Treatment Principles: Impairments Of Postural And Gaze Stability Flashcards
1
Q
What are the general goals of treatment for postural and gaze stability?
A
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
2
Q
What are the centrally driven oculomotor exam tests?
A
Smooth pursuits
Saccades
OPK
3
Q
What are the peripherally driven oculomotor exam tests?
A
Head thrust
Head shake
DVA
4
Q
Are central or peripherally driven oculomotor tests faster?
A
Peripheral
5
Q
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?
A
Adaptation
Substitution
Habituation
6
Q
What dictates the mechanism of recovery and type of exercises we will choose?
A
The type of disorder the pt has
7
Q
T/f: visual exercises are only selected when there are visual findings and complaints exist
A
True (KNOW THIS)
8
Q
What is adaptation?
A
A fxn of the cerebellum
A physiologic event allowing the vestibular system to make long term changes in neuronal response to head movt
9
Q
Which type of recovery uses exercise to change GAIN and create a “new normal” VOR to improve stability of gaze?
A
Adaptation
10
Q
What is the ideal gain ratio?
A
1:1 eye:head movt
11
Q
If we do the HIT and throw the head one way and the eyes stay focused, what is the gain?
A
1:1
12
Q
If we do the HIT and throw the head one way and the eyes stray, is the gain 1:1?
A
No it is more like .8
13
Q
What is substitution?
A
Enhancing the use of info from or the fxn of intact systems to substitute for impaired or absent gaze stability systems
14
Q
Which mechanism of recovery uses visual-vestibular interaction exercises?
A
Substitution
15
Q
What is habituation?
A
Decreased sx through repeated exposure to the stimulus
16
Q
What is the simplest form of neuroplasticity, a decrease in synaptic activity, a decrease in amplitude EPSP, a decrease in glutamate and intracellular calcium?
A
Habituation
17
Q
What method of recovery tries to flood the system with NTs to decrease sensitivity?
A
Habituation
18
Q
T/f: habituation is often used with BPPV pts post maneuver who are still fearful of certain movts
A
True
19
Q
What are the error messages we are trying to induce with our treatment of postural and gaze stability?
A
Symptom reproduction
Visual blurring
Off balance
20
Q
How can we track how pts tolerate tx and monitor their sx?
A
With a likert or analog scale
21
Q
When using a scale for monitoring symptoms, what do we do before starting interventions?
A
Set a baseline
Set a sx boundary that you and the pt will not exceed
22
Q
If your are doing your interventions and the sx boundary is crossed, what things can we use to decrease their symptoms.
A
An ice pack to the back of the neck
Peppermints to decrease nausea
Ginger to decrease nausea
23
Q
What is the goal in terms of medication use before starting treatment for postural and gaze stability?
A
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
24
Q
What is VOR adaptation?
A
The capability of the vestibular system to make long term changes in the neuronal response to head movts
25
What is the stimulus in VOR adaptation?
Retinal slip (need a stim strong enough to create retinal slip during movt)
26
What is the error signal in VOR adaptation?
Retinal slip
27
T/f: retinal slip in VOR adaptation results in an adapted cerebellar response
True
28
What is the response to VOR adaptation?
Decreased visual sx (blurriness, double vision/oscillopsia)
Improved postural stability
29
When are changes of VOR gain the greatest?
When tested under trained conditions
30
What is the biceps curl of the inner ear?
VOR adaptation
31
What is the kind of exercise involved in VOR adaptation?
Moving the head with visual fixation
32
What brain structure is the key to adjusting gain?
The cerebellum
33
The cerebellum, specifically the ____ , is responsible for adjusting and maintains the gain of the VOR
Flocculus
34
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
35
What is the treatment goal of VOR adaptation?
Cerebellar adaptation to adjust/adapt the VOR
36
What is treatment recovery called in VOR adaptation?
Vestibular compensation
37
T/f: the NS naturally tries to normalize a hypofxn and trainining tried to drive this function even more
True
38
What are the VOR adaptation exercises we can use?
VOR x1
VOR x2
39
What population would we use VORx1 with?
UVL
40
What is the stimulus in VOR x1?
Slip (blurring) of the image during horizontal and/or vertical diagonal head movts
41
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
42
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
43
How should we start VORx1?
In sitting
Blank background
30 second duration
120 beats/min
Assess sx throughout
44
How can we progress VORx1?
Progress to standing, change BOS, change the background, increase the speed, add walking, etc
45
When a or has mastered progressions of VORx1, what exercise can we move on to?
VORx2
46
What population would we use VORx2 with?
UVL
(Usually for more high fxning pts like athletes but can be anyone progressing from VORx1)
47
What is the stimulus in VORx2?
Slip (blurring) of the image during horizontal and/vertical head motion
48
Does VORx1 or VORx2 drive gain even further?
VORx2
49
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
50
How long should VOR exercises be done?
Start off with 30 seconds at a time and progress to 2 minutes at a time
51
What speed should the VOR exercises be done at?
Start at 120 beats/min Assess sx
52
How many cumulative minutes do we want pts doing VOR exercises at home for in one day?
40 minutes
53
T/f: VOR exercises are done best corrected (with lenses on)
True
54
With VOR exercises, we should not be letting sx get over what score?
6/10
55
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
56
What are the peripheral adaptation VOR exercises?
VORx1
VORx2
57
What are the central substitution VOR exercises?
Gaze shift
Remembered targets
58
When is substitution used?
With severe peripheral cases or central vestibular dysfxn
59
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
60
What are the 3 VOR substitution exercises?
Gaze stabilization (VOR)
COR (cervical)
Optokimetics
61
What population would we use COR substitution exercises for a?
BVL
62
What is the stimulus in COR substitution exercises?
Slip (blurring) of the image during horizontal and/or vertical head motion
63
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
64
How do we perform COR substitution exercises?
The same as VORx1 but slower
65
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
66
Is VORx1 or COR substitution more effective at increasing VOR gain?
VORx1
67
What population would we use optokinetic substitution with?
BVL
68
What is the stimulus in optokinetic substitution?
Slip (blurring) of the image during horizontal and/or vertical motion of a larger visual field
69
What is the response to optokinetic substitution?
Generally increased VOR gain
70
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
71
Sx with optokinetic substitution must subside within ___ minutes of excise
5-10
72
When using optokinetic training, is a larger or smaller screen better?
A larger screen
73
Any escalation in sx must diminish within _____ minutes of completing optokinetic subtraction exercise
10-15
74
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
75
What videos should we start with in optokinetic substitution?
Videos with a stationary vertical visual cue and no sound
76
How long should pts watch optokinetic videos until?
Until they become symptomatic (which can be seconds to minutes)
77
How can we progress optokinetic substitution exercises?
By adding in sound, running videos where the camera is moving up and down
78
How often should optokinetic training be done?
Up to 3x 3-4x/day
79
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
80
To enhance visual tracking to maintain gaze stability during head movts, use ______ as a compensatory strategy
Saccades
81
How do we performs Saccades as a compensatory strategy?
Moving the eyes then head bw two targets
82
When is central pre-programming substitution exercise possible?
When the task is predictable
83
What population would we use imaginary/remembered targets training for?
BVL, central
84
What is the stimulus in imaginary/remembered targets substitution training?
Visual fixation with head movts on an imagined target with EC
85
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
86
What population would we use VOR cancellation substitution exercises for.
Central
87
The VOR is normally suppressed by what?
The cerebellum (esp flocculus)
88
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
89
What population would we use gaze shifting (substitution with saccades)?
BVL, central
90
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
91
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
92
What population would we use lifestyle modification with gaze shifting?
Acute UVL, BVL, central
93
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
94
Would a more severe BVL/central population use remembered targets or gaze shifting?
Remembered targets
95
T/f: pts often require a lot of cueing with gaze shifting exercises
True
96
How would we implement gaze shifting in sit to stands?
Eyes mov to the target located vertical/above the pt before moving
97
How would we implement gaze shifting in stand to sits?
Eyes move to the target located vertical/lower than the pt before
98
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
99
How would we implement gaze shifting in walking?
Have the pt fixate on an object 20-30 feet ahead of them
100
What is the goal of substitution in gaze stabilization and postural stabilization?
To improve the coordination bw vision and vestibular
101
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
102
What kind of method of recovery are using when doing exercises involving head circles, gait with head turns and ball circles?
Habituation
103
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
104
How can we progress habituation exercises?
Increasing the range
Increasing the speed
Decreasing rest
Increasing balance demand
105
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
106
What measures can we use to see the effectiveness of treatment?
DVA
DHI
PSFS
MSQ
107
What is PPPD (persistent postural perceptual dizziness)?
Impaired perception of motion
108
T/f: PPPD required a multimodal treatment plan
True
109
What is involved in treatment of PPPD?
Cognitive behavioral therapy
Medical management
Therapist treatment strategies
110
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
111
What is involved in medical management of PPPD?
Reduction of Meclazine and Benzos
SSRI ramping
112
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
113
T/f: vestibular migraines have more diffuse vestibular sx and first need to be medically managed
True
114
What causes vestibular migraines?
Temporary reduced blood supply to any of the vestibular structures resulting in intermittent vestibular sx
115
What vestibular sx may we see with vestibular migraines?
Vertigo
Disorientation
Imbalance
Visual complaints
Nausea and other autonomic complains
Cognitive fog
116
Are vestibular migraines associated with HA migraines?
Not necessarily
117
T/f: a pt with vestibular migraines may have a family hx of HA migraines
True
118
What vestibular disorders should be medically managed first?
Vestibular migraines
Menieres
Fistula/SCD
Acoustic neuroma
119
What are the mechanical vestibular disorders?
BPPV canalolithiasis
BPPV cupulolithiasis
120
What are the central vestibular disorders?
Cerebellar CVA
BS CVA
TBI
MAV/MAD
Concussion
Blast injury
121
What are the bilateral vestibular disorders?
Ototoxicity
Seq neuronitis
Presybyastasis
122
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)
123
What system gets down weighted in PPPD?
Vestibular
124
Do we use VOR exercises for mechanical disorders like BPPV?
Nope
125
What exercises do we use for mechanical disorders like BPPV?
Canalith repositioning maneuvers
Balance retraining
126
What approach to recovery do we take with a UVL?
Adaptation
127
What approach to recovery do we take with BVL?
Substitution
128
What kind of environment should we use with peripheral VOR deficient pts (UVL, BVL)?
Stable (supine, sitting, standing)
Or unstable (somatosensory, visual, vestibular)
129
What exercises do we use for UVL?
VORx1
VORx2
130
What exercises do we use in BVL?
COR
Imaginary targets
Saccades/gaze shift
131
What approach to recovery do we take for central VOR deficient pts (cerebellar, BS lesions)?
Substitution and modification
132
What environment should we use for central VOR deficient pts (cerebellar/BS lesions)?
Stable (supine, sitting, standing)
Or unstable (somatosensory, visual, vestibular)
133
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)
134
What approach to recovery do we take with pts with motion sensitivity?
Central substitution and modification or habituation
135
What environment should we use for pts with motion sensitivity?
Stable (supine, sitting, standing)
Or unstable (somatosensory, visual, vestibular)
136
What exercises should we use for pts with motion sensitivity?
VOR cancellation (substitution)
Repeated exposures (habituation)
137
What tells us to progress exercises?
Decreased error messages
138
How can we progress exercises for gaze and postural stabilization?
Increasing the speed
Varying posture/surface
Varying duration/frequency
Incorporate postural control
139
Strong (level 1) evidence supports the use of vestibular rehab in what populations?
Acute, subacute, and chronic unilateral hypofxn
Bilateral hypofxn
140
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
141
What gaze stabilization exercises are strongly recommended for peripheral hypofxning?
Adaptation and substitution exercises
142
What gaze stabilization exercises are NOT recommended for peripheral hypofxning?
Isolated saccadic or smooth pursuits exercises
143
What is the recommended exercises dosage for peripheral hypofxning in the acute/subacute phase?
3x/day (min 12 min/day)
144
What is the recommended exercises dosage for peripheral hypofxning in the chronic phase?
3-5x/day (min 20 min/day) for 4-6 weeks
145
What is the recommended exercises dosage for peripheral hypofxning in the bilateral population?
3-5x daily (20-40 min/day) for 5-7 weeks
146
T/f: age and gender do not affect outcomes in vestibular rehab
True
147
Is early intervention more likely to improve prognosis of a chronic or acute hypofxning?
Acute
148
T/f: time since onset of sx doesn’t affect chronic cases prognosis
True
149
T/f: early intervention will not improve acute cases
False, it may
150
What are the possible impacts of comorbidities on vestibular rehab?
Anxiety and depression
Migraines
Peripheral neuropathy
Visual impairments
Cognitive challenges
151
T/f: long term use of vestibular suppressants should we avoided
True
152
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
153
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
154
T/f: telehealth may be a good option for remote pts with VOR and gaze stabilization
True
155
Is balance rehab always for vestibular involvement?
Nope
156
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)
157
A pt that has trouble with unstable surfaces and walks into the clinic with small shuffling steps is likely ______ dependent
Somatosensory
158
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
159
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
160
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
161
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)
162
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)
163
T/f: with balance rehab, we want to maximize the challenge while minimizing the risk
True
164
T/f: there needs to be error detection and error correction with balance rehab
True
165
What is a good error in balance rehab?
Instability that can be recovered from
166
What is a bad error in balance rehab?
Gross instability and falling
167
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
168
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)
169
170
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
171
T/f: in balance rehab, activities (tasks) must be task based, attended, and goal directed for learning
True
172
What three components need to be included in balance rehab interventions?
The environment, task , and individual
173
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
174
We can use both ____ and _____ balance exercises in balance rehab for individuals with peripheral vestibular hypofxning (uni or bilateral)
Static, dynamic
175
What is the optimal balance exercise dosage for chronic unilateral vestibular hypofxning?
Min of 20min daily for at least 4-6 weeks
176
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
177
What is the optimal balance exercise dosage for BL vestibular hypofxning?
Do exercises for 6-9 weeks
178
How long should each rep of balance exercises be done for?
About 1-2 minutes based on sx and performance (errors)
179
What is a positive prognostic sign with balance interventions?
After doing the same exercise multiple times within a session, you see improvement bw trials
180
In balance rehab, if the to isn’t making errors, what should we do?
Make the activity harder until they do
181
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
182
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
183
How can we make weight shifts goal directed?
Have them pushing/pulling drawers
Putting things in a cabinet
184
T/f: core activation is important in COG and LOS training
True
185
T/f: we can also advance COG and LOS training by changing the sensory environment
True
186
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
187
What results do we use to guide multi sensory training?
mCTSIB or SOT
188
One or more of the 3 sensory systems can be affected by what factors?
Inactivity
Age
Disease
189
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
190
What are we looking for when advancing/progressing in multi sensory training?
Small errors that the pt can detect and change during the activity
191
If the pt is not making errors in multi sensory training, what should we do?
Make the activity harder
192
T/f: we should be progressing activities within a session in multi sensory training
True
193
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
194
What is condition 1 of the mCTSIB?
EO, firm surface
195
What sensory system should be working the most in condition 1 of the mCTSIB (EO, firm surface)?
SOM
196
If a pt is unstable in condition 1 of the mCTSIB, they are not effectively using what system?
SOM
197
What treatments can we use for pts unstable in condition 1 of the mCTSIB?
Substitution with VEST and VIS
198
What is condition 2 of the mCTSIB?
EC, firm surface
199
What sensory system should be working most in condition 2 of the mCTSIB?
SOM
200
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
201
202
What pts make have difficulties with condition 2 of the mCTSIB (EC, firm surface)?
Peripheral neuropathy
Aphsyiologic
PPPD
203
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
204
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
205
When doing forced use of SOM, what surface should we use?
Firm , to maximize the ability to use SOM
206
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
207
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)
208
209
What is condition 3 of the mCTSIB?
EO, foam surface
210
If a pt is unstable in condition 3 of the mCTSIB, they are dependent on what system?
SOM
211
In condition 3 (EO, foam) of the mCTSIB, the pt should be using what system the most?
VEST and some VIS
212
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)
213
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
214
How can we reduce SOM? Remove? Engage?
Reduce-SLS, NBOS
Remove-foam
Engage-walking
215
What is condition 4 of the mCTSIB?
EC, foam surface
216
What sensory system should be working the most in condition 4 of the mCTSIB?
VEST
217
If a pt is unstable in condition 4 of the mCTSIB, the are not effectively using what system?
VEST
218
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
219
What is the goal of forced use of VEST?
Stimulate the use of VEST by reducing, removing, or engaging VIS and SOM
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What is a simple way to force use of VEST?
Place the pt on an unstable surface and disadvantage vision
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What are conditions 2 and 4 of the mCTSIB?
Condition 2-EC firm surface
Condition 4-EC foam surface
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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
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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
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What is the goal of forced use of SOM and VEST?
To reduce, remove, or engage vision during tasks and activities
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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
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How do we stimulate the use of vestibular otoliths?
By challenging or engaging the otoliths during specific activities and tasks
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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
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How can we challenge/engage the otoliths in vertical acceleration (saccule)?
By bounding on a ball
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How can we challenge/engage the otoliths in horizontal linear acceleration (utricle)?
Roll back and forth on a ball
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What is involved in postural response training?
Training the individual to use the right strategy at the right time in the right condition
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When should the ankle strategy be used?
On a firm surface, swaying slowly through a small range using small ankle muscles
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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
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When is the hip strategy used?
In unstable surfaces when swaying quaintly through a larger range
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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
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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
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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
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What test should we use to guide postural response training?
The miniBEST test
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What are APRs?
Anticipatory postural responses
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What are RPRs?
Reactive postural responses
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Should we start with internal or external perturbations?
Internal then progress to external
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What other interacting factors should we add into our balance interventions?
Stretching, strengthening, and endurance
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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
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What is the biggest area of the body that people get ROM losses?
The ankle
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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
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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)
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What are two different ways we can do dynamic functional gait training?
Overground walking
Treadmill walking
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What is involved in overground training?
Starts, stops, pivots, turns, different surfaces (carpet, curbs, stairs), and hazard recognition/avoidance
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What is involved in treadmill training?
Increasing speed and speed variation
Dual task activities
Uneven surfaces and different levels
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What are the types of dual tasking?
Motor and cognitive interference
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What are the two delivery methods of dual tasking?
Integrated
Consecutive
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What is integrated dual tasking?
Balance exercises performed simultaneously with cognitive tasks
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What is consecutive dual tasking?
Balance exercises and cognitive tasks performed separately (ie doing an exercise, then doing a cognitive task in the break)
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Is there a significant different bw the effects of integrated DT and consecutive DT? Is one better than the other?
Nope
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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
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What things can we target in dual tasking?
Attention
Memory
Arithmetic
Fluency of categories
Problem solving
Verbal fluency
Info processing
Abstraction skills
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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)
