Vestibular Balance Rehabilitation Therapy (VBRT) in Persons Post CVA

1
Vestibular Balance Rehabilitation Therapy (VBRT)
in Persons Post CVA

• Presented by
• Maureen E. Gordon, PT, MSPT, CEAS
• Certified in Vestibular Rehabilitation
• Certified in Cervicogenic Dizziness
• Physical Therapy at St. Lukes

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How Does the NormalBalance System Work?

• The brain constantly monitors the sensory
  information coming in and uses body movements to
  maintain stable posture
• Changes in sensory information input or motor
  control output require the brain to use the
  correct strategy

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Balance Integration

• Sensory Input
• Visual
• Vestibular
• Proprioceptive
• Central Processing
• Primary Processor (Vestibular Nuclear Complex)
• Adaptive Processor (Cerebellum)
• Motor Neurons
• Positional Movements
• Hip, ankle, and stepping strategies
• Eye Movements

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Peripheral and Central Vestibular System

• Peripheral Vestibular System
• Vestibular end organs (3 semicircular canals, 2
  otolith organs)
• Vestibular portion of the VIIIth cranial nerve
• Central Vestibular System
• Vestibular nuclei
• Vestibulo-ocular pathway
• Vestibulospinal pathway
• Vestibulocollic pathway
• Vestibulo-autonomic pathway
• Vestibulocerebral pathways
• Primary and secondary cortical areas
• Vestibulocerebellum

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Vestibular System Function

• What does it do?
• Senses rotational movements of the head
• Senses linear movements of the head
• Senses head position in space due to gravity
  being a linear acceleration
• What does it do with that information?
• Postural Stability (Balance)
• Gaze Stability (Eye-head coordination)
• Orientation in Space

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Balance Integration

• What am I
• Where am I?
  going to do?

Brain
Sensory Systems
Motor Patterns
Generation of Body Movement
Environmental Interaction
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Balance (Postural) Control
Balance Control
Gaze Stability
Postural Stability
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Gaze Stability
Postural Stability

• The ability to maintain the bodys center of
  gravity (COG) over the base of support (BOS) in a
  given sensory environment.

• The ability to maintain gaze or visual focus on
  an external target during movement.
• A function of an intact VOR (vestibulo-ocular
  reflex) at speeds gt 85 degrees/second.

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Balance Abnormalities in Patients With Stroke

• Sensory Integration
• Decreased ankle proprioception
• Abnormal interactions between the 3 sensory
  systems
• Inappropriately relying on one system over
  another
• Excessive reliance on visual input, even when it
  is inaccurate
• Biomechanical Constraints
• Impaired quality and size of the base of support
• Anteriorly displaced center of pressure in the
  paretic leg
• Poor trunk control
• (Oliveira et al, 2008)

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Balance Abnormalities in Patients With Stroke
(Continued)

• Movement Strategies
• Compensation strategies, e.g. holding objects or
  walls and using stepping strategy more frequently
  than age-matched controls
• Predominant use of hip strategy and use ankle
  strategy less
• Decreased anticipatory control
• Perception of Verticality
• Abnormal postural perception of verticality,
  especially with visuospatial neglect
• Resistance to support weight on nonparetic side
  (pusher syndrome)
• (Oliveira et al, 2008)

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Stroke Symptoms That May Interfere With Balance
and Mobility

• Weakness/hemiplegia
• Spasticity or hypotonicity
• Vestibular/inner ear disturbances
• Affected vision and/or sensation
• Ataxia
• Decreased range of motion (ROM)
• Fatigue and deconditioning
• Pain
• Impaired cognition

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Physical Therapy Evaluation

• Objective Tests/Measurements
• Assessment of Functional Limitations
• Fall Risk Assessment observational measurement
  tools
• Postural Assessment Scale for Stroke Patients
  (Mao, et al. 2002. Benaim, et al. 1999)
• Berg Balance Scale
• Dynamic Gait Index
• Assessment of Impairment
• Oculomotor Exam abnormal smooth pursuit,
  saccades, skew deviation (Kattah, 2009) and VOR
  cancellation
• Computerized Testing, e.g. Balance Master or
  Biodex
• ROM and Strength Testing
• Sensation and Coordination Tests
• Assessment of Spasticity
• Gait Assessment

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Peripheral vs. Central Vestibular Nystagmus with
Oculomotor Testing
Feature Peripheral Central
Effect of Fixation Nystagmus decreases Nystagmus increases or stays the same
Direction of Gaze Mixed plane (e.g. vertical and torsional) Usually single plane vertical, horizontal or torsional
Effect of Gaze Nystagmus increases with gaze toward the direction of the quick phase Nystagmus reverses direction or it does not change
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Computerized Force Plate Testing

• Can assess balance control with greater
  sensitivity than observational methods
• A sensory modality can be removed or attenuated
  and the effect of these changes in postural
  control can be assessed
• Evaluation of hemiparetic patients can show
  asymmetrical distribution of weight in lower
  limbs, difficulty in actively transferring, and
  impaired muscle selection
• (Oliveira et al, 2008)

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NeuroCom SMART Balance Master - Dynamic System
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Physical Therapy Treatments

• Balance Exercises Computerized and
  non-computerized training focusing on
  proprioception, widening BOS, ankle strategy
• Neuroplasticity if damage is done to portions
  of the brain effecting balance, then the goal of
  balance training would be to have different
  portions of the brain take over those functions
  or aid in those functions (Sawakri et al 2008)
• In the chronic stroke population, balance
  impairment and fall risk are associated with
  lower quality of life scores (Schmid 2013)
• Activities for Motor Strategies
• Motor learning is improved with task specificity.
  Therefore, if specific circumstances challenge
  balance, practicing those tasks are more
  effective than practicing general balance tasks
  (Klein et al)

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Physical Therapy Treatments (Continued)

• Gait Training assistive device and bracing, as
  needed
• High intensity gait training with focus on
  increasing the number of steps taken throughout
  the day, and during PT sessions, has been proven
  to help balance and transfers, in addition to
  gait training (T George Hornby)
• Gait speed important measure for fall
  prediction, community participation, and can be a
  balance measure (Beauchet et al 2008)
• Stretching, Strengthening, Conditioning
• Adaptation Exercises gaze stabilization/VOR
  exercises
• Home Exercise Program (HEP)
• Recommendations for Environmental Modification

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References

• Beauchet O, et al. Recurrent falls and dual
  task-related decrease in walking speed Is there
  a relationship? J Am Geriatr Soc 2008
  Jul56(7)1265-9
• Benaim C, et al. Validation of a standardized
  assessment of postural control in stroke
  patients The Postural Assessment Scale for
  Stroke Patients (PASS). Stroke 199930(9)1862-68
• Hornby, T George from University of Illinois.
  Unpublished study to be presented at 2015 CSM
• Kattah, Jorge C, et al. HINTS to diagnose stroke
  in the acute vestibular syndrome Three-step
  bedside oculomotor examination more sensitive
  than early MRI diffusion-weighted imaging. Stroke
  2009403504-3510
• Klein et al. Principles of experience dependent
  neural plasticity Implications for
  rehabilitation after brain damage supplement.
  Journal of Speech, Language, and hearing
  research. S1 5225-5239

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References

• Mao HF, et al. Analysis and comparison of the
  psychometric propeties of three balance measures
  for stroke patients. Stroke 200233(4)1022-27
• Oliveira, Clarissa Barros de, et al. Balance
  control in hemiparetic stroke patients main
  tools for evaluation. Journal of Rehabilitation
  Research Development 200845(8)1215-1226
• Sawakri, et al. Constraint induced movement
  therapy results in increased motor map area in
  subjects 3 to 9 months after stroke. Neuro Rehab
  and Neuro Repair 2008, 220 505
• Schmid, AA, et al. Balance is associated with
  quality of life in chronic stroke. Top Stroke
  Rehabilitation, 2013 Jul-Aug20(4)340-6