The Balancing Act

1. The Balancing Act

2. Vestibular Rehabilitation Therapy Balance Disorders: Facts, Figures, Assessment, and Treatment for Positive Outcomes Lori Miller, MSPT, VRT, ATC/L, CSCS Lisa Jenkins PT,MBA

3. What is Balance • Balance is defined as the ability to maintain your center of mass over your base of support. • Balance is very complex involving multiple systems that interact flawlessly and automatically to coordinate input from our environment and the central nervous system to produce a motor output and keep you upright/vertical. Postural control is related to balance in the dynamic mode.

4. What Is Postural Control? Ability to align the segments of our body in relation to one another in order to maintain stability/orientation in space

5. Components of Balance • Sensory • Sense body position relative to the base of support • Motor • Execute coordinated body movements • Central Adaptation • Use sensory inputs and body movements appropriate to the task conditions

6. Sensory Inputs • Proprioception- Body position relative to support surface- Dominates with fixed support surface- Ineffective on moving/compliant surfaces

7. Sensory Inputs • Vision- Head/eye position relative to surrounding objects - Dominates with stable surround/unstable surface- Ineffective with moving objects • Vestibular- Head position relative to gravity & inertial space- Essential under surface/vision conflict conditions

8. Central Adaptation • Select sensory input or inputs providing the most accurate information • Select the movement pattern or combination of patterns most effective in correcting balance

9. Corrective Movements Ankle Step Hip

10. What is a Fall? • A verbal definition of a fall is very difficult. There have been many definitions, such as “coming to rest at a lower level”, “an unplanned descent to the floor or extension of the floor”, “taking your center of gravity off your base of support”. All of these have validity, but the most accurate is the mathematical definition of a fall being when the center of pressure=center of gravity, when your off your base of support. CP=COG=FALL

11. Elderly Fallers A fall can significantly limit the ability of an older adult to remain independent. More than 1/3 of people aged 65 or older fall each year, and those who fall are 2 to 3 times more likely to fall again! 30% of people who fall suffer moderate to severe injuries such as bruises, fractures, and head trauma.

12. Falls in Hospitals and Nursing Homes • Each year a typical nursing home with 100 beds reports an average of 200 falls, many of which go unreported. • Fall risk is increased when 4 or more medications are used concomitantly. • Fall risk increases significantly in the days after a medication is stopped, dosage adjusted, added or changed. The danger is 1-9 days, the risk actually triples for single event or multiple falls!

13. Fall Statistics More than 95% of hip fractures among adults 65 or older are caused by falls. 23% of hip fracture patients die within a year of injury. The risk of being seriously injured in a fall increases with age. Nearly 85% of deaths from falls were among people 75 or older.

14. Fall Statistics 15,800 people 65 or older died from injuries related to falls in 2005. ~1.8 million people 65 and older were treated in ER’s for injuries More than 433,000 of these patients were hospitalized. These numbers are from 2005 and have been steadily rising over the past decade. (CDC 2008)

15. Dangerous... • Psychological trauma and fear-of-falling cause self-imposed activity reduction Strength Flexibility Mobility FurtherRISK of future falls

16. Costly... • The United States spends an estimated $28.6 billion annually for the treatment of fall-related injuries. • The majority of cost is for the treatment of hip fractures, which average $39,000 per patient. • Medicare costs for hip fractures in 2008 were estimated to be $2.9 billion, these numbers are expected to rise as the baby-boomers age.

17. Muscle Weakness Impaired Vision Use of Assistive Device/Inappropriate Use of Device Age > 80 Cognitive Impairment Medications: Type, Timing, Dosing Non-supportive Footwear Home-Throw Rugs, Lack of Rails or Grab Bars, Clutter Disease Related Issues Polypharmacy Depression Orthostatic Hypo tension/Autonomic Failure Frequent Toileting Dim or Dark Areas Impaired Mobility Sensory Deficits Central Changes-Reflexive or Reactive Balance Postural Changes Orthopedic Problems Low Back Problems Neurological Problems History of Falling Fall Risk Factors In Older Adults

18. Why Is Balance Important? • Balance is fundamental to many daily activities: • Transfers • Walking • Driving • Recreational Activities • Sense of stability and well being

19. Why Is Balance Important? • Loss of balance can be debilitating, leading to self restrictions in movement and fear of falling. • This cycle promotes physical de-conditioning, increased risk of falls, injuries, and many other secondary problems resulting in further functional decline. • This causes a significant decrease in a person’s quality of life. • BALANCE = INDEPENDENCE

20. The Need For Balance Services What is Dizziness? • Subjective, difficult to describe • Different sensation than Vertigo • Terms of dizziness and imbalance often used interchangeably

21. The Need For Balance Services • Dizziness Terms: Vertigo, lightheaded, fuzzy, foggy, woozy, groggy, spacey, heaviness in the head • Disequilibrium Terms: Imbalanced, drunk, unsteady, veering, wandering, weaving, hitting the walls

22. The Need For Balance Services The Problem • Although dizziness is one of the most frequent complaints heard by physicians, it is poorly understood and ill defined. • Research has shown that patients with vestibular disorders will see an average of 4-5 physicians before receiving an accurate diagnosis. • Some of these patients will get a diagnosis, some will just attribute the changes to normal aging.

23. The Need For Balance Services Dizziness Statistics • More than 90 million Americans (~42%) have experienced a problem with balance or feeling dizzy. • The number one reason for hospital visits for people over the age of 65 is dizziness. (National Institute of Health)

24. The Need For Balance Services • Patients with vestibular dysfunction will usually show signs of gait and balance impairments. • Vestibular Dysfunction = Falls Studies done in the U.S. and UK have found that 80% of patient presenting to the ER for a fall related injury had vestibular symptoms.

25. The Need For Balance Services Fall Statistics • Falls are the leading cause of injury, deaths, and the most common cause of non-fatal hospitalization in older adults. (CDC 2010) • Falls are the most common cause of TBI. (Jager et al. 2000)

26. The Need For Balance Services Declined Quality of Life • Approximately 65% of all nursing home admissions are related to falls. (CDC 2010) • Once a person falls, they tend to develop a fear of falling, reduce their activity, thereby increasing the risk of another fall. (Vellas et al. 1997)

27. The Need For Balance Services As economic pressures mount to slow the growth of rising medical costs associated with chronic disease/disorders, the need for cost management is obvious.

28. The Need For Balance Services Impact of Chronic Disorders • 75% of all medical expenditures are spent on managing chronic disorders • Prevalence increases with population age • Strain on the insurance systems • Especially Medicare

29. The Need For Balance Services • Unresolved cases lead to: “Doctor shopping” Extensive diagnostic testing Fear, restriction, & further deterioration Increased risk of falls & injuries

30. Wide Spread Problem • Dizziness & imbalance are common symptoms in a wide variety of diseases.

31. Multiple Sources • The typical chronic disorder has multiple causes that cannot be isolated to a single source.

32. Varied Impairments • Even when a specific cause is identified, the resulting impairments can vary considerably from patient to patient because of the brain’s adaptive responses.

33. Coordinated and Focused • Research shows the most effective management plan for the individual patient requires the coordinated efforts of both physicians and rehabilitation specialists. • Focus is on mitigating the impact of pathology, and on modifying the associated adaptive responses and impairments.

34. The Need For Balance Services Pathology (site-of-lesion) Physiological Changes Brain’s Adaptive Response Impairment Functional Changes Environment & Lifestyle Demands What Is Impairment Information? Disability

35. The Need For Balance Services Management Model

36. Objective Plan/LTG’s • Classification of patients based on pathology and functional impairments. • A long-term care plan which includes progress indicators and expected outcome and is based on patient classification. • Access to surgical, medical and rehabilitation treatments as appropriate.

37. Types of Patient Populations • General Practice/Geriatric • Non-specific • Otology • Vestibular • Post concussion syndrome • Workers’ comp/Medical-legal

38. Types of Patient Populations • Neurology • Parkinson’s Disease • TBI • Multiple Sclerosis • Peripheral Neuropathy/Polyneuropathy • Orthopedics • Ankle/Knee injuries • Low Back/Neck injuries • Head injury/Return to play

39. Relevance & Benefits • Vestibular dysfunction is problematic and can occur at any age. • Vestibular problems result from a wide variety of sources, therefore relevant to most health care professionals.

40. Relevance & Benefits • Medical costs continue to rise in the care of chronic disorders. • One of the most well researched areas of treatment. (evidence based practice)

41. Relevance & Benefits • Physical/Occupational Therapists with specialized training=VRT Specialist • State of the Art technology to measure a person’s performance to identify and isolate the causes of the problem. • Assessment is comprehensive, looking for multiple contributing factors.

42. ANATOMY/PHYSIOLOGY OVERVIEW

43. System Organization Sensory Input Sensory Processing Motor Output Eye Movements Visual Vestibular Proprioceptive Primary Processor (Vestibular Nuclear Complex) Motor Neurons Positional Movements Adaptive Processor (Cerebellum)

44. Main Components of the Vestibular System • Peripheral End Organs detect Head angular velocity and linear acceleration Orientation of the head with respect to gravity • Vestibular Nerve • Central Nervous System Connections • Motor Output Vestibular Ocular Reflex (VOR) – gaze stability Vestibulospinal Reflex (VSR) – postural control

45. Balance System Elements • Vestibulo-ocular System • Coordinate head and eye movements to maintain stable gaze and visual acuity while actively moving about • Posture Control (vestibulo-spinal) System • Maintain postural stability while actively moving about

46. Physiological Characteristics • Vestibulo-ocular System • Horizontal semicircular canal & visual inputs • Responses dominated by short pathway reflexes • Simple movement geometry & biomechanics • Posture Control System • Vertical canal, otolithic, visual & proprioceptive inputs • Responses mediated by complex central pathways • Responses influenced by task & environment • Complex movement geometry & biomechanics

47. Peripheral System • Located deep within the petrous portion of the temporal bone • System consists of membranous and bony labyrinth & hair cells which sense motion. • Bilateral & reciprocal

48. Labyrinth • Bony labyrinth: central chamber, also contains cochlea for hearing Filled with perilymphatic fluid (high Na:K) • Membranous labyrinth located in bony labyrinth Contains 5 sensory organs, 3 semicircular canals, and 2 otoliths – utricle & saccule Filled with endolymphatic fluid (high K:Na)

49. Semicircular Canals (SCC) • Sense head velocity • Enables Vestibulo-ocular reflex (VOR) Allows clear visual acuity Eye movement generated is equal in magnitude and opposite to that of head movement Incredibly precise and accurate as the visual image is maintained on the fovea of the retina for clarity

50. SCC Anatomy • Filled with endolymph • Ampulla-enlarges end area • Hair cells sense head motion and lie on the cupula of the ampulla • As the head turns, endolymph moves in the opposite direction and causes movement of the hair cells and excites the vestibular nerve