Treatment Principles: Impairments Of Postural And Gaze Stability Flashcards
What are the general goals of treatment for postural and gaze stability?
Resolve/minimize a pts impairments and limitations, sx, anxiety, or fears
Decrease a pts disequilibrium
Improve a pts ability to see clearly during head movt
Improve a pts postural control during fxnal activities, esp during ambulation
Decrease a pts risk for falls and injury
Improve a pts overall general physical condition , activity level, and QOL
reduce a pts social isolation
What are the centrally driven oculomotor exam tests?
Smooth pursuits
Saccades
OPK
What are the peripherally driven oculomotor exam tests?
Head thrust
Head shake
DVA
Are central or peripherally driven oculomotor tests faster?
Peripheral
What are the 3 mechanisms of recovery for deficits in dynamic vision, VOR impairment and gaze stability from peripheral or central vestibular dysfxn designed to stabilize gaze?
Adaptation
Substitution
Habituation
What dictates the mechanism of recovery and type of exercises we will choose?
The type of disorder the pt has
T/f: visual exercises are only selected when there are visual findings and complaints exist
True (KNOW THIS)
What is adaptation?
A fxn of the cerebellum
A physiologic event allowing the vestibular system to make long term changes in neuronal response to head movt
Which type of recovery uses exercise to change GAIN and create a “new normal” VOR to improve stability of gaze?
Adaptation
What is the ideal gain ratio?
1:1 eye:head movt
If we do the HIT and throw the head one way and the eyes stay focused, what is the gain?
1:1
If we do the HIT and throw the head one way and the eyes stray, is the gain 1:1?
No it is more like .8
What is substitution?
Enhancing the use of info from or the fxn of intact systems to substitute for impaired or absent gaze stability systems
Which mechanism of recovery uses visual-vestibular interaction exercises?
Substitution
What is habituation?
Decreased sx through repeated exposure to the stimulus
What is the simplest form of neuroplasticity, a decrease in synaptic activity, a decrease in amplitude EPSP, a decrease in glutamate and intracellular calcium?
Habituation
What method of recovery tries to flood the system with NTs to decrease sensitivity?
Habituation
T/f: habituation is often used with BPPV pts post maneuver who are still fearful of certain movts
True
What are the error messages we are trying to induce with our treatment of postural and gaze stability?
Symptom reproduction
Visual blurring
Off balance
How can we track how pts tolerate tx and monitor their sx?
With a likert or analog scale
When using a scale for monitoring symptoms, what do we do before starting interventions?
Set a baseline
Set a sx boundary that you and the pt will not exceed
If your are doing your interventions and the sx boundary is crossed, what things can we use to decrease their symptoms.
An ice pack to the back of the neck
Peppermints to decrease nausea
Ginger to decrease nausea
What is the goal in terms of medication use before starting treatment for postural and gaze stability?
To be on no central or peripheral vestibular suppressants prior to and during tx bc we want to induce sx and these meds will suppress them
What is VOR adaptation?
The capability of the vestibular system to make long term changes in the neuronal response to head movts
What is the stimulus in VOR adaptation?
Retinal slip (need a stim strong enough to create retinal slip during movt)
What is the error signal in VOR adaptation?
Retinal slip
T/f: retinal slip in VOR adaptation results in an adapted cerebellar response
True
What is the response to VOR adaptation?
Decreased visual sx (blurriness, double vision/oscillopsia)
Improved postural stability
When are changes of VOR gain the greatest?
When tested under trained conditions
What is the biceps curl of the inner ear?
VOR adaptation
What is the kind of exercise involved in VOR adaptation?
Moving the head with visual fixation
What brain structure is the key to adjusting gain?
The cerebellum
The cerebellum, specifically the ____ , is responsible for adjusting and maintains the gain of the VOR
Flocculus
How does the cerebellum adjust gain?
It receives input of the movt of the head and movt of the eyes and if not equal, it adjusts the sensitivity of the vestibular neuron output to the eyes to avoid retinal slip
What is the treatment goal of VOR adaptation?
Cerebellar adaptation to adjust/adapt the VOR
What is treatment recovery called in VOR adaptation?
Vestibular compensation
T/f: the NS naturally tries to normalize a hypofxn and trainining tried to drive this function even more
True
What are the VOR adaptation exercises we can use?
VOR x1
VOR x2
What population would we use VORx1 with?
UVL
What is the stimulus in VOR x1?
Slip (blurring) of the image during horizontal and/or vertical diagonal head movts
How do we do the VORx1 exercise?
Place the target at eye level at the near (arms length) and far distance away (on the wall 6 ft away)
Have the pt rotate their head side to side and progressively increase the speed to the point the words are ‘just’ blurry/in focus (goal is to get to DVA speed)
Repeat vertically and diagonally as desired
Perform to tolerance
Progress as tolerated
What are some target examples we can use for VOR training?
A single letter
A typed word
A sentence
A business card
A newspaper article
How should we start VORx1?
In sitting
Blank background
30 second duration
120 beats/min
Assess sx throughout
How can we progress VORx1?
Progress to standing, change BOS, change the background, increase the speed, add walking, etc
When a or has mastered progressions of VORx1, what exercise can we move on to?
VORx2
What population would we use VORx2 with?
UVL
(Usually for more high fxning pts like athletes but can be anyone progressing from VORx1)
What is the stimulus in VORx2?
Slip (blurring) of the image during horizontal and/vertical head motion
Does VORx1 or VORx2 drive gain even further?
VORx2
How do we perform VORx2?
Hold the target at eye level in front of you and then progress to a farther surface in front of you
Move the target AND your eyes at the same time in opposite directions as quickly as possible to facilitate retinal slip until the target is ‘just’ blurry/in focus
Repeat vertically as desired Perform
Period,e to tolerance Progress
Progress as tolerated
How long should VOR exercises be done?
Start off with 30 seconds at a time and progress to 2 minutes at a time
What speed should the VOR exercises be done at?
Start at 120 beats/min Assess sx
How many cumulative minutes do we want pts doing VOR exercises at home for in one day?
40 minutes
T/f: VOR exercises are done best corrected (with lenses on)
True
With VOR exercises, we should not be letting sx get over what score?
6/10
What should we document about performance of VOR exercises?
The speed of their head movts
Time of the set
Sx onset time
Time for sx to return to baseline after rest
What are the peripheral adaptation VOR exercises?
VORx1
VORx2
What are the central substitution VOR exercises?
Gaze shift
Remembered targets
When is substitution used?
With severe peripheral cases or central vestibular dysfxn
What are ways that we can progress gaze stabilization interventions?
Increasing the distance of the target
Increasing the frequency/duration of the interventions
Changing the background
Changing posture (sitting, standing, BOS)
Increasing speed
What are the 3 VOR substitution exercises?
Gaze stabilization (VOR)
COR (cervical)
Optokimetics
What population would we use COR substitution exercises for a?
BVL
What is the stimulus in COR substitution exercises?
Slip (blurring) of the image during horizontal and/or vertical head motion
What is the response to COR substitution exercises?
Cervical afferent info is “re-weighted” as an error message to the cerebellum in a limited dynamic range
How do we perform COR substitution exercises?
The same as VORx1 but slower
What is the difference in mechanisms used with VORx1 and COR substitution exercises?
VORx1 uses the cerebellum to adapt output, while COR substitution uses neck musculature
Is VORx1 or COR substitution more effective at increasing VOR gain?
VORx1
What population would we use optokinetic substitution with?
BVL
What is the stimulus in optokinetic substitution?
Slip (blurring) of the image during horizontal and/or vertical motion of a larger visual field
What is the response to optokinetic substitution?
Generally increased VOR gain
How do we perform optokinetic substitution?
Place the target at eye level at the desired distance away with an optokinetic background to moving optokinetic background
Add a target or postural control task
Sx with optokinetic substitution must subside within ___ minutes of excise
5-10
When using optokinetic training, is a larger or smaller screen better?
A larger screen
Any escalation in sx must diminish within _____ minutes of completing optokinetic subtraction exercise
10-15
Should pts just passively watch optokinetic videos in optokinetic substitution?
No, you should incorporate calming strategies, remind yourself that you are still stable and still, and practice deep breathing if sx escalate
What videos should we start with in optokinetic substitution?
Videos with a stationary vertical visual cue and no sound
How long should pts watch optokinetic videos until?
Until they become symptomatic (which can be seconds to minutes)
How can we progress optokinetic substitution exercises?
By adding in sound, running videos where the camera is moving up and down
How often should optokinetic training be done?
Up to 3x 3-4x/day
What exercises are included in visual/vestibular interaction substitution exercises?
Central vision-smooth pursuits and saccades
Central pre-programming (gaze shifting, remembered targets)
VOR cancellation
To enhance visual tracking to maintain gaze stability during head movts, use ______ as a compensatory strategy
Saccades
How do we performs Saccades as a compensatory strategy?
Moving the eyes then head bw two targets
When is central pre-programming substitution exercise possible?
When the task is predictable
What population would we use imaginary/remembered targets training for?
BVL, central
What is the stimulus in imaginary/remembered targets substitution training?
Visual fixation with head movts on an imagined target with EC
How do we perform imaginary/remembered targets substitution training?
Have the pt look at a target at eye level directly in front of them (like in VORx1)
Have the pt close their eyes and visual the target
With their eyes closed, have them turn their head one way and imagine they are still looking at the target
Have them open their eyes and see how well they have kept their eyes on the target
Repeat vertically as desired
Progress as tolerated
What population would we use VOR cancellation substitution exercises for.
Central
The VOR is normally suppressed by what?
The cerebellum (esp flocculus)
How do we perform the VOR cancellation?
Have the pts eye fixated on a target (usually their held out thumbs) directly in front of their face
Move the head and target slowly at the same time and direction and speed
What population would we use gaze shifting (substitution with saccades)?
BVL, central
What is the stimulus in gaze shifting (substitution with saccades)?
Slip (blurring) of the image or over/undershooting the target during horizontal and/or vertical eye movt bw 2 targets
How do we perform gaze shifting (substitution with saccades)?
Place 2 targets about 8 inches apart (20cm) at eye level
Have the pt look directly at the 1st target with their eyes them follow with their head
Have the pt look directly at the 2nd target with their eyes them follow with their head
What population would we use lifestyle modification with gaze shifting?
Acute UVL, BVL, central
What is the purpose of lifestyle modifications with gaze shifting?
To use visual fixation on a stable target prior to movt and engage gaze shifting to prevent blurring during fxn
Would a more severe BVL/central population use remembered targets or gaze shifting?
Remembered targets
T/f: pts often require a lot of cueing with gaze shifting exercises
True
How would we implement gaze shifting in sit to stands?
Eyes mov to the target located vertical/above the pt before moving
How would we implement gaze shifting in stand to sits?
Eyes move to the target located vertical/lower than the pt before
How would we implement gaze shifting for turning?
Move the eyes first, focus on an object then turn the head, then the body in the same direction as the turn
How would we implement gaze shifting in walking?
Have the pt fixate on an object 20-30 feet ahead of them
What is the goal of substitution in gaze stabilization and postural stabilization?
To improve the coordination bw vision and vestibular
What kind of exercises coordinate eye and head movt?
Moving the eyes smoothly while focusing on a moving target (smooth pursuits)
Moving the head and eyes smoothly while focusing on a moving target (VORx2)
Quickly moving the head and eyes from one target to another without losing visual focus (saccades)
Being able to do all the above in movt and fxn
What kind of method of recovery are using when doing exercises involving head circles, gait with head turns and ball circles?
Habituation
What are the habituation principles?
Find activities that produce MILD symptoms
Choose 3 exercises to be completed 3x/day for 3-5 reps of each exercise with 30 sec rest after symptom resolution for each
Progress by increasing range, increasing speed, decreasing rest, increasing balance demand
How can we progress habituation exercises?
Increasing the range
Increasing the speed
Decreasing rest
Increasing balance demand
T/f: a loss doesn’t come back, the HIT will remain abnormal after treatment, but we can develop adaptation strategies strong enough to compensate for the loss
True
What measures can we use to see the effectiveness of treatment?
DVA
DHI
PSFS
MSQ
What is PPPD (persistent postural perceptual dizziness)?
Impaired perception of motion
T/f: PPPD required a multimodal treatment plan
True
What is involved in treatment of PPPD?
Cognitive behavioral therapy
Medical management
Therapist treatment strategies
What is involved in cognitive behavioral therapy for PPPD?
Helping the or focus less on somatosensatiin and visual motion
Anxiety reduction
Decreasing catastrophic thinking
Lessen perfectionist tendencies
What is involved in medical management of PPPD?
Reduction of Meclazine and Benzos
SSRI ramping
What is involved in therapist treatment strategies for PPPD?
Education/balance confidence through successful exposures
Relaxation and breathing
Visual motion desensitization and habituation
Sensory balance retraining
Fitness and conditioning
Core stabilization
T/f: vestibular migraines have more diffuse vestibular sx and first need to be medically managed
True
What causes vestibular migraines?
Temporary reduced blood supply to any of the vestibular structures resulting in intermittent vestibular sx
What vestibular sx may we see with vestibular migraines?
Vertigo
Disorientation
Imbalance
Visual complaints
Nausea and other autonomic complains
Cognitive fog
Are vestibular migraines associated with HA migraines?
Not necessarily
T/f: a pt with vestibular migraines may have a family hx of HA migraines
True
What vestibular disorders should be medically managed first?
Vestibular migraines
Menieres
Fistula/SCD
Acoustic neuroma
What are the mechanical vestibular disorders?
BPPV canalolithiasis
BPPV cupulolithiasis
What are the central vestibular disorders?
Cerebellar CVA
BS CVA
TBI
MAV/MAD
Concussion
Blast injury
What are the bilateral vestibular disorders?
Ototoxicity
Seq neuronitis
Presybyastasis
What are the unilateral vestibular disorders?
Neuronitis
Labyrinthitis
Acoustic neuroma
Presbyastasis
Ramsey Hunt
Cervicogenic
SCD/fistula
Post medical (Meneires, MAV/MAD)
Post surgical (neuronectomy, fistula repair)
What system gets down weighted in PPPD?
Vestibular
Do we use VOR exercises for mechanical disorders like BPPV?
Nope
What exercises do we use for mechanical disorders like BPPV?
Canalith repositioning maneuvers
Balance retraining
What approach to recovery do we take with a UVL?
Adaptation
What approach to recovery do we take with BVL?
Substitution
What kind of environment should we use with peripheral VOR deficient pts (UVL, BVL)?
Stable (supine, sitting, standing)
Or unstable (somatosensory, visual, vestibular)
What exercises do we use for UVL?
VORx1
VORx2
What exercises do we use in BVL?
COR
Imaginary targets
Saccades/gaze shift
What approach to recovery do we take for central VOR deficient pts (cerebellar, BS lesions)?
Substitution and modification
What environment should we use for central VOR deficient pts (cerebellar/BS lesions)?
Stable (supine, sitting, standing)
Or unstable (somatosensory, visual, vestibular)
What exercises should we do for pts with central VOR deficiency?
VOR cancellation
Imaginary targets/central pre-programming
Saccades/central vision
Gaze stabilization modification
Repeated exposure (habituation)
What approach to recovery do we take with pts with motion sensitivity?
Central substitution and modification or habituation
What environment should we use for pts with motion sensitivity?
Stable (supine, sitting, standing)
Or unstable (somatosensory, visual, vestibular)
What exercises should we use for pts with motion sensitivity?
VOR cancellation (substitution)
Repeated exposures (habituation)
What tells us to progress exercises?
Decreased error messages
How can we progress exercises for gaze and postural stabilization?
Increasing the speed
Varying posture/surface
Varying duration/frequency
Incorporate postural control
Strong (level 1) evidence supports the use of vestibular rehab in what populations?
Acute, subacute, and chronic unilateral hypofxn
Bilateral hypofxn
What are the primary benefits of vestibular rehab?
Reduces dizziness and vertigo
Improves gaze stability
Decreases imbalance and fall risk
Enhances daily activities and QOL
What gaze stabilization exercises are strongly recommended for peripheral hypofxning?
Adaptation and substitution exercises
What gaze stabilization exercises are NOT recommended for peripheral hypofxning?
Isolated saccadic or smooth pursuits exercises
What is the recommended exercises dosage for peripheral hypofxning in the acute/subacute phase?
3x/day (min 12 min/day)
What is the recommended exercises dosage for peripheral hypofxning in the chronic phase?
3-5x/day (min 20 min/day) for 4-6 weeks
What is the recommended exercises dosage for peripheral hypofxning in the bilateral population?
3-5x daily (20-40 min/day) for 5-7 weeks
T/f: age and gender do not affect outcomes in vestibular rehab
True
Is early intervention more likely to improve prognosis of a chronic or acute hypofxning?
Acute
T/f: time since onset of sx doesn’t affect chronic cases prognosis
True
T/f: early intervention will not improve acute cases
False, it may
What are the possible impacts of comorbidities on vestibular rehab?
Anxiety and depression
Migraines
Peripheral neuropathy
Visual impairments
Cognitive challenges
T/f: long term use of vestibular suppressants should we avoided
True
What are the criteria for discontinuing treatment in vestibular rehab?
Achievement of therapeutic goals
Symptom resolution
Reaching plateau in progress
Normalized gait, balance, or vestibular fxn
What are potential tx challenges with VOR and gaze stabilization?
Initial increase in sx
Motion sickness/nausea
Neck pain
Travel time and cost
Adherence issues
T/f: telehealth may be a good option for remote pts with VOR and gaze stabilization
True
Is balance rehab always for vestibular involvement?
Nope
A pt that has trouble with unstable surfaces and walks into the clinic with small shuffling steps likely has trouble on what conditions of the mCTSIB and SOT?
Conditions 3 and 4 (stable surface with visual conflict and unstable surface with EO)
A pt that has trouble with unstable surfaces and walks into the clinic with small shuffling steps is likely ______ dependent
Somatosensory
A pt is only dependent on somatosensation inputs for balance control when?
When they have trouble on any unstable surface or on both condition 3 and 4 of the mCTSIB and SOT
A lot is only dependent on visual inputs for balance control when?
When they have trouble on all conditions with EC (2 and 4 - I think it’s supposed to be condition 4?) and walk in with limited head movt
When there are problems on condition 4 of the mCTSIB/SOT using their vestibular system, does this mean there is necessarily a vestibular lesion?
No
A pt who dead falls backward on condition 4 of the mCTSIB/SOT (EO unstable surface) immediately for 3 trials should make us think that there is what kind of problem going on?
A bilateral vestibular loss (BVL)
What are the general treatment principle for balance rehab?
The behaviors and activities must be variable for learning
The behaviors and activities must be performed in different environments and context for learning
The behaviors and activities must challenge (but not exceed) an individual’s intrinsic capabilities (maximize the challenge minimize the risk)
T/f: with balance rehab, we want to maximize the challenge while minimizing the risk
True
T/f: there needs to be error detection and error correction with balance rehab
True
What is a good error in balance rehab?
Instability that can be recovered from
What is a bad error in balance rehab?
Gross instability and falling
What are the possible impairments we may want to address in balance rehab (long ass list)
COG control and LOS training
Multisensory training
Postural/response strategy training
Fxnal activity training
Gait training
MSK flexibility, strengthening, and endurance training
Dual tasking with cognitive interference
Treatment with balance rehab is most successful when?
When it is directed to the pts identified impairments and limitations
When the activities and exercises are integrative (combine as many impairment categories as possible, combine sensory and motor system challenges, combine impairment training with task and environment challenges)
How can we make activities and exercises integrative?
Combine as many impairment categories as possible
Combine sensory and motor system challenges
Combine impairment training with task and environment challenges
T/f: in balance rehab, activities (tasks) must be task based, attended, and goal directed for learning
True
What three components need to be included in balance rehab interventions?
The environment, task , and individual
What needs to be involved in planning your task based balance interventions?
Need an aerobic intervention to warm up the system
Need two task based interventions
We can use both ____ and _____ balance exercises in balance rehab for individuals with peripheral vestibular hypofxning (uni or bilateral)
Static, dynamic
What is the optimal balance exercise dosage for chronic unilateral vestibular hypofxning?
Min of 20min daily for at least 4-6 weeks
What is the optimal balance exercise dosage for acute/subacute unilateral vestibular hypofxning?
Exercises may be prescribed, but there are no specific dose recommendations that have been made
What is the optimal balance exercise dosage for BL vestibular hypofxning?
Do exercises for 6-9 weeks
How long should each rep of balance exercises be done for?
About 1-2 minutes based on sx and performance (errors)
What is a positive prognostic sign with balance interventions?
After doing the same exercise multiple times within a session, you see improvement bw trials
In balance rehab, if the to isn’t making errors, what should we do?
Make the activity harder until they do
T/f: when advancing balance interventions, we need to make sure we are seeing small errors that the pt can detect and change during the activity
True
What is the task progression for training COG and LOS?
Get good postural alignment first
Then be able to achieve and maintain a centered position
Then be able to move away from and return to a centered position
Then be able to control COG and LOS in different contexts
How can we make weight shifts goal directed?
Have them pushing/pulling drawers
Putting things in a cabinet
T/f: core activation is important in COG and LOS training
True
T/f: we can also advance COG and LOS training by changing the sensory environment
True
What is multi sensory training?
Stimulating/forced use of a sensory system which is impaired or not responding
Reorganizing the use of sensory information in the CNS
Substituting/compensating for an impaired sensory system that is permanently or progressively damaged
What results do we use to guide multi sensory training?
mCTSIB or SOT
One or more of the 3 sensory systems can be affected by what factors?
Inactivity
Age
Disease
What are the tx parameters for multi sensory training?
1-2 min each exercise
Repeat the same exercise multiple times within a session
Progress within a session
What are we looking for when advancing/progressing in multi sensory training?
Small errors that the pt can detect and change during the activity
If the pt is not making errors in multi sensory training, what should we do?
Make the activity harder
T/f: we should be progressing activities within a session in multi sensory training
True
If a pt has difficulty with mCTSIB condition one, what may be going on?
A central issue or the pt is making it up bc we don’t expect to see issues here
What is condition 1 of the mCTSIB?
EO, firm surface
What sensory system should be working the most in condition 1 of the mCTSIB (EO, firm surface)?
SOM
If a pt is unstable in condition 1 of the mCTSIB, they are not effectively using what system?
SOM
What treatments can we use for pts unstable in condition 1 of the mCTSIB?
Substitution with VEST and VIS
What is condition 2 of the mCTSIB?
EC, firm surface
What sensory system should be working most in condition 2 of the mCTSIB?
SOM
If a pt is unstable in condition 2 of the mCTSIB, they are not effectively using what system? They are overrelying on what system?
Not effectively using SOM
Overrelying on VIS
What pts make have difficulties with condition 2 of the mCTSIB (EC, firm surface)?
Peripheral neuropathy
Aphsyiologic
PPPD
What treatment can we use for pts unstable in condition 2 of the mCTSIB?
Sensory re-weighting with forced use of SOM and disadvantaging VIS and VEST
What is the goal of forced use of SOM?
To stimulate the brains use of SOM inputs by reducing, removing, or engaging VIS during activities and tasks
When doing forced use of SOM, what surface should we use?
Firm , to maximize the ability to use SOM
How can we reduce VIS? Remove? Engage?
Reduce-low light, sunglasses, head movt, tech box thingy
Remove-EC
Engage-focus on an object, playing cards
What are ways that we can disadvantage/engage vision? (Just know generally I think)
Move eyes smoothly while focusing on a moving target (smooth pursuits)
Quickly move the head and eyes from one target to another without losing visual focus (saccades)
Move the head smoothly while keeping the eyes fixed on a target (VOR/gaze stabilization)
Move the head and eyes smoothly while focusing on a moving target (VORc)
Visual scanning with head movt (targeting)
What is condition 3 of the mCTSIB?
EO, foam surface
If a pt is unstable in condition 3 of the mCTSIB, they are dependent on what system?
SOM
In condition 3 (EO, foam) of the mCTSIB, the pt should be using what system the most?
VEST and some VIS
What treatments can we use for a pt unstable in condition 3 of the mCTSIB?
Sensory re-weighting with forced use of VIS by taking away SOM with dynamic gait or an unstable surface
Provide strong visual cues (vertical cues. Visual targets, mirror with tape)
What is involved in forced use of VIS?
Reducing, removing, or engaging SOM
Providing a strong stable visual cue to maximize the ability to use VIS
How can we reduce SOM? Remove? Engage?
Reduce-SLS, NBOS
Remove-foam
Engage-walking
What is condition 4 of the mCTSIB?
EC, foam surface
What sensory system should be working the most in condition 4 of the mCTSIB?
VEST
If a pt is unstable in condition 4 of the mCTSIB, the are not effectively using what system?
VEST
If a pt is unstable in condition 4 of the mCTSIB, what is involved in treatment?
Sensory re-weighting with forced use of VEST by taking away VIS and SOM
What is the goal of forced use of VEST?
Stimulate the use of VEST by reducing, removing, or engaging VIS and SOM
What is a simple way to force use of VEST?
Place the pt on an unstable surface and disadvantage vision
What are conditions 2 and 4 of the mCTSIB?
Condition 2-EC firm surface
Condition 4-EC foam surface
If a pt is unstable in condition 2 (EC firm) and 4 (EC foam) of the mCTSIB, they are _____ dependent and unable to compensate with either ____ or _____
Visually, SOM, VEST
If a pt is unstable on both condition 2 (EC, firm) and 4 (EC, foam), what is involved in treatment?
Sensory re-weighting with forced use of SOM and VEST by disadvantaging VIS
What is the goal of forced use of SOM and VEST?
To reduce, remove, or engage vision during tasks and activities
What interventions can be involved in VEST and SOM forced use?
Head turning/tilting activities
Using distracting treatment environments
Place the pt in conflicting situations
How do we stimulate the use of vestibular otoliths?
By challenging or engaging the otoliths during specific activities and tasks
How can we engage or challenge the otoliths during specific activities/tasks?
Tilting/translations movts like vertical and horizontal linear activities, head tilting laterally and vertically, and challenging the vestibular system as a whole then in parts
How can we challenge/engage the otoliths in vertical acceleration (saccule)?
By bounding on a ball
How can we challenge/engage the otoliths in horizontal linear acceleration (utricle)?
Roll back and forth on a ball
What is involved in postural response training?
Training the individual to use the right strategy at the right time in the right condition
When should the ankle strategy be used?
On a firm surface, swaying slowly through a small range using small ankle muscles
When we want to train the ankle strategy, what should we do?
Put the pt on a stable surface
Put targets close together
Slow movt pace/sway
When is the hip strategy used?
In unstable surfaces when swaying quaintly through a larger range
When wanting to train hip strategy, what should we do?
Put the pt on a narrow or unstable surface
Place targets far apart for larger range
Faster pacing/quicker sway
When do we use the stepping strategy?
When taking a step to re-establish a new BOS when our COG is displaced beyond our LOS
When wanting to train stepping strategy, what should we do?
Pt the pt in a condition where they are forced outside of their LOS
Create large perturbations
Put the pt on a NBOS
What test should we use to guide postural response training?
The miniBEST test
What are APRs?
Anticipatory postural responses
What are RPRs?
Reactive postural responses
Should we start with internal or external perturbations?
Internal then progress to external
What other interacting factors should we add into our balance interventions?
Stretching, strengthening, and endurance
What are some examples of ways we can incorporate stretching into our balance interventions?
By using a toe wedge in balance exercises during fwd weight shifts to stretch the heel cords
By doing alternating toe taps with increased distance to promote heel cords and hip flexor stretching
What is the biggest area of the body that people get ROM losses?
The ankle
What are some ways we can incorporate strengthening into our balance interventions?
Alternating step taps with increased distance to terminal extension for stabilizer strengthening
Eccentric STSs for quad strengthening
Alternating step ups/downs
Weight shifts on uneven surfaces will strengthen the ankle muscles
NBOS will strengthen the hip muscles
Incorporate resistance bands and PNF wherever possible
Gait training for LE strengthening
How can we progress gait training?
Consider the persons specific impairments
Make it more fast paced and variable
Add directional changes
Add an altered BOS
Walk with gait pattern variations
Negotiation of obstacles
Train in different sensory environments (carpet, level, indoor, outdoor)
What are two different ways we can do dynamic functional gait training?
Overground walking
Treadmill walking
What is involved in overground training?
Starts, stops, pivots, turns, different surfaces (carpet, curbs, stairs), and hazard recognition/avoidance
What is involved in treadmill training?
Increasing speed and speed variation
Dual task activities
Uneven surfaces and different levels
What are the types of dual tasking?
Motor and cognitive interference
What are the two delivery methods of dual tasking?
Integrated
Consecutive
What is integrated dual tasking?
Balance exercises performed simultaneously with cognitive tasks
What is consecutive dual tasking?
Balance exercises and cognitive tasks performed separately (ie doing an exercise, then doing a cognitive task in the break)
Is there a significant different bw the effects of integrated DT and consecutive DT? Is one better than the other?
Nope
When might we choose to do consecutive DT over integrated DT?
When the pt is an older adult who can’t handle the load of doing integrated DT
What things can we target in dual tasking?
Attention
Memory
Arithmetic
Fluency of categories
Problem solving
Verbal fluency
Info processing
Abstraction skills
What should be included in patient education for balance interventions?
The cause of their balance problem (provide the framework for your choice of treatment)
ID possible safety hazards (poor lighting, darkness)
Instruct in precautionary measures (night light, pocket flashlight)
