Disclaimer: The views and opinions expressed in this presentation reflect those of the speakers and do not necessarily reflect those of the United States Department of Veterans Affairs.
Neuropathy can be challenging to address, but it’s very common in cancer rehab. And it’s not just chemotherapy-induced peripheral neuropathy (CIPN) either.
In this replay episode, guest Dr. Kayla Gomes, PT, breaks down her treatment approach for patients with neuropathy, no matter the cause. You’ll learn how to start evaluating & treating your patients with neuropathy, plus gain some additional tools for your neuropathy toolbox.
Listen now!
Peripheral neuropathy is a disease of the peripheral nervous system
Simple definition, but this umbrella term encompasses soooo many different types of neuropathies.
Common peripheral neuropathies can include length-dependent sensory-motor neuropathies (like diabetes-related neuropathies), chemical exposure-related neuropathies (hello CIPN), & idiopathic neuropathies.
Evaluating the person with peripheral neuropathy
Dr. Gomes recommends a comprehensive sensory screen, no matter the cause of neuropathy. At bare minimum, you should include monofilament (specifically 5.03 monofilament for protective sensation) & vibration testing.
Additionally, you should be checking foot & ankle strength, followed by functional assessments like single leg balance.
Dr. Gomes also recommends outcome measures like the DGI or FGA, especially when tracking changes that may occur with exposure to neurotoxic chemotherapies or immunotherapies.
Depending on the nerves that are affected, your patient may have different symptoms with their neuropathy. Patients affected by small fiber neuropathy may have more pain, paresthesias, temperature loss, & even autonomic issues.
On the other hand, patients with larger fiber neuropathies may experience painless paresthesias, loss of vibration, proprioception, & potentially even deep tendon reflexes, not to mention decreased strength.
Don’t forget these important evaluation components for peripheral neuropathy:
Balance & falls is absolutely a concern for patients with neuropathy, but they are far from the ONLY issue these patients can face.
Skin issues are especially important to check for & on your patients with neuropathy. Dr. Gomes recommends turning skin checks into an immediate education opportunity to implement DAILY skin checks.
Additionally, patients should be screened for vestibular issues. Ask them about lightheadedness, dizziness, vertigo, hearing loss, or ear ringing.
Red flags still count with neuropathy
In this episode, Dr. Gomes & I shared some patient cases that you’ll definitely want to hear if red flags make you nervous.
But it all comes back to basics. Common neuro red flags include sudden changes in speech, swallowing, vision, bowel/bladder control, numbness or tingling in the face.
Treating your patient with peripheral neuropathy
As with all things in PT, it depends. But here’s some actual helpful tips from Dr. Gomes:
If a person has decent foot/ankle strength, you may be able to strengthen those muscles to improve foot drop. However, some patients may need more compensatory strategies because they may not recover full function.
Balance/stability/vestibular training is massively important from a safety standpoint. Dr. Gomes also recommends using the Rating of Perceived Stability Scale with your patients, especially with your balance/stability interventions.
Products Dr. Gomes discussed:
Further recommended reading:
- Peripheral Vestibular Hypofunction Clinical Practice Guideline
- Effect of Low-Intensity Physical Activity and Moderate- to High-Intensity Physical Exercise During Adjuvant Chemotherapy on Physical Fitness, Fatigue, and Chemotherapy Completion Rates: Results of the PACES Randomized Clinical Trial
- Effects of exercise on cancer patients suffering chemotherapy-induced peripheral neuropathy undergoing treatment: A systematic review
- Effects of Exercise during Chemotherapy on Chemotherapy-Induced Peripheral Neuropathy: A Multicenter, Randomized Controlled Trial
About Dr. Kayla Gomes, PT
Dr. Kayla Gomes, PT, is a Neurologic Clinical Specialist who has gained experience working in multiple settings with varied patient populations; including hospital based outpatient, inpatient rehab, and acute care. She has had the pleasure of working within an interdisciplinary team to successfully publish a manuscript in The Journal of Neurologic Physical Therapy. Her commitment to clinical education includes acting as a Credentialed Clinical Instructor as well as completing a project to address burn out and improve resilience for stakeholders in ClinEd during the COVID 19 Pandemic. She is an active member of the American Physical Therapy Association and was selected as the 2021 Centennial Scholar for the CT Chapter of the APTA. She currently serves as a Delegate representing the CT Chapter at the APTA’s National House of Delegates.
Contact Dr. Gomes at KaylaGomesPT@gmail.com or follow her on Twitter/X @NU_DPT
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Transcript
Elise Cantu (00:20)
my goodness, y’all. First of all, welcome back to this episode of the Onco PT podcast. And if you’ve been following along over the month of December, you know we have been counting down the top episodes of the Onco PT podcast for 2024. We started with number five and today we are finally at number one. And I am so thrilled to share this with you. This interview that I did with Dr. Kayla Gomes, who is a neuro whiz was all about the crossover between
oncology and neuro and neuropathy beyond what we tend to hear about within oncology.
Elise Cantu (00:56)
Now, what I love about this conversation with Dr. Kayla Gomes is not only do we talk about neuropathy, what is it, but most importantly, what do we need to be aware of as OncoPTs as our patients are coming into us, not just with oncology problems, but also with pre-existing neural issues such as neuropathy that may be compounded by the cancer and or the cancer treatments. So again, our patients don’t just live in silos where there are oncology patients only,
They’re humans who have led full human lives with a full human experience and likely have some other issues that are pertinent that we need to be prepared to address, even as OncoPT’s in our little OncoPT bubble. I know that you were going to love this conversation with Dr. Kayla Gomes. Number one, because it was fantastic. But number two, because it was the most popular episode of the OncoPT podcast for 2024, which means…
that a lot of you really loved it already. And some of you even listened to it more than once. Now, I don’t know who it is. Don’t worry, I’m not creeping on you that much, but I do know that this was the most popular episode of 2024. And I cannot wait to share it with you again. Thanks so much for joining me on this countdown and enjoy my conversation with Dr. Kayla Gomes.
Elise – @TheOncoPT (02:14)
If you’re anything like me, your schooling in PT school when it comes to vestibular issues was pretty minimal. For me, in the very last three weeks of my PT school career, we had a special topics kind of pick your own adventure of different optional classes that we could go to. And one of them was actually vestibular. And so I thought, wow, this is really cool. Learned a few things. And then I promptly thought,
this will be something that I’ll look more into in the future and you know, like someday, but I probably won’t need it right away. Well, imagine my surprise when I started having patients in oncology who were having all kinds of vestibular issues. It is way more common than we think, and it tends to fly under a lot of people’s radars. And so I’m so excited to welcome back Dr. Kayla Gomes to talk all about BPPV and what the…
the bridge between vestibular and oncology is, but most importantly, what you can start doing with your patients today who are experiencing these different vestibular issues. So Kayla, welcome back to the Onco PT podcast.
Kayla Gomes (03:22)
Thanks for having me back. It was so much fun the first time I had to come back.
Elise – @TheOncoPT (03:26)
Oh my God, I couldn’t wait to have you back. So it was honestly perfect timing. So I’ve got my phone up because I wanted to read this tweet that you sent out. So beginning of March, you sent out this tweet and it was honestly mind boggling. So in six days, my student and I treated eight patients for BPPV. Only three of them were referred to us for balance vestibular problems. And then at the bottom, screen your patients for
BPPV and then I do like the little correction, darn it at the end, but that’s a different story. So clearly, this is a very common issue in other disciplines, not just within oncology, but like this is kind of a big deal.
Kayla Gomes (04:01)
Yeah.
Oh yes. Yeah, it’s very big in the neuro space and the geriatric space just because of the populations that it affects more often. Mm-hmm.
Elise – @TheOncoPT (04:20)
Mm-hmm. Okay, so rewind. What is BPPV? Right?
Kayla Gomes (04:23)
What is it? Sure. So BPPV stands for the nine paroxysmal positional vertigo and I think the best way to I’m getting snaps. The best way to explain BPPV is to either look at a picture or a model as you’re explaining the system. So I have my model here for people who are watching it.
Elise – @TheOncoPT (04:50)
amazing.
Kayla Gomes (04:51)
There’s also a great picture on physiopedia of the inner ear system. So in your inner ear, you have organs that help with this, um, knowing where you are in space and gaze stabilization. I tell patients, you know, you have these two bumpy organs, your, um, otoliths that have these calcium crystals in them that sit on a bed of gel. So if you’re tilting or if you’re moving forward and backwards, like,
in a car or up and down, like you’re standing up or you’re in an elevator, those crystals move on the gel and tell you where you are in space. What can happen though is those crystals, which are called otoconia, can become displaced from the utricle and end up in these semicircular canals. And those semicircular canals are responsible more for rotation. So if you’re turning your head looking up.
You have three semicircular canals on each side. They are set 90 degrees from each other and how do I describe this? Like your right posterior semicircular canal is opposite your left anterior semicircular canal. So when one is excited, the other one is inhibited, and that’s how your body knows where you are in space and where your gaze stabilization comes from.
So the semicircular canals project to that vestibular ocular reflex. I think people will start getting like bad flashbacks to PT school if you like look up the VOR and like where all the projections go. Something to remember is that it’s not just projecting to or being responsible for the vestibular ocular reflex, there’s also.
vestibulo spinal reflex and the VCR, which deals more with like head writing and balance reactions, right? So BPPV doesn’t just affect, you know, your gaze stabilization or the sense of vertigo, you know, a sense of motion when you’re not actually moving. It also can affect your balance and your sense of where you are in space.
Elise – @TheOncoPT (06:49)
Mm-hmm.
Mm-hmm. It was really interesting. I know I mentioned this kind of off air, too. This was a very special topic. I was like, this is cool. This is interesting. I probably won’t need it. And then imagine my surprise when BPPV did indeed show up in oncology.
Kayla Gomes (07:13)
Yeah. Yep.
happen. Right, right. And like, I think it’s really intimidating for people, because like you said, depending on what school you went to, some people have more vestibular training than others. And I was saying to you, off there, like BPPV can be as complicated as you want it to be. Like the orientation of, you know, where the otoconia is in the canal and where it’s moving is excitatory to one canal or
if it’s moving a different way, it’s inhibitory to another canal. And people start learning that, especially with like the horizontal canal. And it’s like, oh, I can’t do this. I can’t do this. I think what is most helpful is looking at a diagram or if you can, getting a 3D model and just looking at it over and over and over again. And that’ll give you a better idea of like what your eye movements might mean based on which canal is affected.
but it’s very common. It’s very, very common. And that’s why I was screaming from the rooftops about screening.
Elise – @TheOncoPT (08:30)
This is a loaded question, so I’m aware that I’m asking you, like there’s a lot coming. What causes a person to experience BPPV?
Kayla Gomes (08:42)
So most cases are idiopathic or spontaneous. There are risk factors that make you more likely to have BPPV. The biggest thing is age. You’re more likely to get BPPV the older you are. And that’s also the case with other vestibular disorders, just with how the inner ear changes as we get older. There’s also secondary causes of BPPV. The most common is head trauma.
Elise – @TheOncoPT (08:54)
Mm-hmm.
Mm-hmm.
Kayla Gomes (09:14)
So if you’re seeing a younger patient with head trauma, it’s possible they have BPPV, along with other vestibular issues. I won’t get into all of that. People talk about Meniere’s disease and vestibular neuritis and labyrinthitis. Any sort of disorder or disease of the inner ear could lead to a higher chance of getting BPPV later. So people who are older, who might have inner ear disease already.
If you’re female, there’s a lot of discussion about osteoporosis and osteopenia, right? These otoconia are made of calcium. So if someone has osteoporosis or osteopenia, there’s a breakdown of those otoconia perhaps a little bit more, we think. And also vitamin D serum levels, that’s pretty controversial in the BPPV world, but…
Elise – @TheOncoPT (09:44)
Mmm.
Kayla Gomes (10:10)
Vitamin D has a lot to do with blood calcium levels and bone synthesis, so I’m on team low vitamin D, I think precludes people to getting more BPPV.
Elise – @TheOncoPT (10:22)
Okay, so if you’re watching this, first of all, I hope you’re watching this video because Kayla has this amazing model that she’s shown us and probably gonna show us a couple more times in this interview. My mouth was on the floor with that little tidbits about the calcium and the vitamin D because, and I was literally just going over some information about this previously, we know in oncology that bone issues,
Kayla Gomes (10:24)
Her mind is blown
Elise – @TheOncoPT (10:50)
bone density issues are so, so common. And again, maybe that’s, you know, the treatment that the person is on, maybe they were already predisposed to having bone mineral density issues. And then, you know, even the lack of activity and the, you know, more sedentary time can combine with other things, you know, may accelerate a person’s bone loss. And then you’re telling me that’s potentially related to BPPV, like.
Kayla Gomes (10:55)
Yeah.
Yeah. And just as we get older, like these otoconia are calcium crystals and they just kind of degrade over time and there’s little tendrils that keep them together that degrade over time. So they’re more likely to kind of float away than a person who hasn’t been around the sun as many times. Yeah. And there’s also cells within the semicircular canals, which help kind of absorb otoconia if they’re floating around. And as we get older, we have less of those cells. They’re called dark cells.
Elise – @TheOncoPT (11:19)
Oh boy, Kayla!
Kayla Gomes (11:51)
Mm-hmm. Ha ha ha.
Elise – @TheOncoPT (11:53)
I do appreciate the disclaimer that you told me both off and on air is that BPPV can be as complex or as not. Like there’s layers to it and it’s very clear that I have reached level one layer in my understanding and we’re talking like level 10 or something right now. This is so interesting.
Kayla Gomes (12:03)
Mm-hmm.
Sure.
Yeah, yep. And like other causes, and we’ll get into this with the crossover of oncology and BPPV. Think like dental, oral maxillary, even cervical surgery. Think of the positions that people are in, and then you have these high frequency vibratory tools that they’re using. It’s not uncommon.
Elise – @TheOncoPT (12:18)
Oh.
Yeah.
Kayla Gomes (12:43)
that someone goes in for dental work and they’re like, oh my God, I like went back in the chair and they drilled on my tooth and then boom. Or I’ve had patients with spinal fusion surgery, same thing. They wake up and they’re like this. Yeah, yep.
Elise – @TheOncoPT (12:59)
Okay, well, it is very much clicking now that I have a lot more screening to do, especially, you know, I’m so glad you mentioned, you know, the dental work and whatnot. You know, a lot of my patients before they go in for chemo, they’ll usually have kind of like a last hurrah with the dentist isn’t quite the phrasing, but they’ll go in for kind of a pre-chemo, this is kind of the last dental treatment that you’re going to get for a while because of just how…
Kayla Gomes (13:05)
Hahaha!
Sure.
Mm-hmm.
Elise – @TheOncoPT (13:27)
just all the things that are happening. And then you add on top of that my patients who are going through head and neck cancer treatment and, you know, oh man, oh man.
Kayla Gomes (13:40)
Yeah, I was preparing for this and I saw an article on radiation treatments for head and neck cancers and like nasopharyngeal cancers and they followed patients over time. And those who had, I think it was more than two or three, I’d have to look, treatments of radiation and it was like a certain dosage were more likely to get BPPV later.
Elise – @TheOncoPT (13:48)
Yeah!
Oh my God, can you please send me that article later? Oh my God, I need my hands on this. Holy cow. Okay. So we’ve kind of answered the question that I was going to ask next, but I’m going to ask it anyways. Um, is there any crossover between oncology and BPVV?
Kayla Gomes (14:06)
I will, yes. Yes, I will. Mm-hmm.
Yes.
Of course. Yeah, I think like, I think like big picture. And of course, there are younger adults who get cancer. But older adults are, I don’t want to speak out of turn, I’m not an oncology PT, but older adults are the majority of the people who get cancer. And the older you are, the more likely you are to get BPPV. And then cancer treatments themselves, we talked about
Elise – @TheOncoPT (14:28)
course.
Kayla Gomes (14:47)
you know, head, neck and spine surgery and procedures, you know, if there’s bone mets and someone needs like spinal fusion or something like that, radiation, chemo, cisplatins. I talked about this a little bit last time on the neuropathy episode, but there’s like some controversy about cisplatins being only ototoxic, meaning causing hearing loss, but.
Elise – @TheOncoPT (14:58)
Yeah.
Kayla Gomes (15:16)
there’s not as much research regarding the toxicity to the vestibular system itself. Listen, like some articles say there was zero change and some said 50% of patients had decreased vestibular function after their chemotherapy treatments. Listen, I’m not a pathophysiologist, but when I think about just the proximity of these organs to each other, when I think about…
Elise – @TheOncoPT (15:23)
How interesting.
Mm-hmm.
Kayla Gomes (15:44)
the neurotoxicity of cisplatin or any of the platinum agents. When I think about how similar the hair cells are in the cochlea versus the inner ear or the vestibular system.
I just, and we know that patients who have other inner ear disorders like sensorineural hearing loss, you know, vestibular neuritis, like all these things, get secondary BPPV. We talked about bone density. You know, it’s a more rare type of cancer, but parathyroid cancer, you know, and the effects on bone density, blood calcium, all that good stuff.
Elise – @TheOncoPT (16:00)
I mean.
Yeah.
Mm-hmm.
Kayla Gomes (16:29)
I had a patient a very long time ago who had a degenerative central neurological disorder and they started getting dizzy and they referred to me for that central neurological disorder. But I was like, this doesn’t like this sounds like BPPV and they had BPPV and I was like, and she’s like, what causes this? Because she was pretty young. I was like, and I told her what I told you, it’s usually older adults, but if there’s issues with like bone density or.
Elise – @TheOncoPT (16:44)
Mm-hmm.
Yeah.
Kayla Gomes (16:59)
whatever, and she like stopped me and she was like, they caught my parathyroid issues, my parathyroid. I have cancer, I had cancer and I had it treated. They caught it because of like the calcium levels in my blood were all out of whack and that’s when this all started. And like that’s very anecdotal, but I just always think about that now. Yeah, and then falls. We talked about neuropathy last time, but…
Elise – @TheOncoPT (17:15)
Whoa.
I mean, it’s very relevant, yeah. Whoa.
Kayla Gomes (17:29)
Patients who fall, we will go over this later when we talk about screening, we need to screen them for BPPV. And if they fall and they hit their head, they need to be screened for BPPV after they’ve had any other medical workup that’s necessary. And finally, I think this is where people get really freaked out with patients who have cancer.
Elise – @TheOncoPT (17:33)
Mm-hmm. Yeah.
Mm-hmm.
Kayla Gomes (17:57)
and BPPV is intercranial tumors. And like I did some reading about this before I came on here. It’s usually like cerebellar tumors. And we can talk about this with treatment and screening, but they are zebras. They’re pretty rare cases. But we need to be able to catch red flags as we see them. Mm-hmm.
Elise – @TheOncoPT (18:01)
Mm-hmm.
Totally.
So as Kayla laid out for us, there is significant crossover between this, you know, again, I tend to think or I thought of BPPV as a neuro issue. And it’s like, yes, but in oncology, we know that it crosses so many domains of physical therapy, ortho, neuro, right, all the things. And this is absolutely one of those, you know, these experiences, these concepts that absolutely cross over.
Kayla Gomes (18:43)
Mm-hmm.
Right.
Elise – @TheOncoPT (19:00)
keep going with this, Kayla, that I want to bring up, that I’ve seen in my experience and I really want your neuro perspective on this. You know, a lot of our patients in oncology are on many medications at the same time. Right, and so I wanted to make sure, you know, if that’s a thing, let’s talk about that too, because I mean, my God.
Kayla Gomes (19:14)
Oh yes, I didn’t even talk about polypharmacy. Yes, yeah.
Yes, yes, polypharmacy is definitely a concern. If they’re on gabapentin and they’re also on an antidepressant and they’re also on like some other like central nervous system depressant. Yes, that can make them dizzy, that can make them fall. So, I in my PT school did not get as much pharmacology but we are responsible for looking at patients’
Elise – @TheOncoPT (19:44)
Bingo.
Kayla Gomes (19:54)
or a medication list and seeing if there’s any interactions or if a patient has a change in medication, you know, we need to be able to catch that. For me, in my practice, it’s usually medications related to cardiac issues. Patients come in, they’re really dizzy when they stand up or they get out of bed and they’re referred for BPPV, but they end up just being on perhaps, you know, too strong a dose of…
Elise – @TheOncoPT (20:04)
Yeah.
Mm-hmm.
Kayla Gomes (20:23)
of blood pressure medication. And we can screen for that, right, with orthostatic testing, but you need to be able to differentiate.
Elise – @TheOncoPT (20:29)
Mm-hmm.
Oh my God, that’s one of the patients that I actually did some vestibular work with because it was just so glaringly like we have to do this. And because in particular, this patient fell multiple times. It was like, okay, this is, we can’t, we were working on obviously on the balance and what not interventions, but it was like, we cannot not work with the vestibular stuff. And so did some work with her on that.
Kayla Gomes (20:44)
Yeah.
Mm-hmm.
Elise – @TheOncoPT (21:04)
And it was so interesting because this patient of mine was also in the healthcare field and so had some understanding and so it was really fun to sit with her and kind of go through this list of, okay, you’re on this medication, you’re on this medication. And so between the two of us, we were very much kind of breaking down like, oh, there’s a whole lot here that is contributing to this, you know, not only the falling, but also, I mean, she…
Kayla Gomes (21:10)
Mm.
Yeah.
Elise – @TheOncoPT (21:34)
Oh man, so much of that. So much.
Kayla Gomes (21:34)
Fogginess is brutal. It’s your chemo. Well, no, it might be a million drug interactions that you’re having too. If people are interested in polypharmacy and the interactions, I highly recommend the beers criteria. Beers like the drink, it stands for, I don’t know what it stands for. It stands for something, but it’s used a lot in geriatrics to, you know.
Elise – @TheOncoPT (21:39)
Yeah.
That’s okay.
Kayla Gomes (21:59)
help figure out what drug interactions may be happening or what medications may not be the safest, especially for older adults. Yeah.
Elise – @TheOncoPT (22:02)
Oh, I love that.
Yeah. Ooh, yes. We’ll definitely be including that and then also that article on radiation that Kayla mentioned previously. Oh man. There is even just in this conversation so far, Kayla, we’ve tapped into a lot more factors that are probably contributing or need to be looked into more in the oncology patient population, which is very, it’s interesting and it’s exciting to me. And it’s also…
Kayla Gomes (22:23)
Yeah.
Elise – @TheOncoPT (22:36)
this is another thing I need to be screening for, because I had a patient, not that long ago, who fell in the grocery store parking lot, and I did not even think about BPPV or vestibular issues being part of that patient’s presentation, so, mm, I’m thinking. Okay, so now we’ve established, this is very common, very much a factor, very much something to be considered in oncology also. What can we do about it?
Kayla Gomes (22:53)
Yeah.
Elise – @TheOncoPT (23:06)
it.
Kayla Gomes (23:08)
So before we treat it, we need to screen and diagnose it appropriately. You gotta know what you’re treating. So subjective history, subjective history, subjective history. BPPV is a very specific thing. It is episodic. It usually has a spontaneous onset or maybe they have had trauma. The duration is short. It should be less than a minute.
Elise – @TheOncoPT (23:32)
Mm-hmm.
Kayla Gomes (23:37)
And there’s always a caveat with that, because BVPB can make people feel really sick and really panicked. So patients will be like, oh, it lasts forever. I’m like, okay, well, when you turned in bed, like what happened? And they’re like, I had like the spinning, but then I felt horrible for like hours. And I was like, do you feel horrible or were you spinning? Like how long did that spinning sensation last? And if you really dig, you’ll find that the spinning sensation is relatively short.
Elise – @TheOncoPT (23:42)
Yeah.
Mm-hmm.
Kayla Gomes (24:04)
but then how sick people can feel or how anxious people can feel can last a lot longer, which is totally valid and fine. And then what’s the triggering event? It should be positional. Sometimes that’s really obvious, like the turning in bed. If someone says to you, they get this sense of motion when they’re turning in bed, you should be, you know, the light bulbs in your head for beeping PV should be going off.
Elise – @TheOncoPT (24:09)
Definitely.
Mm-hmm.
Kayla Gomes (24:32)
But again, it’s not always so obvious. Like I have a very, I work at the VA, I have a very independent population who, like all these older adults who are like, I was up on a ladder, painting my ceiling, and I got really, really dizzy, or tying my shoes, like bending forward, bending up, sometimes just turning really quickly, you know. It’s not like, oh, I feel dizzy all the time. That’s not.
Elise – @TheOncoPT (24:53)
Yeah.
Kayla Gomes (25:01)
that’s not BPPV, I think that’s more often polypharmacy or cardiac issues, maybe some mental health issues too. Yeah, you know, the basic differential diagnosis is very important. Is there a hearing loss with it? Because then if it’s a hearing loss, we need to think about more of like a neuritis or a labyrinthitis.
Elise – @TheOncoPT (25:11)
Well.
Kayla Gomes (25:28)
Big bad scary thing that everyone’s worried about is stroke, but you know, when did it come on? It came on last night when I was turning in bed, is very different than, I woke up last night with this really horrible headache. I have been dizzy for hours, I’ve been vomiting and I can’t walk. That’s very, very different. So get a good subjective, then a vestibular ocular screen.
Elise – @TheOncoPT (25:47)
Very different. Yeah.
Kayla Gomes (25:57)
You should probably do one before you just move someone right into a Dick’s Hall Pike or something. My order of operations. And, you know, this is just from my practice developing over time. I kind of group it in my head as central, peripheral, and then positional. So central is your smooth pursuits and your saccades. I do VOR cancellation. I do like a cervical range of motion check.
Elise – @TheOncoPT (26:16)
Mm-hmm.
Kayla Gomes (26:27)
just to see if anything elicits that dizziness, if they have maybe a cervicogenic piece. People worry a lot about VBI, vertebral basilar insufficiency. Do you remember learning about that test in PT school?
Elise – @TheOncoPT (26:44)
I do, and now I’m like, oh my God, how do I actually do that? I mean, cause you’re, oh, go ahead. Oh, where,
Kayla Gomes (26:49)
yeah, you got it. Yeah, you got it. It’s nailed it. You get that right on the NPTE right now if you took it. But it’s but it’s very controversial. The sensitivity and specificity is basically a coin flip. And and like also you are the traditional one is you have them lay on their back you rotate their head and extend their head. I don’t do that.
Elise – @TheOncoPT (26:56)
Yes!
interesting.
Oh, that’s good.
Kayla Gomes (27:15)
When I’m doing my cervical range of motion screen, I do a modified version where while their head is turned to the side, I’m looking to see how they’re feeling. If you learn in PT school, the five D’s and three N’s. Five D’s. Are they dizzy? Do they have double vision? Dysarthria, dysphagia, drop tacks, meaning they like pass out, right? Or the three N’s, spontaneous, nystagmus, nausea, vomiting, numbness in the face.
Elise – @TheOncoPT (27:38)
Mm-hmm.
Kayla Gomes (27:44)
So I have them turn, I keep talking to them, then I have them bring their chin up so that it is that more like closed down positioning. And I have them keep talking to me, if they’re kind of quiet, I ask them to count to 10, we hold it, and that’s my screen. Realistically for VBI, you should probably consider a patient’s medical history. Do they have hypertension? Do they have hyperlipidemia? Do they have cervical stenosis? Do they have these things that makes it more likely?
Elise – @TheOncoPT (27:55)
Mm-hmm.
Kayla Gomes (28:14)
that could be a factor. So smooth pursuits, saccades, cervical range of motion. I then do a bedside head impulse test or head thrust where you’re holding on to the top of their head, you tilt their head down about 10 degrees, and then they look at your nose or they look at your glasses, keep your eyes right here on my nose, and then you turn their head relatively quickly.
Elise – @TheOncoPT (28:15)
Mm-hmm.
Kayla Gomes (28:45)
that would be looking for, you know, a decreased VOR. Then you can do VOR testing, take a look at my pen, turn your head side to side. Is that staying in focus? Horizontal, vertical, you can look for retinal slip, and then you can also ask them what their visual fixation is like.
All right, and we haven’t even gotten to positional testing yet.
Elise – @TheOncoPT (29:09)
I was going to say, can I pause you real quick? What is retinal slip? That’s not something I’m familiar with.
Kayla Gomes (29:11)
Yes, yep. Oh, that’s a great question. So retinal slip is where you’re looking at something and you turn your head. So the vestibular ocular reflex is one of the fastest in the body. It’s responsible for keeping your gaze stable on that object as you turn your head quickly, right? So if that reflex is delayed, if it’s slowed, when you turn your head
Elise – @TheOncoPT (29:31)
Mm-hmm.
Kayla Gomes (29:41)
That VOR doesn’t keep up and your eyes will travel with your head and then snap back. It’ll have that corrective saccade. Yep. So, um, or if they’re doing like a VOR head shake, they’re keeping their eyes on something and turning their head instead of their eyes staying on the pen. You might see it kind of slip. Yeah.
Elise – @TheOncoPT (29:47)
Okay.
Okay, that makes more sense. Thanks for defining that, because I’m like, what is that? I don’t know what that is.
Kayla Gomes (30:03)
Yep.
what? And so then I then I explained to patients like, Hey, I’ve noticed that you have a slowed VOR that could be because of your age, it could be because of some disease of the inner ear system. Again, there’s some controversy, just BPPV, like, can you see it, quote unquote, see it with like a head thrust?
And I totally, I think you can, but that’s me. So I tell them, like, there are exercises we can do to speed up, well, not really speed up, like compensate for a slow VOR because of like a unilateral or bilateral, the subular hypofunction, gonna shelf that for the sake of this talk. There’s exercises we can do, but before I can do that with you, I need to check on…
another potential cause of vertigo. And that’s when I get my model out, I give my whole spiel that I gave at the beginning of this podcast, because I think this is so important. If you start talking about like crystals in your head and how it gives you a sense of where you are in space, and then you say to the patient, okay, got it. And then you lay them back and then they get vertigo, that is the craziest experience ever. Like I like to educate my patients of what is physically happening.
Elise – @TheOncoPT (31:07)
Mm-hmm.
Kayla Gomes (31:31)
Because then, you know, if it’s positive, they’re a lot more calm. And I’m already explaining to them like, hey, from what you say, it could be possibly this canal or this canal. We’re going to test all of them. And then the repositioning maneuvers, we’ll get into the treatment. It’s all about just turning your head in relation to gravity. And then we can figure out what repositioning maneuver might be effective for you.
Elise – @TheOncoPT (31:44)
Mm-hmm.
I really like that in that way that you’re educating and not just, you know, again, there’s crystals or there’s rocks in your head. I hear that a lot from patients. It does sound a little voodoo-ish. And so I appreciate not only are you coming at it from a, you know, anatomically, scientifically, this is what’s actually like in your body right now. But what I really like, Kayla, is that you’re already starting to identify potential. What is it?
Kayla Gomes (32:06)
It sounds like voodoo magic. It’s crazy.
Yeah.
Mm-hmm.
Elise – @TheOncoPT (32:28)
if it is this that I think based on the information that I’m gathering is happening, that’s it’s zooming in for the patient on, oh, not only do we have an idea of what it could be, but also more specifically, which one of these is happening? And I think that’s very solution oriented. Like it’s even for me, I’m like, oh, then that’s narrowing it down to what the problem is and how we’re gonna fix it. And I think that is, I mean,
Kayla Gomes (32:33)
Right.
Yeah.
Yeah. Yep.
Elise – @TheOncoPT (32:57)
Bravo, bravo.
Kayla Gomes (32:59)
And I think it’s like any differential diagnosis with PT orthopedics, neuro, whatever, you should probably have a good idea of what it is just from their subjective history. And then my exam is just confirming that. But along the way, you need to educate your patient, especially something like this where vertigo and specifically BPPV can make people feel so ill.
I feel bad for our primary care providers where it’s like, even if they have some understanding of what BPPV is, they got 15 minutes and it’s like, oh, I wanna do this test for inner ear, crystals in your ear, slam the patient on the table and then they don’t have time to treat it. And then they say, oh, go to a physical therapist. And patients are like, what are you talking about? And rightfully so, because this is not anatomy that normal people learn about.
Elise – @TheOncoPT (33:36)
Yeah.
Totally.
Your ear is for hearing, right?
Kayla Gomes (33:56)
Yeah. Crystals in my head. Okay. You take your crystals and put them somewhere else. Yeah, yeah. So then again, basics of PT school and nystagmus is those quick eye movements. I want you to think like central over here, peripheral over here. Central is spontaneous.
Elise – @TheOncoPT (33:59)
Chris, yeah, okay, Kayla.
Kayla Gomes (34:24)
patients looking at you and you start seeing eye movements, uh-uh, that’s not BPPV, that’s a referral out if they haven’t already had some medical assessment, great. More central, when we start thinking about direction, if it’s a pure vertical or a pure torsional, probably central. You know, I can get into this later. Does that mean we need to necessarily send them to the emergency room? Mwuh.
fixation. So if you see a spontaneous and you say, okay, can you look here at my finger? Does that decrease? Or does it stay the same? It stays the same, probably more central. Over here with peripheral, with posterior canal, BPPV, that really classic upbeat torsional or turning nystagmus towards that affected ear.
little clinical pearl here if you’re doing your Dix Hall pike or you’re doing your roll test and you’re like, do I see a nystagmus or it’s really, really small? Have them look in the direction you think that the nystagmus is going. That should increase the amplitude. So posterior semicircular canal, up-beating torsional nystagmus, horizontal canal where everybody is like, I can’t be a vestibular therapist, I don’t get it, is that lateral.
Elise – @TheOncoPT (35:35)
Ooh, good to know.
Kayla Gomes (35:50)
nystagmus, which can change direction depending on if it’s say your right ear turning your head right versus left it’ll always be towards the ground in certain situations. See this is where things get complicated. X-nay what I said, but right, right. So okay, so that’s the direction and with BPPV when you bring them back they’ll typically be a delay in the nystagmus.
Elise – @TheOncoPT (36:06)
That’s so interesting though.
Kayla Gomes (36:20)
and it will, there’s a crescendo decrescendo where, oh, there it is, oh my God, I feel terrible, I feel terrible, and then you’ll start to see it slow down. The patient will start to feel better, then the stagmas starts to slow down, amplitude starts to slow down.
Elise – @TheOncoPT (36:30)
Yeah.
Kayla Gomes (36:38)
So some clinical pearls that I have been learning about and has made me change my practice. When I went to the VA, I wasn’t a vestibular therapist. I had previously treated mostly stroke, MS, brain injury, spinal cord. So I was like, oh, let me just do a Dix Hall Pike. Oh, it’s positive. And then the Dix Hall Pike is the first position of the epilate. I would just treat them.
But then I got burned too many times where they had multi-canal involvement, or maybe it was in both ears, and that just would make my patients feel more sick. So I think like a lot of people would always start with the Dix Hall Pike. And then maybe if you had more experience, then you would do a roll test. Cause I learned in PT school that the great majority of BVPV was posterior.
Elise – @TheOncoPT (37:19)
Okay.
Kayla Gomes (37:38)
posterior canal, right? That it was like 80% horizontal was like 10 to 20% and then anterior canal less than 2% or does it even exist? Also very controversial. Yes, yes, I’m not going there. We now know there’s some new research coming out that horizontal is much, much more common than we once thought. Like closer to 40%.
Elise – @TheOncoPT (37:39)
Mm-hmm.
Oh, interesting.
Wow, that’s pretty significant. Huh.
Kayla Gomes (38:08)
of cases. And horizontal canal, another clinical pearl, that’s the BPPV that makes people throw up. That’s the ones that make them feel sick. Especially if they convert from a posterior to a horizontal canal. Like if you don’t do your repositioning maneuver right, which is
Elise – @TheOncoPT (38:26)
Oh no. Oh no!
Kayla Gomes (38:34)
So now what I do is I do like a supine roll test first. I do that first, I check both ears, I have the patient sit up, and then I do my Dix Hallpikes. So you’re looking for, does the patient feel sick in any of these positions? And you’re looking for the nystagmus in the direction. And hopefully the nystagmus direction is, you know, confirming which ear you’re testing.
Elise – @TheOncoPT (39:01)
Mm-hmm.
It’s still, it’s kind of one of those, I know it’s not voodoo, but sometimes it feels like voodoo that, you know, if you move someone’s head in a certain way, their eyes will move in a certain way. I get it. I anatomically understand it, but it is still so interesting to kind of conceptualize that as I sit here. I’m like, how about that?
Kayla Gomes (39:09)
I know.
Yeah.
Right, and I think in the beginning, if people are like, I’m gonna do it, I’m gonna learn this, you just memorize the eye movements and are like, okay, up beating, right torsion, right posterior canal, I’m gonna treat it with this right effley, you know? And we haven’t even talked about canalithiasis, where the otoconia is floating freely through the canal versus cupulothiasis, where it’s just stuck here. If it’s cupulo, typically it’s a sustained nystagmus. You’ll still see that.
Elise – @TheOncoPT (39:35)
Mm-hmm.
Mm-hmm.
Kayla Gomes (39:50)
crescendo decrescendo, but it’s just going to have a more instantaneous onset of nystagmus and it’s just going to like last forever. And you know, which repositioning maneuver you do depends upon which canal it is, if it’s canalithiasis or cupulothiasis, and most importantly patient factors. So we can go over that too. Yeah, yes.
Elise – @TheOncoPT (39:52)
Mm-hmm.
Uh-huh.
Yes, I would. Yes, please. Let’s do that.
Kayla Gomes (40:21)
Because, you know, when I started treating BPPV and when I had a student who had never done this before, shout out Sarah, she did great. It’s really overwhelming how many repositioning maneuvers there are. Especially because in school you only learn like the Epley, maybe like the Liberatory,
Elise – @TheOncoPT (40:46)
I do remember the barbecue, but not the other two that you just mentioned after, yeah. Yeah.
Kayla Gomes (40:51)
Right, right. So like, there’s so many, and it’s like, I kind of want you to like flip the script in your head where it’s like, oh my God, there’s so many repositioning maneuvers and instead be like, oh my God, there’s so many repositioning maneuvers, which gives me so many more options to treat my patient. Because the most important thing is moving somebody’s body through gravity to get the crystals back to where they need to go.
Elise – @TheOncoPT (41:09)
Boom.
Kayla Gomes (41:21)
My student used to be like, we need to get your crystals home. That’s what we need to do. And so like, you know, speaking of like, you know, patient factors, maybe your patient’s really kyphotic. Maybe your patient had a cervical fusion. Maybe your patient has bone myths. So an epally where they’re extended back might not be the best choice. So what could you do instead?
Elise – @TheOncoPT (41:45)
Totally.
Kayla Gomes (41:49)
You could do the smart maneuver. You can do the libatory maneuver. This sounds flippant, but like Google it. There’s like so many options. If you have a bed that has a Trendelenburg, I work in outpatient, unfortunately I don’t have that. But if you like work in acute care or in an inpatient rehab that has a bed that Trendelenburgs, it’s not how much neck extension you get, it’s how much you’re tipped back from gravity.
Elise – @TheOncoPT (42:17)
Yeah.
Kayla Gomes (42:19)
Right, so use your resources. Or can you get a bunch of pillows under their trunk? Or can you have the patient bridge if they’re mobile enough? You know.
Elise – @TheOncoPT (42:26)
Mm-hmm.
Kayla Gomes (42:33)
I’ll pause there.
Elise – @TheOncoPT (42:37)
with you so far and I do, it does feel more comforting to know, because I really, I really appreciate the flipping the script instead of like, there’s so many maneuvers. There’s so many maneuvers. There’s so many options because again, I think one of the things that we can get tripped up on when it comes to, especially the oncology patient population is, oh, but my patient has blah, you know, again, whether that’s metastasis, like you mentioned, or, you know, a cervical fusion, any number of things that’s kind of, you know,
Kayla Gomes (42:38)
Okay.
Yeah.
Right, right.
Mm-hmm.
Elise – @TheOncoPT (43:06)
They’re not, they don’t fit really well into that, you know, this category. Well, that’s okay because we’ve got other options here, which is really exciting.
Kayla Gomes (43:15)
Right.
Right, I’m trying to think about what I want to talk about next, because there are two separate soap boxes and clinical pearls that I want to make sure I get to. Because when we talk about like screening BPPV, like people I think know well enough that oh, positional vertigo, turning in bed, vertigo, a sense of motion, a sense of the room spinning when it’s not there. We know as adults get older.
Elise – @TheOncoPT (43:26)
Oh, I’m here for it. I’m so here for it.
Kayla Gomes (43:48)
they are less likely to report these more typical vertigo, like I’m turning sensations. And they might say something like more generalized, like, oh, I’m lightheaded or I feel off. But then you go ahead and test them in there. It’s that nystagmus.
Elise – @TheOncoPT (43:55)
Yes.
Kayla Gomes (44:09)
You need to screen them. You can read in the literature about community dwelling older adults who are asymptomatic. Like, this is an old article, like 11% had BPPV. If you start looking into patients who fall, or people who are going to fall clinics, 25% of them have BPPV. You need to screen them. And a lot of these patients won’t even say that they’re spinning or say that they have vertigo. Something that blew my mind when I went to CSM.
Elise – @TheOncoPT (44:26)
Yeah.
Kayla Gomes (44:38)
And I feel like this happens in my vestibular practice a lot where I see something and I’m like, what is that? And then months or years later, I go to a course and I’m like, that’s what that was. And so at this course, they talked about vestibular agnosia where, you know, this is all theory, but they think because there’s some disruption in the projections from the vestibular system to the thalamus that
Elise – @TheOncoPT (44:53)
I love that.
Kayla Gomes (45:09)
Patients don’t even have a sense of vertigo. They’re just falling. But then you test them and you see this nystagmus, clear as day. And in this CSM course, they were especially talking about this in the brain injury population, where they’re falling or they have all these balance deficits and they don’t tell you, like, oh, I’m not dizzy. Oh, I don’t have vertigo.
Elise – @TheOncoPT (45:12)
Whoa.
Oh my God.
Kayla Gomes (45:38)
And there was this woman, oh, I can’t remember her name. She talked about at her inpatient rehab unit, brain injury unit. She started talking to patients about this and they’re like, no, I don’t have it. And she started doing the Dix Hall Pike on people and almost every, like a great majority of patients have BPPV. And she was like, oh my God. And so then it became this quality improvement project where every single patient with brain injury in her unit must be tested for BPPV before their discharge.
Elise – @TheOncoPT (45:55)
Oh my god.
Kayla Gomes (46:10)
And so like I’m going to these courses and I’m like, oh my God, because for me, it was kind of these, it was this thing, like I took my NCS, like I understood. Yeah, in theory, I am supposed to be screening every patient who falls, who was of a certain age, especially like over 60 for BPPV. I know I should be doing this. Was I doing it for everyone? No, I would do it for the people who reported like feeling dizzy or feeling a sense of vertigo.
Elise – @TheOncoPT (46:27)
Mm-hmm.
Right?
Kayla Gomes (46:39)
But did I do it for everybody? No, I didn’t. And I’m very honest about that. So when I started like reading more up on like these vestibular agnosia, sort of people with like subjective BPPV, meaning sounds like a duck, quacks like a duck, like every time I turn in bed, it lasts this amount of time. I’m like, I’m so sure it’s gonna be BPPV. And then you bring them back and you see nothing. It’s like, what’s going on?
Elise – @TheOncoPT (47:04)
Huh. Ha.
Kayla Gomes (47:07)
So for years, vestibular therapists just treated people and they got better. So more articles are coming out that if you follow people with that subjective BPPV, weeks later, they usually develop a nystagmus. It’s probably false negatives or compensation or something. So I’m reading all this, and I’m like, oh my god, I’m freaking out. And I’m talking to my student about this. And she’s like, well, let’s just start screening people, everybody who’s falling. And like, you know.
Elise – @TheOncoPT (47:20)
Oh my god.
What?
Kayla Gomes (47:36)
I see a mix of ortho, I see a mix of neuro. So that in that one week, like six days, we ended up catching eight patients with BPPV. And only three of them were referred to me for balance or dizziness or vestibular issues. They were just guys who.
Elise – @TheOncoPT (47:44)
Oh my god.
Kayla Gomes (47:54)
were falling or they’re like, yeah, I felt kind of lightheaded. And then my students like, I’m going to do it. I’m going to, I’m going to test. And we had someone with vestibular agnosia who brought them back up beating towards the nystagmus, they did not feel a thing. We treated them, you know, brought them back to Dick’s hall pike, nystagmus was gone. And the next time he came in, he goes, what did you do? I can walk better than I have in a very long time.
Yeah. You know, like these clinical pearls where patients are like, I’m suddenly falling when I get up in the middle of the night. And for no reason. We’re like, I got up and I got really lightheaded. I don’t know, I think I just, I didn’t drink enough water. We’re like, okay, get on. We’re testing them. And everybody was popping positive. And so for me, you know, I take vitals with every single one of my patients. Like that is…
Elise – @TheOncoPT (48:22)
That’s what I’m talking about. Oh my God.
Kayla Gomes (48:50)
something that’s very important to me in my clinical practice.
This is like becoming a vital is vital moment. And I wanted to come on here and talk about this because BPPV is more common than you think, period. And so you should be screening your patients for it. And I understand there’s time constraints and there’s barriers, but it’s so important. And in this oncology population, there’s fear of
Elise – @TheOncoPT (48:59)
Oh my God.
Kayla Gomes (49:26)
the what ifs, well, what if they have an intracranial something or what if like no one has caught a VBI yet, right? I think something to remember is that we have screening tools like the VBI tests or modified tests. I know they’re not like super accurate, but for strokes, we have the hints exam. You have your subjective history. Like you have sensation, you have reflexes, you have strength testing, like
We as physical therapists are really good at assessing risk versus risk. So I have this patient who’s falling all the time, they’re really dizzy, but they have bone mets in their T-spine. Okay, we need to decide, you know, the relative risk of pathological fracture with positional testing versus the risk of they fall because they might
which can result in fractures or more serious complications down the road. Like I feel so passionately about screening for BPPV because I literally think it saves lives. Like a thousand percent.
Elise – @TheOncoPT (50:31)
Absolutely.
Yeah! Oh my god!
You know, and one of my favorite things on this podcast, Kayla, is to catastrophize. It’s me. But that’s, I think what that’s what gets the point across for a lot of people is when you think about me as a 31 year old, when I fall, which like is not, let me be clear, I don’t fall, but like, if I slip on something, you know, it’s because I was not, I was being dumb or whatever. And it’s not going to be catastrophic for me.
Kayla Gomes (51:00)
I know some therapists for that. Yeah.
Right.
Elise – @TheOncoPT (51:10)
I’m healthy, I’m fine. But for my patient who is dealing with cancer, even if it’s curative treatment intent, a fall could be the thing that completely turns everything, that entire course, the entire plan for that patient completely on its head. Because, again, here’s where the catastrophizing comes in, patient falls. They break their hip. They need a hip replacement now.
Kayla Gomes (51:16)
Mm-hmm.
Breaks are hit. And then, yeah.
Elise – @TheOncoPT (51:41)
Maybe they’re a candidate for hip replacement. Maybe they’re not. They’re in the hospital. They develop an infection, a chance per infection in the hospital. And I mean, just there’s so many opportunities for falls to just blast through every plan that we had and like, well, throw it all out. This is an instant where we throw the baby out with a bath water kind of situation. A fall is that.
Kayla Gomes (51:51)
Mm-hmm.
Elise – @TheOncoPT (52:08)
big of a problem and it should be as like that big of a concern for every therapist listening to this. And the fact that we now have BPPV, not that we now have, it’s always been there. It’s just very top of mind right now because we’re talking about it in this conversation. There is that one more thing that could very much be contributing to that person’s fall risk. That is something that we need to be paying attention to. So girl, I am so here for this. I’m so here for this.
Kayla Gomes (52:37)
And I understand there’s barriers too, but I get a little ornery about that because you can do a vestibular ocular screen, smooth pursuits, saccades, outside head thrust, VOR times one, cervical range of motion in five minutes. You can do that. We didn’t talk about like patient reported outcome measures, anything like that.
Elise – @TheOncoPT (52:58)
Totally.
Kayla Gomes (53:05)
There’s the DHI, the Dizziness Handicap Inventory. It’s long. I’m not expecting people who see their patients for 30 minutes to necessarily give everyone a DHI. But there is another clinical pearl here. The five item DHI where Dr. Sue Whitney, she’s one of the big people in BPPV world, found five questions that were most specific and sensitive to BPPV.
Yeah, does looking up increase your problem, getting in and out of bed, turning in bed, quick movements of your head and bending over? And the scoring on that, the higher the score, the higher probability they have BPPV. I have made a little form that I use in my clinic and have given to our primary care residents for people who are not well-versed in vestibular stuff. But if a patient comes to you and they’re falling or they’re dizzy, give them this.
Elise – @TheOncoPT (53:51)
Oh my god. Oh my god.
Kayla Gomes (54:04)
and if it’s above a certain score, you should probably be doing at least a Dix Hall Pike.
Elise – @TheOncoPT (54:09)
Oh my-
Kayla Gomes (54:11)
So like.
It needs to be made a priority. We used to think in the PT world, taking vitals on everybody was extra and took too much time. And I think mostly we’ve gotten over that. I think this needs to be also one of those things because it’s so important. Yeah, that’s very exciting. Yes.
Elise – @TheOncoPT (54:16)
Yes.
This is so exciting. Oh my God. I’m also, can we rewind for a minute? Your student who was so excited about this, like.
Kayla Gomes (54:40)
Hahaha
She was so excited. She became a pro. By the end, she really did.
Elise – @TheOncoPT (54:48)
I love students so much and I love young PTs for this reason because I think as we practice and we get jaded by the system or whatever, it’s easy to lose that excitement and passion. And I think that is where the innovation occurs. And I just want to like, first of all, major snaps to your student, major snaps to you, Kayla, for being the CI who’s like, let’s go.
Kayla Gomes (54:51)
Mm-hmm.
Yeah.
Mm-hmm.
Yeah.
Yeah.
Elise – @TheOncoPT (55:16)
Look what’s happening. Like you are changing in this micro environment. Like I don’t know. I don’t know the right microcosm or micro-organic, you know, environment that you’re in. You are making these clinical practice changes that are going to be the foundation upon which, you know, BPPV becomes the next vitals or whatever that is. I mean, oh my God. I’m so excited.
Kayla Gomes (55:23)
Yeah.
Yeah.
Yeah.
Yeah, students are so open because they are developing their clinical practice. And that’s why it’s such a gift to teach because it challenges you, right? You know, I present my student with the information and saying out loud to her, I know I should be testing more people. And she goes, why don’t we just do it? I’m like, you’re right, let’s just do it. And then you catch all these people. And I’m like, okay, I’m gonna do it a lot more often. No. Yeah.
Elise – @TheOncoPT (55:56)
Mm-hmm.
You’re right.
Oh my God. Major proud clinician moment. Like way to be a great CI, Kayla. I’m just, oh my God. I’m so excited. So for the PT who’s listening to this right now who says, I’m not a vestibular whiz. I am on board. You have sold me, Kayla, on the importance of screening patients for this. What can I do to help my patients?
Kayla Gomes (56:12)
Okay.
Mm-hmm.
Elise – @TheOncoPT (56:38)
who are experiencing BPFED.
Kayla Gomes (56:38)
Sure.
So first of all, you have to screen it. I just talked about all of that. If you’re nervous about your skills, a little bit of practice. Like if you have access to MedBridge, there is a 10 minute vestibular ocular screening course, which taught by Jeff Walters, which is wonderful. The vestibular content on MedBridge is fantastic. From like really entry level BPPV to like these atypical cases like, oh my God, I saw this thing. I don’t know what it was. Oh, that’s what it was.
Elise – @TheOncoPT (56:58)
Nice.
Kayla Gomes (57:11)
So anything by Sue Whitney or Jeff Walters on MedBridge is great. Assessing risk versus risk. We are experts at doing this. Listen for those subjective red flags. If patients are saying 10 out of 10 headache or changes in vision, dysarthria, dysphagia, you’re passing out.
numbness and tingling in the face, some of these more central signs like, spontaneous and astagness and they haven’t been worked up, it might be time to talk to another provider or refer out. And also, have the bravery to treat this, to test for it and then to treat this. You are a smart PT, you are a problem solver. If one position…
repositioning maneuver isn’t working, there are other ones. You know, if it’s not working, you know, if you’ve done at least two repositioning maneuvers and you’ve done a couple visits, it might be time to send the patient out to a more specialized PT or maybe an ENT, that’s totally fine. I think finding a partner or finding a vestibular mentor would be really excellent. Vestibular first, they sell really great models, they have really great content.
Elise – @TheOncoPT (58:38)
nice.
Kayla Gomes (58:38)
they are helping out with this dizzy care network. So the idea is for patients and clinicians who are looking for clinicians who have more vestibular experience, they can put in their location and there it is. So that’s in development right now. So I would encourage anyone listening with vestibular experience to get on that list.
Elise – @TheOncoPT (58:56)
Oh my God, amazing. Yeah.
Kayla Gomes (59:04)
I would encourage people who are looking for a mentor or a partner to get on that list. But it just like anything else in PT, it takes practice. There’s some really great content creators out there, vestibular first, balancing act rehab, it’s all in your head that go over like different tests and repositioning maneuvers.
Elise – @TheOncoPT (59:08)
Mm-hmm.
Kayla Gomes (59:29)
looking at the eyes is challenging, especially if you don’t have goggles. I don’t, it’s a skill like anything. There’s websites out there where you can just look at ocular movements all day. For my more like inpatient inclined people, Rebekah Griffith is doing, she’s the EDPT, you know her. She’s a friend of this podcast. She and Vestibular First are doing like really great work in the EQ care space. And then for like, there’s also,
Elise – @TheOncoPT (59:39)
Mm-hmm. That’s cool.
We love her.
Oh my God, love.
Kayla Gomes (59:58)
Peter Johns, he’s an emergency medicine physician who talks about BPPV versus a neuritis versus stroke. Like those are the big three that people worry about and get scared about. So he has some really great content too.
Elise – @TheOncoPT (1:00:08)
Nice. Yeah.
Oh my God. Man, talk about dropping all the pearls here, Kayla. That was amazing. Wow.
Kayla Gomes (1:00:17)
Well, like I stand on the shoulders of giants, really. Like I said, I’m relatively new to treating vestibular disorders and BPPV, and so I just am very thankful that there are great educators out there in this space. So you can learn as much as you want to learn when you’re looking into BPPV.
Elise – @TheOncoPT (1:00:37)
Very cool. Oh my God. I will link to all of those resources that Kayla mentioned. I will also throw in, so I am an affiliate with MedBridge. So I do have a coupon code that can save you on your subscription that I will be putting into the show notes as well. So you can definitely grab that and save. MedBridge is a wealth of information. I am a little biased. I will let y’all know.
Kayla Gomes (1:00:59)
Yeah.
Elise – @TheOncoPT (1:01:02)
Um, I do have two courses on MedBridge that are not in any way affiliated with vestibular. So I will be hopping on the vestibular pages of MedBridge cause this is, you’ve sold me like I’m, I’m ready, Kayla. Let’s go. Oh my God. Anything else you want to leave my listeners with today, Kayla?
Kayla Gomes (1:01:14)
They’re excellent. Yep, they’re excellent.
Screen your patients for BPPV. Do it. And you will be surprised, like I was, how many patients have BPPV.
Elise – @TheOncoPT (1:01:35)
I think I’m gonna like maybe do like a recap episode and report back on what I find because I bet I have a couple of patients in mind right now that I’m thinking, I wonder, I wonder.
Kayla Gomes (1:01:41)
You should.
I wonder. And you know what? My student used to say this, your prob, like your Spidey sense, you’ll develop, you’ll develop this Spidey sense and you’re probably right.
You’ll see. Yeah. Add a little blurb. It’s like, I caught five patients with BPPV and then I called Kayla how to treat them. Yeah.
Elise – @TheOncoPT (1:02:04)
Stay tuned y’all. I’m gonna I’m gonna go find out
And then I’m gonna tag Kayla and be like, and Kayla told me to. Where can people follow you and learn more from you on the internet?
Kayla Gomes (1:02:24)
I am on Twitter, I should know my handle, at nu underscore dpt. You can email me at Kayla Gomes, pt at gmail.com. Like I said, I made this like five item DHI. I just ripped it from the article that Sue Whitney made. If you want a copy of it, I can send it to you. If you have any questions, we can chat. Whatever you want to email me.
Elise – @TheOncoPT (1:02:50)
Oh my God, amazing. Kayla, thank you so much for coming back on the podcast. I knew this was going to be a good episode. I was not prepared for how excited I am about vestibular and BPPV. And also, you know, and I think this is, I’ve had a string of really, really great interviews on the podcast lately that have really, not only am I learning things, but I think I’m also
Kayla Gomes (1:03:03)
Yes.
Absolutely.
Elise – @TheOncoPT (1:03:20)
unlearning some patterns as I’m doing these interviews and listening to the guests. And this is another one that I’m like…
Kayla Gomes (1:03:23)
Yeah.
Elise – @TheOncoPT (1:03:31)
I gotta change this. I gotta change how I’m doing things because I’m missing things and, ah, this is really cool, Kayla. Thank you. Thank you for this. Ha ha ha.
Kayla Gomes (1:03:32)
Yeah.
Yeah, thank you.