Vestibular Rehabilitation Flashcards
what is the idea behind vestibular rehabilitation
symptom and impairment driven rehabilitation based upon exercise to assist with compensation
those with _______ are appropriate patients for vestibular rehabilitation
head/visual motion that provokes symptoms
balance, gait, or gaze stability impairments
stable central or peripheral lesion
no specific ages
those with _______ are inappropriate patients for vestibular rehabilitation
episodic or spontaneous fluctuating symptoms
no provocative activity or balance dysfunction
progressive central lesions
in those with acute UVH, what is important to remember regarding timing of rehab
Early VRT (<2wks of onset): increased VOR gain and adaptation
Late VRT:
increased compensatory saccades and substitution
for those with Chronic UVH or Bilateral VH, what does timing implementation of VRT affect
there is no effect of time of VRT implementation from time of onset on efficacy of VRT
compare median of recovery time in those with chronic UVH vs BVH
U = 4 months
B = 12 months
in those with chronic UVH/BVH, what did VRT improve
symptom severity
balance confidence
gait speed
DGI score
DVA
what are the mechanisms of recovery in VRT
adaptation of reflexes
substitution
habituation
what is the thought behind adaptation VRT / what is the expected outcome
long term change in neuronal response of the vestibular system to head movement
what is hoped to be produced during adaptive VRT
error signal (retinal slip)
- while moving the head to induce change in the VOR
what is the overarching goal of adaptation exercises
gaze stability
postural stability
reduction of symptoms
what is retinal slip
the difference between actual movements of the eyes and desired movement needed to keep image stable
what is substitution defined as in VRT
use of alternative strategies to replace lost or compromised function
if the VSR is compromised, what is substituted in place
other sensory systems like vision or somatosensory
if the VOR is compromised, what is substituted in place
COR = cervical ocular reflex
what is the COR
pre-programmed eye movements elicited by mechanoreceptors at cervical joints
what is the definition of habituation in VRT
long-term reduction of a response to noxious stimulus through repeated exposure to provocative stimulus
what factors can modify rehabilitation outcomes
anxiety
depression
peripheral neuropathy
migraine
abnormal binocular vision
abnormal cognition
what medications can affect rehabilitation outcomes
long term use of vestibular suppressants (meclizine)
what has been proven to help modify symptoms without affecting rehabilitation outcomes in those with chronic vestibular disorders
low dose antihistamines
or
zofran
what are the components of VRT
gaze stabilization exercises
habituation exercises
balance/gait activities
general conditioning
what does the CPG peripheral vestibular disorders recommend?
what can it improve?
VRT
- postural/gaze stability
- decrease subjective complaints
- improve QOL
for peripheral UVH, what is the treatment option
gaze stabilization exercises
habituation
for BVH what is the treatment option
gaze stabilization exercise
for motion sensitivity, what is the treatment option
habituation
for central vestibular dysfunction, what is treatment option
habituation
for BPPV, what is the treatment option
canalith repositioning manuevers
what is vestibular rehabilitation treatment determined by
symptoms
impairments
activity limitation
participation restrictions
gaze stabilization exercises are designed to ____ and are performed by _____
increase gain of the neuronal response of vestibular system
continuously moving head in horizontal and vertical directions
what are the variations of gaze stabilization exercises for adaptation
VOR x1 - only head moving
VOR x2 - object and head moving in opposite directions
what would indicate therapist to modify gaze stabilization exercises for adaptation
- if object gets blurry
- retinal slip occurs
- saccadic intrusion
all indicate to slow head speed
what are the variations of gaze stabilization based upon substitution
eye-head movement between target
remembered target
explain eye-head movement exercise protocol
eyes and head facing on 1st target
eyes shift to 2nd target (lateral or vertical) while head is still
head then turns to face 2nd target
protocol of remembered target exercises
eyes focused on a target
– close eyes
head turns while eyes remain on the target
open eyes and check for accuracy
what are eye-head movements between target exercises beneficial for
BVH in order to reduce oscillopsia with head movements
dosage of gaze stabilization exercises for those with acute/subacute UVH
3x a day
≥12 min daily
dosage of gaze stabilization exercises for those with chronic UVH
3-5x a day
> 20 min daily
4-6 weeks
dosage of gaze stabilization exercises for those with chronic BVH
3-5x a day
20-40 min
5-7 wks
when educating patient on gaze-stabilization exercises, what is important to explain
there will be an increase in symptoms and that is supposed to happen!!
empowering patient to recognize increase symptoms and to pace themselves based upon this
–> should not last more than 20-30 min
what are the variables most important to progress during gaze stabilizing exercises for those with hypofunction
duration and speed
what are the variables that can be manipulated in gaze stabilization exercises
duration
speed
background complexity
position
distance
target size
dose
what is the goal for duration to extend to
2 minutes
- begin with 1 to start
related to speed, what is the goal during gaze stabilization exercises
retinal slip while maintaining focus and moving head as quickly as possible
what can be used to cue patient on speed during gaze stabilization exercises
letter almost going out of focus, but not
to keep symptoms minimal and to return to baseline before next repetition
what can be used as an external cue during gaze stabilization exercises? any specifics?
metronome
range of 40-144bpm
about 96 bpm initially with goal of 240bpm
what is the head speed necessary for VOR activation
> 120° per second at 2 Hz
- around 120 bpm
regarding a position / balance change, what are the options for manipulation
seated/standing
static vs dynamic
altered base of support
altered support surface
walking variations
what are the walking variations that can be implemented in gaze stabilization exercises
overground / treadmill
forward, backward / sideways
how can vision be manipulated in ways other than just closing the eyes
having patient move the head
have patient look at a dynamic object
regarding distance variable of gaze-stabilization exercises, what are our options
near the target (arm length)
far (6-10 feet)
walking toward and away
size of target
letter size in regard to distance of target
close = 14 pt
far = 54 pt
indications of postural control interventions
self-report of disequilibrium with head motion/walking
instability with head motion while walking
high risk for falls / history of falls
restricted activity
balance and gait exercises are based upon principles of
substitution
goals of postural control exercise
minimize symptoms w/head motion
normal use of sensory inputs for balance
reduce falls / fall risk
return to normal activities
optimal balance exercise dosages for those with chronic UVH
minimum of 20 min daily
≥ 4-6 wks
optimal balance exercise dosages for those with chronic BVH
daily exercise for ≥ 6-9 wks
what are the balance training principles
consider static and dynamic balance
challenge pt but allow success
observe posture
consider other systems that may be affected during
consider goals and what PLOF looked like
when challenging patients during balance training, what can be added
concurrent tasks
- manual or cognitive
head movements
when implementing balance interventions, it is important to remember to
maintain safety
allow for early success for confidence
HEP within tolerance
guideline of HEP within balance intervention
only 3-5 different balance exercises
maximization of challenge with minimization of risks
what indicates motion provoked dizziness
dizziness of vertigo with position changes / dizziness with busy visual background
interventions for motion provoked dizziness are based upon
habituation principles
goal of motion provoked dizziness rehabilitation
minimization of symptoms with positional changes
what is important to determine when considering motion provoked dizziness
if symptoms are due to
- positional or movement changes
or
- visually provoking environments
what measures are used in motion provoked dizziness if determined cause is positional changes
motion sensitivity tests
modified MST
what measure is used in motion provoked dizziness if determined visually provoked
visual vertigo analog scale
treatment considerations for motion provoked dizziness related to
- environment
- exercises
- reps
- frequency
- intensity
moderately stimulating environments
≤ 4 movements
3-5 reps per motion
2-3x a day
fast enough to produce mild-moderate amount of dizziness
when to eliminate exercises in HEP related to motion provoked dizziness
can be performed for 2 days without symptoms
when to check BP during treatment
if symptoms are brought on by moving from heart low to heart high positions
when is it time to discharge a patient from VRT
achievement of primary goals
resolution of symptoms
normalized balance/vestibular function
plateau in progress
average POC associated with
- chronic UVH
- chronic BVH
U = 4-6 weeks, once a week, HEP
B = 6-9 weeks, once a week, HEP, maintainance of activity
