New Interventions:New Interventions:Physical Therapy: The Physical Therapy: The

New “Drug” into the New “Drug” into the Management of the Dizzy Management of the Dizzy

PatientPatient

Brian K. Werner, MPTBrian K. Werner, MPTDecember 15, 2006December 15, 2006

CME – Sunrise Grand RoundsCME – Sunrise Grand Rounds

Brian K. Werner, MPTBrian K. Werner, MPT Master’s DegreeMaster’s Degree in Physical in Physical

TherapyTherapy Northern Arizona University – Northern Arizona University –

Flagstaff, AZFlagstaff, AZ National Certification of National Certification of

CompetencyCompetency – Vestibular – Vestibular Assessment and TreatmentAssessment and Treatment

Miami School of Medicine: Miami School of Medicine: Physical Therapy Department – Physical Therapy Department – Miami, Fl (2000)Miami, Fl (2000)

ServiceService Founder, Director and Lead Founder, Director and Lead

Clinician of Balance Centers of Clinician of Balance Centers of America: Las Vegas and America: Las Vegas and Henderson (2001-2005) BranchHenderson (2001-2005) Branch

ServiceService Owner and Lead Clinician of the Owner and Lead Clinician of the

Werner Institute of Balance and Werner Institute of Balance and Dizziness, Inc. (11/05 to present)Dizziness, Inc. (11/05 to present)

What is Physical Therapy?What is Physical Therapy?

Form of exercises designed Form of exercises designed to improve functional to improve functional independence in patientsindependence in patients

Commonly associated with Commonly associated with pain management.pain management.

Treatment of dizziness and Treatment of dizziness and falls is a new modality.falls is a new modality.

PT’s are licensed clinicians PT’s are licensed clinicians (Masters/Doctorates) that are (Masters/Doctorates) that are under a board that certifies under a board that certifies licenses annually.licenses annually.

PT’s require 15 CME/CEUs PT’s require 15 CME/CEUs annually.annually.

Prevalence of Dizziness Prevalence of Dizziness General PopulationGeneral Population

Nazareth, et. al, 1999 Nazareth, et. al, 1999 • Reported 4% of patients 18 to 65 who consult Reported 4% of patients 18 to 65 who consult

with GP reported persistent symptoms of with GP reported persistent symptoms of dizzinessdizziness

• 3% considered dizziness “severely 3% considered dizziness “severely incapacitating.”incapacitating.”

This is over 15 million AmericansThis is over 15 million Americans Yardley, et al, 1998 (follow-up study of Yardley, et al, 1998 (follow-up study of

Nazareth)Nazareth)• One in 10 peopleOne in 10 people of working age experience of working age experience

dizziness with some degree handicap (Yardley, dizziness with some degree handicap (Yardley, et al, 1998).et al, 1998).

• 18 months later concluded:18 months later concluded: 24% more handicapped24% more handicapped 20% had recurrent dizziness20% had recurrent dizziness 20% improved20% improved

Kroenke, et al (1992)Kroenke, et al (1992)• Patient with initial complaint of dizzinessPatient with initial complaint of dizziness

Two weeks – 70% no resolutionTwo weeks – 70% no resolution 3 months – 63% no resolution3 months – 63% no resolution 11 months – 47% no resolution11 months – 47% no resolution

CONCLUSION:CONCLUSION: simple observation and simple observation and reassurance are not appropriate in many cases.reassurance are not appropriate in many cases.

Prevalence of DizzinessPrevalence of Dizziness Older/Aged PopulationOlder/Aged Population

1000 Internal Medicine Clinics reported 1000 Internal Medicine Clinics reported dizziness 3dizziness 3rdrd most common complaintmost common complaint over age 59 with chest over age 59 with chest pain and fatigue noted more (Kroenke, 1989).pain and fatigue noted more (Kroenke, 1989).

• Over age 75 – number one complaintOver age 75 – number one complaint (Koch & Smith, (Koch & Smith, 1995)1995)

Sloan et al, 1989 reported 18.3% of adults over 60 Sloan et al, 1989 reported 18.3% of adults over 60 suffer dizziness significant enough to seek physician, suffer dizziness significant enough to seek physician, take medication, or interfere with normal activities “a take medication, or interfere with normal activities “a lot” during the past year.lot” during the past year.

Graying of AmericaGraying of America (U.S. Census Bureau) (U.S. Census Bureau)• 65 and over will double over the next few decades65 and over will double over the next few decades

20% of the US population20% of the US population• 85 and over will quadruple85 and over will quadruple

Prevalence of DizzinessPrevalence of Dizziness

Kroenke, et al, 2000 Combined Literature Kroenke, et al, 2000 Combined Literature Review of 12 Articles on Etiology of Dizziness:Review of 12 Articles on Etiology of Dizziness:

• 44% - Vestibulopathy (PNS)44% - Vestibulopathy (PNS)• 11% - Vestibulopathy (CNS)11% - Vestibulopathy (CNS)• 16% - Psychiatric16% - Psychiatric• 26% - Other conditions26% - Other conditions• 13% - Unknown causes13% - Unknown causes• 6% - Cerebrovascular disease6% - Cerebrovascular disease• 1.5% - Cardiac Arrhythmia1.5% - Cardiac Arrhythmia• <1% - Brain Tumor<1% - Brain Tumor

Don’t most people with dizziness Don’t most people with dizziness recover spontaneously?recover spontaneously?

6-8 weeks?6-8 weeks? others say 6 months to a year…others say 6 months to a year… 80%/20% 80%/20% It is part of old age…It is part of old age… It will go away on its own..It will go away on its own.. It’s all ‘in your head’”…It’s all ‘in your head’”… Learn to live with it…Learn to live with it… What is the consensus?What is the consensus?

PT Opinion:PT Opinion: Look at how many fallers we have in our Look at how many fallers we have in our seniors…I think we are missing a lot of patients.seniors…I think we are missing a lot of patients.

40% of the US Population (40 Million) go to their MDs for 40% of the US Population (40 Million) go to their MDs for handicapping dizziness.handicapping dizziness.

Yesterday I had 38 patients on my schedule with chronic Yesterday I had 38 patients on my schedule with chronic dizziness…I get referrals from less that 1% of the local MDs?dizziness…I get referrals from less that 1% of the local MDs?

• Where are all the people going…Where are all the people going…

Why Are We Seeing So May Why Are We Seeing So May Patients with Chronic Dizziness?Patients with Chronic Dizziness?

Population growthPopulation growth More aging population – baby boomersMore aging population – baby boomers Multiple Medications=Increased Risk for Multiple Medications=Increased Risk for

DizzinessDizziness More Chronic diseasesMore Chronic diseases With Existing Dizzy Patients – With Existing Dizzy Patients –

Why aren’t they improving:Why aren’t they improving: MDs not knowing this therapy exists

or actually works• See attached article by Tee and Chee, 2005See attached article by Tee and Chee, 2005

Unstable central or peripheral vestibular system

• Causes repeated changes in the functional status of the Causes repeated changes in the functional status of the system (e.g., Meniere’s,BPPV)system (e.g., Meniere’s,BPPV)

Maladaptive behaviors of avoidance in movements

• Creates a stable locus of the lesion (stalls compensation Creates a stable locus of the lesion (stalls compensation (e.g.., intermittent symptoms post vestibular neuritis, (e.g.., intermittent symptoms post vestibular neuritis, fear of falling)fear of falling)

A second disease process interferes with compensation (e.g., Anxiety, Migraines, Stroke) (e.g., Anxiety, Migraines, Stroke)

Chronic use of medication initiated at onset not appropriately withdrawn (e.g., (e.g., Meclizine, Benzodiazepines)Meclizine, Benzodiazepines)

The Need for Therapy – Building The Need for Therapy – Building the Case…EBM is Paramount!the Case…EBM is Paramount!

Most patients play no active role in Most patients play no active role in their own health caretheir own health care

Rely totally on the Health Care Rely totally on the Health Care Practitioner (HCP) to make decisions.Practitioner (HCP) to make decisions.

Have overly optimistic view of the Have overly optimistic view of the effectiveness of medical treatmenteffectiveness of medical treatment

• Rarely question whether the Rarely question whether the recommended treatment has proved recommended treatment has proved effectiveeffective

Onus on the HCP to provide treatment Onus on the HCP to provide treatment that has undergone rigorous clinical that has undergone rigorous clinical trials and be effective for most patients trials and be effective for most patients with a given diagnosis.with a given diagnosis.

Evidence Based MedicineEvidence Based Medicine (EBM) (EBM) means integrating individual clinical means integrating individual clinical expertise with the best available expertise with the best available external clinical evidence from external clinical evidence from systematic research (Sackett, et al., systematic research (Sackett, et al., 1996)1996)

The Need for VRT – Building the The Need for VRT – Building the Case…Case…

Historical Perspective – Three OptionsHistorical Perspective – Three Options Medical Treatment of Symptoms (Medicate)Medical Treatment of Symptoms (Medicate) Surgical Stabilization (Reparative or Ablation)Surgical Stabilization (Reparative or Ablation) Observation, Reassurance, and Counseling (Learn to Live with It)Observation, Reassurance, and Counseling (Learn to Live with It)

ALTERNATIVE – Vestibular TherapyALTERNATIVE – Vestibular Therapy

Cawthorne and Cooksey, 1945Cawthorne and Cooksey, 1945 Patient who remained sedentary Patient who remained sedentary recovered slowerrecovered slower than those who were more than those who were more

activeactive• Developed Cawthorne-Cooksey (C-C) exercisesDeveloped Cawthorne-Cooksey (C-C) exercises

McCabe, 1970McCabe, 1970 Expanded Cawthorne’s ideas and described “Labyrinthine Exercises” as “our Expanded Cawthorne’s ideas and described “Labyrinthine Exercises” as “our

most single tool in the alleviation of protracted recurrent vertigo.”most single tool in the alleviation of protracted recurrent vertigo.” Hecker, et al, 1974Hecker, et al, 1974

Used C-C exercises with vestibular-type patientsUsed C-C exercises with vestibular-type patients• 84% improved symptoms – other 16% not improved due to lack of 84% improved symptoms – other 16% not improved due to lack of

patient compliance or emotional distresspatient compliance or emotional distress Norre, 1988Norre, 1988

Optimal recovery periodOptimal recovery period in animals following vestibular injury in animals following vestibular injury• Suppressant medications and/or forced inactivity Suppressant medications and/or forced inactivity reducesreduces natural compensation natural compensation

The Need for VRT – Building the The Need for VRT – Building the Case…Case…

Horak, et al, 1992Horak, et al, 1992 Three groups of patients with chronic vestibular complaints (VRT, Three groups of patients with chronic vestibular complaints (VRT,

medication, general activity)medication, general activity)• Those who used VRT showed the Those who used VRT showed the greatest improvementgreatest improvement in functional in functional

performanceperformance General Activity improved to a lesser degreeGeneral Activity improved to a lesser degree Medicated showed the least improvementMedicated showed the least improvement

Fujino, 1996Fujino, 1996 Two groups: Medication and Medication with VRTTwo groups: Medication and Medication with VRT

• 8-weeks – 8-weeks – exercise with medication had less symptomsexercise with medication had less symptoms Shepard, et al, 1990Shepard, et al, 1990

Patients taking vestibular suppressants, antidepressant, Patients taking vestibular suppressants, antidepressant, tranquilizers, and anticonvulsants achieve the same level of tranquilizers, and anticonvulsants achieve the same level of compensation as patients not on meds – length of therapy compensation as patients not on meds – length of therapy significantly longer on medicationssignificantly longer on medications

Telian and Shepard, 1995Telian and Shepard, 1995 General VRT versus Customized ProgramsGeneral VRT versus Customized Programs

• 64% using general therapy had complete resolution64% using general therapy had complete resolution• 85% using a customized had complete resolution85% using a customized had complete resolution

What is Vestibular Retraining What is Vestibular Retraining Therapy (VRT)?Therapy (VRT)?

A set of physical therapy A set of physical therapy exercises designed to exercises designed to “re-“re-calibrate”calibrate” the balance the balance system through specific system through specific practice of in-therapy practice of in-therapy treatment and customized treatment and customized home exercises. These home exercises. These include:include:

HabituationHabituation AdaptationAdaptation Static/Dynamic BalanceStatic/Dynamic Balance Strengthening/EnduranceStrengthening/Endurance Manual Therapy (Cervical)Manual Therapy (Cervical) Behavioral TherapyBehavioral Therapy Repositioning ManeuverRepositioning Maneuver

Vestibular Therapy – The New Vestibular Therapy – The New Drug – Key Concepts Drug – Key Concepts

Referrals When Should I Refer for VRT?When Should I Refer for VRT?

• Specific interventions for BPPV (loose calcium in canal)Specific interventions for BPPV (loose calcium in canal)• Epley/Semont maneuversEpley/Semont maneuvers

• General interventions for vestibular lossGeneral interventions for vestibular loss Unilateral loss (Neuritis/ Labyrinthitis)Unilateral loss (Neuritis/ Labyrinthitis) Bilateral Loss (Ototoxicity/ other)Bilateral Loss (Ototoxicity/ other)

• Persons with fluctuating vestibular loss (help prepare Persons with fluctuating vestibular loss (help prepare patient for future surgical treatments)patient for future surgical treatments)

Meniere’s disease (slowly fluctuating)Meniere’s disease (slowly fluctuating) Perilymphatic Fistula Perilymphatic Fistula

• Experimental treatment where origin of dizziness is Experimental treatment where origin of dizziness is unclearunclear

Post-traumatic vertigo, CNS DysfunctionPost-traumatic vertigo, CNS Dysfunction Multisensory dysfunction of agingMultisensory dysfunction of aging

• Psychogenic vertigo for desensitizationPsychogenic vertigo for desensitization Phobic Positional VertigoPhobic Positional Vertigo Fear of falling/provocationFear of falling/provocation

Vestibular Therapy – The New Vestibular Therapy – The New Drug – Key ConceptsDrug – Key Concepts

Indications/ContraindicationsIndications/Contraindications When is this therapy When is this therapy not not appropriate for my patient ?appropriate for my patient ?

• Almost any patient with dizziness associated with an inner ear dysfunction can benefit Almost any patient with dizziness associated with an inner ear dysfunction can benefit from the therapyfrom the therapy

Not BeneficialNot Beneficial• Vertebral Basilar Insufficiency (VBI)Vertebral Basilar Insufficiency (VBI)

Unless there is a suspicion of BPPVUnless there is a suspicion of BPPV• Postural HypotensionPostural Hypotension• Reducing/eliminating TIAs or StrokesReducing/eliminating TIAs or Strokes

Can help after a TIA/StrokeCan help after a TIA/Stroke• Extremely unstable Meniere’s diseaseExtremely unstable Meniere’s disease

Questionable (might help)Questionable (might help)• Mal De DebarquementMal De Debarquement

Have seen improvement just not complete resolutionHave seen improvement just not complete resolution• Cerebellar DegenerationsCerebellar Degenerations

May improve in strength/enduranceMay improve in strength/endurance• Motion IntoleranceMotion Intolerance

Puma MethodPuma Method• Basal Ganglia SyndromesBasal Ganglia Syndromes (PSP, PD – may help if slowly progressing) (PSP, PD – may help if slowly progressing)

Vestibular Therapy – The New Vestibular Therapy – The New Drug – Key ConceptsDrug – Key Concepts

ComplianceCompliance How Long will my patient How Long will my patient

attend the course or get home attend the course or get home exercisesexercises ? ?

• Analogy: Taking full dose of Analogy: Taking full dose of antibioticsantibiotics

• Twice an week typical – some need Twice an week typical – some need three depending on severitythree depending on severity

• 4 to 12 weeks – again depending on 4 to 12 weeks – again depending on severityseverity

• All patients get a customized home All patients get a customized home program.program.

Vestibular Therapy – The New Vestibular Therapy – The New Drug – Key ConceptsDrug – Key Concepts

Education How do I convince the patient that they need this How do I convince the patient that they need this

therapy versus medication?therapy versus medication?• Probably the hardest thing to do…Probably the hardest thing to do…

Must convince the patient that medications only suppress Must convince the patient that medications only suppress the symptoms – not fix the problemthe symptoms – not fix the problem..

• Horak et al, 1992 – VRT group versus medication reports Horak et al, 1992 – VRT group versus medication reports least symptoms in 6 weeksleast symptoms in 6 weeks

VRT re-calibrates and re-organizes the balance system VRT re-calibrates and re-organizes the balance system naturally without drugsnaturally without drugs

• Same techniques used by NASA and Military fighter pilots Same techniques used by NASA and Military fighter pilots to adapt to environmentsto adapt to environments

• Same techniques used to hit a golf ballSame techniques used to hit a golf ball Dizziness is the error message your brain needs to learn to Dizziness is the error message your brain needs to learn to

overcome your symptoms – suppressing or avoiding your overcome your symptoms – suppressing or avoiding your symptoms only worsens the symptoms.symptoms only worsens the symptoms.

Vestibular Therapy – The New Vestibular Therapy – The New Drug – Key ConceptsDrug – Key Concepts

Duration of Therapy/Refills/Dosing (twice a week)

How will I know when to stop How will I know when to stop the program?the program?

• Stable PNS vestibular disorders: 6 Stable PNS vestibular disorders: 6 to 8 weeks of therapy to 8 weeks of therapy

• Stable CNS vestibular disorders – Stable CNS vestibular disorders – 10 to 14 weeks of therapy10 to 14 weeks of therapy

• Mixed (PNS/CNS) – 14 to 18 Mixed (PNS/CNS) – 14 to 18 weeks of therapyweeks of therapy

Vestibular Therapy – The New Vestibular Therapy – The New Drug – Key ConceptsDrug – Key Concepts

Side Effects/ToxicitySide Effects/Toxicity How do you know the patient is getting the right How do you know the patient is getting the right

therapy?therapy?• The key is the diagnosisThe key is the diagnosis• Second is proper treatment by a proper providerSecond is proper treatment by a proper provider

Physical therapists with certifications in vestibular disorders are Physical therapists with certifications in vestibular disorders are paramount paramount

• Not just any therapist should treat your dizzy patientNot just any therapist should treat your dizzy patient

CostCost Do insurances cover this therapy? YES!!!Do insurances cover this therapy? YES!!!

• The key is diagnosis coding on your partThe key is diagnosis coding on your part Dizziness in most cases in not reimbursable (780.4)Dizziness in most cases in not reimbursable (780.4)

• Must use a functional diagnosis code – 781.2 Must use a functional diagnosis code – 781.2 (dysequilibrium)(dysequilibrium)

Vestibular Therapy – The New Vestibular Therapy – The New Drug – Key ConceptsDrug – Key Concepts

Functional Balance TestingFunctional Balance Testing What type of testing will you do with my What type of testing will you do with my

patients?patients?• Computerized Dynamic PosturographyComputerized Dynamic Posturography• Dynamic Visual Acuity TestingDynamic Visual Acuity Testing• Functional Balance Testing (Sharpened Romberg)Functional Balance Testing (Sharpened Romberg)• Vestibular Auto-Rotational Test (VAT)Vestibular Auto-Rotational Test (VAT)• Infrared-Video Oculography (ENG)Infrared-Video Oculography (ENG)

With CaloricsWith Calorics

Vestibular Therapy – The New Vestibular Therapy – The New Drug – Key ConceptsDrug – Key Concepts

How do I gauge the effects of the therapy with my How do I gauge the effects of the therapy with my patient?patient?

Symptom-mediatedSymptom-mediated• Dizziness questionnaires improvedDizziness questionnaires improved

Reduced symptoms = improved functionReduced symptoms = improved function• ADL questionnairesADL questionnaires

Improved balance confidence – improved functionImproved balance confidence – improved function Findings-mediatedFindings-mediated

• Posturography Scores improvedPosturography Scores improved• VAT scores improvedVAT scores improved

Improved gain, phase, asymmetryImproved gain, phase, asymmetry• Reduced Nystagmus under infraredReduced Nystagmus under infrared• Improved static/dynamic balanceImproved static/dynamic balance

Sharpened RombergSharpened Romberg Single Leg StanceSingle Leg Stance

How Does Vestibular Therapy How Does Vestibular Therapy Work?Work?

How does a figure-skater spin?How does a figure-skater spin? How do NASA astronauts go to space or Nellis How do NASA astronauts go to space or Nellis

pilots tolerate flying a jet?pilots tolerate flying a jet? Adapt and Habituate…to the environment.Adapt and Habituate…to the environment. VRT focuses on the VRT focuses on the plasticityplasticity of of

the central nervous system.the central nervous system. Does not repairDoes not repair the damaged inner ear or the damaged inner ear or

brainstem. brainstem. Works on getting the CNS and brain to Works on getting the CNS and brain to adapt to adapt to

the asymmetrical inputthe asymmetrical input from the VOR and VSR. from the VOR and VSR. Analogies for Patients:Analogies for Patients:

Alternator and Battery SystemAlternator and Battery System• Inner ears – AlternatorsInner ears – Alternators• Brainstem – BatteryBrainstem – Battery

Driving a car with the front end out of alignmentDriving a car with the front end out of alignment• Take your hands off the steering wheelTake your hands off the steering wheel

Types of Patients Seen at a Types of Patients Seen at a Balance ClinicBalance Clinic

Patients ages 10 to 103 years Patients ages 10 to 103 years (Werner,2006)(Werner,2006)

The Effect of Age on VRT OutcomesThe Effect of Age on VRT Outcomes (Whitney, et al, 2003) (Whitney, et al, 2003)• Conclusion:Conclusion: Age does not significantly influence the beneficial effects Age does not significantly influence the beneficial effects

of VRT for persons with vestibular disorders.of VRT for persons with vestibular disorders. Increased time for older populationsIncreased time for older populations

Types of PatientsTypes of Patients Chronic Mobility DisordersChronic Mobility Disorders Dizziness/DysequilibriumDizziness/Dysequilibrium Fall Risk Identification & MgmtFall Risk Identification & Mgmt Head Injury/ConcussionsHead Injury/Concussions Neuro-Degenerative Diseases (MS, PD)Neuro-Degenerative Diseases (MS, PD) Orthopedic (THR/TKR)Orthopedic (THR/TKR) Vestibular Disorders (PNS/CNS)Vestibular Disorders (PNS/CNS) OtotoxicityOtotoxicity Post-Surgical VestibularPost-Surgical Vestibular Workers’ CompensationWorkers’ Compensation Medico-LegalMedico-Legal Performance EnhancementPerformance Enhancement

Does Vestibular Therapy Really Does Vestibular Therapy Really Work?Work?

Currently no “Gold Standard” Currently no “Gold Standard” test/outcome – key is symptom test/outcome – key is symptom reduction and improved ADL reduction and improved ADL independence.independence.

Cochrane ReviewCochrane Review BPPV – Epley Maneuver helps BPPV – Epley Maneuver helps

reduce vertigo reduce vertigo VRT for ULvVRT for ULv

• Currently in protocolCurrently in protocol Question: How much do you Question: How much do you

follow the Cochrane review in follow the Cochrane review in your pt. mgmt?your pt. mgmt?

Efficacy of Vestibular Efficacy of Vestibular Rehabilitation (Review) (Whitney, Rehabilitation (Review) (Whitney, et al, 2000)et al, 2000)

Review of 87 articles on VRTReview of 87 articles on VRT PNS disorders that are stable PNS disorders that are stable

demonstrate better outcomes than demonstrate better outcomes than CNSCNS

PT intervention works in most PT intervention works in most cases of vestibular disorders, cases of vestibular disorders, regardless of age.regardless of age.

Efficacy of VRT on Chronic ULV Efficacy of VRT on Chronic ULV Dysfunction (2003)Dysfunction (2003)

Purpose: Supervised vs. Home Purpose: Supervised vs. Home Program (Used DHI and VAS)Program (Used DHI and VAS)

Prospective StudyProspective Study N=125N=125 Conclusion: Supervised demonstrated Conclusion: Supervised demonstrated

improved DHI and VAS scoresimproved DHI and VAS scores• Regardless of age, gender, or disability Regardless of age, gender, or disability

levellevel

Questions and AnswersQuestions and Answers

ReferencesReferences

Cawthorne, T. (1944). The physiological basis for head exercises. J Chart Soc Cawthorne, T. (1944). The physiological basis for head exercises. J Chart Soc Physiother 106-7.Physiother 106-7.

El-Kashlan, HK., et al. (1998). Disability from vestibular symptoms after El-Kashlan, HK., et al. (1998). Disability from vestibular symptoms after acoustic neuroma. American Journal of Otology 19:101-114.acoustic neuroma. American Journal of Otology 19:101-114.

Hain, T. (2006). http://www.dizziness-and-balance.com/treatment/rehab.htmlHain, T. (2006). http://www.dizziness-and-balance.com/treatment/rehab.htmlHorak, FB., et al. (1992). Effects of Vestibular rehabilitation on dizziness and Horak, FB., et al. (1992). Effects of Vestibular rehabilitation on dizziness and

imbalance. Otolaryngology – Head and Neck Surgery 106: 175-9.imbalance. Otolaryngology – Head and Neck Surgery 106: 175-9.Kreb, DE., et al. (2003). Vestibular Rehabilitation: useful but not universally so. Kreb, DE., et al. (2003). Vestibular Rehabilitation: useful but not universally so.

Otolaryngology – Head and Neck Surgery. 128: 240-50.Otolaryngology – Head and Neck Surgery. 128: 240-50.Norre, M. (1988). Vestibular habituation training. Archives of Otolaryngology – Norre, M. (1988). Vestibular habituation training. Archives of Otolaryngology –

Head and Neck Surgery 114: 883-86.Head and Neck Surgery 114: 883-86.Solomon, D & Shepard, N. (2002). Chronic Dizziness. Current Treatment Solomon, D & Shepard, N. (2002). Chronic Dizziness. Current Treatment

Options in Neurology: Ophthalmology and Otology. 281-288.Options in Neurology: Ophthalmology and Otology. 281-288.Whitney, et al. (2000). Efficacy of vestibular rehabilitation. Otolaryngologic Whitney, et al. (2000). Efficacy of vestibular rehabilitation. Otolaryngologic

Clinics of North America. 33,3; 659-673.Clinics of North America. 33,3; 659-673.Whitney, et al (2003). The effect of age on vestibular rehabilitation outcomes. Whitney, et al (2003). The effect of age on vestibular rehabilitation outcomes.

Laryngoscope. 112,10: 1785-90.Laryngoscope. 112,10: 1785-90.