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What do you do with a patient who presents with any of these balance problems? Anyone with a history of head trauma  with dysequilibrium, dizziness and/or vertigo, falls History of exposure to environmental/chemical toxins Patients undergoing Chemo or Antibiotic Therapy Whenever an ENG is indicated consider the VAT and the Balance Master Any senior with Hx of Falling or imbalance at risk of Falling Post CVA, Parkinson, Alzheimers c caregiver. Post Joint replacement, hip or knee and amputees, ak or bk.

Three Objectives to Learn 1)  Falling can be prevented      Regardless of Age

A Dangerous Loss of Balance Seniors represent the fastest growing segment of our population est > 75 Million. Dizziness and loss of Balance is the #1 Complaint for our senior population. Each year 40% of our seniors experience falls.

"Balance related falls result in..." Balance related falls result in more than 300,000 hip fractures annually with a mortality rate of 30% within one year

"Solving the Problem:" Solving the Problem:  Diagnostics Identifying individuals at risk Screening - Functional Fall Risk Assessments -                                     Rx-Rx Interaction Analysis P.E. Dx Testing VAT Balance Master Audiometry BSR Visual

Solving the Problem: Rehabilitation   The Treatment Specific Balance Directed Rehabilitation Key Protocols Developed from Specific Diagnostic Finding Individualized for Each Patient BPPV - 95%+ Cure Rate

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What causes Dizziness? Balance occurs at an unconscious level Mechanisms of Balance: Internal, Vestibular- where is my head in space, where is it moving to? Sensory Integration - at CNS level External Visual + Somatosensory   Musculo-skeletal Integrity Conflict of any three   =    perception of movement without actual motion

Central Sensory Integration Cerebro-vascular atherosclerosis Cerebellar atrophy Other Central Neuropathies Post stroke Trauma, chronic or acute Poly-pharmacy

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"Berg Balance Test et al" Berg Balance Test et al 14 elements which provides a quantitative prediction of chance of falling

"Specific Hx focusing on systemic..." Specific Hx focusing on systemic disease that can cause dizziness and balance disorders:

"Specific Hx focusing on Stabilizing..." Specific Hx focusing on Stabilizing Sensory & Integration Systems that can cause balance disorders:

"Dizziness:" Dizziness: assoc sx’s and anatomical locations Inner Ear Hearing loss, tinnitus, pressure, pain Internal Auditory canal Hearing loss, tinnitus, facial weakness Cerebello-pontine angle Hearing loss, tinnitus, facial weakness, and numbness, incoordination Brainstem Diplopia, dysarthria, perioral numbness, extreme weakness Cerebellum Imbalance, incoordination Temporal Lobe Absence spells, visual, olfactory, or gustatory hallucinations

"According to the National Institute..." According to the National Institute of Health 60+% of dizziness involves Vestibular disturbances. The best way to Dx Vestibular Disorders is measure the Vestibulo-Ocular Reflex (V.O.R.) with the Vestibular Autorotation Test (V.A.T.)

Vestibulo-Ocular Reflex vs Vestibulo-Spinal Reflex V O R Generates eye movements to maintain  clear vision while head is in motion Utilizes all vestibular and occular affarents and vestibular nuclei V S R Generates compensatory body movements in order to maintain head and postural stability Receives vertical vestibular inputs

"Interaction between the Internal and..." Interaction between the Internal and External signals Normal use: to fix on a visual target while moving the head. Reflex does not activate until head movement of >2 HZ.

VAT Characteristics High Frequency: 2-6 Hz Active Head Movements Horizontal VOR Vertical VOR Testing in the Light Comfortable - Repeated Testing Portable - Bedside Testing

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"ENG" ENG Measures the function     of only one      semicircular canal          (on the horizontal axis) Measures function at       <1 Hz (non-physiological) VAT Measures the function of all three semicircular canals Measures function at  6 Hz (physiological)

"Determine the patient’s current status" Determine the patient’s current status:      1.  Functional Fall risk assessments           Utilize the Berg, Tinnetti, and Functional Reach Tests        2.  Analyze current movement strategies        3.  Which movements provoke dizziness, vertigo ?        4.  Utilize Neurocom Balance Master to determine:           C.T.S.I.B. - Clinical Test for Sensory Integration of           Balance           L.O.S  -  Limits Of  Stability

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"Balance Retraining - addresses non..." Balance Retraining - addresses non-vestibular disorders, decreased mechanical stability Vestibular Rehabilitation - visual exercises with head and body movement BPPV - Benign Paroxysmal Positional Vertigo Self-Directed - exercises continued at home

"Patient’s with or without vestibular..." Patient’s with or without vestibular dysfunction but with significant visual, musculoskeletal, or somatosensory deficits P.T. focus on enhancing function of non-affected faculties Basis of Support Exercises Muscle strengthening exercises Learn a variety of Movement Strategies

"Adaptation" Adaptation Gaze stabilization exercises - re-adaptation of CNS to differential vestibular inputs Substitution Strengthen remaining sensory inputs to compensate for decreased or damaged input

Effects of Vestibular Rehab on Dizziness and Balance          Prospective, blinded Outcomes for 3 groups: Pt’s in Customized Program of Vestibular Rehabilitation and Balance Retraining Pts in General Conditioning Program Pt’s receiving Rx’s:, Dramamine, Meclizine, etc.** After 6 weeks, only Vestib Rehab Decreased Dizziness;  . .  Horak et al, Otolaryg Hd & Neck Surgery 106:p175;

Problem Oriented Approach  Customized Disease Management Obtain an Extensive Medical History Determine Precise Diagnostic Information from Advanced Instrumentation Identify all Problem Areas during the Evaluation

Treatment Progression Increase and alternate speed of exercises Perform exercises in various positions and activities (sitting, standing, walking, obstacles, etc). Exercise in decreasing visual &/or somatosensory input (eyes open,closed, feet together, wide apart, etc. Change Environment (Curbs, grass, stairs, malls, walking in neighborhood, etc.)

67 y.o. mechanic with a  2 yr Hx of dizziness, progressing to disability.  Rx Meclizine without relief. This is a summary slide of VAT test taken BEFORE VOR retraining.  Note grossly abnormal vertical gain and phase.

Same patient as last slide became asymptomatic after only 3 therapy sessions with the VOR retraining exercises. Note that the vertical gain and threshold in the VAT tracings were NORMAL.

Case Study: 85 yo Male, Recent Multiple Fall Hx,  Fear of Falling

73 yo Female, 10 yr Hx Mal de Barqmont after Ocean Cruise

73 yo Female, 10 yr Hx Mal de Barqmont after Ocean Cruise

73 yo Female, 10 yr Hx Mal de Barqmont -  VAT results before and after Treatment

"Falling related injuries - Major..." Falling related injuries - Major contributor to senior morbidity and mortality Effective screening can ID who’s at risk Accurate Dx: Quantitation of Vestibular and Balance function now possible with VAT et al testing Testing is non-invasive and convenient

"Successful treatment of most Balance..." Successful treatment of most Balance-related Disorders that resulted from Disease and/or Injury Results:      _ 75%+ Returned to normal or         near normal function Seniors reacquire their active lives Reduce their Fear of Falling Decrease their morbidity and mortality from Fall related injuries by 1/3

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