?????????? PT for vestibular lesion

1
??????????PT for vestibular lesion

• ???

2
Contents

• Introduction
• Evaluation based on ICF model
• Management based on ICF model
• Meta-analysis Outcome and Guidelines
• Summary

3
????

• ??(dizziness) ???????????????
• ??(vertigo) ???????????
• ???????(oscillopsia)??????????????????
• ????2-3???--2-3?/?

4
Anatomy

• Cranial VIII nerve
• Vestibular
• cochlear

5
????(labyrinth)-????

• ????????????
• FlexionRt front Lt posterior semicircular
  canal
• Side roll Rt posterior-Lt anterior
• Rotation horizontal

6
???

• ???????
• ?????????
• ??????(????vestibular N?spinal neuron)
• ????flexion response, ????
• ????extension response, ????
• ?baby??(???????????????)
• ????????????

7
????

• ???
• ???(???)?? ???????????????????
• ?????
• ????????
• ??????????,??????????

8
Common Vestibular Diagnosis

• ?????????4 ?????
• ?????
• ??????????
• ??
• ???
• ????1-4??,???????
• ???20-50??gt?
• ????????????

9
?????

• ?????????? (BPPV)
• ????????,???2-5?????,????30? counter-rolling ??
• ??????3-6????
• ??????????(MPPV)
• ??????????????
• ????30????????????
• ????(cervicogenic vertigo)
• ????(Tumarkin catastrophy)
• ?????????????,??????
• ???-lateral vestibular nucleus-spine

10
?????

• ??????????(BRV, benign recurrent vertigo)
• 4-15?
• ?????20??
• ???????(O.D., Orthostatic dysregulation)
• ???????? BP?????gt20
• ???????(JUTD, juvenile unilateral total
  deafness)??16-30?????

11
???

• ?????
• lt2???
• ??lt???
• ??gt??
• ???? ??????????visual stimulation?smell or
  auditory stimulation ?????????????????????

12
Common Nonvestibular Diagnosis

• Cerebellar meningioma
• ??????
• ???
• ???

13
ICF Model
Health Condition
Body Function Structure
Activities
Participation
Environmental factors
Personal factors
14
??

• ???????? ??????
• ?????????,????????
• ????????
• ?????????
• ??????????????
• ???????
• ???????????????????????????

15
Assessment

• ??????
• ??(nystagmus)????????
• ?????????

16
Assessment

• ??????(Caloric test)
• Supine, head flexion 30
• 50cc 30??????30????44????44??? ???5????
• ?????15??????????
• ???????????????????3??
• ????1 min?????????
• ????4 min?????

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Assessment-ENG ????

• ???()???(-)???????????
• ??????????
• ???????????????
• ??????????????
• ?????????????

18
Body function structure evaluation

• History
• Hallpike Dix maneuver
• Motion sensitivity test
• Cervical alignment/ pain
• MMT screen
• ROM screen

Observe nystagmus
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Hallpike-Dix maneuver

• Liberatory Manoeuvre
• First Hallpike position to induce symptom
• Rapid rotation to opposite ear down position
• upright
• Epley manoeuvre
• Rapid straight back tilt with symptomatic ear
  down
• Rotation to opposite ear
• upright
• Each position maintain gt 2 min or until symptom
  subside
• Repeat until no symptoms (Epley) (Herdman, Phys
  Ther, 70381-88, 1990)

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Motion sensitivity test
21

• Motion sensitivity test
• ???Frenzels lenses
• ??????(head shake) head flexion 30,
  2?/?,30??70??????14?????????????????????????????
  ??

22
ICF Model
Health Condition
Body Function Structure
Activities
Participation
Environmental factors
Personal factors
23
Assessment-Postural Control

• Romberg
• ???????????, ??????????dorsal column??
• Tandem walk
• Sensory Organization Test
• Postural muscle responses
• Limits of Stability
• Fukuda test

24
Fukuda test (??????)

• 50 steps in-place eyes closed, arms raised
• Normal lt 1m
• 50 steps, lt 30
• 100 steps, lt 45
• Newton, Brain Injury, 1989

25
Motor coordination strategies
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Balance - Sensory organization
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Dizzy and Disequilibrium (????,2001)
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DGI-FGA test (Wrisley et al., 2004)

• ?????? Dynamic Gait Index
• 1.???????? Gait Level Surface
• 2.?????? Change in gait speed
• 3.??????????? Gait with horizontal head turns
• 4.??????????? Gait with vertical head turns
• 5.???? Gait and pivot turn
• 6.????? Step over obstacles
• 7.????? Step around obstacles
• 8.???? Stairs

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ICF Model
Health Condition
Body Function Structure
Activities
Participation
Environmental factors
Personal factors
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Dizziness Handicap Inventory

• ???????????????
• ???????????(?????)?
• ?????????????,?????????????
• ???????????????????????????
• ?????????????????????????
• ?????????????????????????(?????????????????????)?
  
• ???????????????????
• ?????????????,???????????(??????????)???????????
• ???????????????????????
• ??????????????????????
• ??????????????????????????
• ????????????????????
• ?????????????????????

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Dizziness Handicap Inventory

• ?????????????????????????
• ????????????????????????
• ??????????????????????????
• ?????????,??????????
• ????????????????
• ?????????????????????????
• ??????????????????????
• ??????????????????????
• ????????????????????????????????
• ????????????????
• ????????????????????????
• ??????????????????

32
Disability rating scale

• 0 ????,???
• 1 ??????
• 2 ????,?????????
• 3 ???????????
• 4 ?????????????
• 5 ????,????????

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Management based on ICF Model
Health Condition
Body Function Structure
Activities
Participation
Environmental factors
Personal factors
34
????

• ?????????
• ??????????
• ?????????????

35
Recovery Mechanisms

• spontaneous recovery
• vestibular adaptation
• changing the gain, timing, or direction
• substitution
• of other sensory inputs
• of alternative motor responses

central compensation
peripheral restoration
36
Unilateral vestibular neuritis (Strupp et al.,
1998)
37
Benigh paroxysmal positional nystagmus and
vertigo (Horak, 1994)
pre
post
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ICF Model
Health Condition
Body Function Structure
Activities
Participation
Environmental factors
Personal factors
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Steps to take

• 1. Is it BPPV?
• Left Hall-Pike position test, ??nystagmus ??????
• Right Hall-Pike position test
• 2. Decide if posterior or horizontal canal
• Posterior ??????Hall-Pike test ?positive
• Horizontal ???,???????nystagmus
• 3. If posterior do modified Epley (??????)
• 4. If horizontal do canalith reposition (?page
  3)
• 5. Patient education other exercises (pages 4-7)

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Modified Epley for L Post Canal BPPV (Radtke et
al., 2004Neurology)

• Start by sitting on a bed with your head turned
  45 to the left. Place a pillow behind you so
  that on lying back it will be under your
  shoulders.
• Lie back quickly with shoulders on the pillow,
  neck extended, and head resting on the bed. In
  this position, the affected (left) ear is
  underneath. Wait for 30 seconds.
• Turn your head 90 to the right (without raising
  it), and wait again for 30 seconds. 4. Turn your
  body and head another 90 to the right, and wait
  for another 30 seconds.
• Sit up on the right side.
• This maneuver should be performed three times a
  day. Repeat this daily until you are free from
  positional vertigo for 24 hours. 
• (For right ear BPPV, the procedure has to be
  performed in the opposite direction, starting
  with the head turned to the right side.)

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Brandt-Daroff exercisefor posterior canal

1. Is first positioned sitting
2. Rapidly moves into side-lying (stays until
   vertigo stops, waits 30 sec)
3. Sits up (rebound effect), remains for 30 sec
4. Rapidly moves into the mirror-image position
   (stays for 30 sec)
5. Sits up

• Repeats the entire maneuver 5 20 times,
  depending on the
• tolerance or until vertigo no longer occurs
• Repeats the entire sequence 3 times a day until
  without vertigo
• in 2 consecutive days

42
Canalith repositioning maneuver for horizontal
canal
Turns head toward the affected side moves
quickly into supine

• The head should be flexed slightly
• If the patient experiences nystagmus or vertigo,
  stop the movement until the s/s
• stops
• Must keep the head upright for 48 hours

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????- passive

• ????? 4?/?,with visual target at 1.2 m CCW and
  CW ?10?
• ??????? ???? 4?/?,CW, CCW ?15?

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????(2)

• ?????? 1.2 m??, 4???? ??????????????
• ?????

45
Occulomotor test/ exercise

• Whitney, Clin Manage, 1991

46
Vestibular habituation exercises
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Vestibular Electrical Stimulation

• The first step of physical therapy
• Aimed to reduce antigravity failure and to
  increase proprioceptive cervical sensory
  substitution.
• TENS on paravertebral muscle opposite to the
  affected side and on the trapezius of the
  affected side.
• At 1 hr per day at least
• The first half hour pt lye on the SS, in the
  light, and try to keep their eyes open
• The other half hour practice activities in
  upright position and walking during VES

48
Heat and Cervical traction

• ????, ???????????????Whiplash
• 7-9kg, 10 min?10 kg,14kg 10 days rest 10 days,
  traction 10 days, rest 10 days until 30 days of
  traction
• Manual traction by therapist
• Self home traction

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ICF Model
Health Condition
Body Function Structure
Activities
Participation
Environmental factors
Personal factors
50
Cawthorne-Cooksey Exercise
A in bed 1. Eye movements slow-quick 2. Head
movements slow-quick, eyes open-closed B.
sitting 1, 2. as above 3. shoulder shrugging
and circling 4. bending and picking up object
from floor C. standing 1, 2, 3. as above 4.
standing up eyes open-closed 5. throwing balls
from hand to hand 6. standing up while turning
around D. moving about 1. walk a circle while
passing a ball to a person in the center 2. walk
across room eyes open-closed 3. walk up and
down slop/stairs eyes open-closed 4. game
activities
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Foam and dome exercise
(Shumway-Cook and Horak, 1985)
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Balance - Limits of stability
53
ICF Model
Health Condition
Body Function Structure
Activities
Participation
Environmental factors
Personal factors
54
Patient education

• ??????
• ??
• ?????????
• ????
• ??????
• Effective habituation

Effective range
intensity
time
55
Red flags to stop exercise

• ????
• ??????????
• ??????
• ????
• ????

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Exercise Prescription Principles

• adaptation or compensation
• 3-5 exercise items
• moderate tolerable intensity
• moderate repetition
• twice every day
• modify with progression
• resume functional activities

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Contents

• Evaluation based on ICF model
• Management based on ICF model
• Meta-analysis Outcome and Guidelines
• Summary

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Outcome (Hillier, 2009)
59
Outcome (Hillier, 2009)
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Outcome
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Outcome
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Outcome
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Influencing factors (Herdman, 1997)
Positive influences Customized, supervised
exercises Stable unilateral vestibular
loss Symptoms provoked by movement Less severe
initial disability Recent onset
Negative influences Generic, unsupervised
exercises Fluctuating disorders Head injury Mixed
central and peripheral lesion Vestibular
suppressant medications
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Special considerations for BPPV

• recommendations against
• radiographic imaging, vestibular testing, or both
  in patients diagnosed with BPPV
• routinely treating BPPV with vestibular
  suppressant medications such as antihistamines or
  benzodiazepines.
• Options
• should differentiate BPPV from other causes of
  imbalance
• should question patients for factors that modify
  management including impaired mobility or
  balance, CNS disorders, lack of home support
• reassess patients within 1 month

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Summary

• Desensitize vestibular system
• Coordinate eye-head movement
• Improve balance and walking
• Education learn about condition and cope or
  become active

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references

• Schubert MC, Herdman SJ. Vestibular
  rehabilitation. In SB OSullivan and TJ Schmitz.
  Physical Rehabilitation Assessment and
  Treatment, 4th ed. Philadelphia FA Davis,
  2001821-843.
• Allison L. Balance Disorders. In Umphred DA,
  Neurological Rehabilitation, 3rd ed. St Louis
  Mosby, 1995802-837.
• Herdman SJ. Vestibular Rehabilitation.
  DavisPhiladelphia, 1994.
• Jacobson GP, Newman CW, Kartush JM. Handbook of
  Balance Function Testing. St. Louis Mosby, 1993.
• ???????????????,1995?
• ???????????-???????????,1996 ?
• (?)????(????)???????????????,1998?
• ????????????????????????????? 199520182-196?

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References

• Acute phase after resection of acoustic neuroma
  (Herdman et al., 1995)
• Unilateral vestibular loss (Mruzek et al., 1995
  Strupp et al., 1998)
• Bilateral vestibular loss (Krebs et al., 1993)
• Central involvement, head injury (Godbout, 1997)
• BPPV (Ford-Smith, 1997 Banfield et al., 2000)
• Cervical vertigo (Bracher et al., 2000)
• Mixed patient type (Horak et al., 1992 Tilian Y
  Shepard, 1996)
• BPPV Clinical Guidelines (Bhattacharyya, 2008)
• Vestibular rehabilitation cochrane review
  (Hillier Holohan, 2009)