Vestibular and Balance Continuing Education Course

Course Objectives

This course will provide the participant with to ability to:

• Compare and contrast the systems underlying balance.
• Discuss the differences in the balance system with different pathologies, as well as identify the changes that occur across the lifespan, especially with aging.
• Differentiate different causes of imbalance, employ appropriate outcome measures, and implement treatment.
• Perform examinations and interventions for balance dysfunction in patients with orthopedic problems, neurologic problems, and vestibular dysfunction. Utilize the appropriate evidence-based test/tools that are appropriate for specific situations.
• Perform a thorough neurological examination.
• Identify the proper function of cranial nerve 8 when performing specific tests.
• Identify which tools are most appropriate to use for evaluation and treatment when assessing balance, gait, and function.
• Develop evidence-based intervention for patients with vestibular, neurologic, orthopedic, and cervicogenic dysfunction.
• Discuss BPPV tests and interpretations, efficacy of maneuvers, keys to performing techniques for successful results and evidence-based expected outcomes.
• Properly perform the following tests: Canalith Repositioning Maneuver, Dix-Hallpike maneuver, horizontal canal repositioning, Brandt-Daroff exercises, Gufoni maneuvers,and Epley Semont maneuver.
• Discuss common causes of vestibular balance dysfunction, cervicogenic dizziness, and migraine-related vestibulopathy.
• Develop intervention strategies that are relevant to the patient with balance dysfunction, total joint arthroplasties, lumbar spine dysfunction, and vestibular dysfunction.
• Discuss the pathological process that involves BPPV, cervicogenic causes of dizziness and imbalance, concussion, and traumatic brain injury.
• Develop higher-level balance training, fall risk assessment, and intervention programs for the higher-level athlete or individual.
• Develop fall risk assessment programs and intervention programs for varying levels of function, from lower-level to the higher-level athlete.

Learn From the Expert - Diane Wrisley, PhD, PT, NCS

• Diane Wrisley’s evidence-based research and clinical applications provide an encyclopedia of information for the clinician to master evaluation and treatment techniques for balance and vestibular disorders.
• This course encompasses over 30 years of experience in research, clinical skill, and program development.
• Many of the functional assessment tools presented in this course and utilized in today’s rehab environment have been researched and developed by Dr. Wrisley.

Balance and Postural Control

• What is Balance?
• What factors contribute to balance?
• What are the different movement strategies
• How does cognition contribute in our ability to balance?
• Thinking about postural control as a loop
• Factors that affect both the center of gravity and the limits of stability
• The information from the visual system, the vestibular system, and the somatosensory system
• What happens if an individual has a problem within a sensory system?
• Which body movements are necessary to keep us upright?
• The consequence of peripheral neuropathy
• Dealing with an aging vestibular system in your patients
• Problems with the motor control system
• Parkinsons Disease, Down Syndrome and motor control
• Managing with a loss of anticipatory postural control
• Abnormal postural control and sensory organization

Vestibular Anatomy and Physiology

• Learning about vestibular anatomy and physiology and how it contributes to balance and postural control
• Where is the peripheral vestibular system?
• Learning about the semicircular canals
• The common crus Aplasia and its connection to the canals of the ear
• What are the semicircular canals so interesting?
• The ampulla and the sensory organs for the inner ear

Vestibulo-Ocular Reflex and Visual System

• Understanding the lateral vestibular spinal track
• Understanding nystagmus and eye movement patterns
• Measuring gain in the vestibulo-ocular reflex
• The vestibular nuclei and sending and receiving information from the cerebellum.
• Understanding the visual field and deficits
• Different types of eye movements, Conjugate eye movements, lazy eye
• Vergence and Gaze stabilization

Vestbular Examination Overview

• The cardiorespiratory system, cognition, the musculoskeletal system, sensory system, orientation in space, and movement strategies
• The importance of the medication review
• What is the social history of this patient
• The Montreal Cognitive Assessment
• Looking at the integumentary system
• Sensation: Light touch, pinprick, vibration using the 128-Hz tuning fork, monofilaments, and proprioception
• The Dix-Hallpike Maneuver
• Alignment from all directions-anterior, posterior, and lateral
• Understanding intersegmental mobility
• The FACT Test
• The Melbourne Edge Test
• What are Saccades?
• Understanding and testing test optokinetic nystagmus
• Examining convergence, and the ability of the eyes to move symmetrically
• Active and passive VOR
• The Head Impulse Test
• Activities-specific Balance Confidence Scale
• Modified Clinical Tests for Sensory Interaction and Balance
• Tests for gait and balance such as Romberg and the Sharpened Romberg
• The Single Limb Stance Test
• The 30-Second Chair Stand Test
• Five Times Sit to Stand
• The Four Square Step Test
• The Multi-Directional Reach Test
• The Berg Balance Scale
• Tinetti Performance Oriented Mobility Scale, or the POMA
• The Mini-BES Test
• Dynamic Gait Index
• The Time Up and Go
• The Functional Gait Assessment
• The Six-Minute Walk Test
• Fall risk assessment-Morse Fall Scale, the Hendrich II Fall Risk Assessment, and Stratify, the St. Thomas Risk Assessment Tool
• Test higher-level balance - the Star Balance Test, the Balance Error Scoring System, or the High-Level Mobility Assessment Tool
• The Y Direction Test
• Fall risk assessments for home health-The Missouri Alliance for Home Care, or the MAHC-10
• High-Level Mobility Assessment Tool
• The Community Balance and Mobility Scale

Different Factors that Can Lead to Balance Dysfunction

• Motor problems with range of motion, strength, motor control, posture, and intersegmental mobility
• problems with reflexes, sensation, radicular pain, and spasticity
• Decreased cervical spine mobility and its association with the vestibular system
• Strength problems and your balance strategies
• Intersegmental mobility, and patients with lumbar, cervical, and thoracic spine dysfunction
• Relating Reflexes - spasticity or rigidity and CNS Dysfunction
• Hypo-reflexive and association with the peripheral nervous system
• Radicular pain coming with the inner segmental mobility
• Problems with somatosensory information
• Modified Clinical Test of Sensory Interaction Imbalance

Vestibular Causes of Imbalance

• Peripheral and central causes of dizziness from the vestibular system
• Migraine-related vestibulopathy
• Multiple Scherosis and dizziness
• Unilateral vestibular loss, or hypofunction
• Vestibular labyrinthitis and inflammation of the whole labyrinth
• Infarction of the labyrinthine artery, trauma, demyelinating disease, or Meniere’s disease
• Perilymphatic fistula - episodic vertigo, imbalance, and sensorineural hearing loss
• Bilateral vestibular loss and loss of function in the vestibular system in both sides
• BPPV and the most common form of dizziness
• Problems with the vestibular nuclei, the cerebellum, or other vestibular pathways

Benign paroxysmal positional vertigo

• The displacement of the otoconia
• Theories of pathophysiology for BPPV
• Symptoms of the BPPV
• The etiology of the BPPV
• The diagnostic criteria for BPPV
• different tests to diagnose BPPV
• Posterior canal involvement
• Torsional eye movements
• video nystagmography or Frenzel lenses
• The Roll Test tests for horizontal canal BPPV
• Canalithiasis in the posterior arm
• Horizontal canal involvement with canalithiasis
• Treating BPPV - liberatory maneuver, or the Semont maneuver, for posterior or anterior canal
• The Roll maneuver for the horizontal canal
• the Barbecue, or the Lempert
• Appiani, or the Gufoni maneuvers
• Canalith Repositioning Maneuver
• Outcomes after Canalith Repositioning Maneuver
• Brandt-Daroff exercises
• Difficulties in diagnosing BPPV
• Understand BPPV symptoms that recur
• Who is the Canalith Repositioning and the Dix-Hallpike appropriate?
• What are some contraindications?
• Dix-Hallpike for patients with hip replacement

Evaluation Lab Techniques : Demonstrations and Descriptions

• Reflexes are important to test
• Reflexes are graded on a scale of zero to four
• Testing the triceps reflex
• Where do hyperactive reflexes come from?
• Performing sensory testing
• Weinstein Enhanced Sensory Test
• Using the 128-Hz tuning fork
• Testing the cranial nerves
• Testing saccades
• Testing for convergence
• Optokinetic nystagmus
• Vestibular nystagmus
• Testing cranial nerve eight
• Demonstration of tests for the Balance System
• Learning to perform a Sharpened Romberg test
• Learn the Functional Gait Assessment
• Demonstration of the High-Level Mobility Assessment Tool
• Execute a Mini-BESTest
• Learn to execute the Modified Clinical Test of Sensory Interaction and Balance

Treating the Dysfunction

• The intervention is based on impairment rather than diagnosis
• Visual biofeedback devices
• Anticipatory balance control
• Upweighting the vestibular system
• Promote the use of somatosensory inputs
• Treatment for improving balance strategies
• Intervene at the functional task level
• Putting all this information together

Treatment Techniques: Demonstrations and Descriptions

• Creating a balance training treatment program
• Treatment plan progression

Patient Case Study

• 62-year-old post total knee arthroplasty
• This patient will inevitably fall
• How would we evaluate, develop a plan and deliver treatment?

Course Test - Evaluate your knowledge

• Use the Healthclick proprietary online education system which provides the online student with:
• Worldwide access to high definition video, anatomical animations and images, and written information
• The highest quality film in the industry, you can see the difference!
• Stop and resume within a course, the Healthclick system will optimize your course based on your device, connection and remembers where you left off.
• Real-time course updates. We are always adding to each courses, updating content, adding animations, these are not static courses!
• Evaluate your knowledge with the course test on any device.
• Print your state course certificate for CE credit.
• Take the online test as many times as need in order to achieve a 70 % or greater score.