This document discusses vestibular rehabilitation and balance exercises. It notes that management of balance disorders can be challenging, and that untreated balance disorders can greatly impair quality of life. It recommends physical exercises, especially for peripheral vestibular disorders. Various types of balance exercises are described, including Cawthorne-Cooksey exercises, customized programs, Wii games, and home-based video modules. Benefits include reducing dizziness and improving postural control. Indications and contraindications for therapy are provided. Research on a home-based video module for balance exercises in multiple languages is summarized.

1. 1

2. • Management of balance disorder cases is
challenging and controversial
• A lot of conflicts and unresolved issues raised byA lot of conflicts and unresolved issues raised by
clinicians and researchers on theclinicians and researchers on the diagnosis andand
treatment of vestibular disorderstreatment of vestibular disorders
• If untreated, the quality of life balance disordered
patients can be greatly impaired.
2

3.  Selection of appropriate treatment of Central and
Peripheral Vestibular Disordered is undoubtedly
important to assist them to reach the desired
recovery.
 Physical exercises have been shown to help
patients with balance disorders especially
peripheral vestibular disorders cases
3

4. WHAT IS VESTIBULAR
REHABILITATION?
4

5. 5

6. Benefits of balanceBenefits of balance
exerciseexercise
• Reduce the symptoms: dizziness, nausea and
vomiting.
• Increasing postural controlling system.
• Could help patient to accept all weakness or
disease that they faced (familiarized and
adaptation).
6

7. Cont..Cont..
• Prevent from any accident or fall
• Avoid to get psychology signs; palpitation, panic
and others, like those to be faced by chronic
vestibular patient.
• Enhance personal confidence level and increase
quality of life (QOL).
Knowledge sharing Malaysia-Pakistan 7

8. Indications for therapyIndications for therapy
1. General interventions for vestibular loss
- Unilateral loss-vestibular neuritis
or acoustic neuroma (Topuz et al. 2004; Hall et al, 2004;
Enticott et al, 2005).
- Bilateral loss-gentamicin toxicity and related conditions.
1. Fluctuating vestibular problems.
To prepare for anticipated dizziness rather
permanent change in their present
vestibular situation.
- Meniere's syndrome
- Perilymphatic fistula
Knowledge sharing Malaysia-Pakistan 8

9. CONT..CONT..
3. Empirical treatment when the diagnosis is unclear.
- Post-traumatic vertigo
- Multifactorial disequilibrium of the
elderly
3. Psychogenic vertigo for desensitization
Psychological counseling (CBT), with vestibular
rehabilitation may be helpful in patients who
have no significant emotional disorder that
aggravates their vestibular problems (Andersson,
2006; Holmberg, 2006).
9

10. • Vestibular rehabilitation reduces severity of
agoraphobia in persons with agoraphobia and
vestibular dysfunction (Jacob et al, 2001).
5. Acoustic neuroma
5. A stroke, head injury or concussion
5. A history of inner ear problems
5. Diabetes
10

11. 11
- Mal de Debarquement or
"MDD“ or MdDS
- Vertigo and imbalance that
occurs after getting off of a
boat.
http://www.dizziness-and-balance.com/disorders/central/mdd.html

12. 12
VIDEO

13. Types of balanceTypes of balance
exercises?exercises?
 Cawthorne cookseey exercise (CCE) (Adapted
from Dix and Hood, 1984 and Herdman, 1994;
2000)
 Customised CCE
 Bal Ex : Homebased video module for balance
exercises = customised CCE +Prayer movement
 Wii games
 Optokinetic stimulation
13

14. Cawthorne Cooksey ExercisesCawthorne Cooksey Exercises
(Adapted from Dix and Hood, 1984 and Herdman, 1994; 2000)(Adapted from Dix and Hood, 1984 and Herdman, 1994; 2000)
• In bed or sitting
o Eye movements -- at first slow, then quick
• up and down
• from side to side
• focusing on finger moving from 3 feet to 1 foot away from face
o Head movements at first slow, then quick, later with eyes closed
• bending forward and backward
• turning from side to side
• Sitting
o Eye movements and head movements as above
o Shoulder shrugging and circling
o Bending forward and picking up objects from the ground
• Standing
o Eye, head and shoulder movements as before
o Changing form sitting to standing position with eyes open and shut
o Throwing a small ball from hand to hand (above eye level)
o Throwing a ball from hand to hand under knee
o Changing from sitting to standing and turning around in between
• Moving about (in class)
o Circle around center person who will throw a large ball and to whom it will be returned
o Walk across room with eyes open and then closed
o Walk up and down slope with eyes open and then closed
o Walk up and down steps with eyes open and then closed
o Any game involving stooping and stretching and aiming such as bowling and basketball
14

15. Customized Cawthorne-Cooksey Exercise (CCE)Customized Cawthorne-Cooksey Exercise (CCE)
15

16. DISCODISCO
BALLBALL
• A mirrored "disco ball" to
provide optokinetic
stimulation for patients
with vestibular disorders.
• All of these techniques
"involve some degree of
innovative technology to
assess treatment
effectiveness,
measurement of vestibular
function, or reveal
behavior in people with
vestibular dysfunction," Drs.
Schubert and Ryan write.
16

17. Wii gamesWii games
• Alternative and recent innovative of vestibular
rehabilitation
• Nintendo Wii
17

18. Home-based Video Module
for Balance Exercises
18

19. Arabic
Malay
English
Nigeria
Hokkien
Indonesian
Mandarin Persian Tamil
Japan
France

20. Experiences withExperiences with NationalNational
Hospital for Neurology andHospital for Neurology and
Neurosurgery, Central LondonNeurosurgery, Central London
20062006
20

21. 21
Home-based and video guide
 Nine different languages (Malay, English,
Mandarin, Tamil, Hokkien, Nigeria, Parsian and
Arabic) to help patients with various balance
disorders
Consists of 20 movements (divided into 3 levels)
targeting specific functions of balance organs
Adaptation from Customized Cawthorned
Cookseey Exercise and prayer movement

22. - Head & neck
- Eye focusing
- Heaviness of the neck
Knowledge sharing Malaysia-Pakistan 22
- Positioning
- Daily activities i.e
prayer, up and
down
• Return to normal
daily activities
LEVEL 1 LEVEL 2
LEVEL 3
22
- Postural
- Increase the postural
control
- Return to normal
walk, running and use a
stair

23. 23
TECHNIQUES HOW TO USE
BAL EX

24. 24
• Under family supervision
• Start the exercise according to doctor or
physiotherapist advice or start the Bal Ex
exercises from the level 1 till level 3
• Advicely do the exercise 3-4 times per day
(morning, afternoon and evenng)
• Repeat the movement 20 times for every
movement
• Start the Bal Ex exercises slowly and structuredly
according to your capabilities
• Early session patients normally will experience
balance disorders symptoms i.e nausea,
vomiting, vertigo, unsteadiness and others
uncomfort symptoms
• Same exercise ne to be done if the symptom
persistancely there till the symptoms resolved

25. 25
• Once that exercise success (no symptoms of
vertigo, nauea and vomiting), patients can
proceed with the second step 1b and so on till the
end.
• In the begining please aviod from doing the full
step ( 1-20) at the same session.
• Once all the 1-20 movement succussfully done,
you can practice the whole 20 movement at the
same time.
• This Bal Ex modul can be completed after 2 weeks
till 5 months.
• Please don’t do the exercise or
session if you have the symptom of :
- Chest pain
- Shortness of breath
- Felling fainting
- Severe neck or back injury

26. Contraindication for this therapyContraindication for this therapy
• Low blood pressure
• Medication reactions (other than ototoxicity)
• Migraine associated vertigo (although it has been
reported to be helpful nonetheless, e.g. Whitney et
al, 2000)
• Transient ischemic attack -- TIA
• Benign Paroxysmal positional vertigo (BPPV)
(chronic cases only)
26

27. Knowledge sharing Malaysia-Pakistan 27
A STUDY OF THE NEUROCOGNITIVE STATUS IN PATIENTSA STUDY OF THE NEUROCOGNITIVE STATUS IN PATIENTS
WITH PERIPHERAL VESTIBULAR DISORDERS (PVD) USINGWITH PERIPHERAL VESTIBULAR DISORDERS (PVD) USING
SELECTED NEUROLOGICAL TESTSSELECTED NEUROLOGICAL TESTS
(BAL EX MODULE & Customized Cawthorne Cookseey(BAL EX MODULE & Customized Cawthorne Cookseey
Exercise)Exercise)
2 year project 2009-2011 (RESEARCH UNIVERSITY GRANT2 year project 2009-2011 (RESEARCH UNIVERSITY GRANT
99,00099,000
In general, MVVSS and MMSE did not change after
the exercise .
P300 and late latency response (P1 and N1) did
show some improvement after using Bal Ex.
It is common that the physiological changes happen
first before the patients can actually notice the
improvements (as reflected by MVVSS & MMSE).

28. VESTIBULAR
COMPENSATION
28
Patient 1
Video before tx
Video after tx
Video after tx
Patient 2
Video before tx
Video after tx

29. Process occurred during therapyProcess occurred during therapy
29
1. Plasticity
2. Formation of internal models
3. Learning of limits
4. Sensory weighting

30. Factors that leadFactors that lead
to poorto poor
compensation ?compensation ?
30

31. -drugs with action upon the central nervous system (importantly including vestibular suppressant drugs),
and co-morbid systemic disorders.
PLEASE BE TOO SELECTIVE AND CONFIRM BEFORE YOU THINK TO START ANY MEDICATION
SOMETHING IT NOT HELP.
Luxon LM, Davies RA, eds. Handbook of vestibular medicine. London: Whur Publishers,1997.
Knowledge sharing Malaysia-Pakistan 31

32. Knowledge sharing Malaysia-Pakistan 32
http://bal-exercise.blogspot.com/
http://balexstroke2011.blogspot.com/
VIDEO

33. Presented by BALEX Researchers

34. BALEX Research GroupBALEX Research Group

35. Current and future innovationsCurrent and future innovations
1. Bal Ex : Home-based
Video Module for Balance
Exercises
2. Bal Ex Stroke: Home-based training
Module for Stroke rehabilitation
3. Bal Ex Zuraida-shah rotatory chair
4. STAND UP
5. Wheelsaver
6. Bal Ex Foot
7. Bal Ex AUTOFIS

36. 36
GOLD MEDAL MALAYSIA
TECHNOLOGY EXPO 2012
Bal Ex Homebased TrainingBal Ex Homebased Training
Module for StrokeModule for Stroke
RehabilitationRehabilitation

37. Home-based Video Module for Balance Exercises

38. BAL EX VIRTUAL ROOMBAL EX VIRTUAL ROOM

39. Bal Ex Stroke : Home based training Module
for Stroke Rehabilitation
Bal Ex Stroke : Home based training Module
for Stroke Rehabilitation
MALAYSIA
TECHNOLOGY
AWARD 2012(GOLD
MEDAL AWARD)
The ONLY home-based and video guided stroke rehabilitation available in 15 different
languages(Malay, English, Mandarin, Tamil, Indonesian, Japanese, Thailand, Korean,
Cambodia, Arabic, Persian, France, Russia, Sindhi and Urdu) to help patients with
stroke problem

40. Bal Ex Stroke – GES 2013 (KLCC)Bal Ex Stroke – GES 2013 (KLCC)
Global
Entrepreneurship
Summit 2013, Kuala
Lumpur Convention
Centre, Malaysia.
Visited by:
Malaysia Prime
Minister

41. ZURAIDA-SHAH ROTATORY CHAIR-
ITEX 2013 (KLCC)
ZURAIDA-SHAH ROTATORY CHAIR-
ITEX 2013 (KLCC)
GOLD MEDAL
AWARD - 24TH
International Invention,
Innovation &
Technology Exhibition
2013 Kuala Lumpur
Convention Centre,
Malaysia.

42. STAND UP- Manual Footplate for
Balance Rehabilitation
STAND UP- Manual Footplate for
Balance Rehabilitation
• The ONLY manual
footplate balance with
structure manual book,
protocol and video guided to
help patients with various
balance disorders
• Was developed by doctors,
scientists specializing in the
vestibular engineering field
• Consists of 11 movements
(divided into 7 steps)
targeting specific functions of
balance organs (Prayer
Movements)

43. SPECIAL
AWARD
BY -
Association
of Polish
Inventors
Rationalize
s Poland
STAND UP-
ACHIEVEMENT
STAND UP-
ACHIEVEMENT
PECIPTA 2013PECIPTA 2013

44. PECIPTA 2013 – GOLD WINNER AWARDPECIPTA 2013 – GOLD WINNER AWARD

45. INNOVATION & INVENTION COMPETITION
On 25 & 26 August, 2013 Perpustakaan Negeri
Kelantan. Organized by PETRONAS
Awards:
1) Open Category Special Jury Award
2) Invention Award
STAND UPSTAND UP

46. I-INOVA 2013 - Bronze Awards
STAND UPSTAND UP

47. WHEELSAVER- AUTOMATED
CONTROLLER FOR WHEELCHAIR
WHEELSAVER- AUTOMATED
CONTROLLER FOR WHEELCHAIR
WHAT IS WHEELSAVER?
Wheelsaver is an automatic
control device that can be used in
any existing wheelchair or a new
wheelchair. With low cost,
patients are able to own an
electric wheelchair or automated
to facilitate their movement. As
we note an electric wheelchair
very high price and some fetch
more than RM 10,000.

48. ACHIEVEMENT-
BIO MALAYSIA 2013
ACHIEVEMENT-
BIO MALAYSIA 2013
GOLD WINNER AWARD
Bio Malaysia,
PERSADA, Johor Bahru,
Johor.

49. Bal Ex FootBal Ex Foot
49
A modified shoes for this stroke patient to
improve their gait and avoid further
complication

50. ACHIEVEMENT-ACHIEVEMENT-
1. Zuraida Z, Mohd Normani Z, Dinsuhaimi S, Mohd Darimi Y, Zamri H.
Silver Medal for BAL-EX; Home based video module for balance
exercises in MALAYSIAN TECHNOLOGY EXPO 2010, 26 February
2010 PWTC, KL (INTERNATIONAL)
2. U BALANCE ANUGERAH SANGGAR SANJUNG BAGI KATEGORI
KUALITI for BAL-EX; Home based video module for balance
exercises 17 March 2010 USM Pulau Pinang
3. Zuraida Z, Mohd Normani Z, Dinsuhaimi S, Mohd Darimi Y, Zamri H.
ANUGERAH SANGGAR SANJUNG BAGI KATEGORI
PENGKOMERSIALAN for BAL-EX; Home based video module for
balance exercises 17 March 2010 USM Pulau Pinang

51. 4. Winner ( 1st place) for management categories BAL-EX; Home
based video module for balance exercises HEALTH CAMPUS ICC
CENVENTION 2010
5. Gold Medal award for BAL-EX; Home based video module for
balance exercises Konvensyen ICC Wilayah Pantai Timur 2010 di
Hotel Renaissance Kota Bharu pada 26 - 27 Julai 2010
6. 2 star for BAL-EX; Home based video module for balance exercises
MPC ICC National
Convention 7-9 October 2010 in Genting Highland
7. Silver Medal & 3rd place for the Management category BAL-EX;
Home based video module for Balance exercises Bal 7th IPTA ICC
Convention hosted by Universiti Putra Malaysia
8. SILVER MEDAL Intelligent balancing system for patients with
balance disorder for clinically used EKSPO REKACIPTA DAN
PAMERAN PENYELIDIKAN UNIMAP11 JANUARI 2012

52. 9. Gold Medal award for Zuraida z et al. BAL-EX STROKE; Home
based training module for stroke rehabilitation Home based video
module for balance exercises in MALAYSIAN TECHNOLOGY EXPO
2012, February 2012 PWTC, KL (INTERNATIONAL)
10.Winner ( 1st place) for management categories BAL-EX STROKE;
Home based training module for stroke rehabilitation HELATH
CAMPUS ICC CENVENTION 2012 Gold Medal award for BAL-EX
STROKE; Home based training module for stroke rehabilitation 2012
Gambang Resort City Pahang pada 4 - 5 Julai 2012
11.Gold Medal award with three star for BAL-EX STROKE; Home
based training module for stroke rehabilitation KIK National Level
KLCC Kuala Lumpur October 2012
12.Top 10 Finalished for ANUGERAH INOVASI NEGARA (Service
category) KLCC, Kuala Lumpur 5-7 November 2012

53. 13. ITEX Gold Medal For BAL-EX ZURAIDA-SHAH ROTATORY CHAIR
24th
International Invention & technology exhibition ITEX 2013, Kuala
Lumpur Malaysia,
9th
– 11th
May 2013.
14. Jury Awards And Gold Winner For STAND UP- MANUAL
FOOTPLATE FOR BALANCE REHABILITATION in Pustaka Negeri
Kelantan Innovation and design competition 2013 Organize By
Petronas
15. Gold Winner for AUTOMATED CONTROLLER FOR
WHEELCHAIR, Biomalaysia, Bioeconomy Asia Pacific | 21 – 23
October 2013, Persada Johor International Convention Centre.
16. Bronze Medal Award, For STAND UP- MANUAL FOOTPLATE FOR
BALANCE REHABILITATION in I-Innova’13 Ekspo Inovasi Islam
1434 H, Stadium Tertutup Nilai Negeri Sembilan.

54. 17. Gold Winner For STAND UP- MANUAL FOOTPLATE FOR
BALANCE REHABILITATION in Pecipta’13 Transforming Research &
Innovation Towards Commercialisation, 7- 9 Nov 2013 | Kuala
Lumpur Convention Centre Malaysia.
18. Special Awards By Association of Polish Inventors Rationalizes
Poland. For STAND UP- MANUAL FOOTPLATE FOR BALANCE
REHABILITATION in Pecipta’13 Transforming Research &
Innovation Towards Commercialisation, 7- 9 Nov 2013 | Kuala
Lumpur Convention Centre Malaysia

55. THANK YOUTHANK YOU