Nancy - FranceSeptember 22-24, 2011

Marcel Norre’s V.H.T.Marcel Norre’s V.H.T.

An old and very good technic of An old and very good technic of vestibular habituation trainingvestibular habituation training

R. BONIVER

IntroductionIntroductionVestibular rehabilitation is essentially a physical therapy program for persons with symptomatic lesions of the vestibular system. When applied early after the insult it can hasten compensation and reduce symptoms resulting from permanent deficits caused by vestibular injury. It has been shown to be effective when applied to patients with either unilateral or bilateral losses. Compensation occurs through tonic rebalancing at the level of the vestibular nuclei by substitution of vision, proprioception, and peripheral sensation for the missing vestibular input, and by the use of behavioral strategies to deal with the residual deficits. The latter two mechanisms can be facilitaded with vestibular rehabilitation exercises.

Treatment methods must be varied based on the patients underlying disorder. The best prognosis for full recovery is for individuals with acute unilateral vestibular injury. Patients with bilateral lesions will show improvements but will have permanent deficits. Rehabilitation includes vestibular exercises, management of vestibular suppressant medications, general conditioning, and patient instruction. Treatment of symptomatic dizziness is based upon habituation to the provoking stimulus, usually head or eye movement.

Indications of vestibular rehabilitationIndications of vestibular rehabilitation

Unilateral vestibular dysfunction or weakness on one side of the vestibular system

Bilateral vestibular dysfunction

Benign Paroxysmal Positional Vertigo (BPPV) in cases of failure of liberatory procedure

Rationale of Rehabilitation TreatmentRationale of Rehabilitation TreatmentThere is obvious clinical and experimental evidence that compensation develops progressively in a rather fast way for the static components, in a slower and sometimes incomplete way for the dynamic components. Compensation appears to be a complex mechanism, which includes the intervention of several structures, uses different strategies and evolves at a different rate for the several manifestations of imbalance. It is an active process and it is subject to decompensation. It has been shown that the several signs expressing balance disturbance can have a separate evolution not only concerning their static and dynamic aspects but also concerning VOR and VSR.

The development of compensation obviously is dependent on sensory input and needs many central functions from the VN-level on. If they are lesioned or disturbed (e.g. by drugs), a delay of development of compensation has to be expected.

Multisensory input as well as sensorimotor activity has been proved indispensable for developing compensation. Moreover, repeated confrontation of the centers with the disturbing situation is the very stimulus for adequate re-organization. Indeed adaptation functions as an error-controlled process. A normal functioning of the centers is postulated for successful application of REHAB. Habituation is manifestly a basic mechanism for developing this compensation.

- the use of specific exercises adapted to the exact dysfunctional situation in the particular patient;

- The very stimulus is repetitive presentation of the situation, which has to be corrected and adapted, to the centers. This means, e.g., that activation is advised as soon as possible after a sudden loss;

- It is important to withdraw inhibiting drugs;

- Reservations have to be made if central signs are present.

MANOEUVERS OF THE VHT-TESTBATTERYSEQUENCE

DIRECTION OF MANOEUVER

DESCRIPTION

change of positionfrom to

M1 middle sitting supineM2 left supine left sideM3 right left side right sideM4 middle supine sitting

standingM5 * turning to the right

turning to the leftsitting, change of positionfrom to

M7 right nose closed to left knee right ear closed toright shoulder

M8 left nose closed to right knee left ear closed toleft shoulder

sitting, movementsM9 * turning head CCW **M10 * turning head CW ***M11 * bending forwardM12 * from sitting to erect standing positionM13 * moving head forwards/backwards

change of positionfrom to

M14 left sitting to head hanging and turned to the left

M15 left return to sitting positionM16 rignt sitting to head hanging and

turned to the rightM17 right return to sitting positionM18 middle sitting to head hanging in

midlineM19 middle return to sitting position

* Manoeuvers where nystagmus never occured** Counter-clockwise*** Clockwise

- Application of VHT and follow-up:

The M’s found positive (M+) for each particular patient are used as his adequate exercises. Each exercise is repeated five time successively with elicitation of vertigo. The patient maintains the vertigo-eliciting position as long as vertigo is persisting. Two sessions a day are advised. The exercises are executed in an « active » way, preferably without assistance, except in very elderly people. The therapy is applied at home.

The patient’s evolution is monitored by weekly repeating the testing on the testbattery. If his total score becomes 0, the end-evaluation is planned approximately two months after onset. If after one week the score is still positive, the patient is re-motivated and encouraged. Application of exercises is corrected, if necessary. The patient is further followed weekly until his score becomes 0. For each patient an end-evaluation is done two months after onset.

How to use the table of scoreHow to use the table of score

a) For each manœuvre it is noted:- typical vertigo TV- dizziness AV- without vegetative signs TV- or AT-- with vegetative signs TV+ or AT+- intensity +/-, +, +++- time of symptoms in sec.

b) First consider the time and secondly the adequate column.

Your obtain a score and you add the scores of each manœuvre to obtain a total score.

+/- + ++

t = Time in sec.

AV- AV+ TV- TV+ AV- AV+ TV- TV+ AV- AV+ TV- TV+

1 1.0 2.0 3.0 6.0 3.0 6.0 9.0 18.0 9.0 18.0 27.0 54.0 2 1.3 2.6 3.9 7.8 3.9 7.8 11.7 23.4 11.7 23.4 35.1 70.3 3 1.5 3.0 4.4 8.9 4.4 8.9 13.3 26.6 13.3 26.6 39.9 79.8 4 1.6 3.2 4.8 9.6 4.8 9.6 14.4 28.8 14.4 28.8 43.3 86.5 5 1.7 3.4 5.7 10.2 5.1 10.2 15.3 30.6 15.3 20.3 45.9 91.8 6 1.8 3.6 5.3 10.7 5.3 10.7 16.0 32.0 16.0 32.0 48.0 96.0 7 1.8 3.7 5.5 11.1 5.5 11.1 16.6 32.2 16.6 32.3 49.8 99.6 8 1.9 3.8 5.7 11.4 5.7 11.4 17.1 34.3 17.1 34.3 51.4 102.8 9 2.0 3.9 5.9 11.7 5.9 11.7 17.6 35.2 17.6 35.2 52.8 105.5 10 2.0 4.0 6.0 12.0 6.0 12.0 18.0 36.0 18.0 36.0 54.0 108.0 11 2.0 4.1 6.1 12.2 6.1 12.2 18.4 36.7 18.4 36.7 55.1 110.2 12 2.1 4.2 6.2 12.5 6.2 12.5 18.7 37.4 18.7 37.4 56.1 112.3 13 2.1 4.2 6.3 12.7 6.3 12.7 19.0 38.1 19.0 38.1 57.1 114.0 14 2.1 4.3 6.4 12.9 6.4 12.9 19.3 38.6 19.3 38.6 57.9 115.9 15 2.2 4.4 6.5 13.1 6.5 13.1 19.6 39.2 19.7 39.2 58.8 117.5 16 2.2 4.4 6.6 13.2 6.6 13.2 19.8 39.7 19.8 39.7 59.5 119.0 17 2.2 4.5 6.7 13.4 6.7 13.4 20.1 40.1 20.1 40.1 60.2 120.4 18 2.3 4.5 6.8 13.5 6.8 13.5 20.3 40.6 20.3 40.6 60.9 121.8 19 2.3 4.6 6.8 13.7 6.8 13.7 20.5 41.0 20.5 41.0 61.5 123.0 20 2.3 4.6 6.9 13.8 6.9 13.8 20.7 41.4 20.7 41.4 62.1 124.0 21 2.3 4.6 7.0 13.9 7.0 13.9 20.9 41.8 20.9 41.8 62.7 125.0 22 2.3 4.7 7.0 14.1 7.0 14.1 21.1 42.2 21.1 42.2 63.2 126.0 23 2.4 4.7 7.1 14.2 7.1 14.2 21.3 42.5 21.3 42.5 63.8 127.0 24 2.4 4.8 7.1 14.3 7.1 14.3 21.4 42.8 21.4 42.8 64.3 128.0 25 2.4 4.8 7.2 14.4 7.2 14.4 21.6 43.2 21.6 43.2 64.7 129.0 26 2.4 4.8 7.2 14.5 7.2 14.5 21.7 43.5 21.7 43.5 65.2 130.0 27 2.4 4.9 7.3 14.6 7.3 14.6 21.9 43.8 21.9 43.8 65.6 131.1 28 2.4 4.9 7.3 14.7 7.3 14.7 22.0 44.0 22.0 44.0 66.1 132.0 29 2.5 4.9 7.4 14.8 7.4 14.8 22.2 44.3 22.2 44.3 66.5 133.0 30 2.5 5.0 7.4 14.9 7.4 14.9 22.3 44.6 22.3 44.6 66.9 133.8 31 2.5 5.0 7.5 14.9 7.5 14.9 22.4 44.8 22.4 44.8 67.3 134.0 32 2.5 5.0 7.5 15.0 7.5 15.0 22.5 45.1 22.5 45.1 67.7 135.0 33 2.5 5.0 7.6 15.1 7.6 15.1 22.7 45.3 22.7 45.3 68.0 136.0 34 2.5 5.1 7.6 15.2 7.6 15.2 22.8 45.6 22.8 45.6 68.3 136.0 35 2.5 5.1 7.6 15.3 7.6 15.3 22.9 45.8 22.9 45.8 68.7 137.0 36 2.6 5.1 7.7 15.3 7.7 15.3 23.0 46.0 23.0 46.0 69.0 138.0 37 2.6 5.1 7.7 15.4 7.7 15.4 23.1 46.2 23.1 46.2 69.3 138.0 38 2.6 5.2 7.7 15.5 7.7 15.5 23.2 46.4 23.2 46.4 69.7 139.0

From the formula f (A) g (I) log 10 . (t) (M. Norré)

V.H.T. EVALUATION (FROM MARCEL NORRE).

Comparison with sinusoïdal support Comparison with sinusoïdal support surface translation (Corna et al. 2003)surface translation (Corna et al. 2003)

MeasuresMeasures

- body sway and subjective score of sway during quietstana EO or EC.

- Standard deviation of the A.P. displacement of the malleolus, hip and head during A.P. platform translation.

ResultsResults

both intervention are effective with the some results.

Advantages of Marcel Norre V.H.T.Advantages of Marcel Norre V.H.T.

- Lost cost furnitures:

- One examination table

- One chair

- One cushion for the neck

- Easy to realize, after discussion with the specialist, for the patient at home or with the physiotherapeut

- Easy to evaluate with the score table.

CONCLUSIONCONCLUSION

Marcel Norre’s V.H.T. is still up to date for the rehabilitation of vertigo.

Marcel Norre’s V.H.T. is, according to our experience, one of the best treatments for permanent labyrinthine lesions and facilitates quickly the mechanisms of central compensation.

This technique is cheap, easy to carry out .

We also use V.H.T. with success in failure of liberatory manoeuvers in cases of benign paroxysmal vertigo.

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