Vestibular System and Rehabilitation Techniques. Neurological physiotherapy

Vestibular System and Rehabilitation Techniques. Neurological physiotherapy

• 1.
  Dr Zonera Khalid;PT Lecturer at Bolan Medical university and Health sciences, Quetta.
• 2.
  Vestibular system:  Sensoryinformation about motion, equilibrium, and spatial orientation is provided by the vestibular apparatus, which in each ear includes the 1. Utricle 2. saccule 3. Three semicircular canals.  The utricle and saccule detect gravity (information in a vertical orientation) and linear movement.  Sensory hair cells that are activated by movement of inner ear fluid (endolymph).
• 4.
  Peripheral Vestibular System Primary functions includes:  Stabilization of visual images on the fovea of the retina during head movement to allow clear vision.  Maintain postural stability especially during head movement.  Provide information used for spatial orientation.  Specific role is  Relative position of head in relation to compliant or moving surface  Distinguish between exocentric and egocentric motion which frequently confuses the visual system. Egocentric motion perception: Observer may perceive himself as being stationary in a moving surround Exocentric motion perception: Observer may experience an illusion of self-motion, so that the actually moving surroundings appear to be stable
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  Central Vestibular System Many vestibular reflexes are controlled by processes with in the brainstem.  There are connections between vestibular nuclei and reticular formation, thalamus and cerebellum.  Vestibular pathways terminate in cortical area.
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  Central Vestibular System Connection to cortex, thalamus and reticular formation enable the vestibular system to contribute to:  Integration of arousal  Conscious awareness of the body  Discriminate between self movement and environment.
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  Central Vestibular System Cerebellar connection to vestibular system helps in:  Maintain calibration of VOR (Vestibulo Occular Reflex).  Contribute to posture in static and dynamic activities.  Influence the coordination of limb movements.
• 8.
  Physiology and MotorControl  Important system are:  Tonic Firing Rate  VOR  Push & pull mechanism  Inhibitory cutoff  Velocity storage system
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  Tonic firing rate Resting firing rate 70-100 spikes/s.  Head motion can detect inhibition & excitation.
• 10.
  VOR  Maintain stabilityof an image on the fovea of the retina during rapid head movement.  Generate rapid compensatory eye movement in the direction opposite the head movement.
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  Push & Pullmechanism  Brain detects head movement and direction through comparison of inputs between two vestibular systems.  With respect to turning of head:  Ipsilateral horizontal SCC has an increased firing rate.  Contralateral horizontal SCC has decreased firing rate.  A faulty interpretation will lead to disturbance in:  Gaze stabilization  Postural stability  Motor perception
• 13.
  Inhibitory Cutoff  Hyperpolarizationof the hair cells in the opposite labyrinth can decrease the firing rate to zero, at which point the inhibition is cutoff.
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  Velocity Storage System The signal generated by movement of cupula is brief, lasting as long as cupula deflected.  The response is sustained by a circuit of neurons in medial vestibular nucleus.  Lasts > 10 seconds.  Assist the brain in detecting the low frequency head rotation.
• 16.
  Vestibular Dysfunction  Poorsense of upright causing problem with orientation in space  Decreased postural control  Poor gaze stability/ nystagmus at rest/ during movement  Sensitivity/ intolerance to motion  A tonic labyrinthine reflex
• 17.
  Vestibular Disorders  CNSdisorders  Vascular lesions  TBI  Specific peripheral apparatus dysfunction  Acoustic neuroma  Ageing or following whiplash
• 19.
  Assessment  Subjective  Objective Vision- smooth persuit, saccades, visual field  VOR  Motor skills  ROM  Somato-sensation
• 20.
  Assessment  Positional/ Movementtest  Perception of upright  Balance  Functional ambulation measures  High level skills
• 21.
  Oculomotor & Vestibulo-Ocular Testing  Baseline  Eye follow/ head stationary  Saccadic eye movement (is a quick, simultaneous movement of both eyes between two or more phases of fixation in the same direction. The phenomenon can be associated with a shift in frequency of an emitted signal or a movement of a body part or device.)  Head movement/ stationary object  Head movement/ object movement in-phase  Head movement/object movement out-of-phase  Passive head shaking
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  Hallpike Dix Test
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  Hallpike Dix Test
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  Roll Test forHorizontal SCC
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  Motion Sensitivity Quotient
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  Vestibular Rehabilitation  Spontaneousrecovery  Vestibular adaptation  Substitution
• 31.
  Principles to GuideManagement  Decrease overactivity/ tension  Positioning and active inhibition of TLR eg sidelying vs supine, encourage flexion/rotation from supine and extension/rotation from prone, correct sitting and standing  Rocking/ swaying in supported position  Positioning and handling skills to attain length for active holding and during displacement
• 32.
  Principles to GuideManagement  Establish gaze stabilization and progressively challenge this function during re-training to restore both static and dynamic component of the VOR  Decreased dizziness and develop tolerance to motion of the head and body in space  Specific positioning protocols  Habituate the vestibular system with repetitive eye, head, body motion
• 33.
  Principles to GuideManagement  Establish postural control and mobility on firm surface with minimal handling ○ Practice postural holding with eyes closed ○ Initially use slower paced activities that involves head displacement that occurs with normal movement ○ Progress to faster displacements that are externally paced
• 34.
  Principles to GuideManagement  Practice in conditions of visual/ proprioceptive conflict ○ EC on compliant surface ○ Wobble board/ trampoline ○ Use uneven surfaces, terrain ○ Vary the lighting ○ Work in busy crowded environments  Restore general conditioning and endurance  Educate about residual deficits/ safety awareness
• 35.
  Exercise to ImproveGaze Stability  Acute stage  Business card on wall with head moving horizontally for 1 minute  Vertical movement for 1 minute  Repeat exercise then on large pattern i.e; checkerboard vertically and horizontally depending on nausea  Sub-acute stage  Move card and head in opposite direction horizontal/ vertical for 1 min- increase duration
• 36.
  Exercise to ImproveGaze Stability  Chronic stage  Patient fixates on visual target placed on wall in front while bouncing up and down on trampoline
• 38.
  Exercises to IncreasePostural Stability  Feet together – eyes on target in front and head moving R/L for 1 min- increase time  Walk with assistance  Walking with head turning to R/L  Eyes Open- Feet Together and standing heel-toe-arms first stretched then across chest and holding for 5-15 min  Practice above with Eyes Closed
• 39.
  Exercises to IncreasePostural Stability  Standing on foam  Walking backwards  Count backwards as walking  Walk on different surfaces  Walk with tandem stance and then braiding  Walking and turning first in large circles and then small to both sides  Walking on ramps
• 40.
  Exercises to IncreasePostural Stability  Maintain balance sitting on swedish ball and then bouncing or when bouncing on trampoline  Doing above with visual fixation on stationary target facilitating otolith-ocular reflex  Walk in crowded area with flow of traffic and against it
• 41.
  BPPV  Diagnosis isbased on  Latency of 1 or more seconds after head is moved in to provoking position  Gradual reduction in vertigo and nystagmus <60 sec Characteristic nystagmus  Reversal of the nystagmus and recurrence of vertigo when person returns to sitting  Decreased intensity of vertigo with repeated movement in provoking position
• 42.
  BPPV  Other symptomsrelated with BPPV ○ Postural instability ○ Disequilibrium ○ Unsteady gait ○ Sensitivity to head movement
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  BPPV  Canalithiasis  Hallpike-Dixtest ○ Posterior canal ○ Horizontal canal  Capulolithiasis  Brandt-Daroff habituation exercises  Liberatory maneuver
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