on the floor with eyes closed, (3) standing on a compliant foam mat with eyes open, and (4) standing on foam with eyes closed. The mCTSIB is a modified version of the familiar “Foam and Dome” test (CTSIB), where the two conditions of using a dome to create visual conflict are eliminated. The four conditions systematically alter somatosensory inputs and eliminate visual inputs to determine whether the patient is able to utilize remaining sensory inputs to maintain balance. Condition 1 is the baseline assessment in which visual, vestibular, and somatosensory inputs are available. In condition 2, vision is occluded, leaving somatosensation and vestibular inputs responsible for maintaining balance. When standing on foam in condition 3, somatosensory inputs are rendered less reliable (not absent), requiring vestibular and visual inputs for maintaining static postural control. Patients with vestibular loss often lose their balance under condition 4, where vision has been occluded and somatosensory information has been altered; thus, the patient must rely primarily on effective vestibular information to maintain orientation to upright. Although the mCTSIB provides insight into the effectiveness of integration of visual, vestibular, and somatosensory inputs in driving postural control, it cannot be used as a diagnostic tool. For this and all functional outcome measures, findings must be clinically correlated with a comprehensive impairment-level sensory and motor examination to gain a clear clinical picture of the contributing factors underlying the deficits in balance and mobility to develop a targeted plan of care. While these standardized tools have been well accepted measures of balance and functional mobility, they do not assess balance during higher level locomotor activity, or while incorporating head turns, a very important component of assessment for patients with vestibular dysfunction. Other standardized assessments of postural control that incorporate functional tasks during locomotor activity, such as walking with head turns and negotiating obstacles, and provide a scoring system to quantify the degree to which the patient can maintain postural stability while performing these functional mobility Patient self-report measures Self-report measures are standardized assessment tools that aim to quantify the degree of limitation the patient is experiencing. Measurement of health status regarding level of function, disability, and quality of life provides valuable insight to understanding the impact a condition has on the individual patient, and helps the clinician develop a tailored intervention program to address those individual barriers to recovery. Information from self-report measures should be cross- referenced with information gathered on clinical examination to create a comprehensive clinical picture, and because the patients’ perception of their condition can lead to over- or underestimating their level of limitations. These outcome measures can offer information regarding the amount of change the patient has experienced in self-management, returning to their previous roles, and quality of life through rehabilitation. Self-report measures can be generic, in that they measure general function or quality of life in any patient group. Examples of such measures are the Short-Form-36 Health Survey (SF- 36) and the Functional Independence Measure (FIM). The limitation of using generic measures in patients with vestibular disease is that they are not sensitive enough to capture the impact of the patients’ condition on their everyday lives. For that reason, condition- specific outcome measures are used. These measures often assess different aspects of disability, so the clinician’s selection of specific tools should be guided by the measurement properties of the tool as well as the particular domains of the condition the tool aims to measure. Self-report measures widely used by physical therapists in patients with vestibular disease include the Motion Sensitivity Quotient (MSQ), the Vertigo Symptoms Scale (VSS), the Dizziness Handicap Inventory (DHI), the Vertigo Handicap Questionnaire (VHQ), the Vestibular
tasks, are important to include in the vestibular examination. The Dynamic Gait Index (DGI) and the Functional Gait Assessment (FGA) are two such tests that are useful to measure postural control in patients with vestibular disease. The DGI assesses the patient’s ability to maintain balance during walking with head turns, negotiating obstacles, and changing direction; speed of walking is measured. Eight items are scored on a 0 to 8 scale with a maximum score of 24. A DGI score of less than 19/24 was found to be able to predict fall risk in patients with vestibular disease (Whitney, Hudak, et al., 2000). The FGA is a modification of the DGI, including more challenging tasks to reduce the ceiling effect seen in the DGI for higher functioning individuals with balance limitations. The FGA has 10 items scored on a 0 to 3 scale, with a maximum score of 30 points. Some of the modifications include walking backward and with eyes closed, which is particularly difficult for persons with vestibular dysfunction. The DGI has been validated for use in patients with vestibular dysfunction (Wrisley et al., 2004) with a score of 22/30 or less to be 100% sensitive and 72% specific in predicting fall risk in the community-dwelling adult population (Wrisley & Kumar, 2010). This test can also provide information to help the clinician develop treatment strategies based on the components of functional mobility found to be most difficult for the patient. Observational gait assessment is another important component of examination of postural control. The presence of deviations such as asymmetrical step length, slowed cadence, guarded movements, diminished reciprocal movement ( en-bloc ), widened base of support, or veering from a straight path are all indicative of difficulty with postural control. Although these standardized tests can determine the extent of functional mobility and balance deficits, they are not diagnostic for the presence of vestibular dysfunction, and the findings must be correlated with the impairment level examination to identify the contributing factors to the patient’s mobility limitations. Disorders Activities of Daily Living (VADL) scale, the Falls-Efficacy Scale (FES), and the Activities-Specific Balance Confidence (ABC) scale. The Life Space Assessment (LSA) tool has been recently validated to measure mobility and function in persons with vestibular disorders. Measures of symptom level The MSQ and VSS are tools that measure the degree of symptoms the patient is experiencing. The MSQ quantifies the severity of symptoms provoked by stereotypical movements that were designed for treatment. Seventeen movements such as sitting to supine, coming up to sit from forward bending, and standing and turning, which are typically provocative in patients with vestibular dysfunction, are assessed in terms of the patient’s report of intensity and duration of symptoms. The calculated percentage score provides a level of severity of sensitivity to motion. Items on the MSQ are used to guide treatment programs and document outcomes (Shepard et al., 1990; Smith- Wheelock et al., 1991). The VSS assesses the relationship of emotional and anxiety symptoms with vestibular symptoms. The scale consists of 36 items that ask the patient how often they experienced particular symptoms in the past 12 months. Tally scores of subscale items help to discriminate patient symptoms due to severity of vertigo, autonomic symptoms, and severity of symptoms due to somatic anxiety. The vertigo subscale scores were found to be well correlated with presence of vestibular disease, and anxiety subscale scores were significantly correlated with other measures of anxiety (Yardley, Masson, et al., 1992; Yardley, Todd, et al., 1992).
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