Compensation and Constraints

The downstream effects of avoiding discomfort.

Compensation

In the last year of getting my doctorate in audiology, I had the honor of being competitively selected to be an extern at The Cleveland Clinic. The top ranked ENT & Audiology Department was a hub for referrals for the most unique and challenging hearing and balance disorders from around the globe.

The most memorable and valuable rotation was supporting Dr. Judith White, otolaryngologist and Head of the Vestibular and Balance Disorders Program at the time. All patients referred to her clinic had already been unsuccessfully treated by at least one specialist for whatever underlying disorder was contributing to chronic imbalance.

My first lesson was the power of a thorough case history. When knowledgeable about the range of potential causes of dysfunction in a specific area, she taught me 75% of disorders could be accurately diagnosed from a comprehensive assessment of a patient’s symptoms, medical history, and reported experience alone. We would spend at least 30 minutes, often much more, with each patient upon their first visit. All subsequent, objective testing was then utilized to identify or rule out possibilities contributing to a problem based on the unique information obtained from the case history. Considerations relating to the inner ears, eyes, body, and mind were always thoroughly investigated. We were holistically supporting people, not treating specific disorders.

My second lesson was on the inevitability of compensation people will adopt when responding to persistent problems of known or unknown nature. Compensation, in the medical realm, is the mind and body’s adaptation to imposed constraints. If moving your head causes the world to spin around, you’re likely to stop moving your head. Regardless of underlying cause, every person reported to our clinic with guarded movements to prevent the possibility of continued imbalance. In response to this self-imposed constraint, the neural reflexes, muscles in areas like the neck, synergy in the complex balance system, and even one’s psychology unproductively compensated.

I remember one woman in particular. In her mid-30s, married with two children, she reported intermittent, brief episodes of vertigo (spinning sensation) in response to particular head and body movements for the past ten years without successful intervention from countless specialists.

Benign Paroxysmal Position Vertigo (BPPV) is the most common cause of episodic vertigo. It is so prevalent that we will often assess patients for its presence regardless of case history because the evaluation only requires a trained eye and the ability to put a patient in different body positions.

The inner ears have three canals responsible for maintaining our sense of orientation during head movement in all directions. Sensors firing in each canal from each ear at over 1000 impulses per second provide the brain information on how to reflexively move the eyes in a particular plane as the head moves to maintain gaze. The movement of the eyes during dynamic positioning of the head is called nystagmus.

In BPPV, crystals (otoconia) that typically sit on a gelatinous membrane responsible for sending the vestibular impulses to the brain become dislodged into one of the three canals of the inner ears. These crystals then disrupt fluid movement and subsequent neural firing coming from the vestibular system to make the brain believe it is spinning. Watching eye movements while placing the body and head in certain positions provides a properly educated person with information on which canal and ear may be impacted by BPPV. After diagnosis of BPPV, a person can be moved in a particular manner to guide the crystal back to its intended location. With no equipment, a person can be assessed, treated, and systematically cured of the most common condition impacting vestibular dysfunction. Successful treatment of this perceptually devastating condition is one of the most rewarding experiences for a trained vestibular specialist.

The woman was understandably extremely nervous prior to my assessment. She had been tested and repositioned many times over the past decade unsuccessfully and had gotten to the point where the experience of vertigo caused vomiting. Reassuring her I was trained by one of the best experts in the world and the chance of throwing up was worth it for a proper assessment of what sounded very likely despite previous failed attempts, she agreed to trust me. Her previous report of when vertigo appeared suggested the right ear was the target. Based on the nature of her symptoms and case history, I made a call to test the rarest canal impacted by BPPV. At only a 5% prevalence rate, the anterior semicircular canal is positioned to make the chance of a crystal falling into it unlikely and consequently harder to treat. As I laid her back into a position known as the Deep Dix-Hallpike, her eyes began jumping in a pattern consistent with right anterior canal BPPV. I held her head in a steady position as she partially filled up one of the emesis (fancy for puke) bags with breakfast. Stability in this moment is crucial. Imagine a light stone floating in a circular tube. As you move it, the stone will respond to the hydraulic energy and then slowly settle once the movement has stopped. Allowing the head to move after a positive diagnosis of BPPV prevents the ability to effectively progress into a repositioning maneuver - it’s a wasted opportunity. After her eyes stopped dancing, indicating the otoconia and vestibular system had settled, I began the slow, controlled progress of moving my patient’s head in each of the planes necessary to treat the rarest form of BPPV. As I supported her head, neck, and body while moving her, she kept one hand on the barf bag and the other on my arm as if she was riding the worst rollercoaster she’s ever been on. When finished, we sat together and discussed next steps. Due to the nature of her unique case history, we would withhold retesting her to ensure the crystal cleared until the following day and have her sleep in a reclined position that evening. The following day, we repeated the assessment. With bag at the ready and trust in the process, she held onto me as I put her into the same Deep Dix-Hallpike position from the day before. No nystagmus, vertigo, or nausea.

She was stunned. As I slowly tested the other canals in each ear, my patient was now in tears. Ten years of suffering resolved with moving the head and body in a particular way. We decided to schedule a follow-up in a few weeks just to ensure she was good to go.

Upon return, she stated she no longer was experiencing the familiar, full bouts of vertigo when laying down, but she continued to experience dizziness of various descriptions whenever moving her neck. Ten years of guarding movements had caused progressive atrophy of this region and all the systems that work through it. Following two months of vestibular physical therapy, primarily aimed at neck movements like the ones found in standing position of this month’s daily challenge, she reported she felt like she was a new person without constraints.

Her mind and body readapted to the stimulus she was no longer guarding herself from - movement of the head. Ten years of degradation caused by understandable attempts to prevent unmanageable vertigo was reversed with two months of consistent, strategic effort in her area of opportunity.

Constraints

Compensation in one area naturally causes downstream consequences in another.

An injured knee guarded often leads to hip surgery. A difficult conversation chronically avoided leads to further fracturing of a relationship. Preservation of psychological safety constrains what is perceptually safe.

Avoidance of specific discomfort causes progressively increasing challenges.

Easier now, harder later.

The world is going to deliver adversity of all shapes and sizes. Often, external constraints will at least temporarily limit our full capacity, especially when their causes are unknown. We often passively or unknowingly adopt constraints without understanding future ramifications.

Which constraints will you accept and which will you reject?

Will you resign yourself to limitation, or will you accept what’s outside your control while exploring every option even if it takes ten years?

The woman I was lucky to serve inspired me. For ten years, she refused to quit seeking support while doing what she could to show up for her children and family. She naturally experienced the consequences of compensation while continuing to explore options for improvement. Ten years of resilience. Ten years of not giving up. Two months to full recovery when she found her solution.

We always have a choice.

Constrain wisely.