Vestibular Rehab: The Essentials

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Dizzy childVestibular Rehabilitation : 

Dizzy childVestibular Rehabilitation Mohamed Shabana,MD Prof of Audiology Faculty of Medicine –Cairo University

Slide 7: 

Environmental Interaction Visual System Vestibular System Somato- Sensation SENSORY ENVIRONMENT The conditions which exist (or are perceived to exist) in the real world around us which impact balance

Slide 8: 

Environmental Interaction Visual System Vestibular System Somato- Sensation SENSORY ENVIRONMENT Darkness, Crowds Gravity, Linear & Angular Head Movement Sandy beach, Woods, Icy surface

Slide 9: 

Stable vs. unstable conditions place different demands on the individual Stable = low control demand Unstable = high control demand SENSORY ENVIRONMENT Environmental Interaction Visual System Vestibular System Somato- Sensation

Slide 10: 

Visual System Vestibular System Somato- Sensation Compare, Select & Combine Senses SENSORY INPUTSVisionVestibularSomatosensory

Slide 11: 

Vestibular System Compare, Select & Combine Senses Semi-circular canalsOrientation Navigation Utricle & SacculeHorizontal & vertical acceleration & deceleration VESTIBULAR RECEPTORS

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“Disagreement” between the three senses or the right Vs. left sides SENSORY CONFLICT Resolution is perceptually challenging Recognize accurate inputs Suppress inaccurate inputs

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Choice of Body Movement Select & Adjust Muscle Contractile Patterns -Selecting which movements -Sequencing muscle contractions -Scaling muscle contractions -Timing the movements MOTOR PLANNING “Where are my head, trunk & limbs in relationship to each other?” “Where is my body in relationship to my environment?”

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Generation of Body Movement Reflexes Automatic Postural Responses Anticipatory Postural Set Voluntary Movements Vestibular-Ocular (VOR) Vestibulo-Spinal (VSR)

Slide 17: 

between the individual, the task, & the environment. Balance is the result of interactions ...

Slide 18: 

Balance is a Feedforward Movement induced sensations = Feedback CONSTANT CYCLE Attention & Anticipation =

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During the action = Knowledge of performance (KP) “What is my body doing?” After the action = Knowledge of results (KR) “Did I accomplish the goal?” Movement producessensory feedback:

Slide 22: 

Postural Control Needs Practice & experience Integrity of all systems

Immature development : 

Immature development Defect in one system Central processing Inability to experience varies up right position

Vestibular system developmentin occulomotor function : 

Vestibular system developmentin occulomotor function DVA by 3years POSTURE By adolescence

Slide 26: 

So, The vestibular system matures at different rates So, Examination of the child should include both: Vestibulo-spinal reflex Vestibulo-ocular reflex

Vestibular compensation : 

Vestibular compensation A case of severe vertigo of 11 years, examined weekly . 3 instances one week apart Looking



Vestibular compensation : 

Vestibular compensation 1-direct first relay 2-communiating with other side 3-other inputs and outputs

Vestibular compensation : 

Vestibular compensation Static and dynamic Static constitutes horizontal nystagmus because of the unequality of the neural activity between both vestibular nuclei, with cancelation effect of the effect of the vertical canals together with occular head tilt : including head tilt to the lesion side, skew deviation to lesion side and occular rolling to the lesion side

Slide 34: 

Dynamic : including Dynamic vestibulo-ocular reflex Otolith dynamic response Occular counter torsion

Acute ULVD Compensation (1) Static imbalance : 

30/10/2010 Shabana 35 Acute ULVD Compensation (1) Static imbalance Ipsi-lesional head tilt and occular rotation Spontaneous nystagmus , reflects static tonic imbalance Ipsi-lesional SVV deviation Lateropulsion to lesion side Reduction of vertigo in static positions in 1-3/7, independent of vision ‘Cerebellar clamp’ Inhibits activity contralateral vestibular nuclei Sensitises ipsilateral VN  Recovery Nystagmus

ULVD Compensation (2)Dynamic imbalance : 

30/10/2010 36 ULVD Compensation (2)Dynamic imbalance Recovery dependent upon visual inputs Takes much longer ~6/12 Reduced VOR Sharpened COR Altered properties of vestibular neurons Hypersensitivity Extra-labrynthine afferent sprouting Substitution of increased activity in occular motor nuclei and proprioceptive afferents

Vestibular compensation : 

30/10/2010 Alan Sealy, Aberdeen Balance Clinic 42 Vestibular compensation Dizziness commonly begins with periferal vestibular asymetry (inner ear) Compensate centrally from periferal lesion Often, compensate poorly altered motor programmes Increased cervical tone Increased use of vision Results in ’compensated vertigo’ Vertigo reduced Headaches / Chronic cervical dysfunction Visual disturbances  Chronic imbalance / Dizziness

Evidence of Benefits of Exercise for Vestibular Loss (1) : 

30/10/2010 43 Evidence of Benefits of Exercise for Vestibular Loss (1) Customised VRT better than general training + medication Horak et al 1992 VRT improved gait + balance function over controls in bilateral vestibular failure (some) Krebs et al 1993 VRT - greater imrovement in postural stability + symptoms post acoustic neuroma section than controls Herdman et al 1995

Evidence of Benefits of Exercise for Vestibular Loss (2) : 

30/10/2010 44 Evidence of Benefits of Exercise for Vestibular Loss (2) Physiotherapy improved dizziness and stability in cervicogenic vertigo Karlberg + Magnusson 1996 Patients presenting to GP’s received better outcomes (function + symptoms) after VRT than control groups Yardley et al 1998 UVL + BVL patients showed greater gait improvement post VRT than training Krebs et al 2003

Evidence of Benefits of Exercise for Vestibular Loss (3) : 

30/10/2010 Alan Sealy, Aberdeen Balance Clinic 45 Evidence of Benefits of Exercise for Vestibular Loss (3) VRT improves central vestibulospinal compensation after vestibular neuritis Strupp et al, 1998 Combined CBT and VRT reduces dizziness in older people Johansson et al, 2001 VRT improves physical therapy outcomes after BVL Brown et al, 2001 Subjective + objective measures improved after VRT in patients with migraine + vertigo Wrisley, Whitney and Furman, 2002

Evidence of Benefits of Exercise for Vestibular Loss (4) : 

30/10/2010 46 Evidence of Benefits of Exercise for Vestibular Loss (4) VRT + balance training improved balance in primary care setting Hansson, Mansson + Hakansson 2004 VRT for patients with WAD reduces handicap and improves postural control Hansson et al, 2006 Patients with central vestibular dysfunction improved subjective + objective measures after VRT. Cerebellar dysfunction improved least. Brown et al, 2006

Vestibular imbalance : 

30/10/2010 47 Vestibular imbalance Central compensation – Neuro-Plasticity Adaptation Habituation Substitution

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30/10/2010 Shabana 48 GAZE STABILITY EXERCISES (1)The basics Follow moving target, head movements Follow target with eyes only, head still Eyes focussed on stationary target, head moving Rapid eye movements between 2 points on wall.

Gaze stability : 

30/10/2010 Shabana 49 Gaze stability


30/10/2010 shabana 50 GAZE STABILITY EXERCISES (2) Progressions Stable  unstable Slow  fast Simple  complex Context specific Speed Plane Environment Multi-tasking

Slide 51: 

30/10/2010 Alan Sealy, Aberdeen Balance Clinic 51

Functional vestibular rehabilitation : 

30/10/2010 ٍٍ 52 Functional vestibular rehabilitation Provoking movements or positions Integrate vision / gaze stability Graded exposure - Repeat movements Compliance ”That which doesn’t kill you, makes you stronger” Schwartzenegger,A (1985)

Correct Movement Patterns : 

30/10/2010 shabana 53 Correct Movement Patterns Develop an awareness of midline Head on trunk relationship Gait pattern Correct activation of postural muscles Selective trunk muscle control Proprioceptive input from feet

Balance training : 

30/10/2010 shabana 54 Balance training Correct movement patterns Trunk : limbs, muscle imbalance, pain inhibition Functional Balance exs (Surface, eyes, position) Diagonal movements Hip / ankle strategies Gait drills Eyes, bends, turns, speed, agility Stepping, lunging, jumps, hops, reaching Core stability, gym, ’activate the patient’ Psychology: ’talk the patient better’

Treatment Summary : 

30/10/2010 shabanak 55 Treatment Summary Rehab for Vestibular Asymetry Tracking / Pursuits / Gaze stability / Saccades (rel. to speed, context, plane, balance) Functional movements / activities Specific to patient Graded exposure Restore normal movement head / neck movement Correct Movement Paterns Functional balance training

Tai chi : 

30/10/2010 shabana 56 Tai chi Improved postural control + gait function Better than VR! Tai chi improved Lower bodyfunction; VR improved Upper Combine TC+VR ِAzam et al, 2005

Slide 57: 

In the Chronic Dizzy Patient – Why are symptoms continuing? Why has the Natural Compensation process not worked? Group 1 – The patient has an UNSTABLE lesion, ie, the locus of the lesion is changing over time. – The historical hallmark is spontaneous events – More likely to be assisted with medicine or surgery –Group2 The patient has a STABLE lesion yet uncompensated by the central process – The historical hallmark is symptoms are provoked by something – More likely to be served with VBRT

Slide 58: 

‘unstable’ lesions - changing over time: 1– Meniere’s 2– Migraine 3– Anxiety (and other psychological) disorders 4– Degenerative CNS disorders » MS, Cerebellar paraneoplastic 5– Cardiovascular disorders / orthostatic hypotension 6– Mass lesions of the CPA » Schwanoma, meningioma (respond very well to therapy) 7– Autoimmune inner ear disorder

VBRT in Children : 

VBRT in Children Anecdotal reports have suggest that children as young as 3-4 do well with directed activities for eye / head coordinated movements as therapy exercises – using usual childhood play and sports

Slide 60: 

Rine et al 2004 --- completed a prospective, single blinded, placebo-controlled wait listed design of exercise versus placebo (no exercise) on children with bilateral vestibular hypofunction. Ages were 3-8 yrs. Groups were age matched and matched for functional deficit – 21 randomly assigned to experimental or control group

VBRT in Children : 

VBRT in Children While only a single study with a special homogeneous group of children its well controlled design strongly supports: – The effectiveness of VBRT in children with exercises activities used in adults modified to be age appropriate for children – The ability to obtain reliable quantitative assessment data on young children

Slide 62: 

Study by Medeiros et al, Otology & Neuro-tology (2005) Unilateral peripheral involvement suspected from positional nystagmus or caloric asymmetry > than 20% 16 patients mean age 8yrs. 16 age and gender matched controls Primary outcome measure conditions 5 & 6 on EquiTest and the ratio of condition 5 to condition 1 (vestibular ratio) All evaluated on CDP pre / post therapy; controls at same Interval All patients given same exercise activities seen during 4 in lab sessions

Slide 63: 

The results from this more heterogeneous group of children also support the contention that VBRT is an effective treatment procedure for children using adult techniques for the intervention Like the study of Rine – this one also points out the reliability of the use of objective testing methods in children.

New VBRT intervention Work : 

New VBRT intervention Work Use of alternative sensory input to improve balance and gait in bilateral hypofunction – Auditory feedback related to body angle and sway – Vibratory feedback to the torso related to body angle and sway – Tactile feedback to the tongue for body angle and sway .

Slide 65: 

Devices to help with traditional habituation and adaptation exercises done in home therapy Force platform auditory or visual feedback for in lab. training: 2005 Cochrane review with 7 studies and 246 subjects showed improved standing balance but impact on general balance, gait and independence is unclear and requires further study

Vestibular rehabilitation therapy in children. : 

Vestibular rehabilitation therapy in children. Vestibular disturbances are underdiagnosed in children. However, balance impairment may compromise the normal development of affected children.. Sixteen children with peripheral vestibular disorders (mean age, 8 yr 7 mo) constituted the cohort and were consecutively treated with vestibular rehabilitation therapy. RESULTS: All children completed the treatment. Total recovery of symptoms occurred in nine (56.3%) patients, whereas a dramatic partial recovery was observed in the remaining seven (43.7%) children. Posturography Conditions 5 and 6, the vestibular ratio of the sensory analysis, and the composite equilibrium score had a significant quantitative improvement after vestibular rehabilitation therapy.. Medeiros etal. 2010

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