Timothy C. Hain, MD
Professor Emeritus, Northwestern University Medical School, Chicago IL, USA.
EMAIL ADDRESS: email@example.com
Page last modified: April 30, 2018
Also see: Placebo devices
Recently there has been an upsurge in vestibular fraud -- both testing and treatment. This is an inflammatory topic, because it involves billing and assessment of competence. In discussions like this, one inevitably ends up implying that certain groups are incompetent and/or unethical, and this invitably ends up generating some very unfriendly emails. Nevertheless, we diffidently offer our opinions here. The author (Dr. Hain), is an emeritus professor at Northwestern University in Chicago, and does vestibular testing and treatment routinely. He competes with some of the groups being discussed here. Commentary sent to the email address above is gladly accepted but it may be added to the content of this page.
Vague and misleading advertisement for VRT.
Advertisement for "KoreBalance" therapy that Dr. Hain scanned in from his local (Chicago) paper.
OK - so how do we know that this is fraud ?
At the top, it asks "do you suffer from ... tinnitus ... " There is no device that is effective for tinnitus or Meniere's disease. While this advertisement does not directly indicate that this device is useful for these conditions -- the implication is strong. There is also an implication that this device can treat vertigo, motion sickness and faintness. It seems very implausible to us that training administered for 30 minutes twice/week can treat any of these conditions.
Second, lets look at what actually is being advertised -- Korebalance is a trademark of SportKat. Because this device is computerized, this device can be operated by someone with the same general expertise as the person who operates the cash register at your local convenience store. This advertisement does not mention any supervision by a physician. The lack of detail is disturbing.
Groups that advocate this procedure are generally stand-alone physical therapy groups without medical supervision. The author of this page feels that use of this device is usually a good indication that there will be unrealistic promises, unethical marketing practices, and inexpert care. See our page about how to find a VRT provider.
This advertisement does not pass the "would you send a family member to this group" test. I would not send someone from my family to a group that implied that they could treat tinnitus with a computerized balance testing machine.
In the Sunday paper here in Chicago, we saw several advertisements for treatment of dizziness. We have put one of them above. This advertisement is extremely misleading - -the device being marketed (not even shown in the ad) is not proven to work and in fact, here it is suggested that it could be effective for conditions involving hearing (tinnitus) !
Here, the potential for abuse is gigantic as these practices have no mechanism to sort out the numerous causes of dizziness, and deceptive advertising is permitted.
Gyrostim device. This images is from this site (which is for a chiropractic practice).
The "Gyrostim". Unproven device for treatment of dizziness.
A chiropractic practice in Chicago recently installed a "Gyrostim" device (see below). This is a carnival ride type gadget, advocated by Dr. Carrick (a chiropractor), for nearly any type of dizziness. This device is also advocated for treatment of MdDs, and a physical therapy practice in Asheville NC, installed a device as well. A discussion of the Gyrostim, suggesting that it is "quackery", can be found here. The same machine is advocated (by chiropractors) for concussion as well as many other unrelated conditions.
We are not seeing places like Harvard or Mayo install these devices for treatment. We are seeing out of the way practices in North Carolina and chiropractors put these devices into service.
According to the Gyrostim website, the Gyrostim has NOT been approved for by the FDA. Here I quote from their website accessed on 4/30/2018 -- "The GyroStim™ has not been cleared by the FDA for marketing as a medical device. Applications and use of the GyroStim are at the discretion of the owner/operator. GyroStim has not been approved for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease."
Oddly enough, although PT practices and Chiropractors are installing these devices, there is no scientific evidence that the Gyrostim helps anyone. Let me repeat -- as of today (4/14/2018), there are NO SCIENTIFIC PAPERS IN PUBMED on the Gyrostim. It would be reasonable to call the Gyrostim an experimental device.
What we do have though are papers on "pitch while rotating", which is the core part of this device. Pitch while rotating is a very powerful source of motion sickness (Raphan et al, 1983; Raphan et al,1999).
We have heard that taking a "ride" on this device is very costly. This makes some sense. There are substantial risks here, both for the patient (might be a waste of time and money), and for the clinic (expensive gadget, will it be profitable, will people get hurt and sue clinic ?)
Overall: The Gyrostim is an unproven method of treatment for vestibular problems. It may help people through habituation. It would seem very reasonable to try the Gyrostim as part of an experimental protocol. We are dubious though that one should pay for something that is unproven. Unproven things are not always fraud, and sometimes they are ahead of their time, but the context here is disturbing. This is also very much a "buyer beware" situation. Unless you have money to burn, and don't mind vomiting that much, we think best to avoid this device. Things may change once there is a reasonable paper published showing that this device has a measurable, objective positive outcome. This would not be that easy though, as all our measures of imbalance are greatly affected by effort.
Our suggestions regarding avoiding fraud in vestibular rehabilitation treatment
- Chiropractic or stand-alone allied health professions such as audiology or physical therapy practices should not be permitted to bill for vestibular treatment procedures without physician oversight, because they do not have the appropriate expertise, the potential for abuse is extremely high, and because we have personally observed a large number of inappropriate claims. Of course, if someone wants to pay out of pocket for treatments involving this device, thats their business. We just don't think that insurance dollars should be going to pay for this.
- As an alternative, a strong credentialing procedure should be established for VRT. We think that credentialling should be of physicians -- preferably neurologists and physiatrists.
- Gyrostim treatment for dizziness is presently unproven. At best, it is experimental. We think it is generally best to avoid treatments without a scientific basis, especially if they are costly.
Here we refer to individuals - -mainly chiropracters -- who advocate and bill for a mixture of valid anatomy/physiology with irrational and ineffective treatments. Chiropractors often generate notes that are "word salad" -- they produce notes that seem to be randomly generated mixtures of medical words, that have no meaning at all. This often results in outrageous statements:
The above is copied from a chiropractic note from a local practice in Illinois. Lets deconstruct this paragraph. First sentence -- vague and meaningless, also ungrammatical. Second sentence -- "Proto-onco gene" -- onco-gene has to do with cancer. What on earth is this doing in a note about an inner ear problem ? Third sentence -- "We need to restore plasticity ... ". This is strange -- one treats BPPV with a physical maneuver. Next sentence -- "coupled manipulation ...". This is nonsense. Last sentence -- "We also need to some ...". Not grammatical, but it is true that actitity might help. So -- Chiropractic word salad.
Another example of this is the site http://www.askdrjohnson.com/dizziness.php -- where a "chiropractic neurologist", "Dr. Johnson", makes some very unreasonable claims.
On this site, "Dr Johnson" indicates that cerebellar disorders can be detected by tests of coordination - -this is true. However, he leaves out a large amount of critical information -- as only a small fraction of dizziness conditions are caused by cerebellar disorders. This in nearly all situations -- this observation that cerebellar disorders can be diagnosed by specific clinical procedures --- is irrelevant to almost all dizziness.
Then, "Dr Johnson" goes on to indicate that the cerebellum can be treated by (and I quote -- italics added to make it clear what is being quoted)
"Treatment of the cerebellar dysfunction may include:
- Unilateral (one-sided) Adjustments: Extremities (arms and legs), lumbar (low back) and cervical (neck) spine will be manipulated on one side only to fire muscle spindle cells (muscle receptors) and joint mechanoreceptors (joint receptors) into the same cerebellum and opposite cerebra cortex (brain). The thoracic (mid-back) spine will be globally manipulated to fire the dorsal columns (back part of the spinal cord) and reduce rib fixations.
- Caloric: A warm water caloric of 180 milliliters may be administered in the ear to stimulate the ipsilateral (same side) cerebellum.
- Eye Exercises: Eye exercises may be used to increase the frequency of firing to the cerebellum and frontal lobe of the brain.
- Heat Therapy: Heat therapy is used to promote an increased metabolic and healing rate to the involved tissue. Increased heat helps increase activation to the brain. Heat has immediate soothing and palliative effects as decreased joint stiffness, decreased muscle spasms and releases histamine and bradykinin causing vasodilation of the tissues.
One or all of the procedures may be employed to restore the cerebellum to its normal function."
These statements (even if they were relevant and they are not) are either false or simply extremely misleading, as none of the procedures "Dr Johnson" advocates are legitimate methods of making a durable change to cerebellar function.
For those patients with dizziness who chose to spend their personal cash on these types of procedures -- we wish them well, but we think their money could be better spent. There is a latin phrase -- caveat emptor (buyer beware).
Our suggestion regarding dealing with Chiropractic vestibular treatment fraud.
- A strong credentialing procedure (see here) should be established for VRT providers. We do not think that VRT should require a physical therapy (or chiropractic) degree, but we think that the provider should establish that they are competent, through successful completion of an examination.
- Chiropractic treatment for vertigo, similar to physical therapists, should need a referral from a medical doctor, with an explicit authorization every month, to be paid. If treatment is not authorized, payments should be discontinued and clawed back if needed.
There are also many instances where the individuals proposing the treatments could be well intentioned, but the treatment advocated obviously will never result into anything useful. One wonders why such devices manage to flourish in spite of their lack of reasonableness. One interpretation is that "hope springs eternal", but another possibility is simply that these projects are being funded by government grants. See this page on placebo devices for more.
- Raphan, T., et al. (1983). "Nystagmus generated by sinusoidal pitch while rotating." Brain Res 276(1): 165-172.
- Raphan, T., et al. (1999). "Canal and otolith afferent activity underlying eye velocity responses to pitching while rotating." Ann N Y Acad Sci 871: 181-194.