PPPD: EARLY DETECTION AND INTEGRATIVE REHABILITATION THERAPY IMPROVES OUTCOMES - Academy of Neurologic Physical Therapy
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RUSK REHABILITATION PPPD: EARLY DETECTION AND INTEGRATIVE REHABILITATION THERAPY IMPROVES OUTCOMES Jennifer Fay, PT, DPT Board-Certified Clinical Specialist in Neurologic Physical Therapy (NCS) Artmis Youssefnia. PT, DPT, CAPS, CEEAA Board-Certified Clinical Specialist in Geriatric Physical Therapy (GCS) Tara Denham, PT, MA Eva Mihovich, PhD
HISTORY AND
PATHOPHYSIOLOGY OF
PERSISTENT POSTURAL
PERCEPTUAL DIZZINESS
Jennifer Fay PT, DPT
BOARD-CERTIFIED CLINICAL SPECIALIST IN NEUROLOGIC PHYSICAL THERAPY (NCS)
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Disclosures • None RUSK REHABILITATION
Objectives
• Familiarize yourself with the history of Persistent Postural Perceptual Dizziness (PPPD).
• Understand the pathogenesis of abnormal sensory weighting/dominance and/or autonomic nervous
system maladaptation.
• Understand the definition and diagnostic criteria of PPPD
• Recognize key signs/risk factors for developing PPPD
• Apply new strategies to manage patients with PPPD to avoid common obstacles to recovery.
• Examine the role of communication, tone, and patient education when discussing recovery with patients
with PPPD.
• Identify the core symptoms of anxiety related to vestibular disorders and describe evidence-based
interventions for anxiety management in the vestibular population.
• Facilitate development of integrated treatment teams (vestibular rehabilitation specialists, vision therapists
and rehabilitation psychologists) to address multiple symptoms in a coordinated treatment plan.
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History • 1870s three German physicians described syndromes of dizziness and discomfort in motion rich environments, accompanied by autonomic arousal, anxiety, and avoidance of provocative circumstances. • 1970s small case series were published describing various syndromes of spatial disorientation and aberrant motion sensations including: – supermarket syndrome – Space phobia/agoraphobia – Motorists vestibular disorientation syndrome – Visually induced motion symptoms – Physiologic height vertigo RUSK REHABILITATION
• Brandt and Dietrich Phobic Postural Vertigo
1986
• Jacob et al: Space Motion Discomfort
1989
• Bronstein: Visual Vertigo
1995
• Staab: Chronic Subjective Dizziness
2004
• Committee for Classification of Vestibular Disorders
2006
• Diagnostic Criteria for persistent postural perceptual dizziness
2017 published in Journal of Vestibular Research
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Persistent Postural Perceptual Dizziness:
A common chronic dysfunction of the vestibular system and
brain that produces persistent non-vertiginous dizziness,
unsteadiness, and non-spinning vertigo that are exacerbated
by postural challenges and perceptual sensitivity to space-
motion stimuli.
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Epidemiology • UK: 4% of all patients registered with a general practitioner experience persistent symptoms of dizziness. • UK neurology outpatient clinics: 2% of all secondary referrals were diagnosed primarily with vertigo or dizziness. • Tertiary dizziness centers-PPPD is second most common diagnosis accounting for 15-20% of all patient presentations. • Prospective studies of patients followed for 3-12 months after acute vestibular ailment suggest that PPPD will develop in 25% individuals. RUSK REHABILITATION
Disease Burden • There are more than 2 million U.S. emergency department (ED) visits annually for dizziness or vertigo, comprising roughly 4.4% of all ED chief symptoms in awake patients1.(Newman-Toker) • Patients with dizziness undergo more diagnostic tests and have greater lengths of stay (LOS) than those without dizziness, comparable to what is seen in those with chest pain. • Resource use, particularly neuroimaging, is increasing over time. • Total U.S. national costs for patients presenting with dizziness to the ED are substantial, estimated to now exceed $4 billion per year. RUSK REHABILITATION
Trigger:
Cycle of Persistent
Distortion of Perception of
Vestibular Crisis
Concussion
Postural Perceptual
Afferent
Signals
Dizziness
and Panic Attack Dizziness (PPPD)
“High Alert” Unsteadiness
Neck Stiffness
Gait Disorder
Utilization of High
Demand Postural Dizzy Acute
Recovery
Control Strategies Experience Adaptation
High Anxiety
Excessive
Vigilance
Predisposing factors:
Limited knowledge Neurotic personality
Threatening and Pre-existing anxiety disorder
provocative words History of Trauma
Internet
Medical Tests
Adapted from Stoyan Popkirov et al. Pract Neurol
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Louw and Puentedura 2013Pathophysiology • Three key mechanisms by which this disorder is thought to develop: 1) Stiffened postural control 2) Shift in processing spatial orientation information to favor visual over vestibular inputs 3) Failure of higher cortical mechanisms to modulate the first two processes. RUSK REHABILITATION
High Risk Postural Control Strategies RUSK REHABILITATION
Secondary Functional Gait Abnormality
• Increased body sway and amplified compensatory movements of the arms during tests of stance (rombergs)
• Slow or hesitant gait and/or “walking on ice” pattern
• Slowness remains unchanged after gait initiation
• More demanding postural tasks such as standing in tandem position or walking backwards can normalize body sway
and gait.
• Fail to return to normal relaxed postural control strategies following their use of high-threat postural responses (e.g.,
stiffening of stance) that are transiently activated during balance challenges.
RUSK REHABILITATIONCortex
Awareness of Motion
Stimuli Voluntary
Conscious Control of Locomotion and
Movement Oculomotor Control
CNS Control
of Posture and
Locomotion Amygdala
Autonomic Autonomic
Threat
Evaluation Nuclei Responses
Sensory End
Organs
Central Vestibular Reflexive Postural
Visual, Vestibular &
Processing and Oculomotor
Somatosenosy Cues
Multisensory Integration Control
RUSK REHABILITATIONCortex
Awareness of Motion
Voluntary
Stimuli
Locomotion and
Conscious Control of
Oculomotor Control
Movement
PPPD
Amygdala
Threat Autonomic Autonomic
Evaluation Nuclei Responses
Sensory End
Organs
Central Vestibular Reflexive Postural
Visual, Vestibular &
Processing and Oculomotor
Somatosenosy Cues
Multisensory Integration Control
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DIAGNOSTIC CRITERIA FOR
PERSISTENT POSTURAL
PERCEPTUAL DIZZINESS
Artmis Youssefnia PT, CEEAA, CAPS
Board-Certified Clinical Specialist in Geriatric Physical Therapy (GCS)
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17Disclosures None 18 RUSK REHABILITATION
Objectives Understand the definition and diagnostic criteria of Persistent Postural Perceptual Dizziness Recognize Key Signs/Risk Factors for developing Persistent Postural Perceptual Dizziness 19 RUSK REHABILITATION
Diagnostic Criteria as per International Classification of
Vestibular Disorders (ICVD)
A. One or more symptoms of dizziness, unsteadiness, or non‐spinning vertigo are present on
most days for 3 months or more.
1. Symptoms are persistent, but wax and wane.
2. Symptoms tend to increase as the day progresses, but may not be active throughout
the entire day.
3. Momentary flares may occur spontaneously or with sudden movements.
B. Symptoms are present without specific provocation, but are exacerbated by:
1. Upright posture,
2. Active or passive motion without regard to direction or position, and
3. Exposure to moving visual stimuli or complex visual patterns,
although these three factors may not be equally provocative.
20 RUSK REHABILITATIONC. The disorder usually begins shortly after an event that causes acute vestibular
symptoms or problems with balance, though less commonly, it develops slowly.
1. Precipitating events include acute, episodic, or chronic vestibular syndromes, other
neurologic or medical illnesses, and psychological distress.
a) When triggered by an acute or episodic precipitant, symptoms typically settle
into the pattern of criterion A as the precipitant resolves, but may occur
intermittently at first, and then consolidate into a persistent course.
b) When triggered by a chronic precipitant, symptoms may develop slowly and
worsen gradually.
D. Symptoms cause significant distress or functional impairment.
E. Symptoms are not better attributed to another disease or disorder.
21 RUSK REHABILITATIONYES
*Anxiety disorder
*Neurotic personality
ACUTE EVENT
*POTS
*Migraine PRECIPITATING
*h/o concussion or trauma FACTORS
*Neuro-otologic event
*Medical event
YES
Complete standard
*Dizziness
*Swaying/rocking or NO vestibular evaluation
unsteadiness as per CPG
*Hypersensitivity to motion PRESENT
stimuli SYMPTOMS
*Difficulty with precision
visual tasks
YES 3PD
*Upright posture
*Head or body motion
*Exposure to complex or
motion rich environment PROVOCATIVE TIME:
*Anxiety/Stress YES YES
FACTORS frequency/duration
*Medical Event
*Cumulative burden of
activities
*15/30 days
22
Diagnostic Tree *>3 months3 Subtypes
1. Psychogenic PPPD is triggered by a psychiatric disorder, usually panic disorder in which
panic attacks produce lightheadedness or vague vertiginous sensations.
2. Otogenic PPPD is caused by a vestibular dysfunction.
3. Interactive PPPD is also precipitated by an acute vestibular or medical condition but
occurs in patients with preexisting anxiety.
Regardless of subtype, PPPD almost always starts with an acute
process
According to diagnostic criteria: symptoms need to be present for
greater than 3 months-early detection can help prevent prolonged
recovery
23 RUSK REHABILITATIONProvocative Factors
1. a. Active or Passive Motion of self that is not related to a specific direction or position
b. Upright Posture
2. Exposure to large-field moving visual stimuli or complex (fixed or moving) visual patterns.
3. Performance of small-field precision visual activities (ie reading, computer or fine motor
tasks).
24 RUSK REHABILITATIONYellow Flags 1. (+) Cumulative burden of activity 2. Symptoms resemble one or more 3PD diagnostic criteria and do not follow diagnostic criteria of another vestibular disorder 3. Acute event was not otogenic 4. History of concussion or trauma 5. History of migraines/headache 6. Panic Attacks 7. Anxiety: multisystem response to a perceived threat or danger (can utilize Generalized Anxiety Disorder-7 item scale) 8. Catastrophic tendencies: ruminating about irrational worst case outcomes 9. Hyper-vigilance: state of increased alertness 10. Increased stress or anxiety present at time of acute event (includes “happy” life events”) 25 RUSK REHABILITATION
Anxiety
CATASTROPHY
26CUMULATIVE BURDEN OF SYMPTOMS: Increase in symptom
intensity due to culmination of provocative activities throughout
the day
9
8
7
6
SYMPTOM 5
INTENSITY
4
3
2
1
0
6:00 AM 8:00 AM 10:00 12:00 2:00 PM 4:00 PM 6:00 PM 8:00 PM 10:00 12:00
AM PM PM AM
TIME
27 RUSK REHABILITATIONONE OR MORE SYMPTOMS OF 3 P D 1. Dizziness: non-motion sensations of disturbed or impaired spatial orientation 2. Unsteadiness: feelings of being unstable while standing or walking 3. Internal non-vertiginous dizziness: false or distorted sensations of swaying, rocking, bobbing, or bouncing of oneself 4. External non-vertiginous dizziness: similar sensations of movement of the surroundings Does not follow diagnostic criteria for another vestibular disorder If temporal pattern does not follow exact symptom chronology for 3PD (less than 3 months and is not 50% of the time) could still be 3PD. 28 RUSK REHABILITATION
ACUTE EVENT WAS NOT OTOGENIC • Concussion • Autonomic Disorder: POTS • Surgery • Kidney Failure • Heart Failure 29 RUSK REHABILITATION
CONCUSSION, TRAUMA or MIGRAINE
If the patient fulfills ANY of the
diagnostic criteria for 3PD
then it should serve as
1. Persisting
subjective non- another yellow flag!
Headache
vertiginous dizziness
and/or unsteadiness
with upright posture.
2. Hypersensitivity to
motion stimuli, Chronic Sleep
including the
patients own
Dizziness Persistent
Disturbance
movement and Postural
motion of objects in Perceptual
the visual surround.
Dizziness
3. Difficulties with
precision visual
tasks.
Mood Cognitive
Lability Changes
3031 RUSK REHABILITATION
TREATMENT STRATEGIES FOR PERSISTENT POSTURAL PERCEPTUAL DIZZINESS Tara Denham MA, PT
Three types of referrals
Treatment from Treatment from No previous
NYU PT outside PT treatment
• Traditional VR therapy • General PT exercises • Sedentary lifestyle
• Unsuccessful • Unsuccessful • Unsuccessful
33 RUSK REHABILITATIONReasons Previous Treatments Unsuccessful
Traditional VR therapy is not appropriate
Need to switch approach
If patient has normal DVA no reason to do X1 or X2 Viewing progressions
Must have strategies to decrease anxiety
Positive reinforcement
Need to set patients up for success
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34Evaluate 2 minute walk test Motion sensitivity (MSQ) Activities patients are avoiding GAD - 7 Don’t ask how is your dizziness (0-10) 35 RUSK REHABILITATION
General Rules Symptoms should return to baseline 15-20 minutes Split up exercises into manageable components if needed Perform standing rest breaks Several short shopping trips better than long Any activity that increases symptoms can be an habituation exercise 36 RUSK REHABILITATION
Pacing Gentle approach in the beginning Build trust that exercise are not harmful Increase intensity gradually Daily exercise plan overcomes instinct to avoid activity Schedule breaks 37 RUSK REHABILITATION
Persistence/ Visual flow and complexity
Persistance
Habituation may take more time than the compensation process for a UVL
Consistent benefits require 8-12 weeks of therapy and home exercises
Visual Flow and complexity
Use exercises that include visual complexity to address the visual symptoms of 3PPD
Real world settings
Use indoor and outdoor settings that patients encounter to promote integration into daily
activities
38 RUSK REHABILITATIONAutonomic
dysregulation
Relaxation
and breathing
Motion
Visual Vertigo
Intolerance
Treatments Desensitization
Habituation exercises
exercise
Fatigue
Aerobic
exercises
39 RUSK REHABILITATIONAutonomic Dysregulation Relaxation techniques 4 Square breathing Relaxation videos Meditation apps (Eva to discuss more) 40 RUSK REHABILITATION
Motion intolerance
Habituation
Repeat motions that are provocative
Grounding activities (provide three points of contact)
Set functional goals
– Do one activity that they used to enjoy
– Increase “normal “ activities weekly
41 RUSK REHABILITATIONVisual vertigo
Decrease visual dependence
Sensory comparison exercises
VOR cancellation with busy background
2D immersion into stimulation visual scenes
Start slow example 30 seconds at a time
Slowly increase complexity of visual stimulus (optokinetic to rollercoasters)
3D virtual reality
Headsets
Study
42 RUSK REHABILITATIONFatigue
Start a walking program early
Initiate aerobic activity
Stationary bike
Treadmill when tolerated
Other activities patient enjoyed (running, swimming, bicycling)
43 RUSK REHABILITATIONKey points Strong association with anxiety but not a psychiatric disorder Patients rarely fall Usually normal gaze exam Significant motion intolerance Difficulty in crowds 44 r RUSK REHABILITATION
Restructure vague goals into specific activities
• What does “get your life back” mean to you?
Normalize schedule
Introduce aerobic activity
•
Promote healthy sleep/wake cycle. sleep.org
45 RUSK REHABILITATIONTrends Individuals with negative and emotional beliefs about their condition tend to have prolonged recovery and increased perception of illness (Kit et. al, 2014) Higher educated individuals may have attributes that also contribute to prolonged recovery (possibly increased knowledge, hypervigilance, high achievers) (Snell DL, Brain Injury, 2011) 46 RUSK REHABILITATION
Talking points Evidence that the original problem has healed Validate that symptoms are real and there is an reason for what they feel dizzy Can get better and back to life activities Problem is with functioning of CNS not structure or disease Discuss reweighting of sensory systems Explain anxiety can be manifested in different ways There may always be triggers, you can recognize them and avoid them when possible Listening is just as important as speaking 47 RUSK REHABILITATION
Do’s and Don’t’s
DO:
Be their coach!
Use motivational interviewing.
Educate on condition and common complaints that accompany 3PD.
Legitimize patient’s symptoms and reassure on outcome of recovery.
Manage distress/negative expectations and provide suggestions to decrease stress/anxiety.
Set them up for success.
(Lambert et al, 2018)
48 Rusk Rehabilitation Don’t :
Ask frequently about symptoms or medications.
Ask patient to keep a symptom diary.
Over-refer to other specialists or suggest multiple opinions or tests (especially if scans have been
normal)
49 RUSK REHABILITATIONPSYCHOLOGICAL CONSIDERATION
FOR PATIENTS WITH PPPD
PRESENTED BY EVA G. MIHOVICH, PH.D
SENIOR PSYCHOLOGIST, RUSK REHABILITATIONObjectives: • Identify core symptoms of anxiety related to vestibular disorders. • Describe evidence-based interventions for anxiety management in the vestibular population. Disclosures: I have no financial or nonfinancial disclosures regarding this presentation 51 RUSK REHABILITATION
Psychological precipitants of
PPPD
The most common psychological precipitants of PPPD are
anxiety disorders. According to Staab, et al, 2017, the
predominant diagnostic categories are
Panic attacks (15%)
Anxiety (15%)
52 RUSK REHABILITATION53 RUSK REHABILITATION
Panic Attack Description DSM-5 An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes. The surge can occur from a calm state or an anxious state. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders such as depression, PTSD, substance abuse and some medical disorders, such as vestibular disorders 54 RUSK REHABILITATION
Panic Attack Criteria-DSM-5 Four or more of the following symptoms must occur to diagnose panic attack: 1) Palpitations, pounding heart, or accelerated heart rate 2) Sweating 3) Trembling or shaking 4) Sensations of shortness of breath or smothering 5) Feelings of choking 6) Chest pain or discomfort 7) Nausea or abdominal distress 55 RUSK REHABILITATION
Panic Attack Criteria, con’t 8) Feeling dizzy, unsteady lightheaded or faint 9) Chills or heat sensation 10) Paresthesias (numbness or tingling sensations) 11) Derealization (feelings of unreality) or depersonalization (being detached from oneself) 12) Fear of losing control or “going crazy” 13) Fear of dying 56 RUSK REHABILITATION
Prevalence of Panic Attacks-DSM-5 In US general population, 12 month prevalence estimate is 11.2% in adults. No significant ethnic or racial differences, but females more frequently affected than males. In panic disorder, which is a psychiatric diagnosis characterized by recurrent panic attacks, the ratio of female to male is 2:1. Interestingly, prevalence rates of panic attacks in Europe appear to range from 2.7-3.3% 57 RUSK REHABILITATION
58 RUSK REHABILITATION
Definition of Anxiety-DSM-5 • Anxiety disorders include disorders that share features of excessive fear and anxiety • Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat • Fear and anxiety can overlap, but differ in significant ways. Fear is more often associated with surges of autonomic arousal necessary for flight or fight, whereas anxiety is more often associated with muscle tension, vigilance in preparation for future danger and avoidant behaviors 59 RUSK REHABILITATION
Generalized Anxiety Disorder (GAD) –DSM-5
• GAD is typified by recurrent excessive anxiety and worry about a
number of events or activities, such as work
• The individual finds it difficult to control worry
• The anxiety/worry are associated with 3 or more of the following 6
symptoms
1) Restlessness, feeling keyed up or on edge
2) Being easily fatigued
3) Difficulty concentrating/mind going blank
4) Irritability
5) Muscle tension
6) Sleep disturbance or restless, unsatisfying sleep
• Causes significant distress or impairment
60 RUSK REHABILITATIONPrevalence of GAD-DSM-5
• The 12 month prevalence of GAD is 2.9% in adults
in the general community of the US.
• The 12 month prevalence in other countries
ranges from 0.4-3.6%
• Lifetime morbid risk is 9.0%
• Females 2X likely to experience GAD than males
• Individuals of European descent tend to
experience GAD more frequently than persons of
non-European descent (Asians, Africans, Native
Americans, etc)
61 RUSK REHABILITATIONGAD-7
Over the last 2 weeks, how often have you
been bothered by the following Not Several More than Nearly
problems? at all days half the every day
(Use “ ✔ ” to indicate your answer) days
1. Feeling nervous, anxious or on edge 0 1 2 3
2. Not being able to stop or control worrying 0 1 2 3
3. Worrying too much about different things 0 1 2 3
4. Trouble relaxing 0 1 2 3
5. Being so restless that it is hard to sit still 0 1 2 3
6. Becoming easily annoyed or irritable 0 1 2 3
7. Feeling afraid as if something awful might
0 1 2 3
happen
(For office coding: Total Score T = + + )
Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from
Pfizer Inc. No permission required to reproduce, translate, display or distribute.
62 RUSK REHABILITATIONGAD-7 Scoring • This is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of “not at all,” “several days,” “more than half the days,” and “nearly every day,” respectively. GAD-7 total score for the seven items ranges from 0 to 21. • Scores represent: • 0-5 mild • 6-10 moderate • 11-15 moderately severe anxiety • 15-21 severe anxiety. 63 RUSK REHABILITATION
THE PSYCHOLOGICAL TREATMENT OF PPPD
Key Elements of Vestibular Rehabilitation Psychology Utilization of evidenced based treatment for anxiety, e.g. Cognitive Behavior Therapy (CBT) CBT can be augmented with another evidence based treatment, Mindfulness Based Stress Reduction (MBSR) Therapeutic flexibility and creativity to accommodate the often highly idiosyncratic presentation of physical symptoms Collaboration with vestibular rehabilitation therapists is likely to enhance treatment 65 RUSK REHABILITATION
CBT Definition of Anxiety
“When you feel anxious, worried, panicky, or
afraid, you’re telling yourself that you’re in
danger and that something terrible is about to
happen…Once you start to feel anxious, your
negative thoughts and feelings begin to
reinforce each other in a vicious circle”
-D. Burns, 2006
66 RUSK REHABILITATIONThe “Vicious Cycle” of Anxiety and Dizziness 67 RUSK REHABILITATION
A CBT Model of PPPD
“Psychological processes are implicated in the development and maintenance
of PPPD, with similarities to cognitive models of health anxiety and panic
disorder, and there is evidence that CBT is an effective treatment… It is
suggested that dizziness becomes persistent when it is processed as a threat,
and that it is maintained by
1) unhelpful appraisals
2) avoidance and safety behaviors
3) attentional strategies including selective attention to body sensations
associated with dizziness.”
Whalley and Cane, 2016
68 RUSK REHABILITATIONCognitive Behavioral Model of Persistent Postural Perceptual Dizziness (PPPD)
Initial or precipitating phase Persistentphase
Vulnerability Triggers for current episode Vulnerability Triggers for current episode
• Pre-existing anxiety Acute vestibular disorder,e.g. • Pre-existing anxiety Acute vestibular disorder,e.g.
• Sensitivity tointernal sensations • Benign ParoxysmalPositional • Sensitivity tointernal sensations • Benign ParoxysmalPositional
• Illness history Vertigo (BPPV) • Illness history Vertigo (BPPV)
• Beliefs about illness • Vestibularneuritis • Beliefs about illness • Vestibularneuritis
• Beliefs about copingability • Labyrinthisis • Beliefs about copingability • Labyrinthisis
• High trait anxiety • Vestibularmigrane • High trait anxiety • Vestibularmigrane
• Low trait extraversion • Meniere’s disease • Low trait extraversion • Meniere’s disease
or or
Panic attack with focus on Panic attack with focus on
balance sensations balance sensations
Balance control system Balance control system
dysfunction resulting dysfunction resulting
in balance symptoms Leads to / influences in balance symptoms
Initially: Later: Prevents changein Initially: Later:
• Acute vertigo • Persistent • Acute vertigo • Persistent
• Imbalance dizziness Pathway inactive • Imbalance dizziness
• Nausea • Hypersensitivity • Nausea • Hypersensitivity
ABC
• Vomiting to motion and • Vomiting to motion and
visual stimuli visual stimuli
Appraisals Appraisals
• Threatbeliefs • Threatbeliefs
• Healthbeliefs • Healthbeliefs
Emotional response to Emotional response to
appraisal (typically appraisal (typically
anxiety) anxiety)
Behavioural Attentional Behavioural Attentional
adaptation strategies adaptation strategies adaptation strategies adaptation strategies
• Avoidance of any movements or Voluntary • Avoidance of any movements or Voluntary
activities that may cause • Vigilance to environment for activities that may cause • Vigilance to environment for
dizziness symptoms -e.g. head or potential threats to safety or dizziness symptoms -e.g. head or potential threats to safety or
body movements, walking, stability body movements, walking, stability
socialising • Mental checking of bodily socialising • Mental checking of bodily
• Safety behaviours sensations related to balance • Safety behaviours sensations related to balance
- Holiding on for safety - Holiding on for safety
Involuntary Involuntary
• Central‘up-weighting’of visual • Central‘up-weighting’of visual
and somatosensorycues and somatosensorycues
• Central down-weighting of • Central down-weighting of
vestibular cues vestibular cues
Copyright © 2017. Reprinted with permission from Elsevier.
69 RUSK REHABILITATION
PSYCHOLOGY LS ®
Whalley, M. G., Cane, D. A. (2017). A cognitive-behavioral model of persistent postural-perceptual dizziness. Cognitive and Behavioral Practice, 24(1), 72-89.The CBT “Tool Box” of Vestibular Psychology
A.Psychoeducation
B.Identification of triggers/symptom tracking (includes
thought patterns)
C.Mindfulness
D.Anxiety Management
E.Cognitive Restructuring
F.Reinforcement of self esteem and self efficacy
70 RUSK REHABILITATIONAnxiety Management Training Breathing Exercises Square Breathing Technique (Breathe in to a count of 4, hold for a count of 4;exhale to a count of 4; do 4 times Grounded Breathing Technique (Employs mindful awareness of feet on the ground to counterbalance lightheadedness, dizziness, etc.) Patients who have a pre-existing breathing exercise (yoga) can practice that instead Be cautious about monitoring increased lightheadedness due to breathing exercises; do not want to increase anxiety during exercise 71 RUSK REHABILITATION
Mindfulness Training Mindfulness, the act of paying attention without judgment, is helpful for several reasons. Mindfulness meditation is a well known stress reduction technique, so it is useful for anxiety management skills training It can be helpful for emotional regulation, enhancing the skill of mindfully observing unpleasant emotions and sensations (anxiety and dizziness) without overreacting. Mindfulness can be useful in helping the vestibular patient “radically accept” that s/he may have a recurrent or permanent disorder that will necessitate the need to utilize the skills learned in vestibular rehabilitation and psychotherapy throughout his/her life 72 RUSK REHABILITATION
Imagery Imagery, picturing a scene or event in one’s mind and eliciting various sensory components, can be utilized in several ways • Relaxation- picturing a pleasant location can deepen relaxation • Performance enhancement- can be use to augment virtual reality when devices are not available between treatment sessions • Behavioral rehearsal-can enhance preparing for a stressful event 73 RUSK REHABILITATION
Stress Inoculation 74 RUSK REHABILITATION
Stress Inoculation Stress inoculation is a therapeutic approach that combines several techniques or interventions to train individuals to cope with unpleasant emotional or physical arousal (anxiety, anger, pain and dizziness) in anticipated stressful situations. Components are: 1) Acquisition of a rapid stress reduction technique, such as breathing or cue control 2) Development of coping self statements, which are sentences or phrases that reduce arousal and positively yet realistically reframe habitual negative thought patterns to encourage success 3) Imaginal rehearsal of the anticipated stressful event, utilizing relaxation strategies and coping self statements during imagery to reduce arousal experienced during the imagery exercise 4) Reinforcing success when the stressful event is actually faced in real life. Exposure to the event is reinforced even if it is not completed, to build confidence. 75 RUSK REHABILITATION
CASE PRESENTATION
History:
• Patient is a 46 year old female presenting to vestibular physical therapy evaluation May 2018
accompanied by her husband.
• October 28, 2017 she passed out while in the bathroom, hit her head with LOC for 5 minutes.
• She felt fine afterwards therefore went to work as an RN in a local hospital the next day.
• One week later she was in her car driving and started to get palpitations and subsequent dizziness.
• She decided to stay home from work for a week and she began to feel better however became a
cycle of one week on/off from work due to increase in symptoms.
• November 11, 2017 - went to ED for dizziness. Reports CT was normal.
• MRI in December - Patient states MD reported "brain swelling."
• December 19, 2017 - stopped working
• Was bound to her bed throughout remainder of December due to severe dizziness and imbalance.
• MRI in February 2018 - "bulging discs and pinched nerves" as well as "brain swelling."
• March 2018 saw cardiology due to report of palpitations with subsequent dizziness. Wore a holter
monitor for 72 hours which was unremarkable therefore was told her symptoms are "just vertigo."
• March 2018: Patient reports she went for additional opinions from different Neurologist and Neuro-
opthalmologist who are in agreement that patient's symptoms are 2/2 concussion.
RUSK REHABILITATIONCurrent Symptoms: • Current symptoms: Difficulty sleeping, constant dizziness that increases with head and body movements, throbbing/pulsating headaches, imbalance. • Requiring one person assist for all mobility • Furniture reaching within the home • 5 minute tolerance to standing or walking • Sensitivity to light and sound • Limits exposure to crowds • Increased anxiety related to fear of provocation of symptoms • Symptoms provoked by: light, loud sounds, busy environments, quick movements of head and/or body, bending down, prolonged screen time, watching moving objects pass by, reading RUSK REHABILITATION
Social History • Patient lives with husband and 2 children. • One child with special needs living in a facility • Previous relationship with domestic abuse. • Prior history of depression/anxiety • Course of therapy from January–February 2018 did not help RUSK REHABILITATION
Clinical Findings: • No spontaneous or gaze evoked nystagmus • Negative HIT • 7 line difference on DVA • 14/30 on the FGA • Distance on the 2 minute walk test: 88m (norm 183m) • DHI: 82 • ABC: 23% • GAD-7: 15 indicative of anxiety RUSK REHABILITATION
Video
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RUSK REHABILITATIONIntervention • Habituation to visual motion stimuli through optokinetic videos with 3 point contact • Aerobic exercise (treadmill at home) • Patient education regarding PPPD with written handouts and visual aids • Weekly goals for increasing pleasurable activities (attending church, decorating house, walking with her husband) • Education regarding meditation and grounded breathing • Vestibular psychology RUSK REHABILITATION
Outcomes • Functional Gait Assessment: 23/30(improved from 14/30 at evaluation) • Dizziness Handicap Inventory: 82 (unchanged) • Activities Specific Balance Confidence Scale: 64% (improved from 23% at evaluation) RUSK REHABILITATION
PSYCHOLOGY CASE PRESENTATION
References:
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REHABILITATIONReferences
• 10. Sohsten, E., R.S. Bittar, and J.P. Staab, Posturographic profile of patients with persistent postural-perceptual
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RUSK REHABILITATIONReferences American Psychiatric Assn., Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. (DSM-5). (2013). American Psychiatric Publishing. Burns, D.B., When Panic Attacks. (2006) Harmony Books. Clark DB, H.B., Smith MG, Furman JMR, Jacob RG, (1994)Panic in otolaryngology patients presenting with dizziness or hearing loss. American Journal of Psychiatry, 151: p. 1223-1225. Dieterich, M. and J.P. Staab, (2016) Functional dizziness: from phobic postural vertigo and chronic subjective dizziness to persistent postural-perceptual dizziness. Curr Opin Neurol,. Johansson, M., et al., (2001) Randomized controlled trial of vestibular rehabilitation combined with cognitive-behavioral therapy for dizziness in older people. Otolaryngol Head Neck Surg, 125(3): p. 151-6 Naber, C.M., et al.,( 2011) Interdisciplinary Treatment for Vestibular Dysfunction: The Effectiveness of Mindfulness, Cognitive-Behavioral Techniques and Vestibular Rehabilitation. Otolaryngology-Head and Neck Surgery, 145(1) P. 117-124 Popkirov, S., J.P. Staab, and J. Stone. (2018) Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Pract Neurol, 2 18(1): p. 5-13. Staab, J.P., et al. (2017) Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Barany Society. J Vestib Res,. 27(4): p. 191-208. 87 RUSK REHABILITATION
References, Cont Whalley, M.G. and Cane, D.A. (2017) A Cognitive-Behavioral Model of Persistent Postural- Dizziness. Cognitive and Behavioral Practice, V 24 (1) Yardley, L., (1994 ) Prediction of handicap and emotional distress in patients with recurrent vertigo: symptoms, coping strategies, control beliefs and reciprocal causation. Soc Sci Med,. 39(4): p. 573-81. Yardley, L. (2000). Overview of psychologic effects of chronic dizziness and balance disorders. Otolaryngolic Clinics of North America, 33(3), 603-616. Yardley, L., Britton, J., Lear, S., Bird, J. & Luxon, I.M. (1995). Relationship between balance system function and agoraphobic avoidance. Behavior Research Therapy, 33(4), 435-439. 88 RUSK REHABILITATION
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