FYZICAL BALANCE PARADIGM

Transcription

1 FYZICAL BALANCE PARADIGM Each day, you will see patients with dizziness associated with vestibular disease and you will now have a tool to help these patients Conceptual Guideline to the Management of the Balance and Vestibular Disorder Patient

2 1 Contents FYZICAL BALANCE PARADIGM (FBP)... 4 Rationale... 4 Purpose... 4 Evidence... 4 Current Contributors to the FYZICAL Balance Paradigm (FBP):... 5 Rationale... 6 What is Missing with the Conditions?... 7 Rationale for Conditions... 7 Rationale General Presentation of Patient... 8 Rationale Static or Dynamic Training The FYZICAL Balance Paradigm Key Thoughts Within the Stage: Between Stages: Scoring the Paradigm (in progress) Where should I start? Symptom Management: Head Movements Vestibular Dysfunction Visual Vestibular Mismatch (VVM) or Visually Dependent Patients Somatosensory-Vestibular Mismatch (SVM) or the Surface Dependent Patient Somatosensory-Visual Vestibular Mismatch (SVVM) or the Surface and Visually Dependent Patient Visual-Vestibular Dysfunction (Movement Dysfunction)... 25

3 2 Gaze Stabilization Exercise (VOR) Paradigms Description USING THE METRONOME CONVERSION CHART What is Peak Head Velocity (PHV)? Can you give me an example of how to use the Metronome Conversion Chart? So where do you start? How do I determine 30 deg/sec of PHV? What is Recommended? Now that I have my PHV, where do I start? What targets do I use for training the VOR? Visual Vestibular Dysfunction (VVD - VVM) Visual Dependent Visual-Vestibular Dysfunction (VVD- VVM) Visually Dependent (Alternative) Visual-Vestibular Dysfunction (VVD-SVM) - Somatosensory Dependent Visual-Vestibular Dysfunction (VVD-SVM) - Somatosensory Dependent (Alternative) Visual-Vestibular Dysfunction (VVD-SVVM) Surface and Visually Dependent Visual-Vestibular Dysfunction (VVD- SVVM) - Visual/Somatosensory Dependent (Alternative) Visual Dysfunction (VisD) - Complex Visual-Vestibular Patient... 43

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5 4 FYZICAL BALANCE PARADIGM (FBP) The CONCEPTUAL FRAMEWORK Rationale Each year, over 2.2 million people go to their PCP and specialists like OTO and Neuro for problems with dizziness. Many of these people need physical therapy services in the form of Balance Retraining Physical Therapy (AKA: Vestibular Rehabilitation) to reduce and resolve the dizziness symptoms. Moreover, there are millions of people in the US with movement disorders and complex balance problems that also need skilled physical therapy services. Currently, there is no specific balance paradigm in the literature to progress patients with balance dysfunction and only a few paradigms that address progression (Knoll, 2015, Chen, 2013). Vestibular Rehabilitation, 4 th Edition, only gives general guidelines with therapeutic progressions but again, not specific programs. Purpose The purpose of this paradigm is to assist the physical therapist (PT), physical therapist assistant (PTA), Athletic Trainer (ATC), or Trained Technician in a conceptual framework to progress patients in medically necessary rehabilitation. Evidence The FYZICAL Balance Paradigm is based off the evidence-based Clinical Test for Sensory Interaction in Balance (CTSIB), originally developed by Shumway-Cook and Horak in The paradigm is now used as the gold standard for balance testing on Computerized Dynamic Posturography (CDP) as the Sensory Organization Test (SOT) and a modified version called the Modified CTSIB, which does not

6 5 include Conditions 3 and 6. From the CTSIB test paradigm, there is a progressive challenge of the three sensory systems (Vision, Vestibular, and Somatosensory) of the patient through six conditions. I want to thank the members of FYZICAL in helping design the paradigm I could not do it without them. Current Contributors to the FYZICAL Balance Paradigm (FBP): Chester Brown, PT (Las Cruces, NM) Bridget Scholljegerdes, PT (Las Cruces, NM) Kennen Bitton, PT, DPT (El Paso, TX) Mike Rawlings, PT, DPT (Las Cruces, NM) Virginia Reed, PT, DPT (Ft. Myers, FL) RJ Williams, PT, DPT (Henderson, NV) Erin Bryant, PT, DPT (Omaha, NE) Dave Dowdy, PT, DPT (Bonita Springs, FL) James Mortensen, PT, DPT (Las Vegas, NV) Danielle Richie, PT, DPT (Woodstock, GA) Morgan Hind, PT, DPT (Bonita Springs, FL

7 6 Rationale During the Sensory Organization Test (SOT) on the Computerized Dynamic Posturography (CDP), there are six conditions that are measured. These six conditions are based off the classic Clinical Test for Sensory Interaction in Balance (CTSIB). The conditions are: CONDITION INTERACTION Condition 1 All Senses Condition 2 Somatosensory-*Vestibular (Eyes Closed) Condition 3 Somatosensory-*Vestibular (Visual Conflicted) Condition 4 Visual-*Vestibular (Surface Conflicted) Condition 5 Vestibular (Surface Conflicted/Eyes Closed) Condition 6 Vestibular (Surface & Eyes Conflicted/VOR) *Vestibular System is involved but is a secondary input.

8 7 What is Missing with the Conditions? Often it is asked, what about testing the patients for head motion during the testing where is it in the CTSIB paradigm. Many have attempted to add the head turn and nod into the paradigm. This was the Head Shake SOT developed with the NeuroCom/Natus CDP system and in the future the Bertec CDP system. Key: Know that during CONDITIONS 2, 3, 5 and 6, you will incorporate head motion into the treatment. Rationale for Conditions For each condition, there are three senses that are measured: Visual, Vestibular, and Somatosensory. Each Condition has a dominant sensory input during the testing. When writing your flowsheets, you are going to use the symbol capital C to represent Condition and the number 1-6 to represent a specific condition on the SOT or CTSIB. CONDITION Condition 1 (C1) Condition 2 (C2) (Somatosensory-Vestibular Interaction) Condition 3 (C3) INTERACTION Visual field is stable Surface is fixed Vestibular system is engaged Visual field is eliminated (Eyes Closed) Surface is fixed Vestibular system is engaged Visual field is conflicted/gse Training Surface is fixed Vestibular system is engaged

9 8 Condition 4 (C4) Condition 5 (C5) Condition 6 (C6) Visual field is fixed Surface is irregular/compliant/bos narrows Vestibular system is engaged Visual field is eliminated Surface is irregular/compliant/bos narrows Vestibular system is engaged Visual field is conflicted/gse Training Surface is irregular/compliant/bos narrows Vestibular system is engaged Rationale General Presentation of Patient For each condition, there are general patient presentations you are going to see. CONDITION C1 (Grounded) C2 GENERAL PATIENT PRESENTATION During this condition, the patient is just standing with all senses engaged, so this is not a difficult condition to fail. Patients that fail this condition are going to be: Frail and very ill Have severe vestibular dysfunction (may be very acute onset) Very complex and chronic movement disorder Malingering (functional overlay) During this condition, the patient has lost visual input, and the primary sense for balance is somatosensory and secondarily vestibular. Patient with sensory loss in the feet like diabetic peripheral neuropathy will often fall or become unsteady. Patient with visual dependency due to a vestibular weakness will also have an increase in sway, but this is often offset by a healthy somatosensory system.

10 9 (Grounded) C3 (Grounded) Frail and very ill Have a Somatosensory Dysfunction or disease (i.e., Peripheral Neuropathies, Diabetes) Have severe vestibular dysfunction (may be very acute onset) Have severe visual dependency Very complex and chronic movement disorder Malingering (functional overlay) During this condition, the patient is having to Preference the somatosensory system when there is a visual conflict (i.e., a sway reference surround). Patients with the beginning Phases of DPN or patients with VVM often will sway more. Abnormal findings are associated with poor CNS compensation. Frail and very ill Have severe vestibular dysfunction (may be very acute onset) May have beginning stages of somatosensory disease Often will be visually dependent Poor CNS Compensation Very complex and chronic movement disorder Malingering (functional overlay) During this condition, the somatosensory system is disadvantage, so the primary sense for balance is vision and then vestibular. This is called the Visual-Vestibular Interaction. Patients that do poorly during this condition include: C4 (Ungrounded) Frail and Very ill May be surface dependent (Somatosensory Vestibular Mismatch) Vestibular Hypofunction (Often will see an increased hip strategy) Multisensory Balance Dysfunction

11 10 C5 (Ungrounded) C6 (Ungrounded) This is the classic vestibular dysfunction test when both vision and somatosensory are disadvantaged. Particularly with vision, it is eliminated. Patients that do poorly during this test include: Frail or ill Vestibular Hypofunction Multisensory Dysfunction With this condition, again both vision and somatosensory are disadvantaged, the difference is the vision is sway referenced. The CNS should Preference vestibular inputs is here. Abnormal patients will include: Vestibular dysfunction Multisensory Balance Disorders Very ill or frail Rationale Static or Dynamic Training When developing your treatment, you have two choices: Static or Dynamic exercises. When performing C1-C3 exercises, they can only be static exercises with a focus on grounding (i.e., using somatosensory cues to control dizziness symptoms). C4-C6 can be static or dynamic exercises. These are ungrounding exercises and force the patient to challenge balance with reduced somatosensory cues. Below are specific activities that can be used to challenge each of the sensory systems. Note that some overlap. For instance, narrowing the BOS challenges both the somatosensory system and the visual system.

12 11 Note: Patients with deficits on the CTSIB in C1-C3 often will have significant balance disorder, anxiety during testing, and/or may be exaggerating for secondary gain in general. CONDITION C1 - S C2 - S C3 - S C4 - S C4 - D C5 - S C5 - D C6 - S C6 - D STATIC/DYNAMIC Static (Grounded) Static (Grounded) Static (Grounded) Static (Ungrounded) Dynamic (Ungrounded) Static (Ungrounded) Dynamic (Ungrounded) Static (Ungrounded) Dynamic (Ungrounded) The FYZICAL Balance Paradigm

13 12 CONDITION Surface Vision Stages (1 to 4) *Static Only (1-3 CONDITIONS) CONDITION 1 (C1) CONDITION 2 (C2) CONDITION 3 (C3) *Grounded (Stable) *Grounded (Stable) *Grounded (Stable) Eyes Open (Fixed) Eyes Closed 1. GSE 2. Visual Conflict #S1: Supine #S2: Sitting #S3: Standing w/ Support #S4: Standing w/ No Support CONDITION 4 (C4) CONDITION 5 (C5) Un-Grounded (Unstable) Un-Grounded (Unstable) Eyes Open (Fixed) Eyes Closed Static S1: Sitting on Compliant/Irregular Surface S2: Standing Narrowed BOS on Firm Surfaces Dynamic D1: Weight Shifting/ Bending/Stooping/Reaching D2: Walking (All Directions) on Firm Surface CONDITION 6 (C6) Un-Grounded (Unstable) 1. GSE 2. Visual Conflict S3: Standing on Compliant/Irregular Surface with Normal BOS D3: Narrow BOS Walking/ Turning (All Directions)/ Obstacles S4: Standing Narrow BOS on Compliant/ Irregular Surface D4: Narrowed BOS Walking/ Turning on Compliant/ Irregular Surface (All Directions)

14 13 CONDITION Name Stage and Simple Exercises CONDITION 1 (EYES OPEN) GOAL: All senses interacting CONDITION 2 (EYES CLOSED) GOAL: Somatosensory-Vest Interaction CONDITION 3 (EYES CLOSED) GOAL: Somatosensory- Vestibular Interaction CONDITION 4 (EYES OPEN) GOAL: Visual- Vestibular Interaction CONDITION 5 (EYES CLOSED) GOAL: Vestibular Interaction CONDITION 6 (EYES OPEN) GOAL: Vestibular Interaction (Postural) with Gaze System C1-S1 (1) C1-S2 (2) C1-S3 (3) C1-S4 (4) C2-S1 (1) C2-S2 (2) C2-S3 (3) C2-S4 (4) C3-S1 (1) C3-S2 (2) C3-S3 (3) C3-S4 (4) Stage 1 - Supine Rolling and Hold, Head Turns Right/Left Stage 2 Sitting and bending, 7 head positions Stage 3 Standing in P-bars, wall, using a FWW, 7 head Stage 4 Standing unsupported, bending, turning, 7 head Stage 1 - Supine Rolling and holds with eliminated vision Stage 2 Sitting and bending, 7 head positions with eliminated vision Stage 3 Standing in P-bars, 7 head (Static/Dynamic Head Movements), Standing w/ wall support with eliminated vision Stage 4 Standing unsupported, 7 head with eliminated vision (Static and Dynamic Head Movements) Stage 1 Supine with GSE/Visual Conflict (Head Movement) Stage 2 Sitting with GSE/Visual Conflict (Head/Eye Movement) Stage 3 Standing in P-bars on with wall support with GSE/Visual Conflict (Head/Eye Movements) Stage 4 Standing unsupported with GSE/Visual Conflict (Head/Eye Movements) C4-S1 (2) Stage 1 Static Sitting on compliant surface (bosu, Swiss Ball), 7 Head, Change Positions with Holds (Bending, turning, leaning) C4-D1 (2) Dynamic Weight shifting (Fwd, BWD)/Bending C4-S2 (4) Stage 2 Static Standing with NBOS (Romberg, PR, Tandem, SLS), 7 Head C4-D2 (4) Dynamic Walking (FWD, BWD, SIDE STEPS), 7 Head (on level ground, Treadmill) C4-S3 (6) Stage 3 Static Standing on Compliant/Irregular Surfaces (Foam, Wobble, Tramp, Shuttle, Incline/Decline, Bosu) 7 Head C4-D3 (6) Dynamic NBOS Walking (Partial/Tandem), Carioca, Turning, 7 Head C4-S4 (8) Stage 4 Static Standing NBOS on compliant/irregular surfaces (Shuttle, Foam, Wobble, Tramp) with NBOS (Romberg, PR, Tandem, SLS) C4-D4 (8) Dynamic NBOS walking with compliant/irregular Surfaces (Cushions, Shuttle, Wobble, Treadmill) C5-S1 (2) Stage 1 Static Sitting on compliant surface (Bosu, Swiss Ball), 7 Head, Change Positions with Holds (Bending, turning, leaning) C5-D1 (2) Dynamic Weight shifting (Fwd, BWD)/Bending C5-S2 (4) Stage 2 Static Standing with NBOS (Romberg, PR, Tandem, SLS), 7 Head C5-D2 (4) Dynamic Walking (FWD, BWD, SIDE STEPS), 7 Head (on level ground, Treadmill) C5-S3 (6) Stage 3 Static Standing on Compliant/Irregular Surfaces (Foam, Wobble, Tramp, Shuttle, Incline/Decline, Bosu) 7 Head C5-D3 (6) Dynamic NBOS Walking (Partial/Tandem), Carioca, Turning, 7 Head Static/Dynamic C5-S4 (8) Stage 4 Static Standing NBOS on compliant/irregular surfaces (Shuttle, Foam, Wobble, Tramp) with NBOS (Romberg, PR, Tandem, SLS) C5-D4 (8) Dynamic NBOS walking with compliant/irregular Surfaces (Cushions, Shuttle, Wobble, Treadmill) C6-S1 (2) Stage 1 Static Sitting on compliant surface (Bosu, Swiss Ball), Change Positions (Bending, turning, leaning) with GSE/Visual Conflict C6-D1 (2) Dynamic Weight Shifting/Bending (FWD, BWD) with GSE/Visual Conflict C6-S2 (4) Stage 2 Static Standing with NBOS (Romberg, PR, Tandem, SLS) with GSE/Visual Conflict C6-D2 (4) Dynamic Walking (FWD, BWD, Slow, Fast, Side Stepping) with GSE/Visual Conflict (Head Movement) C6-S3 (6) Stage 3 Static Standing on compliant/irregular Surfaces with GSE/Visual Conflict C6-D3 (6) Dynamic NBOS Walking (Partial/Tandem), Carioca, Turning, 7 Head Static/Dynamic C6-S4 (8) Stage 4 Static Standing NBOS on compliant/irregular surfaces (Shuttle, Foam, Wobble, Tramp) with NBOS (Romberg, PR, Tandem, SLS) with GSE/Visual Conflict C6-D4 (8) Dynamic NBOS walking with compliant/irregular Surfaces (Cushions, Shuttle, Wobble, Treadmill) with GSE/Visual Conflict

15 14 Key Thoughts 1. There are going to be transitions within the Stages and between stages. Within the Stage: Romberg Partial Romberg Tandem Single Leg Stance Support o Both hands o One Hand Between Stages: Ex. C1-S1 to C1-S2 (Supine to Sitting) Ex. C4-D1 to C4-D2 (Weight shifting to walking)

16 15 Scoring the Paradigm (in progress) CONDITION Total Points Stable/Unstable C1 10 C Points C3 10 Static Dynamic C Static Dynamic C Points Static Dynamic C Severity 0-23 Severe Moderate Mild 70+ Minimal to No TOTAL: 90 Points

17 16 Where should I start? If in doubt, start at C1 and modify your progression based off the suspected dependency (visual, somatosensory, or both). Symptom Management: When performing the exercises, use the Rule of 5 for symptoms. - If the patient comes in under a 5/10, and you perform the exercise the patient goes above a 5/10, if it takes under 5 minutes to get back to the baseline, this is appropriate. - If the patient is coming in above a 5/10, and you go up to a 7/10, if you can get the patient back to 5/10, this is appropriate. - If you cannot get the patient back to baseline, go down a stage or reduce the repetitions, counts, and/or sets. Repetitions: For repetitions, start with 5 repetitions and work to 25. Counts: Start with a 5-count hold and work to a 25-count hold.

18 17 Head Movement: Start with 5 times - head (Turns, Nods, Rolls) and work to 25 times. Use a set time 30 seconds to one minute. Grounding: Between exercises, consider using grounding therapy (C1-S2/C2-S2) to help the patient recover. This is billable time when you teach the patient! What are the 7 Head Positions and Why? The rationale behind the 7 Head Positions is regarding the various function of the otolith organ and semicircular canals. The otolith organs control: Bob (up/down), Heave (side/side), and Surge (forward/backward). The canals control Yaw (rotation), Pitch (nodding), and Roll (ear to shoulder). The 7 head positions allow the therapist to hit these movements when treating the patient.

19 18 Head Movements During the head movements, the patient moves the head in single planes (YAW/PITCH/ROLL). As the patient progresses, it has been considered to do multiplane movements like PNF patterns or more functional movements (patient specific). Vestibular Dysfunction The patient you are going to see the most often in your balance center is the Vestibular Dysfunction Patient. This is going to be a patient that has developed (1) a vestibular weakness and/or (2) has injured vestibular system and is now naturally relying on visual cues, somatosensory cues, or both. This can be a mal-adaptive reliance and create dizziness symptoms requiring physical therapy to recalibrate the balance system. Each mismatch will have a unique conceptual sequence to follow to progressively challenge the patient in therapy. There are three patterns you will see: 1. Visual-Vestibular Mismatch (Most Common VVM): Patients with VVM are Visually Dependent and will often complain of increase symptoms when there is a conflict to their visual system. This is described as exocentric optokinetic flow. An example would be standing in a mall or a crowd of people while they are walking by you.

20 19 Treatment: Patients with VVM need a constant somatosensory cue to offset the challenge to the visual system. 2. Somatosensory-Vestibular Mismatch (SVM): Patients with SVM are Surface Dependent and will often complain of increased symptoms when their base of support is narrowed. This will create what is described as a egocentric optokinetic flow. An example would be standing on a boat while it is rocking. It would be walking in a grocery store or in a mall. Treatment: Patents with SVM need a constant visual cue to offset the challenge to the somatosensory system. 3. Somatosensory-Visual Vestibular Mismatch (SVVM): Patients with SVVM are both Surface and Visually Dependent and will complain of symptoms when both their vision and surface are conflicted. Many patients will be SVVM and will have varying degrees of dependency. This will create what is described as a allocentric optokinetic flow. Example would be walking in a mall with people walking toward or around you. Treatment: Many patients will have both visual and surface dependencies of variations that require a combination of challenges to the visual and somatosensory systems.

21 20 Visually Dependent (Exocentric Flow) Avoid head movement Walks slowly Avoid environments with motion (Malls, Stores) Walks En-Bloc (Robot) Reports visual sensitivity w/o visual deficits Sits a lot Examples of Dependent Patterns Surface Dependent (Egocentric Flow) Walks slowly Wide Base of Support Used Assistive Device Reports touching walls furniture at home Sits a lot Deconditioned and weakness common Surface-Visually Dependent (Allocentric Flow) Compilation of Both Visual Vestibular Mismatch (VVM) or Visually Dependent Patients Description: You are going to run into patients that will over rely on their vision to maintain balance. Ideal Patient: This will be a visually dependent patient. They will be often walking slowly, they might complain of visual sensitivity and not want to move his/her head. Purpose: The patient with this pattern will often be very dependent on vision. This will be a slow decrease in visual cues.

22 21 Vestibular Dysfunction: Visual-Vestibular Mismatch (VVM) [Visual Dependent Patient (Static)] STATIC (S) Stage (S1) Stage (S2) Stage (S3) Stage (S4) Sx Severity Severe Moderate Mild Minimal to No Position Supine Sit Stand w/ Support Stand w/o Support C C C Position Sitting on Compliant Standing firm/nbos Standing on Compliant/Irregular Stand Compliant/Irregular w/nbos C C C Vestibular Dysfunction: Visual-Vestibular Mismatch (VVM) [Visually Dependent Patient (Dynamic)] DYNAMIC (D) Stage (D1) Stage (D2) Stage (D3) Stage (D4) Sx Severity Severe/Fall Moderate Mild Minimal to No Surface Weight Shifting/Bending/ Stooping Walking/Firm Surfaces Walking NBOS/Obstacles Walking NBOS/Obstacles with Compliant/Irregular Surfaces C C C

23 22 Somatosensory-Vestibular Mismatch (SVM) or the Surface Dependent Patient Description: These are progressions for patients that may have dependent patterns when assessing them during your evaluation. Ideal Patient: This will be a surface dependent patient. They will be often walking slowly, using an assistive device, and fearful of falling. They may complain of motion sickness. Purpose: Looking at the progression, you are going to slowly decrease reliance on Somatosensory cues. Vestibular Dysfunction: Somatosensory-Vestibular Mismatch (SVM) [Somatosensory/Surface Dependent Patient (Static)] STATIC Stage (S1) Stage (S2) Stage (S3) Stage (S4) Severity Severe/Fall Moderate Mild Minimal to No Position Supine Sit Stand w/support Stand w/o Support C C C Position Sitting Compliant Stand Firm NBOS Stand Compliant/Irregular Stand Compliant/Irregular w/nbos C C C

24 23 Vestibular Dysfunction: Somatosensory-Vestibular Mismatch (SVM) [Surface Dependent Patient (Dynamic)] Dynamic (D) Stage (D1) Stage (D2) Stage (D3) Stage (D4) Sx Severity Severe/Fall Moderate Mild Minimal to No Surface Weight Shift/Bending/Stoop Walking/Firm Surfaces Walking NBOS/Obstacles Walking NBOS with Compliant/ Irregular Surfaces C C C Somatosensory-Visual Vestibular Mismatch (SVVM) or the Surface and Visually Dependent Patient. Ideal Patient: This is often the classic fall risk senior that has severe weakness or injury to the vestibular system. This patient will over rely on both visual and somatosensory cues due to the severity of the injury or more often due to avoidance behavior (Maladaptive Behavior). Purpose: Looking at the progression, you are going to slowly decrease reliance on Somatosensory and Visual cues.

25 24 Vestibular Dysfunction: Somatosensory-Visual Vestibular Mismatch (SVVM) [Visual > Surface Dependent Patient (Static)] Stage (S1) Stage (S2) Stage (S3) Stage (S4) Sx Severity Severe/Fall Moderate Mild Minimal to No Position Supine Sit Stand w/ Support Stand C C C Position Sitting on Standing Standing on Standing (Both) Compliant firm/nbos Compliant/Irregular C C C Somatosensory-Visual Vestibular Mismatch (SVVM) [Visual > Surface Dependent Patients (Dynamic)] Stage (D1) Stage (D2) Stage (D3) Stage (D4) Sx Severity Severe/Fall Moderate Mild Minimal to No Surface Weight Shifting/Bending/Stooping Walking/Firm Surfaces Walking NBOS/Obstacles Walking NBOS/Obstacles with Compliant/Irregular Surfaces C C C

26 25 Visual-Vestibular Dysfunction (Movement Dysfunction) When doing your assessment for the patient, you are going to find patients that have both a (1) gaze instability along with a (2) postural instability (static and/or dynamic balance). This is the classic Visual-Vestibular Movement Dysfunction Pattern. These patients will also present like the Vestibular Dysfunction Patient with a dependent pattern VVM, SVM, SVVM. The difference with this patient is that when assessing for visual deficits, the patient will have abnormal visual impairments supporting the Visual-Vestibular Mismatch (VVM). Often the visual symptoms will be more severe than the Vestibular Dysfunction patient because they are over relying on a weak or damaged visual system.

27 26 Gaze Stabilization Exercise (VOR) Paradigms Description These are progression that can be used in a conceptual framework to assist in a systematically move your patients through more complex visual challenges. When you are assessing to decide what dependent pattern you are seeing, these patients will often have a visual-vestibular movement dysfunction. During your assessment, you are going to use the dependent pattern to decide how you are going to challenge the visual system. KEY: For patients you suspect are visually dependent, you are going to maintain the somatosensory cue both slowly increase the challenge to the visual cue (i.e., change target type or increase the speed of the head movement). KEY: For patients you suspect is surface dependent, you are going to maintain the visual cue but challenge the somatosensory cue (i.e., Supine, sit, standing w/o support, NBOS/compliant standing, and Walking). KEY: For patients you suspect are both surface and visually dependent, you will challenge both system. Note: For patients you suspect have a Visual Movement Dysfunction (VisD - Gaze Instability with no Postural Instability), there are two approaches: 1. Maintain target type and head speed and change the surfaces from Sitting Standing (Normal BOS) Standing (NBOS/Irregular Surface) to Walking. This is likely more used with more well compensated disorders 2. Change the target type and head speed but maintain the surface fixed until you get to the intended speed. In this scenario, the somatosensory system is a larger sensory system and can decrease the overall load to the training. This will be used in less compensated or poorly compensated disorders.

28 27 USING THE METRONOME CONVERSION CHART We know that activities of daily living require both gaze stability and head movement. The technical term is call peak head velocity (PHV), which is the peak head speed when the head or eyes past the midline of gaze or the position of the head when moving and is measured in degrees/second (deg/sec). Below is a chart for PHV for various activities. What we know is for general walking, we need a minimal up 30 deg/sec of PHV and for sports and high functioning activities, we need at least 120 deg/sec or more of PHV. For seniors between the ages of 74 and 89, the research has shown we need a maximum of deg/sec of PHV. A term in the literature you will come across is oscillopsia. This term represents the failure point where the vestibulo-ocular reflex (VOR) can no longer maintain visual acuity at that particular speed. This can be formally measured on the Gaze Stabilization Test (GST) on the Bertec Visual Advantage (BVA/Bertec) or InVision (NeuroCom/Natus) systems. So, the question arises what head speed should the PT start patients? Some would say start them at oscilloptic boundary while others would say start them at a level under oscillopsia and work them up to this speed.

29 28 Starting at oscilloptic boundary is like starting the patient at their level of strength day one. It does not make sense and will often cause severe discomfort, dizziness, and most patients will not continue. It is recommended by the expert vestibular clinicians that we start the patient lower than oscilloptic boundary and use the other central oculomotor responses (Smooth Pursuits, Saccades, Optokinetics) to assist the weak VOR up to the point of oscillopsia then push into oscillopsia as tolerated. What is Peak Head Velocity (PHV)? Peak Head Velocity (PHV) is the maximum velocity of the (1) head or (2) eyes at the middle of the range of motion. Can you give me an example of how to use the Metronome Conversion Chart? Example of Using the Metronome Peak Head Velocity (PHV) Chart: 30 deg/sec PHV equates to: degrees of ROM with a 30 BPM setting on the Metronome degrees of Range of Motion (ROM) with a 20 BPM setting on the Metronome degrees of ROM with a 60 BPM setting on the Metronome

30 29 So where do you start? If in doubt, start the patient at 30 deg/sec of PHV as this is the minimal required amount for walking. This is a clinical decision by the therapist. If you think the patient can tolerate higher speeds to start, start higher. How do I determine 30 deg/sec of PHV? Using the Metronome Conversion Chart, you have two variables to determine your PHV: 1. The distance of the head movement 2. The speed of the Metronome in Beats per Minute (BPM) What is Recommended? If you look at the Metronome Conversion Chart, +/-20 degrees is the sweet spot of the chart. What is means in NOT a total of 20 degrees, it means a radian from center of 20 degrees right and 20 degrees left a total of 40 degrees. Looking at the chart a range of motion of 20 degree with the metronome set at 30 BPM equates to approximately 30 deg/sec of PHV.

31 30 Now that I have my PHV, where do I start? You must determine if your patient is Visually Dependent, Somatosensory Dependent, or Both Surface and Visually Dependent. Once you have identified, you can use the Progressive Framework to progress the patient through his/her exercises. What targets do I use for training the VOR? There are five (5) target types you are going to use to train your patient. You must have a set of handheld targets and you will need a set of wall targets. They are: Simple/Simple (SS)

32 31 Complex/Simple (CS)

33 32 Simple/Complex (SC)

34 33 Complex/Complex (CC)

35 34 Two Targets (Choice of PT as to target Type) - Two Simple Targets (SS/SS) - Simple and a Complex Simple Target - Two Complex/Complex Targets (CC/CC) What is the distance from the target I use? When performing the sitting exercises, you will want to train the patient at two distances: Approximately 2-3 feet or at arm s length and up to 16 feet. When doing your walking exercises, it is recommended you perform at arm s length and then when performing the distance target, you can walk TOWARDS or AWAY from the object on the wall or scan the room for targets when doing Two Target training at distance. It is important to make sure your targets for distance are easy to see for the patient and legible. How long do I do the Gaze Stabilization exercise with the patient? There are two camps looking at this right now. For an older person, it is recommended starting the patient at 30 seconds and work them up to 1 minute. A lot of these patients just need a specific time versus attempting the 5- time rule use the Metronome to assist the patient with the exact amount of time. For younger adults, it is recommended to use the rule of 5 with a pause:

36 movement (Full Cycles) How do I train CNS Oculomotor gaze instabilities? Let s start with Smooth Pursuit Exercises. If you have identified a smooth pursuit or visual tracking problem, realize that this is often a permanent finding and often it will not completely resolve as it is a CNS disorder. Nevertheless, patients with visual tracking issues often avoid tracking causing this to get weaker. Using the Metronome Conversion Sheet, start with the slowest speed as Smooth Pursuits are not designed for fast movement. Start the patient at 15 deg/sec of Peak Target Velocity (PTV) and work to 50 deg/sec. Should I Also Follow the Dependent Pattern with these patients? Absolutely, you are creating a visual challenge to the balance system and this can increase dizziness symptoms and avoidance behaviors if you do not stay consistent. How long do I do the Gaze Stabilization (Smooth Pursuit) exercise with the patient? For an older person, it is recommended starting the patient at 30 seconds and work them up to 1 minute. For younger adults, it is recommended to use the rule of 5 with a pause: movement (Full Cycles)

37 36 How do Train for Gaze Stabilization Exercises (Saccades)? The key to saccadic training is random and unpredictable changes in the target. These can be found online at various websites and will be developed in the future for members of FYZICAL. What speed should I set the Metronome? Different than smooth pursuits system, saccades are fast eye movements. It is recommended to start saccadic training at 60 BPM and work the patient up to 200 BPM if possible. Make a saccadic eye chart like the one below and have the patient practice saying the number or letter. A simple way to challenge the saccadic system is to take two post cards with writing on them and have them approximately inches apart and have the patient saccade back and for between the cards reading one word at a time. Visual Vestibular Dysfunction (VVD - VVM) Visual Dependent Head Speed: Fixed (E.g., Start at 30 deg/sec at +/- 20 deg) Use Your Conversion Chart Surface Cue: Fixed Distance: 2-3 feet and 16 feet Total Time: 1 minute/each distance

38 37 Ideal: For patients that need a somatosensory cue to offset a severe vestibular weakness in the gaze system. Often this patient has a severe vestibular hypofunction (Visual -Vestibular Dysfunction). CONDITION 3 CONDITION 6 Target Supine Sit Stand Stand(NBOS) Walk *SS *CS *SC *CC Targets *Key: SS Simple Target/Simple Background, CS - Complex Targets/Simple Background, SC Simple Targets/Complex Background, CC Complex Targets/Complex Background. 2 Targets (SS/SS, CS/CS, SC/SC, CC/CC) Visual-Vestibular Dysfunction (VVD- VVM) Visually Dependent (Alternative) Head Speed: Fixed (E.g., Start at 30 deg/sec at +/- 20 deg use your Conversion Chart) or starting at oscilloptic boundary. Surface Cue: Constant Visual Cue: Progressive Distance: 2-3 feet and 16 feet Total Time: 1 minute/each distance Ideal: For patients that need more of a somatosensory cue to offset a moderate to mild vestibular weakness in the gaze system (Visual Dysfunction).

39 38 SS 1,CS 2,SC 3,CC 4, 2 2 Targets 5 CONDITION 3 CONDITION 6 Target Supine Sit Stand Stand (NBOS) Walk 30 deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec Start with a SS to 2 targets. Visual-Vestibular Dysfunction (VVD-SVM) - Somatosensory Dependent Head Speed: Fixed (E.g., Start at 30 deg/sec at +/- 20 deg use your Conversion Chart) or starting at oscilloptic boundary. Surface Cue: Progressive Distance: 2-3 feet and 16 feet Total Time: 1 minute/each distance Ideal: For patients that need over rely on somatosensory cues to offset a moderate to mild vestibular weakness in the gaze system (Visual-Vestibular Dysfunction).

40 39 CONDITION 3 CONDITION 6 Target Supine Sit Stand Stand (NBOS) Walk SS CS SC CC Targets *Key: SS Simple Target/Simple Background, CS - Complex Targets/Simple Background, SC Simple Targets/Complex Background, CC Complex Targets/Complex Background. 2 Targets (SS/SS, CS/CS, SC/SC, CC/CC) Visual-Vestibular Dysfunction (VVD-SVM) - Somatosensory Dependent (Alternative) Head Speed: Fixed (E.g., Start at 30 deg/sec at +/- 20 deg use your Conversion Chart) or starting at oscilloptic boundary. Surface Cue: Progressive Visual Cue: Progressive Distance: 2-3 feet and 16 feet Total Time: 1 minute/each distance Ideal: For patients that is compensating, but incompletely, for a Visual-Vestibular Dysfunction at assessment.

41 40 SS 1,CS 2,SC 3,CC 4, 2Tarrgets 5 CONDITION 3 CONDITION 6 Target Supine Sit Stand Stand (NBOS) Walk 30 deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec Start with a SS 2 Targets. Visual-Vestibular Dysfunction (VVD-SVVM) Surface and Visually Dependent Head Speed: Fixed (E.g., Start at 30 deg/sec at +/- 20 deg use your Conversion Chart) or starting at oscilloptic boundary. Surface Cue: Progressive Visual Cue: Progressive Distance: 2-3 feet and 16 feet Total Time: 1 minute/each distance

42 41 Ideal: For patients that is compensating, but incompletely, for a Visual-Vestibular Dysfunction at assessment that need more advanced training. SS 1,CS 2,SC 3,CC 4, 2 Targets 5 CONDITION 3 CONDITION 6 Target Supine Sit Stand Stand (NBOS) Walk 30 deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec deg/sec Start with a SS 2 Targets.

43 42 Visual-Vestibular Dysfunction (VVD- SVVM) - Visual/Somatosensory Dependent (Alternative) Head Speed: Fixed (E.g., Start at 30 deg/sec at +/- 20 deg use your Conversion Chart) or starting at oscilloptic boundary. Surface Cue: Varied/Random Visual Cue: Progressive Distance: 3 feet to 16 feet Total Time: 1 minute Ideal: For patients that need a complex visual and somatosensory cue to offset a well-compensated, but incompletely compensated vestibular weakness in the gaze and postural system. CONDITION 3 CONDITION 6 Target Supine Sit Stand Stand (NBOS) Walk SS CS SC CC Targets

44 43 Visual Dysfunction (VisD) - Complex Visual-Vestibular Patient Head Speed: Fixed (E.g., Start at 30 deg/sec at +/- 20 deg use your Conversion Chart) or starting at oscilloptic boundary. Surface Cue: Random Visual Cue: Random Distance: 3 feet to 16 feet Total Time: 1 minute Ideal: For patients that need a complex visual and somatosensory cue to offset a well-compensated, but incompletely compensated vestibular weakness in the gaze and postural system. CONDITION 3 CONDITION 6 Target Supine Sit Stand Stand (NBOS) Walk SS CS SC CC Targets