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Fiuggi 2013
LA
RIABILITAZIONE
VESTIBOLARE
Università degli studi di Perugia
Dott. MARIO FARALLI Responsabile del Servizio di Vestibologia
della Clinica Otorinolaringoiatrica di Perugia
VESTIBULAR REHABILITATION THERAPY (VRT)
1) enhance gaze stability
2) enhance postural stability
3) improve vertigo
4) improve activities of daily
living
adaptation
substitition
Goals of VRT
habituation
head eye movements
various body postures and activities
various head and trunk orientation
mantaining balance with a reduced support base
movements provoking vertigo
exposing patients gradually to various
sensory and motor enviroments
The key exercises
for
VRT
VESTIBULAR REHABILITATION THERAPY (VRT)
• Stable vestibular lesion
• Central lesions or mixed central
and peripheral lesions
• Head injury
• Psychogenic vertigo
No evidence of progressive process
Natural compensation appears to be incomplete
VRT is indicated for the following conditions
Shepard NT, Telian SA. Programmatic vestibular rehabilitation. Otolaryngol
Head Neck Surg 1995;112:173-182.
their prognoses are likely to be more limited
than the average patient with a stable peripheral injury
Their conditions often include cognitive
and central vestibular involvement
along with a peripheral component
• Elderly with dizziness
• Vertigo with uncertain etiology
psychiatric intervention will also be required
greater reduction in fall risk
an empirical trial of vestibular physical
therapy may be a helpful option
• BPPV
balance training may be useful sometimes
after treatment BPPV
Shepard NT, Telian SA. Programmatic vestibular rehabilitation. Otolaryngol
Head Neck Surg 1995;112:173-182.
Shepard NT, Telian SA. Programmatic vestibular rehabilitation. Otolaryngol
Head Neck Surg 1995;112:173-182.
Hall CD, Heusel-Gillig L, Tusa RJ, Herdman SJ. Efficacy of gaze stability exercises in older adults with
dizziness. J Neurol Phys Ther 2010; 34:64-69.
Shepard NT, Telian SA. Programmatic vestibular rehabilitation. Otolaryngol
Head Neck Surg 1995;112:173-182.
Shepard N, Asher A. Treatment of patients with nonvestibular dizziness and disequilibrium. In:
Herdman SJ. Vestibular Rehabilitation. 2nd ed. Philadelphia: F.A. Davis Co., 2000;534-544.
Seok JI, Lee HM, Yoo JH, Lee DK. Residual dizziness after successful repositioning
treatment in patients with benign paroxysmal positional vertigo. J Clin Neurol 2008;4:107-
110.
VESTIBULAR REHABILITATION THERAPY (VRT)
• Unstable lesion
• Ongoing labyrinthine pathology
• Meniere
Habituation is impossible
Situations Where VRT Is Not Indicated
Shepard NT, Telian SA. Programmatic vestibular rehabilitation. Otolaryngol
Head Neck Surg 1995;112:173-182.
VESTIBULAR REHABILITATION THERAPY (VRT)
semicircular
canal origin nystagmus
Static signs
Natural course of vestibular lesion
Otolithic origin subjective visual vertical
subjective visual horizontal
ocular tilt reaction
lateropulsion
Dinamic signs
asimmetry VOR
postural instability
VESTIBULAR REHABILITATION THERAPY (VRT)
dinamic
signs
Natural course of vestibular lesion
Otolithic dysfunction
Functional
recovery
static
signs
Semicircular canal dysfunction
Enhancing gaze stability
Vestibular adaptation Substitution by other eye movement systems
Enhancing postural stability
Substitution by vision or somatosensory cues
Enhancing gaze stability
Repeated periods of retinal slip
induce vestibular adaptation.
Yaw and pich
plane are effective
Progressive increase
of retinal slip error
View target moving in
the opposite direction
Various directions of head
movements should be
imployed
Patients should perform exercises for gaze stability four to five times
daily for a total of 20-40 minutes/day, in addition to 20 minutes of
balance and gait exercises.26
Vestibular adaptation
LA RIABILITAZIONE VESTIBOLARE
There is evidence that they help
people overcome chronic dizziness.
Studies have particularly shown that
it is helpful in bilateral vestibular loss
(Herdman et al, 2007),
Gaze stabilization eyes
Indications for gaze stabilization:
• unilateral vestibular disturbances such as vestibular neuritis
• tumors of the 8th nerve removed.
• bilateral vestibular loss.
• Central vestibular disorders
Condition in wich gaze stabilization is not indicated:
• not helpful in positional vertigo
• not tolerated by persons with cervical vertigo
• intermittent vestibular problems that return to normal such as:
• Non vestibular problems – i.e blood pressure fluctuations, medication induced dizziness
migraine associated vertigo
Meniere’s disease
LA RIABILITAZIONE VESTIBOLARE
The aim is to improve vision while
the head is moving, generally while
viewing an earth stationary object.
Gaze stabilization eyes
Daily practice of exercises made progressively more complex and difficult:
• unilateral vestibular disturbances
• tumors of the 8th nerve
• bilateral vestibular loss.
• Central vestibular disorders
• Protocol of head movement
1. Head turn with pause
2. Head turn back and forth continuosly without pause
(sinusoidal, generally slow and medium)
3. Occasionally, one adds in linear movement (angular movements)
• Speed of head movement • target distance while moving head
1. Slow
2. Medium
3. Fast (head thrust)
1. Near
2. far
LA RIABILITAZIONE VESTIBOLARE
The aim is to improve vision while
the head is moving, generally while
viewing an earth stationary object.
Gaze stabilization eyes
Daily practice of exercises made progressively more complex and difficult:
• unilateral vestibular disturbances
• tumors of the 8th nerve
• bilateral vestibular loss.
• Central vestibular disorders
• Background while moving head (multisensory interation)
1. Eyes closed
2. Blank background
3. Busy background (i.e. checkerboard), very busy background (i.e. grocery store)
4. Very busy moving background (i.e crowds, windy outdoors, watching waves
come in)
1. Misleading background (i.e rotating visual surround, twisting golf umbrella,
walking against a crowd moving the other direction, head and target moving in
other direction
LA RIABILITAZIONE VESTIBOLARE
The aim is to improve vision while
the head is moving, generally while
viewing an earth stationary object.
Gaze stabilization eyes
Daily practice of exercises made progressively more complex and difficult:
• unilateral vestibular disturbances
• tumors of the 8th nerve
• bilateral vestibular loss.
• Central vestibular disorders
• head position on trunk
1. Middle
2. Left and right
3. Up and down
4. Roll
• head position with respect to gravity
1. Upright
2. Supine
3. prone
• other things going on that require mental processing by themselves
1. Movement such as walking, treadmill
2. Thinking/talking/driving
Enhancing gaze stability
Substitution by other eye-movement systems
exercise for saccade and vestibulo-ocular reflex exercise for imagery pursuit
Corrective saccades become a part of the adaptive strategy to
augment the diminished slow-phase component of the VOR Schubert MC, Zee DS. Saccade and vestibular ocular motor adaptation. Restor Neurol
Neurosci 2010;28:9-18.
patients with a deficient vestibular system exhibited an
enhancement in the pursuit system, with open- and closed-loop
pursuit gains that were about 9% higher than those of the controls Bockisch CJ, Straumann D, Hess K, Haslwanter T. Enhanced smooth pursuit eye
movements in patients with bilateral vestibular deficits. Ne-uroreport 2004;15:2617-2620.
learn to use stable visual references and surface somatosensory information
use the remaining vestibular function
Enhancing postural stability
identify efficient and effective alternative postural movement strategies
recover normal postural strategies
Goals
Adattamento alle patologie dell’equilibrio
Ricalibrazione
Nuova strategia comportamentale
Memorizzazione e adattamento psicologico
La stabilità della lesione
Eventuali patologie del SNC
Lo stato psichico
L’età
Il tipo di vita
L’uso di farmaci
Lo stato dell’apparato motorio
Le patologie a carico degli apparati compensatori
Patologie intercorrenti
La mancanza di tempo da dedicare agli esercizi riabilitativi
disturbo dell’equilibrio
cronicizzato per difficoltà di adattamento
Bilancio funzionale
Identificazione causa difficoltà adattamento
Rimozione o miglioramento delle cause
(fase plurispecialistica)
Terapia rieducativa non strumentale
domiciliare e/o ambulatoriale
Terapia rieducativa strumentale ambulat.
selezione dei pazienti
e
programmazione protocolli
Indurre abitudine allo stato patologico
Indurre un contrasto sensoriale
Favorire una sostituzione sensoriale
Facilitare un transfer
Ridurre il gain di alcuni riflessi
tecniche
riabilitative Postura e marcia
Oculomotilità
funzioni
cognitive/comportamentali
Protocollo di Cawthorne e Cooksey
Protocollo di Pittsburgh e Miami
Balance coordination training (Bct)
Balance Retraining/Compensation
and Habituation Therapy
Progressive Walking Program
Tecnica Box
Marcia su percorsi memorizzati
Auto-analisi percettiva
Una nuova prospettiva
Premesse:
Una diversa processazione delle informazioni
sensoriali nella genesi dei riflessi e nella
percezione spaziale
La possibilità di introdurre nel sistema informazioni
sensoriali nuove in grado di condizionare le
risposte
0 10 20 30
-160
-120
-80
-40
0
40
80
120
Am
plitu
de, d
eg
Time, sec
1° Trial
2° Trial
5° Trial
Influence of repeated sequences of asymmetric stimulation
on the vestibulo-ocular reflex (slow phases)
0 1 2 3 4 5 6 7 8 9
-30
0
30
60
90
120V
OR
end
poi
nt, d
eg
Trials
Influence of repeated sequences of asymmetric stimulation
on the vestibulo-ocular reflex (slow phases)
0 10 20 30 40
-180
-120
-60
0
60
Imag
inar
y ta
rget
pos
ition
, deg
Time, sec
Influence of repeated sequences of asymmetric stimulation
on the pointing task
1° Trial
2° Trial
5° Trial
1 2 3 4 5 6 7 8 9 10
-50
0
50
100
150
200
250
300
350
Am
plitu
de, d
eg
Trials
VOR end point
Imaginary target position
Comparison between the amplitude of self motion
perception and VOR slow phase
Asymmetric vestibular
stimolation
Final target
Final target
CCW
CW CCW
CW
0 10 20 30 40
-180
-120
-60
0
60
Im
ag
ina
ry ta
rg
et p
ositio
n, d
eg
Time, sec
Asymmetric vestibular
stimolation
Self motion perception in normal subject
VOR
VOR
perception
perception
Criteria for enrollment
Previous unilateral vestibular dysfunction
Recovery of normal function
Clinical evaluation: caloric test,
HST,Vibration,Vemp’s,SVV, posturography
(VSR)
Criteria for enrollment
asymmetricVOR
functionalrecovery
0 5 10 15 20 25 30
-80
-60
-40
-20
0
20
40
60
80
Platform
Qp + Sp
Sp
Am
plitu
de, d
eg
Time, sec
Symmetric vestibular
stimulation
• VOR
Patient 1
0 10 20 30
-60
-40
-20
0
20
40
60
Imag
inar
y ta
rget
pos
ition
, deg
Time, sec
Platform
Pointer
• Perception
Patient 1
Symmetric vestibular
stimulation
0 10 20 30 40
-180
-120
-60
0
60
joestick
X Axis Title
Platform
joestick
0 10 20 30 40
-180
-120
-60
0
60
Platform
Asymmetric vestibular stimulation
• Pointer task
Time
Am
plit
ude
Time
Am
plit
ude
Patient 1
Patient
Previous
dysfunction
VOR (E.O.G.)
Pointing test
(symmetric)
Pointing test
(asymmetric)
C. M.
Dx
Balance
1° Trial 25°dx
2° Trial 35°dx
3° Trial 40°dx
4° Trial 40°dx
Cw 10° sn
Ccw 80°dx
∆ = 90°
F. F.
Sn
Balance
1° Trial 0°sn
2° Trial 5°sn
3° Trial 10°sn
4° Trial 10°sn
Cw 80° sn
Ccw 42°dx
∆ = 122°
A.G.
Sn
Balance
1° Trial 15°sn
2° Trial 20°sn
3° Trial 22°sn
4° Trial 25°sn
Cw 50° sn
Ccw 0°dx
∆ = 50°
Patient Previous
dysfunction
VOR (E.O.G) Pointing test
(symmetric)
Pointing test
(asymmetric)
O.M. Dx Balance
1° Trial 12°dx
2° Trial 5° sn
3° Trial 8° sn
4° Trial 3° dx
Cw 8° sn
Ccw 13° dx
∆ = 21°
Results
VOR
VOR
perception
perception
Paziente 1
Paziente 4
Conclusion
Opposite effect on VOR and self motion
perception following asymmetric input
Asymmetric VOR is always associated with an
asimmetric self motion perception
Asymmetric self motion perception is not always associated with an asymmetric VOR
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