Transcript

Dr. Ayla Wolf  00:01

Ayla, welcome to life after impact, the concussion recovery Podcast. I'm Dr Ayla Wolf, and I will be hosting today's episode where we help you navigate the often confusing, frustrating and overwhelming journey of concussion and brain injury recovery. This podcast is your go to resource for actionable information, whether you're dealing with a recent concussion, struggling with post concussion syndrome, or just feeling stuck in your healing process. In each episode, we dive deep into the symptoms, testing, treatments and neurological insights that can help you move forward with clarity and confidence. We bring you leading experts in the world of brain health, functional neurology and rehabilitation to share their wisdom and strategies. So if you're feeling lost, hopeless or like no one understands what you're going through, know that you are not alone. This podcast can be your guide and partner in recovery, helping you build a better life after impact. All right. Sophia, how are you doing today?

Sophia Bouwens  01:03

I'm doing really well. Ayla, how are you today?

Dr. Ayla Wolf  01:08

I am good. It's super hot and humid out. So I'm happy to be recording this podcast in a nice, air conditioned room.

Sophia Bouwens  01:15

You know? What's interesting is this time of the year in Chinese medicine is like such a rising energy, heat, and we're in this transition into like dampness. And it's interesting, because in my experience at the neuroscience center, and even in my own life, I've been noticing a lot of people are getting more dizzy. For our

Dr. Ayla Wolf  01:39

listeners who don't know what dampness means, maybe you could explain what that term means in Chinese medicine, and then how that might translate to an increase in dizziness.

Sophia Bouwens  01:54

So that's a great lead. So dampness in Chinese medicine is like the stickiness, you know, when it's humid or hot and heavy and like, kind of damp outside, or there's kind of this, like griminess, sensation of it's not everything's not super clear. It's both like a feeling and also a physiological condition, right? So it can lead to more phlegm, it can lead to more digestive disruption. It can lead to more like sticky skin conditions, and it can also lead to this feeling of like fogginess or brain fog. And this condition of just not clear thinking can disrupt our ability to sense the world around us and lead to the sense of like imbalance or dizziness, and

Dr. Ayla Wolf  02:42

people are also eating way more ice cream, which is super phlegm and damp forming.

Sophia Bouwens  02:49

Yes, exactly. So the one

Dr. Ayla Wolf  02:52

of the ways that I look at dampness, this concept of dampness, from a Chinese medicine perspective, is a stagnation within the lymphatic system, and that can also create a sense of heaviness and swelling and edema. But within the inner ear we also have endolymph, so we have a very special kind of lymph in the inner ear, and the viscosity of that is different from other lymph in the body. And so when we think about dampness causing dizziness, it can also mean that the endolymph itself is actually congested and that the body isn't producing enough new, clear, healthy endolymph, almost like the blood can become thick, the endolymph can become thick, and so that can also cause things like dizziness or vertigo or disequilibrium, and all these type of inner ear disorders.

Sophia Bouwens  03:54

Fascinating. Do you think hydration would affect that? I

Dr. Ayla Wolf  03:58

think that the electrolyte balance is important, or just the amount of electrolytes, but also, if you think about this idea that the endolymph is unique, and it's in one part of the body, our body is supposed to have the wisdom to be able to have the right concentration of different electrolytes in different parts of the body. And so obviously, when people have underlying health issues or even, again, like a head trauma that affects the ear or the structures around the ear, that's where you can actually get some of this congestion that happens in that particular part of the body, which makes people more susceptible to things like dizziness.

Sophia Bouwens  04:41

Well, let's dive in. So today we're going to talk about BPPV. BPPV

Dr. Ayla Wolf  04:47

is Benign Paroxysmal Positional Vertigo, which is such a mouthful that people tend to abbreviate it as BPPV. You.

Sophia Bouwens  05:00

There's a lot of interesting terminology in this discussion as we go the words, not not only the name is complex, but the words that describe the mechanisms and these weird organs that are in between our ears and have so much effect on our sense of balance in space in the world, they have the strangest names we're not used to hearing. So it's fitting that the title of the condition is kind of complex, but we're going to also work to be making it really, really straightforward and understand some of these more complex words that we use to describe this condition,

Dr. Ayla Wolf  05:36

for sure. And I feel like people that come into my office fall into two camps. The first camp is when I say BPPV, they give me a blank look, and they've never heard that term or that abbreviation before ever. And then the other camp is people who have kind of associated all vertigo as BPPV. And then I have to explain that while BPPV is often the most common kind of cause of vertigo, not all Vertigo is BPPV. So those are kind of the two camps of people that I feel like I see, and I figured I'd just like throw that out there that, you know, it's important, it's important to recognize that this is one source or one cause of vertigo, but it's not the only it's not the only cause,

Sophia Bouwens  06:28

no, and that's really important because oftentimes describing this sensation is really important for the correct diagnosis, or even for people to go down the trail of looking for The correct diagnosis. So there's a lot of people confuse dizziness and vertigo. Can you describe or define what each of those are and how they might feel or be described differently by patients?

Dr. Ayla Wolf  06:53

Yeah, so Vertigo is a bit more straightforward, I think, to different or to define because vertigo true. Vertigo is a sense of rotation or spinning. And so people will either feel like the world is spinning around them, or they feel like they are spinning. And so that is what we would consider to be a true vertigo sensation, whereas dizziness is more of a vague sensation of being disconnected from your environment. You know, some people will describe it as being like they'll feel oftentimes when you're dizzy, you are also off balance, right? So people can be like, Well, I feel off balance. Or maybe people will say, I feel a little lightheaded. But often it's like this, the sense of in a like disorientation, where you're just all of a sudden not feeling normal in your own body because of the dizziness.

Sophia Bouwens  07:55

And one marked thing I noticed, and I don't think you can correct me if I'm wrong, because you know so much more about this topic than I do. I have had vertigo twice, and the second time I had this like, extreme feeling of being, like, pulled to the ground. It felt like I was in like a tilt, a whirl, and just like being propelled over, and I couldn't, it was kind of awful, kind of terrible.

Speaker 1  08:24

And I was like, Oh my gosh, that that is definitely vertigo of some kind.

Sophia Bouwens  08:31

You got tested and got this, you know, everything was treated well and that, thank goodness I knew I had the tools to have that done quickly. But I think that this, like strong pulling sensation or forceful sensation happens sometimes. Does it always happen in vertigo?

Dr. Ayla Wolf  08:50

So vertigo can change directions, or, you know, it can be directional in nature, but sometimes the direction of the vertigo, it's not always just like, Oh, I feel like the world is spinning to the right, or the world is spinning to the left. Some people will say, you know, they'll say, I feel like I'm like, doing a backflip, where I'm like, going back into the left, or I feel like I'm falling forward into the right. And so people can have all of these diagonal directionalities to their sense of vertigo, which might also feel like you're like being pulled to the floor. But then when there is vertigo, there can also be an otolithic component, where, if there's just hyperactivity happening within the otolithic organs, that can also cause a sense of being, feeling like you're being pulled to the ground, okay, and so sometimes, you know, which, when we talk about vertigo, this is where, like you mentioned, there's all this like neuroanatomy that we have to get into. But the thing that causes the. Spinning is dysfunction within the semicircular canals. So those are part of the vestibular system in the inner ear, and then another part of the vestibular system are the otolithic organs. And so I think it's important to recognize like these are special organs that we have in the inner ear, and they have lots of sensory receptors that are picking up every single time our bodies are moving forwards, backwards, side to side, or up and down. So you can imagine that if one of these sensors, the one that's telling your brain that we're moving down, if that's firing too much, you're literally going to feel like you're being pulled to the floor.

Sophia Bouwens  10:46

Yep, and that was awful. That's what was happening. So there's these, it was. There's these otolithic organs, but there's also these semicircular canals. And can you describe for listeners that can know what those what those are, what those look like, or how they translate information to us.

Dr. Ayla Wolf  11:07

Yeah. So if we are going to talk about this in terms of shapes, we could say that in the inner ear, we have this thing called the vestibule, and we can picture the vestibule as a box, and then inside that box we have the otolithic organs, our two otoliths. And then on the outside of the box we've got half circles, which represent the three semicircular canals. And so on the right ear we have three semicircular canals. And on the left ear, we have three semicircular canals, so we've got six in total. And so those canals, every time our head is turning in a certain direction, they're picking up on that direction, and they're sending that information to the brain. And the best analogy that I like is to imagine if you had a bowl with a marble in it. Every time you tipped the bowl, the marble would roll right. And so all of these semicircular canals, the three on the right and the three on the left, they're all working together to tell the brain exactly how the head is tipping and tilting and turning every time you move your head. And so it's like, if that bowl was just one big, giant sensor, it would be telling the brain exactly where the marble

Sophia Bouwens  12:34

is. Yeah, I like that. And these canals, they work together to provide information to the brain, kind of where and how our head is turning. Is that right?

Dr. Ayla Wolf  12:44

Yeah. And so the problem is, when there's too much activity happening in a canal, it tells the brain that the head is turning in like more, more than it actually is, or if somebody is perfectly still and that canal is firing, then it's telling the brain that there's that movement is happening when it's not happening.

Sophia Bouwens  13:08

Am I killing the symptoms, like vertigo? Exactly. Okay, so this is complex, and there's all these like mismatch features of things, but I think that gets really interesting and important when we're looking at really how do we treat this? How do we diagnose it? How do we assess it? How we figure out what's going on so we can help correct it? What would you say is some of the hallmarks of BPPV versus just regular dizziness?

Dr. Ayla Wolf  13:40

I think it's important to point out that when people have BP, BV, they can have a pretty long list of symptoms, and so some people like the most common symptom, like people will have vertigo. Other people might actually just feel dizzy, other people could have disequilibrium. Some people can have headaches and nausea and neck tension. So there's a whole long list of possible symptoms that people could experience. But I think that what there's a couple of like differentiating features that are helpful in terms of identifying BPPV, and one of them is that when you have a canal lithiasis, and this is, again, another fancy term, it's a type of BPPV saying that there are, there are calcium crystals that have fallen into the canal that are causing the excessive activity that is Now tricking your brain into thinking that there's movement happening. And so typically, a classic presentation of BPPV is that somebody tips their head into a specific position and all of a sudden they get vertigo. But then as soon as they get out of that position, it calls. Comes back down, so it's not constantly, there all the time. And the thing that my patients often will tell me is when I lay back to go to bed at night, I'll have an episode of vertigo, or when I sit up in the morning, I'll have an episode of vertigo, or when I tilt my head back in the shower to shampoo my hair, all of a sudden I get vertigo, and so people can often identify the position that their head goes into. That then triggers the symptom.

Sophia Bouwens  15:33

And does that help you figure out how to treat it or like does that give you information which position it is or how the angle that they have to turn to. Does that make a difference?

Dr. Ayla Wolf  15:44

So that's often the symptom that clues me in to say, Ooh, that that sounds like BPPV, right? But the absolute best way to really diagnose BPPV is to have the patient put infrared goggles on so that the clinician can actually see their eyes, and then the patient is going to be tilted into certain positions that bias one of the semicircular canals. And if Nystagmus is observed in the eyes that then what's nystagmus? So Nystagmus is a very specific type of eye movement where the eyes are slowly drifting one direction and then they're rapidly correcting back in the opposite direction. The thing that we have to appreciate is the fact that our vestibular system these semicircular canals, they are hardwired into the nuclei that then control the six eye muscles. And so when a canal is over firing, it's going to cause the eyes to move in a very specific direction. So for example, if the left posterior canal is over firing, the eyes are going to be pushed down into the right, and then they're going to correct back up into the left. And there's also going to be a torsional aspect to this as well, meaning the eyes are going to roll, and so you're going to see a nystagmus that is in a very specific direction. And there might also be a torsional component to it, whereas if you have a high firing left horizontal canal, the eyes are going to be pushed to the right and then have a fast correction back to the left, but there's not going to be a torsional component to the eye movement. And so this can all be seen on camera when the patient has these infrared goggles on. And there was a study that I thought was really important, because the study said that if you are only relying on just tilting somebody's head in different positions to see if it triggers dizziness or vertigo, and you're not using infrared goggles, and you're not actually seeing nystagmus, that you're gonna get your diagnosis wrong 50% of the time, basically,

Sophia Bouwens  18:11

wow, that's not good. So you don't just go based on like, what they're feeling. You have to this eye movement component is really important for this diagnosis to be accurate. Is that what I'm hearing you say,

Dr. Ayla Wolf  18:25

yep, that's exactly it. So being able to observe the Nystagmus is really key if we want to have an accurate diagnosis. And then, to add even more complexity, sometimes these calcium crystals that you know, we think are, in some cases, causing the BPPV. There's, there's against, there's very smart people who still aren't quite sure if this calcium crystal theory is like the end all be, all of all causes of BPPV. But to make matters more complex, these calcium crystals, they can adhere to the wall of the canal. And so if they've adhered to the wall of the canal, you might not see the nystagmus during your testing. And so one of the things that can help is to just take a tuning fork and place it on the mastoid, which causes a really gentle vibration, but it can shake those crystals loose off of the canal wall. And so then if there really, truly are free floating crystals in the canal that's causing the vertigo, well now you've kind of loosened them up so that a, you can get an accurate diagnosis, and then B, the head repositioning maneuvers are probably going to be more effective, because you've actually gotten the crystals to shake loose, and then they can more freely fall back into the vestibule where they belong.

Sophia Bouwens  19:51

So complex. So I know that we've already doven into this topic so much, but I want to just backtrack for a second, because I want to be clear on how some. Might describe dizziness or a feeling of imbalance in a way that might tune you in to think it might be BPPV versus other types of dizziness. You

Dr. Ayla Wolf  20:10

don't want to diagnose BPPV based on somebody's symptoms. However, when someone describes vertigo that comes on suddenly and usually calms back down within about 30 seconds to a minute, and seems to be responsive to an adjustment of position. That's always my kind of cue to say this sounds like BPPV

Sophia Bouwens  20:37

versus another type of dizziness, because there are other drivers of dizziness or vertigo, BPPV is just the most common. Is that? Right?

Dr. Ayla Wolf  20:46

Yeah. I mean, there's a million causes of dizziness. That's a whole nother conversation. When people say they're dizzy, that could mean anything that definitely needs a lot more diagnostic workup.

Sophia Bouwens  20:59

Absolutely. So with BPPV, we see this change in head position affects the dizziness. And it's not kind of constant all the time. It's definitely positional. And there are these eye movement components that are present to help us understand what is kind of going on and how we might assess or treat it. And then you talked about this, like crystal component of these crystals are floating around in these canals that are providing feedback into our system. But some schools of thought and some really intelligent people challenge this crystal theory. That's really interesting to me, because for as long as I've learned about BPPV or this vestibular component. It's always this like dynamic between these little sillier hair on the inside of these canals and these crystals floating around. Can you talk more about this idea that maybe that's not the end all be all, maybe there's different types, or maybe there's other things driving this.

Dr. Ayla Wolf  21:57

I think a lot of it is observation, because once you start seeing lots and lots of patients that have vertigo, you start to feel like not everybody falls into a textbook cat, you know, category of BPPV. And that's the thing is, it's like we, you know, we all go to school, we learn these textbook presentations, and then we get out into the real world, and all these people come in and they are they don't fit the textbook right, and not textbook

Sophia Bouwens  22:29

Right, right? A little bit that, no,

Dr. Ayla Wolf  22:33

yeah. And so I think that when you've got a lot of practitioners who see people that always that that maybe don't fit into these textbook descriptions of BPPV, they start to think like, Well, what else is going on? And it also seems like, if you if you go on the internet, there's, you know, there's a new vestibular repositioning technique that shows up, you know, every year. And so now we have all these different repositioning maneuvers, and it's like, okay, well, are is, are they actually dealing with calcium crystals, or are these repositioning maneuvers somehow maybe recalibrating the vestibular system in a way that is actually helping the patient to not be so dizzy or have vertigo. And so I think that when, when very intelligent people are saying, I'm not sure this calcium crystal theory is, is the end all be, all of explaining every single case of BPPV, I think this is where they're coming from.

Sophia Bouwens  23:36

And I wonder, too, if this challenge comes from, like a reoccurrence of BPPV. Like, if it's just these crystals that get dislodged, a what causes them to be dislodged? And what about when those crystals get put back into place? And that continues to be an issue for some patients and not for others.

Dr. Ayla Wolf  23:54

When people do get BPPV, some people end up in the camp where they then start to get it. I don't necessarily It doesn't always have to be frequently, but some patients will say, Oh my gosh, I get it every three months. Some people will say, I get it once a year. Some people will say, I had it years ago and now I have it again. So can reoccur at very different frequencies for different people. But there, I think, has been more interest in trying to understand why does this keep coming back and so we can break it up into kind of a couple different categories. So what they have found is that some people have nutrient deficiencies that can contribute to it. So simple things like a vitamin D deficiency seems to cause reoccurring BPPV. So for some people, it's as simple as, hey, you need to, you need to get your vitamin D status back up to, you know, a healthy level

Sophia Bouwens  24:53

vitamin D is considered like a young atonic or a young vitamin in Chinese medicine. And. Yang helps transform phlegm, or this dampness comes from the sunshine, which helps dry dampness. So if we're thinking of this through the Chinese medicine lens, that's for me, that's where my head goes, like, oh, yeah, this like Yang thing that, like, really helps clear dampness and dry up and clear phlegm. I love Chinese medicine. How it ties into these wisdom. Sometimes, when you see the dots, we can't help but connect them. So vitamin D deficiency can be a contributing factor to reoccurring bppd.

Dr. Ayla Wolf  25:30

Yeah, and I think that's hilarious, that you were able to bring this full circle from when we started talking about dampness to then talking about vitamin D and sunlight drying dampness. So there

Sophia Bouwens  25:41

you go. Are there other things that that mean, not just vitamin D, though, right? There's, like, a lot more,

Dr. Ayla Wolf  25:47

yeah. So I mean, as far as the nutrients, calcium and magnesium, deficiencies can be problematic as well as B vitamin deficiencies. So there's research to show that B vitamin deficiencies can contribute to reoccurring BPPV so those are kind of the big ones as far as nutrients go. And then when people have thyroid dysfunction or parathyroid disorders that can affect calcium metabolism. And so whenever you're throwing off calcium metabolism, obviously those are the people that then also might be dealing with osteoporosis or osteopenia. And so those particular individuals can have reoccurring BPPV.

Sophia Bouwens  26:30

They're more prone to it. And what stands out to me about all those things, those nutrients, calcium, magnesium, B vitamins, is they're really important for nerve function and maintaining that cellular balance. This system is really sensitive to those even small disruptions in the cellular functioning.

Dr. Ayla Wolf  26:51

Yeah, absolutely. And then, I don't know if you saw this, but during covid, especially when the Omicron variant was going around, lots of my patients were coming in with vestibular disorders and with reoccurring BPPV and so infections and anything affecting the inner ear can definitely cause that. And I think one of the most frustrating thing for those patients is that they were all saying the exact same thing, which was, I went to my ENT, they looked in my ears, they told me I was fine, and they sent me home, and they're like but I am still dizzy, and I have vertigo, and I can't walk straight, and I have all these vestibular symptoms. And so in that case, I think again, when you're talking about the inner ear, it is very sensitive to infections. It's very sensitive to inflammation. And as we mentioned before, that idea that if the endolymph is getting congested and it's throwing off the viscosity of the endolymph, all of that can cause vestibular symptoms.

Sophia Bouwens  27:58

It's amazing that we don't all have a lot more vestibular symptoms,

Dr. Ayla Wolf  28:02

yeah, and a lot of this stuff with the reoccurring BPPV, it requires, again, more like investigative lab work, to try to figure out, does somebody have a nutrient deficiency? Do they maybe have a thyroid disorder? Because autoimmune thyroid issues Hashimotos is very common, and autoimmune disorders are on the rise. And especially as people age, it actually becomes more common. And so again, I think in in elderly individuals, a lot of times, doctors aren't they're not searching for an autoimmune disorder. They're not looking for, you know, they're not immediately thinking, let's test the thyroid for Hashimotos with this person who's in their 60s, for example.

Sophia Bouwens  28:46

Do you see this being sensitive to blood sugar regulation or people with diabetes?

Dr. Ayla Wolf  28:51

Absolutely. So that can be another source of why people might have reoccurring BPPV because when people have diabetes and unmanaged high blood sugar that actually causes nerve damage, and in some cases, that causes nerve damage to the inner ear. And so that can be a problem. And then there's also antibiotics that are actually ototoxic, so they're toxic to the inner ear and can cause inner ear damage. And so it's important to recognize for, I think, for people, if they've already dealt with BPPV, to be very careful about antibiotic use and which ones they need to avoid.

Sophia Bouwens  29:32

That's super fascinating, that even things like antibiotics, which could be treated, used to treat things like ear infections or strep or other infections are can have this risk of being ototoxic. Do you know which antibiotics in particular present this highest risk for this ototoxicity?

Dr. Ayla Wolf  29:54

Yeah, they say definitely when people have intravenous antibiotics in certain. Gasses that I think that becomes like one of the higher risk factors. So the aminoglycosides are one example. Streptomycin is is one of those. And then vancomycin has a higher risk. And the macrolides, the that category of antibiotics, which include azithromycin and erythromycin, all are known. I think that's important for people that do have kind of a background in Vestibular Disorders, if they're ever given an antibiotic, I think it would be important they talk to their doctor and read the potential side effects to make sure that they might not be taking something that's ototoxic if they already have different vestibular issues going on. So that's an important thing to keep in mind, all

Sophia Bouwens  30:48

these things we haven't really thought about, but can make such a difference for this really sensitive apparatus.

Dr. Ayla Wolf  30:54

Yeah, even different issues with hormones. So I have a friend who I work out with at the gym, and she was having BPPV, and basically finally figured out that it was hormonal. And so it was happening like at a very specific time in her cycle every month, and once she dealt with her hormonal imbalances, then the vertigo went away.

Sophia Bouwens  31:16

So for women who are menstruating, it could be like that. This comes on a certain time of the month when that gets higher. What about do you see this happening more or less in like menopausal, perimenopausal women, for

Dr. Ayla Wolf  31:28

sure, like with menopause, those hormone changes can affect the diff, you know, the difference between estrogen playing a role in our bone density and our calcium metabolism. So as estrogen levels fall, then all of a sudden, that gets thrown out of balance. So that can also be a trigger.

Sophia Bouwens  31:47

Fascinating, so much. Well, this is an interesting topic, and I think we scratched the surface of it. I think a follow up episode we should do is, like, the complexities of like the visual system, how it plays into this vestibular system, and maybe how things like proprioception or joint position can play into this too. In your book, you do such a nice job of breaking down all these things in relation to BPPV.

Dr. Ayla Wolf  32:10

Oh, well. Thank you so much, and we'll definitely have to do another deep dive into the world of vestibular symptoms here soon. And for you listening, we'd love to hear what specific topics you want to hear more about, and you can do that by clicking the Send us a text link that's at the top of the show notes. I also want to mention there are now video clips from previous episodes on the life after impact YouTube channel, which you can find by searching for at life after impact medical disclaimer, this video or podcast is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice. No doctor patient relationship is formed. The use of this information and materials included is at the user's own risk. The content of this video or podcast is not intended to be a substitute for medical advice diagnosis or treatment, and consumers of this information should seek the advice of a medical professional for any and all health related issues. A link to our full medical disclaimer is available in the notes you.