Welcome to Brainhub Podcast where you will discover the top news and tips on keeping your brain healthy.

Hello and welcome to the Brainhub Podcast I am Matthew Holmes and with me today is Dr. Carlo Rinaudo a chiropractor and the owner of Brain Hub Clinics in Sydney.

Matthew: Good day Carlo, how are you going?

Carlo: Good day Matt, good to be here today.

Matthew: Indeed.  So what has been happening latterly I hear that Brain Hub has moved premises and you have no got two locations in Sydney where people can come along and see you.

Carlo: That is correct, since our last podcast Matt I have since left the previous location in Annadale and now set up two very central locations scattered throughout Sydney, one in Leichhardtand the other one in Gladesville.  So I have been practising here for almost seven, nine years now. So I have got my roots firm in this area for both where I live, where I studied, where I went to school, where my kids attend school and where I have worked for the last seven, nine years as well as from the Lower North Shore of Sydney where it seems we have a number of patients that travel from the Northern beaches or from the North West that come to see us.  So at these two locations we are offering the same services, the same dizziness, balance and sort of treatments for those neurological based conditions.  We are offering all the services that we were offering previously and we have expanded to incorporate the services of massage therapist, acupuncturists, medical doctors, psychologists are all part of our team.  So I would say the move is great for our patients, we are able to offer more services from our central locations.

Matthew: Yes, that sounds great, certainly with the psychology and so forth with dealing with a lot of those vestibular cases and balance cases that can certainly have an aspect particularly with anxiety.  So that probably ties in quite well with what we are going to talk about today.  Basically we got scheduled to go into a bit more deeply about dizziness and obviously with that vertigo, dizziness and vertigo are obviously very common conditions that you see a lot of in your practice Carlo, do you want to tell us a bit about what dizziness is and say how it differs from vertigo and things like that?

Carlo: Sure, I would say out of the conditions that our clinics sees dizziness is certainly the most common and the most prevalence symptom that people call us up and seek some help with.  First of all dizziness is often very loosely described, people will come into the office saying that they have dizziness, and they will describe it in some way when we ask them a few more questions as to can you describe it a little bit further, when does is happen, what exactly do you experience, what are you not experiencing, the definition of dizziness comes out a little bit more.  Dizziness is one of those poorly defined conditions that we often need to tease out a little further. So I often say that the differences between dizziness and vertigo is this, is that dizziness is always described as a perception, it is a very none specific term but it is described as an unsteadiness, a light headiness or a giddiness rather than one perceiving that they are moving.  So it is more of an impaired or altered sensation of themselves, not necessarily a sensation that they are moving.  That sensation of movements is typically described as vertigo or as an impairment or a sensation of poor orientation is often described as dizziness and we often want to tease that out a little further as the clinician because the causes of it and obviously how we can help people with it varies quite considerably. So we certainly want to ask these questions as something that we teach in our cause to practitioners is to really elicit the correct diagnosis from a number of questions that we ask clients.

Matthew: Right, so clearly it is a different sort of thing there, what are some of the more common causes of the vertigo component if that is a little bit more easily defined?

Carlo: Sure, vertigo is often described or defined by two different categories and again as clinicians we want to put someone into one of these categories because again the prognosis, the diagnosis and the management varies considerably.  Those two categories are whether they have something wrong with their inner ear and that can be the little balance receptors in their ear or the nerves that connects the inner ear to the brain and that is described as a peripheral disorder.  So a peripheral disorder is something that affects the nerve or the inner ear on the outside.  A central disorder is really something that affects the brain and the brain only.  So again they are very distinct and something that we want to be clear with.  An example of a peripheral vertigo is classically BPPV which is Benign Paroxysmal Positional Vertigo. It is part of the common cause of dizziness, it is where the little calcium crystals, the little calcium carbonate otherwise known as otoconia in the inner ear, these little canals in the ear becomes dislodged for various reasons, they move into the canals and as they move through the canals and as we move our heads the brain perceives that the world is spinning or we are spinning.  So we get momentary periods of dizziness or vertigo where we feel that the room is spinning. Anyone who has had this will certainly confirm how unpleasant it can be, they often fall to the floor because they feel the room is spinning around or that they are spinning within the room.   So that is a classic condition, a peripheral vertigo condition and another two classical conditions are infections in the inner ear, I know two main types, on is called neuritis which is information of a portion of the nerve that affects only the balance parts and then we have labyrinthitis.  Labyrinthitis is infection of the nerve in the ear that affects both the balance part as well as the hearing part, so people will also get some tinnitus which is ringing sounds in the ear, they might get fullness in the ear which is a discomfort or a full sensation or they also may get some deafness and that is indicative of labyrinthitis.  And that can happen through a number of infectious problems that we get in our ear nose and throat or even in their respiratory systems as well.  So those are our main peripheral vertigo conditions.  I guess some of the most central conditions, those that are affecting the brain shall include things like migraine associated vertigo or vertiginous migraine where people who often get migraines, the classical head and head pain conditions can also get vertigo and a senseless spinning with their migraines.  So that is often described as vertiginous migraine or migraine associated vertigo.  Those are the common disorders that people can get.  Another one is described as Meniere’s, Meniere’s really should be included in the peripheral disorders those affecting the inner ear, unfortunately with Meniere’s it is quite a debilitating disease that as people get dizziness they get tinnitus which is that ringing sound and they also can get deafness and fullness in the ear as well and that can last hours if not days when they have it and they can also get attack every so often and that has been associated with dietary problems or immune problems, salt intake amongst others as well.  So I guess those are the more common vertigo conditions to answer your question Matt.

Matthew: Yes, so I suppose what comes out there is all of those have that perception of movement and the speeding type of sensation that you are describing.  What are sort of some of the causes perhaps of dizziness where you get these less well defined symptoms and conditions themselves don’t really have names as much as my understanding anyway of the dizziness, do you want to tell us a little bit more about that?

Carlo: I think probably the three main dizziness conditions that are reported and we see in our practice include cervicogenic dizziness and that by definition is dizziness that comes from basically a neck that is not working too well, their joints in the upper neck are very strong connections with the balance parts of the brain, with their balance parts of the brain, with their visual parts of the brain amongst others and when the upper neck is not working for instance from a whiplash injury or a concussion or arthritis, poor posture, injuries of any sort many chiropractics or physical therapists will see this patients present to their to their practice. They often can have dizziness associated with these cervicogenic or neck related conditions.  Unfortunately through the work that we can do with the neck and with balance and visual retraining we can really help these people.  So cervicogenic dizziness is one that we need to include.  Another is described as a light headedness or a presyncope. Presyncope basically means it is almost that fainting state where someone from a seated position may stand up quickly or they may lying down or they may sit up quickly, that change in blood pressure, the blood pressure change is not first enough or great enough to combat the change in gravity as opposed as it goes from a sit to a standing position.  Basically parts of the brain don’t get enough blood supply to it as the body changes in gravity.  So what happens is that they get a little light headed and they get a little oozy in their head and this is a very common symptom particularly those with age and the elderly, they may say to you I feel a little lightheaded, I feel a little dizzy when I get up, well this is the reason for it.  It is often described as an orthostatic hypertensive problem or presyncope problem where basically the cardiovascular system or the part of the brain that controls the cardiovascular system aren’t working as well as they should and for that reason they get a little lightheaded and they report it as a sense of dizziness.  Medication is also another cause of that as well.  I guess finally the other form of dizziness that we tend to see a fair bit in our office is what we call or describe as a persistent postural perceptual dizziness, it is a big word, big title, shorter name is 3PD which is persistent postural perceptual dizziness.  And expanding on that name, persistent meaning that it can unfortunately stay with you for some time, postural meaning that your posture and movement of your body can often exacerbate these symptoms, perceptual is an interesting term because it means that the patient will always perceive they have these dizziness symptoms but in fact as a clinician when we examine them we often may find very little wrong with them and we may go into a full series of balance tests that involve ocular or eye movement tests, blood pressure tests, balance tests and by and large these people may look relatively ok, or what happens is because they have had these problems for so long just like a chronic pain patient their brain actually rewires itself a little bit to perceive that they have these dizziness symptoms in the absence of actually having any real problems, any physical problems I should say.  The way in which we typically help people like these apart from some of the rehabilitation that we may provide is additionally work with other councillors or psychologists particularly those that use cognitive behaviour therapy and help them through emotional or rather behavioural strategies overcome some of these perceptual persistence symptoms.  So I guess they are other main causes of dizziness that we see commonly in our office.

Matthew: I am sure that many people when they get things like dizziness and vertigo one of the things that sort of jumps to their mind is that they are having a stroke or have a brain tumour or something like that, and most of the time it is one of the sort of less causes that you have referred to.  These can be a cause though of dizziness and vertigo and how can people tell if it is something they need to seek urgent attention for?

Carlo: It is a great question Matt, often it could be difficult, difficult for even clinicians, often I get calls from new clients or people interested in the work that we do, they have a bout of severe dizziness and vomiting overnight or over the weekend they present it to the emergency department and often get dismissed from the hospital because nothing serious has happened.  One of the things that I indicated to clients as well as teach other practitioners is look for other symptoms that may indicate that something more serious is occurring.  If it is, if you do get dizziness and you are vomiting you may think that the world is ending even though it may be relatively benign people often think the worst and I certainly don’t begrudge them in thinking that.  But if it is a dizziness condition and it is affecting only the ear and they have BPPV or they have got one of the infectious complaints or they have an attack of Meniere’s it affects only the inner ear, there are no effects on other parts of the body.  So that being said we shouldn’t see any other signs or symptoms outside of the inner ear.  To give you an example, if someone has trouble talking, swallowing, chewing that is typically not a good sign, if someone has troubles with incontinence, they have troubles holding their bowel or bladder that is not a good sign, they have pins and needles in their hands or feet that is generally not a good sign.  That being said, also anxiety and panic attacks can also cause that same symptom.  If they have troubles walking or they have weakness in their hands or they have weakness in their feet, additionally that is not a good sign.  So if anyone has dizziness and they present with any of those difficult with chewing, swallowing, talking, unable to move their hands, unable to move their legs, get funny sensations impacts the body or they have altered bowel and bladder control I would typically say that is not a great sign and it is pretty best that they seek emergency care.  Fortunately though the series causes of dizziness are relatively rare which is great but for the average person who may not know otherwise I can certainly understand why they would think the worst.

Matthew: Yeah, so they really need to just be sure, go and get checked and most of the time it is not going to be anything serious but it is really something you don’t want to walk around with isn’t it?

Carlo: Exactly and so much on the side of consciousness but  you are not getting any of these other symptoms you could be fairly confident that it is not anything of serious notes but certainly if you are concerned more than that seek first aid care immediately.

Matthew: What are some of the treatment that can be done for vertigo and dizziness?

Carlo: Treatment for vertigo and dizziness always depend on what the cause is.  I mentioned earlier the differences between and inner ear problem to a nerve problem to a brain related problem or a neck related problem or a cardiovascular related problem.  So your first step should always be seeking care and assessment with an appropriate trained person who can dissect and really tease out which one of those causes is the case.  So in my office we spend sometimes almost up to two hours on an initial consultation whereby we go through a very comprehensive examination, we ask all the right questions, they help tease out which one of these is potentially causing it and then we do an examination that looks at balance, looks at spinal control, looks at eye movement, looks at inner ear, looks at other brain function and then we say okay based upon that this is more or likely what you are suffering from.  And then from that this is what we can do and these are our expectations.  Some conditions are very favourable to the sort of work that we do, conditions like BPPV I would say in terms of the migraine associated vertigo we get some great results and other conditions we can help manage it very effectively.  So with BPPV you can almost get a nine percent resolution in symptoms after the first one or two visits purely from the work that we do which is great for the patient so that they can get back on their feet and feeling better again pretty quickly.  Treatments involve many things from specific head movements that we may do to exercises that involve the eyes, balance exercises, neck related exercises, dietary advice, lifestyle advice. Again I guess it is somehow difficult question to answer that unless we knew what their condition was but certainly our goal is to accurately diagnose what is going on and for the vast majority of people we can certainly help them and for some people we can help them tremendously, very quickly to a point where they are all back to normal.  For others they have more complicated cases whereby we can help manage their symptoms, we can help lessen the frequency or the severity of their symptoms and sometimes we need to co-manage with various other specialities like medical doctors, ENTs, nutritionists or naturopaths as well as psychologists for some of those conditions that we mentioned earlier.  So there is many things that we can do and there is very few people that we are unable to help which is great.

Matthew: Yeah, so it sounds like this might be something we might want to look into in more detail in the future, no doubt we will cover some of these conditions perhaps in more depth in upcoming episodes.  Is there anything else you would like to add in closing?

Carlo: Just the basic summary, with dizziness be sure to seek the assistance and care of someone who looks at it from a very integrated perspective.  There is many reasons why someone would have dizziness as we spoke of today, so it makes sense to have a practitioner to go through all the systems that are involved because sometimes it can be just a change in medication that causes it or it could be because they have a recent ankle sprain and that in itself has changed the mechanics of their body which has then changed the way the brain integrates this information.  It could be that they have had a recent ear infection or it could be that they have got anxiety and fear and that that is perpetuating their dizziness.  So there is never a one size fits all approach to this so be sure to see someone who can look at it from a very integrated perspective. The team at Brain Hub certainly attempts to do that, we work with people and if we feel that we don’t cover all those bases we certainly work with the appropriate people to make sure that we do.

Matthew: Well, if you have got any questions about today’s episode or if you would like to leave a comment or anything else like that please pop along to brainhub.com.au/blog, on that website as well you will find all the contact details for the practice should you want to get in touch with Carlo and book an appointment or anything like that.  In addition to that you will also find a full transcript of today’s episode, if you want to have a read through be sure to subscribe on iTunes, Stitcher or whatever other platform you are using to listen to so that you don’t miss any future episodes.  So until next time take care.

Thanks for listening to the Brainhub Podcast, for more information and to subscribe visit brainhub.com.au.

References

1: van Leeuwen RB, van der Zaag-Loonen H. Dizziness and neck pain: a correct
diagnosis is required before consulting a physiotherapist. Acta Neurol Belg. 2016
Sep 6.

2: Martins E Silva DC, Bastos VH, de Oliveira Sanchez M, Nunes MK, Orsini M,
Ribeiro P, Velasques B, Teixeira SS. Effects of vestibular rehabilitation in the
elderly: a systematic review. Aging Clin Exp Res. 2016 Aug;28(4):599-606.

3: Hillier S, McDonnell M. Is vestibular rehabilitation effective in improving
dizziness and function after unilateral peripheral vestibular hypofunction? An
abridged version of a Cochrane review. Eur J Phys Rehabil Med. 2016 Jul 12.

4: Ribeiro KM, Freitas RV, Ferreira LM, Deshpande N, Guerra RO. Effects of
balance Vestibular Rehabilitation Therapy in elderly with Benign Paroxysmal
Positional Vertigo: a randomized controlled trial. Disabil Rehabil. 2016 Jun
24:1-9.

5: Dommaraju S, Perera E. An approach to vertigo in general practice. Aust Fam
Physician. 2016 Apr;45(4):190-4.

6: Edlow JA, Newman-Toker D. Using the Physical Examination to Diagnose Patients
with Acute Dizziness and Vertigo. J Emerg Med. 2016 Apr;50(4):617-28.

7: Dieterich M, Obermann M, Celebisoy N. Vestibular migraine: the most frequent
entity of episodic vertigo. J Neurol. 2016 Apr;263 Suppl 1:S82-9.

8: Tjernström F, Zur O, Jahn K. Current concepts and future approaches to
vestibular rehabilitation. J Neurol. 2016 Apr;263 Suppl 1:S65-70.

9: Grill E, Penger M, Kentala E. Health care utilization, prognosis and outcomes
of vestibular disease in primary care settings: systematic review. J Neurol. 2016
Apr;263 Suppl 1:S36-44.

10: Ouchterlony D, Masanic C, Michalak A, Topolovec-Vranic J, Rutka JA. Treating
Benign Paroxysmal Positional Vertigo in the Patient With Traumatic Brain Injury:
Effectiveness of the Canalith Repositioning Procedure. J Neurosci Nurs. 2016
Apr;48(2):90-9;

11: Liu Y, Wang W, Zhang AB, Bai X, Zhang S. Epley and Semont maneuvers for
posterior canal benign paroxysmal positional vertigo: A network meta-analysis.
Laryngoscope. 2016 Apr;126(4):951-5.

12: Schlick C, Schniepp R, Loidl V, Wuehr M, Hesselbarth K, Jahn K. Falls and
fear of falling in vertigo and balance disorders: A controlled cross-sectional
study. J Vestib Res. 2016;25(5-6):241-51.

13: Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to
Diagnosing Acute Dizziness and Vertigo. Neurol Clin. 2015 Aug;33(3):577-99, viii.

14: Arnold SA, Stewart AM, Moor HM, Karl RC, Reneker JC. The Effectiveness of
Vestibular Rehabilitation Interventions in Treating Unilateral Peripheral
Vestibular Disorders: A Systematic Review. Physiother Res Int. 2015 Jun 25.

15: Jahn K, Kressig RW, Bridenbaugh SA, Brandt T, Schniepp R. Dizziness and
Unstable Gait in Old Age: Etiology, Diagnosis and Treatment. Dtsch Arztebl Int.
2015 Jun 5;112(23):387-93.

16: Furman JM, Balaban CD. Vestibular migraine. Ann N Y Acad Sci. 2015
Apr;1343:90-6.

17: Hain TC. Cervicogenic causes of vertigo. Curr Opin Neurol. 2015 Feb;28(1):69-73.

Dr Carlo Rinaudo (Chiropractor and PhD candidate) is the clinic director of Brain Hub, a clinic in Sydney focussed on helping people with dizziness and vertigo conditions, poor balance, whiplash and concussion symptoms.

The clinic and its practitioners use a range of modalities to help assess and manage these conditions and/or symptoms. Vestibular rehabilitation therapy and other brain-based therapies are primarily utilised, along with standard Chiropractic and physical therapy techniques.

The growing evidence showing support for the management of these conditions comes primarily from the physical therapy and clinical neuroscience fields, rather than chiropractic specific. Fortunately, Dr Rinaudo with post-graduate training both in Australia and from overseas is experienced to translate this knowledge into clinical practice. Additionally, he is currently undertaking a PhD from the University of New South Wales (UNSW) and Neuroscience Research Australia (www.neura.edu.au)  in Vestibular Therapy, more specifically clinical trials on how to help people with dizziness and vertigo conditions. He is working alongside leading researchers and Neurologists in the field. Additionally, the benefits expected from his PhD research will be used to further validate the use of vestibular rehabilitation therapy for other related conditions like whiplash and concussions.

Dr Rinaudo is a frequent speaker at national events, as well as lecturer in the field of vestibular rehabilitation and dizziness conditions to other health practitioners.