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A LOGICAL APPROACH TO THE DIZZY PATIENT. Dizziness and balance disorders center www.susqneuro.com. Conditions. Vertigo BPPV Labyrinthitis Other Conditions: MS, migraine, Meniere’s etc Non-Vertigo Gait Dysfunction (countless neurological oto, ortho conditions Elderly:

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A logical approach to the dizzy patient l.jpg

A LOGICAL APPROACH TO THE DIZZY PATIENT

Dizziness and balance disorders center

www.susqneuro.com


Conditions l.jpg
Conditions

  • Vertigo

    • BPPV

    • Labyrinthitis

    • Other Conditions: MS, migraine, Meniere’s etc

  • Non-Vertigo

    • Gait Dysfunction (countless neurological oto, ortho conditions

  • Elderly:

    • PD, frontal lobe disease, neuropathy, multi-deficit, stroke

  • Post-Injury

  • Psych


A philosopher in the vestibule l.jpg
A philosopher in the vestibule

  • We move

  • An unmoving earth is our base of operation

  • If our base moves we have no hope of orientation: hopelessly lost.

  • Discomfort comes from shift in orientation.

  • Need an absolute set of coordinates.

  • Problem of shifting base.

  • Developed from lateral line system in fish

  • Which way is down??


Oscillopsia l.jpg
Oscillopsia

  • Bilateral vestibular dysfunction

  • Shows function of vestibular system

  • When the world moves with your head it drives you crazy

  • We need a solid base of operations

  • Result: “Visual Dependence”

  • Foam Pad Romberg positive.


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VESTIBULO-OCULAR REFLEX (VOR)

KEEP YOUR EYES ON THE PRIZE

Our world seems not to move though

We Do


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Dizziness- Logical Approach -strategy for lecture

  • Go into some basic principles

  • applications and testing

  • get into a few prominent diagnoses


Dizziness l.jpg
DIZZINESS

  • EIGHT MILLION PHYSICIAN VISITS/YR

  • AVERAGE: 5 VISITS WITHOUT RESOLUTION OF PROBLEM

  • Dizziness affects 10% of adults over 40

  • LOSS OF LIVLIHOOD, FALLS INJURIES

  • SYSTEMATIC APPROACH


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DIZZINESS

  • VERTIGO

  • LIGHT-HEADEDNESS

  • DYSEQUALIBRIUM

  • GAIT DYSFUNCTION

  • NEAR SYNCOPE

  • ANXIETY


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Dizziness: Pointed questions

  • Vertigo or Not?

  • Standing or Seated?

  • Isolated or ass’d with Other symptoms?

  • Constant or paroxysmal?

  • Caused by positional change?


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DIZZINESS:

  • A MULTIDIMENSIONAL APPROACH

  • AREAS OF EXPERTISE

    • NEUROLOGIST

    • OTOLOGIST

    • REHAB SPECIALIST


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2


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COWS: Fast Phase of Nystagmus

  • Cold – Opposite

  • Warm – Same

  • Each vestibule tonically pushes eyes to opposite side

  • Cold inhibits, warm stimulates and ear

  • Fast phase of nystagmus: cortical correction





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Vertigo or not?

=Nystagmus or no nystagmus


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Inner ear teleology

  • Utricle and Saccule – Gravity receptors

    • Which way is down??

  • Semicircular Canals - Planar angular accelerometers

    • What’s moving what is still??

    • Which Way is down??


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Why Vertigo?? conditions

  • Converting accelerometer (semi-circular canals) into gravitometers – BPPV

  • Stimulating accelerometer: Meniere’s, labyrinthitis

  • “central” mechanism: hallucination in CNS – much less potent

  • Something stimulates accelerometer (SCC)


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Vertigo DDx

BPPV

Meniere’s

Vestibular neuritis

Bilateral vestibular Loss

Post-traumatic vertigo (labyrinthine concussion)

Perilymph fistula

Migraine and epilepsy

Cerebro-vascular Disease


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Dizziness Battery

Orthostatics and both arms

Hallpike

Fukada

Head Thrust

Head Shake

Romberg (conventional, tandem, foam pad)

Fistula test


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Benign Paroxysmal Positional Vertigo

Recurrent

One ear down position

Positive Hallpike

Transitory positional vertigo

“Vertigo induced by postional change” Unique


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BPPV History

  • Variable history: Many patients complain of waxing and waning dizziness, not always vertiginous and aren’t aware of episodic nature

  • Classic: In bed when turn, looking up, or down

    • Tie shoelace or put clothes on line

  • Remits and exacerbates


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BPPV predispositions

  • Age

  • Post vestibular neuritis

  • Post trauma

  • Ear infections


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BPPV

  • Canalithiasis: By far majority. Set up eddy currents in fluid filled canal

  • Cupulolithiasis: otoliths adherent to walls


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  • Posterior nystagmus are delayed by approximately 15 seconds (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Symptoms and reversed nystagmus may recur when the patient is brought to a sitting position.Nystagmus fatigues on repeated trials. Peripheral nystagmus is latent, paroxysmal, geotropic, reversible, and fatigable.

  • Horizontal canal BPPV nystagmus is purely horizontal and asymmetric, with its stronger component beating toward the diseased canal.

  • Anterior canal nystagmus is rotary, with its vertical component beating downward. The vertical component of benign paroxysmal positioning nystagmus (BPPN) is best observed by asking the patient to move the eyes away from the down-most (tested) ear.


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BPPV Variants – Eye Movements (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Posterior SCC: Canalith or cupulo

    • Torsional to side down and upbeat

  • Horizontal SCC: Canalith

    • Horizontal geotropic

  • Horizontal SCC: Cupulolithiasis

    • Horizontal ageotropic

  • Anterior SCC: Canalith or Cupulo:

    • Downbeat and torsional to side down


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BPPV (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.


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Logroll maneuver for horiz canal (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.


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CANALITH REPOSITIONING (EPLEY) (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.


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Semont Maneuver (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.


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Brandt Daroff (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.


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Paroxysmal psychological Vertigo (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

Form of Panic Attack

Sensory overload

“Supermarket Syndrome”

Complication of untreated BPPV + Anxiety

Computation of position and movement

Worst in Aisles and small spaces: comparator of near and distant movement: Car +claustophobia??

Your life depends on it: Therefore intense fear

“Phobic positional vertigo”


Vestibular neuritis l.jpg
Vestibular Neuritis (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Sudden Vertigo and vomiting

  • Emergency room

  • Extreme motion sensitivity: Pts lay like a rock.

  • Kinetophobia

  • Viral or ischemic

    • Herpes simplex and other viruses. Bell’s palsy of the vestib n.

  • Rarely recurs

  • Look for other signs that may relate to VB system or posterior fossa.


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Vestibular neuritis, neuronitis or labyrinthitis (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • No loss of hearing indicates inflammation of vestibular nerve or scarpa’s ganglion (neuronitis)

    • Inferior vestib nerve goes to posterior canal

    • Superior nerve goes to utricle, sup, lat canal

    • Herpes virus?

  • Hearing loss: may be labyrinthitis

  • Any pain or inflammation: ? Bacterial or other treatable infection

  • Can’t distinguish 100% from brainstem stroke


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Vestibular Neuritis: Findings (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Spontaneous horizontal or horizonto-rotatory nystagmus

    • You may have to block fixation to see it.

  • Fast phase away from the offending ear

  • Veer to slow phase

  • ENG suppressed on offending side

  • 5% or so cases may be recurrent

  • BPPV is frequent sequel


Meniere s l.jpg
Meniere’s (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

Severe vertigo and vomiting

Fluctuating Hearing Loss

Fullness

unilateral Tinnitus

Endolymphatic Hydrops


Meniere s42 l.jpg
Meniere’s (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Vertigo + Vomiting last hours

    • Few disorders are paroxysmal in just this way

  • Patients need not have entire tetrad

  • Most common: Severe vertigo, vomiting and tinnitus

  • A number of “Meniere-like” syndromes

    • Previous insults to inner ear


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Meniere’s treatment (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Avoid Salt and Caffeine

  • Diuretic

  • Surgeries

    • Gentamycin injection

    • Vestibular nerve section

    • Hearing sparing operations


Perilymph fistula l.jpg
Perilymph fistula (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Dizziness with change in pressure

  • Nose-blowing dizziness

  • Sound sensitivity “Tullio Phenomenon”

  • Dizziness with exertion

  • Sensori-neural loss on audiogram


Perilymph fistula45 l.jpg
Perilymph Fistula (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Breach of Round window

  • Superior canal dehiscence

  • Cholesteatoma

  • Trauma

  • Post-surgical esp fenestration for otosclerosis

  • Scuba diving


Perilymph fistula breach of round window l.jpg
Perilymph Fistula: breach of round window. (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

From Tim

Hain


Fistula l.jpg
Fistula (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Strain against closed glottis

    • Upbeat nystagmus CW for right ear CCW for left ear

  • Pull in thru closed nostrils

    • Downbeat nystagmus CW for left ear, CCW for right ear

  • OR do fistula test with bulb

  • OR Test for Tullio phenonenon


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Cholesteatoma (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.


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cholesteatoma (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Hearing loss and loss of balance or vertigo

  • Chronic infection or congenital

  • Basically tumor in middle ear and petrous bone


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INPUTS TO BALANCE (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

3


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Construct Program. Elements: (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Clinicians to Evaluate

    • PM&R, Neurology

      • Diagnosis

      • Therapeutic Recommendations

    • Gait Analysis

  • Treatment

    • Vestibular (habituation, exercise, Canalith)

    • Gait and Balance

    • Devices trial and recommendation


Vestibular rehabilitation l.jpg
Vestibular Rehabilitation (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

Compensations

Avoidance (BPPV)

Substitution (Bilateral Vestibular Loss)

Plasticity (Vestibular Neuritis)

Massed practice to retune CNS and compensate

“habitutation”

Repositioning

Gait retraining


Vestibular rehab l.jpg
Vestibular Rehab (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Habituation

  • Canalith repositioning

  • Balance Retraining Exercises and retraining

  • Conditioning

  • Compensation Strategies

    • As in visual dependence

  • Assistive devices

  • Bracing

  • Muscle strengthening


Vestibular rehabilitation55 l.jpg
Vestibular Rehabilitation (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • VOR Stimulation Exercises

  • Oculomotor Exercises

  • Balance Exercises

  • Gait exercise

  • Obstacle course

    www.emedicine.com/ent/topic666.htm#target1


Cawthorne cooksey exercises l.jpg
Cawthorne-Cooksey Exercises (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • In bed or sitting

    • Eye movements -- at first slow, then quick

      • up and down

      • from side to side

      • focusing on finger moving from 3 feet to 1 foot away from face

    • Head movements at first slow, then quick, later with eyes closed

      • bending forward and backward

      • turning from side to side

  • Sitting

    • Eye movements and head movements as above

    • Shoulder shrugging and circling

    • Bending forward and picking up objects from the ground

  • Standing

    • Eye, head and shoulder movements as before

    • Changing form sitting to standing position with eyes open and shut

    • Throwing a small ball from hand to hand (above eye level)

    • Throwing a ball from hand to hand under knee

    • Changing from sitting to standing and turning around in between

  • Moving about (in class)

    • Circle around center person who will throw a large ball and to whom it will be returned

    • Walk across room with eyes open and then closed

    • Walk up and down slope with eyes open and then closed

    • Walk up and down steps with eyes open and then closed

    • Any game involving stooping and stretching and aiming such as bowling and basketball


Vestibular rehabilitation57 l.jpg
VESTIBULAR REHABILITATION (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

HABITUATION

ADAPTATION OF OTHER SENSORY SYSTEMS


Neurologic syndromes l.jpg
Neurologic Syndromes (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

MS

PD

NPH

Stroke

Aging

Multi-sensory Deficit


Slide59 l.jpg

Normal (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.Gait


Tinetti l.jpg
Tinetti (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

Sitting Balance Leans or slides in chair

Steady, safe

= 0

= 1

2. Arises Unable without help

Able, uses arms to help

Able without using arms

= 0

= 1

= 2

3. Attempts to arise Unable without help

Able, requires > 1 attempt

Able to rise, 1 attempt

= 0

= 1

= 2


Tinetti 2 l.jpg
Tinetti (2) (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • 4. Immediate standing

  • balance

  • (first 5 seconds)

  • Unsteady (swaggers, moves feet, trunk sway)

  • Steady but uses walker or other support

  • Steady without walker or other support0,1,2

  • 5. Standing Balance Unsteady

  • Steady but wide stance (medial heels > 4

  • inches apart) and uses cane or other support

  • Narrow stance without support0,1,2

  • 6. Nudged (subject at

  • max position with feet

  • as close together as

  • possible, examiner

  • pushes lightly on

  • subject’s sternum with

  • palm of hand 3 times.

  • Begins to fall

  • Staggers, grabs, catches self

  • Steady0,1,2


Tinetti 3 l.jpg
Tinetti (3) (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • 7. Eyes closed (at

  • maximum position #6)

  • Unsteady

  • Steady0,1

  • 8. Turning 360 degrees Discontinuous steps

  • Continuous steps

  • Unsteady (grabs, swaggers)

  • Steady0,1,2

  • 9. Sitting Down Unsafe (misjudged distance, falls into chair)

  • Uses arms or not a smooth motion

  • Safe, smooth motion0,1,2


Tinetti gait l.jpg
Tinetti Gait (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • 10. Initiation of gait

  • (immediately after told

  • to “go”)

  • Any hesitancy or multiple attempts to start

  • No hesitancy0,1

  • 11. Step length and

  • height

  • a. Right swing foot does not pass left stance

  • foot with step

  • b. Right foot passes left stance foot0,1

  • c. Right foot does not clear floor completely

  • with step0,1

  • d. Right foot completely clears floor0,1

  • e. Left swing foot does not pass right stance

  • foot with step0,1

  • f. Left foot passes right stance foot0.1

  • g. Left foot does not clear floor completely with

  • Step0.1

  • h. Left foot completely clears floor 0.1


Tinetti gait 2 l.jpg
Tinetti Gait 2 (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • 12. Step Symmetry Right and left step length not equal (estimate)

  • Right and left step appear equal0,1

  • 13. Step Continuity Stopping or discontinuity between steps

  • Steps appear continuous0,1,2

  • 14. Path (estimated in

  • relation to floor tiles,

  • 12-inch diameter;

  • observe excursion of

  • 1 foot over about 10

  • feet of the course).

  • Marked deviation

  • Mild/moderate deviation or uses walking aid

  • Straight without walking aid0,1,2

  • 15. Trunk Marked sway or uses walking aid

  • No sway but flexion of knees or back, or spreads

  • arms out while walking

  • No sway, no flexion, no use of arms, and no use of

  • walking aid0,1,2

  • 16.

  • Walking Stance Heels apart

  • Heels almost touching while walking0,1


Multiple sclerosis l.jpg
Multiple Sclerosis (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

May present as typical peripheral vestibulpathy

? lesion at root entry zone


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Multi-sensory deficit (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Aging

  • Loss of neurons in CNS

    • degenerative

    • vascular

  • Arthritis

  • Peripheral nerve dysfunction

  • Vestibular dysfunction


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Multi-sensory deficit (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Physical therapy

    • falls prevention

    • muscle strengthening

    • trying out assistive devices

    • minimizing deficits


Acoustic neuroma l.jpg
Acoustic Neuroma (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.


Acoustic neuroma70 l.jpg
Acoustic Neuroma (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

Unilateral Hearing Loss

VII and V

Unsteadiness rarely paroxysmal vertigo


Vertebrobasilar insufficiency l.jpg
Vertebrobasilar Insufficiency (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

Vertigo

Diplopia

Dysarthria

Dysphagia

Ataxia

Sensory or Motor Loss

Drop attack

Most feared misdiagnosis in older vertiginous patient


Post traumatic vertigo l.jpg
Post-Traumatic Vertigo (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

BPPV

Meniere’s

“Cervical” vertigo

Perilymph fistula

Factitious (psychological) vertigo


Migraine associated vertigo l.jpg
Migraine Associated Vertigo (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

Headache

Bickerstaff

Vertigo occurs as aura or part of HA syndrome


Autoimmune inner ear disease aied l.jpg
Autoimmune Inner Ear Disease (AIED) (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

Hearing Loss

Vertigo

Bilateral “meniere’s”


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AIED (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

Anti HSP-70

Anti Raji Cell

Sed, ANA, RF, C1Q, FTA, Lyme, Thyroids


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Bilateral Vestibular Loss (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

Oscillopsia

Visual Dependence

Aminoglycosides

Advanced Age + Chronic ear disease


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Bilateral vestibular dysfunction (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • Advanced age

  • Unsureness on feet. Symptomatic only when up

  • Positive Romberg

  • Foam Pad Romberg which diminishes proprioception – hallmark

  • Help by increasing proprioceptive feedback –assistive device, practice.


Motion sickness l.jpg
MOTION SICKNESS (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

CHRONIC SENSITIVITY TO MOTION

OTHER PERSON DRIVING

DISCOMFORT WITH MOTION

VESTIBULAR REHAB: HABITUATION


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Mal de Debarquement (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

Persistence of perception of motion after a cruise

Psychophysiological (?)


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Bibliography (latency), peak in 20-30 seconds, and then decay, with complete resolution of symptoms.

  • www.susqneuro.com

    • “Dizziness Explained”, “Benign Positional Vertigo”, “Vertigo: A Logical Approach”

  • www.thain.com. by Tim Hain, MD

  • www.ivertigo.net by Todd Troost, MD

  • www.onbalance.com: Posturography