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Best steps to Treat MDDS (Mal de Debarquement Syndrome)

Learn about what MDDS is, how it can be treated, and other resources to learn more about MDDS management.

Diagnosis criteria for Mal de Debarquement Syndrome

Criteria for the diagnosis of Mal de Débarquement syndrome

1. Non-spinning vertigo characterized by an oscillatory perception (rocking, bobbing, or
   swaying) present continuously or for most of the day.
2. Onset occurs within 48 hours after the end of exposure to passive motion.
3. Symptoms temporarily reduce with exposure to passive motion.
4. Symptoms continue for >48 hours. (More on this in the next section)
5. Symptoms not better accounted for by another disease or disorder.

MDDS diagnostic criteria has changed slightly to include a spectrum of time someone has been experiencing symptoms. This has been designed to help those get a diagnosis and begin treatment sooner which is a great addition. Here they are:

• MdDS in evolution: symptoms are ongoing but the observation period has been less
  than 1 month
• Transient MdDS: symptoms resolve at or before 1 month and the observation period
  extends at least to the resolution point
• Persistent MdDS: symptoms last for more than 1 month

3PD vs MDDS: what are the differences?

When searching for answers and finding a diagnosis, it can be tough to know which description fits best. You can also have more than one vestibular condition to make diagnosis more challenging. Dr. Madison talks with Vestibular Group fit Members the differences between Vestibular Migraine, PPPD, and MDDS as well as treatment considerations if you have a combination of diagnoses.

In this blog we’ll briefly talk about some differences between 3PD (persistent postural perceptual disorder) and MDDS

3PD

• People typically feel worse in car
• Will typically feel worse with walking/movement
• additional 3PD criteria can be found in this blog post here.

MDDS

• People usually feel better in car
• Will tend to feel worse with walking

Non-motion triggered Mal de Debarquement Syndrome

If you’re searching for answers, you might come across non-motion triggered MDDS. This area of vestibular research and classification is still up for debate. Some think this is a different form of chronic dizziness, or vestibular migraine, or something else. Time will tell where this ends up!

MDDS treatment: Dai protocol

A very popular protocol for MDDS treatment is the Dai protocol. A 2018 research study by Dai et al show that 75% of those undergoing treatment had significant improvement when followed for 1 year. This protocol involves a few important tests and equipment to follow and is best to be done with a provider knowledgeable in this protocol. If you’re in a place where a provider isn’t familiar, they can read research and implement the protocol with you.

More information on the Dai protocol can be found here.

A great treatment tool for MDDS or other visual vertigo can be found here through 360 Neuro Health. Talk to your provider before using to find the best dosage and progressions.

Mal de Debarquement Syndrome treatment continued

There are more treatment considerations than the Dai protocol. Medications such as SNRIs/SSRIs and benzodiazepines have been shown to be a beneficial part of treatment for some.

Other factors to consider as part of treatment include:

• sleep
• diet
• exercise
• stress management
• vestibular exercises/VRT
• mindset
• neuromodulation

Dr. Shin Beh goes into detail on MDDS and treatment in his book Disembark, check it out here as well as other great books Dr. Beh has written.

Disclaimer

Interested in learning more? Check out this other blog post on Mal de Debarquement Syndrome

here.

Want to learn more about MDDS,  and other vestibular tools from the experts and be a part of a supportive community to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

Learn tips for dating with a vestibular disorder. We cover dating, relationships and intimacy with Dateability cofounder Jacqueline Child.

Dateability: A Dating app for those with disabilities and chronic illnesses.

Dating with a vestibular disorder can be challenging or intimidating to begin after a receiving a vestibular diagnosis. Jacqueline Child is a co-founder of Dateability and talks with Dr. Madison oak about dating and intimacy with chronic illness and disabilities. Jacqueline encountered ableism on other dating apps, and experiences impacting her self esteem. In october 2021 after a feed tube surgery, Jacqueline expressed her wish for a dating app tailored to people like herself. Jacqueline’s sister proposed they make this wish a reality. Dateability aims to foster understanding, compassion and connection to provide a safe space where chronic illness is not a deterrent to finding meaningful connections and love. Learn more about this app here.

5 Suggestions when dating with a vestibular disorder

1.You’re more than your vestibular condition! Talk about other interests, projects or hobbies you have going on or hope to start!

2. Explaining your vestibular condition can be short and simple at first. Jacqueline compares it to how you’d explain your condition to a child.  Remember, you’ve learned so much about your condition, that it can be overwhelming to someone that is learning. This can vary based on their exposure to the medical field as well (vocabulary and health literacy etc). Keep it easy, if they have follow up questions and you want to answer them, go for it! 

3.If there’s an activity that doesn’t work great for you, let your needs known and suggest an alternative activity. When dating with a vestibular disorder, certain activities might not be the best for you. Instead of saying no to their suggestion, feel free to let me know that won’t work for you and suggest an alternative activity that works for you. For example swap out a bike ride for a picnic in a park, or maybe a tram bike that moves slower and multiple people steer and peddle. 

4.Be honest about your needs early on. You don’t have to list them all out day 1, but when something comes up, mention the relevant information or accommodations needed. For example, if someone suggests a movie and the time is late. Casually mention that staying up late isn’t great for you, and see if the there’s an earlier showing.

5.Communication is key when dating with a vestibular disorder, and discussing your vestibular condition is a very vulnerable thing to do. Practice can help, whether it be with close friends and family, or going on some dates just to practice how you share your story with someone new. 

Tips for Discussing Chronic illness in Dating or with your current partner

• Communication is so important. Be honest about how you’re feeling, and limitations. 
• not communicating your feelings and needs is unfair to yourself and your partner. Expressing your feelings and needs is the best way for others to understand what’s going on. Assuming others can read your mind can make everyone frustrated. 
• hiding symptoms and pushing beyond your limits to appease others ends up backfiring in the end

• Have a codeword or phrase to convey you’re not feeling well. It lets other know what you’re feeling without having to put it into so many words. 
• Longer conversations and explanations might not be necessary at first. But can be beneficial to have eventually to ensure understanding, trust, and building a deeper connection. 

Navigating intimacy with vestibular disorders

Intimacy and sex is an area that is important to address when it comes to dating with a vestibular condition and relationships. This part of romantic relationships can be a source of apprehension when dating or looking for a long-term partner. Communication here is so important (sensing a theme about communication?).  

Having a conversation outside of intimacy and sex can help. Knowing modifications or positions that are best, or how to handle situations when a pause is needed beforehand will help in the moment to do what’s best for your body. This may feel uncomfortable or awkward, but communication is about trust, and knowing your partner cares about you to support you and want what’s best for you in all aspects of life. 

Disclaimer

Want to learn more about dating, relationships, other vestibular tools from the experts and be a part of a supportive community to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

Learn more about gaining self compassion with your vestibular condition and how to adapt mindfulness practices to best suite your needs. Fellow Vestibular Group Fit member Melina is a certified mindfulness instructor and shares her expertise on self compassion and mindfulness but with a chronic illness and vestibular focus.

Meet Melina

Melina is a certified mindfulness educator who offers classes in her community and as a  professor at the University of Rochester. She is also a member of Vestibular Group Fit. Her research and teaching interests include music and the body, the history of somatic practice, and embodied pedagogy. Because she lives with recurrent BPPV and vestibular migraine, much of her meditation teaching focuses on mindfulness for chronic illness and pain.

What is self compassion

Self compassion can feel like this ellusive thing everyone talks about but doesn’t really understand. Melina offers a great definition. Self compassion is about acknowledging struggles, offering ourselves comfort, and extending kindness to ourselves and others facing a similar experience. You are not alone, others have felt exactly what you are feeling now, and that shared human experience unites us to humanity.

Basically, self compassion is  treating ourselves the way we would a close friend who is struggling. We want to extend ourselves the same acceptance we have for our close friends or family. We embrace them for who they are, imperfections and challenges and all. Self compassion is doing the same for yourself.

Self compassion has positive benefits, including calming our nervous system, and can be an important tool in healing and growth. Self compassion can enhance other mindset work you’re already doing for continued growth and impact. Using  self compassion with a vestibular condition can assist in weathering flares or daily challenges while becoming resilient for future challenges.

How to adapt mindfulness practices for you

1.Have a gentle approach. Don’t force changes in thought. Allow yourself to be present in your discomfort. Respond with kindness and allow your body to focus on other thoughts, feelings and sensations as one retreats and another announces its presence.

2. There is no set guidelines you must follow. Pick and choose what you like. There are different anchors available to work on being in the present. A popular anchor is focusing on your breathing. Try the “choose your own anchor” practice. For this  practice, be aware of your vestibular symptoms, and in addition to ours symptoms, focus on something pleasant or neutral. This acknowledges your challenges while finding moments of peace and balance within.

Not sure about positive or neutral areas to focus on? Visit the post on mindfulness and critical thinking that dives into this more here.

3. Create a mindful and safe space. This can be in any position you find comfortable, finding anchors that best fit to your style and needs, picking and choosing different practice aspects that you enjoy.

Melina also recorded three tracks to work on self compassion, mindfulness, and with a vestibular focus. These are available to vestibular group fit members, if you’re interested in becoming a member click here.

Other helpful tips for self compassion with a vestibular condition

1.Treat yourself like you’d treat your best friend. Having symptoms is not your fault, don’t beat yourself up. Treat yourself how you would a friend going through the same struggle.

2. Finding kindness for yourself. This can be stating a phrase like “May I be kind to myself at this moment?” or “it’s okay, I’m here for you”. Consider imagining a pet or person and what you’d say to comfort them. Imagining them may also generate a feeling of kindness or warmth.

3. Remember that you are not alone. Part of the shared human experience is suffering. Say to yourself “I am not alone”. This shared experience connects us to so many others, people we know and strangers. All of this is part of being human.

If you’re interested in learning more, Melina recommends David Treleaven’s work “Trauma-Sensitive Mindfulness”. Learn more about his work here.

Disclaimer

Want to learn more about mindfulness, listen to recorded tracks to guide you through self compassion,  other vestibular tools from the experts and be a part of a supportive community to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here. 

Inflammation and dizziness

Have you tried traditional treatment for your vestibular condition or dizziness but feel like somethings missing? Dr. Emily Kostelnik discusses how unlocking the connection of inflammation and her body helped her find the missing piece of her vestibular treatment and management.

Meet Dr. Emily Kostelnik, PHD

Dr. Emily’s vestibular story

Dr. Emily Kostelnik is a clinical health psychologist and has her own personal experience with vestibular orders and dizziness. She has combined her personal and professional experience to assist others with vestibular conditions through Rooted Behavioral Education (link here) and her practice as a clinical health psychologist The Vestibular Psychologist (website here)

Follow her on instagram at rootedbehvaioraleducation and thevestibularpsychologist. She’s a wealth of knowledge and shares this on her social media accounts!

Dr. Emily also has a course on fucntional medicine, inflammation and alternative answers to dizziness. You can purchase the course here. Vestibular Group Fit members get a $75 discount so look in your premium content, or sign up for the discount ( you still save $15). If you’re unsure if this discount code is still active, email us and ask prior to purchase! 

Dr. Emily Kostelnik was diagnosed with Superior Canal Dehiscence (SCDS) in 2018 with two surgeries to correct. In post partum, Dr. Kostelnik faced debilitating PPPD and VM.

Starting with more conventional treatment (VRT, Heal your headache diet, working with an otolgist), she noticed progress but still noted lingering symptoms. Medications were prescribed to address ongoing floating sensations, trouble with screen time etc but she felt like there was still something missing.

With the assistance of functional and integrative medicine doctors, Dr. Kostelnik researched more the possible role of inflammation and dizziness. This turned out to be an important part of her recovery and management strategy and she’s here to share what she’s learned. Overall she is dizzy free most days!

Yes, Dr. Kostelnik is dizzy from time to time, but again, is mostly dizzy free!

What is inflammation?

To understand inflammation in our bodies, we need to talk about our immune system. Our immune system defends our body from outside threats. Think bacteria, viruses, pollen, infections etc. Anything our body finds suspicious or potentially harmful, our immune system attacks.

Inflammation is the immune system’s response to a threat. Not all inflammation is bad, it is the first part of the healing process. Initially inflammation is good! It helps identify and surround the perceived threat to avoid damage to other tissues or further spread. This is done by the immune system leaking fluid and protective chemicals to the specific area. Typically, the next step is to clean out this area of the threat, and the acute inflammation phase is over and our body starts the next phase of returning to baseline.

When our body doesn’t start the next step and stays in the  inflammatory phase, this can lead to chronic inflammation. In chronic inflammation, our body continues to respond like there is a present threat. A persistent state of chronic inflammation can feel like a decline in our health, like you’re never feeling like your best self.

Chronic inflammation can be a result of: chronic injuries, chronic infections, surgical implants, things we eat, the way we act (or don’t act…mindset is important!), sedentary lifestyle, our environment. A certain combination of factors, everyone is different, can begin to overwhelm our bodies and we then reach a state of chronic inflammation.

How does inflammation and dizziness fit together?

Research has found that people with vestibular disorders (acoustic neuroma, vestibular neuritis, vestibular migraine, BPPV, PPPD) and those with anxiety depression were associated with higher inflammatory markers. Inflammation can affect us all differently. For some, it causes dizziness, for other it may be migraine or a thyroid condition.

If our body is inflammed, and constantly trying to remove a threat, it impacts our body’s ability to function. This is additional energy, resources and stress on our body dedicated to increased inflammation. When our bodies are in this state, it’s hard to reach baseline or feel like your typical self.

3 Ways to that can help improve inflammation

• Exercise can help reduce inflammation in our bodies
• nutrition. our gut biome is super important. Eating inflammatory foods or having guy dysbiosis can impact inflammation in our body
• mindset. working on positive thoughts, or being with others to get a positive mood boost can work wonders for our body!

Mast Cell Activation Syndrome, Histamine, inflammation and dizziness.

We won’t go into much detail here, but you can find more on this via Dr Emily’s social media and in the interview with Dr. Emily and Dr. Madison for vestibular group fit members.

Mast cells release chemicals when a threat is perceived. Mast cells release many different chemicals, one of them is histamine.  Too much histamine in our body can result in histamine intolerance and can contribute to chronic inflammation.

There’s a wide variety of opinion on this subject, and diagnostic criteria can be hard to accurately measure and meet. Even if you don’t meet the diagnostic criteria, you may still benefit from different management options. Talk if over with your doctor.

What about medications, supplements, antihistamines for inflammation and dizziness or MCAS?

Medications

• We can’t tell you what to take, that’s a conversation for your doctor. We’re big fans of taking meds when you need it and if that’s something you want to take. Medications aren’t a sign of failure and don’t have to be a forever thing if you don’t want it to be. Again, this is a hugely important conversation to have with your doctor! If they don’t support your preferences on this topic, find one that does if you can!
• It will be trial and error to find a med that works best for you. Meds are just one part of the treatment pie so keep in mind those other treatment options.
• if you’re on a med and happy with your current plan, great! Keep doing what you’re doing

Supplements

• everyone is different, some may benefit from supplements, others may not.
• this is very person specific, what does your body need and what are the routes to get it?

Anti-histamines

• again, what works best for you?
• some find elimination diets can be helpful, but this is a SHORT TERM SOLUTION. This can help determine why cells get overactive, or discover if there’s a personal connection in histamines, inflammation and dizziness for you
• anti-histamines may help symptom management, but long term use can have other health consequences including increased risk of dementia, or increased production of histamines to counteract the long term blockage. Again, do what works for you, have these conversations with your doctor. This may be a short term solution to dig deeper and find a longer term management plan!

How to Find and Functional Medicine Doctor

Find a list of all functional doctors here at IFM.org.
Reminder, functional doctors may have differing opinions on what they think is going on, and course of treatment. It may take a few to find the right fit or find the help that works best for you! Some may be helpful for inflammation and dizziness, you may find them helpful for other health conditions you don’t feel have been fully addressed!

Disclaimer

Want to learn more about inflammation and dizziness,  and other vestibular tools from the experts and be a part of a supportive community to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

How to get through your ‘To Do’ List & Daily tasks with dizziness

Energy conservation (or pacing) is a way to listen to your body and strategize your day to get chores done while minimizing fatigue and dizziness as much as possible. Read on to learn how to get through your ‘to do’ list and daily tasks with dizziness, learn why it’s hard, ways to get it done today!

Phone battery analogy

Use a 0-100% battery meter to gauge your energy levels and dizziness on any given day. Keep in mind tasks you do will drain your batter, just like using your phone will drain it. Don’t let your energy battery (or phone battery) reach zero. It’s easier to charge when you’re at 70-80% than when you’re at 10%.

6 Tips & Tricks to pace with dizzness

Take a look at these 6 tips to strategize your day. Consider your energy/dizzy battery for the day and these tips to map out your day. Reminder, it’s okay to ask for help, to prep part of a task for a later day (like soaking dishes), or delegate to another family member or service.

Some days we have big plans to get things done, but we wake up with increase symptoms, fatigue, and a lower body battery. That’s okay, it’s not your fault and you are not a failure. Focus on what can be done, including self care to have the capacity for your list another time.

Household and daily tasks with dizziness: the breakdown

In this section we’ll cover some common household chores or daily tasks and discuss why they’re challenging and ways to make them easier.

Our premium content members also have guidance on movements and strength exercises to increase their tolerance to these tasks. Doing exercises and movement will make tasks easier to do in the future. Learn more here.

Dishes

Why it’s difficult:

• Repetitive body movement (from sink to rinse to drying rack)
• eye tracking
• standing balance

How to pace with dizziness:

• Use the dishwasher if available
• stack dishes to move more at once and reduce large/repetitive movements
• soak dishes to make cleaning easier and faster
• wash multiple items before rinsing to reduce movements
• try a suction glass cleaner to take some of the effort of off you.

Laundry

Why it’s difficult:

• lots of up/down movements
• busy visuals
• noise/smells/light depending on the environment
• mental energy to sort and fold

How to pace with dizziness:

• ask for help. Have family take their own pile of laundry to put away or fold
• do folding and sorting seated
• Make laundry your one task for the day. Break down the tasks to give yourself rest time
• don’t fold everything! I’ve started to keep clothes I don’t mind being wrinkly in fabric bins. When I sort laundry I can put my socks in the sock bin, delicates in the delicate bin, and workout shirts/shorts in their bin. Cuts down my laundry time and I realized how much folding I did for things that I didn’t care about needing to be folded.

Stairs

Why it’s difficult:

• physically demanding
• looking down
• visually challenging: seeing both near and far

How to pace with dizziness:

• Use the railing when available
• reduce trips by doing all tasks on the top floor and then going downstairs for tasks
• keep a basket at each end to place objects in that need to go up/down to avoid multiple trips. A great way to get others to help as well!

Cooking

Why it’s difficult:

• looking down
• balancing
• lots of turning and reaching
• tracking
• focus

How to pace with dizziness:

• use some prepped foods like pre cut veggies
• do food prep in sitting when able
• Find simple recipes, The Dizzy Cook is an awesome resource, her cookbook is here
• have some easy frozen and pre baked meals
• use a slow cooker

Computer time

Why it’s difficult:

• tracking and scanning
• head position and posture
• mental fatigue and concentration
• light sensitivity

How to pace with dizziness:

• ergonomics for better computer posture (some extra tips for set up here)
• avalux glasses (code: VERTIGODOC will you get $25 off) or other blue light blocking lenses
• taking breaks with the 20-20-20 rule

Reading

Why it’s difficult:

• mental fatigue and concentration
• tracking and scanning
• head position and posture

How to pace with dizziness:

• audiobooks when able
• use your finger to help track the line you’re reading
• take breaks

Showering, Grocery Shopping, Escalators, Elevators, the dentist/hair dresser, cleaning the house, gardening and more!

Learn why wall these tasks are challenging, ways to get these tasks done now and products that help, and how to work on movements to improve  all of the tasks listed today! All of this and more is included in our supportive community at Vestibular Group Fit!   Find out more at this link: https://tvd.flywheelstaging.com/about-group/

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

Conquer vestibular migraine: a beginners guide

Here is a beginners guide to vestibular migraine. We’ll cover the difference between migraine, vestibular migraine, management tips and tricks, and when to start vestibular rehabilitation (VRT).

What is migraine? How is vestibular migraine different?

In general, migraine is a neurological disorder and has various symptoms that can be present. Here is a list of some common symptoms associated with migraine:

• head pain (typically experienced on one side, near the eye/temple region, but not always)
• vertigo, imbalance, and dizziness
• light sensitivy
• sound sensitivity
• smell sensitivity
• nausea/vomitting
• neck pain
• ear ringing/tinnitus
• visual changes
• tingling
• and more

Migraines act differently with each person. A common misconception is that a migraine is only a bad headache, or if you know someone with migraines and their symptoms are different than what you experience you think “oh well I don’t have migraines because they’re nothing like my friends”. If it’s impacting your life, it’s worth talking to a medical provider about!

Vestibular migraine

Vestibular migraine accounts for 3% of all migraines. This subtype of migraine has specific symptoms relating to the vestibular system (vertigo, imbalance, dizziness, brain fog, feeling “off”, lightheadedness etc).

The International Classification of Headache Disorders criteria for vestibular migraine are:

• At least 5 episodes of vestibular symptoms of moderate or severe intensity lasting 5 minutes to 72 hours
• Current or previous history of migraines with or without aura according to the ICHD classification
• One or more of the following migraine features with at least 50% of vestibular episodes:

1. 1. Headache with at least 2 of the following characteristics
   2. One-sided location, pulsating quality, moderate or severe pain intensity; photophobia or phonophobia
   3. Visual aura

• Not better accounted for by another vestibular or ICHD diagnosis

click here for the research article that outlines this criteria.

The big thing to remember here is that not all vestibular migraines have head pain/headaches. Headache can be present, as well as the other symptoms on the list above in addition to vestibular symptoms.

Phases of migraine

• There are 5 phases to migraine. Again, everyone can experience these phases differently, but are important to know to better identify how your body responds to a migraine event so you can act quickly when you begin to see signs of a migraine for best results.

The 5 phases are:

• Prodrome
  • Symptoms that occur in the beginning of an attack. Can last hours to days
• Aura
  • neurological symptoms that occur right before an attack. Can last 5min-60min
• Attack
  • The most severe symptoms, lasting hours to days.
• Postdrome
  • The end of an attack, gives you a “hangover” feeling. Can last hours to days
• Interictal
  • Symptoms that are experienced between attacks (quick spins, fatigue, light and sound sensitivity are a few). This is due to the underlying migraine condition and where vestibular rehabilitation therapy (VRT) can be helpful. But it’s also very important to get the migraine under control before heading into VRT, more on this later!

When to start Vestibular Rehabiliation (VRT)

VRT is beneficial in addressing residual symptoms after migraine attacks, or the interictal symptoms experienced in day to day life. VRT is most effective when attacks are mostly under control. If you’re having multiple attacks in a month, or you’re having a hard time getting symptoms under control, VRT may not be appropriate at that time. A couple of sessions may be helpful for education to try various methods to get symptoms under control, or addressing neck pain through gentle stretching, manual work, postural and ergonomic education).

VRT is most beneficial when your migraine is under control. Using habituation principles to improve interictal symptoms is best done when your vestibular migraine is under control. If your migraine and symptoms aren’t well managed, trying to do VRT is like throwing gasoline on an already raging fire and hoping it burns out.  This is why VRT can make you feel worse. It’s important to have a therapist familiar with vestibular disorders and vestibular migraine to guide and dose your VRT appropriately.

What should I do when I have a vestibular migraine attack

If you begin to feel an attack coming on, you want to initiate your plan as soon as possible to try to stop th eattack or minimze the severity or time of symptoms. This may look like:

• Acute meds prescribed by your neurologist
• magnesium
• ginger
• grounding and breath work
• gentle walking
• water
• electrolytes
• Cefaly or GammaCore
• essential oils
• icepack/headache hat

Vestibular migraine management

• Start with the basics:
  • eating meals regularly
  • consistent sleep
  • hydration
  • Gentle, daily movement
• Mindfulness and mindset work. Stress can be a big migraine trigger!
• Consider blue light glasses, ice packs/headache pack, educational books (found more in depth here)
• Research backed vitamins and supplements for migraine (full list here). Vestibular Group Fit members get 30% off their fullscript orders!
• Talk to a neuroglist to see if you fit a vestibular migraine diagnosis. Discuss a plan for you regarding preventative, acute and rescue medications.
• Track large symptom days to find patterns. (migraine buddy is a helpful app for this)
• Diet and hormones can also be involved. More on diet here and here and here; more on hormones here and here.

There’s a lot of great content on tis website for vesitbular migraine, I tried to include most of it here but might have missed some. Vestibular Group Fit is a great place to find all this information presented to you in one spot with excellent resources, with a community of others to provide their own experience, advice and guidance for symptom management, lifestyle changes, and support with movement.

Disclaimer

Want to learn more about vestibular migraine management  and be a part of a supportive community to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

3 ways Somatic Therapy can help dizziness

Learn how somatic therapy can help dizziness with psychotherapist Kate Schwab, LCSW. We’ll cover what somatic therapy is, the benefits, and tools to get started today.

Kate Schwab, LCSW is a licensed clinical social worker and psychotherapist. In vestibular group fit, Dr. Madison and Kate talk about how somatic therapy can help dizziness and tools that are helpful in supporting your body.

What is Somatic Therapy

Somatic therapy combines psychology, neuroscience, ethology, physiology, indigenous healing practices, and medical biophysics. Guidance of somatic therapists assist you in learning what your body needs to feel supported.

3 parts of somatic therapy involve:

1. Nervous system activation and overwhelm
2. Pacing
3. Support tools

We’ll take a look at each of these parts to learn how somatic therapy can help dizziness. More information and a recorded interview with Madison and Kate can accessed with a premium account.

How is Somatic Therapy different than Acceptance and Commitment Therapy (ACT) or Cognitive Behavioral Therapy (CBT)?

ACT/CBT are talk therapies type and focus on behavior. Both are symptom management focus. ACT brings in more mindfulness work: what are your behaviors and beliefs and changing those. With somatic therapy, it’s less symptom oriented and more of ‘what’s happening for you internally?’. We are looking at WHY those symptoms are there and deeper work. These areas cover different parts, so if you’ve had ACT or CBT therapy, you could benefit from somatic therapy. Keep reading to learn how somatic therapy can help with dizziness in its unique way.

Who could benefit from Somatic Therapy?

Most people can benefit from this work, and there are many reasons we experience trauma responses. Chronic illness can be traumatic and so in general somatic work can be really useful!

Nervous System Activation and Overwhelm

When first experiencing pain or dizziness, we begin to try everything and anything to make it go away. This urgency can lead to desperation, feeling overwhelmed and hyper vigilant of what we’re experiencing. This heightened state ramps up our sympathetic nervous system- the “fight flight or freeze”. This is not a state we are meant to be in for long periods of time,and normally kicks in when there is an external threat. When the threat is external, like a sudden loud noise or dark looming figure, this is extremely helpful to get us out of that area and to safety. In the case of dizziness, the perceived threat is internal, so how do we get to safety? This is where somatic therapy can help.

This is so so common in dizziness, check out this article on the dizzy anxious cycle and Dr. Emily Kostelnik with Rooted Behavior Education for more on this as well.

Back to how somatic therapy can help with dizziness. Learning how our own body and nervous system begins to ramp up and “activate” helps us identify what our body needs to get through these situations and move towards health and homeostasis. Everyone is different, and each situation is different.

If we ignore these signs, or don’t have the tools to help support what our body is telling us, we can reach a point of overwhelm and our body shuts down on us. Pacing is the practice of identifying these activations, and working on tools to assist your body, a major part of what Kate and other somatic therapists are amazing at!

Pacing

Pacing involves going SLOW. This is not easy and takes practice. This makes us think about the exact moment we are in and what our body is experiencing. Go into a quiet room and focus on moving towards health. Focusing on what you’re feeling right now, what your body needs right now. This is abstract and hard, which is why lovely people like Kate are here to help guide you further. Pacing helps identify what you’re experiencing, and getting support systems in place. This is how somatic therapy can help with dizziness.

Over time and with practice, the goal is you start to learn more about your body and have tools to support it. Pacing helps you be more aware of your window of tolerance. It’s okay to have nervous system activation, people like Kate help you to identify and work through it. If you aren’t in touch with your body, it’s hard to move along various activation states tolerably.

Support Tools, Avoiding Hyperawareness, Derealization/Dissociation

It’s important to check in with your body with chronic conditions and symptoms to avoid doing too much, making it easy to become hyper vigilant of what you’re feeling.

Try and know that you know how to handle this, and you’ve filled your prescriptions, and you can call your doc if needed, you have a support system, and at the same time you need to let your brain set it down and enjoy the moment that you’re in. This is hard and takes repetition and practice.

What about derealization or dissociation?

These come with the feeling like you aren’t real. Like you’re watching your world through a TV. Feeling disconnected or viewing the world from a glass plane. These can be survival mechanisms (and that’s not a bad thing!)  but ways to try to shake this are:

• Breathing (box breathing or 4 counts inhale, 8 counts exhale. Hold briefly before repeating)
• talking out loud to yourself “I’m okay I am present, I am here”
• can you put on a podcast to laugh at, music to sing or dance to?

Give these a try, did it help? These are a few of the ways somatic therapy can help dizziness, derealization and dissociation.

Contact info

Follow Kate for ongoing education or reach out if you have questions or are interested in working with Kate to see how somatic therapy can help dizziness, chronic pain and more! Click here to reach Kate’s website.

Want to learn more about tools, how somatic therapy can help dizziness, and other vestibular tools to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

5 Main Audiology Tests for Vestibular Disorders
With vestibular audiologist Dr. Alexandra Smith, Au.D, CCC-A, F-AAA.

Dr. Alexandra Smith is based in Santa Fe, NM (you can find her clinic here) and works to identify, diagnose, treat and prevent various diseases, injuries or defects of the ear. Audiologists are also able to assist their clients with maintaining good hearing and can assist with hearing devices. Dr. Smith perform audiology testing for vestibular disorders and is going over them in more detail to help you better understand your test results and know what to expect. If you think you’d benefit from audiology testing for vestibular disorders, talk to your doctor about comprehensive audiology testing.

 

This blog post covers some content Dr. Smith covers with Dr. Madison Oak, vestibular physical therapist for our vestibular group fit members. These tests are common when evaluating for vestibular disorders but aren’t always well known or explained. Read below to learn more about audiology tests for vestibular disorders and what they can help tell you about your vestibular condition.

What is a vestibular audiologist?

A specialty within audiology which includes: 

1. Hearing and tinnitus evaluations 
2. Surgical implant care
3. Vestibular evaluation
4. Select vestibular treatments (like the epley maneuver for BPPV) 
5. Diagnostic tests which we’ll go into more detail below! (ECOG, audiogram, VNG, brain wave testing, positional testing and more)

Using audiology tests for vestibular disorders can be another piece of information to consider with other testing (MRI, physical therapy, occupational therapy, ENT, Neurology etc) to best determine a plan of care to manage your vestibular condition. 

What is the role of a vestibular audiologist?

What does audiology testing and vestibular disorders have to do with each other? Anatomically, our inner ear has both a spatial awareness system (the vestibular system) AND hearing portions (the cochlea) that make up the inner ear. The nerve that connects our inner ear to the brain also branches from the same nerve to reach both of these sections. It is also common to have other ear symptoms or hearing changes with vestibular conditions, so it’s important to get  testing done by a specialist in the hearing portion of our inner ear, an audiologist! 

What are the 5 main audiology tests for vestibular disorders?

Common audiology tests for vestibular disorders include: 

1. VNG (Videonystagmography exam)
2. Caloric testing 
3. ECOG (Electrocochleography exam)
4. VEMP (Vestibular evoked myogenic potential)
5. Audiogram

Below, we’ll go into more detail on what these tests measure, what to expect, and how these tests can help with vestibular diagnostics. 

VNG (Videonystagmography exam)

• Goggles are worn to measure and track eye movements using special software and is tracked on a chart
• Wearing the goggles, the audiologist will perform an oculomotor exam (tracking targets, saccades/looking between multiple targets other eye movements) 
• Positional testing such as the Dix hall pike (for BPPV testing) 
• caloric testing, read on to learn more about this one
• VNG can help determine any positional dizziness like BPPV and identify any central signs that may warrant a referral to a neurologist, or peripheral signs that could point to a vestibular condition

Caloric testing

• Done with air or water, each ear gets 1 minute of warm and  1 minute of cool  air/water
• The temperature of the warm and cold air/water is mild.  This temperature change stimulates your vestibular system. This can cause uncomfortable sensations of movement or rotation.
• It is normal to feel dizzy for part of the test and it will go away. All you have to do is keep your eyes open!

• The stimulation of the vestibular system causes the dizzy sensation and eye movements (nystagmus- more on that here)
• These eye movements are being measured with infrared video goggles. The left and right ear are compared to see if the movements are symmetrical.
• If the left and right ear are asymmetrical, this could indicate a unilateral vestibular weakness or vestibular hypofunction (you can learn more about this here)

You are in control and can stop at anytime, it is NOT AN ATTACK.

ECOG (Electrocochleography exam)

• A brain wave test that looks for increased fluid pressure in your endolymphatic sac in your inner ear (indicative of meniere’s disease) 
• NOT a test in isolation of meniere’s disease-more accurate in the middle of an episode but more people don’t get into a clinic for testing during an episode

VEMP (Vestibular evoked myogenic potential)

• Cervical and ocular VEMPS are cVEMP or oVEMP
• Testing otolith function ( the utricle and saccule) 
• Analyze the two branches of your vestibular nerve.
  • Can see if one nerve is stronger than the other or if one side is weaker 
• Can test for 3rd window syndrome like superior canals dehiscence syndrome
• Laying down on the table, one head movement and one eye movement.

Audiogram

• A hearing test, typically for first test you get in a audiologists office 
• Can be very helpful in what’s going on and even help address what you’ve been experiencing 
• Can tell you if you have hearing loss and where (what type of frequencies), and tympanic reflexes that can let us know about any ear pressure that man be going on 
• Labyrinthitis will cause hearing loss
• Meniere’s disease also causes low frequency hearing loss on the affected side 
• Age related hearing loss tends to be in both ears and at higher frequencies.

Can you have normal testing and still have a vestibular disorder?

YES! Certain vestibular conditions will not show up on this testing. Migraine will not show up on MRI, CT scans, ECOG VEMP or VNG or audiograms. These tests can still be helpful for these conditions that require a diagnosis of exclusion to rule out other conditions that these tests can reveal. Audiology tests for vestibular disorders can help lead us to identify specific diagnoses. If testing comes out normal, audiology tests for vestibular disorders can also help consider other diagnoses that would show normal testing. 

Audiology tests for vestibular disorders is one piece of testing to be considered with other providers testing and listening to what you’ve experienced. Listening to your experience and looking at all the test results can help get the right team of providers (OT, PT, Neuro, ENT) in your corner to start your healing journey. It’s natural for this team to change slightly, or change focus for periods of time with certain providers based on your needs. Keep your team in the loop so they can help adjust accordingly, they’re here to help YOU. 

 

Want to learn more about vestibular testing, ear pressure, tinnitus and other vestibular tools to get back to your daily life?  Find out more at this link: https://tvd.flywheelstaging.com/about-group/

 

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

Tips and tricks for traveling with a vestibular disorder

Travel plans can be popular this time of year to spend holidays with family and friends, warm vacation destinations, or other special occasions. Overall, no one really loves traveling, but it can be even more challenging with a vestibular condition.Read below to find some lists of our favorite travel tips with a vestibular disorder and for some specific to different travel types!

How to travel with a vestibular disorder: Preparation is key!

Here are our Top 10 effective tips to help prepare for your upcoming trip and traveling with a vestibular disorder successfully. Keep reading to learn more about how to travel with a vestibular disorder based on specific types of travel! 

1. Make the first planned trip low key. A short trip or close destination is a good idea to test out traveling and make adjustments for future trips. 
2. If staying in a condo or hotel, request a lower floor. This will help with any symptoms with heights and reduce time spent in an elevator (or just using the stairs!) 
3. Make sure you have enough medication prior to your trip. If your meds run out while on your trip, get a refill before travel. Talk to your doctor if it’s a controlled substance to get a plan on how you’re going to have your needed medications for your trip. 
4. Pack a small bag within your suitcase. This gives you something to easily carry important meds or your vestibular kit on day tips at your new destination. 
5. Pack a vestibular travel kit. Pack all the things you use for symptom management in one bag. Make sure this bag is easy to access throughout your travels. Store it in your personal item or carry on bag if you have one. It may include:
   1. Medications (rescue, preventative, over the counter etc) 
   2. Peppermint or ginger (candy or scented oil)
   3. migraine/blue light glasses (we like avalux if you want to check them out here) 
   4. Hat 
   5. Ear plugs/noise canceling headphones
   6. Snacks 
   7. Water 
   8. Travel pillow 

6. Pack your own pillow. Having your own pillow helps ensure a good nights sleep at your new destination. Some people will order and ship a pillow similar to theirs to where they are traveling to cut down on packing! 

7. Stay hydrated throughout your travel day. Taking additional breaks for the bathroom can help keep you active and use it as an opportunity to check in with yourself and take a break if needed. 

8. Get a good night’s sleep the night before

9. Eat a good breakfast on travel day. 

10. Try to stay active before and during travel. Light walks, different position changes while sitting, seated marches, seated kicks, standing heel raises or sitting/standing can help keep your body moving.

How to travel with a vestibular disorder based on transportation (car, train, plane, boat)

Traveling with a vestibular disorder by car

Driving is a common challenge I hear when working with those who have vestibular conditions. If you’re looking for more driving tips, check out our other blog post on driving here. This list is geared more towards longer driving trips to reach your travel destination. Let’s dive into how to travel with a vestibular disorder by car: 

1. Pack ahead of time, if you notice something you’re using regularly, put it in your suitcase so you know you won’t forget it. 
2. Pack up the car the night before 
3. Sit in the front passenger seat, keep your eyes on the horizon
4. Listen to music or audiobooks for entertainment
5. If being the driver helps your symptoms, make sure you’re safe to do so! Talk to your doctor about returning to driving and make sure you practice driving for longer periods of time and learn your drive time limit. 
6. Use gas stops/bathroom stops as time to take a movement break and do gentle stretching, exercise or walking. Use as a time for grounding as well. 
7. If the drive is more than a few hours, consider flying to cut down on overall time traveling.

Traveling with a vestibular disorder by plane

Traveling by plane can be really daunting, especially after living with a vestibular condition. We at The Vertigo Doctor want you to consider flying as an option, especially if it cuts down travel time considerably. Less time spent with the stresses of traveling means the sooner you can start to rest, relax, and recover! Here are ways for traveling with a vestibular disorder by plane: 

1. Have your vestibular travel kit with you on the plan and easy to access in the airport and during the flight 
2. Give yourself plenty of time to reach your gate. Recommended time is usually 2 hours prior to your flight. If you’re not familiar with the airport, or it’s a large airport that involves shuttles, giving yourself more time to rest and ask for help can help reduce the stress of flying! If unsure, ask for help sooner rather than later!
3. Try to book direct flights 
4. Try to avoid flying during really early or really late flights to avoid large shifts in your sleep routine 
5. If changing time zones, try to slowly adjust your sleep schedule by 15 minutes the days prior to gradually match your time zone if possible. 
6. Try to sit in the aisle and near the wings. This can help minimize any rocking from the plane and the aisle gives you ample opportunity to get up and move. 
7. Try to avoid smaller planes that aren’t pressurized 
8. A travel neck pillow or eye mask can help make yourself comfortable on the plane. 
9. Ear planes are ear plugs made for air travel to help with pressure changes. Yawning or gum can also help with altitude changes
10. Ask doctor for any medication suggestions to help with plane (like a decongestant or rescue med if you don’t have one)

Traveling with a vestibular disorder by train

Trains might not be as common in the United States for longer trips, but these tips may help if you take a train for your daily commute. If you’re also trying to travel to another country or continent that uses trains more for  travel such as Europe, check out these tips on how to travel with a vestibular disorder by train:

1. Face forward and on the aisle to avoid too much visual stimuli. Looking outside tends to be more challenging. 
2. Take a short movement break at train stops. 
3. If the train is moving and you need to get up, it’s okay to use your hands to touch the chairs or overhead luggage compartments for more balance when walking on the train.
4. If you have to stand, spread your feet wide to have more support, try finding a pole to hold onto to try to avoid holding your arm overhead for extended periods. If the overhead grips are the only thing available, try to alternate your arms every stop to get a rest. 

Traveling with a vestibular disorder by boat

Whether it be by ferry or a an afternoon on the lake, boating is certainly a way of transportation to be prepared for! Here are some considerations when traveling with a vestibular disorder by boat: 

1. Sit towards the center of boat to reduce rocking 
2. Try to stay outside on the deck if possible. 
3. Talk to your doctor about any recommended motion sensitivity medication to bring in addition to your vestibular travel kit 
4. Sea band or acupressure bands can be helpful for some with sea sickness.

How to recover from traveling with a vestibular disorder

1. Congrats on your trip! 
2. Remind yourself that some “off” sensation or feelings is normal for anyover after a lot of travel and it will get better. 
3. Try a short walk to help “reset” the system 
4. Get good night’s sleep 
5. Grounding, meditation, relaxation. 
6. Try to make the day after travel a calmer day. Something restful and relaxing. If you want to join a group that’s something more adventurous, try to get there a day early to recover and be ready for it!

If you found this article helpful, check out this other article on our site that has additional information on traveling with a vestibular disorder by clicking here.

Want to learn more about managing your vestibular condition with travel, return to driving, hormonal impacts, and other vestibular tools to get back to your daily life?  Find out more below! 

Click here

Disclaimer:

Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here.

Long-COVID rehabilitation: The best Treatment for Long-COVID

We all were affected by the COVID-19 pandemic, and because of that we have all heard of Long-COVID, and hopefully, about Long COVID Rehabilitation. And, no matter what happened to you or around you during the pandemic, somethings has become more and more prevalent over the last few months is Long-COVID. Long-COVID is a hot topic, and I want to start off by saying one thing: You are NOT making it up. I have worked in chronic illness since I gratulated from Physical Therapy school and I understand the gaslighting in the medical system, especially the US medical system. BUT, I am here to tell you that you are making that up. Most people with the COVID-19 virus recover within 1 week, but that’s definitely not the case for everyone. According to UCLA health, one in three people with a COVID diagnosis will develop Long-COVID.

So, today let’s talk about it: what is Long COVID Rehabilitation?

Are you making up Long COVID?

You are not making it up! I want you to know that this is not in your head.
Your symptoms, whichever way you may be presenting, are very real. I have seen many providers who either ‘don’t believe you’ or ‘don’t believe Long-COVID would be so severe’. But, I am here to say that there are many different and debilitating symptoms!
The biggest issue we are having is that we don’t have enough research on covid and Long-COVID, so many provider just don’t know what to do about it at this point.

What are Long-COVID symptoms?

Long-COVID symptoms can be incredibly variable and truly span anywhere from fatigue to cardiovascular issues. Your symptoms can be cardiovascular, respiratory, general fatigue, fever,  difficultly sleeping, and more. Because we just don’t know enough about Long-COVID right now, we can’t make an exact list. But, if you had COVID and now you’re experiencing symptoms you did not have before it could definitely be correlated with Long-COVID. Long COVID symptoms could last anywhere from a few weeks to years. COVID began in early 2020, and patients have been dealing with Long-COVID symptoms since that time. It’s difficult to say at this time if they last forever or not. However, it does seem like we are able to treat Long-COVID, though through LongCOVID rehabilitation and medication.

Long-COVID & Dizziness

Long-COVID is known to cause many different symptoms, as we discussed above. One of the overarching symptoms that we did not touch on above is dizziness. As a provider who treats dizziness and vertigo, I have been treating SO much Long-COVID. It started with just one patient who had dizziness related to COVID-19, but has been a very big influx of my caseload, especially for someone who treats Vestibular Migraine and PPPD usually.

Long-COVID Dizziness is thought to come from the virus infecting and inflaming your inner ear. Your inner ear controls balance and equilibrium, and spatial awareness. Without this organ functioning accurately, you will feel dizzy, light headed, and other related symptoms. Another Long-COVID dizziness diagnosis is POTS. POTS, or Postural Orthostatic Tachycardia Syndrome is an autonomic dysfunction. Autonomic dysfunction is your automatic systems in your body. Everything from digestion to heart rate and breathing are controlled by your autonomic system, because these are all involuntary. And, they’re REALLY important! Long-COVID rehabilitation, can help regardless of the type of dizziness you are experiencing after a Long-COVID diagnosis!

Long-COVID rehabilitation has had its difficulties in treatment, but it’s nothing that my patients and I haven’t been able to trouble shoot. Long-COVID is not one of those sicknesses that you get and then suddenly you just get 100% better again. There may be adaptation and compensations you have to make in your life, and your lifestyle may look a little bit different than it did pre-COVID. However, I do find that specific rehabiltation directed at each of your symptoms is incredibly effective in getting you back to at least some of your ‘normal.’

How do you treat Long-COVID?

Long-COVID is complex, and I like I said above, we just don’t know enough about it. But, we have seen that Long COVID rehabilitation is effective. Your symptoms can range anywhere from looks like POTS to seeming like a concussion. No matter what the symptoms, Long-COVID treatment is rehabilitation. Long-COVID rehabilitation providers are typically physical therapists and occupational therapists. There are also medical providers who have branched into this kind of medicine as well. There are a few studies that have shown to be somewhat effective in treatment with medication. At this time it is all preliminary information. UCLA and Stanford both have excellent West coast treatment centers. Additionally, there are a few others like in Kansas City,  Germany, New York City, and more!

Treating Long-COVID from a medical standpoint and a rehabilitation standpoint is the best way to go about treatment overall. I recommend finding both a medical doctor and a physical or occupational therapist to help you rebuild strength, improve visual symptoms, reduce dizziness, and more.

Long-COVID Rehabilitation

Long-COVID rehabilitation will look like a few different kinds of physical therapy combined into one treatment plan.

At this point, there are not many experienced Long-COVID rehabilitation practitioners, none of have more than a year or so of experience. However, we all piecing together information the best that we can! If you are looking for a provider, I recommend calling around to physical therapist and occupational therapist offices and asking if they’ve had any experience working with Long-COVID rehabilitation patients. And, if there is not someone in your area, try and find someone who is at least willing to learn with you!

Currently, I am taking patients for Long-COVID rehabilitation in the following states via telehealth: Wyoming, Virginia, Maryland, California, New York, and New Jersey!

If you’d like to schedule an evaluation appointment to work with me, email me at [email protected] for more information!