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Vestibular Rehab for Nondizzy Patients: Summary
• Immediately after treatment, the patient may feel worse and more unsteady due to exciting the vestibular apparatus but feel significantly better/see resolved symptoms the following day VOR Retraining • Backbone of vestibular training; used to teach the brain the “new normal” for vestibular quality (learn to either ignore the malfunction or use what is left) • Goal of the exercise: Lock eyes on a stationary target at eye level while shaking or nodding the head; head should move at a speed at which they are able to keep the target in focus • Progressions: ○ Sitting standing walking ○ Change surface type they are standing on ○ Busy backgrounds or different distances ○ VOR ×2: Moving the head and the target in opposite directions • Work up to sets of 60 seconds at a time based on tolerance Gaze Stability • Incorporate gaze stability into ADL training, focusing eyes on a target while doing something functionally or exercising • Looking at a target while walking, swaying, balancing Lasers/Mirrors • Useful for coordinating cervical proprioceptive inputs with visual and vestibular inputs while providing visual feedback • Can help to align body position (e.g., keep laser on a target while balancing or moving) • Find the target: Use a central target; close the eyes and turn the head; keep the eyes closed and try to return to the center target • Maze runner: Use the laser to follow a line or pattern • Can use in a variety of body positions: Sitting, standing, walking Optokinetic Retraining • Used to improve tolerance to visual overstimulation • Can be useful for car sickness • A simulation providing optical illusion of movement so the proprioceptive and vestibular system have to kick in and make adjustments • Have the patient watch for a duration they can tolerate with a 3/10 to 4/10 increase in symptoms; shorten this duration by half and perform reps • Progressions: ○ Sitting standing walking ○ Bigger screen, busier environments ○ Longer durations (60 seconds)
ADL Assessment • Look at movement performance with transfer, dressing, bending, and so on • Does quality of movement decline when head is moving or body is moving (up/down, side/side) • Does balance decline when vision is blocked or not locked on a target? When is the patient trying to concentrate? Balance Assessment • Rhomberg Test : Note sway, intensity, and direction; can be done in sitting: ○ Will tell you the integrity of the vestibulospinal reflexes ○ Firm surface eyes open: All sensory systems working ○ Firm surface eyes closed: Visual system eliminated—test for visual dominance ○ Foam eyes open: Tests coordination between visual and vestibular system ○ Foam eyes closed: Only vestibular system is working • Single Leg Stance : Helps differentiate core/hip weakness versus compromised vestibulospinal reflex • Timed Up and Go : Transfers, gait, and turning ability with little walking distance; low ceiling effect • Functional Gait Assessment : Covers gait techniques and all three sensory systems in a dynamic environment TREATMENTS LEARNING TIP! *For most treatment approaches, vestibular retraining can occur in various positions, depending on the patient’s ability, including standing (with or without assistance), sitting, and/or supine.* BPPV: Posterior Canalithiasis • Typically treated with Epley maneuver: 1. Rotate head to affected side (45 degrees). Lay back, extending head 10 degrees 2. Rotate head to unaffected side (45 degrees) 3. Roll patient's body to the unaffected side with the head still at 45 degrees rotation. The head should be pointing toward the floor 4. Transfer to sitting at the edge of the bed with head in neutral with 5–10 degrees of cervical flexion • Treat the most symptomatic side first • Be sure to hold each position for an appropriate amount of time: Until symptoms stop + 30 seconds
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