Balance Rehabilitation following TBI

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Balance Rehabilitation following TBI

• Chris Byrne
• Epworth Rehabilitation Centre

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TBI Population

• 1.2 per 1000
• 5,500 in Vic per year
• 350 severe brain damage

• 70 male
• 75 are lt 25 yrs
• Significant recovery expected within 6-12 months

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Effects of ABI on Movement

• Ataxia
• Increase tone
• Contracture
• Dyspraxia
• Decreased tone
• Paralysis
• Cognition

• Fatigue
• Reduced co-ordination
• Reduced balance
• Heterotrophic ossification
• Behaviour

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Aims of Balance Re-Training

• Assess static/dynamic balance
• Identify systemic deficiencies
• Identify postural compensation
• Identify directional deficiencies

• Improve static/dynamic balance
• Facilitate selective trunk control
• Improve confidence
• Progressively challenge balance capabilities

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Biomechanics of Balance

• Maintenance of CoG
• Limit of stability
• Cone of stability
• Base of support
• Postural positioning
• Balance Strategies

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Static Dynamic Balance

• Static postural control
• Rhythmic weight shift
• Sinusoidal patterns
• Optimal foot placement
• Unsteady gait
• Dynamic postural control
• Stairs obstacles

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Balance Control
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Neurological Systems

• Contra-coup Injury

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Vestibular System

• Responsible for maintaining
• Balance posture
• Orientation in space
• Dynamic visual focus
• Consists of
• 3 semicircular canals
• 2 otilith organs

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Anatomy Physiology

• Semicircular Canals
• Sense angular acceleration
• Crista (sense organs) housed in ampula
• Hair cells embedded in gelatinous mass

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Anatomy Physiology

• Fluid inertia during angular acceleration results
  in
• Displacement of the cupula
• Bending of sensory hairs
• Excitation of hair cells

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Anatomy Physiology

• Utricle Saccule
• Sense linear acceleration
• Maculae (sense organs)
• Covered by gelatinous mass (otolith membrane)
• Concretions of calcium carbonate (otoliths)
• Inertial mass ? sensitivity to linear
  acceleration, head position

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Vestibular Dysfunction in TBI

• 30-65 ? symptoms of pathology (Herdman, 1997)
• Various mechanisms ? varying pathology
• Complex nature of TBI ? mixed pathology

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Mechanisms

• Concussion
• Inner ear concussion most common
• BPPV caused by
• Intense acceleration utricular otolithic membrane
  ? otolith displaced post.
• Semi-circular canal ? adheres to cupula /free
  floating ? displacement of cupula position
  specific

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Mechanisms

• Temporal bone
• Uni/bilat hypo-dysfunction
• Transverse
• Nystagmus
• ? VOR, VSR ? vertigo
• Longitudinal
• ? hearing
• Vestibular concussion

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Mechanisms

• ? ICP
• Rupture of perilymph fistula b/w mid inner ear
• Fluctuating hearing loss, episodic vertigo,
• Balance gait disorders
• ? memory, concentration, attention

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Mechanisms

• Central vestibular lesions
• Petechial hemorrhage in brainstem
• Spontaneous nystagmus
• Occulomotor problems
• /- vertigo

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Neurological Symptoms

• Vertigo
• Auditory symptoms
• VOR dysfunction
• Nystagmus
• Oscillopsia
• Diplopia tilt
• Nausea
• Vomiting
• Unsteady veering gait

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Recovery

• Cellular recovery
• Recovery of hair cells indicated by research
• Unclear if ? functional recovery
• Spontaneous recovery
• Can result following trauma 3 -14 days
• Common in unilateral disturbance

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Recovery

• Substitution
• Cervico-occular reflex slow phase eye movements
  produced by cervical sensory input ? compliments
  VOR
• Smooth pursuit saccadic eye movement
  contribution
• Cervical sensory input ? following unilateral
  vestibular loss

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Recovery

• Habituation
• ? symptoms with repetitive exposure to
  provocative positions
• Mechanism neural adaptation not clearly
  understood
• However treatment strategies shown to be positive

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Assessment

• Vertigo
• Spontaneous/provoked
• Monitor intensity, duration, effect of mvt,
  conditions that precipitate dizziness
• Eye-head co-ordination
• Saccade smooth pursuit
• Gaze stabilization
• Postural control
• Sit, stand, walk, run

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Assessment

• Functional status strength, ROM, co-ord,
  sensory, pain, cognition, behavioural,fitness
• Rhomberg Test
• Positional nystagmus - Hallpike
• Fakuda Step Test
• Posturography
• Specialist tests

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Summary

• Rehab is complicated by
• Trauma
• Neuromuscular problems
• Visual sensory deficit
• Cognitive behavioural problems
• CNS lesions impair compensation process

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Summary

• Vestibular pathology common in TBI
• Rehab can be successful in facilitating recovery
• Rehab complicated by multiple system involvement
• Treatment guided by Ax, re-Ax clinical reasoning

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