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.