Vestibular Problems, Balance, and Coordination

Balance

The ability to maintain the center of mass (CoM) over the base of support (BOS)

Coordination

The ability to produce smooth, accurate, controlled movements

Over time strength, flexibility, and cardiovascular fitness dec and the vestibular and afferent neuron input needed for balance and coordination inc.

True

Somatosensory

• Musculoskeletal and neuromuscular components

• Indicated by weakness in LE or trunk and pt relies on looking at the ground for balance

Mechanoreceptors

Sensory receptors that are responsible for converting mechanical events (mvmt, tension) in neural signals that can be sent to the CNS

Muscle spindles

Convery info regarding mm length and rate of length change

Golgi tendon organs (GTO)

Convey info regarding mm tension, located in the musculotendinous junction

What is the PTA’s role in aiding the vestibular system?

• Strengthening

• Stretching

• Progressing balance ex.

• Education

Visual

• Indicated by professional assessment and pt uses wide BOS and reaching for support due to dec reliance on musculoskeletal system

• Ex. glaucoma, macular degeneration, cataracts, etc.

How does catartcts present?

Blurry vision

How does macular degeneration present?

Typically a hole somewhere near the center of vision

How does glaucoma present?

Only the center of vision is clear; like seeing through a keyhole

How does a PTA help visual impaired patients in regards to balance?

• Education

• Adaptation in gait

• Modification of home environment

What are the components of the vestibular system?

• Vestibular apparatus in inner ear

• Cranial nerves

• Spina cord tracts (ascending and descending)

Vertigo

Illusion of movement

Disequilibrium

Sensation of being off balance

Oscillopsia

Subjective experience of motion in objects in the visual environment that are known to be stationary

Lightheadedness

A feeling that fainting is about to occur - may be due to hypotension, hypoglycemia or anxiety

Nystagmus

A vision condition in which the eyes make repetitive, uncontrolled movements - named by the direction it goes

• Causes by congenital neurological problem that develops in early childhood

• Called ”acquired” if it develops later in life

• Can be a symptoms of stroke, MS, or trauma

• Can also be caused by inner ear inflammation, meds (anti-epilepsy), CNS diseases

Vestibulo-Ocular Reflex

Maintaining stability of an image of t he fovea of the retina during rapid head movements

Benign Paroxysmal Positional Vertigo (BPPV)

• Occurs when otoconia have been displaced into semicircular canals

• Dix-Hallpike test - position test used to diagnose this

• Helped by Canalith Repositioning Maneuver (CRM); aka Epley maneuver

Meniere’s disease

• Causes thought to be related to inc in endolymphatic fluid that causes distention of membranous tissues

• Dx confirmed by low-frequency hearing loss and episodic vertigo

• Rx: Pharmacological management, reduced sodium diet, gaze and postural stability

Vestibular Schwannoma

• Aka acoustic neuroma

• Tumor from Schwann cells that commonly occurs in the internal auditory canal

• Rx: surgery, gaze stability ex., postural stability exercises, habituation ex

Multiple sclerosis

• Affects CN 8

• Rx: postural stability, strengthening and general balance exercise

Cervicogenic dizziness

• Patho in the cervical spine and soft tissues causes imbalance or dizziness

• Upper cervical patho sensing proprioceptive that is altered and affects spatial orientation

Berg balance test

Objective measure of static and dynamic balance abilities

• Max score of 56 with scores below 45 associated with high risk of multiple falls

Disability handicap inventory

Standardized questionnaire used to measure a patient’s self-perceived handicap as a result of vestibular disorder

Vestibular rehabilitation benefit questionnaire

Developed to specify the benefits of vestibular physical therapy, includes questions about avoidance behavior

Examples of how to progress balance exercises

• Seated (even → uneven, eyes open → eyes closed)

• Standing (double leg stance → single leg, even → uneven, eyes open → eyes closed

• Surfaces (firm → inc instability), foam, trampoline, BAPS

Performing motor tasks effectively requires not only postural equilibrium, but also effective coordination of the many muscles serving to move and stabilize t he joints on which they cross.

True

How do you document balance interventions?

• Specifics of interventions that show progression

• Include balance strategies

• Education