OBJECTIVES BALANCE EVALUATION COMMON CAUSES OF BALANCE DEFICITS POST TBI BRAIN INJURY BALANCE RELATIONSHIP
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1 OBJECTIVES Understand variables that contribute to balance deficits Understand the relationship between a brain injury and balance Become familiar with the components of a vestibular/balance assessment Describe common treatments for balance impairment after brain injury BRAIN INJURY BALANCE RELATIONSHIP COMMON CAUSES OF BALANCE DEFICITS POST TBI 23-81% of persons with TBI have dizziness and lack of balance DIZZINESS PRESENTATION: Umbrella term Spinning/vertigo Feeling off Unsteady Lightheaded MEDICATIONS Side effects (cardiac, tranquilizer, blood pressure, anti seizure medication) >4 increased risk for falling VISUAL IMPAIRMENTS COMMON CAUSES OF BALANCE DEFICITS POST TBI BALANCE EVALUATION VESTIBULAR IMPAIRMENTS (whiplash, virus, concussion, etc.) BPPV Labyrinthine Concussion Traumatic endolymphatic hydrops SENSORY IMPAIRMENTS MENTAL HEALTH ISSUES (psychogenic dizziness) Anxiety Depression Systematic testing of the physiological systems responsible for balance MUSCULOSKELETAL SOMATOSENSORY VISUAL VESTIBULAR
2 BALANCE EVALUATION BALANCE EVALUATION SOMATOSENSORY Sensory discrimination Impaired or absent MUSCULOSKELETAL Strength testing VISUAL Oculomotor testing VESTIBULAR Inner ear/body relationship OCULOMOTOR ASSESSMENT The relationship between what we see, how the brain processes and the motor response. This interaction allows a person to stay balanced in both static and dynamic situations. OCULOMOTOR ASSESSMENT Spontaneous nystagmus Smooth Pursuit Saccades Gazed Evoked Nystagmus VOR Head thrust DVA Testing VESTIBULAR SYSTEM OVERVIEW 3 SEMI CIRCULAR CANALS Bony Labyrinth & Membranous Labyrinth Angular motion Perilymphatic vs. endolymphatic fluid Ampulla: connects to Utricle Co-Planar pairing OTOLITHIC ORGANS Vertical or linear motion Otoconia Hair cells CNS connections: CN VIII to Vestibular Nuclei to VOR and VSP/VCR: posture and eye stability dynamic/static conditions
3 VESTIBULAR SYSTEM ANATOMY VESTIBULAR ASSESSMENT CNS vs. PNS CNS Disorders: CVA MS TBI Brain tumor AVM CNS Treatment Habituation Compensatory techniques/strategies Environmental modifications Education VESTIBULAR ASSESSMENT CNS vs. PNS PNS Disorders BPPV: Otoconia get out of place and settle in the Semi Circular canal Meniere s disease Vestibular Hypofunction PNS Treatment Canalith Repositioning Maneuvers (CRT) Gaze stabilization exercises Compensatory techniques/strategies Environmental modifications Education PNS VESTIBULAR ASSESSMENT BPPV BPPV Cause Crystal (otoconia) has become dislodged and is floating in one of the SCC BPPV symptoms Attacks spinning/vertigo in certain positions May occur with nausea/vomiting in certain positions BPPV TESTING Dix-Hallpike: Determines which semi circular canal (SCC) is involved based on the nystagmus seen in a clients eyes during maneuver. Upward Beating Nystagmus: Posterior Semi Circular Canal Downward Beating Nystagmus: Anterior Semi Circular Canal Nystagmus should fade within a few seconds (canalithiasis). If nystagmus persists (cupulolithiasis). Roll Test: Test for the horizontal SCC. Downward beating Nystagmus: Cupulolithiasis Upward beating Nystagmus: Canalithiasis DIX HALLPIKE (+) Dix Hallpike (nystagmus)
4 WHAT TO DO NEXT? mctsib RECHECK THE CANALS Are they clear? REHABILITATE THE VESTIBULAR SYSTEM (weak after injury) Head motion Eye motion Body motion CLINICAL TEST OF SENSORY INTERACTION ON BALANCE DEMONSTRATION Firm surface eyes open Firm surface eyes closed Foam surface eyes open Foam surface eyes closed mctsib mctsib helps to determine which balance system is impaired. Firm is somatosensory Foam eyes open is vision Foam eyes closed is vestibular Normal score is 30 seconds in each position with no postural sway Strengthen the vestibular system through input from somatosensory, visual and vestibular stimulation. HEAD MOTION + EYE MOTION = VESTIBULAR FUNCTION
5 CONCUSSION Dizziness: 23%-81% of post TBI Concussion can cause: BPPV Labyrinthine concussion Perilymphatic fistula Unilateral vestibular loss Migraines Diffuse axonal injury Post traumatic anxiety Post traumatic vertigo Central post traumatic vertigo CONCUSSION Treatment Multifactorial Multi-professional PT OT Mental Health CONCUSSION VESTIBULAR/OCULAR-MOTOR SCREENING (VOMS) FOR CONCUSSION Treatment 1. Warm Up 2. Balance Specific Exercises 3. VOR/gaze stabilization exercises (VORx1 & VORx2) 4. Eyes Open/closed 5. Habituation 6. Relaxation 7. HEP 8. Exercise Diary (Kleffelgaard 2016) QUESTIONS?
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