BALANCE AND VESTIBULAR REHABILITATION

Presented by:Neha tabbassum KhanM.P.T. 1st yr(Neuro)nehatabbassum@gmail.com

BALANCE IS A COMPLEX PROCESS INVOLVING THE

RECEPTION AND INTEGRATION OF SENSORY INPUTS AND

THE PLANNING AND EXECUTION OF MOVEMENT TO

ACHIEVE A GOAL REQUIRING UPRIGHT POSTURE.

IT IS ABILITY TO CONTROL COG OVER THE BASE OF

SUPPORT IN GIVEN SENSORY ENVIRONMENT.(1)

VESTIBULAR SYSTEM IS RESPONSIBLE FOR

MAINTAINING BALANCE, POSTURE AND THE BODY'S

ORIENTATION IN SPACE. THIS SYSTEM ALSO

REGULATES LOCOMOTION AND OTHER MOVEMENTS AND

KEEPS OBJECTS IN VISUAL FOCUS AS THE BODY MOVES(2)

Definition

Introduction

Peripharal Sensory PerceptionSomatosensory SystemVisual SystemVestibular System• Labryinths•Otoliths

Central Sensory Perception•Through Brainstem•Connections between vestibular nu., Reticular formation,Thalamus & Cerebellum.•Parietal & Insular regions of Cortex.•VOR.

Motor Components Of Balance

Reflexes- VOR- Gaze Stabilization Smooth Pursuit Visual Tracking•VSR- role of Semicircular canals & otoliths.

Automatic Postural Responses•Ankle strategy•Hip strategy •Suspensory strategy•Stepping strategy

Anticipatory Postural Adjustments•A response in advance to counteract the coming forces.

Volitional Postural Movements•These are under conscious control.

Examination

History•Dizziness- vertigo, lightheadedness.•Dysequillibrium•Oscillopsia . •Duration•Circumstances of symptoms.

Tests & Measures•VAS•Dizziness handicap Inventory•Motion Sensitivity Quotient

Physical examination-•Observation of Nystagmus•Head Thrust Test

.

•Head shaking Induce nystagmus•Positional Testing- Hallpike- Dix Maneuver•Dynamic visual Acuity Test.

Balance Tests:Quite Standing- Rhomberg’s Test, Sharpened Rhomberg’s Test, One leg Stand Test.Active Standing- Multidirectional Reach, Functional Reach Test.(Dieterich, 2004)

Sensory Organization Test- This test provides an outcome variable called an equilibrium score, which is based on the visual, proprioceptive, & vestibular systems to maintain standing balance (Chaudhry et al., 2004)

Functional Scales-

•Berg balance Scale

•Timed Up and Go Test. (Carmeli et al., 2002)

•Dynamic Gait Index

•Four Square Step Test. (McCrady & Amato, 2004)

Anemaet & Moffa-Trotter, 1999; Clark, 2004; Houglum, 2005

Benign paroxysmal positionl vertigo

•Canalith Repositioning Maneuver(CRM).

INTERVENTIONS

•Liberatory (Semont) maneuver

•Brandt-Daroff Exercises

Unilateral Vestibular Dysfunction

Gaze stability exercises

Motion sensitivity training

Cwathrone Cooksey Exercises-habituation exercises (1944).

•Graded- slow to quick, eyes open to eyes closed•Eye, Head- in Lying, Sitting, Standing •Shoulder & Trunk•Sit to Stand•Walking up and down slope/steps

Postural stability exercises.

Aquatic physiotherapy. (Gabilan et al)

•Bilateral Vestibular HypofunctionBilateral Vestibular Hypofunction

•Gaze stability exercises.

•Enhancement of somatosensory and

vision to maintain postural stability.

•Balance exercises.

•Exercise in pool.

oElectrotactile stimulation (Camila de Giacomo et al 2007)

Tai Chi was found to balance improvement via the vestibular component of the sensory organization test in healthy, elderly subjects (Tsang & Hui-Chan, 2004)

oTai chi

oComputer-aided rehabilitation- Virtual Reality (2007 Cochrane review claimed that this study had been the only study which reached statistical significance in comparing different forms of vestibular rehabilitation)

Central Vestibular Hypofunction

• Ensure fall prevention strategies and safety precautions.• Educate patient in compensatory strategies to assist gaze stability.• Patient instructions for Home Exercises.

Points to consider.

•Restricting movement may delay recovery.•Rehabilitation should begin early.•Head movement should be encouraged.•Supervised exercise works best.•Patient education is very important.•Follow up. •Recovery with unilateral loss can occur within 6-8 weeks.•Recovery for bilateral loss is six month or more.

Does VRT really Works?

Horak, et al, 1992•Three groups of patients with chronic vestibular complaints (VRT, medication, general activity)•Those who used VRT showed the greatest improvement in functional performance•General Activity improved to a lesser degree•Medicated showed the least improvement

Fujino, 1996Two groups: Medication and Medication with VRT8-weeks – exercise with medication had less symptoms

Shepard, et al, 1990Patients taking vestibular suppressants, antidepressant, tranquilizers, and anticonvulsants achieve the same level of compensation as patients not on meds – length of therapy significantly longer on medications

Efficacy of Vestibular Rehabilitation (Review) (Whitney, et al, 2000)

•Review of 87 articles on VRT•PNS disorders that are stable demonstrate better outcomes than CNS•PT intervention works in most cases of vestibular disorders, regardless of age.

Telian and Shepard, 1995•General VRT versus Customized Programs•64% using general therapy had complete resolution•85% using a customized had complete resolution

Plasticity – changes in central connections to compensate for peripheral disturbances (Wriseley et al, 2002)

Efficacy of VRT on Chronic ULV Dysfunction (2003)•Purpose: Supervised vs. Home Program (Used DHI and VAS)•Prospective Study•N=125•Conclusion: Supervised demonstrated improved DHI and VAS scores•Regardless of age, gender, or disability level

Vestibular rehabilitation therapy in children.(Otol Neurotol. 2005 Jul;26(4):699-703).

Vestibular rehabilitation therapy seems to be a safe and efficacious therapeutic option in children with peripheral vestibular disturbances.

Vestibular rehabilitation and 6-month follow-up using objective and subjective measures (Meli, A.; Zimatore, G.; Badaracco, C.; De Angelis, E.; Tufarelli, D.) Volume 126, Number 3, Number 3/March 2006 , pp. 259-266(8)

 

Cochrane ReviewBPPV – Epley Maneuver helps reduce vertigo VRT for ULVCurrently in protocol (Cochrane Database of Systematic Reviews 2007, Issue 4.)

Formation of internal models -- a cognitive process where one learns what to expect from ones actions. An example of this is a recent study by Herdman et al (2007) showing recovery of better vision in persons with bilateral vestibular loss was attributed to "centrally programmed eye movements".

All patients showed an improvement in quality of life and a reduction in handicap due to dizziness. Improvement in objective test results was also seen. These results were stable at follow-up. A correlation was found between different subjective measures, but there was no correlation between subjective and objective measures.

 Aquatic physiotherapy for vestibular rehabilitation in patients with unilateral vestibular hypofunction: exploratory prospective study. J Vestib Res. 2008;18(2-3):139-46. [Medline] Gabilan YP, Perracini MR, Munhoz MS, Gananc FF

Age may not be a factor in outcome: a study published in 2008 found that patients who underwent aquatic physiotherapy for vestibular rehabilitation achieved improvement in dizziness symptoms, balance, and quality of life regardless of age, use of vestibular suppressant medications, and time since symptom onset.4

Vestibular rehabilitation exercises in acute vertigo. Laryngoscope. Aug 2007;117(8):1482-7. [Medline].Venosa and Bittar recently published a study showing that VRT for acute vertigo lessens the duration of symptoms and the need for vestibular suppressants. Venosa AR, Bittar RS

Conclusions

•VRT re-caliberates and reorganizes the balance system naturally without drugs.•Medications only suppress the symptoms – not fix the problem. •Proper diagnosis of the problem.•Proper treatment by a proper provider.•VRT proves to be beneficial for management of vestibular disorders.

3. Whitney, et al (2003). The effect of age on vestibular rehabilitation outcomes. Laryngoscope. 112,10: 1785-90.

4. Cawthorne, T. (1944). The physiological basis for head exercises. J Chart Soc Physiother 106-7.

5.Badke, M. B., et al. (2004). "Outcomes after rehabilitation for adults with balance dysfunction." Arch Phys Med Rehabil 85(2): 227-33

References

1. Physical Rehabilitation (fifth edition)Susan B o’Sullivan Thomas J Schmitz pg no. 999-1029.

2. Balance and Vestibular Disorders Pg.no-732-774 Darcy &Umphred.

6.Vestibular rehabilitation and 6-month follow-up using objective and subjective measures (Meli, A.1; Zimatore, G.1; Badaracco, C.1; De Angelis, E.1; Tufarelli, D.) Volume 126, Number 3, Number 3/March 2006 , pp. 259-266(8)

7.Medeiros IR, Bittar RS, Pedalini ME, Lorenzi MC, Formigoni LG, Bento RF. Vestibular rehabilitation therapy in children. Otol Neurotol. Jul 2005;26(4):699-703. [Medline]

VIDEO:virtual reality training in balance problem.rv