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CENTRAL VERTIGO-RECENT PERSPECTIVES
Prof. A.V. SRINIVASANM.D,D.M,PhD,F.A.A.N,F.I.A.N
PROFESSOR EMERITUS –
THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY
Prof. A.V. SRINIVASANM.D,D.M,PhD,F.A.A.N,F.I.A.N
PROFESSOR EMERITUS –
THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY
07-01-11-CHENNAI
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Dr_2.avi
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Balance the imbalance
Vertigo denotes a hallucinatory sensation of movement
Being ignorant is not so much a shame as being unwilling to learn
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Prevalence of Vertigo and Giddiness
• 5 % of Patients visiting the General
Practitioner
• 10 % of Patients visiting the
Otorhinolaryngologist
Oosterveld WJ, Adv. Oto-rhino-laryng, 1983, 29, 39-49Oosterveld WJ, Adv. Oto-rhino-laryng, 1983, 29, 39-49
“My Opinions are founded on knowledge
but modified by experience”
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What causes vertigo?
• Contradictory information from
– The vestibular system (ears)
– The visual system (eyes)
– The Proprioceptive system (muscles, joints)
Daroff RB, ‘Faintness, Syncope, Dizziness and Vertigo’ IN Harrison’s Principles of Internal Medicine, 14 th edn, 105
Daroff RB, ‘Faintness, Syncope, Dizziness and Vertigo’ IN Harrison’s Principles of Internal Medicine, 14 th edn, 105
Experience can be defined as
yesterday’s answer to today’s problems
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Types of Dizziness
1. Light headedness2. Multiple sensory deficit3. Cervical spine disease4. Imbalance5. Faintness6. Acute vertigo with nausea and worse
with head motion7. Vertigo present only with head motion
Being ignorant is not so much a shame
as being unwilling to learn
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Sites of Vertigo
The secret of walking on water is
Knowing where the stones are
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Causes of Vertigo (Peripheral Vestibular - arises in Vestibule)
• Benign Paroxysmal Positional Vertigo
• Meniere’s Disease
• Labyrinthitis
• Head Injuries & Surgical Trauma
• Pressure Vertigo
Memory, the daughter of attention ,
is the teeming mother of knowledge - Martin Tupper
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Causes of Vertigo (Intermediate Vestibular - arises in Vestibular Nerve)
• Vestibular neuronitis
• Acoustic neuroma
• Drugs
Science is below the mind; Spirituality is beyond the mind
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Causes of Vertigo (Central vestibular - arises in Vestibular Nuclei)
• VBI (Vertebrobasilar Insufficiency)
• Arteriosclerosis
• Cervical Spondylosis
• Whiplash injuries of Neck
• Brain Tumors
Success is a prize to be won. Action is the road to it. Chance is what may lurk in the shadows at the road side.
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Head injuries
Epilepsy
Multiple sclerosis
Hypoglycemia
Migraine
Non-Vestibular Causes of Vertigo
• Ocular vertigo
• Anemia
• Cardiovascular (orthostatic
hypotension)
• Cerebrovascular disorders
• Psychogenic
• Brain tumors
In any field, find the strangest thing and explore it
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Another classification of vertigo• Paroxysmal Vertigo - sudden attack comes on
quickly, lasts for a short time
• The single attack - sudden intense attack fading away slowly
• Chronic vertigo - not severe
• Positional vertigo - occurs following sudden movements of head in certain positions
• Dizzy spells - lasting a few seconds occurring irregularly
What is mind no matter; What is matter never mind
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Medical History• Description of symptoms by patient
• Classification of vertigo attacks (Which type, how debilitating, frequency, duration, vegetative symptoms)
• Influencing circumstances (Injuries, drugs taken, stress, eating pattern, Illnesses)
• Secondary symptoms (Tinnitus, Hearing loss, Headache, nausea/ vomiting)
Biswas A., ‘Neurotological History Taking’ IN An Introduction to Neurotology, 1998, 8-11
Biswas A., ‘Neurotological History Taking’ IN An Introduction to Neurotology, 1998, 8-11
DIAGNOSIS OF VERTIGO
Take time to think; it is the source of powerTake time to read; it is the foundation of wisdom
Take time to work; it is the price of success
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Adapted from Biswas A.,’Clinical tests in Neurotology’ IN An Introduction to
Neurotology, 1998, 13-25
Adapted from Biswas A.,’Clinical tests in Neurotology’ IN An Introduction to
Neurotology, 1998, 13-25
Balance Tests• Postural tests
– Romberg test
– Unterberger test
– Babinski-weill test
– Barany Pointing test
• Eye movement test– Nystagmus
Character gets you out of bed; Commitment moves you to action; Faith, Hope and Discipline follow
through to completion
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Every thing should be made as simple as possible; but not simpler
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•Patient closes eyes and stretches arms out in front
•Walks on spot for a minute
•Patients with vertigo will start to turn his axis in particular direction
•The knees raised as high as possible
“Healthy Mind and Healthy expression of Emotion go hand in Hand”
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• Deviation to one side in pointing occurs in patients with vertigo
BARANY’S
Give us the GRACE to accept with serenity the things that cannot be changed the COURAGE to change the things that should be changed
and the WISDOM to know the difference
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Patient with vertigo starts to walk in a star shapePatient with vertigo starts to walk in a star shape
Babinsky- Weill Test
Patient closes his eyes and takes 5 steps forward
and 5 steps back for 30 seconds
NATURE, TIME AND PATIENCE are the 3 great physicians
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Spontaneous nystagmus
No nystagmus Nystagmus
eyes closed eyes closed
Eyes openEyes open
No Nystagmus NoNystagmusNystagmus Nystagmus
Peripheral CentralPeripheral or
disorder disorder central
disorder
No Nystagmus NoNystagmusNystagmus Nystagmus
Peripheral CentralPeripheral or
disorder disorder central
disorderTruth comes out of error sooner than that of confusion
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Induced nystagmus• Positional nystagmus
Any nystagmus that occurs when the head
is in position other than normal upright
• Positioning nystagmus
occurs when change of head position and
used to diagnose BPPV
The Truth is Fear & Immorality are two of the greatest inhibitors of Performance to progress
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Differentiation of Peripheral and Central VertigoSign / Symptom Peripheral Central (Brainstem
(Labyrinth) or Cerebellum)
Direction of associated Unidirectional; fast Bidirectional or nystagmus phase opposite lesion* unidirectional
Purely horizontal Uncommon Commonnystagmus without torsional component
Vertical or purely Never present May be presenttorsional nysagmus
Visual fixation Inhibits nystagmus and No inhibitionvertigo
Direction of associated Unidirectional; fast Bidirectional or nystagmus phase opposite lesion* unidirectional
Purely horizontal Uncommon Commonnystagmus without torsional component
Vertical or purely Never present May be presenttorsional nysagmus
Visual fixation Inhibits nystagmus and No inhibitionvertigo
* In Meniere’s disease, the direction of the fast phase is variable.* In Meniere’s disease, the direction of the fast phase is variable.Daroff R. B., ‘Faintness Syncope, Dizziness and vertigo IN Harrisons Principles of Internal Medicine, 14th Edition, 105Daroff R. B., ‘Faintness Syncope, Dizziness and vertigo IN Harrisons Principles of Internal Medicine, 14th Edition, 105
“Fools Admire but of men of sense approve”
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Differentiation of Peripheral and Central Vertigo
Sign / Symptom Peripheral (Labyrinth) Central (Brainstem or Cerebellum)
Severity of vertigo Marked Often mildDirection of spin Toward fast phase VariedDirection of fall Toward slow phase VariableDuration of Finite (minutes, days, May be chronicsymptoms weeks) but recurrentTinnitus and /or Often present Usually absentdeafnessAssociated central None Extremely commonabnormalitiesCommon causes Infection (labyrinthitis), Vascular, demyelinating,
Meniere's, neuronitis, neoplasmischemia, trauma, toxin
Severity of vertigo Marked Often mildDirection of spin Toward fast phase VariedDirection of fall Toward slow phase VariableDuration of Finite (minutes, days, May be chronicsymptoms weeks) but recurrentTinnitus and /or Often present Usually absentdeafnessAssociated central None Extremely commonabnormalitiesCommon causes Infection (labyrinthitis), Vascular, demyelinating,
Meniere's, neuronitis, neoplasmischemia, trauma, toxin
Daroff R. B., ‘Faintness Syncope, Dizziness and vertigo IN Harrisons Principles of Internal Medicine, 14th Edition, 105Daroff R. B., ‘Faintness Syncope, Dizziness and vertigo IN Harrisons Principles of Internal Medicine, 14th Edition, 105
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“The True Art of Memory is The Art of Attention” - S.Johnson
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“ We Sometimes think we have forgotten something when in fact we never really learned it in the first place”
Imp.Your Memory Skills
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Through Action You Create your Own Education - D.B. ELLIS
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• Acute peripheral vestibulopathy (for a maximum of 1 – 3 days)•
• Acute brainstem lesion near the vestibular nuclei• • Frequent and severe attacks of vertigo accompanied by •
nausea and vomiting• Severe benign paroxysmal positioning vertigo with
nausea • and vomiting (0.5 h before the liberatory maneuvers)
• Prevention of motion sickness• • Central positional/positioning vertigo with vomiting.
Thought is the labour of the intellect Reverie is its pleasure
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Saccades and Vestibular Ocular motor adaptation
• Saccade adaptation• Cross-axis adaptation• On axis adaptation: New findings• Changes in the dynamic properties of adapted saccades• A role for forward models in the control of saccades• Behavioral deficits in saccade adaptation with cerebellar lesions• Vestibulo-Ocular Reflex (VOR) adaptation• VOR adaptation induced by position and alternate error signals• Compensatory saccades as an adaptation to abnormal
peripheral VOR function• Physiological correlates of saccade and VOR adaptation
Imagination is more Important than KnowledgeImagination is more Important than Knowledge
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Whatever the Mind can conceive and Believe, the mind can Achieve -Napoleon Hill
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A open foe may prove a curse ; but a pretended friend is worse
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Management of vertigo
• Pharmacotherapy
• Adaptation exercises
• Surgery
“Social Isolation is in itself a pathogenic
Factor for disease production”
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A Vertigo Patient
I WANT ..
• Fewer attacks every month
• Attacks should not be as
bad as before
• Attacks should not last long
A true commitment is a heart felt promise to yourself from which you will not back
down
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Pharmacotherapy(Antivertigo drugs)
Vertigo suppression drugs
• Anticholinergics
• Sympathomimetics
• Antihistaminics
• Psychotherapeutic drugs
• Antiemetic phenothiazines
Drugs modifying underlying pathology
• Cerebroactive drugs• Vasodilators• Diuretics• Corticosteroids• Antibacterial drugs
Thinking is the hardest work there is,
which is probable reason why so few engage in it.
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Site of action of anti-vertigo drugs
• Labryinth – Diuretic and corticosteroids• Blood flow – Vasodilators• Reticular formation – Sympathomimetics• Reticular formation Antiemetic
(cholinergic pathway) Antihistaminesvestibular nuclei Anticholinergics
• GABAnergic suppression - Psychotherapeutic drugs
of vestibular nuclei
Mind is the great level of all things; human thought is the process by which human ends are ultimately answered
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Phenothiazines(Prochlorperazine,Thiethylperazine)
• Prochlorperazine is less sedating than some other phenothiazines but drowsiness still occurs
• Also causes hypotension, Parkinsonian side effects
--Betts T et al, Brit. J. Clin. Pharmac, 1991, 32, 455-8,
--Curley JWA, E N T Journal, 1984, 65, 555-560
• “The drug which most commonly causes parkinsonism in general practice is Prochlorperazine”
--Chaplin S, Geriatric Medicine, 1989, Feb, 13-14
Serious, sincere, systematic studies, surely secure supreme success
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Anxiolytics (Tranquilizers)(Benzodiazepines such as diazepam, Lorazepam)
• No effect on the underlying vertigo
• Helps patient endure the symptoms by allaying anxiety
• Many side effects drowsiness and sedation, dependence
and addiction abuse potential, psychomotor
impairment, memory loss, interactions with alcohol
Harris T, Ear Nose Throat J, 1984, 65, 551-5
“Men of Genius Admired: Men of Wealth envied women of power feared but only women of
character are trusted”
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Diuretics(e.g. Furosemide, Hydrochlorthiazide)
• Used in vertigo and meniere’s disease
• Reduce the volume of endolymph by promoting
urine flow and reducing fluid retention.
• Use mainly associated with electrolyte imbalance
Ludman H, Brit. Med. J., 1981, 282, 454-457, Harris T, Ear Nose Throat J, 1984, 65, 551-5
Ludman H, Brit. Med. J., 1981, 282, 454-457, Harris T, Ear Nose Throat J, 1984, 65, 551-5
“Motivation is the Spark that lights the Fire of Knowledge and
fuels the engine of Accomplishment”
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Cinnarizine, Collin Dollery Therapeutic Drugs, C240-3, Godfraind T et al, Drugs of Today, 1982, XVIII(1), 27-42, Venkataraman S, Neurosciences Today, 1997, Vol. I, 3&4, 205-6, Norre M E, Crit Rev. Phy. Rehab. Med., 1990, 2,2,101-20
AntihistaminesCinnarizine, Flunarizine, Cyclizine
• Drowsiness and blurred vision (Difficult for patients who drive or operate machinery)
• Delay normal vestibular compensation process• Cinnarizine and Flunarizine act via calcium antagonism,
unspecific action may cause side effects– Weight gain & depression (serotonergic effects)
– Extrapyramidal symptoms (dopaminergic effects)
– G.I. upset
Marriage and Private Practice are the two extinguishers of science
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Betahistine
Trusted therapy for more than
41 million
Vertigo patients worldwide
At twenty the will rules
At thirty the intellect
At forty the Judgment
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Betahistine - Summary• Pharmacokinetics: Rapid and complete absorption after
oral route
• Pharmacology: It is a H1 agonist and H3 receptor antagonist. It increases cochlear and cerebral blood flow and regulates firing activity of vestibular nuclei.
• Dose: 24-48 mg /day
• Indication: vertigo, meniere’s syndrome
• Contraindications: not known
• Precaution for use: pheochromocytoma, peptic ulcer, bronchial asthma
“The True Art of Memory is The Art of Attention”
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CLINICAL STUDIESPHARMACOLOGICAL
EFFECTS
“ We Sometimes think we have forgotten something when in fact we never really learned it in the first place”
Imp.Your Memory Skills
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Dose-Dependent effect of Betahistine in• Improving cochlear blood flow (Laurikainen, 1993)
• Reducing firing frequency of vestibular nuclei (Unemoto, 1982 )
• Reducing duration of nystagmus (Oosterveld, 1987)
• Reduction in resting firing of ampullar receptors (Botta, 2000)
Higher the dose, faster and better the effectHigher the dose, faster and better the effect
Through Action You Create your Own Education - D.B. ELLIS
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Results: Comparing efficacy of Betahistine and Cinnarizine in facilitating vestibular compensation
• Lesser Vestibulo Ocular Reflux (VOR) asymmetry score with Betahistine treatment than with Cinnarizine treatment
• Higher degree of vestibular compensation with Betahistine than with Cinnarizine
• Faster recovery with Betahistine than Cinnarizine
Colletti, Acta Otolaryngol, 2000, suppl 544, 27-33Colletti, Acta Otolaryngol, 2000, suppl 544, 27-33
Thought is the labour of the intellect
Reverie is its pleasure
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Global evaluation (n=29)Parameters Excellent-good rating in % of patients by
PatientsPhysicians
PatientsPhysiciansEfficacy 100%
100%
Tolerance 100%100%
Effect on associated 95%95%
symptoms
Efficacy 100%100%
Tolerance 100%100%
Effect on associated 95%95%
symptoms
Bradoo RA, Ind. J. Otolaryngol H N S, 2000, 52 (2), 151-8
Bradoo RA, Ind. J. Otolaryngol H N S, 2000, 52 (2), 151-8
Whatever the Mind can conceive and Believe, the mind can Achieve
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Highlights of the trial• First Indian Trial of Betahistine at a specific dose of
16 mg t.i.d. in medical College
• Betahistine at a dose of 16 mg t.i.d offers faster and better results. 93 % patients completely relieved within 3 weeks of the therapy
• Also proves the excellent tolerance of Betahistine at a dosage of 16 mg t.i.d.
• Focus on new insight into the management of acute cases with this therapy
Bradoo RA, Ind. J. Otolaryngol H N S, 2000, 52 (2), 151-8Bradoo RA, Ind. J. Otolaryngol H N S, 2000, 52 (2), 151-8
Imagination is more Important than Knowledge
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99m Tc HMPAO transaxial images of brain (6mm slices)P.D. Hinduja National Hospital, Mumbai
99m Tc HMPAO transaxial images of brain (6mm slices)P.D. Hinduja National Hospital, Mumbai
Figure I: The top row images show HYPOPERFUSION in the left temporal lobe prior to therapy & the bottom row images of the same patient show complete NORMALISATION OF PERFUSION after 4 weeks of Betahistine therapy 16 mg three times daily
Pre-Betahistine Therapy (15.06.1999) No. 2540
Post-Betahistine Therapy (12.07.1999) No. 2922
Reference ImageReference ImageSPECTSPECT MRIMRI
R L R LR L R L
Krishna BA, Kirtane MV, Neurology India, 2000,48, 255-9 Krishna BA, Kirtane MV, Neurology India, 2000,48, 255-9
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99m Tc- HMPAO transaxial images of brain (6 mm slices)P.D.Hinduja National Hospital, Mumbai
Figure II: The top row images show HYPOPERFUSION in the right inferior cerebellar region prior to therapy. The bottom row images show almost complete NORMALISATION OF PERFUSION following 2 weeks of Betahistine therapy 16 mg three times daily.
Pre-Betahistine Therapy (27.02.1998) No.791
Post-Betahistine Therapy (10.03.1998) No. 1950
Reference Image
SPECT MRI
R L R L
Krishna BA, Kirtane MV, Neurology India, 2000,48, 255-9 Krishna BA, Kirtane MV, Neurology India, 2000,48, 255-9
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99m Tc- HMPAO sagittal images of brain (6 mm slices)P.D. Hinduja National Hospital, Mumbai
Figure III: The top row images show a well-defined focalized HYPOPERFUSION in the right parieto-occipital region prior to therapy. The bottom row images show almost complete NORMALISATION OF PERFUSION of this region after 3 weeks of Betahistine therapy 16 mg three times daily.
Pre-Betahistine Therapy (17.03.1999) No.1086
Post-Betahistine Therapy (08.04.1999) No.1599
Reference ImageSPECT MRI
R L R L
Krishna BA, Kirtane MV, Neurology India, 2000,48, 255-9 Krishna BA, Kirtane MV, Neurology India, 2000,48, 255-9
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A comparison of Betahistine and CinnarizineBetahistine Cinnarizine
• No drowsiness Drowsiness - side effect
• Facilitates compensation slows down compensation
• Suitable for use with should not be used vestibular habituation with vestibular therapy habituation therapy
• No drowsiness Drowsiness - side effect
• Facilitates compensation slows down compensation
• Suitable for use with should not be used vestibular habituation with vestibular therapy habituation therapy Kirtane MV, Ind. J. Otolaryngol H N S, 1999, 51 (2), 27-36 ,
Colletti V, Acta Otolaryngol Suppl 544, 27-33.Kirtane MV, Ind. J. Otolaryngol H N S, 1999, 51 (2), 27-36 ,
Colletti V, Acta Otolaryngol Suppl 544, 27-33.
A open foe may prove a curse ; but a pretended friend is worse
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Betahistine vs. CinnarizineTolerance
Vertin CinnarizineNo extrapyramidal side Extrapyramidal sideeffects on long term since effects (Parkinson’s)no antidopaminergic effects common due to anti-
dopaminergic effects
•No caution required Caution in elderly in the elderly Ref.(Collin Dollery
Drugs)
Discipline Weighs ounces; Regret weighs Tons
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Betahistine vs. CinnarizineTolerance
Betahistine Cinnarizine
No caution in Hypotensive High dose-cautionpatients since no effect in hypotensive-dueon B.P . to possibility(Stough study) of lowering of B.P.
(Martindale ref)
The sign wasn’t placed there
By the Big Printer in the sky
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Betahistine vs. Cinnarizine
Vertin Cinnarizine
•Increases alertness Causes drowsiness (Coelho ref) (Deering study)
•No effect on driving Should not drive or performance (Betts operate machinery Study) Ref(Collin Dollery
Drugs)
It is a great misfortune not to possess sufficient wit to speak well
nor sufficient judgment to keep silent
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•Efficacy (Deering study)•Safety/ tolerance (Deering study)•Facilitates compensation unlike Cinnarizine (Colletti study)•No drowsiness unlike Cinnarizine (Kirtane)•Suitable for use with Vestibular Habituation
Therapy (VHT) unlike Cinnarizine (Kirtane)
Betahistine superior to Cinnarizine in
You are what you think and not what you think you are
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Betahistine -24
• Assured patient compliance
• Convenient dosage
• Established efficacy & safety
Beware the flawless performance
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Dose of Betahistine48 mg /day
Martindale, 2002, Coelho MH IN Basics on Vertigo, Dizziness & Imbalance, 1999
Men will never understand women and women will never understand men;
And that’s the one thing men and women will never understand
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Betahistine given as just 2 doses per day- easier to Rx for patients not wishing to take medicine in middle of day
Conclusion
-Tran Ba Huy, J Fr. Oto-Rhino-Laryngol (JFPRL), 1992, 41 (suppl 3), HV
We do not know one millionth of one percent about anything – Thomas Edison
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MANAGEMENT OF VERTIGO
VESTIBULAR HABITUATION
THERAPY(VHT)
We learn by thinking and the quality of the learning outcome is determined by the quality of our thoughts
R.B. Schmeck
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Vestibular Rehabilitation• Adaptation - A phenomenon which helps a patient with
persisting peripheral dysfunctional state to regain normal balance.
• Habituation - Repeated exposure of the body to “mismatched “ sensory input.
• Compensation – A goal directed process induced by some recognized errors, directed towards its elimination
Norre M E, Crit. Rev. Phy. Rehab. Med., 1990, 2, 2, 101-120, Kirtane MV, Ind. J. Otolaryngol HNS, 1999, 51 (2), 27-36.
Norre M E, Crit. Rev. Phy. Rehab. Med., 1990, 2, 2, 101-120, Kirtane MV, Ind. J. Otolaryngol HNS, 1999, 51 (2), 27-36.
A great many people think they are thinking when they are merely re arranging their prejudices
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Do’s and don’ts in encouraging vestibular compensation
Do’s and don’ts in encouraging vestibular compensation
Encourage• Alertness• Active & passive
movements• Large Support Surface• Fine motor task• Visual stimuli• General care
Avoid• Sedation• Immobility• Dark environment• Solitude standing
Kirtane MV, Ind. J. Otolaryngol HNS, 1999, 51 (2), 27-36.
Kirtane MV, Ind. J. Otolaryngol HNS, 1999, 51 (2), 27-36.
Many Ideas grow better when transplanted into another mind than in the one where they sprang UP
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Colletti, Acta Otolaryngol, 2000, suppl 544, 27-33
Results: Comparing efficacy of Betahistine and Cinnarizine in
facilitating vestibular compensation
• Lesser VOR asymmetry score with Betahistine
treatment than with Cinnarizine treatment
• Higher degree of vestibular compensation with
Betahistine than with Cinnarizine
• Faster recovery with Betahistine than with
Cinnarizine
A woman’s desire for revenge outlasts all her other emotions
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EXERCISES IN VESTIBULAR
HABITUATION THERAPY
Every discovery contains an irrational element or 4 creative intuition
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EXERCISES IN BED : EYE MOVEMENTS
Looking up and then down
I have never let my Medical schooling interfere with my education
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EXERCISES IN BED : EYE MOVEMENTS
Looking alternately left and right
“ He who cannot forgive others destroys the bridge over which he himself must pass”-
Annoy
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EXERCISES IN BED : EYE MOVEMENTS
Convergence Exercises
When they tell you to grow up, they mean stop growing
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EXERCISES IN BED : HEAD MOVEMENTS
Bending alternately forward and backward
A (Neurologist’s) life is like a piece of paper on which everyone who passes by leaves an impression
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EXERCISES IN BED : HEAD MOVEMENTS
Turning alternatively to the left and then right
A medical school should not be a preparation for life. A school should be life
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Shrugging and rotating shoulders
EXERCISES IN SITTING POSITION
“By Nature All Men/ Women are alike but
by Education widely different”
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Bending forward and picking up objects from the floor
EXERCISES IN SITTING POSITION
The art of medicine is caring for the heart of the patient
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EXERCISES IN SITTING POSITION
Turning head and trunk alternately to the left and the right
The best time to cut an umbilical cord is at birth
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Changing from sitting to standing, initially with eyes open and then with the eyes closed
EXERCISES IN STANDING POSITION
There are two theories to arguing with women; neither one works
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Throwing a small (ping pong) ball in, an arc from
hand to hand and following it with the eyes
EXERCISES IN STANDING POSITION
I want to be one in a million in life; but in the end I accept I am one of a million
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EXERCISES IN STANDING POSITION
Throwing a small ball from hand to hand under the knee
We always hold hands. If I let go, she shops
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Throwing and catching the ball while walking
EXERCISES WHILE WALKING
Women use silence to punish men but men loves silence
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Walking around in the room with eyes open and closed
EXERCISES WHILE WALKING
Men prefer looks to brain because most men can see better than they can think
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Walking up and down a flight of stairs
EXERCISES WHILE WALKING
Always tell the truth and then run
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Playing any game involving bending, stretching and aiming with the ball
EXERCISES WHILE WALKING
A woman will lie to make you to feel good;
A man lies to make himself look good
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Dedicated to my family for making everything worthwhile
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LISTEN not to contradict or confute
Nor to Believe and Take for Granted
but TO WEIGH AND CONSIDER
THANK YOUMy sincere thanks to sri madan for his
meticulous computer work My sincere thanks to sri madan for his
meticulous computer work