Tag Archive: vestibular_therapy


Balance BOOT CAMP

I am embarking on a self-created balance boot camp–join me!

My BPPV has been very mild for about a year. The last notable “improvement” I can remember is 13-14 months ago when I began a workout program. I was laying down on my back to do exercises a few times a week, and each time I felt nauseous and the room spun briefly. As the weeks passed, though, my symptoms improved until I could lie down without any vestibular nonsense. Success!

Since then things have stayed pretty stable, which is to say that I have a vestibular issue at least once a week. These episodes are short-lived and mild and for the most part do not interfere with my daily life. (I believe this is true; I need to check my notes to be certain that I am not wearing my rose-colored glasses here.) Periodically my symptoms worsen while remaining mild. During these times I have mild symptoms several days in a row while my vestibular system is obviously trying to sort itself out.

For the past several months, though, the increased symptoms have been my norm. I have been careening into door jambs with some regularity, and I lose my balance around the house fairly often. I decided that since I have had no major flare-ups for a year, it is time to clean up this mess. I am headed to BOOT CAMP!

I have pulled out the exercises that my vestibular physical therapist gave me and will be doing them throughout the month of July. I will tune my vestibular system as finely as possible and reach my maximum ability–which I hope will be “normal” (but I’ll settle for as good as possible). Beyond the exercises, I’ll be challenging myself to walk down stairs without using the handrails (it is so easy to “check out” with my eyes if my hands are telling where I am in space) and looking for other ways in which I am cheating my vestibular system. Wish me luck!

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Return to ONE PILLOW

sleep_300px-Little_Nemo_1906-02-11_last_panelI have been sleeping up on two pillows for the better part of a year and half. Every time I tried to go down to one, my vertigo got worse, so I’ve stayed up–but my goal has been to get back down to one. I decided I would make my move after the Splash and Dash I participated in this summer. (I didn’t want to screw things up right before I was to swim in the ocean!)

I had hints that it might work out. First, last January I had an MRI and had absolutely no vertigo even though I was lying flat on the table. I was so surprised! And second, the vertigo and nystagmus that I have experienced nearly every night for the past 500 nights when I lie back in bed has gradually diminished. It was a curious process, as the nystagmus got very disorganized and weaker, symptoms came and went, very inconsistent. But lately I can lie back and feel nothing. Nothing at all. Novel!

I’ve been getting acupuncture to help manage my stress levels and occasionally to help with the nausea of vertigo. My acupuncturist has been very willing to work with me, for example, when I suggested doing habituation exercises (which are nausea-inducing) immediately before treatment. Likewise, she was game for me to experiment with one pillow during treatment. I lay on a table with only one…and it was fine. That night I went down to one pillow in bed. That was…weird. It felt very unfamiliar and as if my head was at a negative tilt, even though it was level. I was unsteady for a few days, but now I am sleeping on one pillow with no ill effects. It’s been such an easy transition that I am wondering if staying up for as long as I did was a mistake! Then again, the nightly vertigo was so nauseating and strong that I think I can forgive myself. Even my vestibular physical therapist thought I might never sleep on one pillow again. So we’ll see how it goes. Maybe I can put my extra pillow back in storage!

Yep, it’s still there

After I get my hair cut, my habit is to bend over in the parking lot outside the salon and rub my hair so all the little cut pieces fall to the asphalt. Now that our hairdresser comes to our house, I do the same thing over the bathtub or in the front yard. This past week after our hair cuts, I saw that my wife was about to vacuum the hair off of the bathroom floor, so I quickly bent forward to brush my hair bits onto the tile and into the path of the vacuum. Bam! Vertigo. I bounced back upright immediately and suffered no further ill effects, but I demonstrated to myself that the BPPV is still there. In my haste to beat the vacuum cleaner, I moved with greater velocity than usual, and I ended up with my head pointed straight down–a position I assiduously avoid. The symptoms, though brief, were the strong spinning sensations that I would describe as typical BPPV. This was a good reminder that I make mistakes when I rush. Body movements and habits learned over my lifetime will come to the fore when I am distracted or hurried, and I can end up in a position that triggers vertigo.

Other than that, the only other time I have had positional vertigo lately was in the doctor’s office in late January. I’d been symptom-free for a few weeks at that point, but I was concerned that his tests might trigger the vertigo. When he put me back into Dix-Hallpike I had no idea what to expect. I hadn’t been in that position for a month. Nothing on the left, but on the right: bingo – nystagmus. I believe my eyes reversed after I sat up, which hardly happens at home but which correlates to the doctor’s description of “classic BPPV.” It took at least a minute for my eyes to stop “scrolling” after I sat upright, and after a time he did it again with the same results (although the scrolling was a bit shorter-lived the second time). I felt nauseous after that and sat still and quiet for many minutes before the feelings subsided and I could relax and re-engage. The doctor took that opportunity to review my MRI, which shed no light on my problems. I definitely have damage in my inner ear (vestibular testing showed that) and maybe also BPPV on top of that, some or all of the time this past year. It’s hard to know since the inner ear hypofunction can mimic BPPV, I’m told (but I don’t really understand). Anyway, the symptoms are getting better now, after 11 months. I like to think they are going away for good, but I am aware that they will likely come back over the years; I sincerely hope the frequency is never “over the months.”

Within the past few days I have noticed improvements that I’d like to share with you. Back in December, I lost my balance when my scarf blew over my face and covered one of my eyes. I also had trouble maintaining my balance when looking over my shoulder while rolling a suitcase through an airport. This past week I was rolling a suitcase along the sidewalk for a friend and looked over my shoulder with no trouble! In fact, at the time I didn’t even realize what I had done and had absolutely no sense of danger or caution. Then as I walked, my scarf blew over my right eye several times. This made me nervous; I was talking to a work colleague, and I was concerned that I might loose my balance in front of her. My hands were full and I couldn’t adjust the scarf, so I just kept walking and stayed alert. No symptoms; no problems. Hooray! Still hoping this is the End of Vertigo for me.

On December 23 I was thrilled to go for a run with my sister. She started running in 2013, and this was our first time ever to run together. We were less than a quarter mile from her house when I suddenly got vertigo. I stopped in the middle of the sidewalk and spread my arms and legs for stability, then shouted ahead to where she had been pulled by her dog. “Hang on a sec!” I got my bearings and started to jog again–still too unsteady. I told my sister that I would walk home, but after a few steps I realized I needed to hang on to her. It actually felt very natural to ask to hold her elbow, and we walked back to the house.

Here’s what I think happened: while visiting my sister, I did an Epley maneuver using her pillows, which are higher than the ones I usually use. Having more extension in my neck seems to be a ticket to horizontal canal BPPV for me, and indeed for December 24-26 I felt nauseous most of the time. Snapshots from my visit:

  • holding my sister’s elbow as we walked home from an aborted run workout
  • folding a washcloth and kneeling on the floor of the bathtub in order to wash my hair (the shower head was at nose level, and I could not bend or tilt my head to get under it)
  • drinking a wine cooler through a straw to avoid tilting my head back (for those of you wondering: no, alcohol does not seem to be correlated to my symptoms)
  • my dad coming up to me in the kitchen and sweetly asking if I was OK. My wife said I looked bad, and if my dad noticed, too, then I was bad.
  • closing my eyes while watching TV and getting vertigo
  • flinging my hands out to “catch my balance” while playing cards with friends and pretending that suddenly gripping the table edge was just, you know, normal
  • moving around like a stiff-necked robot with my hands constantly on the walls or furniture for reference
  • my wife turning on and off the light over my airplane seat (I couldn’t look up to differentiate the light button from the call button). (For those of you wondering, dehydration–such as that caused by air travel, or alcohol for that matter–doesn’t seem to be correlated to my symptoms, either. I keep looking at this one, but over 11 months of data-gathering, I have no clear connection. Were that that was the problem!)
  • sleeping with my back to my wife for the entire holiday. She tells me that I spooned her in the early morning hours. What can I say? I can’t stay away from her!

I did lots of Epley’s on low pillows and finally felt well on December 27. Noticing how good I felt that day, I was saddened to realize that my family had missed this ebullient, relaxed side of myself when I was feeling so poorly. That hurts. I don’t see my family often, and I am bummed that I was less engaged during their visit. It is harder for me to talk, to think, and to be empathetic when I have strong symptoms. In the moment I notice the change, and to be honest my behavior isn’t that bad, but I am absolutely unable to overcome it.

Cue dark feelings and forebodings….but that is another post.

My quads are my friends

Now that I’m not so free and easy with bending over, I find myself squatting and kneeling down a lot. It’s the only way to get closer to the ground without triggering the vertigo. (I also sit in chairs more often, for example to chop veggies for soup or to clean the rodents’ cage.) I have been thankful for my strong legs and my ability to kneel down and get back up; I know not everyone is so mobile. Even though this has been on my mind, I never stopped to consider the benefits of the spin class I’ve been attending. I’ve been focused on getting familiar with the movement of my body on a bike, with hopes that I’ll be comfortable enough to ride outdoors next spring. (I know a stationary bike isn’t the same feeling as a road bike, but it’s the only thing I can do to work toward that goal right now.)

So I was genuinely surprised in yoga class this past week. After a string of very-modified classes, I finally had a “good” class–one where I could approximate downward-facing dog and do most of the class with minor modifications. (Of course, I skipped the forearm stand. How I wish I could have done it!) During class I was amazed at how easy it was for me to hold a lunge pose with my front knee bent at 90 degrees. I was much more stable than in the past, and I hardly tired even though our instructor has us stay in that position for longer than most. Then it dawned on me: my quads were stronger because of the spin classes. Yay and whoppee!

An update: I have treated the vertigo this week with daily Epley’s, and I have stayed up on two pillows. (Looks like that is going to be a permanent thing. Thankfully, we recently bought a new mattress, and sleeping this way is no longer painful.) It paid off–today is my first “green” day (no symptoms, as opposed to yellow and red days) in a very long time. I was able to move my head around while rock climbing and am nearly back to my former level of skill. That sounds silly as I write it, but it’s true that I’ve been climbing without looking around much at the holds. And no overhangs, of course. I climb with a group of women who climb 5.10 and 5.11’s, so I am definitely the odd girl out at this point. They have been very kind and encouraging as I’ve been working my way back up. I am feeling very positive at this point.

Recently I started running once a week again, and to keep myself on the straight and narrow I signed up for two road races — a 2.5 mile Turkey Trot and a 3.1 mile holiday run. My Training Buddy is joining me on the 5K, and she mentioned the route has a big hill, so I went on Map My Run two weeks ago to find some hilly routes in my neighborhood. I found some great ones and was looking forward to running that afternoon since the temperature was forecast to be warmer than usual.

I’ve learned that it’s a good idea for me to do a preventative Epley’s after yoga and other specific activities.  Even if I am asymptomatic at the time, chances are that I won’t be asymptomatic by morning, so the maneuver helps corral the otoconia and prevent worse symptoms. All this to explain that I did an Epley’s before my run and ended up giving myself much stronger vertigo than I’d had in months (holding on to the wall while going down stairs, closing my eyes while talking to my wife). I treated twice more and couldn’t get things to clear.  I wobbled through some chores, but finally I gave up and spent the afternoon watching Netflix. So much for my hilly run!

After three Epley’s had no effect, I decided to try the Foster Maneuver. I learned about this new treatment through Annie’s blog, and I must say that my cat LOVES this one. (Watch the video below and imagine a cat weaving around the woman’s arms and legs!) I’ve had mixed results with it over the past two weeks. The good news is that it often gets the otoconia moving when the Epley’s does not, so I’m keeping it in my toolbox and beginning to anticipate when it will be most effective.

That said, I’ve had worse episodes lately and even missed some time from work. I felt fine on Thanksgiving for the Turkey Trot–thankfully, running in and around several thousand people wasn’t a problem, and I kept my balance like a pro. One more run before the 5K next weekend!

Forced Prolonged Positioning

When I trigger posterior canal (PC) BPPV, it clears pretty easily with the Epley’s maneuver.  However, ever since I swam crawl stroke and turned my right ear down about 7 weeks ago, I have been fighting mild HC BPPV.  I asked my PT for advice on how to clear it at home, and she suggested a version of Forced Prolonged Positioning.  (The Lempert or BBQ Roll maneuver is another treatment but not one she recommends for home use.)  I was not keen on spending an hour in one position–heck, I have stuff to do–so I decided to grin and bear it.  But the HC vertigo is sneaky, and I’ve been triggering it with fairly subtle movements like moving my head while I talk and by rubbing my face with my eyes closed (e.g. washing my face at the sink or in the shower).  And then last Sunday I went for a run for the first time in a month, and I was too unsteady to look over my left shoulder to check for traffic.  (Although I didn’t mind the micro-breaks I had to take at each corner!)  So that afternoon I brought up the This American LIfe radio archive, arranged some pillows on the couch, and followed my PT’s instructions for FPP.  I ended up on my left side with my face pointed down into the couch.

It was awkward, to say the least.  My body is never happy when I stay in one position for long, so it was also uncomfortable. With some cautious shifting I lasted for 55 minutes, and I did feel a little clearer afterward (though that might have been from the cat naps I took while stuck on the couch).  Every day this week I’ve continued to have what I’ve come to call “micro-vertigo” when I’m nodding my head in conversation or washing/rubbing my face.  “Micro” seems to fit because the triggers are very small movements and the sensation is short in duration and relatively mild.  It’s bearable, but I’d like to clear it up if I can.

Rainbow

The sky was darkening as I commuted home on the train, but I was all smiles.  I had just glanced up and over my shoulder to see the clouds, and I didn’t experience any vertigo (on a moving train!).  I felt so good today.  The oscillopsia was gone, perhaps thanks to the Epley’s I did in desperation yesterday.  I was all smiles when I saw my vestibular physical therapist.  No HC, just some posterior.  She did a single Epley’s, adjusting the angle of my head until she triggered the nystagmus in the first position.  We even got a little nystagmus in the second position, which has been unusual.  I still felt good afterward.  I ate my lunch in the hospital café and then went to my vestibular testing.  Even after that, I didn’t feel too bad.  I lost my balance twice while walking back to work (similar to June 5), but 1.5 hours later I left work feeling grand.  Big smile on my face as I checked for traffic and looked around me, met my spouse at the station and dashed indoors just before it began to pour.

I cleaned up in the kitchen, ate dinner with my spouse, chatted happily about the possible meaning of my vestibular testing experience.  The words came easily, and I realized that I had had some trouble speaking on my harder days, perhaps because so much of my brain was occupied with staying upright and not puking.  An hour or two later, I got a text message from a good friend.  Had I seen the double rainbow, she asked?  I went to the window and saw a beautiful rainbow just outside my door.  We live on top of a hill and had an amazing 180-degree view.  The rainbow was evenly lit all the way across and brilliant.  Its double extended almost completely across.  I grabbed a camera and attempted to capture it.  It was too big to fit in the camera lens!  I remembered to just BE in the moment and enjoy the beauty.  I breathed the rain-washed air.  I watched a bird flying against the blue-gray sky.  I gazed up at the rainbow.

I felt vertigo.

OK, no problem.  I lowered my chin and raised my eyes.  I stole little glances up at the gorgeous colors.  I tried.

But later inside the house, it was all back.  Positional vertigo mostly, maybe some oscillopsia.  I felt nauseous.  I. felt. sick.  SICK.  I tried to feel nonattachment to the glorious equilibrium I had experienced all day, but I couldn’t help myself; I cried.  I sat down beside my spouse and had a pity party.

I felt so good, I said.

It was a beautiful rainbow.  How could I not look up?  How could I not?

Isn’t this what is important in life – beauty, being in the moment?  Recognizing that I might never see such a perfectly formed rainbow, so large and so clear, again?  Seeing it.  Really seeing it.

How could I not look up?

I felt so good.  Now it’s all gone.  Fleeting, like the rainbow.  Nothing lasts.

My spouse comforted me, then suggested I try the Epley’s again.  After all, it helped yesterday.  So I did the Dix-Hallpike with her as my spotter.  Of course, I was positive.  I did the Epley’s on the right.  Nothing too dramatic happened — that’s typical for me.  But afterward I felt immediately better.  The nausea was gone.  I sat down to write this so that my head would be still for a protracted period, and I am hopeful that when I get up to walk, I will still feel OK.

Still, my soul aches.  Please don’t let this be it for me.  Please don’t punish me for looking at beauty.  I will always choose to look.

Drop attack?

Imagine you are walking back to your office, enjoying the weather and observing the activity around you, when suddenly you find yourself flinging one leg out and firmly planting both feet on the sidewalk as if you were catching yourself while falling. You hold completely still as you process what just happened and how your body moved instinctively to “save” you. You become aware of how odd you must look, frozen there, so you cautiously inch backward until you can grab a stair rail and lean against it. You look around, testing your equilibrium. Everything seems fine, but then, everything seemed fine before, too. You wait. After a few more moments, you begin walking again, slower this time with eyes fixed on the ground. Back safely in your office, you tear up with relief and fear, then wipe your eyes and become a perfectly composed employee for the rest of the afternoon.

This happened to me today as I walked back to my office after my PT appointment. I was walking at my normal (fast) speed and was looking around – I felt fine. I had no feelings of disequilibrium and no inkling that anything was wrong. And then suddenly, out of the blue, I almost fell.

Let me tell you how unsettling this is! I have read about people with Meniere’s disease having “drop attacks,” and while I don’t have Meniere’s, I wonder if this would qualify as a drop attack. I didn’t actually fall to the ground, so I imagine some medical professionals would say that it doesn’t count; however, I do think that if I weren’t young(-ish), physically fit, and in possession of an excellent sense of balance (yoga, rock climbing, slack lining), that I would have fallen. I remember reading about baseball player Nick Esasky who had vertigo that went undiagnosed for months because his physical fitness was superb and he aced all the medical tests.  I’m not a professional athlete, but I do wonder how my youth and fitness may complicate our ability to figure out what is going on.

HC BPPV

After some mix ups and delays, I finally got to see a vestibular physical therapist on May 7.  By that point, I’d had vertigo almost daily for three months.  I had cried in the otoneurologist’s office the week before because I felt so nauseous (plus I had nearly fallen in the parking lot on my way in).  I saw my PT four times in 11 days, and while the CRP did relieve my symptoms, it was only temporary.  For the first eight days the vertigo always came back a few hours later or the next morning.  But on the ninth day, the CRP I was doing at home began to stick.  At my appointment on the 17th, my PT gave me her blessing for my vacation trip (warning me to avoid tipping my head back while star gazing), and we made plans to start balance retraining exercises when I returned.

My wife and I traveled to Utah to visit Arches and Canyonlands National Parks, and we hiked every day for eight days.  It was beautiful!  Unfortunately, on the fourth day I apparently converted myself to horizontal canal BPPV (HC BPPV).  While on a ranger-led hike, we had the opportunity to shimmy through a narrow opening in the rock.  I wasn’t going to pass that up!

Image

Yep, that’s me

As best I can figure, this is what created the problem.  I probably looked up at the canyon around us, then looked down as I stepped up on the ledge, then I went face down and horizontal into the slot, turned my head left to look at the camera then right to go out the other side, stood up, then turned and looked slightly downward as my wife wriggled through behind me.  This was some sort of perfect storm as far as my otoconia were concerned.

As we continued to hike, I noticed that I was double checking before stepping down.  I wasn’t aware of feeling unsteady, yet my body was definitely forcing me to be cautious.  At the end of the hike, the ranger gave an inspiring homily and invited us to lean back and stare up at the blue sky in silence.  It was a wonderful moment…and I couldn’t do it.  Tilting my head back was verboten, plus I was beginning to realize that my equilibrium was off.  I sat quietly with my eyes closed.

utahhike

Fiery Furnace section of Arches National Park

For the rest of the trip, I was horribly off kilter in the mornings.  I had visual disturbances that caused me to squint intensely at the ground while walking — and even then, I weaved drunkenly.  I used my hiking poles to get through a short hike or walk each morning, and gradually I became more steady over the course of the day.  It was a revelation to see how helpful it was to have two additional points of contact with ground.  With the poles I didn’t have to rely on visual input to keep my balance, which was good since my eyes were definitely providing suspect data.  At times I focused on the soles of my feet as I hiked, and that reinforced my confidence and allowed my stomach to unclench for a few moments.

Still, I gradually felt worse.  On the last two days of our vacation, I had to hold on to my wife to get around in the mornings.  I think I cried five times in three days — the emotions would just overwhelm me because I felt so nauseous.  I cried with grief and disappointment, because I was almost well before I went on vacation.  I cried with regret, because I seem to have done this to myself by crawling through the rock.  And I cried with fear, because this might be my new normal.

When I felt at my worst, I would lie in bed at night and mentally revisit our hikes.  I distanced myself from my sadness and nausea by visualizing each arch and overlook, challenging myself to remember every detail.  I would think, hiking poles made it so much easier.  I would think, I guess we should focus on hiking trips from now on.  I would think, I guess that isn’t so bad.