Q & A with Susan Whitney, Ph.D about Vertigo

Susan Whitney, Ph.D., a physical therapist at UPMC Department of Otolarynogology in Pittsburgh, Penn., talks about using a virtual grocery store to treat chronic dizziness.

How common is it for someone to have a chronic problem with dizziness?

Dr. Susan Whitney: Dizziness is the most common cause for seeing a primary care physician over the age of 65. Dizziness is extremely prevalent. A lot of people become dizzy and they become better on their own. We see the people who don’t get better on their own.

In patients who have chronic dizziness that won’t get better on its own, what kind of quality of life issues do they have?

Dr. Whitney: A lot of them will become dizzy when they go into malls or stores. Social situations where large groups of people are there are very stressful to people who are really dizzy. Sometimes walking into your house and you have a vibrant carpet can make you feel sick. Places like casinos are horrible because of their carpets and all the noise. It’s not just the dizziness from the visual scene, but it’s also noises and moving around a person that can sometimes make people extremely dizzy.

Are there physiological causes for dizziness?

Dr. Whitney: The symptoms that we’re treating here in the virtual environment are specific to something that we call visual vertigo, and those people are a small subset of all the people who are dizzy. There are a lot of people who are dizzy or have vestibular disorders that don’t have difficulty in grocery stores, so it’s that small group that we think doesn’t get better without an intervention like this that we’re trying to treat.

What is it about a setting like a grocery store that causes the dizziness?

Dr. Whitney: We think it’s the optic flow. If you can imagine standing at a bus stop or in your car and all of a sudden, the truck moves next to you and you push on the brake and you think, ‘Oh my gosh, I think I just moved.’ That’s the feeling that I think people with visual vertigo have all the time – they perceive that the world is moving when it isn’t.

Specifically in the grocery store, is there something about the layout of the items that are there that makes the symptoms worse?

Dr. Whitney: We actually asked people who had this problem what was difficult in the store and which aisles were difficult and easier. I took photographs and I said, ‘Put these in order of easy to look at versus difficult,’ and we placed our store placement of objects based on the people’s perception of what was difficult and what was easy. What we heard was just the white products, the paper products, were an easy aisle to go down. I think some of it has to do with the size of the product and that there isn’t a whole lot of contrast because it’s mostly white. In our more difficult aisles, we have canned products and things that are very small, and no matter what, we’ve been right about that, because every patient who’s been in the store says that those aisles at the end are much more difficult than the early aisles.

What do you have a patient do with the virtual store using computer software?

Dr. Whitney: It’s pretty seamless for the patient. They walk in, they sit down, and we make sure that they’re medically stable before they exercise. We talk to them about the stress they’re in before they start, and then we start the intervention. We have them fill out a form to begin with that asks them whether they get any simulator sickness, because virtual environments have been known to make people feel ill. What we want to do is know how they feel at baseline, and then we look again afterwards to see how they feel, to see if there’s any change. There always is a change and usually, they feel a little worse, but over time, what we’re seeing is over the series of the six visits, the people feel better. That’s what our goal is, so we not only do this, but we also give them some home exercises to work on, because this is an intervention for one hour a week.

What is going on in the brain over these six weeks that’s making it a little easier on the patients?

Dr. Whitney: We really don’t know, but to be honest, our guess is that we’re doing something called habituation, which is actually used widely enough and it’s used for people who have tinnitus or the ringing in the ears. It’s also used for people who have trouble with smells that they can’t smell properly. What we do is we expose people to more and more difficult situations in our world, and then in the other worlds, they expose them to more or less sound, etcetera, to try to get people kind of used to it. It’s similar to what some psychotherapists do for anxiety or panic disorder in that you expose somebody to more and more difficult situations, so that’s the analogous kind of situation for what we’re doing here. If you ask any of those interventionists what they’re doing, they’re going to say, ‘We don’t know, but it works,’ and that’s really what we’re doing here.

How does putting the patient right in the middle of what makes them dizzy help them?

Dr. Whitney: One of the things that we can do here that’s unique is we can immediately make the situation easier or more difficult, so rather than running out of the store, which is what some people might do, what we can do is we can say, ‘Okay, we’re going to stop now,’ and I can immediately stop it and I can say, ‘Okay, well, let’s go back to aisle one, and let’s see if you can tolerate that,’ so there’s a lot more control that I have here than I would in the real world. In the real world, I would potentially have to have her go past all of these extremely difficult aisles and she might not be able to tolerate that.

What kind of a success rate have you had?

Dr. Whitney: I’d say that we’re probably hitting about 75 percent, which I don’t think is too bad because this is really kind of an open trial because we really don’t know exactly what the best thing to do is. What we’re doing is we’re using my clinical judgment as I actually treat the people. I’m hoping that as we go back and look and reflect on this information that we’ll be able to set up better interventions in the future.

When you’re standing here talking to the patient, what is your goal?

Dr. Whitney: I’m actually directing them to certain products, and it’s interesting because sometimes they’ll avoid a position of their head and neck. For example, the Cheerios might be in the upper right hand corner and what they may do is never look at those Cheerios in the upper right hand corner. They’ll wait until they’re down and to the right because they can see them there without getting dizzy. What I try and do is get them to move their head and neck into positions that I want their head and neck to be in as they’re actually ambulating through the store.

Is there a need for continued therapy for patients who relapse?

Dr. Whitney: We haven’t had that experience yet. It’s actually fairly unusual for people to have a relapse of a vestibular disorder, thank goodness.

What percentage of the population has this particular disorder where they would be dizzy in grocery stores?

Dr. Whitney: I don’t know. I can tell you that in one particular type of vestibular disorder, benign paroxysmal vertigo, in one recent paper, nine percent of their population actually had it without having a diagnosis, so dizziness is extremely prevalent. What happens is, especially in women, they don’t complain because they’ve complained to their doctor several times and the doctor either says, ‘You’re old, dizziness is normal,’ and dizziness is never normal. It’s never an acceptable response to say that that’s normal because it’s never normal. That’s what happens a lot, especially to women, they get told, ‘Oh, go home and live with it,’ and that’s not a reasonable response. Nobody should ever accept dizziness as normal.

What is the next step with this research?

Dr. Whitney: Our plan is to move it into something that you can do at home with a head-mounted device. They’re the devices that you put over your head and we have a doctoral student who’s planning on doing that. That’s what we’d like to do is maybe fit it up with a Wii or some of the next generation of systems that you can use in your home.

Does dizziness affect more women than men?

Dr. Whitney: Yes, it’s usually 60/40.

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