Presented by
Maureen E. Gordon, PT, MSPT, CEAS
Certified in Vestibular Rehabilitation
Certified in Cervicogenic Dizziness
Physical Therapy at St. Luke’s
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The brain constantly monitors the sensory
information coming in and uses body
movements to maintain stable posture
Changes in sensory information input or
motor control output require the brain to use
the correct strategy
Balance Integration
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Sensory Input
 Visual
 Vestibular
 Proprioceptive
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Central Processing
 Primary Processor (Vestibular Nuclear Complex)
 Adaptive Processor (Cerebellum)
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Motor Neurons
 Positional Movements
 Hip, ankle, and stepping strategies
 Eye Movements
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Peripheral Vestibular System
 Vestibular end organs (3 semicircular canals, 2 otolith
organs)
 Vestibular portion of the VIIIth cranial nerve
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Central Vestibular System
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Vestibular nuclei
Vestibulo-ocular pathway
Vestibulospinal pathway
Vestibulocollic pathway
Vestibulo-autonomic pathway
Vestibulocerebral pathways
Primary and secondary cortical areas
Vestibulocerebellum
Vestibular System Function
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What does it do?
 Senses rotational movements of the head
 Senses linear movements of the head
 Senses head position in space due to gravity being a linear
acceleration
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What does it do with that information?
 Postural Stability (Balance)
 Gaze Stability (Eye-head coordination)
 Orientation in Space
Brain
Where am I?
What am I
going to do?
Sensory
Systems
Motor
Patterns
Environmental
Interaction
Generation of Body
Movement
Balance (Postural) Control
Balance Control
Gaze Stability
Postural Stability
Gaze Stability
The ability to maintain
gaze or visual focus
on an external target
during movement.
A function of an intact
VOR (vestibuloocular reflex) at
speeds > 85
degrees/second.
Postural Stability
The ability to
maintain the body’s
center of gravity
(COG) over the base
of support (BOS) in
a given sensory
environment.
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Sensory Integration
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Decreased ankle proprioception
Abnormal interactions between the 3 sensory systems
Inappropriately relying on one system over another
Excessive reliance on visual input, even when it is
inaccurate
Biomechanical Constraints
 Impaired quality and size of the base of support
 Anteriorly displaced center of pressure in the paretic leg
 Poor trunk control
(Oliveira et al, 2008)
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Movement Strategies
 Compensation strategies, e.g. holding objects or walls
and using stepping strategy more frequently than agematched controls
 Predominant use of hip strategy and use ankle strategy
less
 Decreased anticipatory control
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Perception of Verticality
 Abnormal postural perception of verticality, especially
with visuospatial neglect
 Resistance to support weight on nonparetic side (“pusher
syndrome”)
(Oliveira et al, 2008)
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Weakness/hemiplegia
Spasticity or hypotonicity
Vestibular/inner ear disturbances
Affected vision and/or sensation
Ataxia
Decreased range of motion (ROM)
Fatigue and deconditioning
Pain
Impaired cognition
Objective Tests/Measurements
 Assessment of Functional Limitations
 Fall Risk Assessment – observational measurement tools
 Postural Assessment Scale for Stroke Patients
Benaim, et al. 1999)
(Mao, et al. 2002.
 Berg Balance Scale
 Dynamic Gait Index
 Assessment of Impairment
 Oculomotor Exam: abnormal smooth pursuit, saccades, skew
deviation (Kattah, 2009) and VOR cancellation
 Computerized Testing, e.g. Balance Master® or Biodex®
 ROM and Strength Testing
 Sensation and Coordination Tests
 Assessment of Spasticity
 Gait Assessment
Feature
Peripheral
Central
Effect of Fixation
Nystagmus decreases
Nystagmus increases
or stays the same
Direction of Gaze
Mixed plane (e.g.
vertical and torsional)
Usually single plane –
vertical, horizontal or
torsional
Effect of Gaze
Nystagmus increases
with gaze toward the
direction of the quick
phase
Nystagmus reverses
direction or it does not
change
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Can assess balance control with greater
sensitivity than observational methods
A sensory modality can be removed or
attenuated and the effect of these changes in
postural control can be assessed
Evaluation of hemiparetic patients can show
asymmetrical distribution of weight in lower
limbs, difficulty in actively transferring, and
impaired muscle selection
(Oliveira et al, 2008)
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Balance Exercises – Computerized and noncomputerized training: focusing on proprioception,
widening BOS, ankle strategy
 Neuroplasticity – if damage is done to portions of the brain
effecting balance, then the goal of balance training would
be to have different portions of the brain take over those
functions or aid in those functions (Sawakri et al 2008)
 In the chronic stroke population, balance impairment and
fall risk are associated with lower quality of life scores
(Schmid 2013)
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Activities for Motor Strategies
 Motor learning is improved with task specificity. Therefore,
if specific circumstances challenge balance, practicing
those tasks are more effective than practicing general
balance tasks (Klein et al)
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Gait Training – assistive device and bracing, as needed
 High intensity gait training with focus on increasing the
number of steps taken throughout the day, and during PT
sessions, has been proven to help balance and transfers, in
addition to gait training (T George Hornby)
 Gait speed – important measure for fall prediction, community
participation, and can be a balance measure (Beauchet et al 2008)
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Stretching, Strengthening, & Conditioning
Adaptation Exercises – gaze stabilization/VOR exercises
Home Exercise Program (HEP)
Recommendations for Environmental Modification
Beauchet O, et al. Recurrent falls and dual task-related decrease in walking
speed: Is there a relationship? J Am Geriatr Soc 2008 Jul;56(7):1265-9
Benaim C, et al. Validation of a standardized assessment of postural control in
stroke patients: The Postural Assessment Scale for Stroke Patients (PASS).
Stroke 1999;30(9):1862-68
Hornby, T George from University of Illinois. Unpublished study to be presented
at 2015 CSM
Kattah, Jorge C, et al. HINTS to diagnose stroke in the acute vestibular
syndrome: Three-step bedside oculomotor examination more sensitive than
early MRI diffusion-weighted imaging. Stroke 2009;40:3504-3510
Klein et al. Principles of experience dependent neural plasticity: Implications for
rehabilitation after brain damage supplement. Journal of Speech, Language, and
hearing research. S1: 5225-5239
Mao HF, et al. Analysis and comparison of the psychometric propeties
of three balance measures for stroke patients. Stroke
2002;33(4):1022-27
Oliveira, Clarissa Barros de, et al. Balance control in hemiparetic stroke
patients: main tools for evaluation. Journal of Rehabilitation Research
& Development 2008;45(8):1215-1226
Sawakri, et al. Constraint induced movement therapy results in
increased motor map area in subjects 3 to 9 months after stroke.
Neuro Rehab and Neuro Repair 2008, 220: 505
Schmid, AA, et al. Balance is associated with quality of life in chronic
stroke. Top Stroke Rehabilitation, 2013 Jul-Aug;20(4):340-6