Balance Retraining Physical Therapy for the
Physical Therapy AssistantCSN PTA Program - 2009
Brian Werner, PT, MPT
President – Werner Institute
Brian K. Werner, PT, MPT• Master’s Degree in Physical
Therapy– Northern Arizona University –
Flagstaff, AZ
• National Certification of Competency – Vestibular Assessment and Treatment
– Miami School of Medicine: Physical Therapy Department – Miami, Fl (2000)
• Service– Founder, Director and Lead
Clinician of Balance Centers of America: Las Vegas and Henderson (2001-2005) Branch
• Service– Owner and Lead Clinician of the
Werner Institute of Balance and Dizziness, Inc. (11/05 to present)
Is There a Need
• Over 65, third leading MD visit– Number one cause of injury death in seniors
• 2% of all physician visits are due to dizziness
• Last year, over 350,000 hip fractures due to falls– Costing Medicare over $32 billion
• Largest population needing service is seniors
Prevalence of Dizziness • General Population
– Nazareth, et. al, 1999 • Reported 4% of patients 18 to 65 who consult
with GP reported persistent symptoms of dizziness
• 3% considered dizziness “severely incapacitating.”
– This is over 15 million Americans/annually
– Yardley, et al, 1998 (follow-up study of Nazareth)
• One in 10 people of working age experience dizziness with some degree handicap (Yardley, et al, 1998).
• 18 months later concluded:– 24% more handicapped– 20% had recurrent dizziness– 20% improved
– Kroenke, et al (1992)• Patient with initial complaint of dizziness
– Two weeks – 70% no resolution– 3 months – 63% no resolution– 11 months – 47% no resolution
• CONCLUSION: simple observation and reassurance are not appropriate in many cases.
We normally don’t think about our balance systems…but
• Vincent van Gogh committed suicide
• This self portrait was completed in 1889, after he cut off his ear
• We think he suffered from Meniere’s disease
Anatomy of the Balance
System
It is Not Just Your Inner Ear
• Balance control is made of several systems• Sensory
– Vision– Somatosensory– Vestibular
• Integrators– Brainstem/Brain– Past Experience
• Motor Systems– Muscles– Motor Nerves
Balance System Anatomy - Vision
• Signals position and movement of the head with respect to surrounding objects
• Good for slow movements or static tilts of the head
• Control through the Oculomotor reflexes
Visual System
• Orientation and balance are maintained via several visual properties:– Saccades– Smooth pursuit– Optokinetic reflex– Depth perception– Visual cortex centers
specially designed to respond to vertical and horizontal stimuli
• Rehabilitation of these “responses” is available
Balance System Anatomy - Somatosensory
• The largest sensory system
• The primary input for balance control with respect to surface
Balance System Anatomy - Vestibular
• Although anatomically developed and responsive at birth, the vestibular system matures along with other senses in the first 7 to 10 years of life.
• Provides information about the head with respect to gravity and inertial forces.
• Cannot work alone but acts as a judge for the other two sensory systems.
• In most cases of dizziness (over 80%), the vestibular system is the cause.
Anatomy - Vestibular
• Bony Labyrinth– Located in the temporal
portion of the skull
• Membranous Labyrinth– Inner tube like structure
housing fluid and sensors
• Endolymph– Fluid that baths sensors, helps
with transmission of impulses, acts as an inertial drag
• Perilymph– Outside fluid from membrane,
acts as a cushion like CSF for brain, helps with nerve transmission
Vestibular System - Specific
• Semicircular Canals– Ampulla
• Bulbous bony opening that houses the cupula
– Cupula• Sensor/Sail that houses
hair cells
– Canals (Orthogonal)• Anterior• Posterior• Lateral
Anatomy of Vestibular System
• Otolith Organs– Otolithic Membrane
• Where calcium stones, crystals, otoconia sit to act as an inertial mass
– Hair Cells• Project into the
membrane
– Two Organs• Utricle• Saccule
Otolith Organs, Continued
• Utricle– Linear Accelerations– Sits horizontal
• Saccule– Linear Accelerations– Sits vertical
Physiology of the Balance
System
Key is the Inner Ear for Balance
• Inner ear functions as a plum line for which the somatosensory and visual system cue off for stability
• Without vestibular function we can still maintain balance but at a cost– Surface dependent
• Loss of vision/vest– Visual diseases
– Visual dependent• Loss of surf/vest
– Diabetics
The Hair Cell is the Structure You Need to Understand
• This is a really small system– Size of thumbnail– 20,000 haircells/inner
ear
• Stereocilia• Kinocilium
– Toward Excitation– Away Inhibition
Hair Cell Continue…
• Semicircular Canals– Hair cells act like a sail in
the wind on cupula– Deflection of the hair cell
by the inner ear fluid causes the cilia to bend
– The direction and “pattern” of the bending is the message of motion
• YAW, PITCH, ROLL– Head on Neck VCR– Gaze Stability VOR– Postural Stability (Stand,
transfers, gait) VSR
Hair Cell Continued…
• Otolithic Organs– Orientation of hair
cells in the otolith organs help to determine movement of the head
– Unlike SSC, the inertial push on the hair cells is GRAVITY!
How We Measure Balance…
We DON’T Measure Structure – Must Measure FUNCTION
All the PTAs Learn How to Both Test and Assess at the Werner Institute
Types of Technology You Work With In a Vestibular/Balance Clinic
Types of Technology…VNG
• Video-Nystagmography (VNG)– Allows visualization of
the eyes in the dark– Like taking your hands
off the steering wheel of your car
• Helps determine origin of imbalance– PNS/CNS (Mixed)
Types of Technology…VAT
• Vestibular Auto-rotational Test– Measure gaze stability
from 2 Hz to 6 Hz– Determines if balance
disorder is PNS/CNS– Helps determine type
of therapy• Hypo Stimulate
– VOR x 1/ x 2
• Hyper Suppress– Oculomotor
Types of Technology…CDP
• Computerized Dynamic Posturography– Gold standard in
postural standing testing
– Helps determine impairments causing imbalance
• Vision, vestibular, touch
– Quantitative
Common Pathologies of the Balance System
First Principle: YOU Must Know the Dizziness You are Treating
• Dizziness is a non-specific term – it can mean several things:– Vertigo– Motion Sickness– Lightheadedness– Dysequilibrium– Behavior Overlay– Compilation of one or more above
Vertigo
• Illusion of motion• Rotational in nature• Two types:
– Subjective: You feel the motion
– Objective: You see the motion
• Commonly associated with inner ear disorder
Motion Sickness
• This is a mismatch between the visual and vestibular system
• Commonly occurs with:– Cars, boats, airplanes– Usually associated
with vestibular injury
Lightheadedness
• Pre-sycope (impending sensation of passing out)
• Patient complain of wooziness or increased symptoms with exertion
• Many times indicative of cardiovascular disease or origin disorder
Dysequilibrium
• Wobbling on your feet• Feeling of
unsteadiness• Commonly seen in
our geriatric and senior populations
• Vestibular ataxia
Behavioral
• Conversion– Small Pathology– Exaggeration of symptoms– Convert/Hysterical overlay
making symptoms worse– Most common patient we
see in clinic
• Factitious Disorder– No pathology– Volitional exaggeration of
symptoms– Functional overlay
• Somatoform Disorder– No pathology– Diagnosed DSM IV
psychiatric disorder• Depression
• Anxiety
• Panic Attacks
• Malingering– No pathology– Volitional exaggeration of
symptoms– Secondary gain
BREAK
Three Most Common Patients Seen in a Balance Program
• BPPV
• Vestibular Neuritis with consequential vertigo, imbalance, and Fatigue/Disuse
• Non-specific Dysequilibrium
Common Pathologies of the Balance System - BPPV
• Benign Paroxysmal Positional Vertigo (BPPV)– Most Common form of
vertigo– Calcium loosens in the
inner ear canals• Creates an illusion of
movement (vertigo)– Can linger for weeks to
years– Relatively easy to treat with
a repositioning maneuver…as long as you know which canal
• Screw it up and vomit is sure to follow
Common Pathologies of the Balance System – Vestibular System
Inflammation
• Vestibular Neuritis- Labyrinthitis– Inner ear infection– Can occur at any age –
including children– Commonly caused by URI– Sends most patients to the
ER as they think they are having a stroke
• Some may be so it is good they go
– Peripheral injury to the inner ear or to the peripheral nerves
How Do You Treat…Vestibular Neuritis
• Treatment is based on symptoms– Blurred vision Gaze
Stability Exercises• VOR x 1/VOR x 2
– Dysequilibrium Static/Dynamic Balance
• EO/C; PR/SR; HT/N/R
– Positioning Dizziness Habituation
• Repetition in symptomatic position
– Fear Conditioning and positive education
• Pavlov’s dog• You must challenge the
symptoms
Dysequilibrium
• Wobbling on your feet• Feeling of
unsteadiness• Commonly seen in
our geriatric and senior populations
• Vestibular ataxia
• Usually a multisensory disorder– Example: Diabetes
• Visual loss due to retinopathies
• Sensory loss due to neuropathies
• Inner ear loss due to vestibulopathies
Let’s Finish With Treatment
How Does Vestibular Therapy Work?
• How does a figure-skater spin?• How do NASA astronauts go to space or Nellis
pilots tolerate flying a jet?• Adapt and Habituate…to the environment.
• VRT focuses on the plasticity of the central nervous system.– Does not repair the damaged inner ear or
brainstem. – Works on getting the CNS and brain to adapt to
the asymmetrical input from the VOR and VSR. • Analogies for Patients:
– Alternator and Battery System• Inner ears – Alternators• Brainstem – Battery
– Driving a car with the front end out of alignment• Take your hands off the steering wheel
Gentile’s Taxonomy of Tasks
• Body Stable Body Transport– Romberg walking
• Without Manipulation With Manipulation– Holding cup– Using AD– Eyes Open/Closed– Head Turns/Nods
• Closed versus Open Environment– In parallel bars– Over the ground with/without
AD
• No Intertrial Variability Intertrial Variability– Same activities– Variable between each
activity
Types of Treatments Available in VRT/BRT
• Strengthening/Conditioning• Static/Dynamic Balance Retraining• Gait Training• Adaptation Training• Habituation Training• Repositioning Maneuvers• Manual Therapies w/ and w/o modalities and
physical agents• Education/HEPs
How Do You Treat…Dysequilibrium
• Visual Loss– Not much we can do
• Teach use lights at home at night
• Refer to MD for treatment
• Glasses adjusted
• Somatosensory Loss– Proper shoes– Assistive device– Infrared Light Therapy for
DPN
• Vestibular Loss– Re-charge the batteries– Substitution of other
senses• Assistive Device
• Also– Disuse Strengthening– Deconditioning
Aerobic retraining– Fear Conditioning
Therapy or Psych. Consult
CASE I
• Patient is a 78 yo male with a insidious onset of “dizziness” for the past three years. He reports a history of DDD/DJD of the cervical to lumbar spine, diabetes type II, and macular degeneration. MMT demonstrated FAIR PLUS bilaterally in lower extremities.
CASE I
CASE I
Multisensory Dysfunction
Pattern
How To Treat…BPPV
• The key is identifying the affected canal– Dix-Hallpike Test
• Treatment– Epley maneuver
• The key is vertigo in the head down position…
– Semont maneuver• The key is vertigo in the
head down position…
CASE II
• Patient is a 35 year old Cirque du Soleil artist that missed a protection mat during a show and hit her head. She reports every time she looks up or rolls over in bed she has a robust spinning sensation. MRI, CAT scan, X-rays are all negative for neurological or bony injury.
CASE II
Always Looking For PTAs… We Do Rotations in Balance – please call
Jim Schiemer, PT at 880-1515.