Balance And Vestibular Rehabilitation

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• Balance And Vestibular Rehabilitation
• By
• Computerized Dynamic Posturography

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INTRODUCTION

• Dizziness and loss of balance are among the most
  common problems bringing patients to their
  doctors office. In fact, 40 of adults
  experience dizziness or imbalance at some point
  in their life. Left untreated, the results can be
  debilitating. As people get older, the onset of
  dizziness and falls from balance problems
  increases.
• These falls can lead to injury, hospitalization,
  surgery and even permanent disability. Dizziness
  and imbalance should not be accepted as
  inevitable effects of the aging process (Venosa
  and Bittar 2007).

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Approximately half of all cases of dizziness
also referred to as vertigo, spinning or an
off-balance sensation are caused by a
vestibular (inner ear) disturbance. Imbalance
often accompanies dizziness and may be related to
a vestibular disorder. While some causes of
dizziness and imbalance lie within the inner ear
(Medeiros et al.,2005).
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The vestibular system is responsible for keeping
us upright and balanced. The three main functions
of the vestibular system are Gaze stabilization,
Postural control and Velocity reception. The
vestibular system normally detects head motion
and position to aid in maintaining balance and
visual stability. When there is a problem with
this system, one may avoid movement to prevent
provoking symptoms. A person may also have
difficulty completing daily or leisure
activities, may become deconditioned and/or fall
and sustain injuries ( Pothula et al.,2004).
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The etiology of peripheral and central vestibular
deficits includes the following age-related
multisensory deficits, strokes and vascular
insufficiencies, cerebellar degeneration,
chemical and drug toxicities, benign paroxysmal
positional vertigo, uncompensated Ménière
disease, vestibular neuritis, labyrinthitis, and
head trauma (Kroenke et al.,1992) .
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Balance Assessment

• Electronystagmography (ENG)
• is a diagnostic test to record involuntary
  movements of the eye caused by a condition known
  as nystagmus. It can also be used to diagnose the
  cause of vertigo, dizziness or balance
  dysfunction by testing the vestibular system.

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Computerized Dynamic Posturography (CDP)

• It is a computerized platform surrounded by a
  visual field.  By changing the tilt of the
  platform, or shifting the images shown on the
  field, the test attempts to define balance
  (postural control) problems related to the
  vestibular system, during the Sensory
  Organization Test (SOT) .

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Sensory Organization Test (SOT)

• (SOT) is a portion of CDP, the visual,
  vestibular, and proprioceptive information is
  manipulated to evaluate the effect on standing
  balance. CDP testing has been proposed as a
  complement to clinical tests that localize and
  categorize the pathology of balance disorders.
  (Amin et al ., 2002 )

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Vestibular Rehabilitation (VR)

• Vestibular rehabilitation therapy has been
  demonstrated to be a highly effective treatment
  for most individuals with vestibular or central
  balance system disorders. The aims of VR is
  acceleration the process of central compensation
  and to recover the functional balance

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• The basis for the success of a VRT program is
  the use of already existing neural mechanisms for
  adaptation, plasticity, and compensation in the
  human brain., which results in an improvement in
  vestibular-ocular control, an increase in the
  gain of the vestibuloocular reflex (VOR), better
  postural strategies, and increased levels of
  motor control for movement. (Venosa and Bittar
  2007) .

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AIM OF THE WORK

• The objective of this study is to
• 1- Assess the role of dynamic platform
  Posturography as (a diagnostic and prognostic
  tool) in patient with Vertigo.
• 2 - Assess the role of dynamic platform
  posturography as a method for rehabilitation
  therapy for patient with vertigo.

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Subjects and Methods

• Subjects
• In this study, a total number of 38 subjects
  were examined. They had an age range of 19 -66
  years and were of both sexes. The subjects were
  divided into two groups

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Control Group (Group A)

• This consisted of 10 normal subjects (6
  females and 4 males having an age range of 30-60
  with mean of 43.89.8). they had never suffered
  from vertigo, imbalance or had history of ear or
  neurological diseases.

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Patients Group (Group B)

• This group included 28 patients with chronic
  symptomatic vestibular deficits disorders of at
  least 3 months duration, and chief complaints of
  unsteadiness, imbalance, and/or motion
  intolerance. They were 20 females and 8 males
  ,their ages ranged from 19 -66years .They had
  diagnosed as unilateral vestibular deficits 10
  of vestibular neuritis ,7 Menieres diseases, 5
  labyrinthitis and 6 of unknown cause .Patients
  were excluded from the study if they had duration
  fewer than 3months , contraindication to head and
  neck movement or they had inadequate follow up
  or they had cognitive deficit ,joint replacement,
  cervical vertigo or major neurologic diseases.

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Equipments

• 1- Audiogram2- Computerized
  Electronystagmography 2 channels, ICS medical
  chart version 5.70 .3- Computerized Dynamic
  Posturography( Smart Balance Master Version 8.1
  from NeuroCom)

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Methods

• All patients were evaluated with the
  following
• Complete medical and neurologic history and
  physical and otologic examination.
• Comprehensive hearing assessment.
• Audiogram.
• Electronystagmography (ENG) test.
• Dizziness Handicap Inventory (DHI) score before
  and after their therapy program.
• Postural stability was assessed by sensory
  organization test (SOT) before and after their
  therapy program.

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The SOT protocol is comprised of the following
six sensory conditions
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Patients received vestibular and balance
rehabilitation by CDP equipment 3 times /week for
3 months. VRT exercises are graduated, beginning
at the minimal skill level that the patient is
capable of performing complexity is increased as
compensation and habituation occur, exercises on
a stability platform, and exercises on a moving
footpath with rehabilitative software. Patients
also performed home exercises for up to 40
minutes per day in the form of gaze stabilization
,balance and gait training.
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Table (1) showing comparison between patients and
control as regard condition 5 and composite score
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Figure (2) shows composite score difference
between patients and control group.
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Figure (1) shows condition 5 difference between
patients and control group
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Assessment of patients after vestibular
rehabilitation therapy

• The patients were assessed by Dizziness Handicap
  Inventory (DHI) and sensory organization test
  before and after vestibular rehabilitation
  program (VRT).

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Marked improvement in condition 5 after VT R was
noted.
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Table (2) showing Comparison between before and
after VRT as regards DHI and SOT  4)
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Figure (3) shows condition 5 difference in
patients between before and after VRT
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Figure (4) shows composite score difference in
patients between before and after VRT
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Figure (5) shows DHI difference in patients
between before and after VRT
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DISCUSSION

• Dizziness and vertigo are among the most
  common symptoms causing patients to visit a
  physician . The overall incidence of dizziness,
  vertigo, and imbalance is 5-10, and it reaches
  40 in patients older than 40 years.

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• Electronystagmography (ENG) has long been the
  gold standard for the evaluation of patients with
  complaints of dizziness and/or vertigo . For many
  years, ENG was the only objective means of
  assessing disorders of the balance system, and it
  is still used widely in clinical practice(Black
  et al.,1988) . Computerized dynamic posturography
  (is less specific than ENG), but it provides more
  global insight into a patient's ability to
  maintain equilibrium under more challenging
  environmental circumstances (Amin et al.,2002)

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• This study included 28 patients suffered from
  vertigo due to unilateral vestibular dysfunction
  , 10 of vestibular neuritis ,7 Menieres
  diseases, 5 labyrinthitis and 6 of unknown cause
  . They were cliniclly evaluated and assessed by
  audiogram to detect site of lesion and affection
  of hearing. We evaluated the significance of
  dynamic posturography (SOT) in vestibular
  function assessment by comparing it with our
  routine equilibrium examinations comprised of
  nystagmographic data.

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• Our result showed highly significant
  statistical difference between patients with
  vestibular dysfunction and control group as
  regards (SOT) . Our result agree with Mirka and
  Black (1990). he studied Patients with
  vestibular loss (11 with bilateral and 101 with
  unilateral vestibular loss) were investigated
  with posturography and compared to healthy
  subjects. patients showed increased postural
  oscillations during SOT.

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• Stewart et al .,(1999) suggested that audiometry
  combined with posturography was a cost-effective
  method of documenting a vestibular disorder.
  Recently Sataloff et al.,(2005) recently
  suggested that CDP adds value because it is
  abnormal in situations where ENG is normal. We
  found that 6 patients (21) had no abnormality of
  vestibular function could be detected by ENG .

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• In spite of these results, the patients
  complained of vertigo of dizziness and showed
  abnormal results in dynamic posturography
  (SOT).In contrast we found 4(14) patients with
  vestibular dysfunction had normal SOT . Our
  result supported by Black et al ., (1994) and
  Also Asai et al .,(1993). In contrast to our
  finding Di Fabio, 1995 found that there is a
  severe disturbance of caloric testing and
  rotatory chair testing, accompanied by a
  normalCDP. CDP is therefore not an adequate test
  for vestibular disturbance, by itself and is not
  100

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• He also concluded that combining posturography
  with other tests of vestibular function increased
  the overall sensitivity for detecting vestibular
  lesions.
• In our study patients received vestibular and
  balance rehabilitation by CDP equipment 3 times
  /week for 3 months ,and home exercises for up to
  40 minutes per day in the form of gaze
  stabilization ,balance and gait training.

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• We observed that 88.31 of patients present
  satisfactory evolution of symptoms through VR
  therapy by questionnaire(DHI) reporting their
  symptoms severity before and after receiving the
  VTR, about 9(32) presented no symptoms
  (dizziness, vertigo, and nausea), 16 (57)
  presented improvement of symptoms and 3 (11)
  presented no improvement .

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• We could notice the same result regarding the
  SOT, as the value average in Condition 5 and
  Balance Index ranged from 45.89 to 60.04
  (Plt0.001) and from 62.14 to 76.25 (Plt0.001), by
  showing improvement on posture stability. When we
  compared the two types of evaluations, we noticed
  that the responses to therapy were similar in
  both, which reveals that the posturography result
  agrees with the (DHI) .

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• Our finding supported by (Novalo et al 2008 ) ,
  Badke et al.,2005 , Black et al ., 2000 and Cohen
  H, 1992 who stated that physiotherapeutic
  vestibular rehabilitation supports the vestibular
  compensation mechanism and patients improved
  significantly after physical therapy,
  demonstrating greater independence in their
  abilities to care for themselves.

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Conclusion

• Combining CDP with ENG testing to vestibular
  function increased the overall sensitivity for
  detecting vestibular lesions.
• CDP considered valuable tool for diagnosis and
  rehabilitation in patients with vestibular
  affection .

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Thanks a lot