L17: Vestibular rehabilitation Flashcards
1
Q
What are 6 problem-based approach to planning treatment programs?
A
- Visual blurring or dizziness during tasks that require stable vision
- Training of gaze stability and / or visual tracking
- Symptoms of dizziness / vertigo exacerbated during movements
- Habituation exercises
- Difficulties maintaining static or dynamic equilibrium
- Exercises to target the identified deficits
- eg unable to maintain postural stability eyes closed on foam
- Instability when walking
- Exercises to improve stability during gait
- Physical deconditioning
- Exercises targeted at improving fitness and strength
- Return to driving
2
Q
What are the 4 different issues in regards to vestibular problems?
A
- Unilateral peripheral vestibulopathy
- Bilateral peripheral vestibulopathy
- Central nervous system dysfunction
- Mixed central and peripheral
3
Q
What are 2 things that can move image off fovea?
A
- Movement of fovea (ie head)
- Movement of object itself
4
Q
When is the vestibular system (i.e VOR) used?
A
When fovea moves
- Eg when jogging
5
Q
When is the visual system (i.e VOR) used?
A
When object moves in space
- Following the path of a tennis ball during a game VOR
6
Q
Visual system is used for____ (high/low)-frequency movements
A
low
7
Q
Smooth pursuit is like a reverse of ____
A
VOR
8
Q
When is smooth pursuit used?
A
Occurs in the absence of vestibular stimulation i.e. VOR needs to be cancelled “follow the finger”
9
Q
Smooth pursuit is ____ modulated
A
centrally
10
Q
When is the saccadic system used?
A
Is used to follow moving unpredictable targets
- Eg trying to swat a fly
11
Q
Saccadic system is _____ mediated.
A
centrally
12
Q
What is the optokinetic system?
A
Takes over from the vestibular system when head movements are too large
- Eg. system that kicks in when on a train watching fast things go pass
13
Q
The optokinetic system has pathways similar to that of ______.
A
smooth pursuit
14
Q
What is the vergence system?
A
- Depth tracking
- Pathways in the parietal, occipital, and frontal regions
15
Q
What is the fixation system?
A
- Utilized to look at stationary object
- Pathways in the occipital region
- Stabilise the eye –.> Fixate on an object
16
Q
If there is damage to the brainstem (eg. pons), what can the problem be?
A
have difficulty controlling these systems (optokinetic, vergence, fixation system)
17
Q
What are the 3 characteristics in the final common pathway?
A
- horizontal eye movements controlled in pons
- vertical and torsional eye movements controlled in the midbrain
- descending modulations from supranuclear structures
18
Q
The ____ is one of the fastest reflexes.
A
VOR
19
Q
What are 4 characteristics of the VOR?
A
- 10-20ms latency
- 3 neurone circuit
- Less effective in dealing with slow or prolonged movement
- Sensitive to acceleration NOT constant velocity
20
Q
What should you check before VOR?
A
Check saccades first –> if this is poor –> break down of VOR
21
Q
What does saccadic pursuit look like?
A
22
Q
What does VOR look like?
A
eyes opposite to head to keep gaze stable
23
Q
What is a gain of the vestibular system?
A
Gain = output /input
i.e. eye mvt/head mvt
24
Q
What is a gain of 1?
A
eye movement velocity = head movement velocity
25
What is a gain of 0.5?
eye movement velocity less than head movement velocity
26
The gain is _____ (increased/decreased) with vestibular loss.
increased
27
What is the purpose of gaze stabilisation exercises?
Recovery of the dynamic vestibulo-ocular responses is due to the adaptive capability - neuroplasticity - of the central vestibular system
ie. the ability of the vestibular system to make long-term changes in the neuronal response to input
28
What is the signal for inducing vestibular adaptation?
Retinal slip
29
What is the retinal slip?
movement of a visual image across the retina (Blurring of movements)
30
What does a retinal slip result in?
an error signal that the brain attempts to minimise by increasing the gain of the vestibular responses
31
What does the recovery of dynamic vestibular function require?
both visual input and movement of the body and head
32
When should x1 and x2 gaze stability exercises be used?
* Improves gaze stability by utilising central preprogramming ie neuroplasticity
* Pre-programing the saccade to compensate for the lack of VOR
33
Unilateral Vestibulopathy (UVL) usually improves in \_\_\_\_-\_\_\_\_\_ weeks
4-6
34
What gaze stabilisation exercises should be used for bilateral Vestibulopathy (BVL)?
* x 1 most useful, majority can’t ever manage x 2
* can take up to 12 weeks to improve
35
What are the 5 guidelines for gaze stabilisation exercises?
1. Consider the stimulus
* the best stimuli are those that incorporate movement of the head and visual input
2. Response to exercise takes time but repeated short bursts are effective
* vestibular adaptation can be induced with periods of stimulation of 1-2 minutes
3. Changes in the vestibulo-ocular system are context specific
* exercises must stress the system in different ways
* different frequencies of head movement - variable
* different head positions
4. Neuroplastic change requires focus on the task
* mental effort will help improve the gain of the system
* patients should be encouraged to concentrate on the task
5. Patients should always work at the limit of their ability
* exercises should stress the patient’s ability ie need to provoke symptoms to reduce symptoms
36
What is the guideline for gaze stabilisation exercises when "considering the stimulus"?
the best stimuli are those that incorporate movement of the head and visual input
37
What is the guideline for gaze stabilisation exercises in "response to exercise taking time but repeated short bursts are effective"?
vestibular adaptation can be induced with periods of stimulation of 1-2 minutes 5-6 mins
* X 5-6 times a day rather than 1 hr X 1 time a day
38
What are 3 guideline for gaze stabilisation exercises when "changes in the vestibulo-ocular system are context specific"?
1. exercises must stress the system in different ways
2. different frequencies of head movement - variable
3. different head positions
39
What are 2 guidelines for gaze stabilisation exercises when "neuroplastic change requires focus on the task"?
1. mental effort will help improve the gain of the system
2. patients should be encouraged to concentrate on the task
40
What is the guideline for gaze stabilisation exercises when "patients should always work at the limit of their ability"?
exercises should stress the patient’s ability ie need to provoke symptoms to reduce symptoms
41
What is the Herdman protocol for gaze stabilisation training in terms of duration?
begin with 1 minute each progress to 2 minutes each aim for continual motion, slow down rather than stop
42
What is the Herdman protocol for gaze stabilisation training in terms of frequency?
3 to 5 times/day, aim for x5
43
What is the Herdman protocol for gaze stabilisation training in terms of plane of movement?
start with horizontal and add vertical only use roll plane in specific contexts eg pilots
44
What is the Herdman protocol for gaze stabilisation training in terms of distance?
near first, then near and far
45
What is the Herdman protocol for gaze stabilisation training in terms of speed?
slowly at first should always see clearly, but at upper limit of ability - need a little retinal slip
46
What is the Herdman protocol for gaze stabilisation training in terms of position?
start in sitting and progress as quickly as possible to standing to progress, change foot position
47
What is the Herdman protocol for gaze stabilisation training in terms of background?
plain wall, target away from wall progress to busy background
48
What is the Herdman protocol for gaze stabilisation training in terms of X1 vs X2?
start with x1 bilateral vestibulopathy can’t usually manage x2 Gaze
49
Herdman protocol for gaze stabilisation training, the speed of the head movement should be increased, as long as the patient is just starting to have trouble keeping the visual target in \_\_\_\_\_
focus
50
For the Herdman protocol for gaze stabilisation training, it is acceptable for the patient to have an increase in their symptoms for a period of about \_\_\_\_min after they finish exercises. If longer than this, than you need to reduce ____ or \_\_\_\_
15; duration; velocity
51
What are 2 things to watch for in gaze stabilisation training?
1. Eyes must be stable during head movement - slow head movement down to learn correct pattern
2. Patient complains of increase in symptoms / restricting other usual activities
52
When a patient complains of increase in symptoms / restricting other usual activities, what are 5 things to do in terms of exercise?
1. slow head movement (may be going too fast)
2. rest longer between exercises (not resting between)
3. spread exercises out during day
4. decrease frequency of exercises
5. decrease duration of exercises
53
What are 3 characteristics of step forward/step back?
1. When increase one aspect, slightly decrease another
2. Have patient do an entire set of exercises with you
3. Instruct patient to expect some increase in symptoms and that this is necessary for the exercises to drive neuroplasticity (and habituation)
54
Gaze stability training may not normalise gain completely. _____ can adapt to use covert saccades to compensate for inadequate VOR ____ …. but doesn’t completely replace intact ____ because covert saccade is more effective if head velocity and direction are predictable. Elite athletes may not recover sufficient VOR at high velocities to return to previous level of competition
CNS; gain; VOR
55
Positive head thrust due to inadequate gain in \_\_\_\_.
VOR
56
What are covert saccades?
* not visible to naked eye
* needs vHIT or similar to identify occurrence
* Allows stable vision even if gain hasn’t returned to normal
57
What are saccades?
Corrective saccades develop to assist the slow phase of VOR
58
What are 2 types of saccades that patients can demonstrate?
1. Undershooting
* Initially smaller amplitude then eyes drift to the target
2. Overshooting
* Saccades back toward the target
* Saccade is generated in opposite direction to head ◦ Eg when have –ve HIT in compensated peripheral lesion
59
What is undershooting in saccades?
Initially smaller amplitude then eyes drift to the target
60
What is overshooting in saccades?
* Saccades back toward the target
* Saccade is generated in opposite direction to head
* Eg when have –ve HIT in compensated peripheral lesion
61
\_\_\_\_ and _____ can substitute for inefficient VOR
Smooth pursuit; saccades
62
Patients with severe bilateral loss will use ____ and ____ to try and maintain focus on the target
saccades; smooth pursuit
63
What are the 3 features of the nature of stimulus in the success in maintaining table target?
1. Predictable (active) vs unpredictable (passive)
* Can't prepare --\> lose vision
2. Sinusoidal vs constant velocity (e.g. walking vs bike)
3. Works well up to 1hz or 100 deg/sec
64
What is the cervical ocular reflex?
During low frequency head movements (less than 0.5 Hz) can cause eyes to move in opposite direction to head movement
65
In healthy people, the cervical ocular reflex makes _____ (a significant/ no significant contribution) to gaze stability / eye movements
no significant
* Only in sub-optimal people
66
What are 2 ways that COR can help with gaze stability at low head velocities in people with BVL and some with UVL?
1. Initiating the saccade in the direction of the head movement
2. Slow compensatory eye movements (catch up)
67
How to do train gaze shifting exercises?
Training saccades
* Eye-head in phase and out of phase
68
What are remembered targets?
Use COR and cervical proprioception
69
How are gaze shifting/saccade exercises are thought to work in terms of training "active eye and head between two targets"?
1. Can be in phase or out of phase
2. Utilises
* Central pre-programming (Between head (brain) and eyes)
* Encouraging use of corrective saccades
* Modification of pursuit strategies
70
How are gaze shifting/saccade exercises are thought to work in terms of training "remembered targets"?
Utilises
1. Substitution of Cervical Ocular Reflex
2. Optimising proprioceptive input
3. Encouraging use of corrective saccades
71
What are 2 ways that gaze shifting exercises can progression?
1. Incorporate into walking and functional tasks
2. “Pencil push-up” exercises
72
What are 3 characteristics of "Incorporate into walking and functional tasks" as Progression of gaze shifting exercises?
1. “Dishwasher” exercise
2. Walking up hallway looking from side to side to cards on the wall
3. Tossing a ball from hand to hand while walking
73
What is a characteristic of “Pencil push-up” exercises as Progression of gaze shifting exercises?
Gaze shifting combined with convergence and divergence = start with these for people with poor visual tracking
* i.e. CNS dysfunction / concussion
74
What can you train with this image?
Only read letters with lines
75
What can you train with this image?
For saccades
Read colour, not letter or number
76
What are 3 characteristics of efficacy of gaze shifting?
1. Efficacy has not been established for gaze shifting (substitution) exercises alone (eg eye / head in phase)
2. Therefore are always used in combination with either gaze stability or habituation exercises
3. These are particularly important where visual tracking is inaccurate i.e central cerebellar issues or concussion; difficulty with reading
* Would start these before x1 gaze stability ie need to be able to track and follow a target at slower head speeds before adding higher velocity VOR training
77
Since efficacy for gaze shifting exercises has not been established alone, what can be done?
Therefore are always used in combination with either gaze stability or habituation exercises (eg eye / head in phase)
78
What is the most important when visual tracking is inaccurate (i.e central cerebellar issues or concussion; difficulty with reading)?
Would start these before x1 gaze stability ie need to be able to track and follow a target at slower head speeds before adding higher velocity VOR training
79
What is the aim of habituation?
to reduce symptoms of dizziness / vertigo with head movements / moving around
80
What are 6 common diagnoses that present with motion provoked dizziness?
1. Cerebellar lesions / degeneration
2. Brainstem lesions
3. TBI or post-concussion
4. Migraines
5. Meniere’s disease
6. Post-concussion
81
What are 2 observations of how habituation exercises develop?
Observation 1: patients who moved more, improved more
Observation 2: needed to provoke symptoms to reduce symptoms
82
What are 2 characteristics of Cawthorne-Cooksey exercises?
1. series of progressively more complex movements, repeated to provoke symptoms
2. with repeated exposure to the stimulus, patients would eventually tolerate the movement or position
83
What is the rationale of habituation?
asymmetrical vestibular function leads to sensory mismatch, which leads to symptom provocation
84
What is the method of habituation?
systematically provoke symptoms to produce a reduction in those symptoms
Dampens and then ramps up the affected side (scales want to be balanced)
85
\_\_\_\_\_ is not known is habituation.
Anatomic substrate
86
What does motion sensitivity chart look like?
87
What is used to to assist with selection of provoking movements in habituation?
Motion-Sensitivity Quotient
88
What does the Motion-Sensitivity Quotient test?
to assist with selection of provoking movements in habituation
89
What should you commence with 2-3 movements that (habituation)?
1. cause mild - moderate dizziness
2. Symptoms settle quickly when movement stops
* E.g. rolling, bending, turning
90
How often should habituation exercises be done?
Patient performs up to 5 reps, twice daily
Progression: bigger, faster and more complex (challenge)
91
How should the habituation exercises should be done?
Movements should be performed quickly enough and through sufficient range to produce mild to moderate symptoms
92
What are 2 characteristics of Habituation: Brandt-Daroff exercises?
1. Patient should rest between each movement until the symptoms stop (should be \<1min)
2. May take 4 - 6weeks for the symptoms to settle
93
What are 5 characteristics of the efficacy of habituation?
1. Effective in patients with vestibular deficits
2. Effective in older individuals
3. Can use complex head movements but with caution
4. Can transfer improved function from one task to another within certain limits
5. Do not use habituation exercises for people with bilateral vestibular hypofunction
94
\_\_\_\_ rehabilitation aims to integrate gaze stability and dynamic balance
Vestibular
95
What does vestibular rehabilitation aim like?
to integrate gaze stability and dynamic balance
96
What are 5 characteristics of the vestibular rehabilitation?
1. Select moderately challenging position to retrain gaze stability initially eg tandem stance (Re-boot the vestibular system)
2. Progress the position to increase the postural challenge during training
3. Introduce conditions that progressively challenge the vestibular system (Narrower BOS; softer / unstable surfaces; visually challenging environments)
4. Practice in functional contexts / add dual tasks (Foggy head --\> "cotton wool" in head)
* manipulate objects while balancing in sitting / standing / step standing / step and reach etc
* bend-pick up objects; catch / throw balloon / ball; carry object while walking
5. Be sure to address patients functional goals
* see clearly while walking ◦ shop in grocery store
97
What are 2 characteristics of recreational activities?
1. Should involve using the eyes while the head and body are in motion eg. Tennis, golf, ping-pong, dancing, Tai Chi, Yoga
2. Normally encouraged once formal vestibular rehab 'Use it or lose it"
* continue to challeneg systems
98
As with any chronic condition, people with vestibular dysfunction who are reluctant to move or limit movement / exercise to reduce exacerbation of symptoms can become generally \_\_\_\_\_\_\_. These patients need cardiovascular _____ and / or ______ exercises
deconditioned; reconditioning; strengthening
99
What are 2 reasons why walking outside for 30mins/day is ideal?
1. Cardiovascular fitness
2. Integration of vestibular system input with visual and somatosensory input by encouraging looking around while walking
100
Why is treadmill training not optimal?
it isn’t ‘normal’ walking
101
Why is treadmill training not optimal compared to "normal" walking?
1. Sensory mismatch --\> systems
2. Externally paced --\> Difficulty to get back once lose footing (falls risk)
102
How long/mych should you aim to do vestibular rehabilitation for?
Aim 60 - 70 minutes / day including 30 minutes outdoor walk (NOT treadmill inside!)
x 5 reps of gaze stability x 2 reps of balance exercises
103
How long should it take for dynamic visual acuity to improve after vestibular rehabilitation?
Dynamic visual acuity should begin to improve within 3-4 weeks - most better/improved by 6-8 weeks
104
Unsupervised customised _____ are better than no exercise
home exercises
105
What are 2 situations where specific vestibular exercises decrease symptoms and improve postural and gaze stability?
1. Chronic bilateral vestibulopathy
2. Acute unilateral vestibulopathy
106
Central vestibular deficits are _____ (faster/slower) to respond to rehabilitation. In fact, people with cerebellar issues respond the least
slower
107
Some patients do not improve despite appropriate VR. Which 2 conditions is it more common to not see improvements?
1. Unilateral vestibulopathy: 12-25%
2. Bilateral vestibulopathy: 18-72%
108
What are 3 factors that don't affect response to treatment?
1. Age and gender
2. Time from onset
3. Presence and number of co-morbidities
109
What are 3 factors that may affect response to rehabilitation?
1. Use of vestibular suppressant medications (Eg. anti-histamine, gabapentin)
2. Negative mood / increased anxiety / maladaptive coping strategies
3. Self-limiting movement / usual activities
110
Visual stability utilises several systems depending on ____ and \_\_\_\_.
context; task
111
People with vestibular loss can use different strategies to compensate for loss of \_\_\_\_\_\_. Training oculomotor system and give strategies. Need to provide a variety of exercises to allow patients to utilise what works ____ for them
VOR; best
112
No mechanism can fully compensate for loss of ______ because it is the \_\_\_\_. (Elite athletes vs usual activity)
VOR; brain
113
What are 4 situations where relapse may occur (because recovery may be "fragile")?
1. Extreme stress of fatigue
2. Illness
3. Prolonged period of inactivity
4. Change in medication
114
“Many factors can affect the final level of recovery and should be kept in mind when talking to patients about their progress and anticipated \_\_\_\_\_”
recovery
115
Since relapse is possible, what should be done in the beginning?
Education that relapse is possible
116
What is "compensated" mean?
We want someone to be compensated
117
What is "un-compensated" mean?
ADD
118
What is "de-compensated" mean?
They come back and they are all better
