The conceptual framework for balance training is simply summarized here, intended as a review for the practicing clinician. However, a detailed approach to balance training lies outside of the scope of this course but can be found in textbooks dedicated to that aspect of rehabilitation care for those who desire further edification (Bronstein et al., 2011). surfaces, quiet areas, etc.) and gradually progress to more challenging environments (outside, busy malls, etc.), eventually incorporating recreational activities such as golf or tennis gradually. As with any rehabilitation program, safety is of utmost importance. Patients who wish to return to swimming must not swim alone initially and must be advised that ocean swimming poses the challenge of not having an adequate sense of orientation due to lack of visual and somatosensory inputs to determine where one is in relation to gravity, or a sense of the direction of “up.” Biking may not be advisable until the patient can demonstrate higher-level balance skills due to the limitations of somatosensory and visual cues to orient the patient to upright and the advanced postural control required to maintain balance while on the bike.
The clinician gains an understanding of the integrity of the visual, somatosensory, and vestibular systems through comprehensive impairment-level examination strategies, and these findings must be correlated with the results of the mCTSIB to determine safe and effective treatment strategies. Aerobic conditioning Rehabilitation programs for patients with vestibular dysfunction should include some component of aerobic conditioning because many patients will reduce their movement and activity level to manage their vestibular symptoms. Incorporating a physical conditioning program will not only manage or prevent deconditioning, but it will provide functionally relevant balance and vestibular system challenges as the patient moves through various environments, over different terrains, and utilizing different speeds of movement to conform to different environmental demands, such as crossing a street or navigating a crowded sidewalk. Prescribing a walking program four or more times per week is a good place to start. The duration is determined by the patient’s baseline ability. The program should begin with less challenging environments (flat
CASE STUDIES
Case study 1 The patient is a 42-year-old male who presents with a history of persistent vertigo that lasted for a few days without any eventful onset. Now that the persistent symptoms have subsided, the patient is noting transient vertigo with bending forward. His past medical history (PMH) is unremarkable. Examination : Normal sensorimotor and coordination testing, normal oculomotor testing. HIT is positive to the right. Right Hallpike-Dix elicits upward and right torsional nystagmus for 25 seconds. Once that fatigues, a left-beating nystagmus is seen. Left Hallpike-Dix demonstrates persistent left-beating nystagmus without a torsional component. Questions 1. What is your interpretation of these findings? 2. What is an appropriate plan of care for this patient? Case study 2 The patient is a 32-year-old female stockbroker who presents to physical therapy as referred by her primary care provider. She has had persistent vertigo and imbalance for the past few days and is finding it difficult to perform her job; she becomes severely dizzy and nauseated when trying to read the stock ticker boards on the floor of the stock exchange. She denies prior illness or injury. Her PMH is unremarkable. Examination : Normal sensorimotor examination noted. Oculomotor examination with Frenzel lenses reveals right- beating nystagmus with central gaze, which increases with gaze to the right. Vestibular testing reveals a positive HIT on the left. Gait assessment is normal, with mild loss of balance with head turns to the left. The mCTSIB reveals increased sway on conditions 3 and 4 without loss of balance. DVA testing reveals a 4-line degradation. DGI score is 23/24 with difficulty walking with head turns. Questions 1. What is your interpretation of these findings? 2. What is an appropriate plan of care for this patient?
Responses 1. Interpretation : The patient’s initial history of vertigo is suspect for vestibular neuronitis. The positive HIT to right confirms right unilateral vestibular hypofunction. Given that vestibular neuritis can result in posterior canal BPPV due to otolith degeneration, the positive right Hallpike-Dix test is not a surprising finding. The persistent left lateral nystagmus may present as a confounding finding. However, recall that vestibular neuronitis typically affects the superior portion of the vestibular nerve, which can result in horizontal canal paresis. The Hallpike-Dix position can stimulate horizontal canals, generating directional nystagmus from asymmetry in horizontal canal inputs. 2. The BPPV should be treated first with an Epley maneuver because it is the source of the patient’s primary complaint, and easily treatable. If movement-provoked vertigo does not subside, reassess vestibular function by the HIT and initiate habituation activities as warranted. Responses 1. The HIT and DVA are the most revealing findings for this patient, indicating left unilateral vestibular hypofunction. Her oculomotor exam reveals second-degree nystagmus that follows Alexander’s law and is suppressed by visual fixation – all indicative of a peripheral vestibular deficit. Further, the finding of second-degree nystagmus is consistent with the timing of onset of her symptoms. The fact that her balance tests (DGI and mCTSIB) did not strongly identify balance deficits can be explained by the fact that her age and lack of sensory or motor deficits provide her with redundant resources to compensate adequately for her vestibular deficits to maintain postural control. Her deficit in gaze stabilization is her chief limitation at this point, making it difficult for her to perform her job. 2. Focus on adaptation exercises, starting with X1 viewing, and progressing to X2 viewing. Habituation exercises should also be prescribed, focusing on walking with head turns because this activity was found to be most challenging. The patient should perform these exercises daily and be followed once weekly for reassessment and progression.
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