigo, 20 years ago. And they take their Meclizine every day, three times a day for their vertigo. And you're just like, “Oh, no, we need to get you off of this.”
[Gopi Shah MD]
It's like Afrin.
[Ashley Agan MD]
It is. Yeah, it's like the Afrin. But yeah, it makes sense.
You know, if you can give them a little something that helps them get through the therapy, you know, if the alternative is they can't do therapy because they're so sick, then it makes sense to have a little bit of a crutch to just help be able to do it.
[Matthew Johnston PT]
Yeah, absolutely. And that might be something on eval or second visit. If we're like, well, this person is really struggling through this. We might make a call and be like, “Hey, this is what's happening. Can we have a discussion about this and is this appropriate?” It's not our decision to say yes or no, but it's our decision I think to at least to notify the provider and say, “Hey, this is what we're seeing. What do you think about something to help them get along without throwing up 10 times during the session?” And that could be something that's helpful.
(8) Treating Vestibular Hypofunction with Vestibular Rehab
[Gopi Shah MD]
So the other vestibular problem you've mentioned is vestibular hypofunction. Is that the same as vestibular neuronitis? What is vestibular hypofunction? Is that the other most common thing that you guys treat?
[Matthew Johnston PT]
Yeah, in my practice, yes. I generally try to split my patients into hypofunction-like things and BPPV-like things. Hypofunction like things could be more of like Meniere’s, migraines, hypofunctions. Obviously we're going to into detail into the evaluation for each of those things and matching treatment. But the style in my, how my brain works, the style of how that's treated and the duration of how that's treated is all kind of similar. So vestibular hypofunction, I think, is more of a broad term. It might be a labyrinthitis or a neuronitis. So where the infection or irritation is in the labyrinth. And that's where kind of more of the dizziness symptoms are coming from, or of the vestibular nerve. And you might see hearing changes with some of these or dizziness, imbalance. Usually these are preceded by like a cold, flu, or virus that affects that inner ear system, or the nerve.
And sometimes you'll see it in like neurological conditions like MS. So it's important to understand like a good history and saying, well, did you have like two or three days of extreme dizziness, nausea, vomiting, and you just like, couldn't get out of bed. That's a very classic sign of maybe a more acute hypofunction.
More often than not, at least in the clinic that I'm currently treating in, I have not come across those people so far. Usually there are people who have like, two or three months ago, these symptoms started and they might have forgotten that bad weekend symptoms, but are coming to see me with kind of like more vague dizziness, imbalance and we kind of identify this hypofunction-like syndrome treatment.
[Gopi Shah MD]
And is the treatment for that etiology specific? Kind of like in the BPPV in terms of canal location. So is the treatment for the vestibular neuronitis, more different than for example, Meniere’s in terms of what they do, what you guys do in PT? Or is it more of a, “well, these are a group of exercises that we do to help stimulate that whole vestibule or labyrinth on that, you know, side,” or how does that look?
[Matthew Johnston PT]
I guess to further branch it down, hypofunction symptoms and treatment looks a little bit different than kind of the “other category,” migraines, Meniere’s, cerebellar ataxia, things like that. So hypofunction symptoms and treatment and seeing a lot of VOR stability. So vestibular ocular reflex, how well a patient's eyes can stabilize when their head's moving or their body's moving. That's something that's usually gonna provoke their symptoms. And it’s almost like running a marathon. Right. The end goal is to be able to run that mileage, completely. For the patient, the goal is to be able to shake their head or do the vestibular, the VOR exercise for 30 seconds to a minute without any symptoms.
So we need to work our way up into that. Just like a runner works their way up into loading their mileage or increasing their mileage. So a patient might start on day one and do like two head shakes and be extremely dizzy and nauseous, especially in the acute phase. And that's somewhere we kind of like to coach up.
Well, you’re going to do this three times a day and it's going to be some, there's gonna be some symptoms involved and here's some guidelines and I want you to kind of wait for it to settle before you do your next one. And so it's a lot of very specific coaching and guiding about how to kind of gradually build their progressions and the duration of how well they can do it.
And then it kind of progresses over time in terms of more intensity and more duration, more complicated visual stimuli, balance involvement. So we can kind of progress it and dose it up over time. But that's a very, that's like the hallmark of hypofunction.
[Ashley Agan MD]
And I assume these patients do have homework to do their, do their exercises at home too, because it's, you know, I like your, your marathon analogy. It's something where it's like, okay, we're, we're going to be working up to this, you know, every little bit you can do when I'm not there is going to help you get that stamina.
[Matthew Johnston PT]
Yeah, that's exactly right. And that's how I phrase it to patients too, is, you know, if you go over on it and run a mile one day and stop, the next time you run that mile, it's going to be equally as challenging, like two months later. So the more consistent you can be three times a day, every day, and that's where that history comes into play. Like if they're a student, you know, or working in some sort of dynamic job, maybe not the best idea to do your exercise before you go to work. Because it's gonna set things off and make you feel like crap all day. So. the more we'd kind of tailor it to the patient's day and the patient’s activities and their tolerance level, the more they're gonna be likely to do it and really reinforcing that the more like, like you said, the more they do it, the faster they're going to progress, the faster they're gonna have resolution of their symptoms, and the better they're gonna get. And sometimes it's hard, especially with patients who've had symptoms for a long time, maybe they’ve tried a couple of different interventions, to get them to push into those symptoms a little bit.
And a whole lot of the times, unfortunately, the physicians will kind of preface the stability therapy as it's “This is going to make you not feel good.” And it might, it might, but I think it's the more we can have that specificity of training and meeting the patient where they're at the more we're going to get it as close as possible.
There's definitely gonna be times we're gonna miss the mark and make them do something that's maybe a little bit too much and have to backtrack or navigate. where there's times maybe we underdose, cause we're a little nervous. This patient might be able to have a little bit more psychosocial aspects to their care. But the closer we can get to that middle ground and the specificity of their treatment, the better they're gonna do, the faster they're gonna be.
[Ashley Agan MD]
And there is a, I think earlier, did you say three to six weeks or there is like an expectation that at some point they're not going to have to do exercises every day. They're going to kind of get back. They're going to habituate and be back to like, kind of a normal level, right?
[Matthew Johnston PT]
Yeah. So generally we're like six to eight weeks is kind of the classic timeframe, where they're going to be done with “seeing me.” I sometimes will get patients and say, “do these exercises for the next one, two or three months,” especially if they've maybe had a little bit more rocky of a time during their treatment, like do these for the next three months or one month, depending on the person to just really solidify, really solidify this habituation process. Really make sure you're on solid ground. You're where you need to be. and then you kind of start tapering off from there. and then we'll check in with the patient kind of long-term.
(9) Treating Ménière’s Disease and Vestibular Migraines with Vestibular Rehab
[Ashley Agan MD]
You mentioned your Meniere’s and your vestibular migraine patients. I'm glad you brought that up because classically I generally don't think of those as being good candidates to refer to vestibular PT because they tend to have episodes of dizziness. So they're not chronically dizzy all the time, and so I don't always think of you guys when I think of Meniere’s or vestibular migraine. So can you tell me more about what that therapy looks like?
[Matthew Johnston PT]
Absolutely. So if we're kind of working on like the decision tree and once we're clearing BPPV, once we're more certain that it's not hypofunction, then we're getting into the kind of other category and that's where this Meniere’s and vestibular migraines come into play. So the evaluation process looks exactly the same.
I'm still checking for BPPV. I'm still checking for hypofunction test findings and symptoms. Just because someone has a Meniere's diagnosis or a vestibular migraine diagnosis, I still need to thoroughly check them out. There's been definitely cases where patients have flare up of their Meniere’s symptoms, but also have BPPV.
And we can get them quicker to baseline if we treat the BPV, and it's, I think it's pretty common for, if you have one disorder you're gonna have maybe more than one. So I think still going through that evaluation process, matching the treatment or habituation or desensitization with their goals, with their function, with what they want to get back to doing, and safety. You know, these are patients, we work on a lot, especially the Meniere’s people, safety and balance training, and just trying to get them more active. I think a lot of times they take this diagnosis and look on the internet and figure out that maybe this is not something that's going to resolve, like BPPV will, and they just stopped doing everything.
And that's something that PT, I think is perfectly positioned to help them kind of coach them through. Well, here's some guidelines about what you can do and how we can do it. And here's when to push symptoms. Here's when to not push symptoms, here's some activities that might be more safe for you to do. Here's some things that might stir up your symptoms and how to plan your day. So a lot of those life skills and life coaching and kind of goal setting and things like that can be really important because we get to spend a lot of time with patients. I know not all physician colleagues get to spend a whole hour with people.
So it's important that patients report what their goals are. So that's a large focus compared to someone who is BPPV. They don’t really get a choice about how they're treated. They get a maneuver. The goal is, probably, I want to get these symptoms to go away, but there's no gray area or creativity in terms of their treatment and even hypofunction patients too, there's no kind of black or white. You're going to get VOR training. That might look a little different if you're a gymnast versus someone's grandma versus an average working adult. So it's going to look a little different. But, there's very little gray area with even the hypofunction patients.
So this other category, it kind of depends on what the patient's goal is. So if the goal is symptom management, we might do more habituation or desensitization training. If the goal is I want to go and be able to bend over pick my grandchild up. Okay, well, let's work on balance. Let's work on strengthening, let's work on those kinds of things.
So it really depends on the patient's goals. And then vestibular migraine people it’s kind of cool because that's where the orthopedic realm kind of comes into play. You know, is there a cervical component to this? And sometimes like when patients don't improve, no matter what type of dizziness they have, maybe we're looking there, just to check.
Cause there are some cases where cervicogenic dizziness is a component to the symptom presentation. So as we kind of branch into the other category and get a little bit more broad on treatment, it comes back to the evaluation process. What we find on treatment, what's symptom reproducing, and then what the goals of the patient are.
[Gopi Shah MD]
To me, it sounds like any patient that comes in with dizziness or balance concerns, PT is a great supplement. Either supplement, diagnostic, treatment. Overall evaluation is extremely helpful, to help further tease that apart to provide overall guidelines, depending on what it is. And even specifically for diagnosis and management for specific disease processes.
[Matthew Johnston PT]
Absolutely. Yeah, I'm biased obviously. I think so, you know, we get to spend a lot of time with patients. We get to listen to their concerns and they might tell us things that they don't tell you guys because just the relationship is different. We're asking patients to do things that don't feel pleasant. So there's a level of inherent trust there.
[Gopi Shah MD]
So that dizzy patient where we haven't found anything on imaging, BNG, our exam, PT is still, vestibular rehab is a great supplement to keep in our back pocket.
[Matthew Johnston PT]
Yeah. I think we look towards our physician colleagues for helping us to rule out red flags, any sort of imaging or diagnostic testing needs, if appropriate medication management. I personally like to bounce off ideas with my ENT and physician colleagues. I think the patients that have the most success are the ones that are coming from providers that are really collaborative with us.
And so really encourage any ENTs listening, find a good vestibular therapist, find someone who, you know, you can talk to and form a relationship with cause it's only going to benefit your patients. And so I think that's extremely important. Patients really, you know, “Oh, Dr. Smith sent me.”
“Oh, well we work with Dr. Smith's patients all the time.” There's just another trust factor in there that gets built. That relationship starts building cause the patient says, “Well, Dr. Smith trust Matt to see me. Matt must know something at least.” So I think the more collaborative the relationship can be the better.
[Ashley Agan MD]
Yeah, absolutely. You've given us a lot of really good information to chew on. Anything else that we can be doing, you know, as ENTs to kind of set patients up for success as we send them to you, anything that we haven't thought of?
[Matthew Johnston PT]
No, I think, you know, we've touched on a lot with the collaborative and expectation, thoughts. I think looking at things from the other side of the relationship, when patients come in and the provider has given them some sort of clear expectation, whether it's “I'm, pretty sure it's BPPV this is maybe the next step in the process and go see vestibular therapist. And here's what maybe might happen.”
Or hypofunction here. Maybe this is a longer term strategy or maybe it's well, we didn't find anything and everything looks really good and there's no red flags. I still think you would benefit from a vestibular evaluation and here's why, and just kind of setting them up as well everything looks still good. Like there's not anything scary going on. So I think a lot of patients come in and be like, I thought I was having a stroke. I went to the emergency department. I was really afraid. My friend had a stroke and his was like dizziness. So I think the more reassurance can happen on the front end, the easier it is for them to kind of come and be really bought into treatment and kind of understand the value and what's happening on our end.
[Gopi Shah MD]
Yeah. Well, thank you so much, Matt, for coming on the show. If people want to find you, I know you're at Excel Physical Therapy in Northeast Philadelphia, so for all of our Philly colleagues out there, Excel Physical Therapy in Northeast Philadelphia. If people want to reach out, have questions for you, where can they find you?
[Matthew Johnston PT]
Yeah, so they can definitely look me up at Excel physical therapy. I'm on LinkedIn as well. So I can, I think that’s how I found you guys initially, and then we can maybe put my email in the show notes. I'm happy to answer emails from physician colleagues or patients who might be listening.
[Ashley Agan MD]
Well, thank you. You're a gem. I'm sure your patients love you. You guys are miracle workers. That's what I always tell patients. I'm like, you're gonna be amazed. They're going to heal you. You're not going to be dizzy. It's going to be awesome. So thank you for being a resource to us because it's amazing. And, thanks for taking the time to come on the show today.
[Matthew Johnston PT]
Absolutely. I always love talking about this type of stuff. And at the end of the day, the more collaborative we can be with our colleagues, no matter who they are, I think the better patients are going to get. So I think that's always a thing that I'm trying to do.
[Gopi Shah MD]
Thank you for our listeners who stopped by and tuned in. You can find us on SoundCloud, Spotify, iTunes, Apple, and Gaana. Please follow us on Instagram and Twitter at _backtableENT. We love feedback, topics, ideas, speakers, or if you ever want to come on the show.
[Ashley Agan MD]
Please subscribe, rate and share with a friend that’ll help us grow and bring you more content.
[Gopi Shah MD]
And that’s a wrap.
[Ashley Agan MD]
We did it. Thanks everybody. Bye.
Podcast Contributors
Matthew Johnston, PT
Matthew Johnston, PT is the clinic director at Excel Physical Therapy and Fitness in Philadelphia, Pennsylvania.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2021, November 9). Ep. 36 – Vestibular Rehab: A Physical Therapist's Perspective [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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