Vestibular physiotherapy: A vital component of treatment in disorders of the balance system
VERTIGO and DEAFNESS CLINIC at BJ 252 Salt Lake KOLKATA -91, INDIA has a very sophisticated and unique VESTIBULAR PHYSIOTHERAPY unit with qualified neuro-physiotherapists especially trained in the physiotherapy of balance disorder patients. This vestibular physiotherapy unit is equipped with different instruments which are devised by neurotologist Dr Anirban Biswas and other gadgets that are procured from Italy. Currently it is the only one of its kind in India and very few neurotology centres in the world have such a dedicated physiotherapy set up only for the physical rehabilitation of balance disorder patients.
Physiotherapy or physical therapy is a form of treatment that is delivered by physical methods such as massage, heat treatment, and exercise or physical workouts (rather than by medicines or surgery) for the management of disease, deformity and/or disability.1The essence of physiotherapy is to improve and enhance the functionality of a dysfunctional or malfunctional body part and to stimulate and boost the residual function of a damaged organ. Physiotherapy basically stimulates the defective/ dysfunctional organ / system in a controlled and graded manner to reactivate the diseased organ and to revive the lost function as much as practicable by physical stimulation. Research has shown that the brain and the vestibular system have an inherent plasticity and can develop new neuronal interconnections in the central nervous system so that new functions can be acquired and lost function restored after some organ / part is damaged or has lost its functionality. Neuroplasticity is the capacity of the brain for continuous alteration of the neural pathways and synapses of the Central Nervous System in response to: – (1) injury/ damage inflicted by the disease and / or (2) repetitive stimulation of the non-functional / dysfunctional body part. The CNS responds to this stimuli by reorganizing its structure, function, and/or by generating new neural connections. After damage to the CNS, there is re-organisation in the brain circuitry in response to demand, new learning and as a response to repetitive stimulation and training. This is the basis of physiotherapy. Neuroplasticity is the process by which musicians improve their skills, i.e., by ‘Practice, practice and more practice of the same thing like repeatedly vocalising the tunes do-re-me –fa-so-la-ti or sa-re-ga-ma-pa-dha-ni-sa over and over again. It is the method by which athletes – practice fundamentals – the same thing over and over and over again’. And this works; it improves performance. It is the hardwiring of the CNS through repetition of activity that leads to improvement in performance. The same mechanism applies to the vestibular system also and the functionality of the vestibular system can be enhanced by training and repeated performance /practice of the same tasks.
Vestibular physiotherapy is physical therapy that helps in the correction of disorders of the balance system and in the improvement of body’s balance mechanism. Some ailments respond to medical treatment, some to surgery and some to physical therapy. Vestibular disorders respond very well to physical therapy and treatment of vestibular disorders is never complete without physical therapy. This of course is not to undermine the role of specific drugs for specific disorders like diuretics in Meniere’s disease, steroids in vestibular neuritis, migraine prophylactics in vestibuar migraine etc.
Physical therapy as a mode of treatment for balance disorders and improvement of balance function was first developed in the 1940s for patients with persistent vertigo and disequilibrium.3,4 Known as the Cawthorne-Cooksey exercises, these exercises were designed to help injured war victims with imbalance and vertigo regain stability. These exercises basically consisted of head and eye movements and were found to improve the patient’s general balance function.5Significant improvements have taken place over the last 70 years, more so during the last 5-7 years.3
A two-pronged approach for vestibular disorders
Vestibular disorders respond best to a two-pronged approachcomprising of medical therapy and physical therapy (Figure 1); surgery has a very minor (if at all any) role and is reserved for very special and rare cases like acoustic neuroma, superior semi-circular canal dehiscence (SSCD) etc.
- Medical therapythat is directed to treat the underlying medical disorder that is causing the vertigo/imbalance e.g., steroids for vestibular neuritis, diuretics for Meniere’s disease, psychotropic drugs SSRIs/benzodiazepines for psychogenic vertigo, migraine prophylactic drugs for Vertiginous migraine etc.
- Physical therapy that is directed to restoration of the normal balance function. It acts by various mechanisms to restore the balance function as discussed below. Just treating the underlying disorder does not restore the normal balance function, it cures or controls the disease and stops the damage to the balance organ but does not restore the normal balance as the dead vestibular cells being made of a specialized sensory epithelium does not regenerate once dead. For restoration of normal balance function physical therapy is necessary.
NOTE: Physiotherapy or physical therapy plays a pivotal role in the management of vertigo. No treatment is complete until the requisite physical therapy for restoration of balance is instituted. The outcome of treatment is hugely enhancedif the clinician utilises and takesrecourse of the tremendous advancements in vestibular physiotherapy while treating a patient of vertigo.
Rationale for vestibular physiotherapy
The rationale for these exercises was based on the following facts:4
- Patients who remained active recovered faster.
- Head movements that provoke dizziness resulted in faster recovery.
The exercises used for vestibular rehabilitation include physical therapy for vestibular hypofunction and canalith repositioning therapy for benign paroxysmal positional vertigo (BPPV) as the latter is also a form of physical therapy. This chapter delves on the benefits of physical therapy for vestibular hypofunction and other causes of unsteadiness / imbalance; canalith repositioning therapy is a separate entity and is not included here as this modality of physical therapy is best done by the clinician himself who thoroughly understands the nuances of vestibular structure and function and not by the physical therapist.
The value of physical therapy in managing all forms of peripheral vestibular disorders is well documented and is the mainstay of treatment for all peripheral vestibular disorders currently.5 However, its use is not limited only to peripheral vestibular disorders and many other forms of balance disorders e.g., psychogenic balance disorders, imbalance disorders of old age (presbyataxia), and selected patients of central vestibular disorders esp those with oculomotor disorders are all helped by vestibular physiotherapy.
Objective of physical therapy
As patients with vestibular disorders present with symptoms of dizziness, feeling of imbalance / unsteadiness and are at risk for falls, vestibularphysical therapy aims to achieve the following:1-3
- Decreasing dizziness
- Improving stability
- Increasing balance confidence and reducing fear of fall
- Decreasing the risk of falling i.e., fall prevention
- Improving the function of the vestibulo-ocular reflex (VOR) and vestibulo-spinal reflex (VSR) esp the vestibulo-collic reflex
- Improving gait, especially with head movements, as many such patientshave a tendency to move “en bloc” as a unit with little rotationof the trunk or head to minimize the sensation of dizziness
- Switching the person’s dependence on one sensory modality so that they can switch between somato-sensory, remaining vestibular function, and vision. This is also called sensory substitution i.e., substituting the lower input from one of the three input systems (vestibular/ somatosensory/ visual) with the that from the intact systems,
- Enhancing walkingmobility and endurance
- Decreasing anxiety that maybe a result of the sensory mismatch that is occurring with theabnormal or absent vestibular input
- Improving the quality of life
Vestibular Physiotherapy aims to improve and enhance the functionality of a dysfunctional or malfunctional part of the vestibular system and stimulate and boost the residual function of a damaged organ and thus improve balance and consequently provide a better quality of life.1
How physical therapy helps in balance disorders?
- Enhances the vestibular compensatory mechanism
- Improves the general balance function and sharpens the balancing skills of the subject.
- Enhances the functionality of a damaged part of the vestibular labyrinth or of a deranged mechanism in the vestibular system.
NOTE: Vestibular compensatory mechanisms refer to the functional changes in the brain, by virtue of which a patient having a damaged balance organ at least partly if not wholly gets back normal balance function. The importance of physical therapy in the management of balance disorders lies in the fact that it enhances and expedites this natural mechanism of vestibular compensation in a very big way.
Vestibular physical therapy involves a program of exercises which help the patients by relieving the symptoms and improving the quality of life, through generation of a sensory conflict, leading to neurological rearrangements (vestibular compensations) (Figure 5.2). Vestibular physical therapy decreases the period of morbidity after a vestibular damage, improves balance, sharpens balance skills and enhances quality of life.
Mechanism of benefits of vestibular physical therapy
Role of the neuro-physiotherapist
Physical therapy provides benefits to the patients only if it is done appropriately (Box 1).2,6 Erroneously done exercises will actually harm the patient rather than offer any benefit. So educating the patient and teaching the exercises properly is an important component of successful physiotherapy.3 Therefore, a qualified neuro-physiotherapist who is trained in handling balance disorder patients or who has worked in a vertigo clinic and understands the nuances of the vestibular system plays a very important role in imparting proper training to the patients for exercises specific to balance disorders.4. The importance of the trained neuro-physiotherapist in the management of balance disorder patients cannot be over-emphasised. Wrongly done vestibular exercises stimulate the vestibular system wrongly as the vestibular system gets used to improper inputs and responds erroneously when stimulated.
Problems of the tear away sheets with Cawthrone – Cooksey exercises:-
The common practice of clinicians handing over tear-away sheets of the Cawthrone-Cooksey exercises to patients of vertigo are a big nuisance in the management of vertigo and should be strongly abhorred by clinicians. Most patients cannot do the exercises properly as they are not trained by professionals and perform the exercises at home erroneously and irregularly. The basis of any physiotherapy is repeated stimulation regularly and systematically in the proper way so that the targeted organ is correctly stimulated in a structured methodical fashion. Improper and irregular stimulation of vestibular system defeats the purpose of physiotherapy as the vestibular system then gets used to wrong inputs because of its inherent plasticity. This in turn leads to improper processing of normal vestibular inputs and actually aggravates the imbalance. The proper way of carrying out the exercises can only be taught by a trained neuro-physiotherapist and exercises should essentially be done under the guidance of the neuro-physiotherapist.
The pharmaceutical companies distribute pads with sheets of the Cawthrone-Cooksey exercises and the names of some anti-vertigo drug advertised on it to doctors who in turn hand over a sheet from the pad to the patients. This practice has converted the entire art and science of vestibular physiotherapy into a joke. Physiotherapy is an art form that has to be learnt physically from a trained and qualified professional and tear away sheets are not a replacement of a qualified physiotherapist.
The Cawthrone Cooksey exercises though 70 yrs old now, are still relevant and effective in some ways but ONLY if properly done under the guidance of trained experts and professionals. Vestibular science was at its infancy when these physical therapies were devised but now with the advancements in our knowledge of vestibular physiology and in vestibulometry, the pride of place of these age old time tested exercises is now lost and these exercises are slowly losing relevance even though there is no denying of their efficacy in a limited way. But better results are obtained by other forms of vestibular physiotherapy that have now been introduced e.g., Tai Chi, Yogic asanas, Virtual Reality exercises, and organ- specific vestibular exercises. The Cawthrone-Cooksey exercises are generalised non-specific exercises. Today science is all about employing razor sharp diagnostic modalities, identifying the exact pathology and then offering therapy targeted specifically to the diseased organ or the system damaged. Modern vestibulometry has made this pin-pointed diagnosis of the exact site of lesion and nature of pathology possible today. Vestibular physiotherapy hence can now be targeted to the precise organ or function that has been damaged by disease. Modern vestibular physiotherapy is hence now more organ specific and much more targeted to the defective organ and is hence more effective. This is discussed in much more details below.
Vestibular physical therapy and neurophysiotherapist
- Vestibular physiotherapy exercises should be tailored to the needs of an individual patient based on (1) the pathology and /or the organ involved , (2) the findings of the detailed vestibulometry tests, and (3) the patient’s level of tolerance,.
- For optimal efficacy, these exercises are to be done without reaching the threshold beyond which neuro-vegetative symptoms occur. The neuro-physiotherapist who is dealing with the patient first-hand during the exercises is the best person to judge that, not the medical doctor / clinician.
Indications for vestibular physical therapy
The physiotherapy exercises for vestibular disorders yields the best outcomes and is very strongly indicated in the following patients:1,.5
- Stable vestibular lesion: In patients in whom evaluation reveals no evidence of a progressive process and the patient’s natural compensation process appears to be incomplete. The ideal patient for vestibular physiotherapy is a patient with a unilateral peripheral vestibular lesion.
Vestibular physiotherapy is a physical therapy directed at restoring deranged balance function and rejuvenating the damaged part of the vestibular labyrinth or balance system.1
- Central lesions or mixed central and peripheral lesions: Patients with stable CNS lesions or mixed central and peripheral lesions; the ones who benefit the most are those with peripheral vestibular lesions i.e., a lesion in the vestibular labyrinth of one side. Modern vestibulometry (detailed elsewhere in this section) can diagnose such lesions with pin-point accuracy provided of course that the vestibulometry (tests of vestibular function) has been done from a reliable place and a complete vestibular assessment has been done..
- Head injury: As these patients may suffer from significant disability due to vestibular symptoms and also may have cognitive and central vestibular involvement along with a peripheral component, Vestibular Rehabilitation Therapy (VRT) is used as a supplement to a comprehensive, multidisciplinary head-injury program
- Psychogenic vertigo: Physical therapy is used as an adjunct in patients with panic disorder and other anxiety disorders with ill-defined vestibular symptoms; in mild anxiety disorders, physical therapy may work similar to behavioral intervention; however, in patients with more severe anxiety, psychiatric intervention will also be required. Exercises with Virtual Reality are a boon and has dramatic effects in these patients
- Elderly patients with dizziness: The addition of vestibular-specific gaze stability exercises to standard balance rehabilitation results in in a greater reduction in fall risk. Special exercises for fall prevention are very effective in such patients
- Vertigo with uncertain etiology: Empirical trial of vestibular physical therapy may be a helpful option in these patients
- BPPV: After specific re-positioning therapy, physical therapy (balance training) may be necessary in a few selected patients to decrease the residual dizziness that can sometimes happen due to an overload / stimulation of the otolith organs by the particles being reinserted into the otolith organs.
Cases where physical therapy may not yield the best results
In the following patients, physical therapy is not very effective but is not contra-indicated:5 Some benefit is definitely obtained but less than other patients
- Patients with unstable lesion
- Patient with ongoing labyrinthine pathology
- Patients whose symptoms occur only in spontaneous episodes, such as seen with Ménière’s disease
- Patients with only spontaneously occurring events of disequilibrium, especially if the spontaneous vertigo or disequilibrium develops more than once per month
Efficacy of vestibular physical therapy
- Several studies, including a Cochrane review have documented the efficacy and safety of physical therapy for persons with peripheral vestibular dysfunction, presenting with dizziness.2
- The negative prognostic features related to vestibular physical therapy are summarized in Box 2.2
- Efficacy has been well documented in patients with both, unilateral and bilateral vestibular lesions.4
Box 2: Negative prognostic factors that may hinder recovery after a vestibular disorder2,3
- Negative mental attitude
- Inability to move head or body
- Distal sensory impairment
- Visual dysfunction (blindness, strabismus, cataracts, macular degeneration, glaucoma)
- Memory impairment/ cognitive decline
- Fear of falling
- Severe anxiety/psychiatric comorbidities
- Simultaneous therapy with vestibular suppressants and / or CNS depressants. All vestibular suppressants i.e., the anti-vertigo medications jeopardise and delay if not inhibit the process of vestibular compensation.
Types of non-specific generalised vestibular physiotherapy (Cawthrone Cooksey) exercises
The Cawthrone–Cooksey exercises improve balance function after a vestibular damage by three ways viz. adaptation, habituation and by sensory substitution. The three together enhance vestibular compensation. The different types of non-specific exercises used for the general management of vestibular disorders are summarized in Figure 3.2,6
Figure 3: Types of exercises in vestibular physical therapy
Adaptation exercises or visual-vestibular interaction exercises use stimuli such as head movement to promote the adaptation of the remaining (non-damaged) pert of the vestibular system. They are effective in the improvement of gaze stabilization (enhance VOR), and improve postural stability (enhance VSR) i.e., improve general balance function after the vestibular organ has been damaged by disease. These exercises need to be taught and demonstrated by expert physical therapists and as already stated are effective only if they are done correctly and regularly by the patient under the guidance of a trained neuro-physiotherapist.1
Exercises to improve gaze stability
This exercise can be carried out with fixing a target and moving the head (Box 5.3) or fixing the head and moving the target while gazing at the moving target (Box 5.4). Horizontal (yaw plane) or vertical (pitch plane) head movements while maintaining visual fixation on a target (placed at various distances from the person’s eye) can induce retinal slip in patients with a defective VOR (Box 5.3).7,8Beginning with the patient seated, slowly, one can progress to the patient standing with the feet shoulder width apart to standing with the feet together to standing partially pointed (one foot half way ahead of the other) to standing pointed (one foot completely in front of the other). The patient should progress from standing on a firm surface to standing on a compliant surface.
VOR exercise to improve gaze stability
- For horizontal head movements*, hold a card with lettering at arm’s length with eyes focused on the letters.
- Move the head from side to side (450), increasing speed with each progression.
- Repeat the entire cycle 20-30 times.
*The head can also be moved vertically and diagonally. Note: Post the card on the wall with a plain background and progress to posting on a wall with a busy patterned background.
Ocular motor exercises*
- · To increase pursuit gain, the patient holds a card with lettering at arm’s length.
- · Then the patient moves the card left and right across the visual field, tracking with eye movement and keeping the head still.
- · The full cycle is repeated 20-30 times.
*The test can be performed in the vertical and diagonal directions with increasing speed but being certain to keep the letters in focus. After this the patient can progress from sitting to standing to a sharpened stance as described above.
Gait stability exercises
These are walking exercises that are carried out with increasing levels of difficulty (Box 5.5).8
Balance training exercises
By improving steadiness, these exercises facilitate the patient to carry out the activities of daily living, work, and leisure. They are designed to address each patient’s specific underlying balance problem(s). A sample exercise is detailed in Box 5.6.8
Box.5: Walking exercises to improve gait stability
- The patient begins by walking next to a wall, with the hand out for support, gradually increasing the number of steps taken without support.
- In another exercise, the patient walks with the head in motion, going left and right with increasing speed.
- A third type of exercise involves the patient walking from one chair to another chair, kept 10-feet away. Upon reaching the first chair, the patient sits without using the hands, waits for 5 seconds, and rises without using the hands. The patient goes to the second chair, touches it, and, with support, practices standing on 1 leg for 5 seconds. The entire cycle is repeated 10 times.
Box 5.6: Balance training exercise
- The patient stands with the feet together.
- The patient may maintain balance by reaching out and touching the wall in front of them.
- The patient begins to take the hands off, one hand at a time and alternates the hands.
- The patient then takes off the hands off the wall for progressively longer periods.
part of the vestibular labyrinth and are just general exercises for improving balance and enhancing vestibular compensation. This is because these exercises were designed at a time when the exact function of each part of the vestibular labyrinth was not known and also because diagnostic neurotology by which a precise identification of the part of the vestibular labyrinth that has been damaged is possible was practically non-existent at that time. It is only after our understanding of the physiology of balance improved and modern vestibulometry reached its present status that these non-specific exercises have lost much of its relevance. Even now other forms of non-specific exercises like Yogic exercises/ Asanas and Taichi exercises have been found to be more effective modalities for improving general balance function as compared to the Cawthrone –Cooksey exercises. This of course is in no way to undermine the clinical utility and relevance of the Cawthrone Cooksey exercises. However, with advancements in our knowledge and understanding of vestibular function in health and disease and with development of newer technology we need to imbibe newer modalities and blend them with time-tested methods.
Now specific physical therapies are available that are targeted for specific parts of the vestibular system (Table 1)1,7 and are found to be very effective. Many of these devices are innovated by the author1 of this write-up who ia a practicing clinical neurotologist and also the owner of the VERTIGO and DEAFNESS CLINIC in Kolkata, India. The interested reader is referred to an article titled ‘Specific organ targeted vestibular physiotherapy: The pivot in the contemporary management of the contemporary management of vertigo and imbalance’ published by the author in The Indian Journal of Otolaryngology Head Neck Surgery 2017;69(4):431-442.The precise site of lesion after any damage in the vestibular system is now very accurately diagnosed by modern vestibulometry. There are specific tests for each part of the vestibular labyrinth and the vestibular system (fig 4). Rapid strides have been made in diagnostic neurotology over the past decade and we are now in a position to make a diagnosis like – ‘the left posterior semicircular canal has a poor VOR gain at high frequencies of stimulation but is functioning normally at low frequencies of stimulation’. There are systems like the V-Gym marketed by an Italian Company called Beon Solutions by which the specific canal can be stimulated at the particular range of frequencies where the canal is incapable of maintaining the requisite VOR gain. There is now a specific physical therapy solution for all types of vestibular defects.
Fig 4A: There are specific tests to diagnose defects for each part of the vestibular labyrinth as depicted in the figure. Each and every part of the vestibular labyrinth – the 3 semicircular canals, the utricle and the saccule, the sup vestibular nerve and the inferior vestibular nerve can be individually tested and its functional status ascertained with utmost precision. Modern vestibulometry has made this possible. Inability to diagnose the specific defect is no longer an alibi.
Fig .4B- All parts of the vestibular system can now be tested by the specific tests.
Hence, now as the exact site of lesion can be diagnosed with utmost precision, specific organ targeted vestibular physiotherapy where the damaged organ can be specifically stimulated is now a reality. If the utricle is damaged or if the posterior semicircular canal of one side is defective then that specific organ can now be precisely stimulated. Outcome of physical therapy is hence much better. We now have different Virtual Reality exercises which are very helpful in stimulation the vestibular system and especially in overcoming many types of psychogenic balance disorders. TaiChi exercises too are very effective in improving balance skills, in expediting vestibular compensation and in enhancing the balance skills of the balance disorder patient. The same goes with the Yogic Asanas many of which serve the same purpose as TaiChi and are very effective. But both TaiChi and Yogic Asanas have to be diligently learnt from experts in the respective disciplines not from physiotherapists or clinicians.
Specific organ targeted vestibular physiotherapy
Using modern vestibular function tests like VNG (Videonystagmography), VHIT (video head impulse Test), fHIT (functional Head Impulse Test), Cervical and ocular VEMP, DVA (Dynamic Visual Acuity), SVV(Subjective Visual Vertigo) etc. it is possible to locate the precise site of lesion and these parts (e.g., the utricle, saccule, semicircular canals) can then be specifically and individually targeted by exercises to sharpen and augment their sensitivity. Modern vestibulometry can not only identify the precise organ that is defective but can also assess at which particular frequency of vestibular stimulation the particular organ is malfunctioning. Some of these tests are detailed below.1
Stimulating the saccules
- This can be achieved using a hydraulically operated linear vertical movement generator at low frequency stimulation of saccule (Figure 5.5A). The saccule senses up down movement i.e., vertical linear movement hence in saccular dysfunction identifiable by the vestibulometric tests the saccule is stimulated by moving the patient vertically.
Figure 5A: Stimulation of saccule using a hydraulically operated electromechanical system1
- In this system, the patient can be made to move up and down while seated on a chair, first with eyes open and then with eyes closed, such that the sensing of the linear movement in the vertical axis is done by the saccule as much as possible. The chair stimulates the saccule at a low frequency of stimulation.
- For mid-frequency stimulation of the saccule the patient is made to sit on a gym-ball available in all fitness equipment stores
- Once the patient is comfortable with the low and mid-frequency stimulations, the patient is made to jump on a trampoline (Figure 5.5C) for high frequency stimulation of the saccule, after being anchored properly by harnesses (not shown here) attached to the walls or to the roof.
Fig 5B; Mid-frequency stimulation of the saccule
Figure 5C: Stimulation of saccule at a high frequency – Jumping on a trampoline
Stimulating the utricle
- Hydraulically operated linear horizontal movement generator can be used for stimulation of utricle at low frequencies (Figure 5.6).The platform of this system moves in the linear plane horizontally. The utricle senses side to side and front-back linear movement and in utricular dysfunction (identifiable by modern vestibulometry) this sensation is jeopardized. Hence to stimulate the utricle the patient is moved repeatedly in these directions in the linear horizontal plane
- The patient stands on the moving platform, first with eyes open, holding on to the railings and then without holding the railing, with eyes open and then with eyes closed; in the initial stages with eyes open then with eyes closed.
- The speed of movement can be slowly increased and
- the task made more difficult by making the patient stand on a soft surface first on two legs with eyes closed, and then on one leg while the platform is moving. Making the task slowly more difficult increases the sensitivity of the utricle in a gradual manner and increases the confidence level of the patient. The tasks are made more and more difficult over a period of a few days. The first few days the patient with the utricular disorder is made to do the exercise with the eyes open holding the railing standing on hard surface then next few days the same thing with eyes closed then when the patient is more comfortable with this then eyes closed standing on a soft surface and so on. All this is done under the guidance of a trained neuro-physiotherapist at our clinic
- VERTIGO and DEAFNESS CLINIC Figure 6: Stimulation of utricle
- at BJ 252 Salt lake Kolkata 91, India.
Stimulation of lateral semi-circular canals
- An electro-mechanically operated device can be used to stimulate the lateral semi-circular canalsat low frequencies (Figure 5.7).
- This device rotates the platform in clockwise/anti-clockwise manner to specifically stimulate the left and the right lateral semi-circular canals.
- The patient stands on the revolving platform, first holding on to the handles, and then without holding on to the handles, and then with eyes closed and finally with eyes closed on a foam pad to eliminate visual and proprioceptive inputs.Each step is made more and more difficult and carried out over a few days under the guidance of a neuro-physiotherapist.
- Another way of stimulating the lateral semicircular canal is by using a V-Gym program of Beon Solutions, Italy. The author uses both systems in his clinic, low frequency stimulation by the above mentioned system and high frequency stimulation by the Beon solutions system. This is an excellent system for stimulating the semicircular canals at specific frequencies and also if required at gradually increasing speeds in set programs.
Figure 7: Stimulation of lateral semicircular canal
Stimulation of anterior and posterior semicircular canals
A mechanically operated angular head movement generator is used for stimulating the anterior (superior) and posterior semicircular canals (Figure 8)
Figure 8: Stimulation of anterior and posterior semicircular canals1
(a) The position for stimulating the right anterior and left posterior semicircular canals; (b) The position for stimulating the left anterior and right posterior semi-circular canals
The anterior and posterior semicircular canals can also be stimulated by the Beon Solutions system. In VERTIGO and DEAFNESS CLINIC the author uses both systems.
Exercises that augment the balance faculty
- Using foam pads (Figure 9A): The patient is made to stand on specially made foam pads of varying firmness, called balance trainers, which are commercially available.
- Initially, the patient stands on firm pads and then on pads of increasing softness, so that the proprioceptive input is gradually deceased step-by-step to vary the proprioceptive input in a graded fashion. Foam pads of varying firmness are available
- The exercises on each pad starts with the patient first standing on both legs, with eyes open, and then with eyes closed, and then on one leg etc., such that the exercises become gradually more challenging in every step.
- Using gym balls : This exercise involves lifting one hand and one leg while sitting on the gym ball (Figure 5.9B) and activities like catching a ball while balancing on the gym ball. The proprioceptors in the soles of the feet are stimulated and the balance function improved by these techniques; maintaining balance while sitting on a gymball is much more difficult as the proprioceptive inputs from the buttocks is much lesser than that from the soles of the feet
Figure 9: Balance enhancing exercises1
(A): Using foam pads; (B): Using gym ball.
maintaining balance while sitting on a gymball is much more difficult as the proprioceptive inputs from the buttocks is much lesser than that from the soles of the feet, so when this is done not only is the vestibular labyrinth stimulated ( as now the patient is getting lesser proprioceptive input and so has to maximise the input from the other input systems like the vestibular and visual systems to maintain balance. Also in this exercise, the brain learns to maintain balance when proprioceptive input is decreased
Stability and Balance improving exercises
- Using a trampoline: The patient stands on a trampoline, first on two legs, then on one leg (Figure 5.10A) and is given tasks like holding a ball and swinging it from side to side (Figure 5.10B). Jumping on the trampoline as shown in Fig 5.5C is different and is used only for high frequency saccular stimulation in patients with saccular defects. Figure 10: Exercises to improve stability and balance using a trampoline
- Using a Bosuball: The patient is asked to stand on an inflatable Bosuball (available in fitness equipment stores), which is connected to an electrical air-pump, such that the contour and the softness of the ball can be changed by operating the air-pump and the task of maintaining balance can be made more and more difficult (Figure 11). The patient initially does it with the ball slightly inflated and the patient standing on it holding the railing with eyes open and finally on the fully inflated bosuball with eyes closed and without holding the railing.
- Using foam pads:The patient is asked to stand on a foam pad and is made to perform tasks like catching a ball (Figure 12).
Figure 11: Exercises to improve stability and balance using a Bosuball Figure 12: Exercises to improve stability and balance using foam pads
Exercises for improving postural stability
The stabilometry apparatus (Fig 13) and any other type of Posturography apparatus like the NeuroCom Equitestis equipped with facilities for balance training and rehabilitation of balance disorder patients. These are primarily for improving postural stability.
Fig 13 Exercises for improvement of postural stabilization using a stabilometry pressure plate. The balance disorder patient is made to undertake different games in which he moves the body and manipulates the body’s center of gravity to touch different visual targets in the display screen
Exercises for managing gait disorders
Body weight support unweaning system has been improvised in the author’s clinic for patients with gait disorders (e.g., gait apraxia, cerebellar ataxia and patients with paraplegia) and patients with a psychological fear of walking (Figure 14). A much more sophisticated instrument for this is available commercially manufactured by an American firm.
Figure 14: Set-up for improvement of gait
Exercises with Virtual Reality
About 45% of balance disorder patients DO NOT have any disorder in the balance system and have psychosomatic problems, conversion disorders etc and need adaptation and exposure to vestibular challenges to overcome the fright and panic attacks that is induced in difficult balance situations. Exercises with Virtual Reality (VR) is a very big help in these patients . Virtual reality programs especially made for balance disorder patients entails presenting to the patient’s senses a computer generated virtual environment that isn’t really there, but from the patient’s perspective is perceived as real. Through virtual reality the patient can be exposed to different situations that simulate conditions where a normal person is expected to experience somewhat frightening unsteadiness e.g., standing at the edge of a precipice or a cliff of a mountain and the vestibular system can be exposed to very challenging situations. These exercises are very effective in allaying the feel of insecurity and the crippling fear of fall that a lot of balance disorder patients often experience. Many if not most patients who have balance disorders develop a severe sense of insecurity, lack of self-confidence and mental anxiety that compounds the balance problem. The insecurity and the unsteadiness perpetuate each other and the patient goes downhill and ultimately becomes a psychological wreck with severe agoraphobia. This needs effective management. Virtual reality therapy is far more effective than SSRIs and counselling in these patients where there is a psychic overlay compounding the balance problem and in patients of psychic balance disorders like Phobic Postural Vertigo (PPV) and Persistent Perceptive Postural Dizziness (PPPD). Though there are some published studies comparing vestibular physiotherapy like the Cawthrone Exercises with VR therapy in patients of vestibulopathy, these studies do not bring out the true efficacy of VR therapy as VR is not the best modality for patients with vestibulopathy. For patients who have purely a vestibular damage without any psychic involvement, physical therapy is the best choice. VR therapy is best suited specifically for balance disorder patients with a psychic overlay and fear of falls as in psychogenic vertigo. In such patients the efficacy of VR therapy is very high. The author in conjunction with some VR firms have devised some exercises on Virtual Reality for balance disorder patients and have found them immensely beneficial in patients of psychogenic vertigo.
- Advances in the realm of vestibular physiology and vestibulometry have resulted in a sea-change in the management of vestibular disorders.
- As it is now possible to pin point the exact site of damage by modern vestibulometry, it is possible to tailor physiotherapy for patients with vestibular disorders as per the defects identified.
- Customised and organ-targeted vestibular physiotherapy utilizing the instruments showcased above targeting the defective organ and modalities like virtual reality, Taichi, yogic asanas is now the in-thing and will change the way vestibular physiotherapy is practiced. This form of physical therapy is very scientific and logical and stimulates the residual function of any dysfunctional sense-organ in the vestibular system.
- The ultimate beneficiary will be the balance disorder patient. Clinicians need to welcome these new modalities and use them for the benefit of the patients.
- Physiotherapy is a very important component of managing vestibular disorders and should be delivered only by trained neuro-physiotherapists who have attained special insight in the vestibular system.
- Experts in physical therapy for balance disorder patients and neurologists who have specialised in neuro-rehabilitation now work in coordination with neurotologists to provide a much better quality of life to most if not all balance disorder patients.
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