Balance and Vestibular

Rehabilitation after

StrokeKirsten Ricci, MD

Magdalena Pietz, PT

Adventist Rehabilitation Hospital of Maryland

Rockville, MD

May 8, 2013

Disclosure

�We have no disclosures

Objectives

� Outline the conditions that benefit from

vestibular and balance rehabilitation

� Review current research that discusses

individuals that would benefit from this

type of therapy

� Identify goals and benefits of vestibular

rehabilitation

Importance of the Topic

� Imbalance and dizzy complaints common

� Chronic impaired balance and dizziness cause decreased safety, reduced independence, and increased disability

� Impaired balance related falls:�Hip fractures

�Rib fractures

�Compression fractures

�Shoulder/arm injuries

�Head injuries

�Death

Vestibular System

� Maintains equilibrium or balance by detecting rotational and linear movements

� Integration of: � Visual information – used to provide stable visual image to allow for making adjustments to posture for balance

� Sensory information – afferent input from body regarding position and location of arms, legs, trunk, and head in space

� Vestibular information – vestibular organ in temporal bone that sends information about movement of the head

Vestibular Organ

� 3 perpendicular semicircular canals –

rotation

� Horizontal

� Superior

� Posterior

� 2 otolith organs – linear

� Utricle

� saccule

Vestibular Organ

� Rotational movement

� Vestibular hair cells in

ampulla of each canal

that sense fluid

movement around

circular canal

� Linear movement

� Otolith mass made of

crystal and

glycoprotein that move

over hair cells to

detect shift

Transduction of Signal

� Hair cells � afferent vestibular nerve fiber (via Vestibulocochlear nerve CN VIII) �Vestibular nuclei of medulla

� Vestibular nuclei relays the signal to multiple regions:� Spinal cord (via vestibulospinal tract) for posture control and extensor muscle tone

� Brainstem and cerebellum for management of equilibrium

� Extraocular muscles for coordination of head and eye movements

Parts of the Cerebellum

� Vestibulocerebellum

� Vestibular input and control balance and eye movements

� Spinocerebellum

� Spinal cord input and controls synergy of movements

� Pontocerebellum

� Cerebral input, via pontine nuclei, and controls the planning and initiation of movements

Disorders of the Cerebellum

� Control rate, range, force, and direction of movements – overall synergy

� Damage results in lack of coordination such as:� Delayed onset of movement

� Over or under shooting targets

� Dysdiadochokinesia – unable to do rapid alternating movements

� Intention tremor – increase tremor at the end of movement

� Rebound phenomenon – unable to stop movement when resistance removed

Conditions Associated with

Vestibular Dysfunction

� Peripheral

� Peripheral vestibulopathy

� Benign positional vertigo

� Vestibulotoxic drug-induced vertigo

� Meniere’s disease

� Others such as local bacterial infection,

genetic anomalies, otosclerosis, etc.

Conditions Associated with

Vestibular Dysfunction

� Systemic

� Drugs – anticonvulsants, antihypertensives,

alcohol, analgesics, sedative hypnotics, etc.

� Hypotension, presyncope

� Infectious disease

� Endocrine disease

� Vasculitis

� Others such as polycythemia, anemia,

sarcoidosis, systemic toxins, granulomatous

disease, etc.

Conditions Associated with

Vestibular Dysfunction

� Central

� Brainstem stroke

� Demyelinating disease

� Cerebellopontine angle tumor – ex. acoustic neuroma, metastatic tumor

� Cranial neuropathy - CN VIII

� Intrinsic brainstem lesion

� Posterior fossa lesion

� Seizure disorders

� Heredofamilial disease – spinocerebellardegenerations: Friedreich’s ataxia, olivopontocerebellar atrophy

Central Vestibular Dysfunction

� Disruption to “vertobrobasilar system”

which includes:

� Brainstem

� Cerebellum

� Occipital lobe

� Vertebral arteries

� Basilar artery

Classic Cerebellar Stroke

Symptoms

� Difficulty with eye movements

� Ataxic movements

� Dizziness

� Nausea and vomiting

Dizziness, Vertigo, and Imbalance

Presentation in the ER

� Estimated 7.5 million seen in primary care

and emergency room for primary

complaint of “vertigo”, “dizziness”, and

“imbalance”

� 3.2% diagnosed with stroke/TIA

� 0.7% of those diagnosed with stroke/TIA

had isolated vertigo and dizziness without

other neurological findings

Other Stroke Causes of

Dizziness and Imbalance

� Neglect syndromes

� Hemiparesis

� Pure motor or sensory

� Motor and sensory

� Visual impairment

� Diplopia

� Hemianopsia

Balance Difficulty Post Stroke

� Pure vestibular impairment – rare

� Multifactorial – majority

� Weakness

� Sensory impairment

� Visual impairment

� Perceptional impairment / Neglect syndrome

� Central vestibular impairment

Examination After Stroke

� Evaluate� Nystagmus

� Central oculomotor function

� Vestibulo-ocular reflex battery

� Long tract signs

� Dysarthria

� Dysphagia

� Hemiparesis

� Coordination

� Visual perception

� Posture

� Gait

Outcomes with Treatment of

Isolated Cerebellar Strokes

� Represent small percentage of all strokes

� Study of 58 patients

� 49 ischemic strokes

� 9 hemorrhagic strokes

Functional Independence

Measure

Outcomes with Treatment of

Cerebellar Strokes

� After rehabilitation:� 80% FIM score > 72 (equal to minimal to no assistance with all tasks)

� 66% FIM score > 90 (equal to supervision to functionally independent with all tasks)

� Hemorrhagic more impaired then ischemic stroke at admission and discharge

� Higher functional independence in strokes with vertigo, ataxia, vomiting, and headache without record of hemiparesis and change in consciousness

Effectiveness of Balance Rehab

Program with Visual Cues After Stroke

� Participants with hemiparesis and at least 12 months post stroke

� Isolated single stroke

� No history of vestibular dysfunction or vertigo prior to stroke

� Underwent platform training for correcting balance and postural asymmetry

� Exercises program – one group with vision deprivation and second group with vision allowed

Effectiveness of Balance Rehab

Program with Visual Cues After Stroke

� All improved significantly

� More improvement with vision deprivation

than with vision allowed with exercises

� Thought process is that increased need for

somatosensory and vestibular information to

make up for lack of vision during exercises

caused increase in improvement, but both

groups improved

Techniques to Treat Balance and

Vestibular Dysfunction

� Physical therapy

� Occupational therapy

� Visual rehabilitation

� Vestibular rehabilitation therapy

� Physician evaluation for reversible causes

of dysfunction, such as medication side

effect or hydration status.

Definition

Vestibular Rehabilitation Therapy

(VRT) is an area of physical therapy

that uses specialized exercises to

retrain vestibular system in order to

improve gaze stability and reduce

symptoms of dizziness/ imbalance.

Vestibular Rehabilitation Therapy

(VRT)

If the brain cannot rely on the information it

receives from the vestibular system, a

person’s ability to maintain posture and

coordinate balance can become overly

dependent on vision or on proprioception.

This can lead to developing new patterns

of movement to compensate for the

change.

Vestibular Rehabilitation Therapy

(VRT)

� VRT exercises involve head, body

and eye movements

� Head movements are necessary in

stimulating and retraining the

vestibular system.

Goals of VRT

� Retrain the brain to recognize and process signals

from the vestibular system in coordination with

vision and proprioception.

� Decrease dizziness and visual symptoms

� Decrease risk of falls

� Improve patients’ independence and function

Who would benefit?

Patients whose common clinical

manifestations may include:

a) subjective complaints often lasting for

months or years

- Vertigo

- Nausea

- Dysequilibrium

Who would benefit?

Patients whose common clinical

manifestations may include:

b) symptoms that are associated with

movements of head or body, and/or

increased visual stimulation.

c) history of falls

d) difficulty walking or unsteady gait

Physical Therapy Evaluation

� Medical History/Symptoms assessment

� Type and intensity of sx’s, h/o falls, effect on ADLS

� DHI

� Oculomotor assessment

� Smooth pursuit, Saccades, Head Thrust, VOR, VOR cancellation,

Head Shake, Static and dynamic visual acuity tests.

� Balance assessment

� Static and dynamic

� Berg balance/Tinetti/DGI/FGA/TUG

� Gait assessment

� Neuromuscular / Musculoskeletal assessment

Therapeutic Interventions

� Exercises:

� Habituation

� Adaptation

� Substitution

� Gait training

� Balance training

� Others as needed, e.g., strength, flexibility

Therapeutic Interventions:

Equipment

� Infrared video goggles for visual motor assessment

� Visual target, e.g., business card with letter drawn (E)

� Varied density soft surfaces: foam (Airex), Dynadisc, Aeromat

� Overhead support harness system

(for safety with ambulation activities)

� Dynavision D2

(training visual and motor function)

Therapeutic Interventions:

Equipment

� NeuroCom Balance Master:

Tests the somatosensory, visual and

vestibular systems to help detect sensory

deficits in balance and postural control. It

can also be used to perform sensory

specific exercises to improve deficient

areas.

Equipment

NeuroCom Smart Equi Test Balance Master

Summary

Vestibular Physical Therapy

� Compliance with HEP is crucial

� In central impairments VRT may take

longer time and progress may be limited

� VRT improves patients functional mobility

and safety

References and Resources

1. Brown KE, Whitney SL, Marchetti GF, Wrisley DM, Furman JM. Physical therapy for central vestibular dysfunction. Arch Phys Med Rehabil 2006;87:76-81.

2. Horak FB, Postural compensation for vestibular loss and implications for rehabilitation. RestorNeurol Neurosci. 2010; 28(1):57-68.

3. Klavora P, Warren M. Rehabilitation of visuomotor skills in poststroke patients using the Dynavision apparatus. Percept Mot Skills, 1998 Feb;86(1):23-30.

4. Bonan IV, Colle FM, Guichard JP, Vicaut E, Eisenfisz M, Tran Ba Huy P, Yelnik AP. Reliance on visual information after stroke. Part I: Balance on dynamic posturography. Arch Phys Med Rehabil 2004 Feb; 85(2):268-73.

5. Bonan IV, Yelnik AP, Colle FM, Michaud C, Normand E, Panigot B, Roth P, Guichard JP, Vicaut E. Reliance on visual information after stroke. Part II: Effectiveness of a balance rehabilitation program with visual cue deprivation after stroke: a randomized controlled trial. Arch Phys Med Rehabil 2004 Feb; 85(2):274-8.

6. Rehabilitation Institute of Chicago, IL: Vestibular rehabilitation: Theory, Evidence and Practical Application.

7. Swan L, Yorke A. An Introduction to Vestibular Rehabilitation.

8. NeuroCom Balance Manager Systems. Clinical Integration Seminar

9. www.vestibular.org (Vestibular Disorders Association)

10. www.resourcesonbalance.com

11. www.dizziness-and-balance.com

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6. Nardone A, et al. Balance Rehabilitation by Moving Platform and Exercises in Patients with Neuropathy or Vestibular Deficit. Arch Phys Med Rehabil 2012;91:1869-77.

7. Kerber KA, et al. Stroke among patients with dizziness, vertigo, and imbalance in the Emergency Department: A population-based study. Stroke 2006;37:2484-2487.

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