Physical Therapist: Shelly Massingale, PT, MPT

1. Concussion has received significant media attention over the last few years. What is a concussion? 

The CDC defines concussion as “a type of traumatic brain injury or TBI- caused by a bump, blow or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth.”  Concussion is commonly referred to as a mild traumatic brain injury (mTBI) and is typically associated with normal structural imaging (normal CT/MRI). Symptoms of concussion  can include dizziness, headache, cognitive changes, mood changes, balance problems, and nausea and vary from person to person and from injury to injury.  Concussion is considered a transient injury that typically lasts a few days to a several weeks before full recovery.  

2. Dizziness and balance problems are common after concussion. Why are these symptoms so common?

Dizziness and balance problems that occur after a head injury are often the result of damage to either the peripheral or central vestibular system.  Our vestibular system is comprised of our inner ear (peripheral vestibular system), the vestibular nerve (connects the peripheral to the central vestibular system), and the areas in the brain that process that information (central vestibular system).  If any of these areas have been affected, the injured person could experience feelings of dizziness, being off balance, vertigo or a combination of these.  Our vestibular system is highly sensitive to movement, so any damage or disturbance to these areas cause symptoms while performing activities of daily living. 

3. Do you recommend that patients pursue vestibular rehabilitation after a concussion?

If a patient sustains a concussion and has any symptoms of dizziness, vertigo, imbalance, or nausea that last more than a few days, I highly recommend pursuing vestibular therapy. Vestibular therapy an effective treatment, and having a specialist take you through a course of treatment will allow you to recover more quickly. The patient’s physician typically makes the initial referral to vestibular therapy after a thorough medical evaluation of concussion.

4. If so, what vestibular rehabilitation techniques help to reduce symptoms and improve function?

The technique used in vestibular therapy depends on the nature and severity of the symptoms, as well as the underlying cause. When someone sustains a concussion, symptoms of vertigo may occur with positional changes. This diagnosis is called Benign Paroxysmal Positional Vertigo (BPPV), which commonly occurs after head injury. The treatment for BPPV is very specific and should be performed by a trained clinician. If BPPV is not present, then balance exercises and vision retraining exercises that address how the head and eyes move together are very effective in reducing dizziness and imbalance. Exercises selected are highly specialized and very specific to the individual’s symptoms and daily activity demands, and should only be performed by a clinician that has training in this type of therapy.

5. Are there specific exercises or strategies most helpful for improving symptoms after concussion?

See above answer 4.

6. Do you recommend vestibular rehabilitation for all patients post-concussion? Are there patients with certain symptoms who benefit most?

Vestibular therapy is not indicated for every patient who sustains a concussion.  Some people will be diagnosed with a concussion and will not have any symptoms related to dizziness, imbalance or vertigo. These patients do not need to participate in vestibular therapy.  On the other hand, any person who is experiencing dizziness, vertigo, and/or imbalance after sustaining a concussion would likely benefit from participating in vestibular therapy, especially if the symptoms persist for more than a few days. 

7. I’ve had quite a bit of neck pain and stiffness after a car accident. Could this be the cause of my dizziness?

Cervicogenic dizziness can occur with a whiplash injury and is often diagnosed with concussion. Cervicogenic dizziness is defined as the presence of dizziness, imbalance or unsteadiness related to movements or position of the cervical spine or related to a stiff or painful neck. The treatment for cervicogenic dizziness is therapy for the neck to help decrease the discomfort and stiffness. Reducing stiffness and muscle imbalance in the neck can help to decrease the sensation of dizziness.

8. Are there any screening measures or tests available that you’d find helpful to have prior to seeing a patient referred for VRT? 

Prior to starting VRT, a patient should be evaluated by a physician with specialized knowledge about concussion and brain injury. A concussion can cause a myriad of symptoms in addition to dizziness/imbalance, so a thorough and complete assessment of post-concussion symptoms is necessary to determine the correct course of treatment for each individual. Depending on the severity of the injury and the symptoms, an audiology evaluation may be helpful to more thoroughly assess inner ear function.  The physician overseeing the case usually determines which clinical tests need to be performed prior to initiating vestibular therapy.

9. What would you want the general public to know about concussion rehabilitation? 

Concussion rehabilitation is most effective and efficient when the patient receives a multidisciplinary evaluation and individualized approach to care. Concussion is a complex injury which should not be addressed using a “cookie cutter” approach to treatment and focusing on treatment of only one aspect of concussion may lead to a longer recovery.  

10. What is your overall key take home message for providers working with patients with suspected post-concussion dizziness? 

I would highly recommend that the provider working with post-concussion dizziness complete specialized training that addresses the nature of concussion/brain injury and reviews appropriate treatment protocols. I cannot stress enough the importance of having a multidisciplinary team of clinicians overseeing the treatment, management and rehabilitation of patients to ensure the patient is receiving the best care for his or her injury.   

Shelly Massingale is the senior director of Banner Concussion Services in Arizona and Colorado. She is a physical therapist and has been a specialist in vestibular and balance therapy for the past 22 years. Shelly has focused her treatment and research primarily in mild traumatic brain injury since 2013 and has lectured nationally and internationally on evaluation and treatment of vestibular and balance deficits related to mild traumatic brain injury. 

Vestibular Disorders: Habib Rizk, MD

1. Dizziness is a common symptom reported by many patients. As an otologist, what about patient-reported dizziness is most concerning to you? What disorders do you most commonly see in the clinic?

Any patient presenting with new neurologic symptoms associated with their dizziness requires a thorough evaluation to look out for central causes. These symptoms could be new onset headaches, slurred speech, paresthesia, weakness in lower or upper limbs. Also, patients with loss of consciousness need to be evaluated to rule out a hemodynamic cause or an arrhythmia. Finally, patients with dizziness associated with audiologic symptoms orients more toward a peripheral inner ear disorder.

In our multidisciplinary dizziness clinic, Meniere’s disease and vestibular migraine and BPPV account for about 50% of our new patients

2. Are there differences based on age? Do kids have the same trouble with dizziness as adults?

In children, migraine equivalents are the most frequent causes of dizziness, as well as post concussive dizziness. While vestibular migraine is prevalent in adults, benign paroxysmal positional vertigo is still the most frequent cause of vertigo in adults. Dizziness is a general term and can encompass vertigo, lightheadedness, imbalance.

3. Many patients have been diagnosed with Meniere’s disease. What is Meniere’s disease? What management is available Meniere’s disease?

Meniere’s disease is a pathology that affects the pressure control of the inner ear fluids resulting in fluctuating symptoms of ear pain, tinnitus and vertigo lasting between 20 minutes and 12 hours. There is a high association with migraines in a large subset of patients. Treatment ranges from low salt diet and diuretics to intratympanic steroids, intratympanic gentamicin injections and surgeries: to preserve hearing such as endolymphatic sac decompression or vestibular neurectomy or that are not hearing preserving such as labyrinthectomy.

4. If a patient experiences a sudden onset of spinning vertigo, should the patient immediately go to the emergency department or is there an alternative pathway to care that you would recommend?

A brief episode of vertigo (room moving or subject feeling that they are moving) lasting less than a minute and triggered by a change in head position, typically would not require a specialized evaluation and is usually a benign paroxysmal positional vertigo. However, as a precaution it is important to be evaluated to see if there is any reason to suspect a stroke. Rarely, posterior fossa strokes will manifest only as vertigo without associated symptoms

5. I’ve been diagnosed with positional vertigo. Is it possible for this to return? What can I do to reduce my risk?

Yes. BPPV is known to recur and that incidence is often quoted to be 10% per year meaning a subject with positional vertigo has a 10% chance of having another “attack” in the same year. Any disorder affecting the inner ear such as meniere’s disease as well as vestibular migraine seems to increase the chances of this happening. Also, low levels of vitamin D have been considered a risk factor in bppv and supplementing for vitamin D deficiency is a low cost low risk intervention that may help (jury is still out on this one)

6. Are there medications that can help with my dizziness?  Alternatively, are there any medications that could potentially worsen a patient’s symptoms or recovery?  What about other treatment options?

During an acute attack of vertigo, meclizine, valium, promethazine may be used. If patient is vomiting, suppositories may be necessary. However, taking them long term is going to affect the brain’s ability to compensate and thus it is not advisable to stay on those medications indefinitely. Depending on the cause of the dizziness, a short course of steroids may be indicated as well as preventive therapy for migraines or for meniere’s disease

7. Imbalance is a significant concern for adults as we age. Why is this the case? Do you have guidance on when to seek out balance therapy resources?

As our population is getting older (a child born today is expected to live to be 130 years old), our sensory systems are aging as well. The same way vision is affected and hearing is affected, balance is also affected. Loss of the function of balance of the ears (vestibular function), loss of proprioception (back pain, hip pain, joint pain , reduced muscle mass) and reduced visual acuity increase dramatically the risk of falls. This in itself cause significant injuries and increase mortality in the elderly. If there is any concern for falls, near falls, hesitant gait or dizziness, a patient needs to be evaluated by a vestibular specialist and started on a vestibular rehab program that will significantly reduce that risk

8. What other specialists might be involved in the diagnosis and management of a patient with a suspected vestibular disorder?

Audiologists to perform an array of vestibular testing that will give us an idea of how the vestibular system is functioning. Vestibular therapists that are primordial in setting up a physical therapy/rehabilitation plan

9. What would you want the general public to know about vestibular disorders?

It is an invisible problem. It can have a significant toll on people from the functional, emotional and even cognitive standpoint. If you have a relative or a friend with a diagnosis of vestibular dysfunction, accepting an injury you cannot see will go a long way helping those patients go on the path to recovery. It is not “in their head”.

10. What is your overall key take home message for providers working with patients with vestibular disorders?

Do not underestimate the pervasive impact of a vestibular dysfunction on your patient’s overall health and functioning. New data even shows potential links with progression to dementia. This goes to say how important is our vestibular function in many dimensions of our lives. A thorough assessment to rule out severe etiologies (tumors, strokes) and to make a good functional assessment, will allow you to establish a multidisciplinary plan of care that should impact their quality of life tremendously.

Habib Rizk, MD, MSc, grew up in Beirut, Lebanon, and is a graduate of the French Faculty of Medicine-Saint Joseph University in Beirut Lebanon. Dr. Rizk completed an Otolaryngology – Head and Neck Surgery (Ear, Nose and Throat, ENT) Residency at Hôtel-Dieu de France Hospital in Beirut with additional fellowship training in Otologic Medicine and Surgery Fellowship with Dr. Michael Teixido as well as in Neurotology at the Medical University of South Carolina (MUSC). He then joined the MUSC ENT Department as the director of the Vestibular Program, and established the only multidisciplinary program in the state of South Carolina to evaluate and manage patients with various causes of dizziness. He is on the board of directors of the American Balance Society, a member of the Equilibrium Committee of the American Academy of Otolaryngology – Head & Neck Surgery as well as a representative of the Academy in a joint task force with the American Academy of Neurology to investigate quality improvement measures in neurotology. 

Dr. Rizk is involved in hearing-related and dizziness-related research and has over 25 articles published.  He also authored several book chapters and published a book about anatomy of the ear geared toward teaching residents and medical students the complex anatomy of the ear and temporal bone. His interests pertain to all areas of otology and neurotology with a specific focus on medical and surgical management of vestibular disorders.