Vestibular Rehabilitation on a Shoe String. BAA November 2013

Transcription

1 Vestibular Rehabilitation on a Shoe String BAA November 2013

2 Overview Need for VR services Vestibular Rehabilitation on a budget: equipment fitting into duffel bag Important components of a VR plan Booklet based VR Devise a practical VR plan

3 The need for VR Services 30 % of the population will experience dizziness or imbalance by the age of 65 years (1) 3% of patients in primary care receiving VR, despite 75% who could potentially benefit (2) Balance problems in elderly cause 50% of falls (3) VR questionnaire(4) 75% had VR service but only 9% had services for elderly 70% of 200 departments didn t reply Reason given for no service: Insufficient funds, staff, training % of dizzy pts diagnosed with BPPV Age group (yrs) Herdman (1) Davis and Moorjani 2003 (2) Yardley 2004 (3) Pothula 2004 (4) Cane 2009

4 Providing service on tight budget is possible! Therapist training most important component, not equipment Teach clinicians about value of vr and build good relationship with them Equipment fitting into a duffle bag Blank cheque- what would you buy? Video frenzels Epley omniax! Building an ideal dizziness and balance programme American Physiotherapy Association VR SIG 2010

5 Epley Omniax ( Easily maneuver and hold the patient in any position to observe, record and instantly play back nystagmus relative to the 3-D spatial orientation of the sccs Efficiently perform multiple assessment and treatment manoeuvres'

6 VR

7 Equipment fitting into a duffle bag Outcome measure eg VRBQ- for assessment and audit Ear model/picture (explaining diagnosis) Patient information sheets- on diagnosis and how to do exercises Letters (for gaze stabilization exercises) Chequered background, stripy umbrella, access to your tube videos (visual vertigo)

8 Equipment fitting into a duffle bag Foam (standing balance- patients can buy from internet) Tennis ball (more advanced exercises) Breathing and relaxation cd/information Couch (for BPPV) Stopwatch (timing exercises and DH/Epley)

9 Home Visual Vertigo Exercises X1 with spotty/ stripy background Scrolling up and down word document Head shake/nod with moving background (eg screen saver) Watching action DVD (still or with head movements, Use of Wii fit balance games Disco ball Playing computer games /You tube videos Walking in progressively challenging places

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11 Make your own visual vertigo video... Look away now if you are visually sensitive!

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13 Remember not to make you video too stimulatory!

14 Training and staff A number of VR courses now exist VR now in the new HTS course (not STP) VR can be given by many different specialities Basic VR is not rocket science! Booklet based VR

15 Important Components Good assessment and patient education Tailored plan, correct level, 5-6 exercises Include adaptation, habituation, substitution Include patient voiced difficulties How many repetitions? Gaze stabilization 60 + s 5x per day Others 2x per day, 60 s so evoke symptoms What level? Always need to evoke mild dizziness/challenge balance system

16 Important Components (2) Lifestyle modification and relaxation Tai chi/yoga or other light exercise Discuss decompensation and discharge when able to continue independently Ability to refer on for more complicated patients

17 Improve Adherence Ensure patient understands the process of VR- eg worse before better etc Make plan relevant to patients life Goal setting for patient Setting expectations as to extent of recovery and time appropriately

18 Improve Adherence Agree specific times in day when patient able to do exercises (preferably 2 x per day) Well written and presented written material Follow up (in person /by phone)

19 Not enough time and resources? Booklet based VR (Yardley)

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21 Yardley at al 2012 Patient in 1 care reporting dizziness during past 2 years, mean duration 5 years Routine care, booklet based with/without 3 telephone support sessions over 12 weeks No real change at 12 wks in vss, but subjective improvement in head movement evoked symptoms (2004: booklet delivered by nurse improvement in all outcome measures at 12 wks) At one year both intervention groups benefited compared to routine care

22 Results Telephone support provided additional reduction in anxiety and depression and higher adherence More research into optimal mode and level of support needed Highly cost effective (best with booklet alone) Booklet + telephone support only 25 more than routine care

23 Stepped care for dizzy patients? Reassurance by GP: patients compensate on their own- top reason given for those who were invited to take part but declined - no longer dizzy Booklet: patients able to do successfully independently (from GP or audiology) Booklet with specialist support (audiology or trained nurses) (check no BPPV and ensure no red flags, transfer face to face if needed) Face to face VR: more severe or distressed by symptoms, anxiety

24 So what about the goldfish?

25 Compensation in gold fish after unilateral utriculus and scc removal. Ott et al 1988

26 Practice on Me! Your aim

27 History Acute vertigo and vomiting for 6 hours when still, exacerbated by movement Movement evoked symptoms after this No other auditory symptoms Got better over time but still there New in last 3 weeks: short lived RV on turning to left side in bed

28 Where to Start?

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30 Test Results VRBQ 40% deficit Dix Hallpike +ve on the left Torsional nystagmus to the undermost ear with upbeating component after a few s lasting for 35 s Oculomotor testing: WNL Caloric testing: Left canal paresis 40% Right directional preponderance 30%

31 Rehabilitate Me! Appointment 1: Epley manoeuvre left to treat left sided posterior canal BPPV Appointment 2: Check BPPV resolved VR assessment and tailor made plan of exercises

32 Vestibular Rehabilitation Assessment Exercise level generating symptoms and exercises chosen: Herdman x 2 paradigm Head shake eyes closed sitting Head nod eye closed standing Sharpened Romberg (modified) eyes closed Circles too difficult X Walking with head turn too difficult X Patient voiced: walking upstairs

33 VR on shoestring is possible! Equipment fits into a duffle bag and is cheap Get some training and set up a service! Think about booklet based VR and how this could be used VR at however basic a level may be able to: Help many routine patients understand and diminish their symptoms Minimize 2 anxiety/ depression Allow patients to self manage relapses

34 More detail about exercises Gaze stabilization Head and body movement Otolith desensitization Standing Walking Patient voiced More advanced

35 Gaze Stabilization Exercises When? Patient reports blurring of visions/catch up of the world on head movement Due to decreased VOR gain Mechanism?adaptation/pre programmed saccades

36 Herdman s Gaze Stabilization Exercises X2 paradigm X1 paradigm can be done vertically or with spotty background. Stick letter on wall Pictures from: Vestibular Rehabilitation Herdman

37 Gaze Stabilization Exercises Adaptation may not underlie recovery, but use of exercises based on generating a retinal slip error signal does appear to induce recovery (Herdman) Time: s, without stopping, 5x per dayincrease in sx expected to occur Adaptation is f specific- do over wide range of f keeping target in focus, different head positions, vertical and horizontal, near and far from target Needs to stress limit of ability

38 Progression of Gaze Stabilization From Tee et al 2005

39 Where Patients Go Wrong X1 X2 Not keeping target in focus Head mvt too large- viewing target out of corners of eye Asymmetrical or wrong head mvt As per x 1 Moving letter and head in same direction

40 Head and Body Movements When? Movement evoked symptoms Mechanism: habituation Need to evoke symptoms repeatedly Head turn/nod/tilt Eyes open/closed Sitting or standing Other body movement exercises eg From lying to sitting Bending down picking up an object Turning in circle standing (eyes open/closed)

41 Otolith Desensitisation When? Problems of soft carpets, cobblestones, escalators Mechanism: habituation Rock back and forwards staring at target On cushion With eyes closed

42 Standing Balance When? Patient reports postural instability (usually more apparent with eyes closed or on soft/uneven surface Romberg Sharpened Romberg Tip toes One leg stance Foam

43 Walking Exercises When? Patient reports instability when walking or has unusual gait With or without head turn/nod Heel to toe walking Walking and stepping over object (elderly) Walking slowly with eyes closed

44 Patient Voiced When? Wherever possible IMPORTANT makes relevant to their lives What? Whatever important to patient and evokes symptoms

45 Advanced Exercises At end of programme Exercises involving unplanned movements Hitting ball against wall, throwing and catching games Patient walking in circle and person giving command eg turn around, touch the floor Sports such as badminton, football