The head and eye movements initially provokes dizziness. To improve patient adherence,

adaptation exercises should start with minimal stimuli and gradually be made more challenging.

An adaptation response can be triggered by as small a stimulus as a slip, the movement of a visual

image across the retina. This can be progressed by varying visual input and/or head and body

Movement and continually reorienting to one's head position in space. Adaptation exercises can

incorporate movements called X 1 (times one) and X 2 (times two) viewing. X1 viewing involves

keeping the eyes fixed on a stationary visual target while the subject moves the head back and

forth, and up and down (Fig. 13-20, A). x 2 viewing involves maintaining visual fixation on a

visual target when head and target move in the same or opposite directions (Fig. 13-20, B). These

these exercises can be performed sittinh,standing, or walking and may involve horizontal or

vertical movements progressing from small to large and from slower to faster.

Tips for adaptation Exercises

Exercise 1-2 minutes to patient tolerance but provoke symptoms.

Change the frequency of the movement and the range of head movement.

Exercise can be completed in the dark using mental imagery-gains will occur, but not to

the same extent s with actual head and eye movement.

Exercises should stress the patient’s ability and be guided by the patient’s ability to

manage symptoms and keep the target in focus.

When the vestibular system is not working well, balance can require compensation with

increased use of the other sensory systems, either vision or somatosensation or both, as discussed

in the section on sensory training. Compensation specifically directed toward dysfunction of the

VOR includes use of a number of possible strategies (Table 13-6).

Gaze stabilization exercises can be used to help patients learn to keep an image on the fovea

during head movements. These exercises are designed to decrease eye saccades during head

movement and to compensate by moving the eyes either before or after the head moves. Different

patients will prefer different strategies so it is best to provide situations and gaze stabilization

exercises and let patients choose their own strategy. Gaze stabilization strategies are appropriate

for both training and compensation. They can be used if the VOR is unlikely to return, as with

bilateral vestibular loss, as well as in the initial stages of an acute unilateral lesion when a patient

is too symptomatic to tolerate adaptation exercises. Exercises may start with X 1 viewing (see Fig.

13-20), as in adaptation exercises, for less than a minute with the client sitting, and the visual

target placed on a plain background. Exercises can be progressed by increasing the distance

between targets or the complexity of targets. Only a few patients with bilateral vestibular loss may

eventually tolerate X 2 viewing.

Table 13-6 Compesantory Strategies for Vestibulo-Ocular Reflex Dysfumction

Alternative Strategy Technique

Cervico-ocular reflex Very slow head movements, may allow eyes to

compesate

Saccade modification Using saccades as a compesantory strategy,

move eyes then head between 2 targets.

Create predictable task Central preprogramming is possibel if it is a

predictable task.

Visual tracking Use visual tracking to mantain gaze stability

during head movement.

Visual fixation While salking, patient fixates on object 20-30

feet away. Once past the object, the patient

picks another object and continues to mantain

visual fixation.

Move eyes first When turning, teach patinet to move eyes first,

focus on object, then turn the head, and then the

body, all in the target direction.

Stop When dizziness strats or imbalance begins, stop

and focus an object. Let symptoms pass before

moving.

Progression of Gaze Stabilization Exercises

Start with a simple target, single letter, or plain business card taped on the wall. While

sitting, have the patient move the head in the direction that it is easiest to focus (side to

side OR up and down) progress to include both motions. If you note corrective saccades

with the exercise, slow the movement.

Using two targets have the patient focus on one with eyes and head aligned, and then

move eyes to the other target without moving the head, focus, then move the head,

keeping the target in focus. Keep targets close enough together that when focusing on one

the other can be seen using peripheral vision.

Use an imaginary target. Have the patient focus on a real target then close the eyes. Teli

the patient to keep the eyes on that target as visualized, have the patient move the head

slightly, still looking at the target. Then have the patient open the eyes and check to see if

he or she has stayed with the target.

Habituation exercises involve repeated exposure to asymptom-causing stimulus or movement

to reduce the pathological response to that movement. These exercises can help with balance in

patients with vestibular hypofunction or BPPV. In contrast to adaptation exercises that use mostly

head and eye movements to learn what altered signals mean, habituation generally focuses on

whole body movements and repeats these until the patient no longer reacts adversely to the

stimuli. The patient is provided with a list of functional motions to rate according to which

motions trigger symptoms: none, some lot The clinan picks a few of the motions that trigger

moderate symptoms. The patient then repeats motions with the goal of eventually generalizing the

lack of symptoms to all functional motions.

Tips for Habituation Exercises

No more than four motions should be selected

Motions should be completed 2 times twice per

Movements should be quick enough and through enough range to produce mild to

moderate but not severe symptoms. Progress speed and range as symptoms resolve

Rest between each mouon for symptoms to stop or calm Symptoms should diminish after

a minute or at least within 5-10 minutes of the routine, if not, regress speed and range

Habituation exercises typically show results within 4 weeks, but are generally continued

for 2 months

orthostatic hypotension should be checked before starting exercises incorporating rapid

changes in height of the head in relation to the heart.

CANALITH REPOSITIONING TREATMENTS OR MANEUVERS

If examination reveals a unilateral vestibular problem consistent with BPPV, the most

effective intervention maybe a canalith repositioning treatment or maneuver. Examination should

reveal which canal requires intervention. Correct canal identification and determination of stability

of the debris, whether it is free-floating, as in canalithiasis or adhering to the cupula, as in

cupulolithi asis, can affect the success tions and speeds of movement should be used for these

different situations. Three basic bedside interventions are used: Canalith repositioning treatments

liberatory maneuvers, and Brandt-Daroff habituation exercises.

Canalith repositioning treatment (CRT also known the Epley maneuver) is used for

canalithiasis of the anterior or posterior canals. The Hallpike-Dix is first performed in the

direction that provokes symptoms, ending in a supine position with the head turned toward the

affected side. This position is maintained for 1-2 minutes, and the clinician slowly totates the

patient's head through moderate neck extension toward the unaffected side and keeps it there

briefly. Finally, the clinician rolls the patient into sidelying with the head turned 45 degrees (nose

down) and then helps the patient slowly sit up.the patient is then fit with a soft neck collar and told

not bend over, lie back, move their head up or down, the head for the rest of the day. Patients are

encouraged to sleep on an extra pillow that evening to keep the head elevated and prevent the

debris from moving back into canal. A modification of CRT designed for the horizontal canal

keeps the patient’s head in the plane of the horizontal canal. Level with the table; this manuever is

sometimes reffered to as the barbecue roll.

The liberatory manuever developed by Semont et al can be used to treat posterior or anterior

canalithiasis or cupulolithiasis. After the provoking positions is determined the patient is moved to

provoking sidelying position with head turned up and kept in the position for 2-3 minutes. The

patient is then turned to the opposite eardown position with the therapist maintaning the alignment

of the neck on the body; the speed of the movement depends on whether the initial nystagmus

indicated canalithiadis or cupulolithiasis, determined by length of the initial nystagmus. if the

examination suggests the presence of cupulolithiasis, the movement should be rapid to jar the

debris from the cupula. if canalithiasis is suspected, the movement may be slow. To treat the

posterior canal the head is turned toward the uninvolved side and the patient is laid on the

involved side (nose up); to treat anterior canal the head is turned toward the involved side and the

patient laid on the involved side (nose down). Following the maneuver, patients should remain

vertical for the rest of the day and sleep with multiple pillows that might. Initially, individuals

were to remain vertical for 48 hours, including while they slept, and avoid the provoking position

for a week after traetment; such rigid restrictions are now thought to be unnecessary. The

liberatory maneuver is typically preferred over Brandt-Daroff exercises, since it often requires

only single treatment. It is believed this maneuver will float the debris through the canal system to

the common crus.

Brand-Daroff exercises were developed as a particular type of habituation exercises, but now are

thought to help dislodge or refloat debris out of the semicircular canals. They have the advantadge

that patients can perform them on their own as a home program, perhaps after a liberatory

maneuver is performed in the office. For these exercises the patient moves rapidly from sitting

into the semi-sidelying potitions that causes their vertigo and holds that position until the vertigo

stops or diminishes. The patient then sits up again rapidly and stays sitting for 30 seconds (Fig 13-

21). Patient are generaly instructed to performed these movements ten times every 3 hours until

patients have no episodes of vertigo for 2 consecutive days.

Tips for Canalith Repositioning Treatment

Identify involved canal.

Determined if the patient has canalithiasis or cupulolithiasis

Consider any precautions for neck movement or joint protection.

Instruct the patient on what to expect during and after treatment.

MULTIDIMENSIONAL OR MULTIFACTORIAL TRAINING

Multiple risk factors and multiple problems contribute to most individuals' falls. Therefore it

can be important to target interventions toward multiple factors simultaneously. Multifactorial

interventions normally include gait training, strengthening programs, balance training, training in

appropriate assistive device use, review of health management (monitoring blood pressure,

numbers and types of medications, vision correction, and assessment of dementia) and

environmental assessment or modification, including a home safety evaluation and patient and/or

caregiver education regarding fall risk. Programs are targeted to the specific areas identified in the

examination. Several studies have shown that falls can be prevented through appropriately

targeted examination and implementation of multidimensional interventions. These interventions

have been tested in individual and group settings, with community-dwelling elderly, home bound

elderly, and nursing home residents and in care settings. Most of the studies report similar

components to their interventions (Table 13-7).

To assess the effects of a multidimensional exercise program on balance and mobility, Shumway-

Cook and colleagues conducted a prospective clinical investigation with 105 community-dwelling

older adult jects were divided into 3 groups: Control group, fully adherent exercise and a partially

adherent exercise group. Although both exercise groups showed a reduction in fall risk, the fully

adherent exercise group decreased their fall risk by 33% compared to the partially adherent

exercise group, which reduced their fall risk by 11%. The control group showed an 8% increase in

fall risk.

Table 13-7 Components of multidimensional Balance training

Exercises and Progression Activities

Balance exercises

Sitting

Standing

Walking

Balance recovery

Using sensory information for postural

orientation (center alignment)

Anticipatory postural adjusment

activities

Integration of sensory and motor

strategies for posture and balance

control

Functional activities

Mobility retraining

Unperturbed gait

Perturbed gait

Transfers

Stail Climbing

Various light conditions

No distractions-distractions

Variety of surfaces

With and without head movements

With and without cognitive tasks

SPESIFIC EXERCISES AS DETERMINED

BY THE THERAPIS BASED ON

IMPAIRMENT

Weakness

Fatigue

Limited ROM

Strengthening

Endurance training

Stretching

Interestingly, these researches found that age, gender, number of medications, number of co-

morbidities, living situation, performance of clinical measures of balance and mobility (other than

Tinetti's POMA), frequency of imbalance, and fall history did not limit their subjects' positive

responses to exercise. A multidimensional intervention can thus reduce falls and improve balance

for a variety of patients. The only variable that emerged as a predictor for exercise adherence was

the type of assistive device used for gait: Patients who used a walker as the primary assistive

device for gait were less likely to follow through with exercises than those who used a cane or no

assistive device.

Rose noted the importance of fostering problem-solving skills to achieve balance and

function versus training specific transfer and gait skills to improve balance and reduce falls Her

program focused on manipulating task goals and performance environments to develop a

repertoire of postural strategies that could be adapted to various demands. Three core ingredients

were (1) COG control training, (2) strategy training, and (3) multisensory training. This

intervention primarily focused on a technology based activities utilizing a support surface that

could be computer programmed, but similar situations can be set-up in a standard clinic as

evidenced in other studies.

Hart-Hughes et al conducted a study in which a "Fall Clinical Team" provided an

interdisciplinary, specialized, and individualized care plan to 57l veterans at-risk for falls and fall-

related injuries. At the time of discharge and at 3-month follow-up a statistically significant

reduction in the number of falls was reported. In regard to fall prevention, at the start of the study,

19% reported no falls in the 3 months prior; at the end of the study 64% reported no fails in the 3

months prior. It is important to note that in this study, grab bars, shower chairs, and other devices

were recommended to provide a safe home environment. These may have contributed to a reduced

fall rate but are common in multifactorial interventions.

Tinetti et al conducted a study with 301 community dwelling individuals over 70 years of age

with risk factors for falling in which the control group received usual health care plus social visits.

The experimental group received a combination of adjustment in their medications, behavioral

instructions, and exercise programs targeted to their specific risk factors. At a 1-year follow-up,

35% of the intervention group had fallen compared to 47% of the control group (p=0.04). The

execises programs in this interventions consisted of gait or gait or transfer training, as needed, and

a progressive, competency-based balance and strengthening exercise program. Subjects were

instructed to perform the exercises twice a day for 15-20 minutes per session. Intervention lasted 3

months.

Chang et al completed a systematic review and metaanalysis of 61 RCTs on interventions for

the prevention of falls in older adults and concluded that the most effective intervention was a

multifactorial falls risk assessment and management program. They also concluded that

strengthening and balance specific exercise programs were effective in reducing the risk of falling.

The goals of a multidimensional program are (1) to resolve, prevent, or reduce underlying

impairments; (2) to utilize effective and efficient task-specific sensory and motor strategies, and

(3) to adapt and train task spesific strategies allow fucntional tasks to be performed in changing

environmental situations. Challenging multiple systems at the time by challenging the individual

(taking them to the outer limit of stability), changing the environment (darker, uneven surface,

movement around the individuual), adding complexity to the task (reading while walking, doing

multiplication tables while balancing on a Dyna-disc) simulates "lifelike" situations and provides

opportunity for the therapist to train the patient in integration of postural control.

PATIENT. OR CLIENT-RELATED

INSTRUCTION: EDUCATION AND SAFETY

Even if patients have the potential for improving their postural control over time, the risk for

falls may be so great that compensatory strategies will be required. Teach patients to stop, hold

onto a stable surface, and refocus if they feel dizzy or unbalanced. When turning, they should

move their eyes first, focus, and then turn their head and body to help minimize dizziness.

All individuals should be taught to identify safety hazards at home and in the community, for

people poor balance, hazards might include poor lighting uneven surfaces, and visually conflicting

environments. Compensation for such hazards might include using night lights, carrying pocket

flashlights. securing throw rugs, and safely using extension cords. A home safety checklis should

be used to assess environmental hazards and help educate the patient, client, care provider, and/or

family. Safety checklists typically include external factors that impact fall risk but should review

internal factors to heighten awareness of risks.

INJURY PREVENTION OR REDUCTION

A primary focus of fall prevention and balance intervention is to reduce or prevent injury

from falls. The previously mentioned interventions strengthening, ROM general conditioning, use

of assistive devices, sensory and multisensory training, vestibular rehabilitation and patient

education, as well as environmental modification-can all be used to reduce or prevent injury from

falls. Research regarding the effect of external hip protectors on reducing injuries from falls is

equivocal, with some studies suggesting that these are helpful and others reporting no benefit. A

RCT with 561 subjects in the Netherlands, including individuals residing in nursing home as well

as those residing in the community, found that hip protectors did not prevent hip fracture: 4 out of

18 fractures in the intervention group occurred while hip protectors were being worn.

The most important considerations in making home modifications to reduce falls are

modifications of surface lighting, obstacles, and activity in the home (see Chapter 35). Adding

grab bars and other safety devices to bathrooms may help reduce the risk of falls. However, some

evidence suggests that changging a familiar environment may increase the risk of falls for the

elderly, particularly they are used to using furniture in its current location for maintaining balance.

CASE STUDY 13-1

BALANCE

Examination

Patient History