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Deborah: Welcome. First, it was a Hitchcock thriller, and now it's a condition that's becoming more common these days and is a mystery to most of us.

So today we'll ask the question, what is vertigo? My guest today is Lorien Appman, MPT, OCS, an orthopedic physical therapist and coordinator at High Pointe Therapy at Deaconess, The Women's Hospital. Thanks for being here, Lorien.

Lorien Appman: Thanks for having me. This is one of my absolute favorite conditions to treat, so I'm happy to be here to talk about it.

Deborah: Oh and people need it treated so badly. So we're really glad you're here. Let's jump right in. In your opinion and your expertise, what is vertigo?

Lorien Appman: So vertigo simply put is a form of dizziness. When people come into the clinic and say, "I'm dizzy, the first thing I'm going to ask them to do is describe that dizziness to me. What does it feel like? Does it feel like you're getting light headed or does it feel like the room is spinning or you're spinning, and true vertigo that is related to the vestibular system, this organ in our inner ear that helps us find our place in the world with gravity. True vestibular issues cause vertigo, which is that room spinning sensation, or it feels like you're spinning or some people will describe it feels like their eyes are jumping around.

Deborah: There is a difference between lightheadedness and dizziness. Can you tell us what it is?

Lorien Appman: Sure. So lightheadedness, that can be caused by lots of different things, but it is not necessarily related to that inner ear vertigo sensation. So you can get lightheaded if your blood pressure drops suddenly, as it will do sometimes when we stand up too quickly or sit up too quickly.

it can be caused by low blood sugars or a myriad of other medical conditions. So when people are describing their dizziness to me, I try to have them peace out. Do you feel light headed or like things are going dark on you, like you're going to pass out or do you get more of the spinning sensation or some people will describe it, " It feels like I'm walking on a boat. that's moving or the ground is moving underneath me." So those types of descriptors, when people go to the doctor for treatment for vertigo can be very helpful so that we know where to start our assessment and where to look for the problem.

Deborah: Excellent. Now, how does vertigo affect balance?

Lorien Appman: So if you wake up in the morning, you roll over, you sit up, you go to stand up and the world is spinning. A lot of times you're going to fall. This is something where people have to grab onto furniture. Patients have described having to crawl to the bathroom in the morning. It can be very debilitating and really limit you to the bed.

Treating this quickly, getting this under control is very important, especially in our elderly population where falls can be deadly. We want to make sure that we are treating vertigo and getting that under control as quickly as possible.

So our balance systems are really... they're just amazing things. If you think about everything it takes to be able to get up out of bed and to stand up, the sensors in your feet are relaying information to your brain about where you are in space. The sensors in our inner ear, that vestibular system that we're talking about today, it’s relaying the information to your brain, your eyes, relaying information to your brain about where you are and all of that information comes together and our brain has to make sense of it so that it can navigate us through our environment without falls. And so anytime any one of those systems are off, it can cause. balance issues, particularly in that inner ear. Let's say your vision isn't as good because it's dark or I have my eyes closed because I'm taking a shower and washing my hair. So suddenly you've taken away that visual input, you have to have good inner ear input in order to maintain your balance.

Deborah: That is so true, you know, we're one of the few mammals that can actually walk upright. It's a feat.

Lorien Appman: Yes.

Deborah: How do we first come to know more about vertigo?

Lorien Appman: So the reason we know about the vestibular system is this was a discovery from NASA. They sent astronauts into outer space, well suddenly you don't have gravity. So your inner ear never registers movement, but the astronauts are, spinning around and moving around. So their eyes are picking up on that movement. Inner ear says, nope, you're not moving. And that conflict between the two caused space dizziness, like outer space sickness. And then what they learned was how quickly people adapt. So these astronauts would adapt very quickly and ignore the inner ear input and just focused on what their eyes are telling them so that they could function.

But then when they came back down the earth, all of a sudden, now they're getting gravity. So now they're getting inner ear input and the same thing would happen and then they'd have to work to reintegrate it. But that's where, all of our knowledge about the vestibular system came from the NASA program, which I think is a fascinating fact.

Deborah: So what are some of the common causes of vertigo?

Lorien Appman: Vertigo could be caused by lots of different things, but the most common is benign positional vertigo. And that is a dysfunction of the inner ear that can happen after let's say you've had a bad cold and some sinus congestions, or you've been held in a funny position, your head was in a weird position for a while or, some people have triggers, being on an airplane and getting the pressure change, or deep sea divers when they go down to a certain depth, any of those types of things that cause pressure changes, can cause this positional vertigo. And essentially with it, what happens is that the sensor in your inner ear that lets you know where your head and your body are positioned against gravity is off.

So when you go to sit up in the morning, your left inner ear could be saying “I'm still laying down" and your right inner ear says, "No, I'm sitting up” and your eyes go, "Yep. I'm sitting up." Well, your brain gets this conflicting information and it doesn't quite know what to make of it. And it sends your eyes on a wild goose chase and that's called a nystagmus. It's a reflex that happens when somebody is having active vertigo. So your eyes do this beat, a dance while they're looking for where you are to orient you to gravity. So as that's going on, your body will sometimes go through this fight or flight response. You're going to get nausea. You break out into a sweat. You just in general feel very ill.

Now after you calm down and your brain figures out that, "Okay. That left inner ear is giving us wrong input. We're going to ignore it." Most people can get up and function, but they don't feel right because you're only getting the signal from the right inner ear and your eyes. You're not getting the normal input from that left inner ear. And I always describe it to patients it'd be a lot like typing in a GPS of where you wanted to go. You get in your car, you put in this address and your body's only telling you about the right-hand turns. It's never telling you about the left-hand turns. You may get where you're going, but it's going to take you a lot longer to get there.

Deborah: Wow. Now the good stuff. Can vertigo be treated?

Lorien Appman: So the good news is positional vertigo is a very simple treatment. When you come in, to get help for your vertigo, one of the first things we do, we ask you to describe it. We make sure that this is truly an inner ear dysfunction, and then we're going to do a test that lets us know which ear is the problem, and which canal is the problem. And we can tell that through a test called the Hallpike-Dix, where we lay you back quickly. Unfortunately, we have to make you dizzy to make you better. So you will get a little dizzy in the office and your eyes will go and do the dance, the nystagmus, and the way that your eyes move can give us clues as to which canal is the problem.

And then we go right into the treatment. Typically, the Epley maneuver is very effective for most positional vertigos. Occasionally, we see something that presents a little bit different and we have to do a different type of maneuver. But we'll do this maneuver in the office one or two times, send you home and say, "Hey, take it easy the rest of the day. Be careful. No step ladders." And within about a week, nine times out of 10, the symptoms are gone. So I always joke with patients. I feel like I have a magic wand sometimes. You're not going to necessarily feel instantly better that day in the office, but the next day is better and the day after that is better and the day after that is better. And then will bring people back in a week and they'll usually say, "I really haven't had any more vertigo, no more incidents, but I feel like it may happen. It might come on."

And in those instances, what we'll do is a little retraining, getting your brain used to listening to both inner ears together, and how your inner ear sensors are working with your eyes so that you can move your head and your body through your environment without stumbles falls or feeling like you need to grab onto the wall

Deborah: This is fascinating. Now, how does physical therapy help vertigo?

Lorien Appman: So we'll do those maneuvers that specifically realign the inner ear to gravity. So you know where you are when you're moving around and then we're going to work on getting you used to that input. So a lot of times, if I've had a patient that has suffered from vertigo for a long time, they will have adapted and changed the way they do things. "I no longer drop my head to look underneath the bed. I have to keep it upright." "I sleep with four or five pillows, so I don't have to lay flat." Or, “I really just don't turn my head when I'm having conversations with people. I will just turn my entire body." So when we start to see those types of adaptations, then we need to work with people so they do get normal input to that inner ear. So some of the things that we'll do will be different eye exercises, head movements, eyes open, eyes closed, standing on foam, different surfaces, turning. All of these different challenges that we can do in the office so that you are getting the best input from your inner ear and you're able to coordinate that with what your sensors in your feet and ankles and the sensors in your eyes are telling your body about where you are. And then people can move through their environment a lot more naturally. One of the common things I hear from people is they struggle in the grocery store with the aisles of things. They're looking down the aisle. People may be walking towards them. It's a very busy environment and that can be really difficult for a patient that's had vertigo to take in all of that information and not feel dizzy. So we'll work on things like walking down a hallway with lots of distractions going on and turning their head different ways.

The eye movements become important too. So how quickly can you scan and move your eyes from one thing to another and does your head have to come along with it or can you dissociate those movements? So those are all things that we can work on in therapy so that you can get around a lot better.

There are some causes of vertigo that are not as simple to treat as positional vertigo. Meniere's comes to mind. It's an auto-immune disease of the inner ear, that can cause hearing loss, ringing in the ears, and then these sudden vertigo attacks. And those aren't going to respond to the maneuvers that we talked about before, like with the Epley maneuver.

So for those people, a lot of what we do is learning to adapt to that dizziness when it happens, what are some concrete things that you can do to stay safe, what are things that you can do to decrease its effect on your body so you don't get nauseous, so you don't get headaches with it. And so we'll work through those activities with patients with Meniere's disease or other vestibular dysfunctions that aren't treated as simply or quickly as the positional vertigo.

Deborah: Well, it sounds like you're really helping people every single day. And we thank you so much, Lorien, for all this valuable information. Thanks for being with us today.

Lorien Appman: Thanks so much.

Deborah: It's all about the coping strategies and treatments for vertigo. And for more information, please visit deaconess.com/thewomenshospital/eventsandeducation/thewomenspodcast. This is The Women's Hospital, a place for all your life. I'm Deborah Howe. Thanks for listening and have yourself a great day.