Understanding Balance Medicine

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Understanding Balance Medicine

• Fall Risk a problem that has reached Critical
  Mass

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The Scope of the Problem
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Fall Risk An Explosion in Incident
From 2000 to 2040 the CDC predicts that the
number of people aged 65 and older will increase
from 43.8 million to 77.2 million
Falls are the leading cause of injury-related
visits to the emergency room in the United States
today.
Among the 65 populace, falls are

• the leading cause of injury death,
• the most common cause of non-fatal injuries,
• the leading cause for trauma related hospital
  admissions

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The Cost Burden to the Healthcare System
In 1991 Medicare costs for hip fractures
(resultant from falls) was 2.9 billion
In 1996 more than 250,000 Americans suffered
from hip fractures. At a cost in excess of 10
billion dollars
According to the American Academy of Orthopedic
Surgeons, the cost for treatment of fall-related
injuries today is estimated at 20.2 billion
It is only 2005 we are only 5 years into the
massive doubling of seniors that the CDC
predicts. We have 35 more years of explosive
growth ahead of us. Imagine where the cost could
be in 2040.
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The Patient Populace

• According to the AMA, 1 in every 4 patients
  suffers from some level of balance dysfunction
• 40 of those 65 and older have balance disorders
  sufficient to put them at risk of falling
• Approximately 2 million physician visits per year
  involve chief complaints of dizziness or loss of
  balance
• In 2001 alone, 1.6 million seniors were treated
  in emergency rooms for fall related injuries
• Ancillary vestibular dysfunction often occurs in
  association with Central Nervous Systems issues,
  Trauma/ Injury, and even deteriorates through
  disuse. Even when success of treatment is found
  for the primary issue, the secondary vestibular
  loss is often overlooked and remains an issue for
  the patient.

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The Systems Involved
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A Simplified View of the Balance Systems
The Visual system is directly brain controlled.
Its function is an obvious one. Within the Visual
system the Oculomotor system helps affix
objects during head-stationary observation.
The Vestibular system reports head movement to
the brain. It is additionally responsible for the
VOR the mechanism that keeps objects in focus
during rapid head movement
The Proprioceptive system tells the brain where
the body is in space.
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What Happens During Conflict?
When one or more of the systems involved in
balance sends a message that conflicts with the
others problems occur!
An Example Imagine that you are a passenger in a
moving vehicle. As you speed along the freeway
you try to read your favorite novel.
Within a short period of time you will experience
car sickness and likely have to stop reading.
The cause of your car sickness is a conflict in
the information being reported to your brain.
Your visual system reports that it is stationary
(because it is focused on your novel), your
vestibular system however reports that you are
indeed moving
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Patients with Balance Dysfunction
experience the Car Sick reaction
everyday of their lives
and really need our help to fix them!
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Taking Action
Screening
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Understanding the Risk factors
Modifiable Risk Factors

• Taking four or more medications
• Lower Body Weakness (Graafmans, 1996)
• Problems with Walking and Balance (AGS 2001)

Modify these risk factors by

• Improving lower body strength
• Improving balance
• (Judge 1993, Lord 1993, Campbell 1999)
• Reviewing medications, reducing wherever/ however
  possible

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What can be Done? Proper Assessment is the
keyand Good Screening is the start!
Dizziness Questionnaires
Perform a combination of Subjective
and Objective Screening tests
Postural Assessment using mCTSIB protocols
Coming soonSwayMeter
Audiometric Screening
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Best practices in Screening include Subjective
questionnaires. Using these, the patient takes
note of their own fall risk factors.
The balance system is very elastic therefore
there can be issues in one system that are
compensated for by another
It is unwise to rely solely on these because
patients often dont know or are afraid to tell
you that they have a balance problem.
Patients often aren't aware that there are
fixes available for their balance issues. They
with-hold their issues out of fear of
limitations, and for other reasons
Postural Assessment using forceplate technology
involves having a patient stand on the platform
with eyes open, then eyes closed (in addition to
other very quick standard tests).
Their Postural Sway represented by Center of
Pressure shifts while on the forceplate is
compared by the forceplate software to a
pre-loaded database of normals and patients with
balance dysfunction
Postural Screening can be performed in 1-2
minutes and will identify even those who dont
know or wont tell as fall risk candidates
Pure Tone Audiometry can Screen and identify
hearing loss
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Taking Action
Diagnostics
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A complete vestibular diagnostic battery includes
testing both the central and peripheral
vestibular systems
The VOR is responsible for keeping images in
focus during everyday locomotion. VOR issues
cause oscillopsia, dizziness and compromised
balance
The VAT (Vestibular Autorotation Test) system is
the only peer-reviewed VOR diagnostic on the
market. It is comprised of 6 18 second tests,
tests VOR at everyday locomotion speeds, and is
fully reimbursed by Medicare and Private
Insurance.
Peripheral
Underlying Central Nervous disorders manifest
themselves in corrective eye movements. The ENG
tests are considered a Gold Standard for
detecting underlying CNS issues
Central
The ENGplus is a fully portable, full field ENG
system that records eye movements at 500 slices
of data per second nearly 10 times faster than
any video system currently on the market. The ENG
battery of tests require 20 to 40 minutes, can be
run by a trained technician, and are fully
reimbursed by Medicare and Private Insurance
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Postural Assessments using Forceplate Technology
While standing on a computerized force platform,
the patient is asked to perform a series of tests.
While performing these tests, the patients CoP
(Center of Pressure) sway is recorded. The
software compares the patients results to those
produced by a normal and balance dysfunctional
group
A common test series used is the mCTSIB which
records the patients CoP sway during the
following tests 1) eyes open/ normal surface, 2)
eyes closed/ normal surface, 3) eyes open/
perturbed surface, 4) eyes closed/ perturbed
surface
The mCTSIB series is designed to compromise
balance systems and measure the effect on the
patients CoP sway. For example the eyes
closed/ perturbed surface compromises both visual
and proprioceptive
Well designed forceplate systems such as the
HUR system - will offer multiple software
interpretation methods for each test
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Taking Action
Rehabilitation
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Balance patients can be retrained by placing them
upon normal and perturbed surfaces and having
them move their CoP in concert with visual cues,
patterns and mazes.
When patients have fallen, they avoid the
direction that the fall occurred in. By working
static patterns the therapist can isolate the
directions their patient is most at risk of
falling toward.
Next, the therapist uses a combination of machine
related and on-the-floor exercises to both
strengthen the patient and help them to develop
hip and ankle strategies to improve balance
The following screenshots are taken from the
SportKAT system which features a patented
adjustable surface and numerous visual/
proprioceptive tasks
The equipment records CoP sway, which can be used
both for analysis and for review with the patient
Maze exercise are timed, and help to rehabilitate
the patient by pushing them towards the
directions they most try to avoid
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Strength and Conditioning the often overlooked
component in balance rehabilitation
With the right equipment, patients can strengthen
the muscle groups, and improve motions to help
reduce fall risk

• HUR equipment is a strong addition to a good
  balance rehabilitation program because
• Its safer - NO impact load at initiation of
  movement
• Its effective - NO ballistics or speed
  limitations
• Its accommodating - truly zero poundage starting
  weights
• Its Quantitative - infinitely adjustable
  resistance increases/ decreases

Using the Push Up/ Pull Down, the patient can
practice sit-to-stand and stand-to-sit motions to
improve skills. The HUR system offers adjustable
assistance levels to this and every motion
Treadmill training has proven to improve gait and
balance while offering cardiovascular exercise.
Even stroke patients with one hemi-paretic limb
perform with near symmetry during treadmill
exercise
Introducing Integrated Balance Strength
Systems A strategic partnership between Med-Fit
Systems and IDS
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Vestibular Rehabilitation Exercises
In combination with the right diagnostic and
rehabilitation equipment and a well trained
staff the following exercise protocols complete
the rehabilitation puzzle.
E
Visual Acuity and VOR Retraining
Saccades and Smooth Pursuit Visual Retraining
Exercises
Brandt-Daroff Exercises
Ankle Sways
Dorsiflexion Exercises
and many more
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Putting the Puzzle Pieces Together for you...
The Integrated Approach to Balance Disorders