California State University, Long Beach
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Adding Balance To Lives

Published: April 3, 2017

Physical Therapy’s Kristin DeMars and Nina Surber perform a balancing act every day at CSULB when they deal with patients at PT@The Beach with dizziness and balance disorders.

Both DeMars and Surber are specialists in vestibular rehabilitation and use their training to help improve patients’ ability to properly use their vestibular systems which control our sense of balance.

“They learn to improve both balance and reduce symptoms of dizziness,” said DeMars, who has been treating patients with vestibular disorders for 15 years. “The specific exercises used depend on the type of impairment the individual has and the activities that are limiting them.”

Common diagnoses seen by DeMars and Surber include benign paroxysmal positional vertigo (BPPV), as well as vestibular neuritis, bilateral vestibular loss due to aging, traumatic brain injury such as concussion, stroke and multiple sclerosis. Patients are assessed with the help of state-of-the-art equipment including infrared goggles to evaluate abnormal eye movements related to vestibular dysfunction and a computerized system to assess both balance and gaze stability.

“Our vestibular system is responsible for controlling our ability to stabilize our eyes when our head and body are moving,” explained DeMars, who first joined the university in 2010. “When we walk or run, if our eyes did not move equal and opposite to our bodies, the world would be bouncing. The vestibular system is responsible for controlling this function which is referred to as gaze stability. If the vestibular system is working properly, we can see clearly when we are moving. The vestibular system also contributes to balance and allows us to align ourselves with respect to the pull of gravity. The vestibular system is our gravity receptor. It tells us where vertical is.”

Surber, a board-certified specialist in geriatric physical therapy and director of clinical education in physical therapy, gets a special satisfaction out of her work as a vestibular rehabilitation specialist at PT@The Beach.

“Vertigo and dizziness can be devastating and disabling conditions for many people, most of whom typically had no prior issues with mobility,” she said. “It undermines confidence and our understanding of how we experience and move in our world. Although vertigo and dizziness disorders are increasingly common as we age, most people don’t know how to fix this and become afraid of moving, which is typically worsens the problem. The greatest satisfaction I get out of being a vestibular rehabilitation specialist at PT at the Beach is giving people the knowledge and tools to overcome their vertigo and dizziness. I love watching our clients recognize their improvements, regain movement confidence and resume their normal activities.”

One of the most common causes for dizziness is BPPV.

“That is a mechanical problem in the inner ear that commonly appears in older adults for little or no reason,” DeMars explained. “They may roll over in bed or sit up and experience a bout of spinning (vertigo.)”

The culprits are tiny calcium carbonate crystals called “otoconia” that sit at the base of the inner ear.

“The crystals are embedded in a layer of gel designed to hold them in place,” she said. “With aging, some believe that the gel dries out and so no longer holds the crystals firmly in place. A simple movement like turning over in bed can nudge the otoconia into the inner ear’s semicircular canals where they don’t belong creating an exaggerated signal to the brain.”

Treatment for BPPV is very successful and is guided by evaluation of eye movements that are produced when the individual rolls to their side or goes from sitting to lying.

“We watch for specific eye movements using our infrared goggles which allow us to visualize the eyes on a magnified computer screen,” she said. “Based on the eye motion observed, we begin to understand in which of the ear’s three canals the crystals are located. Treatment then entails taking patients through specific maneuvers that move the crystals through the semicircular canals back to the base of the inner ear, where they belong. Once the crystals are returned the individual no longer experiences vertigo. We’re fortunate to have really high-tech equipment that enables us to be specific in our treatments.”

Nina Surber (l) and Kristin DeMars demonstrate state-of-the-art equipment, including infrared goggles, in the PT@The Beach clinic.
Nina Surber (l) and Kristin DeMars demonstrate state-of-the-art equipment, including infrared goggles, in the PT@The Beach clinic.

Besides BPPV, DeMars and Surber treat patients with vestibular neuritis which can set the world spinning without any warning.

“For a period of days, the person may not be able to function due to disabling vertigo, nausea and imbalance,” DeMars said. “Once the victim is through the acute stage, ear-nose-throat doctors send them to us for vestibular rehabilitation. Our job is to look at how much vestibular function has been lost. We use computerized systems to assess their balance and to determine if they have a problem with gaze stability. We also use the infrared goggles to assess both the acuity and severity of nerve damage from the neuritis. From our assessments, we are able to prognosticate how long it will take the patient to recover.

“For those patients with nerve damage, the beauty is the human brain is wonderfully able to adapt,” she added. “We think the undamaged side of the brain takes over a little bit but there also is evidence that argues the damaged part does recover over time if it is stimulated. The job of the physical therapist is to give our patients exercises that train coordination of head and eye movement. With those exercises, we can get rid of dizziness and complaints of jumpy or blurry vision.”

Dizziness can be a problem for older adults.

“By the age of 70, 30 percent will experience problems related to imbalance or dizziness. By the age of 88, that figure rises to 50 percent,” she said. “What happens with aging is a loss of sensitivity of the hair cells that are the sensory receptors attached to the nerves. The good news is we have lots of senses so our job as therapists is to figure out which of the systems are working well. Whether it is vision or sensation from the feet, we strengthen each system with balance and eye exercises to get function back. It has been very successful.”

DeMars’ research affects the way she sees the world.

“It’s hard not to watch people’s movements,” she said. “Not only do I observe people as they move but I try to listen, too. One of the concerns about dizziness and imbalance is that people don’t know how much physical therapists can help. We can do something. I’m always advocating to get to the bottom of the problem. We can help people to function better.”