Vestibular Examination & Rehabilitation
Vestibular System FunctionVestibular Examination& Rehabilitation Carmen Casanova Abbott PT, PhDPT 8690, Spring 2012Provides information concerning gravity,rotation and accelerationServes as a reference for the somatosensory& visual systems Contributes to integration of arousal,conscious awareness of the body viaconnections with vestibular cortex, thalamusand reticular formation Allows for:gaze & postural stabilitysense of orientationdetection of linear & angular acceleration2Ascending PathwaysVestibular Anatomy Peripheral sensory apparatusdetects & relays information about head angular &linear velocity to central processing systemorients the head with respect to gravityCentral processing systemprocesses information in conjunction with othersensory inputs for position and movement of headin spaceMotor output systemgenerates compensatory eye movements andcompensatory body movements during head &postural adjustmentsVestibular nerveVestibular nuclei Cerebellum Oculomotor complex Cranial nerves 3, 4, and 6Along with vestibulospinal reflexes coordinatehead and eye movements3Relay CentersCerebellum Monitors vestibular performance Readjusts central vestibular processing ofstatic & dynamic postural activity Modulation of VOR Inhibitory drive of VORThalamusConnection with vestibular cortex and reticularformation ĺ arousal and conscious awarenessof body; discrimination between self movementvs. that of the environment Vestibular CortexJunction of parietal and insular lobeTarget for afferents along with the cerebellum 5Both process vestibular information withsomatosensory and visual input
Descending Pathways Provide motor output from the vestibularsystem to:Extraocular muscles (part of VOR)Spinal cord & skeletal muscles (generateantigravity postural activity to cervical,trunk & lower extremity muscles)Netter, 1997 Response to changing head positionwith respect to gravity (righting,equilibrium responses)8Principles of the Vestibular SystemVestibulospinal Reflex (VSR) Generates compensatory body movementto maintain head and postural stability,thereby preventing fallsTonic firing rate Vestibular Ocular Reflex PushPush-Pull mechanism Inhibitory cutoff Velocity storage system 9Compensatory Eye MovementsVestibular Ocular Reflex (VOR) Optokinetic reflex Smooth pursuit reflex, saccades, vergence Neck reflexes All combine to stabilize object on the samearea of the retina visual stabilityVestibularVestibular-Ocular Reflex (VOR)Causes eyes to move in the oppositedirection to head movement Speed of the eye movement equals thatof the head movement Allows objects to remain in focus duringhead movements 12
Vestibular ProcessingGainKeeps eye still in space while head ismoving Ratio of eye movement to head movement(equals 1) VORTarget fixation14Vestibular ProcessingVelocity Storage Mechanism Vestibular DysfunctionPerseveration of neural firing in thevestibular nerve by the brainstem afterstimulation of SCC to increase timeconstantSCC respond by producing anexponentially decaying change in neuralfiring to sustained head movement Otolith & somatosensory input alsodrive mechanismInjury LocationInner ear Vestibular nerve Central structures and pathways 15Vestibular Pathophysiology Disorders of tone & or gain (vertigo; movementmovement-inducedvertigo) Vestibular nerve/nuclei give abnormal sensoryinformation Tone automatically recovers in a few days; does notneed visual input Compensation for reduced gain depends on visualimages; takes month to years to complete; high speeds& accelerations may never be complete Nystagmus usually transient sign of vestibular lesion;movementmovement-induced symptoms can be chronic18
VOR DysfunctionVertigoDirection of gaze will shift with the headmovement Cause degradation of the visual image In severe cases, visual world will movewith each head movement (vertigo) An asymmetrical firing of the twovestibular systems Gives an illusion of spinning, movement Indicative of any one or combination ofcauses (acute UVH, BPPV, brainstemlesion, vascular hypotension hypotension )Oscillopsia Visual illusion of oscillating movementof stationary objects Can arise with lesions of peripheral orcentral vestibular systems Indicative of diminished VOR gainmotion of images on foveadiminished visual acuityVestibular DysfunctionDemographics DemographicsVestibular disorders manifested by vertigoare a significant health problem,secondary only to LBPNIH study estimates that 40% of thepopulation over the age of 40 willexperience a dizziness disorder duringtheir lifetime23 Falls most common cause of TBI TBI accounted for 46% of fatal falls inolder adults (CDC, 2008) Dizziness most common symptom of TBI,occurring initially in 98%
Dizzy Patient Presentation: Unexplained ornew onset of symptoms Bilateral Vestibular LossMedical referral Constant vertigoLateralpulsionFacial asymmetrySpeech & or swallowing difficultiesOculomotor dysfunctionVertical nystagmusSevere headachesRecurrent fallsUnilateral hearing loss, tinnitis,tinnitis, fullness, ear pain VOR cannot be recalibratedCompensatory mechanisms are used2526Central Vestibular DisordersCompensatory MechanismsSensory substitution Motor substitution Predictive & anticipatory strategies VascularWallenberg’Wallenberg’s SyndromeHead InjuryCerebellar InfarctPostconcussive SyndromeDemyelinating Disease Congenital 27Traumatic Brain Injury28Central Vestibular Disorders 3030-65% suffer symptoms of vestibularpathology during recovery Clinical classification according to threemajor planes of action of the VOR Mechanisms of injury: Determined by ocular motor, postural, &perceptual signsconcussionfracturesintracranial pressure & hemorrhagic lesionscentral vestibular lesionsHerdman,Herdman, 20002930
ROLL PLANE SIGNSYAW PLANE SIGNS(ipsiversive at pontomedullary level; contraversive at pontomesemcephaliclevel)(lateral medulla including root entry zone of VIII and/or vestibularvestibular nuclei)Horizontal nystagmusPast pointing Rotational & lateral body falls Horizontal deviation of perceived straightstraightaheadTorsional nystagmusSkew deviation Ocular torsion Tilts of head, body & perceived vertical 3132PARIETINSULAR VESTIBULARCORTEXPITCH PLANE SIGNS(bilateral lesions or bilateral dysfunctioin of the flocculus)flocculus)Upbeat/downbeat nystagmus Forward/backward tilts & falls Vertical deviations of perceived straightstraightaheadMain sensorimotor integration center Dysfunctions: vestibular seizuressignstilt of perceived verticallateropulsion (“pusher”pusher”) rare rotational vertigo 3334Assessment of the Patient afterWhiplash/ConcussionVestibular AssessmentKnowledge of vestibular testsDetermine unilateral or bilateraldysfunction Positional disturbances Postural stability deficits Functional deficits Other systems Clinical ExaminationHistory Medical History Subjective History Fall History Functional History 35 Upper quarter screenCervical spine instability testsOculomotor testingAmbulationFunctional gait assessmentStatic balanceDynamic balanceMotion sensitivityFall riskActivity levelBalance confidenceQuality of life
Laboratory Vestibular FunctionTestsSensory Organization Test (SOT)Provides sensoryconflictsCaloric test Rotary Chair test Posturography Postural sway ismeasured during 6different sensoryconditionsPerformance patternsmay guideexpectations forcertain diagnoses37Results of Vestibular FunctionTestsComplete vs. incomplete loss Peripheral vs. central dysfunction Direct patient management Assist in outcome prediction 40Blunt Trauma DizzinessPositional Vertigo Exertional Dizziness Migraine Associated Dizziness Spatial ilibrium Normal Structure Function vs.Impairment Vestibular hypofunction symptoms emergefrom functional deficits in:VestibuloVestibulo-ocular systemVestibulospinal systemSensory mismatchPhysical deconditioningHoffer ME, 2004 & 2007Herdman,Herdman, 200742
Differentiation Between Peripheral & CentralCauses of VertigoLoss of VOR/VSR PeripheralNauseasevereImbalancemildHearing LosscommonOscillopsiamildNeurologic Sym. rareCompensationrapidPoor VORDifficulty seeing clearly during headmovements, more so with unpredictable ones Poor VSTResults in diminished confidence in balanceDecreased gait speedIncreased risk for rman JM, Whitney SL, 200043Peripheral Vestibular DisordersVestibular Neuronitis Labyrinthitis Meniere’Meniere’s Disease Acoustic Neuroma Perilymph Fistula Benign Paroxysmal Positional Vertigo(BPPV)44Vestibular Clinical Exam Spontaneous nystagmus (imbalance in tone)Postural instability (abnormal tone & gain,proprioceptive loss)VOR gain (maintained fixation, dynamic visualacuity)Head shaking (compensated UVL, notnecessarily PVL)Calorics;Calorics; pressure sensitivityHyperventilation (anxiety, acoustic neuroma)neuroma)4546Dizziness Handicap InventoryNystagmus Primary diagnostic indicator in identifyingvestibular lesions Physiologic nystagmus vestibular, visual, extreme lateral gaze Pathologic nystagmusspontaneous, positional, gaze evoked 47Three subscalesfunctionemotionphysical aspectsScoringYes4 pts.Sometimes2 pts.No0 pts.Excellent testtest-retest reliability48
Contraindications to DixDix-HallpikeTestHallpike-Dix Maneuver Gold standard used to check for thepresence of benign paroxysmal positionalvertigo (BPPV)Nystagmus induced by this test is anobjective measurement from which we candetermine SCC dysfunction and assess aresponse to treatmentHistory of cervical surgeryRecent cervical trauma Severe rheumatoid arthritis Atlantoaxial and occipitoatlantal instability Cervical myelopathy or radiculopathy Chiari malformation 49Benign Paroxysmal PositionalVertigo (BPPV)50Diagnosis of BPPV5 criteria crucial in diagnosis (Hallpike(Hallpike--Dix Test)1. Signs and symptoms2.3.Sudden, severe attacks of vertigo precipitated bycertain head positions & movements e.g., rolling over, neck extension, bending forwardLightheadedness; nauseaAnxietyAvoids movementDirection & duration of nystagmus differentiatesbetween BPPV & a central vestibular lesion (CVL)4.5.Torsional/linearTorsional/linear--rotary nystagmus;nystagmus; reproducedby provocative positioning with affected eardownNystagmus of 11-5 sec. latencyNystagmus extinguishes 60 sec.1. Canalithiasis:Canalithiasis:2. Cupulolithiasis:Cupulolithiasis: 60 sec.Reversal of nystagmus direction on returning toupright positionResponse diminishes with repetition ofmaneuver (fatigability)Massoud,Massoud, 199651BPPVCupulolithiasis52BPPVCanalithiasis Debris, probably fragments of otoconiafrom the utricle, adhere to the cupula Debris floating freely in the endolymph inthe long arm of the posterior SCC Treatment TreatmentBrandtBrandt-Daroff habituation exercisesSemont liberatory maneuverCanalith repositioning maneuver (CRM)8484-90% remission rate5354
BalanceCan be viewed as a motor skill thatemerges from the interaction of multiplesystems These systems are organized to meetfunctional task goals & are constrainedby the type of environment Balance, like any skill, can improve withpractice 55Systems Approach to Examination Examination of balance & mobility using avariety of tests & measurements todocument functional abilities, determineunderlying sensory, motor, & cognitiveimpairments contributing to functionaldisabilitiesClinical Test of SensoryInteraction In Balance (CTSIB) Assesses pattern of sensory dependencefor balance from timed stance tests duringdistortion of sensory environment Sway and movement strategies areidentified57Walking Speed: The Sixth VitalSignBerg Balance Scale Performance -orientated balanceassessment Interpretation:Fritz S, 2009Complex functional activity that is areliable, sensitive and specific measure Can be used as a predictor of future 45/56 highly specific (96%) for nonfallerssubjects who fell most frequently were thosecloser to cut off 58Correlates with other balance tests59Health statusFunctional declineFallsHospitalizationDischarge locationMortality
Dynamic Gait IndexHabitual Gait Speed (HGS) HGS is used to assess mobility, dynamic balance andLE power Gait velocity is a measure of how well multiple systemsare integrated into lower limb function Gait speeds of 1.8 feet/sec are reported as a higherrisk for recurrent falls Gait speed cut off of 3 feet/sec as high risk for incidentmajor health related events; hospitalization and death Impairments in mobility, balance, and strength requiredfor normal gait speed can be used as signs of disease,frailty, and preclinical disability Measures the ability to adapt gait to changesin task demandsScore 20/24 related to fall history incommunitycommunity-dwelling older adults, people withcentral and peripheral vestibular dysfunctionConcurrent validity with the Berg BalanceScaleCorrelation with ActivitiesActivities-specific BalanceConfidence Scale (ABC)Whitney, 2003; Powell, 1995Bohannon, 1997; Cesari,Cesari, 2005; Guralnik,Guralnik, 2000; Van Swearingen, 199862Functional Gait Assessment (FGA) Modified version of DGI used to assess posturalstabilityDeveloped to increase sensitivity to minorchanges in gait stability; issue with a ceilingeffect seen in the DGI in patients with vestibulardeficitsContains 10 items, 3 new (gait with narrow BOS,walking backwards, walking with eyes closed)Intervention63Therapeutic Intervention ObjectivesChange impairments Improve functional performance Improve capacity to adapt performance tochanging task & environmental demands Mechanism of RecoveryCompensation rebalancing of tonic activity within vestibular nuclei(spontaneous recovery)recovery of VOR (vestibular adaptation)habituation (progressive decline in response to samestimulus)alternative strategies/substitution; in complete loss ofvestibular function 65Results from changes in CNSEnhanced by active movements & processing ofvisual, vestibular, & somatosensory stimuli66
Compensatory MechanismsResult of Early Intervention Substitution or modification of saccadesIncrease gain of the cervicocervico-ocular reflex(COR) Use of central preprogramming in eyemovements Enhancement of smooth pursuitmovement Gain returns quickerIncreased function Decreased gait ataxia Decreased perception of dysequilibrium67Vestibular Exercise ProgramObjectivesGoals of Vestibular Rehabilitation 68Diminish dysequilibrium,dysequilibrium, sense of being “offbalance”balance”Decrease risk of falling e.g., improve ability tosee clearly with head movementDecreased social isolationMotivate patient to comply with activity programHerdman,Herdman, 2001 Complement CNS natural compensationdiminish dizziness & vertigoenhance gaze stabilizationenhance postural stability in static & dynamicsituationsIncrease overall functional activities Patient education 69Vestibular ProgramComponents 70Interventions: Reduced VestibularFunction Retrain VOR & VSR functionGaze stabilization exercises to retrain VORfunctionBalance retraining to retrain VSR functionCardiovascular & strengthening exercises toincrease activity & fitness levelHabituation or canal repositioning maneuversas indicatedadaptation (vestibular system ability to adapt tochanges in sensory information)substitution enhance COR, corrective eye saccades, slower headmovementsretrain postural control 71relies on visual & somatosensory stimuli Sensory organization of visual, vestibular,and somatosensory inputMotor organizationConditioning exercises72
Interventions:Distorted Vestibular Function Canalith Repositioning Maneuvers Treatment of BPPV based on thecanalithiasis hypothesis Objectives:move the canaliths from the canal to theutricleaccomplished via head maneuvers thatrotate the target canal in the gravitationalplane so that the canaliths migrate in theopposite directionRepositioning maneuversBrandtBrandt-Daroff habituation exercisesLiberatory maneuver (Semont(Semont))Canalith Repositioning Maneuver (ModifiedEply)Eply)Habituation exercisesBalance retraining Conditioning exercises 73Interventions:Central Vestibular DysfunctionTreatment Enhancement 74NystagmusNystagmus-based timing of the positioningsequenceVibration of the skullRepetition of the maneuvers at the samesession & at F/UAlteration of the procedure on changednystagmus observationsMaintenance of a generally upright headposition for 48 hours ( optional) Dysfunction same as peripheraldysfunction with exception of n VORgain Substitution exercises Habituation exercises with caution75Interventions:Bilateral Vestibular Lesion76Vestibular Exercises EfficacyCentral preprogrammingModify saccadic & pursuit eyemovements Potentiation of COR (complementsVOR) Substitution with somatosensory stimuli Compensatory strategies eg.,eg., turn onlights lights Help in UVL if spontaneous recovery doesnot occur (Norre & Deweerdt ‘80) Diminish dizziness & dysequilibriumsymptoms (Horak et al ‘92) VSR recovery noted with early intervention Improvement in vestibular function testing(Herdman ‘95) Increased overall functional activity level (Gill(GillBody ‘94) Herdman,Herdman, 20007778
Vestibular System AdaptationCawthorneCawthorne-Cooksey Exercises Address complaints of vertigo & impairedbalanceLong term changes that occur in response ofvestibular system to input Include movements of head, head/eyecoordination, total body movements, &balance tasksAdapts to dysfunction via central repaircapability & redundant sensory & motorfunction Exercises performed in various positions & atvarious speedsAdaptation occurs as errors in performanceare detected and corrected e.g., retinal slip Encourage movement into positions thatprovoke symptomsAdaptive mechanisms:vestibular spinal reflexes, VOR 79Adaptation Exercises 80Adaptive MechanismsPromote use of vestibular system , e.g.VOR, VSRVestibularVestibular-ocular reflex (VOR) Vestibulospinal reflex (VSR) Vestibulocollic reflex (VCR) CervicoCervico-ocular reflex (COR) 8182Gaze Stabilization (GS)Substitution Exercises Maintenance of an image on the fovea duringhead movements (VOR) Older adults demonstrate a decreased ability tofixate a target during balance tasks Alternative strategies & sensory inputsexamples:CORVSR Visual Avoidance Maximize head stability by disassociating headand trunk segments vs. unstable head in spacedue to rigid linking of head and trunk andresultant abnormal postural responses Adaptation of the VOR and resultant decrease infall risk is believed to occur via vestibularspecific GS exercises using adaptation andsubstitution exercises84
Cervicogenic Dizziness Disturbances to afferent input from the neck cancause dizziness, unsteadiness, visual changes,altered head and eye movement controlHabituation Exercises Desensitization to movements Use of repetitive movements Quantify status & progress by comparingresponses to Motion Sensitivity QuotientInterventionOculomotor exerciseEyeEye-neck coordinationProgressive gait dual task activitiesStanding balanceEnvironmental manipulation during gaitDaily HEPKrisjansson,Krisjansson, 200986Effort Exertional HeadacheExercise Guidelines Emphasize fast & powerful muscle activitynecessary for reactive balance controlmechanism Precipitated by any form of exercise e.g., impactactivity, head movement Use postpost-concussion symptom scale to discussS&SPhysical symptomsNeuropsychiatricSleep disturbancesCognitive symptoms Include interlimb coordination as well ascoordination between LE & upper bodymovements Multisegmental coordination will ensure bettersafety if postural responses do not completelyrecover Early intervention should includeLight aerobic, balance and vestibular exerciseNo impact activity, limited head movement andconcentration activities87Gait with Dual Task Performance Evidence of strong association betweencognitive function and gait ability whileperforming another task e.g., math, obstaclecourse Recovery may be slowed by meds, colds, other CNS orperipheral disorders, age changes in visual, vestibular &somatosensory systems BVLs slower to recover (2 years)Compounding effect of cognitive and motordeficits on gait parameters Postural stability may never be normal; adequate posturalstability needs greater sensory cues Increased risk of falling; use of a cane or walker at first,home modification May need to continue exercises to maintain recoveredfunction; walking is a fundamental daily activity Intrinsic (fatigue) and extrinsic factors (uneven surfaces,low lighting) contribute to vestibular functionSlower gait speedShorter stridesIncreased double support timeIncreased stride variability Patient EducationChanges associated with increased fall risk inpopulations prone to fallYogevYogev-Seligmann et al, 200890
Vestibular Function RecoveryRatesRed FlagsUVL: 66-8 weeksBPPV: remission in 1/few treatments BVL: 6 months - 2 years CNS Lesion: 6 months - 2 yearsSudden loss of hearingIncreased pressure / fullness in ear Discharge of fluid from ears or nose Severe ringing in ear BP problems Increased CNS symptoms Increased visual problems 91Physical Therapy Intervention:Prescription Individualized vestibular rehabilitation program:Outpatient, 11-2 times / week (4(4-6 weeks)HEP, 5 minutes, 3x / dayWalking program (health & fitness prescriptions) Compliance to daily program essential tosuccess Exercise graduated for possible increase ofsymptoms during the first week9392
SUMMARY OF VESTIBULAR SYSTEM istulaVertigoType Rotational Rotational RotationalNystagmusDuration ½-2 min. 48-72 hr.NauseaPosturalataxiaSpecificsymptoms-/ -/ 30 min.-24hr. Rotational/linear ositioning,turning inbedAcute onset-Fullness ofear, hearingloss, tinnitus-BilateralVestibularDisorderPermanent Loudtinnitus,Tullio sign,HennebertsignHeadtrauma, earsurgery,sneezing,straining,noseblowing-Herdman, S.J., 1994. Vestibular Rehabilitation. Philadelphia: F.A. Davis Co.-
ACTIVITIES TO FACILITATE MOTOR COORDINATIONMethods of Promoting Ankle StrategyUse small anteroposterior (AP) and mediolateral weight shifts, with hips extended on avariety of surfaces including a tilt board.Alternate step-ups onto a small step without using a rail.Use a Biomechanical Ankle Platform System (BAPS) board.Alternate upper extremity flexion and extension.Methods of Promoting Hip StrategyUse large AP weight shifts on a variety of support surfaces.Stand on a narrow support surface (i.e., balance beam).Perform tandem standing and tandem walking.Perform single-leg stance.Strength and Coordination ExercisesHeal raises, toe raises.Stationary biking, walking, jogging, rowing.Isokinetics in functional patterns, including use of Kinetron .Rubber tubing exercises in standing.Perturbations in standing, using functional electrical stimulation to augment synergicresponses.Movement classes (e.g., Tai Chi, modified aerobics, social dancing).Activities to facilitate sensory organization for patients who demonstrate vestibularocular reflex dysfunction or sensory selection problems.Adapted from information presented by Ann Shumway-Cook, PhD, PT, at the Vestibular Rehabilitationcourse, Medical College of Ohio, Toledo, Ohio, February 1989.
VESTIBULAR SYSTEMTREATMENT SUGGESTIONS*General body responses leading to relaxation1. Slow rocking2. Slow anterior-posterior: horizontal or vertical movement (chair, hassock, mesh net,swing, ball bolster, carriage)3. Rocking bed or chair4. Slow linear movements, such as in a carriage, stroller, wheelchair, or wagon5. Therapeutic and/or gymnastic ballTechniques to heighten postural extensors1. Rapid anterior-posterior or angular accelerationa. Scooter board: pulled or projected down inclinesb. Prone over ball: rapid acceleration forwardc. Platform or mesh net: proned. Slides2. Rapid anterior-posterior motion in prone, weight-bearing patterns such as on elbowsor extended elbows whole rocking and crawling3. Weight-shifting in kneeling, ½ kneel or standingFacilitory techniques influencing whole body responses1. Movement patterns in specific sequencesa. Rolling patternsb. On elbows, extended elbows, and crawling: side by side, linear and angularmotion2. Spinninga. Mesh netb. Sit and spin toyc. Office chair on universal joint3. Any motor program that uses acceleration and deceleration of heada. Sitting and reachingb. Walkingc. Runningd. Moving from sit to standCombined facilitory technique: inverted tonic labyrinthine and inhibitory1. Semi-invented in-sitting2. Squatting to stand3. Total inverted vertical position*Remember all of these treatment suggestions involve other input mechanisms and allaspects of the motor system and its components.ADAPTED FROM UMPHRED, 95
EXERCISES TO IMPROVE GAZE STABILITYEnhance the Cervico-ocular ReflexTape a business card on the wall in front of you so that you can read it.Move your head back and forth sideways, keep the words in focus.Move your head faster but keep the words in focus. Continue to do this for 1-2 min.without stopping.Repeat the exercise moving you head up and down.Repeat the exercises using a large pattern such as a checkerboard (full-field stimulus).Active Eye-Head Movements Between Two TargetsHorizontal Targets:Look directly at one target being sure that your head is also lined up with the target.Look at the other target with your eyes and then turn your head to the target (saccadesshould precede head movement).Be sure to keep the target in focus during the head movement.Repeat in the opposite direction.Vary the speed of the head movement but always keep the targets in focus.Note: Place the two targets close enough together that when you are looking directly atone, you can see the other with your peripheral vision. Practice for 5 min., resting ifnecessary. This exercise can also be performed with two vertically placed targets.Imaginary TargetsLook at one target directly in front of you.Close your eyes and turn your head slightly, imagining that you are still looking directlyat the target.Open your eyes and check to see if you have been able to keep your eyes on the target.Repeat in the opposite direction. Be as accurate as possible.Vary the speed on the head movement.Practice for up to 5 min., resting if necessary.
Home Exercise ProgramEXERCISES TO IMPROVE POSTURAL STABILITY1. Practice walkingturning head from one side to the other10 minutes, 3 times a day2. Practice marching in placeeyes open, eyes closed50 steps3. Step Ups on a small stepmove arms up and down as you step up and downprogress to performing above drill with eyes closed4. Practice heel raises, toes raises15 times each day5. Practice rocking in a rocking chaireyes open, eyes closed6. Ball activitiesbasketball drillssoccer drills7. Practice single leg standingeyes open, eyes closedprogress to 30 second holds8. Standing one leg in front of the othereyes open, eyes closedprogress to 45 second holds9. Perform above standing drills on a foam surfaceuse 2-3 inch foam surface, or a minitrampolinePerform drills three times a day, spending at least 5 minutes on each session.
with respect to gravity (righting, equilibrium responses) 8 Vestibulospinal Reflex (VSR) Generates compensatory body movement to maintain head and postural stability, thereby preventing falls 9 Principles of the Vestibular System Tonic firing rateTonic firing rate Vestibular Ocular Reflex Push-Pull mechanism Inhibitory cutoff
Define Vestibular Rehabilitation Differentiate between components of the general and vestibular‐specific physical therapy examination Distinguish red flags from vestibular dysfunction in patient screening . O’Sullivan SB, Schmitz TJ. Physical Rehabilitation. 7th ed. F.A. Davis; 2019.
The Cochlea Divided into 3 tunnels by the vestibular and basilar membranes –Scala vestibuli ends in the oval window- sound waves vibrate perilymph moves vestibular membrane –Cochlear duct contains the organ of Corti- movement of vestibular membrane causes hair cells to bend –Scala tympani ends in the round window- endolymph vibrates basilar membrane to dissipate sound waves
Validation for Vestibular Rehab Bara et al demonstrated that vestibular therapy appears to help in patients with dizziness and balance problems without variations among age Anzalone et al demonstrated that a positive relation between poor performance on VOMS in the pediatric population may indicate longer recovery time
6. Activities specific Balance Confidence scale – ABC see Geriatric Exam Tool Kit 7. Dizziness Handicap Inventory (DHI) 8. Geriatric Depression Scale 9. Modified Falls Efficacy Scale (MFES) Handouts: (more to come during the vestibular unit) 10. Dizziness symptomology 11. BPPV Treatment Algorighm - Herdman 12. Intertpreting Nystagmus 13.
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graduation, positioning them for college and careers. The grade level ELA standards begin in the Prekindergarten and Elementary ELA Standards section. Please see the introduction for more about how the anchor standards and grade level standards connect. New York State Education Department ENGLISH LANGUAGE ARTS LEARNING STANDARDS (2017) 4 NEW YORK STATE EDUCATION DEPARTMENT Reading Anchor .
