EPIDEMIOLOGIA della...

Fiuggi 2013

LA

RIABILITAZIONE

VESTIBOLARE

Università degli studi di Perugia

Dott. MARIO FARALLI Responsabile del Servizio di Vestibologia

della Clinica Otorinolaringoiatrica di Perugia

VESTIBULAR REHABILITATION THERAPY (VRT)

1) enhance gaze stability

2) enhance postural stability

3) improve vertigo

4) improve activities of daily

living

adaptation

substitition

Goals of VRT

habituation

head eye movements

various body postures and activities

various head and trunk orientation

mantaining balance with a reduced support base

movements provoking vertigo

exposing patients gradually to various

sensory and motor enviroments

The key exercises

for

VRT


• Stable vestibular lesion

• Central lesions or mixed central

and peripheral lesions

• Head injury

• Psychogenic vertigo

No evidence of progressive process

Natural compensation appears to be incomplete

VRT is indicated for the following conditions

Shepard NT, Telian SA. Programmatic vestibular rehabilitation. Otolaryngol

Head Neck Surg 1995;112:173-182.

their prognoses are likely to be more limited

than the average patient with a stable peripheral injury

Their conditions often include cognitive

and central vestibular involvement

along with a peripheral component

• Elderly with dizziness

• Vertigo with uncertain etiology

psychiatric intervention will also be required

greater reduction in fall risk

an empirical trial of vestibular physical

therapy may be a helpful option

• BPPV

balance training may be useful sometimes

after treatment BPPV


Head Neck Surg 1995;112:173-182.


Head Neck Surg 1995;112:173-182.

Hall CD, Heusel-Gillig L, Tusa RJ, Herdman SJ. Efficacy of gaze stability exercises in older adults with

dizziness. J Neurol Phys Ther 2010; 34:64-69.


Head Neck Surg 1995;112:173-182.

Shepard N, Asher A. Treatment of patients with nonvestibular dizziness and disequilibrium. In:

Herdman SJ. Vestibular Rehabilitation. 2nd ed. Philadelphia: F.A. Davis Co., 2000;534-544.

Seok JI, Lee HM, Yoo JH, Lee DK. Residual dizziness after successful repositioning

treatment in patients with benign paroxysmal positional vertigo. J Clin Neurol 2008;4:107-

110.


• Unstable lesion

• Ongoing labyrinthine pathology

• Meniere

Habituation is impossible

Situations Where VRT Is Not Indicated


Head Neck Surg 1995;112:173-182.


semicircular

canal origin nystagmus

Static signs

Natural course of vestibular lesion

Otolithic origin subjective visual vertical

subjective visual horizontal

ocular tilt reaction

lateropulsion

Dinamic signs

asimmetry VOR

postural instability


dinamic

signs

Natural course of vestibular lesion

Otolithic dysfunction

Functional

recovery

static

signs

Semicircular canal dysfunction

Enhancing gaze stability

Vestibular adaptation Substitution by other eye movement systems

Enhancing postural stability

Substitution by vision or somatosensory cues


Repeated periods of retinal slip

induce vestibular adaptation.

Yaw and pich

plane are effective

Progressive increase

of retinal slip error

View target moving in

the opposite direction

Various directions of head

movements should be

imployed

Patients should perform exercises for gaze stability four to five times

daily for a total of 20-40 minutes/day, in addition to 20 minutes of

balance and gait exercises.26

Vestibular adaptation

LA RIABILITAZIONE VESTIBOLARE

There is evidence that they help

people overcome chronic dizziness.

Studies have particularly shown that

it is helpful in bilateral vestibular loss

(Herdman et al, 2007),

Gaze stabilization eyes

Indications for gaze stabilization:

• unilateral vestibular disturbances such as vestibular neuritis

• tumors of the 8th nerve removed.

• bilateral vestibular loss.

• Central vestibular disorders

Condition in wich gaze stabilization is not indicated:

• not helpful in positional vertigo

• not tolerated by persons with cervical vertigo

• intermittent vestibular problems that return to normal such as:

• Non vestibular problems – i.e blood pressure fluctuations, medication induced dizziness

migraine associated vertigo

Meniere’s disease

http://www.dizziness-and-balance.com/disorders/unilat/vneurit.html


http://www.dizziness-and-balance.com/disorders/tumors/acoustic_neuroma.htm


http://www.dizziness-and-balance.com/disorders/bilat/bilat.html



The aim is to improve vision while

the head is moving, generally while

viewing an earth stationary object.


Daily practice of exercises made progressively more complex and difficult:

• unilateral vestibular disturbances

• tumors of the 8th nerve



• Protocol of head movement

1. Head turn with pause

2. Head turn back and forth continuosly without pause

(sinusoidal, generally slow and medium)

3. Occasionally, one adds in linear movement (angular movements)

• Speed of head movement • target distance while moving head

1. Slow

2. Medium

3. Fast (head thrust)

1. Near

2. far



















• Background while moving head (multisensory interation)

1. Eyes closed

2. Blank background

3. Busy background (i.e. checkerboard), very busy background (i.e. grocery store)

4. Very busy moving background (i.e crowds, windy outdoors, watching waves

come in)

1. Misleading background (i.e rotating visual surround, twisting golf umbrella,

walking against a crowd moving the other direction, head and target moving in

other direction


















• head position on trunk

1. Middle

2. Left and right

3. Up and down

4. Roll

• head position with respect to gravity

1. Upright

2. Supine

3. prone

• other things going on that require mental processing by themselves

1. Movement such as walking, treadmill

2. Thinking/talking/driving











Substitution by other eye-movement systems

exercise for saccade and vestibulo-ocular reflex exercise for imagery pursuit

Corrective saccades become a part of the adaptive strategy to

augment the diminished slow-phase component of the VOR Schubert MC, Zee DS. Saccade and vestibular ocular motor adaptation. Restor Neurol

Neurosci 2010;28:9-18.

patients with a deficient vestibular system exhibited an

enhancement in the pursuit system, with open- and closed-loop

pursuit gains that were about 9% higher than those of the controls Bockisch CJ, Straumann D, Hess K, Haslwanter T. Enhanced smooth pursuit eye

movements in patients with bilateral vestibular deficits. Ne-uroreport 2004;15:2617-2620.

learn to use stable visual references and surface somatosensory information

use the remaining vestibular function

Enhancing postural stability

identify efficient and effective alternative postural movement strategies

recover normal postural strategies

Goals

Adattamento alle patologie dell’equilibrio

Ricalibrazione

Nuova strategia comportamentale

Memorizzazione e adattamento psicologico

La stabilità della lesione

Eventuali patologie del SNC

Lo stato psichico

L’età

Il tipo di vita

L’uso di farmaci

Lo stato dell’apparato motorio

Le patologie a carico degli apparati compensatori

Patologie intercorrenti

La mancanza di tempo da dedicare agli esercizi riabilitativi

disturbo dell’equilibrio

cronicizzato per difficoltà di adattamento

Bilancio funzionale

Identificazione causa difficoltà adattamento

Rimozione o miglioramento delle cause

(fase plurispecialistica)

Terapia rieducativa non strumentale

domiciliare e/o ambulatoriale

Terapia rieducativa strumentale ambulat.

selezione dei pazienti

e

programmazione protocolli

Indurre abitudine allo stato patologico

Indurre un contrasto sensoriale

Favorire una sostituzione sensoriale

Facilitare un transfer

Ridurre il gain di alcuni riflessi

tecniche

riabilitative Postura e marcia

Oculomotilità

funzioni

cognitive/comportamentali

Protocollo di Cawthorne e Cooksey

Protocollo di Pittsburgh e Miami

Balance coordination training (Bct)

Balance Retraining/Compensation

and Habituation Therapy

Progressive Walking Program

Tecnica Box

Marcia su percorsi memorizzati

Auto-analisi percettiva

Una nuova prospettiva

Premesse:

Una diversa processazione delle informazioni

sensoriali nella genesi dei riflessi e nella

percezione spaziale

La possibilità di introdurre nel sistema informazioni

sensoriali nuove in grado di condizionare le

risposte

0 10 20 30

-160

-120

-80

-40

0

40

80

120

Am

plitu

de, d

eg

Time, sec

1° Trial

2° Trial

5° Trial

Influence of repeated sequences of asymmetric stimulation

on the vestibulo-ocular reflex (slow phases)

0 1 2 3 4 5 6 7 8 9

-30

0

30

60

90

120V

OR

end

poi

nt, d

eg

Trials


on the vestibulo-ocular reflex (slow phases)

0 10 20 30 40

-180

-120

-60

0

60

Imag

inar

y ta

rget

pos

ition

, deg

Time, sec


on the pointing task

1° Trial

2° Trial

5° Trial

1 2 3 4 5 6 7 8 9 10

-50

0

50

100

150

200

250

300

350

Am

plitu

de, d

eg

Trials

VOR end point

Imaginary target position

Comparison between the amplitude of self motion

perception and VOR slow phase

Asymmetric vestibular

stimolation

Final target

Final target

CCW

CW CCW

CW

0 10 20 30 40

-180

-120

-60

0

60

Im

ag

ina

ry ta

rg

et p

ositio

n, d

eg

Time, sec

Asymmetric vestibular

stimolation

Self motion perception in normal subject

VOR

VOR

perception

perception

Criteria for enrollment

Previous unilateral vestibular dysfunction

Recovery of normal function

Clinical evaluation: caloric test,

HST,Vibration,Vemp’s,SVV, posturography

(VSR)

Criteria for enrollment

asymmetricVOR

functionalrecovery

0 5 10 15 20 25 30

-80

-60

-40

-20

0

20

40

60

80

Platform

Qp + Sp

Sp

Am

plitu

de, d

eg

Time, sec

Symmetric vestibular

stimulation

• VOR

Patient 1

0 10 20 30

-60

-40

-20

0

20

40

60

Imag

inar

y ta

rget

pos

ition

, deg

Time, sec

Platform

Pointer

• Perception

Patient 1

Symmetric vestibular

stimulation

0 10 20 30 40

-180

-120

-60

0

60

joestick

X Axis Title

Platform

joestick

0 10 20 30 40

-180

-120

-60

0

60

Platform

Asymmetric vestibular stimulation

• Pointer task

Time

Am

plit

ude

Time

Am

plit

ude

Patient 1

Patient

Previous

dysfunction

VOR (E.O.G.)

Pointing test

(symmetric)

Pointing test

(asymmetric)

C. M.

Dx

Balance

1° Trial 25°dx

2° Trial 35°dx

3° Trial 40°dx

4° Trial 40°dx

Cw 10° sn

Ccw 80°dx

∆ = 90°

F. F.

Sn

Balance

1° Trial 0°sn

2° Trial 5°sn

3° Trial 10°sn

4° Trial 10°sn

Cw 80° sn

Ccw 42°dx

∆ = 122°

A.G.

Sn

Balance

1° Trial 15°sn

2° Trial 20°sn

3° Trial 22°sn

4° Trial 25°sn

Cw 50° sn

Ccw 0°dx

∆ = 50°

Patient Previous

dysfunction

VOR (E.O.G) Pointing test

(symmetric)

Pointing test

(asymmetric)

O.M. Dx Balance

1° Trial 12°dx

2° Trial 5° sn

3° Trial 8° sn

4° Trial 3° dx

Cw 8° sn

Ccw 13° dx

∆ = 21°

Results

VOR

VOR

perception

perception

Paziente 1

Paziente 4

Conclusion

Opposite effect on VOR and self motion

perception following asymmetric input

Asymmetric VOR is always associated with an

asimmetric self motion perception

Asymmetric self motion perception is not always associated with an asymmetric VOR

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