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Present AND future clinical applications for fall prevention and dizziness management in aging

DEBUNKING MYTHS OF DIZZINESS AND BALANCE

MIKE STUDER, PT, MHS, NCS, CEEAA, CWT, CSST

NORTHWEST REHABILITATI ON ASSOCIATES, INC.

Provider Disclaimer

• Allied Health Education and the presenter of this webinar do not have any financial or other associations with the manufacturers of any products or suppliers of commercial services that may be discussed or displayed in this presentation.

• There was no commercial support for this presentation.

• The views expressed in this presentation are the views and opinions of the presenter.

• Participants must use discretion when using the information contained in this presentation.

Outline and objectives

Participants will be able to:

1) Define and identify the science of treating imbalance, vertigo, and dizziness

2) Identify treatable aspects in the rehabilitation of imbalance and dizziness

3) Identify a logical and stepwise plan to evaluate and treat imbalance and dizziness in older adults

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Balance

•Balance is the skill of keeping the center of gravity within the base of support. This can include considerations of: static and dynamic functions; combined centers of gravity between the person/object and other animate or inanimate objects that they are holding, carrying, or manipulating; as well as anticipated or reactive demands on the system.

•Dynamic balance is the skill of controlling predicted and unpredicted changes to the center of gravity within a mobile base of support

Defining and measuring: balance, imbalance, falls•Fall Defined : Any event that leads to an unplanned, unexpected contact with a supporting surface that is not the result of an outside force or medical event.

•Falls Screening: Ascribing the relative likelihood of or risk for a fall during daily or community mobility (as described in Module B)

•Balance is measured with careful consideration of the resources that are required to maintain balance including: strength, flexibility, endurance, sensory systems, reaction speed, anticipatory and reactive responsiveness, as well as dual task tolerance.

•Screening and measuring lead to individualized rehabilitation, environmental change, medical and physiologic interventions, as well as education and community/evidence-based fall exercise programs

Dynamic Balance – intended, controlled, directional “loss” moving CofG outside BoS

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Evidence: Balance

WHY is balance important?

•Fall prevention

•Fear of falling with resultant inactivity

•Quality of life

•Cost of supervision

•Balance as a harbinger: “Sixth vital sign”

Falls and Fall related injuries in the U.S.

•38% of accidental deaths over 65

•1.64 m treated in ER

•Every hour 1 fatality, 183 in ER

•Estimated Healthcare Cost in 2020: $ 43.8 b

Physiology AND Pathophysiology: Normal aging

• Reduced nerve conduction velocity

• Reduced attention reserves and central processing

• Reduction in VO2 max (cardio + pulmonary limits)

• Mitochondrial capacity reduces efficiency

• Reduction in type I and type II motor units

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Physiology AND Pathophysiology: Normal aging (continued)

• Skin becomes less elastic

• Collagen becomes more fibrotic

• Decreased hydration in intervertebral discs

• Decreased visual acuity/ lens accommodation

Physiology AND Pathophysiology of aging

UNEXPECTED AGE-RELATED CHANGES

•Multi-infarct dementia

•Degenerative Joint Disease

•Degenerative Disc Disease

•Anklyosing spondylitis

•Fibromyalgia?

•Cardiomyopathies/pulmonary fibrosis

Fictional accounts of aging

•Strength

•Balance

•Endurance

•Flexibility

•Memory

•Independence

•Dizziness

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Age Related Changes: Facts and Myths

•Strength: Cannot be improved or recover after ___

•Balance: Falls are a part of aging

•Endurance: Cannot improve or recover after ___

•Flexibility: Cannot improve or recover after ___

•Memory: Forgetting is a natural part of aging

•Dizziness: Part of aging and medications

Fall Risk Calculations: The Parameters

•Physical fitness: Strength, balance, flexibility

•Functionality: Walking speed

•Cognition: Attention

•Comorbids: Neuropathy, vestibulopathy, stroke, PD

•Medication: Psychotropics

•Environment: Clutter, lighting

*NONE of these are comprehensive lists…just examples

The pathophysioologies of imbalance

•Peripheral sensory receptors: Vestibular, ocular, peripheral nerve

•Injury to central nervous: stroke, SCI, concussion, TBI, tumor, infections, trauma, congenital, environmental

•Degenerative Diseases: Charcot, PD, MS, etc.

•Pain, arthritic limitations

•Peripheral effector conditions: Myopathies and neuromuscular diseases

•Indirect system impairments: cardiac, pulmonary and integumentary affecting fitness and resources

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Sensory organ impairments:“Nerves, Eyes, Ears”

Neuropathies

DM

Vitamin B12

Alcoholism

Spinal stenosis

Toxin

Trauma

Idiopathic

Familial: Charcot, other

Vestibulopathies

BPPV

Infections

Structural

Systemic

Ototoxicity

Trauma

Oncology

Congenital

Anomalies

Opthamologies and related

Macular degeneration

Retinopathies

Trauma

Neurologic (brain, brainstem, II-IV, VI)

Congenital

Toxic

The pathophysiologies of neuropathy

Neuropathies

•DM

•Vitamin B12

•Alcoholism

•Spinal stenosis

•Toxin (lead, mercury, chemotherapy)

•Trauma

•Idiopathic

•Familial: Charcot, other

Neuropathies and balance influence

•Absence or presence of partial sensation

•Conduction speed suppression

•Encouraging alternate sensory compensation (visual)

•Creates learned non-use of remaining sensory capacity

•Fear-evoked inactivity that further exacerbates weakness, flexibility and endurance changes

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Vision: THE dominant sensation

Opthamologies and related

•Macular degeneration

•Retinopathies

•Trauma (CN or central)

•Neurologic (brain (stroke or tumor), brainstem, II-IV, VI)

•Congenital

•Toxic

Vestibulopathies: Silent and “invisible” mysteries

Vestibulopathies

BPPV Ototoxicity

Oncology Congenital

Trauma Infections (neuronitis, labyrinthitis)

Systemic (Hydrops, Meniere’s)

Structural (SCD, fistula, etc)

Measurement in BALANCE

Evidence-based treatment is based on:

• Establishing a diagnosis through examination

• Using tests and measures of function, impairment, and participation

• Re-examining patients to ensure that they are improving

• Assigning a plan of care that includes challenging balance in a task-specific manner that is consistent with tested impairments, respects personality, fear, capacity

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Automaticity in BALANCE

For balance to be truly functional and viable, we need accurate, timely, and subconscious reactions:

Video

MUST-KNOW balance screens and measures

Direct balance tests

•BERG

•4 square step test (4SST)

•4 Stage balance test

•BEST or mini-BEST

•TUG and CTUG

•Tandem 10’ walk

Functional measures

(indirect balance)

•2 and 6 min walk tests

•30 second sit to stand

•5x STS

•ABC

*Dynamic Gait Index and Functional Gait Assessment

DIZZINESS• Expectations in the medical community

• Influences of medication

• Associated conditions to rule-out

• Neuropathy

• Cardiac

• Stroke

• Vestibular

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Vestibular hypofunction and the patient with chronic dizziness

What is dizziness?

•Vertigo

•Lightheadedness

•Imbalanced

•Unsteady

•Fearful

DIZZINESS IS NOT:

Vestibular hypofunction and the patient with chronic dizziness

•Positional testing negative

•Orthostasis ruled-out

•Atrial fibrilation/tachycardia

•Medication-induced

The “Flavors of Dizziness”

•Lightheaded

•Imbalance

•Vertigo

•Dizziness

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The “Flavors of Dizziness”: Lightheadedness

•Corollary findings in cardiac or autonomic systems. May include syncopal episodes

•Consistently > 20 mmHg drop in systolic BP in positional testing of orthostasis

•Sx are transient without other lateralizing finding or impairment in neuro exam

•Responsive to medication or compensation

The “Flavors of Dizziness”: Imbalance

•Symptoms cannot be provoked in sitting, no matter the head rotation, optokinetic stimuli, etc

•Dizziness increases from static standing testing when eyes are closed

•Increases further when standing on compliant surface

•Positional testing negative, tests for dizziness in stable postures are negative (head thrust, VOR, etc)

The “Flavors of Dizziness”: Vertigo

•Positional testing reproduces signs and sx

•Accompanied by signs: nystagmus

•Sense of false motion of the world/room, MAY be “spinning”, may include other sensorium

•NOTE: fatigability, duration, direction, or even absence of nystagmus DOES NOT mean that they are not experiencing vertigo*

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Differential diagnostics:

Five “Ds”•Description (when I do this….it feels like this…)•Duration (length and fatigability)

•Direction (of head, of nystagmus)

•Detection (by patient sx, or signs (nystagmus))

•Disposition (how does the patient feel after rx)

Vertigo, Dizziness, or Imbalance?

•Hallpike-Dix test with Epley maneuver

•Semont maneuver

•BBQ roll test

•Motion Sensitivity Quotient

•Dynamic Visual Acuity (DVA)

•Clinical Test of Sensory Interaction in Balance

The “Flavors of (true) Dizziness”

May manifest or be described as:

•Nausea

•Fullness

•Pressure

•Cloudy/foggy

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Dizziness

VertigoLightheadedness

Disequilibrium

Spinning

Swaying

Tilting

Wooziness

Giddiness

Disorientation

Unsteadiness

Imbalance

InstabilityLoss of balance

Off Balance

Unsteadiness

Lightheadedness

Near Blackout

Near Fainting

Near Syncope

Measurement in DIZZINESS

Evidence-based treatment is based on:

• Establishing a diagnosis through examination

•Using tests and measures of function, impairment, and participation

• Assigning a plan of care including habituation, accommodation, motor learning, cognitive-behavioral

• Re-examining patients to ensure that they are improving

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Geriatric Screening: complaints of dizziness in the elderly

THOROUGH subjective:

When sx increase

Duration of sx (since first onset, with each onset)

Provocational movements, positions, environment

Describe sx (see “flavors of dizziness” discussion)

Corollary or associated symptoms: hearing, visual, sensory, clumsiness, slurred speech, etc.

Vestibular hypofunction and the patient with chronic dizziness

RULE-IN DIZZINESS

•Detailed interview

•Motion sensitivity

•Visual provocation

•Medication-induced

RULE-OUT OTHERS

•Ocular screening

•Positional testing

•Orthostasis/other cardiac

•Sensory-specific balance testing

•Symptom checklist

Vestibular hypofunction and the patient with chronic dizziness

“I feel dizzy most of the time when I move.”“It is a weird feeling in my head.”“After I move, I have it when I am sitting.”

Positional testing negative

Orthostasis ruled-out

Atrial fibrilation/tachycardia

Medication-induced

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Symptomatology: GeriatricDizzinessMULTIFOCALLOSS CUMULATIVE

•Gradually more disabling without acute onset

•Imbalance AND dizziness

•“I have vertigo”, yet they MEAN dizziness•Asymptomatic seated with head still

•Provoked with head or body motion

•Severe visual dependence

•Fear-evoked inactivity exacerbates weakness, flexibility and endurance changes

Pathophysiology of geriatric dizziness

Sensory + UVH + Visual = conflict (dizziness)

Somatosensory slowing

Silent or remote unilateral vestibular hypofunction

Gradual visual losses

Geriatric dizziness: Underlying pathologies•Unilateral or Bilateral vestibular hypofunction

•Vestibular labyrinthitis

•Vestibular neuronitis

•Cervicogenic

•Persistent Postural Perceptual Dizziness (PPPD) (after BPPV, other)

•Migraine

•Presbystasis

Recall Geriatric dizziness is the

cumulative loss, multifocal

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Outcome measures: Dizziness

•Dynamic Posturography

•Modified CTSIB

•Dynamic Gait Index: DGI

•Functional Gait Assessment: FGA

•Dizziness Handicap Index

•VRBQ: Vest. Rehab Benefits Questionnaire

•VVAS:Visual Vertigo Analogue Scale

Measurement: The balance + dizziness overlap

•Modified Dynamic Gait Index:

Time + Quality + Assistance

•Functional Gait Assessment

Quality

BOTH: Head rotation, nodding, obstacles, changed speeds, stairs, pivot turn.

FGA: backwards, eyes closed, tandem

Geriatric Screening: Dizziness in the elderly

• BPPV – positional, reproducible

• Motion Sensitivity testing – whole body or stationary with head motion

• Vestibulo-Ocular reflex testing

• CTSIB

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“MUST-KNOW” dizziness measures

•Dynamic Gait Index*

•Functional Gait Assessment*

•Dynamic Visual Acuity

•Clinical Test of Sensory Integration in Balance

•Dizziness Handicap Inventory

•Motion Sensitivity Quotient

Rehabilitation: dizziness

and vertigo

Mechanisms of Vestibular Rehabilitation

•Habituation exercises decrease dizziness and nausea through repetition of symptom-provoking head movements

•Adaptation exercises consist of repeated head movements while focusing on a target

•Substitution involves using an alternative strategy or sensory modality to function

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Recall – why the brain reorganizes…•Reinforced learning (success, food, feedback)

•Persistent error signals• Foot drop, loss of balance, missed target

•Danger/fear that is real or imagined

•Pain, dizziness, blurred vision

Tests and measures: DIZZINESS the essential measures

•Dynamic Gait Index: DGI

•Functional Gait Assessment: FGA

•Clinical Test for Sensory Integration in Balance (CTSIB)

•VIDEO: BALANCE TEST CTSIB MS

•Motion Sensitivity Quotient

•Dizziness Handicap Index

Tests and measures: DIZZINESS the essential measures

Dynamic Visual Acuity Video

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Treating dizziness

Step by step…1. Accurate diagnosis

2. Determine provocational movements

3. Rate level of symptoms (0-10)

4. Investigate fatigability (5 repetitions, rating sx)

5. Prescribe 2-3x (+) per day, 5 rep sets

6. Advance (eliminate asymptomatic) activities

Treating dizziness

Exposure to provoking movements or…?

Video

Rehabilitation: imbalance

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Systems of Balance

Biomechanical

Constraints

Stability Limits

/ verticality

Anticipatory

Postural

Adjustments

Postural

Responses

Sensory

Orientation

Stability in

Gait

Clinical Guidance Statement: AGPT

•Screen ALL older adults about fear or and fall hx

•Risk assessment as indicated by screening

•Intervention built around risk factors, individualized

•Comprehensive: Walking, balance, strength

•Prevention: home, meds, other medical

•Role of PT is primary, secondary, tertiary

Balance Testing and Screening

Assessment*:

How impaired is this patient?

What dosage is needed?

What interventions are indicated?

* Objective documentation and justification for treatment

Screening*:

Is this patient at fall risk?

What level of fall risk?

What areas should be more closely examined?

*Objective justification of assessment

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Can a screen be a “measure”?

Yes…a balance screen CAN be a measure:TUGO

30 second STS

5x STS

So…what screens are primarily screens*

4 Stage Balance Test

Four Square Step Test

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4 Stage Balance Test: Scoring

The Cutoff: Screening Fall Risk

TUGO > 14 sec

30 second STS – norms for age/gender

4 Stage balance – completes through Stage #3 (10 sec)

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Neuroplasticity in Sensory VS Motor

Sensory neuroplasticity AND motor control mechanisms

•Synaptic efficacy

•Synaptogenesis

•Angiogenesis

•Dendritic arborization

•Habituation

What constitutes balance rehabilitation?

Treating the PERSON

•Treating to the body structure or underlying impairment

•Treating toward the activity loss

•Treating the participation

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OBJECTIVELY build treatment plans

•Creating treatments from the results of your assessments…

•Understanding patient personalities, psychological and cognitive influences

•Treating to the body structure , system or underlying impairment

•Treating toward the activity loss (balance specific activities for this module)

•Treating while understanding this person’s roles and responsibilities (participation)

VISION

EYES CLOSED

HEAD NODDING

HEAD ROTATION (SIDE-SIDE)

OBSTRUCTION/DISTRACTION

ARMS LENGTH REACH

SIT TO STAND

REACH BEYOND ARM'S LENGTH

STOOPING/FLOOR RETRIEVAL

MOTION

BASE

ONE LEG

TANDEM

FEET STAGGERED

FEET TOGETHER

FIRM

CUSHIONED

UNEVEN

SLICK

SURFACE

BALANCE REHAB MATRIX

Studer 2017

Treatment of Sensory Orientation: Multisensory Integration

•Step one: Define the sensory impairment and condition of intolerance (specific mode of sensation, central processing error, speed of conduction, etc.)

•Step two: Determine the rehabilitative potential to overcome this sensory loss (peripheral neuropathy, Guillan-Barre, stroke, vestibular)

•Step three: Treatment planning to compensate/retrain or re-learn sensory orientation as indicated

•Step four: Repeated exposure to the environments that will best induce change within a functional context

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Example: Neuropathy

•A very common condition that we do little to nothing about….YET!

•Lumbar stenosis

•Diabetic

•Vitamin B12

•Charcot

•Toxicity – chemotherapy

•Trauma

•….somatosensory reweighting

Neuropathy, balance retraining?

Neuropathy - balance retraining!

Amputee balance retraining!

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Balance rehabilitation: evidence-based and person-specific

•Intense

•Challenging

•Engaging

•Task specific

•Person-specific

•Evidence based (research proven)

•Examination (of this person) based

Rate of Perceived Stability (RPS)

The best balance

prescription includes what

HE thinks is too much or too easy…

Espy, D 2018 – used with permission

Rate of Perceived Stability (RPS)

Espy, D 2018 – used with permission

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Frail Elderly

MCHST

TUGO

10m walk

Four Stage Balance Test

5x STS

Sitting Balance Scale

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Examining + dissecting balance

•Berg Balance Scale

•Modified CTSIB

•Dynamic Gait Index

•Functional Gait Assessment

•Four square step test

•INDIRECT measurement: 2 and 6 minute walk

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Dosage: Balance

•Daily

•Task specific

•Dynamic

•Creates a stimulus (causes imbalance 30%)

Intensity: BalanceTask-specific overtraining via VIDEO analysis:

◦ BALANCE Gait multidirectional

◦ BALANCE Geri Somatosensory Training

◦ BALANCE tandem foam

◦ BALANCE trail making agility

Clinical “PRACTICE”“To boldly go where no evidence has gone before….”….or at least “yet”

VIDEO:

◦ BALANCE VESTIBULAR VisuaLies UVH 1

◦ BALANCE VESTIBULAR VisuaLies UVH (2)

◦ BALANCE VESTIBULAR habituation

◦ BALANCE Visualies Rehabilitation

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SPLAT – Let’s investigate each fall…

•S: symptoms

•P: position

•L: location

•A: activity

•T: time

Fit, Frail, FunctionalParameter Frail Functional Fun

Gait speed < 1.0 m/sec

2.2mph

1.0-1.5 m/sec

2.2-3.3mph

>1.5 m/sec

3.3mph

6 min walk < 1200’ 1200-1750’ 1750’

30 second sit to

stand

< 8 repetitions 8-12 repetitions >12 repetitions

Berg Balance <45/56 45-49/56 >49/56

(Modified by Mike Studer. Original by Marilyn Moffat 2009, CEEAA course 2, San Marcos CA)

Your questions…

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Contact information:Mike Studer, PT, MHS, NCS, CEEAA, CWT, CSST

MIKE@NORTHWESTREHAB.COM

WWW.MIKESTUDER.COM

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