Interventions for the falling patient NOTES

© Copyright K2 Seminars 1

INTERVENTIONS FOR THE FALLING PATIENT

K2 SEMINARS


OBJECTIVES

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OBJECTIVES Upon comple;on of the course, par;cipants will be able to: Í  To iden;fy, through evalua;on of various systems, the set of

constraints (impairments) that result in dysfunc;onal balance responses and increased risk for falls.

Í  To iden;fy, through func;onal tes;ng, and in a quan;fiable manner, those pa;ents who may be at risk for falling.

Í  To modify treatment based func;onal assessment of those pa;ents at risk for falls

Í  To provide a baRery of exercises and treatment op;ons based on the Plan of Care.

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RATIONALE FOR BALANCE PROGRAM IMPLEMENTATION

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RATIONALE -‐ COST EFFECTIVENESS Falls represent the leading cause of serious injury and/or death among the

elderly: Í  50% of those hospitalized for falls survive one year or less. Í  There is a strong correla;on between head trauma a\er the age of 70,

and the onset of demen;a. Í  The downward spiral of cogni;on and func;onal mobility following a fall

results in profound increased in the healthcare costs. Í  It therefore follows that reducing the incidence of falls will in turn reduce

healthcare costs. Example: wrist fractures and hip fractures.


RATIONALE -‐ PREVENTABILITY Therapists can: Î  Iden;fy risk factors, both intrinsic and extrinsic Î  Generate risk profile for pa;ent Î  Determine and implement treatment protocols

Î  Behavioral adapta;ons Î  Environmental adapta;ons Î  Therapeu;c exercise with modali;es Î  Func;onal ac;vi;es’ adapta;ons

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RATIONALE – QUALITY OF LIFE Common scenario Î  Acute illness = prolonged period of bedrest Î  Prolonged period of bedrest = debility and loss of mobility Î  Debility and loss mobility = decreased strength and adap;ve shortening

of key joints (ankle, knee, hip) Î  Decreased strength and adap;ve shortening = loss of righ;ng response Î  Loss of righ;ng response dependent upon adequate strength and range

of mo;on


RATIONALE Reversal of debility can be accomplished by correc;ng

musculoskeletal dysfunc;on as well as ves;bular dysfunc;on by:

Î  balance retraining, Î  strengthening exercises, Î  endurance training and Î  community re-‐entry.



MEDICARE GUIDELINES

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MEDICARE GUIDELINES The following HCFA transmiRals fully support Physical

Therapy interven;on for balance training and fall preven;on:

Í  Balance: REV 262, Sec;on 214.3, item 2c. REV 294, Publica;on 542, Sec;on 5-‐26.8 “Iden&fy the.... problem treated, e.g., to correct a balance/incoordina&on and safety problem...”


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Í  Falls: REV 262, Sec;on 214.3, item 2c. “....training furnished a pa&ent whose ability to walk has been impaired by neurological, muscular, or skeletal abnormali&es require the skills of a qualified physical therapist and cons&tute skilled physical therapy.”




Í  ROM: REV 262, Sec;on 214.3, item 2d. “ROM exercises cons&tute skilled physical therapist only if they are part of a treatment for a specific disease state which has resulted in a loss or restric&on of mobility.”


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Differen?al Diagnosis

VERTIGO or DIZZINESS orIMBALANCE

IMBALANCE

TYPICALLYUNPROVOKED ON

POSITIONALTESTS

BALANCE TESTING-TINETTI-BERG

-FUNCTIONAL REACH-TUG

HISTORY OF:DM, ETOH ABUSE, PVD,OTHER NEUROLOGICALDISORDERS RESULTING

IN PERIPHERALNEUROPATHIES




ORTHOSTATICHYPERTENSION

BP STABLE ALLTHREE POSITIONS

BP DROPS WHENTRANSFERING (AS

COMPARED TOSUPINE BP)

POSSIBLE OTHER CAUSES-VESTIBULAR-CENTRAL-CIRCULATION-PERIPHERAL NEUROPATHY(DM,ETOH USE, PVD)

PROBABLEOH

NO LATENCYOF SX'S

Yes Yes


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VESTIBULARDYSFUNCTION

Hallmarks- Latency of sx's in

provocative position- Habituation of sx's inprovocative position

- Fatigueability of sx'swith repetition of

provocative positions

POSITIONAL VERTIGO MENIERE'S DISEASE

Positional testingENG

Audiology

ENGHearing Test

Hallmarks- Tinnitus

- Hearing loss- True vertigo (actual

sensation of spinning)

Yes Yes




VISUALDYSFUNCTION

UNRELATED TOHEAD POSITION

CHANGE

PROBABLE VISTUBLARDISORDERTYPICAL

COMPLAINTS'WOOZY' DIZZY IN

CROWDED MALLS,GROCERIES,LIBRARIES

OVERLOAD OFVISUAL STIMULUSCOMBINED WITH

FREQUENT CHANGEOF HED POSITION

NYSTAGMUS &C/O DIZZINESS

HABITUATE

PROVOKED ON POSITIONALTESTING

NYSTAGMUS& C/O

DIZZINESS DONOT

HABITUATE

Yes Yes

PROBABLECNS DISORDER

PROBABLE BPPVPROBABLEMENIERESDISEASE

-DM-RETINAL NEUROPATHY-MACULAR DEGENRATION-CENTRAL LESION-NYSTAGMUS

YesYes


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- SCI- CVA- TBI

- Tumour (head)- Acoustic nerve

tumour- Other

CENTRAL LESION

MRICT Scan

Typically- No latency

- No Fatigeability- No Habituation

Also- Provocation

unrelated to headmovement

Checkprotectiveextensionand head

rightreactions




CAUTION!!Vertebral artery test

mimics the headhanging down

position (commonlyassociated with

positional vertigo)

VERTIBRO-BASILARINSUFFICIENCY

Symptoms:- Immediate onset (no

latency)- No Habituation

- Steady worsening ofdizziness leading to

blacking outREMOVE PATIENTFROM POSITION

IMMEDIATELY- Refer patient to

primary Dr forprobable vestibular

study



ICD-‐9 CODING

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ICD-‐9 CODES TREATMENT ABNORMAL POSTURE 781.9 ABNORMALITY OF GAIT (also ataxic gait) 781.2 DEBILITY 799.3 DIFFICULTY IN WALKING (site unspecified) 719.70 DIFFICULTY IN WALKING (ankle/foot) 719.77 DIFFICULTY IN WALKING (lower leg) 719.76 DIFFICULTY IN WALKING (mul;ple sites) 719.79 DIFFICULTY IN WALKING (pelvis/thigh) 719.75 LACK OF COORDINATION 781.3 MUSCULAR/POSTURAL FATIQUE 729.89 MUSCLE WASTING.DISUSE ATROPHY 728.2


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ICD-‐9 CODES MEDICAL ALZHEIMER'S 331.0 ARTHRITIS

OA 715.09 RA 714

CEREBELLAR ATAXIA 334.3 CONGESTIVE HEART FAILURE 428.0 NEUROPATHY 355.9

PERIPHERAL 356.9 DIABETIC 250.6

OTOCONIA 386.8


ICD-‐9 CODES MEDICAL OTOLITH SYNDROME 386.19 OSTEOPOROSIS 733.0 PAROXYSMAL POSITIONAL VERTIGO, BENIGN 386.1 TRANSIENT ISCHEMIC ATTACK (TIA) 435.9 SYNCOPE 780.2


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ICD-‐9 CODES MEDICAL AND TREATMENT CONTRACTURE

ACHILLES TENDON 727.81 ANKLE/FOOT 718.47 HIP 718.45 MULTIPLE 718.49

CONTUSION ANKLE 924.21 HIP 924.01 SHOULDER 923.00


ICD-‐9 CODES MEDICAL AND TREATMENT CVA 436 HYPERTENSION 401.9 HYPOTENSION (POSTURAL) 458.0 LABYRINTHITIS, UNSPECIFIED 386.30 LABYRINTHITIS, VIRAL 386.35 MENIERES DISEASE, UNSPECIFIED 386.00 NEGLECT (HEMI, VISUOSPATIAL) 781.8


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ICD-‐9 CODES MEDICAL AND TREATMENT PAIN (ARTHRALGIA)

LOWER LEG 719.46 PELVIC/THIGH 719.45 LOW BACK 724.20

PNEUMONIA 486 VERTIGO 386.00 VERTIGO, CENTRAL ORIGIN 386.2 VESTIBULAR NEURONITIS 386.12 VESTIBULOPATHY, ACUTE, PERIPHERAL, RECURRENT 386.1


FLOW CHART FOR COMPREHENSIVE APPROACH TOBALANCE REHABILITATION AND FALL PREVENTION

Continue Treatment As Per Physical Therapy Plan of Care

DevelopProgramand TrainPersonnel

YES

One-TimeEval with

Recommendations

NO

FunctionalMaintenance?

NO

NO

RequestSLP

Consult

YES

Safety Awareness/ Carry-over of technique/ Commun-

ication Disorders/ Agitation/ DementiaDebility Secondary to Weight Loss

RequestOT

Consult

YES

Process of Dressing/ ImproperFit or Selection of Clothing/

Grooming/ Bathroom Transfers/Bathing/ Sensory Deficits

Develop Plan of Care basedon set of impairments. Do

impairments relate to any orall of the following?

YES

RehabPotential?

Evaluate,Identifying Impairments

YES

RescreenQuarterly

NO

Appropriatefor Eval?

Screen forBalanceProgram



BALANCE CONTROL

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BALANCE CONTROL Balance control is achieved via a complex interac;on of

numerous systems or ‘sensory organiza;on’ Í  Sensorimotor (3)

Í  Visual input Í  Ves;bular input Í  Propriocep;ve inputs

Í  Musculoskeletal Í  Cogni;ve Í  Cardiovascular


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Propriocep;ve Input

Visual Input

Vestibular Input


BALANCE CONTROL Sensory Organiza;on Theory Í  Percep;on of orienta;on in rela;on to gravity, the support

surface and the surrounding objects requires a combina;on of informa;on from vision, the ves;bular system of the inner ear and the somatosensa;on (skin, pressure receptors on the feet plus muscle and joint receptors which signal movement of a par;cular body part)

Í  No one sense directly measures the posi;on of the body’s COG Í  Vision measures orienta;on of the eyes in rela;on to

surrounding objects Í  Somatosensa;on provides informa;on regarding the support

surface Í  Ves;bular system is not referenced to external objects, but

rather to internal, iner;al-‐gravita;onal reference determining the orienta;on of the head in space


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BALANCE CONTROL Sensory Organiza;on Theory Í  Example: when a person stands next to a large bus that

suddenly begins to move, momentary disorienta;on or imbalance may result. A frac;on of a second is required to decide whether the bus is moving forward or the body is swaying back. In this sensory conflict situa;on, the brain must select the orienta;onally accurate inputs (somatosensory and ves;bular) and ignore the inaccurate one or vision.


BALANCE CONTROL Sensory Organiza;on Theory Í  Under most condi;ons, somatosensory and vision dominate the

control of orienta;on and balance. Both are more sensi;ve than the ves;bular system to subtle movements in the COG posi;on, but both are more prone to provide erroneous orienta;on informa;on as in the case of the moving visual field

Í  Somatosensory informa;on must be ignored if the suppor;ng surface is thickly padded or moving

Í  If both the somatosensory and the vision inputs are inaccurate, the ves;bular system is the only orienta;onal sense.

Í  The combina;on of senses is dependent upon the condi;on in which a person is performing

Í  Because redundant sensory orienta;on informa;on is available, people can stand and walk without vision, upon unstable surfaces and even without ves;bular input


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BALANCE CONTROL Sensorimotor -‐ Visual input Í  Special nerve endings or sensory receptors in the back of

your eye (re;na) are called rods and cones Í  These receptors are sensi;ve to light Í  When light rays strike them, their nerve fibers send

impulses to your brain that provide your brain with visual clues that aid in balance.

Í  For example, when you are outside, buildings are aligned straight up and down, or sidewalks are straight out in front of you.


BALANCE CONTROL Sensorimotor -‐ Visual Output Í  The motor impulses that go to eyeballs coordinate their

movement so that clear vision is maintained while the head is moving either ac;vely (running, watching a tennis match) or passively (sipng in a moving car). The movement of the eyes while the head is in mo;on is controlled automa;cally by the ves;bular system.

Í  When the head is not moving, the number of impulses from the right side is equal to the number of impulses coming from the le\ side. As the head turns toward the right, the number of impulses from the right semicircular canals increases, and the number from the le\ decreases. This difference controls eye movements and allows for clear vision as the head is turning.


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BALANCE CONTROL Sensorimotor -‐ Visual Output Í  In a person with a healthy ves;bular system, normal fast eye

movements (nystagmus) can be observed in the light when the head turns slowly from le\ to right and back again. The eyes will move quickly in the same direc;on that the head is turning. These same eye movements occur even in the dark.


BALANCE CONTROL Sensorimotor -‐ Ves;bular input Í  The inner ear or labyrinth is a complex series of passageways

and chambers within the bony skull. Í  Within these passageways are tubes and sacs filled with a fluid

called endolymph. Í  Around the outside of the tubes and sacs is a different fluid, the

perilymph. Í  Both of these fluids are of precise chemical composi;ons, and

are different. Í  The mechanism in the inner ear regulates the amount and

composi;on of these fluids which is important to the proper func;oning of your inner ear.


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BALANCE CONTROL Sensorimotor -‐ Ves;bular input Í  Part of each labyrinth, or inner ear, is a snail-‐shaped organ

called the cochlea. It func;ons in hearing. Located right next to the cochlea is the part of the inner ear that has to do with balance. This part is called the ves;bular apparatus. On each side of the head it is composed of three semicircular canals and a utricle and saccule.

Í  Each of the semicircular canals is located in a different plane in space. They are located at right angles to each other and to those on the opposite side of your head. At the base of each canal is a swelling (ampulla) and within these ampullae are located the sensory receptors for each canal.


BALANCE CONTROL


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BALANCE CONTROL Sensorimotor -‐ Ves;bular input Í  Inside a semicircular canal. The sensory receptor (cupula) is

aRached at its base, but the top of it remains free. When the head moves in the direc;on in which this canal is located, the endolympha;c fluid within the canal, because of iner;a, lags behind. The same thing happens when spinning a glass of water between your hands. When the fluid lags behind, the sensory receptor within that canal is bent. The receptor then sends impulses to the brain. The receptor is only sensi;ve while it is actually moving -‐-‐ just like the hairs on the arm. Try to move just one hair -‐-‐ you can feel it as you bend it. When you stop, you don't feel anything anymore. (Clothes are con;nually bending hairs -‐-‐ you are not aware of that.) The same thing happens in the hair cells of the cupula.


BALANCE CONTROL


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BALANCE CONTROL Sensorimotor -‐ Ves;bular input Í  In a healthy individual both sides of the ves;bular system are

func;oning properly, the two sides of the ves;bular system send symmetrical impulses to the brain. That is, the impulses coming from the right side conform to the impulses coming from the le\ side.

Í  All of the sensory input concerning balance, from the eyes, from the muscles and joints, and from the two sides of the ves;bular system, is sent to the brain stem, where it is sorted out and integrated.


BALANCE CONTROL Musculoskeletal Í  The input that the brain receives from muscles and joints

comes from sensory receptors that are sensi;ve to stretch or pressure in the ;ssue that surrounds them. As legs, arms, or other parts of the body moves, the receptors respond to the stretch of the muscles surrounding them and send impulses through many sensory nerve fibers to the brain.

Í  Especially important are the impulses that come from the neck, which indicates the direc;on in which the head is turned, and the impulses that come from the ankles, which indicate the movement or sway of the body in rela;on to the floor when standing. This kind of input provides the brain with informa;on about the standing surface -‐-‐ whether it is hard or so\, bumpy or smooth.


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BALANCE CONTROL Musculoskeletal output Í  The motor impulses that are sent from the brain to the other

muscles of the body control their movement so that balance can be maintained whether in sipng, standing, or turning cartwheels.

Í  Some of the impulses that leave the brain stem go back to the cerebral cortex, carrying informa;on to the thinking centers that tell the body it's okay to see trees whirling in circles when turning cartwheels. When prac;cing these and similar new ac;vi;es, the brain learns to "read" different kinds of sensory input as normal.


BALANCE CONTROL Musculoskeletal output Í  This is exactly what happens as a baby learns to balance through

prac;ce and repe;;on. The impulses from the sensory receptors to the brain stem and out to the muscles form a pathway. With repe;;on, it becomes easier for the impulses to travel over the same network or pathway, un;l many ac;vi;es of keeping balance becomes automa;c. Physiologists say that these nerve pathways become "facilitated." This is the reason why dancers and athletes prac;ce their ac;vi;es over and over again. Even very complex movements become almost automa;c over a period of ;me. Anyone who has learned to ride a bicycle, swim, or ski can relate to this idea. This is also the basis for therapy in trea&ng people with a damaged ves&bular system -‐-‐ the exercises mimic the movements that make them feel dizzy and lose their balance. AGer a &me, the brain "learns" that the input from this ac&vity is "normal" for the damaged system, and the side effects of dizziness and balance decrease.


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BALANCE CONTROL Integra;on Í  The brain stem also receives input from two other areas of the

brain -‐-‐ the cerebellum(coordina;on center), and the cerebral cortex, which func;ons in thinking and memory. As the brain stem is integra;ng all the input it receives concerning balance, the cerebellum may contribute informa;on about automa;c movements that have been learned through constant prac;ce, e.g. adjustments in balance needed to serve a tennis ball.

Í  The cerebral cortex contributes previously learned informa;on. For example, you have learned that icy sidewalks are slippery and that you have to step on them in a different way in order to keep your balance.


BALANCE CONTROL Integra;on Í  As integra;on of all the sensory input takes place, the brain

stem sends out impulses along motor-‐nerve fibers that begin in the brain stem and end in the muscles. These muscles make the head and neck, the eyes, the legs, and the rest of the body move and allow the maintenance of balance and have clear vision while the body is in mo;on.


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BALANCE CONTROL Essen;al to balance control is the condi;on of postural stability. Í  The state whereby the body is able to effec;vely and func;onally

manipulate combina;ons of mobility and stability in the gravita;onal field.

Í  Two components to postural stability: Í  equilibrium and Í  orienta;on.


BALANCE CONTROL Equilibrium: Í  whereby the totality of sensorimotor systems controls the body’s

center of mass with respect to its base of support so as to either allow for purposeful movement, or to resist perturba;ons.

Orienta;on: Í  whereby the totality of sensory input is acted upon by the motor

system to effect op;mal func;onal alignment.


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BALANCE CONTROL Í  Balance will be effected when the center of mass of an object

projects within the object’s base of support. Í  An object becomes unstable when this fundamental condi;on is

not met. Í  In the living organism, however, the sensorimotor system allows

for contrived instability-‐-‐ whereby the center of mass projects beyond the base of support-‐-‐ followed by recovery (when we walk, for example).


BALANCE CONTROL Í  The degree to which the individual is able to displace one’s center

of mass outside one’s base of support without falling or losing one’s stance is an important indicator of balance control; it is referred to as one’s limits of stability.

Í  Limits of stability are described in terms of two components: Í  mechanical limits of stability and Í  internal representa;on of stability.


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BALANCE CONTROL Í  Mechanical Limits of Stability:

Í  Describes the area about which the individual is able to move without shi\ing the base of support.

Í  Depends on the musculoskeletal and neuromuscular capabili;es of the individual.

Í  As these capabili;es are diminished, so the mechanical limits of stability decrease as well

Í  Sway envelope 12o anterior posteriorly; 16o laterally Í  If the COG alignment is forward, backward or to either side, a small sway envelope can be tolerated

Í  Sudden falls occur because small oscilla;ons are sufficient to extend the COG beyond the limits of stability


BALANCE CONTROL


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BALANCE CONTROL


BALANCE CONTROL Í  Internal Representa;on of Stability:

Í  Refers to one’s self-‐perceived limits of stability, that is, the area about which the individual perceives movement can occur without shi\ing the base of support.

Í  This neural representa;on of stability may be either less or greater than the (true) mechanical limits of stability.

Í  Where it is less, the individual may be excessively fearful, and the fear, in turn, may diminish performance to the point of increasing the risk for falls

Í  Where it is greater, the individual may be at increased risk due to habitual over-‐es;ma;on of his or her capabili;es.


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POSTURAL ANALYSIS!!!


PHASES OF RISING FROM CHAIR

Í  Begins with ini;a;on of forward trunk flexion and ends just before the buRocks li\ from the chair

Í  The ankle ac;vely dorsiflexes in conjunc;on with forward trunk lean (hip flexion) to bring the center of body mass forward over the feet


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Í  Begins as buRocks li\s from the chair and ends when the hips are fully extended Í  Most cri;cal point for muscle ac;va;on is at ‘seat off’ when thigh and buRock

leave the seat Í  Concentric knee extension followed by concentric hip extension



Í  Begins a\er full hip extension and ends when quiet stance is achieved



FALLS CLASSIFICATION

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FALLS CLASSIFICATION Í  What Cons;tutes a Fall? Í  Defini;on:

Í  Is it when an individual is discovered on the floor, the incident is described as a fall. May be an inaccurate descriptor, given the many alterna;ve circumstances that are possible, e.g. the confused, disoriented pa;ent who sits down inappropriately.

Í  Is it when an individual experiences an episode of instability, but does not wind up on the floor; such an incident may be inappropriately downplayed.

NOTE: It is important to correctly weigh the risk of future falls once a pa;ent has fallen. Need to dis;nguish between the truly unstable pa;ent from the one whose fall is more accurately characterized as random and untypical.


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FALLS CLASSIFICATION Í  Defini;on:

Í  A fall is defined as an episode in which, due to whatever cause, the individual experiences a loss of stance from which he is unable to recover without the assistance of any external forces (e.g. grabbing onto a rail; falling against a wall; contact guard assist).


FALLS STATISTICS Í  Percentage of persons (older than 65 yo) experiencing one or

more falls per year Í  25%-‐35% of community dwelling elderly Í  33%-‐67% of hospitalized elderly Í  60%-‐66% of ins;tu;onalized elderly

Í  United States falls costs (Gregg et al) Í  1994 $20.2 Billion Í  2002 $32.4 Billion

Í  United States deaths associated with falls (Wolinski et al) Í  1990 – 6601 persons Í  1999 – 10,000 persons Í  2002 – 12, 900 persons (Centers for Disease Control, 2003)


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FALLS RISK WITH ELDERLY Í  History of falls within the last 6 months single most predic;ve

factor for a future fall Í  Falls not due to age but due to age related changes predisposing

elderly to falls: Í  Decreased strength Í  Decreased somatosensory awareness Í  Decreased hearing

Í  Likelihood to falls Í  Age 65+, falls risk of 30% Í  Age 85+, falls risk of 42%-‐49% Í  Age 100+, falls risk of 83%


CRITICAL FALL TIME WITH ELDERLY Í  At night

Í  Due to decreased visual acuity when lights are low or turned off

Í  Due to increased urina;on (urine produc;on increased at end of day)

Í  A\er Meals (Postprandial Hypotension)(Vloet et al, Netea et al) Í  A decrease in systolic blood pressure of 20 mm Hg or more a\er meal inges;on

Í  Most common a\er breakfast (75% of pa;ents hypotensive) Í  Upon Standing Up

Í  Decrease in systolic blood pressure of 20 mm Hg or more a\er postural change

Í  Supine to sit Í  Sit to stand


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FALLS AND TURNING Dite et al, 2002, Thigpen et al, 2000

Í  Falling while turning is eight ;mes more likely to result in a hip fracture (due to landing on the hip) than falling while walking straight

Í  A slow and/or unsteady turn has been linked to a fall risk



Í  Studies based finding significant differences between fallers and non-‐fallers are based upon three characteris;cs: (can be assessed during the Timed Up and Go Test (TUG) Í  The number of steps taken to turn, Í  The ;me taken to turn, Í  The steadiness of the turn


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TURNING 180O WHILE WALKING

NON FALLERS

FALLERS

Turn Time

< 2 sec

> 4 sec

Turn Steps

1-3 steps

> 4 steps

Turn Performance

Steady fluent Non-hesitant

Unsteady NOT fluent Hesitant

Timed “Up and Go” Test

< 10 sec

> 10 sec


FALLS CLASSIFICATION Í  Three types of falls

Í Base of support perturba;ons: these are falls in which there is an unexpected devia;on of the base of support, where the instability is a result of the center of mass being outside the base of support.

Í  Examples include tripping, ataxic gait, difficulty with stairs. The center of mass is “fixed” over a displaced base of support.


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Í Center of mass perturba;ons: these are falls in which the center of mass, either via an external force (e.g. a “push”), or self-‐generated movement (e.g. bending), moves beyond the base of support.

Í  Examples include jostling, falling backwards when arising from a chair. The base of support is “fixed” under a displaced center of mass.



Í No obvious perturba;ons: These are falls of physiological origin.

Í  Examples include orthosta;c hypotension, fain;ng, TIA.


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CAUSES OF FALLS Factors contribu;ng to falls can be described as either: Í  Extrinsic Factors: these are the environmental variables that act

upon the individual to increase the risk for falls. Examples include ice and wet surfaces, poor ligh;ng, steps, obstacles, ramps OR

Í  Intrinsic Factors: the set of physiological variables that act upon the individual to increase the risk for falls. These include dysfunc;ons of the neurological, musculoskeletal, and cardiovascular systems, and side effects of pharmacological agents.

Í  Handout “Falls Risk Assessment Tool”


FALL PREVENTION Fall preven&on is best implemented by considering both the intrinsic

and extrinsic factors that interface with the individual. Í  For example, in considering a pa;ent who has stumbled and

fallen because of a throw rug, the therapist might adapt the environment by elimina;ng the rug, evaluate the ambient ligh;ng (extrinsic factors) and also assess foot clearances during gait, with careful evalua;on of the associated musculoskeletal structures, i.e. strength, tone, ROM, propriocep;on, etc., at the ankle, knee, and hip (intrinsic factors).


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FALL PREVENTION Í  Pa;ents taking more than 3-‐4 drugs are at increased risk for falls Í  Medica;on regimens can be adjusted to prevent seda;on,

confusion and postural hypotension Í  Medica;ons associated with risk of falls:

Í  Cor;co-‐steroids Í  Cardiac meds

Í Digoxin Í Diure;cs Í Type 1A an;-‐arrythmics Í Calcium channel blockers

Í  Psychotropic meds Í Seda;ve hypno;cs Í An;depressants Í Neurolep;cs Í Tranquilizers


CAUSES OF FALLS Balance rehabilita&on is primarily concerned with the intrinsic

factors. For example, the pa;ent who demonstrates decreased ability to correct a posterior sway might benefit from therapy with the goal of enhancing func;on of the ;bialis anterior. However, extrinsic factors can be addressed in any environment by preventa;ve measures



INDICATORS FOR THE BALANCE REHABILITATION

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INDICATORS FOR THE BALANCE REHAB Reasonable indica;ons for balance rehabilita;on Í  Specific interven;ons for BPPV

Í  Epleys or Canalith Reposi;oning Maneuver Í  Brandt’s exercises Í  BBQ Roll (horizontal canal BPPV)

Í  Persons with fluctua;ng ves;bular problems, not necessarily dizzy at ;me of therapy; The objec;ve here is to prepare the person for an;cipated dizziness rather than to make any permanent change in their present ves;bular situa;on. Í  Meniere’s disease Í  Perilympha;c fistula

Í  Psychogenic ver;go for desensi;za;on Í  Brandt’s exercises for phobic postural ver;go Í  Other situa;ons where there is irra;onal fear in situa;ons in which balance is challenged


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INDICATORS FOR THE BALANCE REHAB Reasonable indica;ons for balance rehabilita;on Í  Empiric treatment for situa;ons where diagnosis is unclear

Í  Post trauma;c ver;go Í  Mul;factoral disequilibrium of the elderly

Í  Postural habitua;on Í  Muscle strength atrophy or loss Í  Missing sequencing algorithms


POOR INDICATORS FOR THE BALANCE REHAB

Persons not likely to benefit from the program include persons without balance or ves;bular problems

Í  Low blood pressure Í  Medica;on reac;on Í  Migraine related ver;go Í  Transient ischemic aRack


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UNCLEAR INDICATORS FOR THE BALANCE REHAB

Some condi;ons where therapy may provide some benefit Í  Mal de debarquement (MDD) Í  Cerebellar degenera;ons Í  Basal ganglia syndromes like Parkinsons Í  Idiopathic mo;on intolerance


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BALANCE STRATEGIES

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BALANCE STRATEGIES Í  Adults center of gravity is located 2 cm anterior to the vertebral

column at the S-‐2 level (Braune & Fischer 1984)or approximately 55% of a person’s height (Hellebrandt et al 1938)

Í  The goal in postural control is to maintain ones center of mass within the base of support.

Í  Pre-‐programmed movement strategies are at work to decrease the degrees of freedom within the limits of stability.

Í  These movement strategies are employed automa;cally in response to a s;mulus (feedback control), or voli;onally based on prior experience with current environmental condi;ons (feed-‐forward control).

Í  In the above example, one might normally correct a posterior sway via ac;va;on of the foot dorsiflexors. A response of this sort is referred to as a movement strategy.


BALANCE STRATEGIES Defini;on: A movement strategy can be defined as the manner by which the

individual ac;vely recovers postural stability from a state of instability.

For ambulatory individuals, there are three (3) primary movement strategies: Í  Ankle, Í  Hip Í  Stepping


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BALANCE STRATEGIES Ankle movement strategy described as: Í  Most commonly used strategy Í  A fine-‐motor response of the intrinsic and extrinsic muscles of the

foot and about the ankle, whereby the mechanical advantage (leverage) at the foot/ankle brings about large but controlled devia;ons of the center of mass via small amplitude movements.

Í  When implemented: when highly controlled movements are required (e.g.walking along a narrow ledge).

Í  Ineffec;ve when: standing on a non-‐firm surface (e.g. sand) or surface does not accommodate en;re foot (e.g. on the rung of a ladder).


BALANCE STRATEGIES Ankle movement strategy Í  Used for slow, small amount of sway when standing on firm, long

surfaces. Í  Results in shi\ing of the center of mass A/P by primarily rota;ng

the body about the ankle joints. Í  The muscle spindles are ac;vated in a distal to proximal sequence

to generate ankle muscle contrac;on Í  Older adults fall backwards due to:

Í  Limits of stability are less in the posterior direc;on Í  Visual cue absent due to the anterior placement of eyes Í  Tibialis Anterior selec;vely weaker than other LE muscles


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BALANCE STRATEGY ANKLE

LEANING BACK Í  To ini;ate movement

Í  Triceps Surae (concentric)

Í  To control backward lean Í  Tibialis Anterior (eccentric)

Í  To prevent falling backward Í  Tibialis Anterior (concentric)

LEANING FORWARD Í  To ini;ate movement

Í  Tibialis Anterior (concentric)

Í  To control forward lean Í  Triceps Surae (eccentric)

Í  To prevent falling forward Í  Triceps Surae (concentric)


BALANCE STRATEGIES Hip movement strategy described as Í  A fine and/or gross motor response in which large hip and/

or trunk movements result(s) in rapid accelera;ons of the center of mass.

Í  Implemented when upper body is displaced outside of base of support.

Í  Ineffec;ve when ves;bular system is impaired. Used on low-‐fric;on surfaces (e.g. ice) since hip and trunk movements generate greater shear forces between foot and surface.


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BALANCE STRATEGIES HIP

Usually used if balance perturba;on is greater than what the ankle strategy can handle

Used if base of support is small and cannot be changed


BALANCE STRATEGIES Stepping movement strategy described as: Í  A gross motor response in which one or more steps are

taken so as to re-‐contain the center of mass within the base of support.

Í  Implemented when center of mass is displaced beyond mechanical limits of stability.

Í  Ineffec;ve when weight-‐bearing is restricted or when on irregular or unstable surfaces or if the sensorimotor system is impaired.


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BALANCE STRATEGIES STEPPING

Older adults tend to step laterally to recover balance when balance is challenged in the anterior-‐posterior direc;on


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BALANCE ASSESSMENT

91 © Copyright K2 Seminars 92

BALANCE ASSESSMENT Í  Clinical History and Physical Exam

Í  Range of Mo;on (note devia;ons from normal at hip, knee and ankle)

Í Muscle Strength (MMT, handheld dynamometer of hip, knee and ankle)

Í Muscle Tone (note devia;ons from normal in trunk and LE's)

Í  Sensa;on (tac;le/propriocep;on in LE's) Í  Coordina;on (check the following if present and give loca;on) Í Ataxia Í Tremor Í Dysmetria Í Other: shoe assessment


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BALANCE ASSESSMENT Í  Postural control during func;onal ac;vi;es

Í  Tinep Balance and Gait Assessment Í  Berg Balance Scale Í Mul;direc;onal reach test vs func;onal reach test Í Modified Timed Up and Go Test (mTUG) Í  Chair stand test Í  Arm curl test Í  Back scratch test Í  Sit and reach test Í Modified clinical test of sensory integra;on of balance (mCTSIB)

Í  6 minute walk test Í  Pull test

See above tests in handout


BALANCE EVALUATION -‐ TINETTI Í  Time to complete: 10 to 15 minutes Í  Time to score included in the ;me to complete Í  Scoring: Scoring of the Tinep Assessment Tool is done on a

three point ordinal scale with a range of 1 to 2. A score of 0 represents the most impairment while a 2 would represent independence of the pa;ent. The individual scores are then combined to form three measures; an overall gait assessment score, an overall balance assessment score and a gait and balance score

Í  Interpreta;on: The maximum score for the gait component is 12 points. The maximum score for the balance component is 16 points. The maximum total score is 28 points. In general, pa;ents who score below 19 are at a high risk for falls. Pa;ents who score in the range of 19-‐24 indicate that the pa;ent has a risk for falls


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BALANCE EVALUATION -‐ Tinep Í  Interrater reliability was measure in a study of 15 pa;ents by

having a physician and a nurse test the pa;ents at the same ;me. Agreement was found on over 85% of the items and the items that differed never did so by more than 10%. These results indicate that the Tinep Assessment Tool has a good interrater reliability


BALANCE ASSESSMENT Func;onal Reach Test

Í  The Func;onal Reach test is another simple tool for assessing dynamic standing balance during a func;onal task. A yards;ck is mounted on a wall at shoulder (acromion) height of the person being tested. The person stands next to the wall, with feet about shoulder width apart. The person makes a fist, then extends the arm closest to the wall forward in a plane parallel to the yards;ck. Note the posi;on of the third metacarpal rela;ve to the yards;ck


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BALANCE ASSESSMENT Func;onal Reach Test

Í  The number in the line with the person’s third metacarpal is the star;ng point.

Í  The therapist instructs the pa;ent to “Keep your arm parallel to the yards;ck and reach forward as far as you can without taking a step.”

Í  Note the ending posi;on of the person’s third metacarpal rela;ve to the yards;ck. The number in line with the third metacarpal is the ending point

Í  A func;onal reach greater than 10 inches is ‘normal’; less than 10 inches is atypical; 6-‐10 inches the person is two ;mes likely to fall; less than 6 inches, the person is four ;mes likely to fall (Duncan, P. Personal Communica;on, April, 1998)


BALANCE ASSESSMENT Mul;-‐Direc;onal Reach Test

•  This test allows for analysis of the pa;ent’s voluntary postural control. It is used to evaluate how far pa;ents are able and/or willing to lean away from a stable base of support in mul;ple direc;ons.

•  Equipment/set-‐up : Yards;ck •  Star;ng Posi;on: Posi;on a yards;ck at the level of the

pa;ent’s acromion process. This may be achieved by affixing the yards;ck to the wall. Placing the yards;ck on a rolling IV pole with height adjustable clamp or a rolling mirror with Velcro is also an op;on that may facilitate test administra;on. Par;cipant stands with feet shoulder width apart and arm raised to 90 degrees(parallel to floor, palm facing medially).

98 © Copyright K2 Seminars


•  Protocol : The pa;ent is instructed to reach as far forward as possible without lepng their feet raise off the floor or their hand touch the yards;ck. Loca;on of the middle finger (in inches) is recorded. Trial distance (in inches) is obtained by subtrac;ng the end number from the star;ng posi;on number. Perform one (1) prac;ce trial to ensure pa;ent understanding of instruc;ons followed by 1 trial that is recorded. Repeat similar protocol for reach backwards, le\ and right.


•  NOTE: True standardized test involves performance of one (1) prac&ce aRempt and three (3) trials. The mean of the three trials is recorded as the “distance reached” and the movement strategy that the par&cipant used for each aRempt is noted. Can perform only one prac&ce and one trial due to &me constraints and pa&ent fa&guability.

Mul;-‐Direc;onal Reach Test (MDRT) •  ·∙ Forward Reach: •  ·∙ Backward Reach: •  ·∙ Lateral Reach Right: •  ·∙ Lateral Reach Le\:



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Í  Modified TUG measures the ;me it takes a subject to stand up from an armchair, walk a distance of 10 feet, turn, walk back to the chair and sit down.

Í  Intratester and intertester reliability found to high in the elderly

Í  For iden;fying people who fall, the TUG was found to have a sensi;vity and specificity of 87%


BALANCE ASSESSMENT Timed Up and Go Test

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Í  Tasks: Pa;ent is asked to sit comfortably in a chair Pa;ent is then asked to rise Pa;ent is asked to stand s;ll Pa;ent is asked to walk towards a wall Before they reach the wall, the pa;ent is

asked to turn without touching the wall and return to the chair

Pa;ent is asked to turn around and sit down



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MOBILITY TASK

TIME

FALLERS

SIT TO STAND

_______ sec

> 4 sec

10 FOOT WALK

_______ sec

> 6 sec

TURN

_______ steps

> 4 steps

10 FOOT WALK

_______ sec

> 6 sec

STAND TO SIT

_______ sec

7 sec

TUG SCORE

_______ sec

> 10 sec



BALANCE ASSESSMENT Chair Stand Test


Chair Stand Test (Number of Stands) Sex Age 60-64 65-69 7074 75-79 80-84 85-89 90-94

of Scores for Men 14-19 12-18 12-17 11-17 10-15 8-14 7-12

of Scores for Women 12-17 11-16 10-15 10-15 9-14 8-13 4-11

Normal range of scores is defined as the middle 50% of each age group. Scores above the range would be considered “above average” for the age group and those below the range would be “below average”. (Rikli R, Jones CJ. Senior Fitness Test Manual. : Human Kinetics. 2001)

BALANCE ASSESSMENT Arm Curl Test


Arm Curl Test (Number of Curls) Sex Age 60-64 65-69 7074 75-79 80-84 85-89 90-94

of Scores for Men 16-22 15-21 14-21 13-19 13-19 11-17 10-14

of Scores for Women 13-19 12-18 12-17 11-17 10-16 10-15 8-13

*Normal range of scores is defined as the middle 50 percent of each age group. Scores above the range would be considered “above average” for the age group and those below the range would be “below average.” Rikli RE, Jones CJ. Senior Fitness Test Manual. Champaign, IL: Human Kinetics. 2001. U/E (Arm Curl Test): • Arm used: __ Left __ Right • Weight: 5lbs (Female): __ 8lbs (Male): __ • Number of repetitions completed in 30 seconds: ___

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BALANCE ASSESSMENT Clinical Test of Sensory Interac;on & Balance (CTSIB)

MODIFIED CTSIB BALANCE SCREEN

Proceed to next condition when one

30-second trial is completed

Condition 1: Eyes open, firm surface

sec

Pass

Fail

Condition 2: Eyes closed, firm surface

sec

Pass

Fail

Condition 3: Eyes open, foam surface

sec

Pass

Fail

Condition 4: Eyes closed, foam surface

sec

Pass

Fail

TOTAL SCORE: ______

120 sec


DIZZINESS EVALUATION

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DIZZINESS EVALUATION Í  Dizziness evalua;on

Í  Descrip;on of the spell Í Hallmark of peripheral dizziness is the definite sensa;on of rela;ve mo;on with the visual world, namely ver;go

Í Sensa;on is usually described by pa;ents as a "spinning" or "whirling" feeling or the no;on that they or their surroundings are moving in a circular fashion

Í Peripheral labyrinthine disorders, the descrip;on is brief and very focused on ver;go.

Í Acute central nervous system (CNS) dysfunc;on may or may not have sensa;ons of ver;go, whereas chronic CNS, cerebrovascular, cardiovascular, and metabolic causes of dizziness seldom produce true sensa;ons of rela;ve mo;on



Diagnostic flowchart of vertigo for physical therapists. Source: Vestibular rehabilitation by Susan J Herdman, 3rd ed Philadelphia, FA Davies 2007:230 (OTR: Ocular tilt reaction; SVV: Subjective visual vertical; Rx: Treatment)

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Í  Symptoms accompanying peripheral disease Í Pa;ents with peripheral ver;go have dis;nc;ve features of onset, dura;on, and accompanying symptoms in rela;on to their dizziness.

Í Peripheral ver;go comes in spells and usually lasts seconds (benign posi;onal ver;go), minutes (Ménière's disease), or hours (ves;bular neuri;s).

Í Hearing loss, ;nnitus, and aural fullness are frequent symptoms of peripheral disease.

Í Posi;on changes exacerbate the dizziness, and lying s;ll lessens the symptoms. Benign posi;onal ver;go, for instance, is highly suspected in cases of brief ver;go brought on by a simple posi;on change such as rolling over in bed. In most aRacks, the onset is sudden although the offset is less well defined. For the most part, pa;ents feel fine between spells. © Copyright K2 Seminars

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Í  Symptoms accompanying central nervous disease Í Unlike peripheral ver;go, central causes of dizziness produce a more variable picture. The sensa;on may be described in a variety of ways: spinning, ;l;ng, pushed to one side, lightheadedness, clumsiness, or even blacking out.

Í  If documented loss of consciousness is present, a peripheral e;ology of the dizziness is rarely if ever at fault.

Í Also helpful for localiza;on is the presence of accompanying signs of neural dysfunc;on, that is, dysarthria, dysphagia, diplopia, hemiparesis, severe localized cephalgia, seizures, and memory loss.

Í  The ;me course of symptoms is more variable from minutes to hours, and the effect of movement or posi;on change is less predictable.

Í  These symptoms lead the clinician to suspect brain stem or cor;cal rather than labyrinthine sources.



Í  Accompanying auditory complaints Í The single most useful localizing symptom in a dizzy pa;ent is a unilateral otologic complaint: aural fullness, ;nnitus, hearing loss, or distor;on.

Í By carefully evalua;ng these complaints, the clinician frequently can localize both the side and the site of the lesion before any examina;on or tes;ng is done.

Í Frequent causes of unilateral auditory disease with dizziness include endolympha;c hydrops, perilympha;c fistula, labyrinthi;s, ves;bular neuri;s (slight high-‐pitched loss with ;nnitus), and autoimmune inner ear disease.


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Í  General physical and emo;onal health Í Many medical condi;ons and emo;onal factors can create a sense of dizziness and imbalance.

Í Hypertension, hypotension, atherosclero;c disease, endocrine imbalances, and anxiety states are common causes of lightheadedness, near syncope, and/or instability but rarely produce a sense of true ver;go.

Í  In addi;on, medica;on side effects and excessive caffeine, nico;ne, and alcohol intake should be inves;gated as a source of dizziness.

Í  Ideally, these condi;ons have already been addressed by the pa;ent's primary care physician before a referral for formal evalua;on by a neurotologist or neurologist.



Í  Physical examina;on: A\er the history is complete, the clinician performs the rou;ne full head and neck examina;on. This is important for two reasons:

Í Dizzy pa;ents frequently have other ear, nose, and throat pathology and

Í  Structural problems of the ear, nose, and throat at ;mes cause dizziness or indicate a more widespread process.

Í  Common findings on the rou;ne examina;on related to dizziness include cerumen impac;on, o;;s media with effusion, chronic o;;s with otorrhea, chronic sinusi;s with nasal airway obstruc;on, and oropharyngeal findings consistent with sleep apnea.

Í  Congenital deformi;es of the pinna, external auditory canal, and face raise the ques;on of labyrinthine involvement.


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Í  At the conclusion of the regular examina;on, the specialized examina;on for dizziness is performed:

Í  Spontaneous nystagmus Í Gaze nystagmus Í  Smooth pursuit Í  Saccades Í  Fixa;on suppression Í Head thrust Í Headshake Í Dynamic visual acuity Í Hallpike posi;oning Í  Sta;c posi;onal Í  Limb coordina;on Í Romberg stance Í Gait observa;on Í  Specialized tests


DIZZINESS EVALUATION Í  Spontaneous Nystagmus

Í  Ac;on. Ask the pa;ent to fixate on a sta;onary target in neutral gaze posi;on with best corrected vision (glasses or contact lenses in place). Observe for nystagmus or rhythmic refixa;on eye movements. Repeat under Fresnel lenses to observe effect of target fixa;on.

Í  Interpreta;on. If nystagmus is observed, par;cular aRen;on is paid to the amplitude, direc;on, and effect of target fixa;on. Lesions of the labyrinth and nerve VIII produce intense, direc;on-‐fixed horizontal-‐rotary nystagmus that is enhanced under Fresnel lenses. The nystagmus also intensifies when gazing in the direc;on of the fast phase (Alexander's law). This paRern can be seen in both irrita;ve (bea;ng toward the affected ear) and destruc;ve (bea;ng toward the unaffected ear) lesions of the labyrinth, nerve VIII, or (rarely) the ves;bular nuclei. In contrast, lesions of the brain stem, cerebellum, and cerebrum cause less intense, direc;on-‐changing horizontal, ver;cal, torsional, or pendular nystagmus that is diminished under Fresnel lenses. Examples include periodic alterna;ng nystagmus (PAN), congenital nystagmus, and lesions of the midline cerebellum.


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DIZZINESS EVALUATION Í  Gaze Nystagmus

Í Ac;on. Ask the pa;ent to gaze at a target placed 20 to 30 degrees to the le\ and right of center for 20 seconds. Observe for gaze-‐evoked nystagmus or change in direc;on, form, or intensity in spontaneous nystagmus.

Í  Interpreta;on. The ability to maintain eccentric gaze is under control of the brain stem and midline cerebellum, par;cularly the ves;bulocerebellum (especially the flocculonodular lobes). When these mechanisms fail to hold the eye in the eccentric posi;on, the eye dri\s toward the midline (exponen;ally decreasing velocity), followed by refixa;on saccades toward the target. Such gaze-‐evoked nystagmus is central in origin and always beats in the direc;on of intended gaze. In contrast, enhancement of peripheral spontaneous nystagmus (linear slow component velocity) occurs without direc;on change when gazing in the direc;on of the fast phase. Causes of gaze-‐evoked nystagmus include a drug effect (seda;ves, an;epilep;cs), alcohol, CNS tumors, and cerebellar degenera;ve syndromes.


DIZZINESS EVALUATION Í  Smooth Pursuit

Í Ac;on. Ask the pa;ent to follow your finger as you slowly move it le\ and right, up and down. Make sure the pa;ent can see the target clearly and you do not exceed 60 degrees in total arc or 40 degrees per second.

Í Interpreta;on. Normal eye tracking of a slowly moving discrete object generates a smooth eye movement that the examiner can easily see. Cerebellar or brain stem disease can cause saccadic eye tracking in which the pa;ent repeatedly loses the target and then catches up with a small saccade. In most cases, abnormal pursuit is nonlocalizing within the CNS, although ipsilateral loss of pursuit can be ascribed to parietal lobe lesions. The examiner must make sure the pa;ent can see the target and is aRen;ve to the task.


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DIZZINESS EVALUATION Í  Saccades

Í Ac;on. Ask the pa;ent to look back and forth between two outstretched fingers held about 12 inches apart in the horizontal and ver;cal plane. Observe for latency of onset, speed, accuracy, and conjugate movement.

Í  Interpreta;on. Saccadic eye movements are refixa;on movements that involve the frontal lobes (voluntary saccades), brain stem re;cular forma;on (voluntary and involuntary saccades), and oculomotor nuclei III, IV, and VI. Delayed saccades are seen in cor;cal and brain stem lesions, and slow saccades accompany brain stem disease. Inaccurate saccades (especially overshoots) are associated with lesions of the cerebellar vermis and fas;gial nuclei. Finally, disconjugate eye movements with slowing of the adduc;ng eye and overshoots of the abduc;ng eye imply medial longitudinal fasciculus pathology frequently associated with mul;ple sclerosis.


DIZZINESS EVALUATION Í  Fixa;on Suppression Test

Í Ac;on. Ask the pa;ent to fixate on his or her own index finger held out in front at arm's length. Unlock the examina;on chair and rotate the pa;ent up to 2 Hz while the pa;ent stares at the finger moving with them. The examiner observes for a decrease in the visual-‐ves;bular nystagmus that is evoked during rota;on without ocular fixa;on.

Í  Interpreta;on. The modula;on of nystagmus invoked by rota;on is a CNS phenomenon heavily dependent on the cerebellar flocculus. Failure of fixa;on suppression in the presence of adequate visual acuity implies floccular dysfunc;on. This test is similar in nature to the fixa;on suppression performed a\er caloric s;mula;on during electro-‐oculography.


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DIZZINESS EVALUATION Í  Head Thrust Test (Head Impulse Test)

Í Ac;on. Ask the pa;ent to fixate on a target on the wall in front of the pa;ent while the examiner moves the pa;ent's head rapidly (>2000 deg/sec2) to each side. The examiner looks for any movement of the pupil during the head thrust and a refixa;on saccade back to the target. Either direct observa;on of pupillary movement or the use of an ophthalmoscope is employed to document eye movement.

Í  Interpreta;on. Introduced by Halmagyi and Curthoys[5] in 1988, the head impulse test was described as a reliable sign of reduced ves;bular func;on in the plane of rota;on for the ear ipsilateral to the head thrust. The observa;on of eye movement during the maneuver is a sign of decreased neural input from the ipsilateral ear to the ves;bulo-‐ocular reflex (VOR) because the contralateral ear is in inhibitory "satura;on" and cannot supply enough neural ac;vity to stabilize gaze. In such instances, the eye travels with the head during the high-‐velocity movement, and a refixa;on saccade is necessary to refoveate the target. Bilateral refixa;on movements are seen frequently in cases of ototoxicity.


DIZZINESS EVALUATION Í  Postheadshake Nystagmus

Í Ac;on. Tilt the head of the pa;ent forward 30 degrees and shake the head in the horizontal plane at 2 Hz for 20 seconds. Observe for postheadshake nystagmus and note direc;on and any reversal. Fresnel lenses are preferred to avoid fixa;on. The maneuver may be repeated in the ver;cal direc;on.

Í  Interpreta;on. Postheadshake nystagmus is considered a pathologic sign of imbalance in the ves;bular inputs in the plane of rota;on.[6] In most instances, a peripheral cause is iden;fied with the nystagmus directed toward the stronger ear. A small reversal phase is some;mes observed. Signs of central e;ology include prolonged nystagmus, ver;cal nystagmus following horizontal headshake ("cross coupling"), and disconjugate nystagmus.


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DIZZINESS EVALUATION Í  Dynamic Visual Acuity

Í Ac;on. Ask the pa;ent to read the lowest (smallest) line possible on a Snellen eye chart with best corrected vision (glasses, contact lenses). Repeat the maneuver while passively shaking the pa;ent's head at 2 Hz, and record the number of lines of acuity "lost" during the headshake.

Í  Interpreta;on. Excessive re;nal slippage during head movement is a sign of ves;bular dysfunc;on. In the clinical examina;on, the most frequent e;ology is bilateral ves;bular loss related to ototoxicity or aging. Poorly compensated unilateral dysfunc;on can also cause loss of dynamic visual acuity but is harder to iden;fy with this clinical test. It is important that the examiner shake the pa;ent's head to avoid pauses during which the pa;ent can see the target.


DIZZINESS EVALUATION Í  Dix-‐Hallpike Maneuver

Í Ac;on. With the examina;on chair unfolded like a bed, turn the pa;ent's head 45 degrees to one side while seated and rapidly but carefully have the pa;ent recline. Observe the eyes for nystagmus and, if present, note the following five characteris;cs: latency, direc;on, fa;gue (decrease on repeated maneuvers), habitua;on (dura;on), and reversal upon sipng up.

Í  Interpreta;on. A posi;ve maneuver is diagnos;c for benign posi;on ver;go, which is thought to be due to otoconial debris either floa;ng (canalithiasis) or fixed (cupulolithiasis) within the posterior semicircular canal of the undermost ear. Characteris;cs of classical posi;oning nystagmus include geotropic torsional direc;on, brief latency (5 to 20 seconds), decline with repeated posi;oning, 30 seconds or less dura;on, and reversal upon arising. Atypical posi;oning nystagmus may imply either peripheral or central disease.


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DIZZINESS EVALUATION Í  Posi;onal Tests

Í Ac;on. Ask the pa;ent to lie s;ll in three posi;ons -‐-‐ supine, le\ lateral, and right lateral -‐-‐ for 30 seconds and observe for nystagmus. Use of Fresnel lenses is recommended.

Í Interpreta;on. The presence of a sta;c posi;onal nystagmus is nonlocalizing by itself and must be interpreted in the light of other physical findings. In general, however, ver;cal posi;onal nystagmus is central in origin, implying cranial-‐cervical or fourth ventricle origin.


DIZZINESS EVALUATION Í  Limb Coordina;on Tests

Í Ac;on. Ask the pa;ent to perform a series of coordina;on tasks such as finger-‐nose-‐finger, heel-‐shin, rapid alterna;ng mo;on, and fine finger mo;on (coun;ng on all digits). Observe for dysmetria or dysrhythmia.

Í Interpreta;on. The presence of limb dysmetria or dysdiadochokinesia is a useful indicator of cerebellar cor;cal disease, which may or may not accompany midline or ves;bulocerebellar oculomotor dysfunc;on.


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DIZZINESS EVALUATION Í  Romberg Test

Í Ac;on. Have the pa;ent stand with feet close together and arms at the side with eyes open and then eyes closed. Observe for the rela;ve amount of sway with vision present versus absent.

Í  Interpreta;on. The Romberg stance is primarily a test of somatosensa;on and propriocep;on and not of ves;bular input. Pa;ents with compensated bilateral ves;bular loss stand normally in both eyes-‐open and eyes-‐closed Romberg posi;on because of adequate propriocep;on from the stable support surface. There are two ways, however, to make this test more sensi;ve to ves;bular deficits -‐-‐ tandem stance and 3-‐inch foam. In the tandem stance, the support surface cues are sufficiently altered that ves;bular cues play a greater role in maintaining upright posture. Similarly, when the pa;ent stands on a compliant support surface such as 3-‐inch foam, somatosensory cues are muted and ves;bular cues become more important.


DIZZINESS EVALUATION Í  Gait Observa;on

Í Ac;on. Ask the pa;ent to walk 50 feet in the hall, turn rapidly, and walk back without touching the walls. Observe for ini;a;on of movement, stride length, arm swing, missteps and veering, and signs of muscle weakness or skeletal abnormality (kyphoscoliosis, limb asymmetry, limp).

Í  Interpreta;on. There is no such thing as a "ves;bular gait." If a pa;ent suffers an acute unilateral loss of otolithic func;on, the pa;ent will tend to veer toward the side of the lesion. However, a variety of central brain stem and musculoskeletal lesions also produce lateral devia;on during ambula;on. Difficul;es with gait ini;a;on and turns and decreased arm swing can be seen in extrapyramidal disease. Gait ataxia implies cerebellar dysfunc;on and is dis;nctly different from gait devia;on associated with uncompensated peripheral ves;bular disease. Finally, exaggerated hip sway, rhythmic devia;ons, and an excessive reliance on touching the wall during walking may cons;tute signs of a func;onal gait disorder.


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DIZZINESS EVALUATION Í  Tragal Compression, Pneuma;c Otoscopy, Tullio Phenomenon, Valsalva With Pinched Nostrils And Closed Glops Í Ac;on. With Fresnel lenses in place, observe for nystagmus or tonic eye devia;ons with symptoms of dizziness under four test condi;ons: (1) steady tragal compression to increase pressure in the external auditory canal, (2) posi;ve and nega;ve pressure applied with the pneuma;c otoscope, (3) presenta;on of loud tones via tuning fork or impedance bridge, and (4) increased pressure during breath holding against pinched nostrils or closed glops.


DIZZINESS EVALUATION Í  Tragal Compression, Pneuma;c Otoscopy, Tullio Phenomenon, Valsalva

With Pinched Nostrils And Closed Glops Í  Interpreta;on. Consistent eye devia;ons or nystagmus during any of the preceding maneuvers implies abnormal coupling between either the outside atmosphere or the intracranial space and the inner ear. This can occur with abnormal connec;ons between the labyrinth and the middle ear or middle fossa at the following sights: oval window (fistula, excessive footplate movement), round window (fistula), lateral semicircular canal (fistula), and superior semicircular canal (dehiscence). In par;cular, eye eleva;on and intorsion with loud sounds or Valsalva maneuver against pinched nostrils is sugges;ve of superior canal dehiscence syndrome and has been described by Minor.[7] In addi;on, cranial-‐cervical junc;on abnormali;es (Arnold-‐Chiari malforma;on in par;cular) produce ver;cal downbeat nystagmus with any maneuver that increases intracranial pressure.


131

DIZZINESS EVALUATION Fukuta Step Test

Í  Ac;on. Ask the pa;ent to march in place with arms extended and eyes closed for 1 minute. Note the degree of lateral rota;on at the end of the maneuver.

Í  Interpreta;on. Most normal subjects deviate less than 45 degrees in rota;on to one side during the step test, whereas some pa;ents with uncompensated unilateral dysfunc;on deviate more than 45 degrees toward the affected side. This finding alone, however, is not conclusive for otolith dysfunc;on.


DIZZINESS EVALUATION Hyperven;la;on

Í  Ac;on. Ask the pa;ent to take 20 deep breaths in and out in rapid succession, observe for nystagmus under Fresnel lenses, and record symptoms.

Í  Interpreta;on. Hyperven;la;on has two effects: (1) cerebrovascular vasoconstric;on and (2) eleva;on of blood pH. Vasoconstric;on causes lightheadedness and ;ngling of the hands and lips and may reproduce the symptoms of pa;ents with hyperven;la;on syndrome or anxiety. More specifically, irrita;ve nystagmus (toward the affected ear) secondary to elevated pH and increased eighth nerve firing is seen in lesions that affect the ves;bular nerve such as petrous apex lesions, acous;c schwannoma, and eighth nerve demyelina;on.


133

DIZZINESS EVALUATION Mastoid Oscilla;on

Í  Ac;on. Place a vibra;ng source on the mastoid ;p and observe for nystagmus under Fresnel lenses. Note direc;on and waveform and effect of target fixa;on with removal of lenses.

Í  Interpreta;on. Mastoid oscilla;on acts as an excitatory s;mulus to both labyrinths and, in some cases of asymmetry, produces a horizontal-‐rotatory nystagmus toward the stronger ear. In a sense, this nystagmus is similar in origin to that produced by the headshake maneuver.


DIZZINESS EVALUATION Í  A thorough history and structured oculomotor and posture-‐gait examina;on is crucial in the work-‐up of pa;ents with dizziness and imbalance.

Í  Laboratory tests for dizziness primarily play a confirmatory role following a complete history and examina;on of these pa;ents.



VESTIBULAR EVALUATION

136

VESTIBULAR EVALUATION Í  The following evalua;on requires the resident to perform a variety of movements, progressing from minimal to maximal movement. These movements will induce specific symptoms related to ves;bular dysfunc;on (dizziness, ver;go, nausea, nystagmus). This allows the therapist to gather specific informa;on regarding: Í the severity of symptoms (to establish a baseline) Í tasks which induce symptoms and places the resident at a higher risk of falls

Í specific movements which must be incorporated into therapy in order to promote habitua;on


137

VESTIBULAR EVALUATION Í  Intensity of symptoms are scored 0 to 10 using the Modified Borg Ra;ng Scale: 0 =no symptoms 0.5 =very, very weak (just no;ceable) 1 =very weak 2 =weak 3 =moderate 4 =somewhat strong 5 =strong 6 7 =very strong 8 9 10 =maximal


VESTIBULAR EVALUATION

Í  Perform the following movements and note response according to: Í Intensity:numerical value using Borg Ra;ng Scale Í Dura;on:how long it takes to return to baseline number Í Dizziness:present/not present Í Nystagmus:present/not present

Í  The resident may experience such an intense onset of symptoms that it may be necessary to complete the tes;ng over several treatment sessions.


139

VESTIBULAR EVALUATION Ves;bular evalua;on to include the following: Í  Pa;ent name and age Í  Diagnosis Í  Past medical history Í  Present medical history Í  Subjec;ve/social Í  Medica;ons Í  Observa;on Í  Gait Í  Strength Í  Sensa;on Í  Range of mo;on all per;nent joints Í  Coordina;on Í  Deep tendon reflexes Í  Postural signs – blood pressure in supine, sit and standing


VESTIBULAR EVALUATION Í  Balance

Í Sipng sta;c/dynamic Í Standing sta;c/dynamic Í Romberg (x 60 seconds) sway Í Tandem walk, eyes open (10 steps x 3 sets) Í Tandem walk, eyes closed (10steps x 3 sets) Í Standing, one leg, eyes open (x 30 seconds) Í Standing, one leg, eyes closed (X 30 seconds) Í Ankle hip strategy Í Stepping strategy


141

VESTIBULAR EVALUATION Protec;ve extension/head righ;ng reac;ons Í  Eye movement – test for nystagmus Í  Saccades – REM from one object to another, head s;ll Í  Smooth pursuit – follow moving target, head s;ll Í  VOR – move pa;ent’s head while pa;ent fixates on target Í Quick head nod (x 10 reps) Í  CTSIB (sensory organiza;on) (see CTSIB eval form) Í  Posi;onal tests (BPPV)


VESTIBULAR EVALUATION Ves;bular Ocular Reflex (VOR) Í  For most peripheral labyrinthine or ‘central’ neurologic disease, the eyes are the windows to the ves;bular system

Í  Inspec;on of the eyes can provide considerable informa;on to assist in preliminary diagnosis

Í  Two categories of eye movement Í Reflexive eye movements generated by s;mula;on of the peripheral ves;bular apparatus

Í Voluntary eye movement generated in the cerebellum


143

VESTIBULAR EVALUATION Ves;bular Ocular Reflex (VOR) Í  Defined as reflexive eye movement in response to head movement Í  Role of VOR is to allow for stable gaze or focus while head is moving Í  If performs this func;on by causing eye movements that are equal and

opposite of head movements, ie visually canceling out head movement Í  Visual acuity degrades when the visual scene moves past the re;na at

speeds greater than 3o to 5o per second (Leigh & Zee) Í  DO the test Í  Hold this page about 18 inches in front of you and move your head to

and fro at maximum speed that s;ll allows for clarity and easy reading Í  Now with your head sta;onary, move page back and forth at the speed

at which you move your head. No;ce the degrada;on of the visual acuity. Why….


VESTIBULAR EVALUATION Ves;bular Ocular Reflex (VOR) Í  It is impossible to voluntarily move the eyes at speeds needed to maintain visual acuity during typical head movements

Í  The latency of response for the VOR is less than 16msec while latency for a voluntary eye movement is 70msec (Leigh & Zee)

Í  Pa;ents with chronic VOR deficit do not typically complain of ver;go, but rather complain of mo;on-‐provoked dysequilibrium or disorienta;on as head movement results in blurring of their visual environment


145

VESTIBULAR EVALUATION Ves;bular Ocular Reflex (VOR) Í  Sta;c evaula;on

Í Spontaneous or gaze nystagmus Í  Dynamic evalua;on

Í Head thrust Í Dynamic visual acuity


146

GAIT ASSESSMENT

147

% OF GAIT

CYCLE

DOUBLE LEG STANCE

10%

SINGLE LEG STANCE

40%

DOUBLE LEG STANCE

10%

GAIT ASSESSMENT STANCE PHASE OF WALKING


GAIT ASSESSMENT SWING PHASE OF WALKING

Í  Swing phase applies to the ;me when the foot is in the air for limb advancement

Í  Swing begins as soon as the toe is li\ed from the floor (toe off) and end with ini;al contact of the foot (heel strike)


149

GAIT ASSESSMENT GAIT CYCLE

Í  Stride length measures the ini;al and second contact of the same foot Í  Step length is the interval between ini;al contact of each foot Í  Step length of the le\ and right leg make up one stride length


GAIT ASSESSMENT NORMS

•  Bohannon RW et al. Comfortable and maximum walking speed of adults aged 20-‐79 years: Reference values and determinants. Age Aging 1997; 26:15-‐19

•  Lusardi MM et al. Comfortable and fast gait speeds of the frail community-‐living older adults. CSM paper 2002


AGE (YEARS) MALE FEMALE 20S 3.57 3.47 30S 4.17 3.81 40S 3.72 3.53 50S 3.07 3.59 60S 3.11 2.85 70S 3.08 2.79

151

GAIT ASSESSMENT STANCE PHASE OF WALKING

% OF GAIT

CYCLE

DOUBLE LEG STANCE

10%

SINGLE LEG STANCE

40%

DOUBLE LEG STANCE

10%

NORMAL

20%

20%

20%

FALLER


GAIT ASSESSMENT GAIT CYCLE

NORMAL AGED GAIT PATTERN Í  Reduced stride length Í  Even right & le\ length Í  Decreased gait speed

FALLER’S GAIT PATTERN Í  Reduced stride length Í  Increased step width Í  Uneven right & left length Í  Decreased gait speed


153

GAIT ASSESSMENT CHARACTERISTICS OF FALLERS

Í  Usually stop walking when talking (spinal loop algorithm missing – motor cortex takes over)

Í  Fear of falling resul;ng in shorter singe leg stance and decreased stride length reducing forward momentum allowing more ;me for balance recovery

Í  Increased step width Í  Stride to stride variability


GAIT ASSESSMENT STAIRS

Í  Ascent Í Requires greater stability with longer double limb support phase and shorter single limb support phase

Í Concentric contrac;on of the Quads and Triceps Surae Í  Descent

Í More dynamic and challenging movement Í Requires more balance Í Eccentric contrac;on of the Quads and Triceps Surae


155

GAIT ASSESSMENT WALKING WHILE TALKING FALLS RISK

Walk 40 feet, normal pace Í WWT – Simple:

Í Walk 40 feet and recite alphabet Í Taking > 20 seconds indicates falls risk

Í WWT-‐ Complex: Í Walk 40 feet while reci;ng every other leRer of the alphabet

Í Taking > 33 seconds indicates falls risk Verghese J et al: Validity of divided aRen;on tasks in predic;ng falls in older individuals: a preliminary study. Journal of American Geriatric Society; 50(9):1572-‐1576


156

BALANCE REHABILITATION

157

BALANCE REHABILITATION Í  The successful plan of care for balance rehabilita;on

depends on careful observa;on of the individual’s movement strategies (or lack thereof) and/or compensa;ons.

Í  The individual who is observed to implement inadequate, ineffec;ve or inappropriate strategies must then be evaluated further to determine the set of impairments, i.e. the intrinsic factors, impac;ng his or her postural movement strategies.

Í  Horak and WoollacoR characterize these impairments as constraints, that is, “limita;ons on sensing and moving for postural control.”


BALANCE REHABILITATION Í  Constraints: Í  Musculoskeletal—significant decrease in strength and power

of the knees and ankles when compared to non fallers (Whipple et al)

Í  Ankle dorsiflexion is markedly diminished and may account for postural instability and backward falls

Í  Key muscles for risk of falls (most important to least important)(Nursing home fallers) Í  Tibialis Anterior (87%) Í  Triceps Surae (73%) Í Quadriceps (40%) Í  Hamstrings (35%)


159

BALANCE REHABILITATION Í  Constraints: Í  Musculoskeletal-‐-‐muscle weakness about ankle joint will

compromise effec;veness of ankle strategy: Í  Gastroc-‐soleus weakness: impaired ability to decelerate forward progression of center of mass during gait.

Í  Tibialis anterior weakness: impaired ability to restore center of mass over base of support following posterior-‐directed perturba;on.

Í  Fa;gue and subnormal endurance of an;-‐gravity muscles: flexed posture will result in anterior displacement of the center of mass, close to, or beyond the limits of stability.


BALANCE REHABILITATION Í  Constraints: Í  Musculoskeletal-‐-‐muscle weakness about hip and knee

joints will compromise effec;veness of hip strategy: Í Quadriceps: impaired ability to correct hip and knee alignment to correct anterior perturba;on beyond tolerance of the ankle strategy.

Í  Hamstring weakness: impaired ability to correct hip and knee alignment to correct posterior perturba;on beyond tolerance of the ankle strategy


161

BALANCE REHABILITATION Í  Constraints: Í  Neuromuscular

Í  Hemiplegia may result in a foot drop or dysfunc;onal synergy -‐ dominated movement paRern.

Í  Ataxia may result in an inability to consistently maintain the base of support under the center of mass secondary to erra;c LE placement.

Í  Apraxia: incorrect motor sequencing may result in dysfunc;onal center of mass/base of support rela;onship, e.g., premature trunk and hip extension when arising out of a chair results in posterior displacement of center of mass at the moment the center of mass needs to be displaced anteriorly.


BALANCE REHABILITATION Í  Constraints: Í  Neuromuscular

Í  Loss of joint posi;on sense (propriocep;on) may result in misjudgement of step clearance (algorithm malfunc;on)

Í  Loss of deep pressure may result in loss of important cue related to the forward progression of the center of mass in the gait cycle

Í  Inner ear surgery or disorder (Menieres, BPPV) Í Inner ear provides accurate informa;on about posi;on and movement of the head in space

Í Control of compensatory eye movements (gaze stability) and whole body equilibrium during head movements, posture and locomo;on


163

BALANCE REHABILITATION Í  Constraints:

Í  Visual dysfunc;on: blindness, nystagmus, visual field cut (hemianopsia), macular degenera;on, diabe;c re;nopathy

Í  Visual impairments (Lord et al) (most important to least important) Í Depth percep;on( improper glasses, cataracts, glaucoma, macular degenera;on)

Í Low contrast visual acuity(loss of ability to perceive colors and dark from light when environment is dark(low contrast) or light (high contrast)

Í Distance-‐edge contrast sensi;vity(edge of steps) Í High contrast visual acuity Í Ground visual field loss(loss of peripheral vision when looking down at ground in front of pa;ent)


BALANCE REHABILITATION Í  Constraints: Í  Cogni;ve

Í  Excessive fear of falling can result in decreased performance.

Í Over es;ma;on of one’s abili;es. Í  Lack of safety awareness, e.g. failure to lock wheelchair; abandonment of assis;ve device.

Í Note typical fall ;mes and have pa;ent in ac;vi;es (U;lize demen;a pa;ents’ crea;veness)



VESTIBULAR REHABILITATION

166

VESTIBULAR REHABILITATION BPPV


Modified from Herdman SJ and Tusa RJ: Benign Paroxysmal Positional Vertigo in Vestibular Rehabilitatioin, 1999; FA Davis Company, Philadelphia pg 467

167

VESTIBULAR REHABILITATION Rehabilita;on Philosophy

Í  To use physical ac;vity to decrease symptoms and the need for medica;on.

Í  Can be achieved by fa;guing the dizziness response and compensa;on through central sources

Í  May need to reintroduce and strengthen weak or missing balance strategies

Í  An emphasis on func;onal responses or ac;vi;es are used so that the pa;ent can incorporate them into their daily rou;ne

Í  Ac;ve par;cipa;on of the pa;ent is impera;ve to the success of the program


VESTIBULAR REHABILITATION Rehabilita;on Goal

Í  To decrease dizziness symptoms and improve efficiency of balance reac;ons in order to return the pa;ent to highest level of func;on


169

VESTIBULAR REHABILITATION 4 general categories of therapy

Í  Self directed exercises Í  Home based program Í  Pa;ent follows prescribed exercise regimen Í  Used with pa;ents that do not require supervision during exercises and

are are not in an acute state Í  Should expect a significant reduc;on or elimina;on of symptoms in 3

to 4 week ;me span Í  Ves;bular rehabilita;on

Í  Designed for pa;ents with acute symptoms and may require supervision during their exercise regimen

Í  May include a variety of ves;bular therapy apparatus Í  Emphasis on falls preven;on Í  One to two 60 minute sessions with an average of 8-‐10 sessions Í  As pa;ent progresses, a home program would be added to hasten the

rehabilita;on process


VESTIBULAR REHABILITATION 4 general categories of therapy

Í  Balance retraining Í  For pa;ents with a loss of balance, unsteadiness or surefootedness Í  Most of these pa;ents do not report ver;go or dizziness Í  Emphasis on prac;cal solu;ons to common problems like gepng

around in the dark or walking on uneven surfaces Í  Falls preven;on, movement coordina;on and improved par;cipa;on in

daily ac;vi;es are priori;es for this category Í  Educa;on

Í  Educa;on of pa;ent and family as to expecta;ons are an important aspect of the program

Í  Provision of printed materials, interac;on with well pa;ents that have has success with the program

Í  Pa;ents o\en become fearful about doing anything that might provoke a ‘loss of balance’ episode that their scope of daily ac;vi;es is markedly reduced


171

VESTIBULAR REHABILITATION Acceptable models to explain why therapy works:

Í  Adapta;on Í  Central ves;bular mechanism learns to adopt to the imbalance signal

coming from an impaired peripheral sensory receptors Í  Gaze stabiliza;on exercises work to retune the ves;bulo-‐occular reflex

to eliminate the re;nal slippage and the pa;ent’s percep;on of mo;on

Í  Subs;tu;on Í  The role of compensatory shi\s when one or more sensory system is

lost or damaged Í  Visually impaired individual does not develop beRer hearing acuity,

and vice versa a hearing impaired pa;ent does not gain beRer vision, they simply u;lize their remaining senses more efficiently


VESTIBULAR REHABILITATION Acceptable models to explain why therapy works:

Í  Liberatory, Reposi;oning, Desensi;za;on Í  Several different procedures to manage otolith dysfunc;on or Benign Paroxysmal Posi;onal Ver;go

Í  Include procedures to resolve the otoliths that have escaped from the utricle and are now floa;ng in the semicircular canals by loosening, dislodging or ignored through a single or repe;;ve posi;oning manuever


173

DIZZINESS AND THE ELDERLY Otologic Dizziness

Í  Otologic dizziness is the most common type of dizziness in the elderly. Í  This is mainly due to an increased tendency for the elderly to develop

benign paroxysmal posi;onal ver;go (BPPV). Í  As a rule of thumb, about 50% of dizziness is caused by BPPV by the age

of 80, compared to about 20% for all ages considered together Í  Meniere’s syndrome is also a significant cause of dizziness in the older

popula;on and has its highest incidence above fi\y years of age. Meniere’s syndrome usually presents as spells of rapid decline in hearing, a roaring ;nnitus, ver;go, and monaural fullness. Í  Acutely, ves;bular suppressants and an;eme;cs are used. Í  Over the long-‐term, a two gram salt diet combined with a mild diure;c

such a Dyazide (HCTZ -‐ triamterene) may reduce the frequency of aRacks.

Í  Recently, an outpa;ent treatment for Meniere's involving injec;ons of gentamicin through the eardrum has been rapidly gaining popularity. It is about 90% effec;ve for unilateral disease.



Í  Ves;bular neuri;s is a monophasic self-‐limited condi;on typified by ver;go, nausea, ataxia and nystagmus.

Í  Both ver;go at rest and posi;onal ver;go are o\en present. Í  Spontaneous nystagmus differen;ates this disorder from

BPPV. Í  Severe ver;go usually only lasts two to three days. Í  An an;-‐eme;c, such as phenergan, may be used acutely.

Ves;bular suppressants such as meclizine should be used sparingly as they may delay central compensa;on to the lesion.

Í  Older pa;ents with prior central disease, peripheral neuropathy, visual troubles, or difficul;es that restrict ambula;on may not recover as quickly and may benefit from ves;bular physical therapy.


175


Í  Bilateral ves;bular paresis is most commonly caused by exposure to ototoxic medica;ons, par;cularly courses of gentamicin las;ng 2 weeks or longer.

Í  Other causes include spirochete infec;ons of the inner ear, autoimmune processes, and age-‐related changes.

Í  Symptoms include oscillopsia and ataxia, o\en without ver;go. Í  It is important to advise the pa;ent to avoid any agents that may suppress

the ves;bular system, such as meclizine, as well as an;cholinergic agents such as many of the tricyclic an;depressant medica;ons.

Í  Ototoxic agents must be avoided above all, par;cularly gentamicin. Í  Ves;bular rehabilita;on physical therapy is usually helpful, but full

recovery is never aRained in many pa;ents. Recovery depends on the degree of ves;bular loss and on the individual’s ability to compensate.


DIZZINESS AND THE ELDERLY Central Dizziness

Í  Central dizziness is rela;vely less common than otologic dizziness but, as it is most o\en secondary to vascular events involving the cerebellum and brainstem, it may be a harbinger of dangerous associated condi;ons.

Í  Dizziness caused by vertebrobasilar migraine, common in mid-‐adulthood, is much less prevalent in the elderly.

Í  Many other neurologic disorders may cause ver;go by disrup;on of the brainstem/cerebellar pathways.

Í  Pa;ents with central ver;go are o\en distressed by ataxia, nausea, and illusions of mo;on for years.

Í  Although it is uncommon for seizures to present as dizziness, they deserve a special men;on because they respond well to treatment with an;convulsant medica;on.


177

DIZZINESS AND THE ELDERLY Central Dizziness

Í  Historical clues include a history of very brief spinning sensa;ons or "quick spins". The pa;ent may also have a history of loss of consciousness.

Í  In the treatment of central dizziness one must first aRempt to address the cause. In the case of vascular events, for example, vascular risk factors should be treated.

Í  A pa;ent with "quick spins" should have an electroencephalogram.

Í  Ves;bular physical therapy is o\en helpful in this popula;on.


DIZZINESS AND THE ELDERLY Medical Dizziness

Í  Medical e;ologies of dizziness are very diverse but mainly include hypotension and cardiac events, infec;on, low blood glucose, and medica;on.

Í  Here dizziness interfaces with syncope. Í  Both occult cardiac arrhythmias and acute myocardial infarc;ons may

manifest as dizziness. Í  Medica;ons are a common contributor to dizziness and ataxia as elderly

pa;ents are o\en on mul;ple drugs, which places them at high risk for these side effects. Medica;ons are the most common cause of symptoma;c orthosta;c hypotension as well as hypoglycemia.

Í  Treatment begins by removing any unnecessary agents and drug "tuning", or subs;tu;ng similar, but beRer tolerated, medica;ons.

Í  For example, an H2 blocker which does not cross the blood-‐brain barrier such as rani;dine may be beRer tolerated than one that does, such as cime;dine.


179

DIZZINESS AND THE ELDERLY Drugs that can cause ataxia

Í  Anticonvulsants (e.g., phenytoin, carbamazepine) Í  Antihypertensives and drugs with hypotension as side effects Í  Adrenergic blockers (e.g., propranolol, terazosin) Í  Diuretics (e.g., furosemide) Í  Vasodilators (e.g., isosorbide, nifedipine) Í  Tricyclic antidepressants (e.g., nortriptyline) Í  Phenothiazines (e.g., chlorpromazine) Í  Dopamine agonists (e.g., L-dopa/carbidopa) Í  Ototoxic drugs and vestibular suppressants Í  some of the mycin antibiotics (e.g., gentamicin) Í  Anticholinergics (e.g., transdermal scopolamine,

promethazine, amitriptyline, meclizine)


DIZZINESS AND THE ELDERLY Drugs that can cause ataxia

Í  Loop diuretics (furosemide) Í  cis-platinum Í  Psychotropic agents Í  Sedatives (e.g., barbiturates and benzodiazepines) Í  Drugs with Parkinsonism as side effects (e.g.,

phenothiazines) Í  Drugs with anticholinergic side effects ( e.g., amitriptyline) Í  Miscellaneous drugs Í  cimetidine


181

DIZZINESS AND THE ELDERLY Psychogenic Dizziness

Í  Psychogenic dizziness is common and includes en;;es such as anxiety disorders, panic aRacks, agoraphobia, soma;za;on syndrome, and malingering.

Í  This group is difficult to diagnose because organic dizziness is o\en accompanied by considerable and o\en appropriate anxiety.

Í  Considerable cau;on should be taken in diagnosing psychogenic ver;go. Í  Anxiety syndromes and panic syndrome o\en respond to treatment with

benzodiazepines, but usually require larger doses than the amounts used for ves;bular suppression.

Í  Soma;za;on syndromes are difficult to treat and rou;nely would refer such pa;ents to psychiatry.

Í  In pa;ents where malingering seems possible, it is important to carefully document objec;ve findings and to quan;fy func;onal status, par;cularly where dizziness may be preven;ng return to work or func;on.


DIZZINESS AND THE ELDERLY Unlocalized Dizziness

Í  At all ages, about one-‐third of pa;ents with dizziness will go undiagnosed.

Í  These pa;ents usually need to be followed more closely than pa;ents in whom a clear diagnosis is available.

Í  Empirical trials of medica;on, psychiatric consulta;on, and ves;bular physical therapy may be helpful op;ons.



VESTIBULAR REHABILITATION

184

VESTIBULAR REHABILITATION Who is appropriate for ves;bular rehabilita;on

Í  Person with complaints of or history of dizziness or ver;go which has resulted in impaired mobility or falls. Considera;ons

Í  Ves;bular impairment may be due to a combina;on of factors, i.e. age related changes, medica;on, disease or injury. It is important to determine the underlying problem in order to most effec;vely direct treatment.

Physician consulta;on, par;cularly an ENT physician referral,

may be appropriate prior to therapy evalua;on.


185

VESTIBULAR REHABILITATION Six sub-‐categories that can be referred for treatment

Í  Unilateral ves;bular loss or distor;on (peripheral) Í  Pa;ents that report a sense of feeling of exaggerated mo;on when turning, or moving their head quickly.

Í  Pa;ents with distor;on within the ves;bulo-‐ocular reflex, visually provoked ver;go or an accompanying queasiness

Í  High Frequency non-‐compensated weakness in one or both systems provoked by dynamic movement (peripheral) Í  Pa;ents that report a sense of feeling of exaggerated mo;on when turning, or moving their head quickly.

Í  Pa;ents with distor;on within the ves;bulo-‐ocular reflex, visually provoked ver;go or an accompanying queasiness



Í  Bilateral ves;bular loss (peripheral or central) Í  Pa;ents report an unsteadiness or loss of surefootedness Í  Usually visual or surface dependent Í  Rapid movement or change in posi;on does not typically provoke any ver;go unless they have otolith (BPPV) involvement

Í  Dysequilibrium (central motor or movement coordina;on deficit) Í  Pa;ents present with robust and symmetrical peripheral ves;bular func;on as indicated by caloric responses on ENG and no indica;on of mo;on intolerance

Í  Dysfunc;on is usually secondary to central and/or descending motor tract defects ie cerebellar deficit or infarcts as well as cervico-‐spinal tract degenera;on


187


Í  Benign Paroxysmal Posi;oning Ver;go (peripheral-‐otolith) Í  Good historian and can relate very specifically the move or change in posi;on that provokes the ver;go

Í  Remain symptom free as long as they avoid the posi;oning change

Í  Feel unseRled for several hours post provoca;on, even though acute aRack lasts for a few seconds

Í  Also have some ves;bular weakness indicated by caloric response on the same ear with the BPPV



Í  Central Dizziness (vascular or neurologic) Í Most frustra;ng as to the origin of their ‘constant dizziness and foggy-‐headedness’ related to cerebrovascular or vertebrobasilar vascular insffuciencies

Í O\en report that the only ;me they feel relief is when they are lying down

Í O\en have underlying medical needs ie cardiovascular superceding or inhibi;ng recommended therapy

Í  Suggested that minimal head and neck movement used in ves;bular rehabilita;on protocols may be of greater value than the sedentary lives many of these pa;ents lead


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VESTIBULAR REHABILITATION Í  If the onset of symptoms was sudden and recent (within past 3 to 6 months) then the chance of "recovery" is promising. Treatment and goals would focus on: Í decreasing symptoms by a process of habitua;on* Í improving balance Í improving func;onal mobility Í educa;on of resident/family members/staff

*Habitua;on is defined as the reduc;on of a response to a s;mulus by repeated exposure to the s;mulus. This usually occurs in 4 to 6 weeks but may take as long as 8 to 12 weeks. Habitua;on exercises include those movements which provoke symptoms and must be performed at least 2 ;mes per day, 6 to 7 days per week.


VESTIBULAR REHABILITATION Í  If the onset of symptoms was gradual and present for more than 6 months, the problem may be chronic. Expecta;on for "recovery" may be unrealis;c. Treatment and goals would focus on: Í compensa;on strategies to improve safety and mobility Í modifying the environment/task to promote safety Í assess the need for assis;ve devices Í educa;on of resident/family members/staff



EXERCISE PROTOCOLS

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EXERCISE PROTOCOLS Non tradi;onal Í  Tai chi chuan prac;;oners have a maxim: Let the mind lead the chi and the chi mobilize the body. Before you move an arm, there are three processes:

Í  First, you have to think about it. Tai chi involves body-‐mind training.

Í  If you want to raise the arm, you mentally visualize the arm rising, and with that visualiza;on, your body begins to move.

Í  Under the direc;on of your mind, your body starts moving upward.


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EXERCISE PROTOCOLS Ves;bular rehabilita;on exercises Objec;ve: Í  To ameliorate of ex;nguish dizziness, ver;go or mo;on intolerance.

Í May be brought on by posi;onal changes, rapid posi;oning, or visual s;muli

Í  This classifica;on typically related to abnormal VOR func;on due to a peripheral ves;bular dysfunc;on, typically exacerbated with head movement


EXERCISE PROTOCOLS Ves;bular rehabilita;on exercises Objec;ve: Í  Exercises and ac;vi;es to promote habitua;on of dizziness and ver;go are typically the exact movements which provoke the symptoms. Choose 3 or 4 of the movements, perform these movements 10 ;mes, 2 ;mes per day, 6-‐7 days per week. Also incorporate the specific movements into func;onal ac;vi;es


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EXERCISE PROTOCOLS Ves;bular rehabilita;on exercises Symptoms: Í  Dizziness, unsteadiness, imbalance, ver;go, nausea. Í  Since the ves;bular system interacts with the nervous system, other symptoms may be experienced as problems with vision, muscles, thinking and memory, headaches, muscular aches in neck and back, sensi;ve to mo;on, noise, bright lights and fa;gue


EXERCISE PROTOCOLS Ves;bular rehabilita;on exercises Í  EXAMPLE: If ver;go is provoked with head rota;on to the right, supine to sit from the right, sit to stand and ;l;ng head up then treatment may involve performing each of these movements 5 ;mes in a row, however, a more meaningful and func;onal outcome will be more mo;va;ng. The goal may be to get a cup of coffee. The task includes rolling to the right, sipng up, standing and walking to the kitchen and having to take a coffee cup off a high shelf. The result is that the specific movements are performed in a func;onal context, and the resident gets their cup of coffee.


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EXERCISE PROTOCOLS Ves;bular rehabilita;on exercises Í  Habitua;on (significant decrease in symptoms) is not noted within 2 to 4 weeks, it may be necessary to begin to introduce compensatory strategies into treatment.


EXERCISE PROTOCOLS Hallpike exercises for the treatment of ver;go Í  Sit in the middle of your bed, facing the head of the bed (to pillow end). Place a pillow under your knees.

Í  Turn your head to the . Í  Lie down as quickly as you can, keeping your head turned to the so that your head slightly overhangs the foot of the bed.

Í  Remain in this posi;on for as long as you are experiencing dizziness, or for the count of 20 4 you have no symptoms.


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EXERCISE PROTOCOLS Hallpike exercises for the treatment of ver;go Í Now, sit up as quickly as you can. Í  Again, wait un;l your symptoms subside (or for the count of 20 if you have no symptoms). Repeat the en;re exercise again.

Í  Perform this exercise: 5 Times to the ________ 5 &mes to the ________

Í  Do each set of 5 exercise &mes per day. Í  Reform with eyes open & closed.(Circle one)


EXERCISE PROTOCOLS Hallpike-‐Brandt Modifica;on Í  Sit on your bed with your feet flat on the floor. Í  Turn your head to the ___________. Í  As rapidly as possible, fall to the ________side and turn your head slightly upward.

Í  Stay in this posi;on for as long as your symptoms last (or for 15 seconds if you have no symptoms).

Í  Sit up as rapidly as possible and lay down on the opposite side, keep your head slightly upward.

Í Wait un;l your symptoms subside (or 15 seconds if you have no symptoms) and repeat the en;re exercise again.


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EXERCISE PROTOCOLS Brandt’s Exercise Objec;ve: Í  To decrease dizziness/ver;go caused by an inner ear disorder; your symptoms are typically provoke by specific body or head movements.


EXERCISE PROTOCOLS Brandt’s Exercise Í  Sit on the side of your bed with feet flat on the floor. Í  Quick lie onto your ________ side and turn your head slightly upward

(nose to ceiling). Í  Stay in this posi;on un;l your symptoms subside (15 to 20 seconds if

you have no symptoms). Í  Sit up quickly and stay sipng un;l your symptoms go away. Í  Now lay down on your opposite side, head turned slightly upward and

remain in this posi;on un;l all symptoms subside. Í  Sit up quickly and stay sipng un;l your symptoms subside.


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EXERCISE PROTOCOLS Brandt’s Exercise Í  Do this exercise to each side X ;mes Í  Repeat 2 ;mes a day


EXERCISE PROTOCOLS Ves;bular Habitua;on Exercises Objec;ve: Í  To decrease dizziness/ver;go caused by an inner ear disorder. Your symptoms are typically provoked by specific body or head movements. For the habitua;on exercise to be effec;ve, you need to stay in the posi;on that provokes your symptoms un;l they stop. This allows the brain sufficient ;me to ‘re-‐adjust’ the incorrect message from the semi-‐circular canals (which relays balance informa;on from the inner ear to the brain).


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EXERCISE PROTOCOLS Ves;bular Habitua;on Exercises Í  Brandt’s exercise. Í  Head Turns (sipng)

Í Quickly turn your head to the le\ Í Return your head to the center Í Quickly turn your head to the right

Í Nose to Knee (sipng) Í Quickly bend forward, bringing your nose towards your le\ knee. Keep your feet on the floor

Í Return to upright sipng Í Quickly bend forward, bringing your nose towards your right knee

Í NOTE: Stay in each posi;on un;l the symptoms stop


EXERCISE PROTOCOLS Ves;bular Habitua;on Exercises Í  Head Tilts (sipng)

Í Quickly ;lt your head to the le\ (le\ ear to le\ shoulder, as is comfortable)

Í Return your head to the center Í Quickly ;lt your head to the right (right ear to right shoulder, as is comfortable)

Í  Roll Side to Side (lying on your back) Í Quickly roll onto your le\ side Í Return to lying flat on your back Í Quickly roll onto your right side

Í NOTE: Stay in each posi;on un;l the symptoms stop


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EXERCISE PROTOCOLS Gaze Stabiliza;on Exercises Objec;ve: Í  Gaze stabiliza;on is the process whereby the inner ear

‘drives’ your eye movement in response to head movements, in order to keep your gaze fixed on an object.


EXERCISE PROTOCOLS Gaze Stabiliza;on Exercises Í  Cooksey Exercises (done in sipng, preferably in an armchair for increased safety) Í (1)Hold your thumb out at arms length. Move your head side to side while keeping eyes fixed on thumb.

Í (2)Hold your thumb out at arms length. Move your head up and down while keeping eyes fixed on thumb.

Í (3)Hold your thumb out at arms length. Move thumb side to side, while you move your head in the opposite direc;on, keeping eyes fixed on thumb.

Í Same as #1, instead move your thumb side to side. Í Same as #2, instead move your thumb up and down. Í Same as #3, instead move your thumb and head up and down.


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EXERCISE PROTOCOLS Gaze Stabiliza;on Exercises Í  Cooksey Exercises (done in sipng, preferably in an armchair for increased safety) Í (3)Hold your thumb out at arms length. Move thumb side to side, while you move your head in the opposite direc;on, keeping eyes fixed on thumb.

Í Same as #1, instead move your head up and down. Í Same as #2, instead move your thumb up and down. Í Same as #3, instead move your thumb and head up and down.


EXERCISE PROTOCOLS Gaze Stabiliza;on Exercises Í  Tracking moving objects

Í Most ves;bular pa;ents experience difficulty in the tracking of moving objects. Symptoms may be provoked in crowded environments that are visually ‘over-‐loaded’ (e.g. shopping malls, supermarkets, crowded restaurants, busy highways). This typically results in:

Í avoidance of the busy visual environment Í decreased mo;on of your head and neck, as you try not to provoke your symptoms of dizziness, nausea, ver;go, dysequilibrium, etc.


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Í Unfortunately, just a muscle will atrophy with disuse, so too will your balance be affected with a decreased use of your visual tracking mechanism (ves;bular-‐ocular connec;on). The following progression is meant to strengthen this system

Í YOU MUST REMEMBER TO MOVE YOUR HEAD SEPARATELY FROM YOUR BODY. DO NOT move your head and body together, as if you have a ‘s;ff neck’



Í You should perform these exercises as tolerated, and let your symptoms decide when to progress to the next level. Examples of moving objects to track are: airplanes, cars, pedestrains, birds, trees, boats, etc.


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EXERCISE PROTOCOLS Gaze Stabiliza;on Exercises Í  Tracking moving objects (progression)

Í Sipng in a quiet environment: (on your deck/porch, part bench, etc); if your symptoms are severe this will allow you to track one object at a t and begin to regain your confidence to move your head/neck separate from your body.



Í Sipng a a crowded environment: (at a shopping mall, a busy street, etc); you will now be challenged to track one moving object that is interspersed with many moving objects. At this stage, try not to track mul;ple moving objects. You should be gaining confidence in the ability to once again be in a busy place, and have control over your symptoms.


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Í Standing in a quiet environment Í Standing in a crowded environment Í Walking in a quiet environment Í Walking in a crowded environment

Í The goal is to be able to once again be able to take daily walks, move your head and neck normally, be able to track moving objects. This will help to strengthen your balance system and to decrease your symptoms.


EXERCISE PROTOCOLS Walking program for ves;bular rehabilita;on Objec;ve: Í  To improve overall stamina and endurance, and to regain your normal daily func;oning.

Í  Because of your inner ear disorder, it is likely that you a now less ac;ve, have decreased stamina, ;re easily, and have difficulty comple;ng your daily rou;ne.

Í  As your symptoms of dizziness begin to subside, your will find that you have an increased confidence in your physical func;oning, you must now begin to strengthen your balance system


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EXERCISE PROTOCOLS Walking program for ves;bular rehabilita;on Í  Begin by walking on level terrain for _________ minutes/day

Í  Your goal is to walk 20 to 30 minutes/day to improve your cardiovascular fitness.

Í  As you improve, you should progress to: Í Walking on gentle hills and uneven terrain(grass, beaches, etc)

Í Incorpora;ng head turns as you walk; begin by looking at sta;onary objects as you walk; you will then progress to tracking of moving objects as you walk.

Í  If you are reluctant to begin a daily walking program because of decreased confidence in your balance, it is recommended to have a walking partner.


EXERCISE PROTOCOLS Balance Retraining Exercises Objec;ve: Í  To improve and enhance the pa;ent’s motor coordina;on and movement as it relates to their ability to maintain their center of gravity during sta;c and dynamic movement

Í  Prac;ce appropriate guarding techniques with all ac;vi;es. Choose ac;vi;es which are challenging and related to daily task requirements


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EXERCISE PROTOCOLS Balance retraining exercises Exercises: Í  Stand on one leg for 30 seconds. Switch feet and repeat. Í  Stand with feet hip width apart with eyes closed for 30 seconds. Move feet closer and repeat.

Í  Stand heel to toe with eyes closed for 30 seconds. Switch feet and repeat.

Í Walk heel to toe forward, then backwards. Í  Balloon toss. Increase amount of movement off midline required to hit the balloon.


EXERCISE PROTOCOLS Balance retraining exercises Exercises: Í  Ball toss/kick. Vary size and weight of the ball. Increase amount of movement off midline required to toss/kick the ball.

Í  Stand on ;lt board with feet hip width apart. Prac;ce keeping the board s;ll then voluntarily moving it in forward/backward direc;on. To make this more difficult move feet closer together or introduce perturba;ons to person or ;lt board. Turn the board around and prac;ce side to side direc;on. Balloon or ball toss also makes this more challenging.


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EXERCISE PROTOCOLS Balance retraining exercises Exercises: Í  Squat to pick up objects off the floor. Vary the size and weight of the objects. If this is too difficult you may start by placing objects on a step stool or mat and progress to the floor.

Í  Stand on foam with feet hip width apart and eyes open for 30 seconds. Close eyes and repeat. Bring feet closer together to make more difficult.

Í  Step ups ( can use step stool or stair step). Vary height of step and direc;on of stepping (forward, sideways, diagonal).

Í  Lunges forward, sideways, and in diagonal direc;on.


EXERCISE PROTOCOLS Balance retraining exercises Exercises: Í  Stand on one leg with the other foot placed on a ball (approximately basketball size, however the larger the ball the more difficult the task). First, prac;ce keeping the ball s;ll, then move slowly forward and backwards in a straight line. Also prac;ce moving the ball side to side and in circles.

Í Walk forward 1 0 \. and stop quickly. Repeat. Í Walk forward 1 0 \., quickly pivot turn and walk back. Repeat, turning the other direc;on.

Í Walk backwards 5 \. and stop quickly. Repeat.


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EXERCISE PROTOCOLS Balance retraining exercises Exercises: Í Walk forwards varying the speed, i.e. very slow ... fast ... very slow.

Í Walk forwards stepping over objects on the floor. Repeat. Í Walk in a straight line while rota;ng your head from side to side. Repeat.

Í Walk in a straight line while ;l;ng your head up and down. Repeat.

Í Walk in cluRered environment. Í Walk in distrac;ng environment (noise, people, traffic).


EXERCISE PROTOCOLS Balance retraining exercises Exercises: Í Walk on different surfaces (carpet, grass, gravel, sand, etc.). Í Walk carrying various objects (glass with water, food tray, etc.)

Í Walk in/out doors (vary type and weight of doors). Í Walk in/out of elevator (emphasis on ;me constraint to enter/exit).

Í  Prac;ce gepng on/off escalator.



GOALS

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GOALS Educa;on LTG: Resident's wife will understand and verbalize

appropriate precau;ons to reduce the risk of falls as instructed by therapist.

STG: Resident's wife will verbalize 4 of 8 precau;ons and recommenda;ons as instructed by therapist.

LTG: Nursing staff will understand and carry over recommenda;ons provided by therapist 100% of the ;me.

STG: Nursing staff will place bedside commode next to resident's bed at night and keep call light accessible to resident when le\ unaRended as instructed by therapist.


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GOALS Safety LTG: Resident will lock wheel chair brakes prior to

standing lOO% of the ;me without verbal cues.

STG: Resident will lock wheelchair brakes prior to standing 50% of the ;me with verbal cues.


GOALS Func;on LTG: Resident will ambulate with a walker 300 \. (room

to day room) independently demonstra;ng appropriate safety awareness and compensatory strategies as per therapist instruc;ons.

STG: Resident will ambulate with a walker 150 \. with min assist and verbal cues for safety awareness and use of compensatory strategies.


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GOALS Ves;bular Rehab LTG: Resident will perform func;onal mobility ac;vi;es

maintaining a symptom intensity below 4 on the Modified Borg Ra;ng Scale.

STG: Resident will tolerate ves;bular habitua;on exercises 1 0 reps 2 ;mes per day with a reduc;on of symptom intensity from 8 to 4 on the Modified Borg Ra;ng Scale.

STG: Dura;on of ver;go and or nystagmus will be reduced by 50% in 4 weeks when in Brandt’s posi;on.


GOALS Balance Training LTG: Resident will be require CGA to maintain balance

while ambula;ng on various surfaces. STG: Resident will demonstrate appropriate movement

strategies and compensatory techniques with min assist and verbal cues while ambula;ng on carpet, grass, gravel and sand.

STG: Resident will stand on one leg with support x _____seconds.


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GOALS Balance Training STG: Resident will tandem walk with support x ____

steps (typically 3 X 10 steps for evalua;on) STG: Resident will increase ;me in Romberg stance

from ____secs to ___secs STG: Resident will demonstrate improved protec;ve

extension and head righ;ng reac;ons to moderate perturba;ons.


GOALS Musculoskeletal LTG: Resident will demonstrate sufficient lower extremity muscle strength in order to ascend/descend ramp to dining room with CGA. STG: Increase le\ hip and knee extension from 3+/5 to 4/5 to require moderate assistance to allow gait with walker.



EXAMPLES

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CVA Í  Deficits based on site and extent of lesion Í  Wide range of deficits from low level to high level of physical

performance (sta;c as well as dynamic balance deficits) Í  Sensory systems affected (o\en vision and propriocep;on) Í  Motor systems affected (decreased strength, impaired

weight bearing, impaired protec;ve extension, impaired equilibrium, impaired gait)

Í  Cogni;ve systems affected Í  Percep;on systems affected


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CVA Í  Orthosta;c hypertension Í  Risk for falls in women with strokes (prospec;ve falls report,

n=124) Í  Balance problems while dressing (odds ra;o, 7.0) Í  Residual balance, dizziness, or spinning stroke symptoms

(odds ra;o, 5.2) Í  Falls risk not linearly related to number of impairments

(motor+sensory+visual impairments)


PUSHER’S SYNDROME Í  Tendency of a person with CVA to ac;vely push away from

the non paralyzed side and to resist any aRempt to hold a more upright posture

Í  NOT a ves;bular lesion Í  Possibly due to higher order disrup;on in somatosensory

informa;on processing Í  Person is ac;vely adjus;ng body to subjec;ve ver;cal biased

to side opposite cerebral lesion Í  May not have fear of falling


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Strategies for Trea;ng Pusher’s Syndrome

Í  May take longer to achieve same func;onal goals as other pa;ents

Í  Use vision to focus on upright orienta;on of surrounding objects/persons

Í  Motor control principles using elicita;on of ac;vi;es that use desired posture and prac;cing those ac;vi;es with repe;;on (look & go)


Hemi-‐neglect Syndrome Í  Spa;al neglect – mul; modal problem Í  Failure to acknowledge, orient, or react to s;muli located on

contralateral side to lesion Í  Visual explora;on – laser against the wall, smooth pursuit,

saccadic eye movement Í  Vibra;on (80 Hz) concurrent with visual training Í  Es;m may improve sipng postural stability on an unstable

sipng surface(Peremou et al, 2001) Í  Visual explora;on with trunk rota;on


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Mul;ple Sclerosis Í  Characterized by demyelina;on and subsequent gliosis Í  Lesion in op;c nerve, subcor;cal white maRer, cor;cospinal

tracts, posterior columns of spinal cord, cerebellar peduncles, 8th cranial nerve

Í  Symptoms are variable due to variability in course and lesion site

Í  Sensory deficit – visual changes (blurred/double vision, loss of vision in one eye); parathesias; somatosensory changes

Í  Motor deficits – spas;city; weakness or paresis of limbs, tremor, coordina;on difficul;es, ataxic gait


Mul;ple Sclerosis Í  Psychological changes – fear of falling? Í  Cogni;ve changes – bradyphrenia, impaired aRen;on and

concentra;on Í  Neuroplasi;city or func;onal reorganiza;on in brain

structures based on altered paRerns of use (Reddy el al, 2002)


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Mul;ple Sclerosis CaQaneo et al 2002

Í  50 persons with MS – 54% fell one ;me in 2 months; 32% recurrent fallers

Í  60% fallers used cane Í  Tinep vs Berg – significant difference in scores

Í  Difficulty standing with eyes open Í  Sharpened Romberg Í  Difficulty controlling mediolateral movements


Mul;ple Sclerosis

Í  If spas;city levels high, co-‐contrac;on is factor in gait and can be in balance (Thoumie and Mevellec 2002)

Í  Balance disturbances may be present with or without limb ataxia

Í  Balance strategies (hip, ankle, stepping) are impaired. Hip strategy may be absent or reduced. Retrain the strategy. Ankle strategy may also be impaired due to decreased ankle strength, slowed ankle contrac;on or co-‐contrac;on

Í  May have problems with ver;go and nystagmus due to involvement of 8th cranial nerve (Alpini et al 2001, Brandt and Dietrich 2000)


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Mul;ple Sclerosis

Treatment Í  Habitua;on for ver;go Í  Gaze stability exercises Í  Sensory balance exercises Í  Incorporate eye and head movement into balance training


Mul;ple Sclerosis

Í  Fa;gue affects 77% of pa;ents with MS (Schwartz, Couthard-‐Morris, Zeng 1996)

Í  Central phenomenon related to pro-‐inflammatory cytokines(Coral et all 2001)

Í  Motor fa;gue with sustained contrac;ons, repe;;ve contrac;ons, and and ambula;on and lower extremity is decreased(Schwid et al 1999)

Í  Fa;gue reduces with aerobic training(Mostert and Kesselring 2002)


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Mul;ple Sclerosis

Í  Assessment should cover all contributors to balance – sensory, motor, perceptual and cogni;ve

Í  Develop treatment strategies specific to deficits within each system and that integrates each system

Í  Educa;on and aRen;onal strategies necessary Í  Assess and address the psychological contributors to

balance, especially fear of falling


Parkinsons Schenkman 1989

Í  Absence of medica;on pa;ents executed ankle and hip strategies simultaneously

Í  Musculoskeletal impairments limi;ng balance response include loss of neck mobility, forward head posture, thoracic kyphosis with loss of thoracic mobility, loss of pelvic mobility and loss of lower extremity mobility

Í  Akinesia or a general decreased in purposeful ini;a;on of voluntary movement and rigidity contribute to fixed postures and loss of muscle length

Í  Treat tone with mobility exercises to maintain and regain flexibility


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Q & A


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K2 SEMINARS

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K2 SEMINARS

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Interventions for the falling patient NOTES

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