Centrex University

Becky Olson-Kellogg, PT DPT GCS CEEAA presented a great course on Vestibular Rehabilitation on May 3rd. Here are some highlights:

1. Benign Paroxysmal Positional Vertigo or BPPV is the most common peripheral vestibular disorder. Because of its anatomic position, the posterior canal is involved 80-90% of the time in BPPV. Treatment using a canalith reposition maneuver can often improve patient symptoms in 1-2 visits.

2. For other vestibular disorders, there are 3 main treatment theories. They can be combined to meet individual patient needs.
a. Adaptation – Long term changes in response to input. The best exercises incorporate head movement and visual input. Just like progressive resistive exercise, the vestibular system needs continuous progressive challenge to improve. If the exercises are easy, the patient won’t get better. Exercises may include head movements, with fixed gaze or with gaze moving from object to object. Consider taping a playing card or list on the wall and having the patient turn their head from one side to the other, focusing and refocusing on the object. Vary head movements (turns, nods, circles), and speed of movement. The patient must focus on the exercise (no distractions), perform 1-2 minutes at a time.
b. Habituation – repetitive exposure to a provocative movement will gradually reduce the adverse reaction. Select 3-4 movements that cause the most increase in symptoms. Perform 10-20 times , 2-3 times per day. Must be performed quickly enough and through sufficient range of motion to produce moderate symptoms. Rest between exercises. Example: begin with static standing, add arm or head movement; change to compliant surface or eyes open/eyes closed to progress.
c. Substitution – when there is a complete bilateral loss of vestibular function, the visual and somatosensory system input needs to be increased to compensate for the loss. Examples: Heel walking or toe walking to increase somatosensory input; use a walker or cane for ambulation; add nightlights to increase visual input at night.

3. If your patient does not have a vestibular disorder, can you use the vestibular treatment strategies with the older adult who has a balance problems? Absolutely! Postural control is maintained through sensory information provided from the visual, vestibular and somatosensory systems. Normal age related changes include diminished visual, vibratory and proprioceptive input so enhancing and strengthening intact systems is a great strategy. And many of our older adult patients to not move around like they used to or perform the same activities or chores. So they may have less opportunity to practice or use their balance skills. Practice improves performance!
You might consider:

• Static standing
  o With and without upper extremity support.
  o Eyes open/eyes closed
  o Narrow base of support
  o Tandem stance
  o Semi tandem stance
  o Single leg standing
• Standing on compliant surfaces
  o With upper extremity movement
  o Head turns
  o Perturbations
• Dynamic balance:
  o Gait drills
  o Fast/slow
  o Heel walking
  o Toe walking
  o Side stepping
  o Grapevine
  o Obstacle courses
  o Box step, dance steps
  o Figure 8, start/stop, circles
• Dual Task training/Walking with:
  o Head turns
  o Talking, counting, naming objects
  o Carrying objects
  o Path finding

On March 22, 2014, Alissa Boroff, BA, COTA/L, MN-AS, CAPS, our Director of Access Solutions presented a continuing education titled “Universal & Accessible Design: Promoting Aging in Place”.

So, you probably want to understand a couple of things like what exactly is Access Solutions, and what is meant by Universal Design…

     1. Centrex Rehab’s Access Solutions is a service created by Alissa in 2006.   Access Solutions is a consultation service that Alissa and her staff provide to assess and recommend redesign to create a livable and accessible home environment for those where the environment creates barriers due to a person’s current and progressive functional decline and impairments.  Access Solutions not only designs the environment for today’s challenges, but for challenges that are likely to occur going forward as a person experiences decline or general changes in aging.  It is a fee based service which may be private pay or covered through such programs as a grant, or for payors such as medical assistance.

     2. Universal Design is an approach to design of all products and environments to be as usable as possible by as many people as possible regardless of age, ability or situation without the need for adaption or specialized design.  In general, it refers to “smart design for long term living”.  Some very basic examples of a universal design product are a comfort height toilet, wider doorways and hallways and lever handles.

As a PT or PTA, there are 3 takeaway messages:

     1. Consider if your patient/client wants to remain living at home when you evaluate them and find out if they can fully access their home.  They may require specialty products or features in their home to promote safety and access.

     2. Think about the 7 basic principles of Universal Design that Access solutions will address to help achieve your patient’s  ability to age in place goal:
a)  Equitable Use – the product or features is useful and marketable to people with diverse abilities
b)  Flexibility in use – the product or design accommodates a wide range of individual preferences and abilities
c)  Simple and Intuitive – use of the product or design is easy to understand, regardless of the user’s experience, knowledge, language skills, or current concentration level
d)  Perceptible information – the product or design communicates necessary information effectively to the user, regardless of ambient conditions or the user’s sensory abilities
e)  Tolerance for error – the product or design minimizes hazards and the adverse consequences of accidental or unintended actions
f)  Low Physical Effort – the product or design can be used efficiently and comfortably with a minimum of effort or fatigue
g)  Size and Space for Approach and Use – appropriate size and space is provided for approach, reach manipulation, and use regardless of the users body size, posture or mobility

     3. Who you should contact: If you have a patient/client who may benefit from Centrex Rehab’s Access Solutions, you can contact Alissa Boroff at  aboroff@centrexrehab.com