Saturday, November 7, 2020

One of the Toughest Causes of Dizziness I See

Spontaneous spells of spinning with seconds to minutes duration can be difficult to treat. I am very interested in treatment options for vestibular paroxysmia (VP) so I wanted to conduct a literature review and see what I could find. Here is an abstract I wrote based off the following recent study:

Bayer, O., Brémová, T., Strupp, M., et al. (2018). A randomized double-blind, placebo-controlled, cross-over trial (Vestparoxy) of the treatment of vestibular paroxysmia with oxcarbazepine. Journal of neurology, 265(2), 291–298.


Vestibular paroxysmia (VP) can be extremely frustrating to patients and clinicians because of it’s spontaneous and unpredictable nature.  Spells usually last seconds and can occur many times a month.  This monocenter, randomized, placebo-controlled, double-blind, cross-over clinical trial examined the therapeutic effect of Oxcarbazepine (OXA) in patients with VP.


43 patients between the ages of 18-80, who were diagnosed as having definite or probable VP, were enrolled for a treatment period of seven months total.  There were two treatment protocols.  Each protocol followed the same following time frames and study structure: three months of treatment or placebo followed by a one month “wash-out period” followed by the opposite placebo or treatment for three months.   OXA was the study medication and identical filling capsules were used as placebo.  Patients were randomised and evaluated by physicians periodically.  Side effects were monitored and investigators and patients were blinded to the treatment allocation sequence.


Unfortunately, the study experienced a high number of dropouts because of adverse events, relief of symptoms, or no improvement.  In the remaining participants, OXA was found to reduce the number of attacks by nearly a half (3.15 under OXA, and 5.91 under placebo treatment).


OXA treatment provided significant relief compared to placebo for individuals battling VP.

Relevance to Physical Therapy

One of the greatest challenges I face as a vestibular therapist is figuring out how to stabilize spontaneous attacks of spinning lasting seconds or minutes.  In these tough cases, my role shifts from a provider of vestibular rehabilitation to a patient advocate helping triage to the most appropriate physician.  I will often encourage my clients to video their eyes during attacks to confirm the presence or absence of a vestibular problem that may be causing the attacks.  Once a vestibular problem is confirmed and characteristics fit the VP diagnosis, I can then make informed referrals to specialists.  Sometimes patients will ask what treatment options exist and I can use this study as a potential source of information.  The patient may choose to share this study with their physician which may assist in providing a more evidence based form of treatment.

Thursday, November 5, 2020

A Potential Missing Link Managing Mal De Debarquement Syndrome

Mal De Debarquement Syndrome can be extremely debilitating. I have enjoyed hearing Dr. Djalilian speak in the International Vestibular Diploma Course and wanted to dig a little deeper into some of his research. Here is an abstract I wrote based on his research on MdDS. I included some helpful links below as well.

Ghavami, Y., Haidar, Y. M., Ziai, K. N., Moshtaghi, O., Bhatt, J., Lin, H. W., & Djalilian, H. R. (2017). Management of mal de debarquement syndrome as vestibular migraines. The Laryngoscope, 127(7), 1670–1675. 


Mal De Debarquement Syndrome (MdDS) is a sense of continuous movement, often described as rocking, that continues for weeks, months, or years after being on a ship, plane, train, or other prolonged continuous movement-related activity.  Unfortunately, traditional vestibular rehab can sometimes be unsuccessful at providing relief.  Nortriptyline and other migraine prophylactic medications have been reported to help suffering individuals find relief.  The purpose of this study was to investigate whether or not migraine prophylaxis would help decrease dizziness and improve quality of life in individuals suffering from MdDS.


Clients battling dizziness and balance disorders, who presented to the researcher's tertiary neurotology clinic, were triaged into various diagnostic categories.  32 total patients met the MdDS criterion and were enrolled in their study.  15 clients were treated with education on migraine lifestyle changes and participated in the researcher's prescription-based migraine protocol.  This protocol included the following possible drugs individually or combined in various groups: Nortriptyline, Verapamil, and/or Topiramate.  Nortriptyline was the most common drug prescribed.  The trial cohort was compared with 17 past patients treated with vestibular rehabilitation and physical therapy (control group).


73% of the trial cohort had a large improvement reported using a visual analog scale (VAS).  A statistically significant difference was found in some quality of life (QOL) measures using a pre/post-treatment QOL survey.  There was minimal to no change in VAS or QOL in the control group.


This study reinforces the hypothesis that MdDS will respond well to migraine prevention-based lifestyle change education combined with a special migraine prophylactic drug management protocol.  

Relevance to Physical Therapy:

Physical therapists helping clients battle MdDS should be aware that the potential cause for failure to compensate may be migrainous.  Therefore, positive treatment outcomes may be more likely when migraine prevention-based lifestyle changes such as diet, sleep hygiene, and stress reduction education are employed in conjunction with the migraine prophylactic protocol described in this study.  In my opinion, neck therapy and overall health and wellness programs should also be considered.  If improvement within three to six visits (usually over a period of two to three weeks) is not realized, a change in the treatment approach should be initiated.  It is not clear if this type of therapy was included in their control group.  


Original Research Article:

Dr. Djalilian (one of the authors of this article) giving an outstanding lecture on Migraine management: