Rehabilitation of Balance and Vestibular System Disorders

Rehabilitation of Balance and Vestibular System Disorders An introduction to the management of fall risk and vestibular patients. Arturo Miguel PT, MS, MBA Introduction Personal Background

Why Balance and Vestibular Therapy? Background Falls are among the most common and serious problems facing elderly persons Associated with considerable mortality, morbidity, reduced functioning, and premature nursing home admission Generally result from an interaction of multiple and diverse risk factors, many of which can be corrected with education

and physical therapy (Haddad, 2018) Prevalence (CDC.gov) Each year, 3 million older people who fall are treated in the emergency room Risks usually become evident after injury

Additionally, falling is the leading cause of injury related death in seniors Rate is three times higher in nursing homes and hospitals Self imposed functional limitations Recurrent falls are a common reason for admission to long term care institutions (40% of nursing home admissions) Costs

(CDC.gov) Fall related injuries account for 6% of medical expenditures for persons over 65 In 2015, the total medical costs for falls totaled more than $50 billion. Medicare and Medicaid shouldered 75% of these costs.

Course Objectives Observe and identify deficits affecting balance senses and balance systems. Demonstrate competence in performing balance and oculomotor screens. Perform fall risk assessment and intervention plan. Develop and execute evidence based treatment plans for patients

with balance and/or vestibular dysfunctions including BPPV and vestibular weakness. What is Balance? The ability to maintain ones center of gravity (COG) over a base of support (BOS) in a given sensory environment. COG is at anterior to S2 in standing BOS is your feet Greater base laterally than A/P

Motor Response: Balance Strategies Motor responses start from the ground up 1. 2. 3. 4. Ankle Strategy Hip Strategy

Stepping Strategy Protective Reactions (Cheng, 2015) Ankle Strategies Primary strategy for balance Controls sway Hip strategies

Start when ankle strategies fail. Hips thrust anterior/posterior to shift COG over base of support. What is normal sway? In an everyday situation where there is minimal sensory inputs, we should rely on our ankle strategies. A quick down and dirty way to observe sway is a Romberg

and Sharpened Romberg Test. Romberg Screen Simple way to qualify and quantify patients standing balance Have patient stand with feet close together, arms folded, for 20 seconds. Observe patient for overall sway. Watch for ankle, hip or stepping strategies. (Agrawall 2011)

Balance Strategies Video Can you make any observations based on this patients balance strategies? Balance Strategies Video #2 Can you make any observations on this persons balance strategies?

Stepping Strategies & Protective Reactions If hip strategies fail, we take a step in the direction of the COG displacement in an attempt to increase our base of support. If stepping strategies fail, we extend our upper extremities to protect from fall. Other Strategies

Squat Reactions Studies show when a posterior force is such that a person squats or attempts to flex knees in an effort to reduce the forces on spine. Hopping Reactions Seen mostly in gymnasts when knee flexion is inhibited in response to a proper dismount. (Cheng, 2015) Question What diagnoses can you think of that may affect a persons

ankle Strategies? Hip Strategies? Stepping Strategies? Protective Reactions? Balance Systems: Sensory Three Balance Systems Vision Somatosensory Vestibular

Visual System Acuity/Sharpness vs. Oculomotor control Acts as backup to somatosensory system (Tomamitsu, 2013) Inputs may become more dependent with age. (Lee, 2017) Somatosensory System Feeling the ground under your feet

Includes sensation and proprioception in the joints Acts as a backup to the visual system Vestibular System Senses angular rotation of your head as well as linear

acceleration Stabilizes vision via Vestibulo-Ocular Reflex (VOR) Acts as a mediator when there is a conflict between the other two sensory systems. Question What diagnoses can you think of that may affect a persons Somatosensory system? Visual? Vestibular?

Somatosensory System Neuropathy (Tosizadeh, 2015 Camargo, 2015) CVA (Hughes, 2011) Ankle Injuries (Han, 2015) MS (Fling, 2014) LE Amputee (Hunter, 2017) Visual System Parkinsons

Contrast sensitivity Impaired visuospacial ability (Hill, 2016) Multiple Sclerosis Optic neuritis Optic neuropathy (Hickman, 2014) CVA Visual field cuts Visuospacial neglect (Winters, 2017)

Vestibular System Vestibular hypofunction A significant disparity between vestibular function from one side to the other (Iwasaki, 2015) Menieres Disease Presents with vertigo, pressure in the ear, tinnitus and profound sudden hearing loss (Nakashima, 2016)

Concussion A mild TBI may result from blunt trauma to the head(Ayers, 2018) Balance Screens Romberg/Sharpened Romberg 5 Times Sit to Stand Timed Up and Go Test Berg Balance Scale Dynamic Gait Index

CTISB Computerized Dynamic Posturography 5 Times Sit to Stand (5xSTS) Equipment needed: Chair and stopwatch Pt performs sit to stand five times without support Timer starts when pt initiates sit to stand Timer finishes upon sitting on 5th repetition Normal times: <13.6 seconds (Guralnik, 2000) Mean for Parkinsons: 20.25 +/- 14.2 seconds (Duncan, 2011,

Mong, 2010) Timed Up and Go Test (TUG) Equipment required: Chair, tape and stopwatch Measure 10 feet from chair, mark with tape Pt stands, ambulates 10 feet to marker, turns around and returns to sit in chair. Timer starts upon standing then stops once pt is seated. Normal time:

60-69 years 8.1 seconds 70-79 years 9.2 seconds 80-99 years 11.2 seconds (Bohannan, 2006, Whitney, 2004) Berg Balance Scale Set of 14 functional tests Patient is graded 0 to 4 points Equipment required: chair ruler

stopwatch stool or step Normal score: >49 (Pereira, 2013) Goal: Based on the score, up to 4 points in a 4 week period Dynamic Gait Index (DGI) Set of 8 functional gait tests Equipment required: stairs with rails

shoebox or step equivalent 2 cones stopwatch Normal score: >19 (Whitney, 2004) Goal: up to 3 point improvement in a 4 week period. (Johnson, 2011, Herman, 2009) Observing Gait: A Review Observe your patient the moment they stand up in the waiting

room and walk towards the testing area. Observe overall gait quality Cadence Decreased gait speed is associated with an increased mortality (White, 2013) Decreased gait speed may also be consistent with fall risk (Roos, 2013) Step length

Step width Heel strike Toe off Arm swing Common Gait Deviations Antalgic Ataxia Spinal involvement (Gilbert 1978) Cerebellar (Bultmann, 2014)

Shuffling Parkinsons (Rahman, 2008) High Stepping/Foot slap or foot drop (Westhout, 2016) Trendelenberg (Petrofsky, 2001) Circumduction, Hip Hike (Burke, 2001) Gait Deviations Video What observations can you make on this persons gait

quality? Gait Deviations Video #2 What observations can you make on this patients gait quality? Clinical Test for Sensory Integration and Balance (CTSIB) Allows the tester to isolate balance systems with different

conditions. Foam and Dome Test requires a foam cushion a stopwatch a lampshade-like dome (Whitney, 1998 Haghpeykar, 2003) Computerized Dynamic Posturography Utilizes force plate technology to qualify and quantify a

subjects use of balance senses as well as perform analysis on postural reactions. Sensory Organization Test utilizes similar conditions as CTSIB Considered Gold standard for sensory organization and postural testing (Alahmari, 2014)

Neurocom Balance Master Bertec CDP Sensory Organization Test (SOT) SOT Results Demo and Group Exercise Separate into small groups

Practice each test with each other 10-15 minutes for each group Questions? Treatment Plan Considerations for the Non-Vestibular Balance Patient Review the impairments and functional limitations Consider activities that provide the most bang for the buck Keep it simple

Be creative! Examples of Balance Activities in Parallel Bars Activity Alternating Tap Ups/Cone Taps Step-Ups Lateral Step Ups Step Up and Overs

Rationale Promotes rhythmic weight shift, coordination and balance strategies (Roijezon, 2015) Examples of Balance Activities in Parallel Bars Activity

Ball Toss while on variable surfaces Over the shoulder ball toss on variable surfaces Rationale Promotes coordination,

ankle and hip strategies and A/P control Promotes coordination and balance strategies and incorporates trunk and cervical rotation (Haran, 2008) D1D2 Ball Handoff on

variable surfaces with Adds strengthening to the Examples of Balance Activities Activity Tall kneeling activities Activities sitting on a

Theraball Rationale Helps to promote hip strategies and trunk stability Examples of Balance Activities: Progression Activity Standing with head turns

while on variable surfaces i.e. firm, foam, balance beam, dyna disc, tilt board Rationale Promotes sensory reweighting and balance strategies.

Head rotation stimulates vestibular function. Variable surfaces promotes hip and ankle strategies. Examples of Gait Activities Activity Rationale

Gait with change speedslow/ Emphasizes improving gait fast Gait with gentle head turns Sidestepping Crossovers D1D2Braiding

quality Head turns stimulates vestibular function with activity Examples of Gait Activities: Progression Activity Gait with ball toss Gait with lateral ball toss Backwards walking

Rationale Emphasizes improving gait quality, coordination and vestibular function Patient Example 80 yo pt comes to your clinic with a script that says PT Evaluate and Treat dx: deconditioning s/p extended hospital stay

Pt presents with the following observations: Bilateral PF and DF weakness, hip and knee extensor weakness 5xSTS: 29 seconds (modified using upper extremities for support) Berg: 43, DGI: 18 without AD Pos romberg with posterior LOB at 10 seconds with eyes open List some activities would you consider in your treatment plan? Questions Is this patient at risk for future falls?

What measurable goals can be considered for this patient? Should we consider recommending an assistive device? What is the patients prognosis? Patient example #2 76 yo female is referred to your clinic with a script that says: PT evaluate and treat dx neuropathy. Pt presents with the following observations: Bilateral foot drop when ambulating, steppage gait pattern

Berg 41, DGI 14 with LOB noted when changing gait speed and when performing tap ups onto step as well as step-to pattern when climbing steps. Falls on CTSIB when standing on foam cushion Constant reaching for support using walls, chairs and other equipment in clinic. List some activities that you would consider for your intervention plan. Questions Is this patient at risk for future falls?

What measurable goals can be considered for this patient? Should we consider recommending an assistive device? What is the patients prognosis?

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