#WeCanFixThat: The one with diploplia (double vision).

At Redpoint, we pride ourselves in our ability to treat a wide array of diagnoses.  One of the things we see a fair amount of is vertigo, so I thought nothing of it when I saw *Nancy scheduled for an evaluation for this ailment.

The curveball, as I learned during my initial evaluation with her, was that she had already been evaluated by an Ear, Nose, and Throat Specialist and was told she did not have vertigo (or an ear infection, or any obvious problems with her eyes, for that matter).  She was given a clean bill of health by the specialists, despite still having symptoms of dizziness. 

Sure enough, my diagnostic testing for vertigo was negative.  Then, I thought, perhaps it’s related to the cervical-occular reflex which can lead to dizziness if you neck is stuck on one or both sides.  But when I checked out the mobility in her neck, it was normal.  Scratch that off the list!  In fact, Nancy had very little to write home about in her evaluation.  She was, as I told her, the most “normal” 61 year old I have ever evaluated!  The only things I could find “wrong” with her were poor balance, and a little aberration in her eye movement when moving in 1 direction.  I found that during my eye exam on Nancy, I could provoke “unsteadiness” which we took to be double vision, or diploplia, if I took her vision all the way to the right side. 

Without a clear diagnosis, I was working only on instinct.  This actually happens a lot in physical therapy… at least, at Redpoint Physical Therapy.  We might not always know what the problem is, but we find a few things that could be contributing to the problem which, if fixed, might help resolve the patient’s complaint.  This was how Nancy’s case was going.  I suspected that if I worked on all of Nancy’s balance centers, and at the same time, taught her recalibration exercises for her visual-vestibular system, that we might see success.

Balance is a complex function.  Most people are aware of the vestibular system – the complex canals in your inner ear that provide constant feedback to your brain about head movement and positioning.  People are less likely to consider the impact of the visual system on balance, but it makes sense once you try to balance with your eyes closed.  The last major portion of balance is the feedback your brain gets from joints and muscles, called proprioception.  Your tendons (the part of your muscle that attaches to your bone) have a structure called a golgi tendon organ (GTO) which is sensitive to stretch.  When the GTO gets stretched, it activates muscle spindle fibers, leading to contraction of that muscle.  In real life, this is when you’re walking down the street and you step on a rock, causing your ankle to roll to 1 side.  If your GTOs are working properly, you immediately correct your foot position and avoid falling or injuring your ankle.  If you’re a chronic ankle sprainer and your GTOs are stretched out, you end up in a heap on the ground before you realize what happened. 

The good news is, you can improve all portions of your balance system!

Feedback from your vestibular system, visual system, and joint and muscle proprioception are all processed in the cerebellum, which if you remember from an earlier post this year, is a wonderful learning computer.  I got to work with Nancy with exercises that considered all 3 portions of her balance.  She was prescribed exercises for her eyes to do at home to improve the visual-vestibular connection.  In the clinic, we challenged her balance by standing on squishy surfaces (which impacts the feedback you get from your feet and helps to fine tune your GTOs), adding head movement (altering feedback from the vestibular system), and performing dynamic movements in different positions to improve balance with daily activities.

After 6 visits, Nancy reported 100% resolution of her double vision and feelings of unsteadiness!  Her balance had significantly improved during the course of treatment and she was able to move her eyes in any direction without symptoms.  Cool!

This case is an excellent example of how versatile the field of physical therapy is.  With such a broad understanding of the functions of the human body, we are able to trouble shoot your problems in the same way a good mechanic considers your car.  And – at least at Redpoint – we think it’s fun!

So please remember, even if we can’t fix it, we can always help or point you in the right direction.

But most likely… #WeCanFixThat!

*Patient name and some information have been changed to protect anonymity.