1. Rehabilitation of Balance and Vestibular System Disorders
An introduction to the management of fall risk and vestibular patients.
Arturo Miguel PT, MS, MBA

2. Introduction
Personal Background
Why Balance and Vestibular Therapy?

3. Background
Falls are among the most common and serious problems facing elderly persons
Associated with considerable mortality, morbidity, reduced functioning, and premature nursing home admission
Generally result from an interaction of multiple and diverse risk factors, many of which can be corrected with education and physical therapy (Haddad, 2018)

4. Prevalence (CDC.gov)
Each year, 3 million older people who fall are treated in the emergency room
Risks usually become evident after injury
Additionally, falling is the leading cause of injury related death in seniors
Rate is three times higher in nursing homes and hospitals
Self imposed functional limitations
Recurrent falls are a common reason for admission to long term care institutions (40% of nursing home admissions)

5. Costs (CDC.gov)
Fall related injuries account for 6% of medical expenditures for persons over 65
In 2015, the total medical costs for falls totaled more than $50 billion. Medicare and Medicaid shouldered 75% of these costs.

6. Course Objectives
Observe and identify deficits affecting balance senses and balance systems.
Demonstrate competence in performing balance and oculomotor screens.
Perform fall risk assessment and intervention plan.
Develop and execute evidence based treatment plans for patients with balance and/or vestibular dysfunctions including BPPV and vestibular weakness.

7. What is Balance?
The ability to maintain one’s center of gravity (COG) over a base of support (BOS) in a given sensory environment.
COG is at anterior to S2 in standing
BOS is your feet
Greater base laterally than A/P

8. Motor Response: Balance Strategies
Motor responses start from the ground up
Ankle Strategy
Hip Strategy
Stepping Strategy
Protective Reactions
(Cheng, 2015)

9. Ankle Strategies
Primary strategy for balance
Controls sway

10. Hip strategies
Start when ankle strategies fail. Hips thrust anterior/posterior to shift COG over base of support.

11. What is normal sway?
In an everyday situation where there is minimal sensory inputs, we should rely on our ankle strategies.
A quick down and dirty way to observe sway is a Romberg and Sharpened Romberg Test.

12. Romberg Screen
Simple way to qualify and quantify patient’s standing balance
Have patient stand with feet close together, arms folded, for 20 seconds.
Observe patient for overall sway.
Watch for ankle, hip or stepping strategies.
(Agrawall 2011)

13. Balance Strategies Video
Can you make any observations based on this patient’s balance strategies?

14. Balance Strategies Video #2
Can you make any observations on this person’s balance strategies?

15. Stepping Strategies & Protective Reactions
If hip strategies fail, we take a step in the direction of the COG displacement in an attempt to increase our base of support.
If stepping strategies fail, we extend our upper extremities to protect from fall.

16. Other Strategies “Squat Reactions”
Studies show when a posterior force is such that a person squats or attempts to flex knees in an effort to reduce the forces on spine.
“Hopping Reactions”
Seen mostly in gymnasts when knee flexion is inhibited in response to a proper dismount.
(Cheng, 2015)

17. Question What diagnoses can you think of that may affect a person’s
ankle Strategies?
Hip Strategies?
Stepping Strategies?
Protective Reactions?

18. Balance Systems: Sensory
Three Balance Systems
Vision
Somatosensory
Vestibular

19. Visual System Acuity/Sharpness vs. Oculomotor control
Acts as backup to somatosensory system (Tomamitsu, 2013)
Inputs may become more dependent with age. (Lee, 2017)

20. Somatosensory System Feeling the ground under your feet
Includes sensation and proprioception in the joints
Acts as a backup to the visual system

21. Vestibular System
Senses angular rotation of your head as well as linear acceleration
Stabilizes vision via Vestibulo-Ocular Reflex (VOR)
Acts as a mediator when there is a conflict between the other two sensory systems.

22. Question What diagnoses can you think of that may affect a person’s
Somatosensory system?
Visual?
Vestibular?

23. Somatosensory System Neuropathy (Tosizadeh, 2015 Camargo, 2015)
CVA (Hughes, 2011)
Ankle Injuries (Han, 2015)
MS (Fling, 2014)
LE Amputee (Hunter, 2017)

24. Visual System Parkinson’s Multiple Sclerosis CVA Contrast sensitivity
Impaired visuospacial ability (Hill, 2016)
Multiple Sclerosis
Optic neuritis
Optic neuropathy (Hickman, 2014)
CVA
Visual field cuts
Visuospacial neglect (Winters, 2017)

25. Vestibular System Vestibular hypofunction Meniere’s Disease Concussion
A significant disparity between vestibular function from one side to the other (Iwasaki, 2015)
Meniere’s Disease
Presents with vertigo, pressure in the ear, tinnitus and profound sudden hearing loss (Nakashima, 2016)
Concussion
A mild TBI may result from blunt trauma to the head(Ayers, 2018)

26. Balance Screens Romberg/Sharpened Romberg 5 Times Sit to Stand
Timed Up and Go Test
Berg Balance Scale
Dynamic Gait Index
CTISB
Computerized Dynamic Posturography

27. 5 Times Sit to Stand (5xSTS)
Equipment needed: Chair and stopwatch
Pt performs sit to stand five times without support
Timer starts when pt initiates sit to stand
Timer finishes upon sitting on 5th repetition
Normal times: <13.6 seconds (Guralnik, 2000)
Mean for Parkinson’s: / seconds (Duncan, 2011, Mong, 2010)

28. Timed Up and Go Test (TUG)
Equipment required: Chair, tape and stopwatch
Measure 10 feet from chair, mark with tape
Pt stands, ambulates 10 feet to marker, turns around and returns to sit in chair.
Timer starts upon standing then stops once pt is seated.
Normal time:
60-69 years 8.1 seconds
70-79 years 9.2 seconds
80-99 years 11.2 seconds (Bohannan, 2006, Whitney, 2004)

29. Berg Balance Scale Set of 14 functional tests
Patient is graded 0 to 4 points
Equipment required:
chair
ruler
stopwatch
stool or step
Normal score: >49 (Pereira, 2013)
Goal: Based on the score, up to 4 points in a 4 week period

30. Dynamic Gait Index (DGI)
Set of 8 functional gait tests
Equipment required:
stairs with rails
shoebox or step equivalent
2 cones
stopwatch
Normal score: >19 (Whitney, 2004)
Goal: up to 3 point improvement in a 4 week period. (Johnson, 2011, Herman, 2009)
We use rehab steps in our clinic which has 6 inch steps. This is a great opportunity to assess gait quality. Follow directions and score the lower of the two if there is any doubt…the patient must definitively score in the range to achieve the points.

31. Observing Gait: A Review
Observe your patient the moment they stand up in the waiting room and walk towards the testing area.
Observe overall gait quality
Cadence
Decreased gait speed is associated with an increased mortality (White, 2013)
Decreased gait speed may also be consistent with fall risk (Roos, 2013)
Step length
Step width
Heel strike
Toe off
Arm swing

32. Common Gait Deviations
Antalgic
Ataxia
Spinal involvement (Gilbert 1978)
Cerebellar (Bultmann, 2014)
Shuffling
Parkinson’s (Rahman, 2008)
High Stepping/Foot slap or foot drop (Westhout, 2016)
Trendelenberg (Petrofsky, 2001)
Circumduction, Hip Hike (Burke, 2001)

33. Gait Deviations Video
What observations can you make on this person’s gait quality?

34. Gait Deviations Video #2
What observations can you make on this patient’s gait quality?

35. Clinical Test for Sensory Integration and Balance (CTSIB)
Allows the tester to “isolate” balance systems with different conditions.
“Foam and Dome Test” requires
a foam cushion
a stopwatch
a lampshade-like dome (Whitney, 1998 Haghpeykar, 2003)

37. Computerized Dynamic Posturography
Utilizes force plate technology to qualify and quantify a subject’s use of balance senses as well as perform analysis on postural reactions.
Sensory Organization Test utilizes similar conditions as CTSIB
Considered “Gold standard” for sensory organization and postural testing
(Alahmari, 2014)

38. Neurocom Balance Master

39. Bertec CDP

40. Sensory Organization Test (SOT)

41. SOT Results

42. Demo and Group Exercise
Separate into small groups
Practice each test with each other
10-15 minutes for each group

43. Questions?

44. Treatment Plan Considerations for the Non-Vestibular Balance Patient
Review the impairments and functional limitations
Consider activities that provide the most “bang for the buck”
Keep it simple
Be creative!

45. Examples of Balance Activities in Parallel Bars
Activity
Alternating Tap Ups/Cone Taps
Step-Ups
Lateral Step Ups
Step Up and Overs
Rationale
Promotes rhythmic weight shift, coordination and balance strategies
(Roijezon, 2015)

46. Examples of Balance Activities in Parallel Bars
Activity
Ball Toss while on variable surfaces
Over the shoulder ball toss on variable surfaces
D1D2 Ball Handoff on variable surfaces with weighted ball
Rationale
Promotes coordination, ankle and hip strategies and A/P control
Promotes coordination and balance strategies and incorporates trunk and cervical rotation (Haran, 2008)
Adds strengthening to the above

47. Examples of Balance Activities
Activity
Tall kneeling activities
Activities sitting on a Theraball
Rationale
Helps to promote hip strategies and trunk stability

48. Examples of Balance Activities: Progression
Activity
Standing with head turns while on variable surfaces i.e. firm, foam, balance beam, dyna disc, tilt board
Rationale
Promotes sensory reweighting and balance strategies.
Head rotation stimulates vestibular function.
Variable surfaces promotes hip and ankle strategies.

49. Examples of Gait Activities
Activity
Gait with change speed slow/fast
Gait with gentle head turns
Sidestepping
Crossovers
D1D2Braiding
Rationale
Emphasizes improving gait quality
Head turns stimulates vestibular function with activity

50. Examples of Gait Activities: Progression
Activity
Gait with ball toss
Gait with lateral ball toss
Backwards walking
Rationale
Emphasizes improving gait quality, coordination and vestibular function

51. Patient Example
80 yo pt comes to your clinic with a script that says “PT Evaluate and Treat” dx: deconditioning s/p extended hospital stay
Pt presents with the following observations:
Bilateral PF and DF weakness, hip and knee extensor weakness
5xSTS: 29 seconds (modified using upper extremities for support)
Berg: 43, DGI: 18 without AD
Pos romberg with posterior LOB at 10 seconds with eyes open
List some activities would you consider in your treatment plan?

52. Questions Is this patient at risk for future falls?
What measurable goals can be considered for this patient?
Should we consider recommending an assistive device?
What is the patient’s prognosis?

53. Patient example #2
76 yo female is referred to your clinic with a script that says: PT evaluate and treat dx neuropathy.
Pt presents with the following observations:
Bilateral foot drop when ambulating, steppage gait pattern
Berg 41, DGI 14 with LOB noted when changing gait speed and when performing tap ups onto step as well as step-to pattern when climbing steps.
Falls on CTSIB when standing on foam cushion
Constant reaching for support using walls, chairs and other equipment in clinic.
List some activities that you would consider for your intervention plan.

54. Questions Is this patient at risk for future falls?
What measurable goals can be considered for this patient?
Should we consider recommending an assistive device?
What is the patient’s prognosis?