This is an excerpt from the book, “Professionally Unstable: Tales of Treating the Desperately Dizzy” by Dr. Anthony Veglia, DPT.
Awaiting me in the lobby was a middle-aged man, monotone in voice, flat in affect, and hard of hearing. With his diagnosis, I knew that I would be just a single step in his long journey. Years prior to this man’s entrance into my clinic, a tumor was found in his skull. For those with undiagnosed dizziness, the fear of an unknown brain tumor is a worry that I am constantly hearing from patients. Fortunately, a tumor being the cause of chronic dizziness is so much rarer than a straightforward vestibular diagnosis. That being said, this would be the exact type of tumor they are likely imagining. Unlike many vestibular diagnoses, a slow-growing, benign tumor will not appear with sudden, explosive levels of symptoms.
“So, it was a left acoustic neuroma resection? And everything went as planned?” I asked.
“Sorry, you’re gonna have to speak up.” He said, turning the right side of his face towards me.
“So sorry.” Considering this man just became perfectly deaf in his left ear, I asked again using my outside voice. “Did the surgery go as planned? Any unexpected surprises?”
“No surprises. They told me it went well. We did tons of work in the hospital to get back to walking without falling over.”
An acoustic neuroma is a tumor made out of the nerve from the ear to the brainstem. Rather than an infection, such as a labyrinthitis, the information passes through a large growth. Remarkably, the majority of these tumors require literally zero treatment. Give that tumor a scan every few years, make sure it isn’t changing size, and don’t fix what isn’t broken. For many, there are even no symptoms related to
dizziness, hearing loss, or imbalance. This might sound surprising, and I get that. It’s a strange thing, even for myself, to wonder how many people out there will never know they have one of these tumors because it simply never causes any problems throughout their lifetime.
By definition, an acoustic neuroma is a benign tumor. This does not mean that it isn’t dangerous, it simply means that it doesn’t spread to other areas of the body, causing tumors elsewhere. In case you didn’t know, there’s not a ton of free space in the body. In fact, there are zero unused spaces within the body, and the brainstem does not appreciate a tumor squishing it.
If big enough, and if the tumor is indeed getting larger over time, a surgeon will go in and sever the entire nerve. They will try to spare any amount of the nerve possible, so some may have some vestibular or hearing sense in that ear, but for my patient, 100% of hearing and 100% of the balance sense in this left ear was lost forever.
“How did the hospital rehab go, in your opinion?” I wanted to gauge his readiness for further challenge.
“I won’t let this keep me down. I want to drive. I want to work. I’ll do what I have to do.” He answered without a pause. In my professional opinion, he did sound pretty dang ready to me.
“How were the first few days?” I wondered. When the brain initially loses such a profound quantity of information, that period will be the most challenging, by far.
“Oh, the roof was a wall, the wall was the floor… I couldn’t even sit upright. I couldn’t balance, but the dizziness was under control since they had me on a lot of drugs.” He explained in his monotone voice. Though he never expressed much facially or vocally, the cadence of his words let me into his mind a tiny bit, and I could sense a certain satisfaction with his recovery thus far.
“Makes sense, and our time together should be nothing compared to those first few days.” I explained, giving a big thumbs up.
“Oh, that reminds me, am I still supposed to keep taking those drugs for the dizziness?”
“Nope! At this point, it will actually delay your improvement. You need to feel the dizziness to get past the dizziness and feel imbalance to regain balance. Masking it will prevent your brain from learning how to improve.”
“Oh, good. I’m sick of those anyways. They make me sleepy. Perfect.” He gave a single, determined nod.
“Yeah, anti-dizzy meds have their time and place, but I’m happy to get people away from those side effects.”
We ran through our tests and found polarized results. The instant that this man’s eyes closed, it was like turning on a wind tunnel. His body swayed on a boat deck in the middle of a storm. With an unmoving head, his walking was normal, but upon turning his head leftward, all bets were off. Finally, lying down on his left side would leave him nauseated and wiggling, but not spinning.
“Alright, so I have few more things I want to check, but what’s the number one task on your agenda?” I prepared to jot down his answer.
“Gotta drive before I can start working again. I can’t do any work from home.”
“We better conquer that, then!”
His first piece of homework tasked him to walk forward at a casual pace and slowly (very slowly, in fact) turn his head far right and far left, in constant motion. Too hard? Slow the head down. Too easy? Speed the head up.
“For now, I don’t care about foot speed.” I said, standing just behind him with my hand on his gait belt, and my head positioned to his right for the sake of his hearing. “Just find a head speed that’s tolerable, but a challenge.”
“Let’s do it.” He said plainly.
It was rough at first, but that’s expected. Movements were necessarily slow, cautious, and gentle, and even then, the dizziness was significant. At times, I had to tug on that gait belt with two hands, or else he would have said hello to the floor. This isn’t like tripping… he simply couldn’t tell that he was losing balance until it was far too late.
The second homework task was to lie down on one side for thirty seconds, sit up tall for thirty seconds, then lie down on the other side for thirty seconds. Repeat, repeat, repeat for five minutes. Sitting and right sidelying were fine positions. Left sidelying was an amusement park ride. Simply put, his brain did not know what position he was in. How would it? How would a television display an image once it’s been unplugged?
I make it a huge priority to leave a patient with hope on their first day of treatment, and to this day, I use the story of this specific man as my go-to for what is achievable with vestibular rehabilitation therapy. This first day is always included in my retelling.
“Welcome back! How’s the last week-and-a-half been?” I asked as we sat down.
“It’s been challenging, I would say.” He answered flatly.
“Oh? How’s that homework been treating you?” He mulled it over for a moment as I prepared my note.
“The sheet said to do the homework twice a day. But you said it’s a hard thing to overdo it with this diagnosis, right?” The patient asked.
I raised my eyebrows, intrigued and excited to hear the follow-up.
“That’s true. As long as it’s tolerable, it’s not a bad thing to do more, though you might get to a point of diminishing return.” I explained. “How… how often did you do it?”
“Not the same amount each day, but I would say that I worked through the sheet at least three times most days.”
“That’s great! And how did they feel?” I tried to maintain enough enthusiasm for both of us.
“Pretty bad. Well, at first it was pretty bad. It got easier. Not as dizzy, so I sped it up more as I went.”
As with many patients, I first took him through the homework routine to witness any progress. Turning the head left and right while walking? Rather than the patient staggering, I was staggered by the pace that he was moving his head. If his neck moved any faster, it would be reasonable to describe it as chaotic.
“Wow. I guess you worked at it pretty hard, then! Well, how about up and down this time?”
“Oh, I haven’t worked that one. That wasn’t on the homework.” He questioned.
“No, you’re right. This’ll be a brand new one.”
Despite what he had just accomplished, the vertical version was teetering and unstable again, though not quite as extreme.
“Dang, I thought I was doing better than that.” It was almost helpful that he did not have a tone of dejection. In another person’s voice, it may have been demotivating for me to hear negativity in that moment, but I knew this man could have victory over this.
“There is specificity in all this. The more variety in the movements we practice, the more effectively we’ll be ready for anything. You practiced horizontal head movements, so you’re better at those. Now, we’ll do vertical!”
Whether it would be expressed or not, I did wonder if he found it frustrating to practice. However, he continued onward, tilting his head far up and far down. He may have stumbled but did not stop. For homework, however, I decided to take it even
further. Considering that this man would likely master any exercise in just a few days, I schemed to give him a challenge that could keep the entire week busy.
“Alright, now, look where the ceiling and the wall meet, then the opposite where the wall and the floor meet.” I pointed dramatically. “And not just ‘look,’ but point your nose at it so your whole head moves diagonally.”
“I’ll give it a shot.” He nodded. He began and the imbalance was plain to see, and the challenge was set. “Holy crap. Seriously? Wow.” He commented with a bit of a chuckle, for once. I grinned from ear to ear.
“You got this. These silly diagonals will be nothing soon.”
From this moment onward, I knew that this case was going to be a blitz. The big question here was to what level did this patient seek to reach.
“Can I get back on my kayak?” He asked at the onset of our third visit.
“Kayak? What are we talking? Lakes, rivers?”
“White-water rapids. I haven’t done it in a little while because of all this, but seeing how it’s going so far, I’ve been wondering if that would be possible.” The patient explained, subtly popping with excitement.
“Oh! So, you’re going to need to do rollovers and twists, right?” I asked, realizing the sheer scope of the challenge for a fifty-eight-year-old man with one ear lost to accomplish.
“Yeah, that’s the thing I’ve been thinking about. Is that possible to get back to?”
“I don’t see why not! Especially in this early phase, let’s keep this progress going!” I encouraged with my tone probably being a bit over-the-top.
For the following few weeks, I provided challenge after challenge, and this one-eared kayaker performed them often and performed them aggressively. He didn’t mind such disorientation if it was for a good step forward. I did some research on kayaking in my free time before future visits.
I created multiplanar head movements exercises, such as walking while rotating his head in a large circle, faster and faster. I made him flip from lying on his right side to his left side and back rapidly, forcing him to cross his arms so that he could only use his abdominals. The goal was to perform a full roll, 360 degrees, underwater, as there is a special level of kayak rolling with one’s hands tucked into their armpits, called a “tallit paarlatsillugit timaannarmik” which is a term that I outright refuse to try to pronounce (feel free to give it a shot).
To be honest, I sometimes struggled to keep up with Kayaker’s improvement. I had to come up with challenges on the fly because my standard progression would sometimes already be beneath him. Prior to this neuroma resection surgery, he was used to heading to his work office up to six days per week, so his cabin fever was getting hotter. Kayaker was now driving again and recounted to me how free he felt. He no longer needed to be dropped off by family members, but on one visit, he had company again.
“Hello, nice to meet you, you must be this kayaker’s wife!” I greeted a woman sitting in the lobby next to Kayaker.
“It’s great to meet you, ‘Doc,’ as my husband calls you.” She giggled. “I wanted to see some of this action in person! I hope you don’t mind! I can always go run an errand instead.” She said, bubbly in voice and mannerisms.
“Of course, you can come back!” I waved the two of them back to the PT area. “Life can be busy, but I always appreciate family members getting involved.”
As we walked, Kayaker explained, “we’re meeting some friends near the clinic after this, so it worked out well schedule-wise.”
“The more, the merrier!” I instantly enjoyed the difference in energy levels between these two.
Once Kayaker and I sat in our chairs, his wife ran straight up to me and whipped out her phone.
“Oh, I gotta show you something first. He doesn’t want me to show you, but I think you need to see this!” She bounced up and down.
“You don’t need to show him, honey.” Kayaker commented as he slightly darted his eyes away. “She really wanted to record me, but I didn’t know that she was filming.”
“Oh, he’s so silly, watch this, I’m so proud of him!”
On her phone, what unfolded before me was a video shot through the blinds of a kitchen window, peering into the backyard. On the east side of the backyard was a sizeable pool, and in its center was a familiar man sitting atop a dark red kayak, donned in a helmet, and wielding some trusted paddles as his weapon of choice. He took some energetic breaths, bouncing slightly as he did. Suddenly, he whipped over towards his right side, dunked his head, and continued the movement beneath the surface. Just a moment later, popped out from the left side, nailing and freezing at a perfectly vertical orientation, still breathing rhythmically as he reached his peak.
Moves like these are vital when kayaking on rapids, as a sudden tilting over is far too challenging to simply resist. Instead, you accept the momentum and add to it, therefore spinning completely around once again. And in this moment, you can’t see, as your eyes are closed, you have no solid surfaces to feel as you really don’t want to feel ground underwater, and this man had only one ear to sense all that head movement.
“No way…” I said aghast.
“Exactly! He did it! He’s so cool.” She exclaimed, giving a big wink to her husband.
“Alright, that’s enough…” He murmured with the smallest hint of a smile, resting between flattery and embarrassment. With his tan complexion it was hard to identify, but I like to imagine that he was blushing.
“I must say, this has been quite an impressive journey. Not a lot of fifty-eight-year-olds can bounce back from a complete loss of one ear, only to flip 360 on a kayak
within a matter of months. I’m in my twenties, pretty athletic, and have both my ears. I definitely can’t do that…” I admitted. “You’ve really turned this around!”
“Literally!” Kayaker’s wife chimed in.
“Good one!” I laughed. Kayaker nodded silently.
“Well, I definitely notice that it’s easier to flip to the right than to the left, but I’ll keep working on it.”
“Oh, I have no doubt about that.”
I retested the One-Eared Kayaker on all our first-day metrics. I can honestly say that this was a formality. However, one reason that I retest patients is to give them tangible awareness of their own gains and/or any lingering deficits. With his charming wife cheering him on, this man no longer had difficulty with any challenges that I gave him. I discharged Kayaker without hesitation as his goals for therapy were met.
This is one of my favorite stories to share with patients on their first days. The second most common diagnosis that I treat is a unilateral vestibular hypofunction secondary to vestibular neuritis. While an infection to the nerve can cause asymmetry between the ears, the amount can range anywhere from 20% to rarely seeing a complete loss.
What could give more assurance than hearing that a middle-aged man with an unquestionable 100% loss journey from relearning to walk all the way to kayaking white-water rapids within three or so months? And to emphasize, the patient’s ear did not change in the slightest with my treatment: I didn’t duct tape his nerve back together. Instead, vestibular rehab challenged his brain to compensate for the loss. Hard work and good science smashed together.
This patient advanced himself to a frankly comical level and I am blessed to have seen it happen. So, no matter the vestibular loss in one ear, there is always potential to improve. Not every patient desires to reach these heights but hitting the goals that we set is the point of all this. Should you be dealing with symptoms, limitations, or fear,
just know that there is potential for incredible gain. It may take equally incredible work, but it is inevitable with time and consistent challenge.
Goals are always relative, though, such as the next tale, as rather than extreme sports, a set of stairs could spell life or death.
