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Vestibular Rehabilitation Therapy

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					The



Balancing




Act
 Vestibular Rehabilitation
         Therapy

   Balance Disorders: Facts, Figures,
Assessment, and Treatment for Positive
               Outcomes
Lori Miller, MSPT, VRT, ATC/L, CSCS
         Lisa Jenkins PT,MBA
            What is Balance
 Balance is defined as the ability to maintain your
  center of mass over your base of support.
 Balance is very complex involving multiple
  systems that interact flawlessly and automatically
  to coordinate input from our environment and the
  central nervous system to produce a motor output
  and keep you upright/vertical. Postural control is
  related to balance in the dynamic mode.
       What Is Postural Control?




Ability to align the segments of our body in relation to one
another in order to maintain stability/orientation in space
      Components of Balance
   Sensory
    – Sense body position relative to the base of
      support
   Motor
    – Execute coordinated body movements
   Central Adaptation
    – Use sensory inputs and body movements
      appropriate to the task conditions
               Sensory Inputs
   Proprioception
    - Body position relative to support surface
    - Dominates with fixed support surface
    - Ineffective on moving/compliant surfaces
                 Sensory Inputs
 Vision
  - Head/eye position relative to surrounding objects
  - Dominates with stable surround/unstable surface
  - Ineffective with moving objects
 Vestibular
  - Head position relative to gravity & inertial space
  - Essential under surface/vision conflict conditions
         Central Adaptation
 Select sensory input or inputs providing the
  most accurate information
 Select the movement pattern or combination
  of patterns most effective in correcting
  balance
Corrective Movements




  Ankle   Hip   Step
               What is a Fall?
   A verbal definition of a fall is very difficult.
    There have been many definitions, such as
    ―coming to rest at a lower level‖, ―an unplanned
    descent to the floor or extension of the floor‖,
    ―taking your center of gravity off your base of
    support‖. All of these have validity, but the most
    accurate is the mathematical definition of a fall
    being when the center of pressure=center of
    gravity, when your off your base of support.
                     CP=COG=FALL
            Elderly Fallers
A fall can significantly limit the ability of an
       older adult to remain independent.
More than 1/3 of people aged 65 or older fall
    each year, and those who fall are 2 to 3
         times more likely to fall again!
 30% of people who fall suffer moderate to
   severe injuries such as bruises, fractures,
               and head trauma.
     Falls in Hospitals and Nursing
                 Homes
 Each year a typical nursing home with 100 beds
  reports an average of 200 falls, many of which go
  unreported.
 Fall risk is increased when 4 or more medications
  are used concomitantly.
 Fall risk increases significantly in the days after a
  medication is stopped, dosage adjusted, added or
  changed. The danger is 1-9 days, the risk actually
  triples for single event or multiple falls!
            Fall Statistics
More than 95% of hip fractures among adults
        65 or older are caused by falls.
23% of hip fracture patients die within a year
                   of injury.
 The risk of being seriously injured in a fall
              increases with age.
Nearly 85% of deaths from falls were among
              people 75 or older.
              Fall Statistics
 15,800 people 65 or older died from injuries related
                    to falls in 2005.
  ~1.8 million people 65 and older were treated in
                    ER’s for injuries
      More than 433,000 of these patients were
                      hospitalized.
These numbers are from 2005 and have been steadily
       rising over the past decade. (CDC 2008)
                Dangerous...
   Psychological trauma and fear-of-falling cause
    self-imposed activity reduction


                    Strength
                    Flexibility
                    Mobility
          Further  RISK of future falls
                   Costly...
 The United States spends an estimated $28.6
  billion annually for the treatment of fall-related
  injuries.
 The majority of cost is for the treatment of hip
  fractures, which average $39,000 per patient.
 Medicare costs for hip fractures in 2008 were
  estimated to be $2.9 billion, these numbers are
  expected to rise as the baby-boomers age.
      Fall Risk Factors In Older
                Adults Depression 
   Muscle Weakness
                                     Orthostatic Hypo
   Impaired Vision                   tension/Autonomic Failure
   Use of Assistive                 Frequent Toileting
    Device/Inappropriate Use of
    Device                           Dim or Dark Areas
   Age > 80                         Impaired Mobility
   Cognitive Impairment             Sensory Deficits
   Medications: Type, Timing,       Central Changes-Reflexive or
    Dosing                            Reactive Balance
   Non-supportive Footwear          Postural Changes
   Home-Throw Rugs, Lack of         Orthopedic Problems
    Rails or Grab Bars, Clutter      Low Back Problems
   Disease Related Issues           Neurological Problems
   Polypharmacy                     History of Falling
    Why Is Balance Important?
   Balance is fundamental to many daily
    activities:
    – Transfers
    – Walking
    – Driving
    – Recreational Activities
    – Sense of stability and well being
    Why Is Balance Important?
 Loss of balance can be debilitating, leading to self
  restrictions in movement and fear of falling.
 This cycle promotes physical de-conditioning,
  increased risk of falls, injuries, and many other
  secondary problems resulting in further functional
  decline.
 This causes a significant decrease in a person’s
  quality of life.
 BALANCE = INDEPENDENCE
The Need For Balance Services
             What is Dizziness?




        Subjective, difficult to describe
        Different sensation than Vertigo
   Terms of dizziness and imbalance often used
                  interchangeably
The Need For Balance Services

                 Dizziness Terms:
Vertigo, lightheaded, fuzzy, foggy, woozy, groggy,
             spacey, heaviness in the head

             Disequilibrium Terms:
Imbalanced, drunk, unsteady, veering, wandering,
            weaving, hitting the walls
The Need For Balance Services
                        The Problem
 Although dizziness is one of the most frequent complaints
  heard by physicians, it is poorly understood and ill defined.

   Research has shown that patients with vestibular disorders
    will see an average of 4-5 physicians before receiving an
                       accurate diagnosis.

   Some of these patients will get a diagnosis, some will just
             attribute the changes to normal aging.
The Need For Balance Services

            Dizziness Statistics
 More than 90 million Americans (~42%)
 have experienced a problem with balance or
                feeling dizzy.
 The number one reason for hospital visits
  for people over the age of 65 is dizziness.
       (National Institute of Health)
The Need For Balance Services
  Patients with vestibular dysfunction will
    usually show signs of gait and balance
                  impairments.
       Vestibular Dysfunction = Falls
Studies done in the U.S. and UK have found
 that 80% of patient presenting to the ER for
      a fall related injury had vestibular
                   symptoms.
       The Need For Balance
             Services
                 Fall Statistics
   Falls are the leading cause of injury, deaths,
     and the most common cause of non-fatal
    hospitalization in older adults. (CDC 2010)

    Falls are the most common cause of TBI.
                 (Jager et al. 2000)
     The Need For Balance
           Services
        Declined Quality of Life
  Approximately 65% of all nursing home
 admissions are related to falls. (CDC 2010)
 Once a person falls, they tend to develop a
 fear of falling, reduce their activity, thereby
 increasing the risk of another fall. (Vellas et
                    al. 1997)
  The Need For Balance
        Services

As economic pressures mount to
slow the growth of rising medical
   costs associated with chronic
disease/disorders, the need for cost
     management is obvious.
    The Need For Balance
          Services
     Impact of Chronic Disorders

75% of all medical expenditures are spent
       on managing chronic disorders
 Prevalence increases with population age
     Strain on the insurance systems
            – Especially Medicare
  The Need For Balance
        Services
         Unresolved cases lead to:

           ―Doctor shopping‖
      Extensive diagnostic testing
Fear, restriction, & further deterioration
   Increased risk of falls & injuries
Wide Spread Problem

 Dizziness
          & imbalance are
common symptoms in a wide
   variety of diseases.
        Multiple Sources

 Thetypical chronic disorder has
  multiple causes that cannot be
   isolated to a single source.
    Varied Impairments

 Even   when a specific cause is
       identified, the resulting
impairments can vary considerably
 from patient to patient because of
   the brain’s adaptive responses.
Coordinated and Focused
   Research shows the most effective
management plan for the individual patient
  requires the coordinated efforts of both
 physicians and rehabilitation specialists.
  Focus is on mitigating the impact of
pathology, and on modifying the associated
   adaptive responses and impairments.
              The Need For Balance
                    Services
                   Physiological   Brain’s Adaptive
Pathology            Changes          Response
(site-of-lesion)




                                            Functional       Environment &
                           Impairment        Changes        Lifestyle Demands



  What Is Impairment
  Information?                                        Disability
The Need For Balance
      Services




     Management Model
        Objective Plan/LTG’s

 Classification of patients based on pathology
  and functional impairments.

 A long-term care plan which includes progress
  indicators and expected outcome and is based on
  patient classification.

 Access to surgical, medical and rehabilitation
  treatments as appropriate.
Types of Patient Populations
   General Practice/Geriatric
     Non-specific
   Otology
     Vestibular
     Post concussion syndrome
     Workers’ comp/Medical-legal
    Types of Patient Populations
   Neurology
     Parkinson’s Disease
     TBI
     Multiple Sclerosis
     Peripheral Neuropathy/Polyneuropathy
   Orthopedics
     Ankle/Knee injuries
     Low Back/Neck injuries
     Head injury/Return to play
    Relevance & Benefits
Vestibular dysfunction is problematic and
           can occur at any age.
 Vestibular problems result from a wide
  variety of sources, therefore relevant to
      most health care professionals.
     Relevance & Benefits

Medical costs continue to rise in the care of
             chronic disorders.
 One of the most well researched areas of
   treatment. (evidence based practice)
     Relevance & Benefits
   Physical/Occupational Therapists with
     specialized training=VRT Specialist
  State of the Art technology to measure a
 person’s performance to identify and isolate
          the causes of the problem.
 Assessment is comprehensive, looking for
         multiple contributing factors.
ANATOMY/PHYSIOLOGY
     OVERVIEW
                 System Organization
Sensory Input      Sensory Processing     Motor Output

                                                     Eye
Visual              Primary Processor
                                          Motor      Movements
                    (Vestibular Nuclear
                    Complex)              Neurons    Positional
Vestibular                                           Movements
                   Adaptive Processor
Proprioceptive     (Cerebellum)
  Main Components of the
    Vestibular System
          Peripheral End Organs detect
 Head angular velocity and linear acceleration
 Orientation of the head with respect to gravity
                Vestibular Nerve
     Central Nervous System Connections
                 Motor Output
Vestibular Ocular Reflex (VOR) – gaze stability
Vestibulospinal Reflex (VSR) – postural control
     Balance System Elements
   Vestibulo-ocular System
    – Coordinate head and eye movements to maintain
      stable gaze and visual acuity while actively moving
      about
   Posture Control (vestibulo-spinal) System
    – Maintain postural stability while actively moving
      about
    Physiological Characteristics
   Vestibulo-ocular System
    – Horizontal semicircular canal & visual inputs
    – Responses dominated by short pathway reflexes
    – Simple movement geometry & biomechanics
   Posture Control System
    – Vertical canal, otolithic, visual & proprioceptive inputs
    – Responses mediated by complex central pathways
    – Responses influenced by task & environment
    – Complex movement geometry & biomechanics
       Peripheral System
 Located deep within the petrous portion of
              the temporal bone
 System consists of membranous and bony
  labyrinth & hair cells which sense motion.
           Bilateral & reciprocal
               Labyrinth
    Bony labyrinth: central chamber, also
         contains cochlea for hearing
Filled with perilymphatic fluid (high Na:K)
  Membranous labyrinth located in bony
                   labyrinth
 Contains 5 sensory organs, 3 semicircular
   canals, and 2 otoliths – utricle & saccule
Filled with endolymphatic fluid (high K:Na)
   Semicircular Canals (SCC)
                 Sense head velocity
      Enables Vestibulo-ocular reflex (VOR)
              Allows clear visual acuity
 Eye movement generated is equal in magnitude and
          opposite to that of head movement
Incredibly precise and accurate as the visual image is
    maintained on the fovea of the retina for clarity
              SCC Anatomy
            Filled with endolymph
         Ampulla-enlarges end area
 Hair cells sense head motion and lie on the
             cupula of the ampulla
 As the head turns, endolymph moves in the
  opposite direction and causes movement of
    the hair cells and excites the vestibular
                      nerve
       SCC Arrangement
          6 canals – 3 each side
    Anterior, posterior, and horizontal
 Canals are of right angles with respect to
                  each other
   Horizontal canals sloped 30 degrees
  Canals reciprocate and form 3 coplanar
                    pairs
     Right anterior and left posterior
        SCC Arrangement
        Right and left horizontal
     Left anterior and right posterior
 Planes of canals close to the planes of the
             extra ocular muscles
  Coplanar pairing allows for push-pull
             arrangement in SCC
  Right head turn results in endolymph
           displacement to the left:
          SCC Arrangement
1.   Cupula & hair cells are deflected
2.   Excitation occurs on the right side
3.   Depolarization occurs on the left side
4.   Right head motion is detected
                 Otoliths
   Sense linear acceleration and static tilt
 Utricle senses horizontal linear acceleration
  Saccule senses vertical linear acceleration
    Hair cells project into gelatinous type
  mixture that has calcium carbonate crystals
          (otoconia) embedded within.
        Otoconia are gravity sensitive
                 The three canals are:
Roll             •Horizontal
                 semicircular canal;
                 detects rotation of the
                 head around a vertical
       Pitch
                 axis (i.e. the neck), as
                 when doing a pirouette.
                 •Superior semicircular
                 canal; detects rotations
                 of the head in the
           Yaw   sagittal plane, as when
                 nodding.
                 •Posterior semicircular
                 canal; detects rotation
                 of the head around a
                 rostra-caudal (anterior-
                 posterior) axis, as when
                 cart wheeling.
         Vestibular Nerve
  Sends signals from labyrinth through the
         internal auditory canal (IAC)
 IAC contains the cochlear nerve (auditory),
       facial nerve (motor and sensory)
           Vestibular Nerve
   Enters the brainstem at the pons and medulla
                        junction
 Central processing is done at the level of the pons
       and medulla by the vestibular nuclei and
    cerebellum with numerous connections to the
   cortical regions, ocular motor nuclei, thalamus,
  and reticular activating system (arousal, conscious
      awareness, moment discrimination self vs.
                      environment
               Motor Output
            VOR – gaze stability
  With fast head movement, eyes move in
    opposite direction as head with equal
                  magnitude
Image is kept on the retina and vision is clear
                   as a result
           How VOR Works
  Head turns right, endolymph flows left and
                  deflects cupula
 Hair cells fire on the right, inhibit on the left
  Information is transmitted to the vestibular
                       nuclei
  Excitatory impulses to ocular motor nuclei
    right eye medial rectus & left eye lateral
                rectus is contracted
            Motor Output
           VSR – Postural control
                How it Works:
             Body moves or tilts
   Movement sensed by canals and otoliths
     Vestibular nerve and nuclei activated
    Impulses transmitted to the spinal cord
 Muscles activated to maintain postural control
Vestibular System & Postural
           Control
                   Sensory-
             Perception of motion
Orients head and body to vertical with respect
                   to gravity
                   Motor-
 Control of body’s center of mass, static &
                    dynamic
 Stabilizes head during postural movements
                         Balance Control

Sensory Organization                       Motor Control

          Determine                     Initiate Automatic/
         Body Position                 Voluntary Movements


     Compare, Select                      Select & Adjust
    & Combine Senses                 Muscle Contractile Patterns


Visual     Vestibular    Somato-      Ankle     Thigh     Trunk
System      System       Sensation    Muscles   Muscles   Muscles



         Environmental                        Generate
          Interaction                      Body Movements
Whirlwind of Activity!
    Peripheral vs. Central
          Disorders
Peripheral: Vestibular apparatus and
  vestibular nerve to root entry in the
               brainstem
 Central: Vestibular centers in pons,
       medulla, and cerebellum
Usually present with other neurologic
               symptoms
     Peripheral                 Central
   BPPV                       CVA/TIA
   Vestibular Neuritis &      Migraine
    Labyrinthitis              Multiple Sclerosis
   Endolymphatic              Mal de
    hydrops & Meniere’s         Debarquement
   Ototoxicity                Cerebellar Injury
   Perilymphatic Fistula
   Acoustic Neuroma
Central vs. Peripheral Symptom
              Sets
                Pure vertical      Positional Vertigo-
                  nystagmus              BPPV
                Spontaneous           Spontaneous
                  nystagmus         nystagmus 2-3
                  prolonged        days-acute neuritis
             Little or no nausea         Nausea
             Abnormal ocular-       Normal ocular-
             motor                     motor
                UMN signs           No UMN signs

                 Abnormal               Normal
                coordination          coordination
             Usually no hearing    May have hearing
                    loss                 loss
                BPPV
  Benign Paroxysmal Positional Vertigo
 Most common vestibular disorder provoked
               by position
                               BPPV



   Otoconia are displaced into semicircular
                     canals
          Canalithiasis (floating)
           Cupulothiasis (stuck)
       Vestibulithiasis (on the nerve)
                             BPPV



      Produces true vertigo symptoms
 Most common with head injury in persons <
                      50
          Idiopathic in the elderly
                 BPPV
        Patient symptoms include:
  Positional vertigo with turning in bed,
        bending over, or reaching up.
            Vertigo < 1 minute
 Lightheadedness, imbalance, nausea, or
  floating feeling lasting for hours or days
       after the initial BPPV episode.
          Usually no hearing loss
         BPPV Treatment
   Otoconia in canal can be repositioned
    through manual maneuvers (Epley’s,
      Appiani, Semont, Brandt-Daroff)
 Maneuver used is determined by positioning
       the head to provoke nystagmus.
         Vestibular
    Neuritis/Labyrinthitis
 2nd most common vestibular disorder
 Inflammation of the vestibular nerve
         Vestibular
    Neuritis/Labyrinthitis

   Most causes are bacterial or viral
               Herpes
          Measles/Mumps
            Epstein-Barr
             Bells Palsy
    Vestibular Neuritis/Labyrinthitis
 Results in unilateral vestibular hypofunction
 Absence of input from involved side, strong
            bias from the intact side
 Brain interprets this as spinning toward the
                    intact side
               Labyrinthitis
   Infection travels to the cochlea, affecting
      the cochlear portion of the vestibulo-
        cochlear nerve (cranial nerve #8)

        Hearing loss will be evident with
                   labyrinthitis
               Treatment
  Vestibular rehab not appropriate for the
                  acute phase
 MD may prescribe vestibular suppressants
         such as antivert or meclizine
 Vestibular rehab is appropriate for the sub-
                  acute phase
   Endolymphatic Hydrops
    Results from abnormalities with re-
   absorption of endolymphatic fluid in the
                   inner ear
  Primary idiopathic: Meniere’s Disease
 Secondary: from an underlying condition
  Endolymphatic Hydrops

               Symptoms
 Meniere’s: episodes of severe, violent
vertigo, nausea, tinnitus, hearing loss, ear
pressure or fullness, and imbalance—with
         attacks lasting for hours
  Secondary Hydrops: resulting from
  underlying disorder, with less violent
      symptoms, but longer lasting
     Endolymphatic Hydrops
           Treatment
  Hydrops diet: restrictions with salt, sugar,
              caffeine, and alcohol
 MD prescribed meds for symptom control
  during attacks (diuretics, beta histamine)

  VRT can be effective in the reduction of
  symptoms.
    Endolymphatic Hydrops
          Treatment
In intractable dizziness/vertigo chemical
destruction of hair cells, or surgical section
                of the nerve
 Vestibular rehab cannot stop Meniere's
   attacks—habituation is best, but most
  patients need medical management in
            addition to therapy.
                Ototoxicity
   Certain drugs are known to cause damage to
          the inner ear, some permanently.
    Amino glycoside antibiotics: gentamycin,
     Streptomycin, kanamycin, tobramycin,
                      neomycin
              Ototoxicity
Symptoms manifest with bilateral vestibular
                        loss
   No vertigo, no vomiting, no nystagmus
 Patients will c/o of imbalance, oscillopsia,
    hearing loss, fullness feeling of the ear
 Some effects profound (severe imbalance,
  inability to tolerate head movements, wide
    based gait, inability to walk in the dark
     Ototoxicity Treatment
      Reduce exposure of ototoxins
     No treatment to reverse damage
    Balance training, assistive devices
 Cochlear implants for severe hearing loss
      Perilymphatic Fistula
    A defect or tear in the oval window
    (connective tissue membrane) which
separates the middle ear from the fluid filled
                   inner ear
  Significant changes in atmospheric or
     intracranial pressures can cause this
  Airplane travel, diving, weightlifting,
childbirth, head injury, inner ear infection(s)
     Associated Symptoms
       An initial ―pop‖ may be heard
   Dizziness, vertigo, imbalance, nausea,
                   vomiting
        Mimics BPPV & Meniere’s
 Ringing or fullness in the ears, hearing loss
     Perilymphatic Fistula
           Treatment

 Once  diagnosed treatment is typically
  rest, and if the problem persists then
 surgical intervention may be required.
  VRT is appropriate post surgical as
              healing dictates
         Acoustic Neuroma
   Benign tumor on the vestibulo-cochlear nerve
 Presents with slow progressive hearing loss, mild
   imbalance, and sensory loss of the facial nerve
     Usually a slow growing tumor/very rare
    Diagnosed through hearing tests and MRI
 Management is ~ 50% surgical, ~25% radiation,
                 and ~25% untreated
         VRT is applicable post surgery
                  CVA/TIA
   The central and peripheral vestibular system
    is affected when the vertebral-basilar artery
                 is involved with CVA
     Other vascular syndromes involving the
    Anterior and/or posterior inferior cerebellar
        arteries can cause vertigo, nystagmus,
     lateropulsion, visual illusions, sensory loss
      of the face and limbs, Horner’s syndrome
           (ocular disease), and ataxic gait
Migraine Associated Dizziness
     Vestibular symptoms are present in ~35% of
                   migraine sufferers
 Vestibular symptoms can be present for minutes at
  a time and can present as dizziness with or without
      a headache, imbalance with a headache, and
  spinning sensations before the headache comes on
  Treatment is typically medically managed along
       with VRT and lifestyle modifications and
                 avoidance of triggers.
           Multiple Sclerosis
 Impacts balance with sites of demyelination of the
       8th cranial nerve and the vestibular nuclei
 Vertigo is an initial presenting symptom in ~5% of
                           cases
  Pendular nystagmus, motor control latency, and
     UMN signs are typically present and can be
                 picked up with testing
      ~50% of MS patients respond to VRT
Mal De Debarquement (MDD)
    Prolonged imbalance and/or rocking
  sensation that occurs after getting off a boat
 Vestibular system fails to readapt to stable
                    ground
 Symptoms will appear immediately after a
                  ship voyage
 Symptoms will usually increase in enclosed
          spaces or when motionless
Mal De Debarquement (MDD)
   Symptoms improve during movement
  Most often occurs in females 40-50yrs
  Diagnosis of exclusion- CNS/vestibular
             testing are normal
     Usually self limiting 6-12 months
        VRT usually very helpful
      Cerebellar
        Injury

   The cerebellum plays a critical role in neural
      plasticity, as it allow the CNS to adapt to
                   vestibular lesions.
     The VOR and VSR are fine tuned by the
                        cerebellum
   If the cerebellum is not intact, recovery from
       vestibular problems will be challenging
 Substitution strategies are best suited for this type
                         of patient
    Cervicogenic Dizziness
 Defined as a ―non specific sensation of
      altered orientation in space and
 disequilibrium originating from abnormal
afferent activity from the neck.‖ (Cass, SP)
       Cervicogenic Dizziness
    These patients do not experience a true vertigo,
     but describe vague dizziness and disorientation.
     Theory behind this disorder is that there is a
    disruption or abnormality of the afferent input to
    the vestibular nuclei from damaged cervical joint
      proprioceptors, which results in skewed input
           leading to dizziness and imbalance
Cervicogenic
 Dizziness




                •Dizziness &
                 imbalance
               associated with
                  neck pain
      Cerviogenic Dizziness
   Reported in patients that have severe cervical
  arthritis, herniated cervical discs, head trauma, or
                     whiplash injury.
      Studies indicate the best treatment is a
   combination of manual therapy with vestibular
   exercises. This combination has been found to
      overall reduce neck pain and dizziness and
                    increase balance
 Precautions and prescreening for vertebral artery
      insufficiency, or upper cervical instability
     Mechanisms of Vestibular
            Damage
  Viral Infections (labyrinthitis, vestibular
                   neuritis)
 Fluid-level disorders (Meniere’s, hydrops)
    Trauma (TBI, perilymphatic fistula)
     Benign tumors (acoustic neuroma)
 Vascular disorders (CVA/TIA, migraine)
        Vestibular Recovery
   The vestibular system cannot repair itself
     when damaged, recovery must happen
     through CNS compensation/adaptation
                   techniques.
        Vestibular Recovery
     Acute stages of compensation involve the
  ―cerebellar clamp‖, in which the brain recognizes
   that unequal signals are incorrect and turns the
       signal off (3 days with some symptom
                     improvement)
 Compensation moves toward adaptation through
  recalibration of the VOR and VSR. This is done
 based on the error signals of blurred vision (retinal
                    slip) and sway.
        Vestibular Recovery
  The cerebellar clamp will gradually release at the
                  end of the acute stage.
    In chronic stages of compensation the brain
  receives information from both inner ears and that
               information is recalibrated.
 Habituation: repetition of movements that provoke
    dizziness, symptoms occurring from movement
             reduce as the CNS habituates.
         What Is Vestibular
          Rehabilitation?
  A non-invasive approach for patients with
  vestibular and balance disorders.
 A systematic, individually designed regimen of
  exercises and activities that address the unique
  needs of individual patients.
     GOALS OF VRT
     (VESTIBULAR REHABILITATION THERAPY)




   Retrain the brain to recognize and
    accurately process signals from the sensory
    input system that affect balance
    GOALS OF VRT
    (VESTIBULAR REHABILITATION THERAPY)




 Help the brain recognize the sensory input
  & create the appropriate output motor
  responses
 Coordinate appropriate postural strategies in
  relation to the sensory input with respect to
  the environment
     Functional Goals of VRT
1.   Decrease dysequilibrium – sense of being off
     balance
2.   Decrease oscillopsia-visual blurring during head
     movement
3.   Improve functional static & dynamic balance
4.   Improve activity level and physical conditioning
5.   Reduce social isolation & promote active
     involvement for improved quality of life
    Fundamentals of VRT

Retraining the VOR (gaze stability, head &
             eye coordination)
  Retraining the VSR (balance activities,
                   COG)
 Habituation (desensitizing the dizziness)
   Substitution (when adaptation is not
        possible—cerebellar stroke)
    Barriers to Recovery
         Vestibular suppressants
 Appropriate for acute stages, but limit
recovery in the chronic stages. (Meclizine,
  Antivert, Xanax, Valium, Compazine,
                Phenergan)
 Intact cerebellum needed for recovery
    Why are Balance Problems
        Difficult to Solve
   Balance control is a complex interaction of
     several system inputs which are fast and
         undetectable without technology
      Multiple contributing factors may be
       involved (diabetes, vision changes)
    Why are Balance Problems
        Difficult to Solve
 Most problems are multifactorial and are difficult
  to narrow down because the brain has created an
       adaptive response to the initial problem
 A ―disease diagnosis‖ often does not point to the
                appropriate treatment.
  Adaptive processes of the brain are at different
     levels and rates of speed in each individual
    Why Test Balance Function?
 Balance Impairments Significantly Impact
  Daily Life Functions
 Medications and/or Surgery Slow or Arrest
  Progression
 Medical Cures Rare
 Responsive to Functional Management
  Because of Central Adaptation
      Main Components of a
      Balance Assessment
 Assessing balance necessitates the evaluation of
  multiple systems, both physical and cognitive
 The goal is to find the cause of the balance
  impairment, design a program to improve balance,
  decrease the risk of falls, determine the need for
  equipment, home modification, and assistive
  devices.
 Reliable, repeatable, and thorough evaluations are
  necessary with objective data.
    Main Components of the
     Balance Assessment
 Subjective Assessment- Hx, meds,
  problems, etc…(DHI, ABC)
 Functional Mobility and Gait- Observations,
  Tinetti, Berg, DGI, TUG, Fall Risk
    Main Components of the
     Balance Assessment
 Musculo-skeletal Assessment- Strength, ROM,
  Posture
 Movement Strategies and Sensory Systems used
  for Balance- SOP, SOT, MCTSIB,
  Static/Dynamic/Reflexive/Reactive/Functional
  Balance, VOR/DVA, MCT, ADP, Functional
  Movement Patterns vs. Compensatory Strategies,
  Task Specific Movements, Coordination, Fluidity
 Cognitive Assessment- Mini Mental, Follows
  Instructions, Processing Latency
What Is Computerized Dynamic
   Posturography (CDP)?
  A scientific framework for understanding
   the control of balance & postural stability
  Objective method for quantifying
   impairments in use of sensory inputs, use of
   motor patterns, and central adaptation
  Computerized dynamic posturography is the
   ―gold standard‖ for quantification of
   balance impairments.
    Why Impairment Information?
   In all non-specific and some lesion-specific
    disorders, site-of-lesion does not provide
    the pathway to an outcome

   Patients with similar pathologies but
    different impairments must be managed
    differently
    Balance Control Impairments
   Sensory Impairments
    – Ineffective use of Vestibular input
    – Ineffective use of Visual input
    – Ineffective use of Somatosensory input
   Motor Impairments
    – Delayed and/or ineffective motor responses
    – COG misalignment
    Balance Control Impairments
 Central Adaptive Impairments
   – Inappropriate use of Conflicting Input(s)
   – Use of Inappropriate Movement Patterns
 Psychological Overlay/Exaggeration
   – Inconsistent Sensory & Motor Test Results
   – Results Inconsistent with ADL Function
   – Voluntary Sway Responses
Sensory Organization Test
       Normal  Eyes  Sway-Referenced
(SOT) Vision  Closed     Vision


     Surface
      Fixed




                       1   2      3
     Sway-Referenced
         Surface




                       4   5      6
SOT Information
             Is there a sensory balance
              problem?
             Is it real or exaggerated?
              (with MCT)
             Which sensory system(s)
              are impaired?
             Are there secondary
              problems?
               – Movement strategies
               – COG awareness
        Vestibular Impairment
 Ineffective Vestibular
  Control
 Possible Causes:
  -Bi-/Unilateral Loss
  -CNS Deficits
 Problem Conditions:
  -Unstable Surfaces &
   Moving Surrounds
 Possible Treatments:
  -Medical
  -Rehabilitation
Vision Preference Impairment
 Destabilized By Visual
  Conflicts
 Possible Deficits:
  -Sensory Integration
 Problem Conditions
  -Moving Visual
   Surrounds
 Possible Treatments:
  -Rehabilitation
Vestibular/Vision Impairment
 Ineffective Visual &
  Vestibular Control
 Possible Deficits:
  -CNS
  -Vestibular & CNS
 Problem Conditions:
  -Unstable Surfaces
 Possible Treatments:
  -Medical?
  -Rehabilitation?
  -Lifestyle
       Vestibular/Proprioception
              Impairment
   Ineffective Surface &
    Vestibular Control
   Possible Deficits:
    -CNS (Severe)
    -CNS & Vestibular
   Problem Conditions:
    -Absent/Conflicting
     Visual Conditions
   Possible Treatments:
    -Rehabilitation?
    -Lifestyle
               Summary
 Effective treatment depends on:
    comprehensive assessment (site-of-lesion and
     impairments)
    design of a functionally significant plan
     individualized to that patient’s impairment
     needs
    competent execution of evidence based practice
     techniques to effectively stimulate the affected
     systems.
 Many balance patients benefit significantly from
  functionally oriented management programs.
    Targeting the RIGHT Care!
       Individualized care plans that are targeted to
          address known and measured problems.

   Targeted treatment plans = working on the right
                 thing at the right time.

   Very cost effective approach, helps to eliminate
    ―doctor shopping‖ and random consumption of
                   medical resources
Rehab Management Model
           Effective Outcomes
   Effective communication between physicians &
    therapists, monitoring patient progress, making
    necessary adjustments to POC as needed

   Patients regain stability, leading to safer activity,
    reducing the risk for secondary problems

   Good functional outcomes for the patient

   High patient satisfaction rate/Win-Win
         Thank You!
    REGIONAL MEDICAL CENTER
CENTER FOR DIZZINESS AND BALANCE
           DISORDERS
 731 Leighton Avenue Anniston AL 36207
             256-235-5236
        Lsmiller@rmccares.org

				
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