Introduction
What do you do with a dizzy patient? or a patient with a history of multiple falls? After ruling out acoustic neuromas, common systemic diseases, and trying Meclizine or other otologic sedatives and perhaps B vitamins for a couple weeks, what’s next? CT/MRI’s, ENG’s?

Dizziness and balance disorders present one of the most difficult and time-consuming diagnostic challenges a healthcare provider can face. Even after an exhaustive diagnostic investigation, what can you do about it? Live with it? Do a chemical or surgical procedure to destroy part of the inner ear?

Population at Risk
The population at greatest risk are seniors over the age of 65. The endemic problem of balance disorders and fall-related injuries results in as much as a 35% mortality rate within the first year of injury after a fall related fracture depending on the population studied.

Adult and pediatric age groups who have experienced head trauma, chronic otitis media, exposure to potent ototoxic antibiotics and/or chemotherapy and have continuing vertigo and dizziness as a result, can greatly benefit.

The Problem
In most practices, including ENT and Neurology, there has been a lack of definitive diagnostic tools and appropriate specialized and skilled rehabilitation programs. In addition, where some degree of skilled rehab is available, it is not integrated into a comprehensive, focused medical based solution.

The Diagnostic and Treatment Solution
It has been well established that there are numerous medical programs across the country that successfully address and treat balance disorders. These programs, such as the USC Balance Center and others {Mayo Clinic, University of South Florida and Oregon State University}, consistently diagnose and treat balance disorders and evidence a 30%to 40% decrease in falls among their independent living senior patients. This success is predicated upon focused examinations, state of the art diagnostics and highly skilled supervised rehabilitation programs, proven to work {see Citation Addendum}.

The Integrative Balance Program is closely modeled upon these programs and has evidenced the same success. In addition, we have developed specific enhancements to these university-based protocols, addressing osteoporosis and drug-drug interaction components. The vast majority of patients treated in our offices have experienced substantial increases in balance and mobility.

Diagnostic Methodology
The program diagnostics consist of a detailed balance history, a physical exam to assess ocular, vestibular, and neuro-muscular deficiencies, audiometry, a complete physical therapy evaluation utilizing NeuroCom Balance Master protocols, a Berg Balance Scale and Tenetti Screening Test to quantify risk, video occulography (VOG) and a Vestibular Autorotation Test (VAT). The VAT is the primary vestibular diagnostic tool employed to obtain objective quantifiable data.

This painless, portable, 18-second computerized test was developed by the USC Center for Balance Disorders; a division of the Department of Otolaryngology, Head and Neck Surgery. The VAT monitors the vestibular ocular reflex (VOR) in a physiological natural simulation of real world, real time head and eye motions. Unlike the ENG, the VAT measures Vestibular function in all three semi-circular canals vs only the horizontal at physiological head rotational velocities of up to 6 Hz vs 2Hz. Supporting research for the VAT was published in the Journal of Vestibular Research, Vol. 8, No.4, 1998.

The Nuerocom Balance Master is essentially a computerized postulography device (a device which measures real-time dynamic total body movement under different conditions of posture and locomotion) that is used diagnostically as well as therapeutically. It allows us to measure limits of stability, sensory integration, weight distribution and real-time analysis of movement. See below for a description of the treatment applications

This focused methodology provides our medical rehab team the means to generate a meaningful diagnosis. From the subjective and objective data collected we derive a specific diagnosis and assign relative contributions of peripheral (ocular, vestibular, and/or somatosensory), and central (sensory integration, CNS processing) components. Of all equilibrium problems, more than half can be directly related to an inner ear disorder and a majority of all causes of dizziness can be found during our evaluation.

Treatment Phase
The integrative nature of the human balance system contains within it the key to effective treatment of most balance disorders. As you know, the brain receives a constant stream of up-to-date input from the eyes, inner ear and muscles, joints and soles of the feet {somatosensory system} in order to perceive position and velocity with in the basis of support {BOS}. The information is then processed and fed back to the muscles of the body to maintain the BOS.

The brainstem, cerebral cortex, and cerebellum can eventually adapt to ignore abnormal or unequal impulses from the inner ear. Vestibular rehabilitation exercises often enable the brain to habituate the dizziness problem so that it does not respond in an abnormal way, and does not result in the individual feeling dizzy. An example of habituation is observed with ice skaters who spin around, stop suddenly, and do not apparently have any balance problems. Computerized visual feedback is used to retrain the patient to recognize Center of Gravity (CG) changes before they cause movement outside the BOS system and to effect appropriate stepping and other strategies to continuously maintain a stable BOS.

Vestibular Rehabilitation Efficacy
It is essentially uncontroverted that vestibular rehabilitation aids the development of compensatory and symptomatic recovery systems in balance disorder patients. The clinically supported approach to rehabilitation {Shumway-Cook and Horak, 1990; Shepard et al, 1993; Herdman, 1994} places the emphasis on customized exercise programs and balance and gait training during dynamic rather than static tasks. Specific exercises from specifically devised tasks, which precipitate the patient’s symptoms, are used. The patients, under the supervision of a physical therapist specially trained in vestibular rehab techniques, practice these exercises at the limit of their ability until they are in most cases rendered asymptomatic. The exercises advocated for balance and gait retraining vary depending upon the individuals difficulties.

The Integrative Balance Program utilizes the NeuroCom Balance Master in its rehabilitative programs to further increase the effectiveness of balance retraining. This system employs the same technology used by NASA to measure the equilibrium of shuttle crews after flights in space. The Balance Master uses interactive technology to guide and prompt patients throughout treatment, thus giving them real time visual feedback. The computerized system consists of a sensory platform on which patients sit or stand. During a therapy session, patients move their bodies in ways that control a small figure on the computer screen linked via the platform. The goal is to make the figure reach “targets” on the screen, much like a commercial video game. The physical therapist can design targets to encourage specific movements by the patient; thus helping them build physical stability, endurance and confidence. Substantive research conducted at Oregon State University under the auspices of Debra Rose, Ph.D. determined the superior effectiveness of this modality compared to traditional rocker boards and balls.

BPPV
The revolutionary management of BPPV (Benign Paroxysmal Positional Vertigo) that has occurred within the last 3-4 years further illustrates the efficacy of vestibular rehabilitation. BPPV is a common type of vertigo that can be caused by the displacement of otolithic particles, which give the brain positional information about gravity through sensory outputs from the inner ear via the 8th nerve. The single positional maneuvers described by Semont et al {1988} and Epley {1992} rely upon the anatomical configuration of the semicircular canals and the ability to reposition the head, thus moving the displaced particles from the hair cells into the body of the labyrinth where they appear to be absorbed by the lymphatics. This technique brings about the immediate resolution of vertigo in 80-90% of patients within 1 to 3 treatments. With the use of specially designed video recording Frenzel lens goggles for the initial confirmation of the BPPV diagnosis, we can then perform this technique in our treatment regimen and our patients respond dramatically.

Patient Outcomes
We have had great success with this course of rehabilitation in our Santa Monica office. Within eight to twelve sessions of rehabilitation, nearly 75% of our patients have shown significant improvement in their balance and mobility. We anticipate fall rate reduction to be consistent with the published figures of 30 to 40%. Much of our success is attributable to the interaction between the medical diagnostic component of the program and the course of physical therapy rehabilitation. We require initial, midpoint and discharge medical reviews of physical therapy to insure progress and avoid unnecessary treatment. This “focused” approach to the management of balance disorders allows for detailed specialization in the protocol as well as the wherewithal to direct attention to the home environment and the activities of daily living.

Indications for Patient Referrals
1. Any patient with a history of head trauma with complaints of continuing dysequilibrium, dizziness and/or vertigo, and/or incidences of multiple falls.
2. Patients with a history of exposure to any environmental hazards including toxic spills, liquid or gaseous chemical exposures and who are complaining of dysequilibrium, dizziness and/or vertigo and/or falls and/or incidences of multiple falls.
With the VAT we can quantitate the relative degree of decreasing function of the inner ear caused by these agents. This allows us to see changes in function before permanent damage is done.
3. Patients undergoing ototoxic chemo or antibiotic therapies.
4. Whenever a standard ENG is indicated, consider the VAT and Balance Master.
5. Whenever an ENG is read as “normal” but the patient continues to express significant Vestibular dysfunction, dizziness, or balance disorders.
6. Seniors who are at risk for falls or have a history of falls.

Conclusion
This program will provide specialized expertise to help you effectively diagnose and treat the dizzy and balance disordered patients in your medical group. For the last 24 months, we have made an extensive survey of the protocols used by the leading balance centers in the country. With this experience we have integrated the best of their diagnostic and therapeutic approaches along with my own innovations to provide the most advanced program available in an outpatient office setting. To further advance our knowledge and efficacy, we are also conducting clinical research trials on ways to improve the retaining process. Our rehab facility in Santa Monica is conveniently located. We are the only practice in this area with both a VAT and NeuroCom Balance Master, as well as VOG and ENG instrumentation.

There are compelling reasons to make available the Integrative Balance Program to your patients. These diagnostic and rehabilitative services are well recognized as the accepted standard of medical care for the treatment of balance disorders. Medicare, Workers Compensation and private insurance already cover nearly all of these enumerated services. Most importantly, this program allows us, as physicians, the ability to effectively treat and rehabilitate a condition that deeply impacts our patient population.

We look forward to meeting you and further discussing this important opportunity.
Sincerely yours,

Steven M. Kaye, MD
Executive Director


Citation Addendum
1. Binder EF, Brown MB, Birge SJ. Effects of moderate intensity exercise program at reducing risk factors for falls in frail older adults. J Am Gerialr Soc. 1991: 39A50.

2. Ledin T, Kronhead AC, Moller C, Odkvist I.M., OlssonB. Effects of balance training in elderly evaluated by clinical tests and dynamic posturography. J Vest Res. 1991;1:129-138.

3. Lichtenstein MJ,. Shields SL, Shiavi RRG, Burger MC. Exercise and Balance in an aged women; a pilot controlled clinical trial. Arch Phys Med Rehabil. 1989;70;138-143.

4. Tinetti ME, Basker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med. 1994;331:821-827

5. Stuart ME, Rose DJ. The effectiveness of the balance efficacy scale to measure changes in confidence associated with the completion of a balance intervention program. J Aging Phys Act. 1995;(suppl):26.

6. Rose DJ, Clark S. Measuring the effectiveness of a balance intervention for older adults with a history of falling; a comparison of selected functional an objective tests of balance, J Aging Phys Act. 1995;9 supp l0:27.