The inner ear balance organ… What is it? What does it do? And how can something that small make me feel this unwell?

Rebecca Brown, Vestibular and Face physiotherapist

Our inner ear balance organ is called the Labyrinth. It is an incredible fluid filled organ that provides us with so much information. There are two areas called the saccule and utricle- these give us the perception of linear movement. Linear movement is up, down, forwards and backwards. There are also 3 areas called your semi-circular canals. These canals allow us to know if we are bending forwards/backwards, tilting to the side or turning left and right. For those science wizzes out there, you may be more familiar with the terms Yaw, Pitch and Roll. 

We cannot see your Labyrinth, it is deep within your ear. In saying that, your Vestibulo-ocular reflex allows us to see what is happening and if there is an issue with your balance organ. 

Wow, that sounds complex… 

It is complex but very cool. As I am sure you are all aware the body has some incredible reflexes that allow us to function… The Vestibulo-ocular reflex allows us to keep the world in focus while our head moves. During your assessment at The Facial Physio we will be looking at how your eyes move in relation to your head. It is not a vision test like what you would do at the optometrist, it is an inner ear balance test. 

If there is an issue with your Labyrinth or within your Labyrinth we will be able to assess this with your VOR. Many of our clients report the world spinning, seeing the room flicking by and being unsteady / unable to walk in a straight line. This can be due to the Labyrinth. For example: if someone has had a virus that affects their balance organ or if someone’s calcium carbonate crystals, that sit on the membrane of the utricle, become dislodged into their semi-circular canals. These are a couple of examples that can result in the above symptoms and can make you feel so unwell. 

We will give you an in-depth explanation at your appointment and we can provide you with handouts to take home. 

Ramsay Hunt Syndrome

Dr Ellie Seckold - Face Physiotherapist

RHS is a fancy name for shingles specifically effecting the facial nerve.

It is NOT Bells Palsy. But it can be hard to differentiate between RHS and Bells in the early stages of the disease.

Similarities:

• Both are types of viral facial nerve paralysis

• They come from a similar family of virus

• Both normally result in a COMPLETE paralysis of the facial nerve on 1 side

• Both can experience pain around the ear

• Both can experience a change in taste on the tongue same side as the paralysis

Differences:

• RHS is rarer, affecting 1/50 000 as opposed to Bells 1/10 000 people

• The prognosis drastically differs

• RHS can present with vesicles (shingles RASH) on the ear, inside the ear, on the tongue or in the mouth

• RHS can present with a LOSS of HEARING on the affected side, as opposed to hyperacusis (increased sensitivity to sound) which is what normally happens in Bells palsy

• RHS can cause VERTIGO, this doesn’t happen in Bells palsy

What is the prognosis for RHS?

We usually give the nerve 6 months to a year for most of the recovery to occur. Complete recovery is not as common as in Bells palsy, but some people do completely recover. With the right medications at the right time and access to appropriate care, we can help get you as close to normal as possible. People can continue to improve beyond a year - we are just getting improvements from different things. For example, teaching the nerves to be less confused (managing synkineis) can be done at any stage; or teaching muscles to adapt and create expression slightly differently can be achieved at any stage.

What should I do if I have or think I have RHS?

Present to your GP or ED, appropriate medical management in the first 48hrs of onset paralysis includes prescription of steroids to remove swelling from the nerve and antivirals to treat the shingles virus. If you have loss of hearing, this is an ENT emergency and you should see an Ear Nose and Throat specialist as soon as possible. With the correct care early, hearing can be preserved. Your fabulous medical team will also screen to check that there is nothing else naughty going on.

In terms of physiotherapy interventions, we can be engaged as early as needed to discuss eye care, balance and what to expect. We start appropriate face exercises as movement starts to return. The aim of this is to encourage smooth return of messages down the nerve, as there is an increased risk of Synkinesis (confused nerves) in RHS. We keep track of your recovery to ensure you are hitting appropriate recovery markers and time points and facilitate access to facial nerve specific medical specialists for extra help early when it is appropriate.

We will touch on appropriate treatment interventions, what works and what doesn’t in future posts. We will also go in to synkinesis. What this space!

What happens in a vestibular/vertigo assessment?

Rebecca Brown - Vestibular and Face Physiotherapist

Dizziness, Lightheaded, Vertigo, Imbalance…

These words are commonly used by our clients to describe their symptoms.

The goal of a Vestibular Assessment is to figure out if your symptoms are coming from your inner ear balance organ, due to a central cause (something that could be related to the brain/ the pathways within the brain), a proprioceptive issue (this could be dizziness from the neck, imbalance due to altered lower limb sensation/ strength) or a combination of two or more of these. 

We allocate one hour for our assessments. They involve a screen of your cranial nerves, oculomotor examination (looking at your eyes and the movement of your eyes in different directions), infrared goggle assessment (we place goggles on you to look at your eyes in the dark), we assess for Benign Paroxysmal Positional Vertigo “The crystals” (this involves us lying you down with your head turned in different directions) and we assess your balance, gait and neck. 

Our initial assessments always involve a thorough assessment, explanation and depending on what our assessment shows us we will treat what we find and/ or establish a home program and plan of attack for the future. 

If you are ever unsure about what the treatment involves, what you should bring to your assessment or if you need to bring someone with you, please do not hesitate to speak to our friendly reception staff. Our reception staff should be able to answer your questions but if they are unsure they will pass on the message to the Physiotherapists who will personally contact you about your queries. 

What is a Bell's palsy?

Bells’ Palsy is the most common cause of facial nerve paralysis. Affecting about 1 in 10 000 people is is rare yet common!

But what the heck is it?

Bell’s Palsy is essentially a transient idiopathic unilateral mononeuropathy of the facial nerve.

One more time in English !?

It is a transient (usually resolvable) idiopathic (sneaky) unilateral (one sided) mononeuropathy (injury affecting 1 nerve).

How do I know if I have a Bell’s Palsy?

Usually people have a change in taste and or pain behind their ear in the days leading up to the Bell’s palsy coming on… but without the paralysis this could be literally anything! A Bell’s can’t be diagnosed until the paralysis starts and it MUST be diagnosed by a Doctor - please present immediately to your GP or local emergency department. It is a diagnosis of exclusion, which means that they need to rule out everything else before arriving at the conclusion that it is a Bell’s Palsy.

What causes it?

TBC. Best rationale is that for some reason your immune system was a bit low, maybe you were run down. Your body then decided it was time to get sick, you just got super unlucky that instead of a cold you most likely had a reactivation of a virus related to the shingles/chicken pox/ or cold sore family. It chose your facial nerve. When a virus attacks a nerve it has to swell. The facial nerve after it exits the brain travels through the longest bony canal in the body this is where it gets squished. Its in a bony tunnel so the inflammation has no where to go, it squishes the nerve, the nerve cant get messages past... nothing works. This is why medication is incredibly important very early and why you must see a doctor.

What else could it be?

Not to scare anyone but the reason you need to see a doctor is that they need to assess and rule out shingles, tumours, strokes and a host of other nasties to make sure you are all ok!

Ok I have just been diagnosed with a Bell’s Palsy. What next?

You will be prescribed Prednisone and maybe antivirals. The prednisone or prednisolone is the most important thing to do in the first 2 days of onset. If you get it in time there is a tonne of research to say it increases your chance of a full recovery. It is a hard core steroid that will help remove the swelling quickly and take away the squish, so hopefully the nerve will be ok! Don’t skimp out on your prednisone if it has been prescribed to you!!!

What to expect:

Your face will worsen to a complete paralysis for the first 3 days even with the meds- don’t panic this is normal and expected.

We expect the first flicker of movement at around 3 weeks after onset.

On average we expect 80% of people who got prednisone to be about 90% better at 3 months after the paralysis. The stats are slightly lower if you didn’t get the right meds at the right time.

My face was TOTALLY paralysed… I must have had a really horrible case.

Incorrect! Most Bell’s palsy SHOULD be completely flaccid within a couple of days of it starting. This is normal!

Will I be totally normal again?

80% of people have a complete recovery. The 20% who don’t have very variable degrees of residual injury and we will go through these in other posts. These people receive the most benefit from face physiotherapy.

Ok when do I stress about not having a perfect recovery?

Your health care provider or face physio will help keep track of where you are up to and make sure you are within normal recovery times. Any variation from the theme we should have you present early to a facial nerve specialist or to one of the two wonderful facial nerve clinics in Sydney for early assistance.

Is there a way of predicting if I will have a good recovery?

The Prince of Wales public hospital has the only ENOG machine in NSW - it is a super cool nerve testing machine that give us a comparison of the ok and cranky nerve. If this is done within the first week and reassessed at around 3 weeks post they can check how your nerve is recovering and predict how smooth your recovery will be.

How do I get one of these? Present to ED at POWH :)

When should I see a physio?

Whenever you like!

I find that I generally see patients very early (in the first week or 2) mostly for education, checking eye care routines, answering questions and coming up with a clear treatment plan. We can start exercise therapy ect when you start getting movement. There is no evidence to suggest massage, acupuncture or electrical stimulation will help at this stage. Electrical stimulation can do damage DON’T go there please. Massage and acupuncture won’t do damage and if it helps you to feel better and have a nice stage of mental and physical being for recovery feel free to go for it - that’s an optional extra. They are yet to be proven to directly physically heal the nerve.

I was told I’ll be right in 6 weeks.

The research says 3 months on average . If you are a lucky unicorn who is better is a couple of weeks… Fantastic! we will high five you are the exception to the rule! Go you :)

How does a jaw joint (TMJ) work?

Hi team!

Time for Jaw anatomy and mechanics! There is a lot of power if knowing how a joint works when treating or doing home exercises. If it makes sense… everything is easier!

The TMJ - temporomandibular joint - or Jaw is a pretty epic joint. Essentially it does two joints jobs in the one space.

Fun fact: Yes .. also you would have just seen TMJ = the official name of the joint. NOT the actual injury/condition. The condition is called a “temporomandibular joint disorder”, usually abbreviated to TMD.

You have two usually identical TMJs. One on each side of your head. They sit immediately in front of your external auditory canal (ear hole), this is why people often report ear pain, blocked ears, difficulty equalising and tinnitus with TMJ problems.

Inside your joint you have a special disc. It sits in the cavern of joint between your mandible (lower jaw bone) and your skull. This is not like your spinal discs! It is attached to the back of the joint by a bungy cord called the retrodiscal lamina and at the front to a very clever muscle called the lateral pterygoid.

As you open the first this we do in hinge, the joint rotates in position. The lateral pterygoid then contracts, pulls the disc forward and out of the socket. This is turn pulls the mandible forward - imagine a baby version of a snake opening its mouth. The bungy cord then helps pull everything closed via elastic recoil.

Now all of this happens with the help and support of some of the strongest pound for pound muscles in the whole body. When these muscles misbehave (clenching/grinding/bruxing, trauma) and decrease the available space for the mechanism to work, it can fail. This can cause locking, clicking, pain and problems.

For more info and some amazing stick figure artistry please check out our insta! @thefacialphysio

Have a great day!

Ellie

Brandt Daroff exercises ... Should I do these at home for vertigo?

If you have been given Brandt- Daroff exercises as a handout by anyone without a vestibular assessment or find exercises on the internet to treat BPPV, please FREEZE and read this first!

If these exercises have been prescribed to you by a Vestibular Specialist/ Expert then they may be an appropriate exercise for management of BPPV (crazy crystals - see blog “help I’m dizzy”). Otherwise, there are some more appropriate and effective treatments.

Firstly… hands up who knows what Particle Repositioning Manoeuvre or Brandt Daroff Exercises (bottom are? See the pictures on our Instagram (@thefacialphysio) for what they look like.

Brandt Daroff Exercises were developed in the 1980's. It is a non-specific exercise that usually gives all the canals a “good shake up” without specifically targeting one. It was prescribed to patients because it was thought to be simple enough to do at home alone. Unfortunately, in my experience I have noticed that rather than being simple and easy to do at home; many of my patients have presented feeling worse off, imbalanced and lightheaded.

Why?

-          Crystals can end up in other canals

-          They may be treating the wrong canal

-          Restricted Neck range of movement can result in these exercises aggravating neck pain

-          If patients are by themselves at home they may feel very vulnerable and unsafe

-          Patients can experience anxiety and fear with making themselves vertiginous

-          They may not complete the exercise due to symptom provocation

-          Age and comorbidities can play a factor

-          People do not have the time to repeatedly do these exercises.

Epley manoeuvre was invented in the 1990s and is best performed by a clinician.  The Epley manoeuvre specifically targets the posterior/ anterior canals and usually will only take one to three treatments to move the crystals back home. It is recommended not to do this at home unless it has been prescribed for you and you have a friend or family member there to help.

Dorado et al 2012 did a randomised prospective clinical trial where they reviewed Particle Repositioning Manoeuvre (modified Epley) Versus Brandt-Daroff Exercise for Treatment of Unilateral Idiopathic BPPV of the Posterior Semicircular Canal. The article looked at the short and long term outcomes of these manoeuvres for treating unilateral BPPV.

They concluded that “PRM (Modified Epley manoeuvre) is a more effective treatment and as safe as the Brandt Daroff exercises. It does not reduce the recurrence of BPPV but it may delay the onset of the second recurrence in comparison to the Brandt Daroff”.

The take home message is…before you try the Brandt-Daroff exercises, please see a Vestibular Physiotherapist or someone who specialises in these conditions, who can do a Vestibular Assessment. Dizziness and Vertigo are overly complex symptoms that may not always be due to BPPV. A Dix-Hallpike and Roll Test are the most appropriate assessment tools at identifying the canal and ear involved and guide us on which treatment would specifically target that area.

Bec

I have vertigo and my crystals are loose!

My Crystals are loose

If you are diagnosed with BPPV (“crystals being loose”) please do not go home with a handout or find an exercise on google and treat it by yourself. Why you say? One of the analogies I like to explain to people… Would you take medication without even knowing what you were taking it for or without knowing what it could do? Treating BPPV is complex.

What is BPPV?

Benign Paroxysmal Positional Vertigo.

Lets break this down; Benign (“harmless”- even though it may not feel harmless), Paroxysmal (“sudden” episode), Positional (triggered by change in head position relative to gravity) and Vertigo (when you see the world spinning, dizziness and imbalance).

It is characterised by an episode (or multiple) of “spinning” associated with change in head position that can last for less than a couple of minutes.

Why does it occur?

Our inner ear balance organ – The Labryinth, has different areas which give us information on linear and angular movement. Two areas known as the saccule and utricle have surfaces with hair cells that are covered by a gel like membrane. On top of this membrane sit calcium carbonate crystals.

In BPPV some of these crystals can come loose.

There are many reasons this can occur: trauma (a knock to the head), neuritis (inflammation of the nerve), idiopathic (no reason), some people may have a predisposition due to their general health (diabetes, hypertension, age).

Before we treat your BPPV we must determine what ear the crystals are loose in and more specifically which canal.  (Remember you have 3 canals in your left and right balance organs. You have two ears that the crystals can be lose in.) Keeping this in mind we do not expect you to be able to diagnosis this yourself at home, let alone be able to pick the right treatment. If your crystals are loose and you try and self-treat not only can it make you very unwell and feel like you are losing your balance, it can be scary and disorienting.

How do we assess?

When you come in to see us the most important thing is taking a thorough history and objective assessment- including the Dix-Hallpike and Roll tests for BPPV. Dizziness is very complex. That is why we have state of the art technology to assess your eye movements and record your nystagmus.  

How do we treatment:

The most effective treatment for BPPV is a Canalith repositioning treatment/manoeuvre (Modified Epley and BBQ roll). A lot of people have been prescribed the Brandt-Daroff exercises. This exercise definitely serves a purpose, but it is not as specific or effective in treating BPPV in comparison to the CRT. Amore Dorado et al 2012 did a randomised control trial that showed Brandt-Daroff exercises resulted in 25% remission of BPPV in comparison to CRT, which resulted in 80.5% remission.

Know that when you come and see us for treatment, we will be using the most effective treatment for you. Please do not do a Brandt-Daroff, somersault or any other manoeuvre by yourself at home. Doing this can result in the crystals ending up in different canals/ multiple canals and you feeling very unwell.

Dizziness is what we see day in, day out, why not come in and let us help you. 

References:

Amor-Dorado JC, Barreira- Fernandez MP, Aran-Gonzalez I, Casariego-Vales E, Llorca J, Gonzalez-Gay MA. Particle repositioning maneuver versus Brandt-Daroff exercise for treatment of unilateral idiopathic BPPV of the posterior semicircular canal: a randomized prospective clinical trial with short and long term outcome. Otol Neurotol. 2012.

Help I'm Dizzy!

I am dizzy… What to do?

We have all Dr Googled in our lives, but I would stress the importance of avoiding this when you are dizzy. 

As we are all aware google can diagnosis us with a whole lot of weird and wonderful (scary) conditions.

We are experts in assessing dizziness. A Vestibular Physiotherapist will thoroughly assess your inner ear balance organ to identify if that could be the cause of your symptoms.

We treat vertigo, dizziness, light-headedness, imbalance, BPPV, Vestibular Dysfunctions, Meniere’s, Persistent Perceptual Postural Dizziness, Mal De Debarquement, Cervicogenic dizziness and Vestibular Migraines.

If we think you require further investigation in regards to your dizziness we will discuss with you and your physician the most appropriate plan for your health.

How are we managing the ever evolving COVID-19 pandemic?

We are infection control nerds and we take it really seriously.

As physios we already wash hands between patients and use hand sanitiser before and after patient contact. We already change linen and paper bed and head covers between each patient. We have private rooms and only ever see one person at a time. Additionally we don’t stack out patients - we already have a sneaky 15min buffer between all our consults so there are never many people in the practice.

Now we are also:

• Disinfecting everything that patients have been in contact with between each consult.

• Sending out COVID pre-screening questions for every new or follow up face-to-face consult

• Taking temperatures on entry to the practice

• Kindly asking people to reschedule if they are sick at all or have a random temperature that does not settle.

• We use masks when we are unable to socially distance and gloves for all patient contact.

As health care workers if we have any symptoms at all of any kind we need to be COVID swabbed and cleared before return to work. This is why we are asking anyone who is sick not to present - it doesn’t matter if its not COVID if we pick it up we can’t see patients. We treat a lot of immunocompromised patients, older patients and very young patients. We are doing our best to allow for people to access safe health care through this mental time!

If you have any concerns, please let us know :)

The rise of Bruxing and headaches during the COVID Pandemic

I hope everyone is going well. I for one am sick of treating in face masks… I feel like Darth Vader but it is what it is. Better over cautious than not cautious enough!

One thing I have noticed is that we are seeing a heck of a lot of headache and bruxing (clenching/grinding) episodes. So I thought this would be a good place to look at why this could be the case. Research evidence for the COVID period is a constantly changing field. Most research is currently directed at the effects, process, treatment and prevention of COVID. We should start to see some research looking at the musculoskeletal and psychosocial impact of the pandemic from a lockdown perspective over the next year or two.

Why could there be more people with headache and jaw pain?

1. Stress…. Global pandemic will do that! Not to mention the loss of jobs, decreased or drastically changed work, financial and health related worries, isolation, inability to travel, home schooling/return to school.

2. Spontaneous home office set up and working from home for both the work force, people studying and school kids.

3. Increased prescriptions of SSRI’s (anti-anxiety/depression medications): increased rates of anxiety, depression, stress can lead of more people being prescribed SSRI’s. Some SSRI’s can have a side effect of clenching and grinding teeth! Not everyone will experience this side effect but it is worth knowing about.

4. Decreased exercise - or exercising too much too quickly: Both can be contributing factors in multiple types of musculoskeletal injuries. Regular exercise is a key management tool for managing the way we process pain particularly in people with chronic headache or migraine and is also a very effective way to regulate mood …. so we don’t take out stress on out teeth and jaw!

What do you think?

Bulk Billed Telehealth is a go for physiotherpay!

Hi Everyone!

I’ve been slack on blogging. But with social distancing, isolation and a HUGE drop off in physio work secondary to COVID… I now have time! I hope you are all staying safe, washing your hands and social distancing. Get ready for all things faces :) But first a general update.

Sadly this week I had to temporarily the Lindfield satellite location in response to the NSW COVID lockdowns. We are bunkering down on the Abbotsford shop front location as we can go super over the top on our infection control measures to make it as safe as humanly possible. As some of you know our Abbotsford location is also our general practice “Physio Science”. As of next week, Tate will be stepping back from physio-ing and taking up a job as a greenskeeper so we can keep the practice open in some capacity through this tough time and bounce back afterwards. I will still be seeing face-to-face consults for faces and general practice while it is allowed and safe to do so. All our patients will be screened with COVID questions before coming in and we are checking temperatures. We are encouraging anyone who could be seen via telehealth to give it a go.

On the up side, we FINALLY got Medicare codes for telehealth! YAY! This means anyone who was/is/could be eligible for a Medicare plan for physio is now also eligible for BULK BILLED Telehealth. Yes you heard me, no gap telehealth consults to get us through this craziness. Just because COVID -19 has started an apocalypse doesn’t mean TMD, facial paralysis, migraines or face pain will just vanish. This gives us reasonable and helpful means of continuing to see the people who need it, while the world is going crazy...without breaking the bank. We are all in the same boat at the moment… businesses closed, bleeding out money because of the lockdowns or people being let go. It sucks, but if we can stop this virus sooner rather than later we can all get back to normal. The Medicare rate for physio is still woefully low BUT it is something and it is a step in the right direction!

Check out our insta @thefacialphysio for how-to do telehealth and please feel free to email or call if you have any questions!

Stay safe,

Ellie