Simplified Vestibular Rehabilitation Therapy 9811598681, 9789811598685

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Simplified Vestibular Rehabilitation Therapy Byung In Han

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Simplified Vestibular Rehabilitation Therapy

Byung In Han

Simplified Vestibular Rehabilitation Therapy

Byung In Han Do Neurology Clinic Daegu South Korea

ISBN 978-981-15-9868-5    ISBN 978-981-15-9869-2 (eBook) https://doi.org/10.1007/978-981-15-9869-2 © Springer Nature Singapore Pte Ltd. 2017, 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Foreword

I am delighted that Dr. Han publishes Vestibular Rehabilitation Therapy. Vestibular rehabilitation programs capitalize on the innate plasticity of the balance system to advance the natural compensation process and to hasten recovery. Vestibular rehabilitation therapy should be the mainstay in managing all forms of central as well as peripheral vestibular disorders. Dr. Han is a unique figure. After residency training in neurology, he had worked at a private neuro-otology clinic for several years before he opened his own clinic. Besides a neuro-otologist, he is an artist mostly interested in drawing portraits with charcoal pencils. He also had been trained for Hapkido, a Korean martial art, and ballet. This book is the result of all these experiences. Fortunately, I had an opportunity to write papers on benign paroxysmal vertigo and several books with him. He has got many talents and is really enthusiastic in every aspect both clinically and academically. This book contains the key information for vestibular rehabilitation therapy in a simplified way using illustrations drawn by the author himself and photographs taken by a professional photographer. This book is based on his personal experience as a clinician running a private clinic, and would be especially useful for the care of ambulatory patients in the primary healthcare facilities. 

Ji-Soo Kim, MD, PhD Department of Neurology, Seoul National University College of Medicine Seoul, South Korea Dizziness Center, Seoul National University Bundang Hospital Seongnam, Gyeonggi-do, South Korea The Korean Society for Ocular Motility Seongnam, Gyeonggi-do, South Korea Korean Society of Neuro-Ophthalmology Seoul, South Korea

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Preface

I became interested in vestibular rehabilitation therapy (VRT) during the time I was working as the vice-president of the Oh Neurology Clinic between 2005 and 2007. Since then I have written two review articles on VRT [1, 2] but could not afford to have VRT room. Since 2008, I came to run my own primary clinic, Do Neurology Clinic, and realized that it was a challenge for me to deliver the therapeutic results that my patients with dizziness deserve. Like many of us who operate a primary clinic, I do not have a specialized therapist, equipment, and/or space for exercise therapy. So, I designed and developed my own exercise program, simplified VRT (sVRT). sVRT is a streamlined version of VRT, intended for use in primary healthcare facilities for ambulatory patients. sVRT is a product of a comprehensive review of domestic and foreign literature merged with my own experiences in Hapkido, a Korean martial art, and ballet. The exercises for sVRT include a variety of movements. Those movements performed by me and professional dancer were recorded in footage in a way that is easy for the patients to follow along. The recorded footages were edited with titles, music, and narration. The final footages were displayed on a monitor and the patients follow on. sVRT requires readily accessible resources: a display monitor, one instructor, and a chair. I have applied sVRT to my patients with dizziness and realized that sVRT was safe and effective. Also, sVRT has received positive reviews from the 29th Bárány Society Meeting 2016 in Seoul, Korea [3], where I introduced sVRT to the audiences. These optimistic outputs lead me to decide to publish this book. I am grateful to Kyungtae Kang and Hye Jung Lee, students of Kyungpook National University, School of Medicine, for the editing; Hyun Ah Kim for the choreographic photo model; Eun Hye Shin, Hyun-jin Goo, Hye-min Jung, and Myeong-ji Lim for the photo model; and last but not the least, Je Yeon Ahn for the photos. I sincerely wish for this book to benefit both the patients and the therapists practicing sVRT.  Furthermore, I hope my work will lay the groundwork for clinicians developing more intuitive and effective therapeutic exercises.

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Preface

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November 5, 2019, Byung In Han, MD, PhD, President. Do Neurology Clinic. References 1. Han BI, Ko PW, Lee HW, Kim HA, Lee H. Vestibular rehabilitation in central dizziness. Res Vestib Sci. 2015 Dec;14(4):97–100. 2. Han BI, Kim JS, Song HS. Vestibular rehabilitation therapy: review. J Clin Neurol. 2011 December;7(4):184–96. 3. Han BI, Simplified vestibular rehabilitation therapy. 29th International Barany Society Meeting. Seoul 2016 June.

Daegu, South Korea

Byung In Han

Contents

1 Vestibular Rehabilitation Therapy: Review of Indications, Mechanisms, and Key Exercises ����������������������������������������������������   1 1.1 Introduction������������������������������������������������������������������������������   1 1.2 Indications��������������������������������������������������������������������������������   1 1.3 Natural Course of Peripheral Vestibular Lesions����������������������   2 1.4 Principles of VRT����������������������������������������������������������������������   3 1.4.1 Enhancing Gaze Stability����������������������������������������������   3 1.4.2 Enhancing Postural Stability����������������������������������������   5 1.4.3 Decreasing Vertigo��������������������������������������������������������   9 1.4.4 Improving Activities of Daily Living����������������������������  11 1.5 Factors Affecting Recovery������������������������������������������������������  11 1.6 Practicing Exercise��������������������������������������������������������������������  12 1.6.1 Principles of the Exercises��������������������������������������������  12 1.6.2 Components of the Exercises����������������������������������������  12 1.6.3 Exercise Modification ��������������������������������������������������  12 1.6.4 Exercise Frequency and Duration ��������������������������������  13 1.6.5 How to Progress������������������������������������������������������������  13 1.6.6 Special Situations����������������������������������������������������������  14 1.7 Summary ����������������������������������������������������������������������������������  14 References������������������������������������������������������������������������������������������  14 2 Vestibular Rehabilitation in Central Dizziness ����������������������������  17 2.1 Introduction������������������������������������������������������������������������������  17 2.2 Usefulness of VRT for Selected Central Dizziness������������������  18 2.3 Cerebellar Degeneration ����������������������������������������������������������  18 2.4 Parkinson Disease (PD)������������������������������������������������������������  19 2.5 Conclusion��������������������������������������������������������������������������������  19 References������������������������������������������������������������������������������������������  20 3 Implementing the Exercises������������������������������������������������������������  21 3.1 Assessments for VRT����������������������������������������������������������������  21 3.2 Exercises for VRT ��������������������������������������������������������������������  22 sVRT Exercises and YouTube Link������������������������������������������  23 3.2.1 Gaze Stability Exercises ����������������������������������������������  27 3.2.2 Postural Stability Exercises������������������������������������������  38 3.2.3 Habituation Exercises ��������������������������������������������������  68

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3.3 General Exercises����������������������������������������������������������������������  80 3.3.1 Warming-Up Exercises ������������������������������������������������  80 3.3.2 Cooling-Down Exercises����������������������������������������������  84 3.3.3 Shoulder Stretch������������������������������������������������������������  86 3.3.4 Upper Cross Syndrome Exercises ��������������������������������  92 3.3.5 Leg Stretches Using a Chair ����������������������������������������  93 3.3.6 Leg Stretching��������������������������������������������������������������  99 3.3.7 Leg Strengthening Exercises Using a Chair ���������������� 103 3.3.8 Leg Strengthening Exercises���������������������������������������� 108 3.3.9 Lower Cross Syndrome Exercises�������������������������������� 113 3.4 Software “Do Smart®” and the Equipment “Balance Pro®” for sVRT������������������������������������������������������������������������������������ 115

About the Author

Dr. Han  is a neurologist and the President of Do Neurology Clinic and Do Balance Center. His major interests are headache, dizziness, tinnitus, sleep problems, and vestibular rehabilitation therapy. He has published several books and papers including several SCI and nonSCI journals. The transcranial Doppler exam of Do Neurology Clinic was recognized as a national representative technique in 2010. He has made presentations and research posters regarding dizziness, tinnitus, and vestibular rehabilitation therapy in several national and international symposiums. Besides his busy schedules, he also involves himself in community and charitable activities, such as volunteering to visit local nursing home together with his staff. Dr. Han is a man of many talents. He is an accomplished violinist, is an artist with an emphasis on drawing portraits with charcoal pencils, and has also practiced Hapkido, a Korean martial art, for 6 years which has allowed him to become a Hapkido master of the third degree. He uses these talents to serve his staff and community to provide quality treatment and a safer environment for the colorful people of Daegu. Education MD, Kyungpook National University School of Medicine, Daegu, South Korea, 1986–1990 MS, Pusan National University School of Medicine, Pusan, South Korea, 2004–2006 PhD, Kyungpook National University School of Medicine, Daegu, South Korea, 2007−2009

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1

Vestibular Rehabilitation Therapy: Review of Indications, Mechanisms, and Key Exercises

1.1

Introduction

Most patients with peripheral vestibular lesions have a benign cause and undergo spontaneous resolution due to the self-limiting nature as well as the process of central nervous system compensation [1]. Vestibular compensation results from active neuronal changes in the cerebellum and brain stem in response to sensory conflicts produced by vestibular pathology [2]. Occasionally, even in the absence of ongoing vestibular lesions, poor compensation or maladaptive postural control strategies are adopted [2]. Vestibular rehabilitation programs capitalize on the innate plasticity of the balance system to advance the natural compensation process [1]. The earliest VRT was developed by Cawthorne and Cooksey, which is called Cawthorne–Cooksey exercises to treat patients with labyrinth injury from surgery or head injury [3, 4]. They found that exercises designed to encourage head and eye movements hastened recovery. Their value in managing all forms of peripheral vestibular disorders rapidly became apparent and formed the mainstay of treatment for this group of patients. The exercises for vestibular rehabilitation can be categorized into two groups, physical therapy for vestibular hypofunction and canalith repositionThis chapter refers to a published paper: Han BI, Ko PW, Lee HW, Kim HA, Lee H.  Vestibular Rehabilitation in Central Dizziness. Res Vestib Sci. 2015 Dec;14(4): 97–100. © Springer Nature Singapore Pte Ltd. 2021 B. I. Han, Simplified Vestibular Rehabilitation Therapy, https://doi.org/10.1007/978-981-15-9869-2_1

ing therapy for benign paroxysmal positional vertigo (BPPV). The latter is beyond this review. In this chapter, we will focus on the physical therapy for vestibular hypofunction, also called vestibular rehabilitation therapy (VRT), balance rehabilitation therapy, or balance retraining therapy.

1.2

Indications

VRT is indicated for the following conditions: 1. Stable vestibular lesion: VRT is indicated for any condition characterized by a stable vestibular deficit, in which evaluation reveals no evidence of a progressive process and the patient’s natural compensation process appears to be incomplete [2]. 2. Central lesions or mixed central and peripheral lesions: Patients with stable central nervous system (CNS) lesions or mixed central and peripheral lesions should not be excluded from treatment, although their prognoses are likely to be more limited than the average patients with a stable peripheral injury [2]. A trend for poor overall performance was seen for the mixed central-peripheral disease compared with the pure unilateral peripheral disease, but no significant differences have been appreciated until now. 3. Head injury: Patients with head injuries suffer from significant disability due to vestibular symptoms. Their conditions often include 1

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1  Vestibular Rehabilitation Therapy: Review of Indications, Mechanisms, and Key Exercises

cognitive and central vestibular involvement along with the peripheral component; therefore, VRT techniques are used as a ­supplement to a comprehensive, multidisciplinary head injury program [2]. 4. Psychogenic vertigo: Patients with panic disorder and other anxiety disorders often seek treatment for ill-defined vestibular symptoms. After appropriate evaluation is performed, VRT may be recommended as an adjunctive measure for their conditions. If the anxiety is mild, VRT functions as a behavioral intervention similar to exposure therapy for the treatment of phobias. If the anxiety component is significant, and particularly if panic attacks are frequent, psychiatric intervention will be required as well [2]. 5. Elderly with dizziness: In older adults with symptoms of dizziness and no documented vestibular deficits, the addition of vestibular-­ specific gaze stability exercises to standard balance rehabilitation results in a greater reduction in fall risk [5]. 6. Vertigo with uncertain etiology: It is not always possible for the physician to determine whether the patient’s complaints are due to stable vestibular disease with inadequate central compensation or due to unstable labyrinthine function [2]. For the patients in whom the cause of vertigo is not clarified even though extensive diagnostic efforts were delivered, an empirical trial of vestibular physical therapy may be a helpful option. Recognition of patients for whom the symptoms are not the direct result of a vestibular lesion does not prevent the use of a vestibular rehabilitation as an adjunct treatment [6]. 7. BPPV: One study reported that, for the patients with BPPV, residual dizziness after successful repositioning was observed in two-­ thirds of the patients, and disappeared within 3  months without specific treatment in all cases [7]. Nevertheless, balance training may be necessary after the treatment of BPPV [8]. 8. Cases not indicated: If the lesion is unstable, habituation will be nearly impossible. If the patient has ongoing labyrinthine pathology, VRT is generally fruitless [2]. Patients whose

symptoms occur only in spontaneous episodes, such as seen with Meniere disease, are unlikely to benefit from VRT. VRT is unsuccessful in patients with only spontaneously occurring events of disequilibrium, especially if the spontaneous vertigo or disequilibrium develops more than once per month [9]. For those patients, the primary objective is to prepare the person for anticipated dizziness rather than to make any permanent change in their present vestibular situation [10]. Among the patients suspected of perilymphatic fistula, the patients who become worse during exercise therapy are more likely to benefit from other treatments such as surgery [9].

1.3

 atural Course of Peripheral N Vestibular Lesions

The symptoms and signs of acute vestibular neuritis are derived from the static imbalance and dynamic disturbances in inputs from the semicircular canals and the otolithic organs. Static imbalance is related to the differences in the level of tonic discharge within the vestibular nuclei with the head still, and dynamic disturbances are related to the impaired compensatory responses during head movements [11]. Static signs comprise nystagmus (semicircular canal origin), subjective visual vertical (SVV) or horizontal (SVH), ocular tilt reaction (OTR), and lateropulsion (otolithic sign). Dynamic signs include vestibuloocular reflex (VOR) asymmetry (semicircular canal sign), ocular counter-rolling (OCR), and postural instability (otolithic sign) [12]. The otolith dysfunction appears to improve more rapidly than the canal-related impairments during the short-term follow-up [13]. Static signs and symptoms gradually abate within weeks, even in the presence of continued peripheral dysfunction. Dynamic signs, however, persist for life, if vestibular function does not recover and lead to blurred vision and imbalance when the patients make head turns toward the side of the affected labyrinth [14]. Within 48 h, most will be able to walk about and most can be back to normal activities within about 2 weeks. After 3 months, most

1.4  Principles of VRT

will be as well as they were ever going to be, which is subjectively back to normal. At this time, most patients will show only minor abnormalities of static vestibular function such as 1–2°/s of spontaneous nystagmus in darkness only, often accentuated by head shaking or application of vibration to the mastoid, a slight ipsilesional deviation of the SVH or SVV, and rotation toward the side of the lesion during the stepping test [12]. Generally, it is expected to see the improved function within 6 weeks, but the longer the problem has existed, the longer the time needed to see improved function [15]. For the patients with resection of acoustic neuroma, performances during the Romberg test with the eyes closed 3 days after the surgery offers a predictive value in determining which patients will benefit from brief vestibular adaptation exercises. This may be applied to patients with acute unilateral vestibular dysfunction [16]. The recurrence rate of vestibular neuritis (VN) is low, and no recurrence has been observed in the initially affected ear. However, a relapse may go undetected in those with a persistent and complete unilateral vestibular deficit [14]. The symptoms may get worse or relieved sometimes. This seems to be a common pattern during improvement and is related to overactivity during the good days which causes excessive fatigue resulting in increased symptoms within 24‑36 h [1]. Even after vestibular compensation is achieved and symptoms are largely resolved, there may be occasional periods of symptomatic relapse due to decompensation. This may be triggered by a period of inactivity, extreme fatigue, a change in medications, or an intercurrent illness. A relapse of vestibular symptoms in this setting does not necessarily imply ongoing or progressive labyrinthine dysfunction [2].

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ocular or vestibulospinal reflexes, whereas vestibular substitution refers to using alternative strategies to replace the lost vestibular function [12, 18]. The term “vestibular compensation” is mostly used as a synonym for vestibular substitution [17]. However, it is sometimes used to describe the general recovery from the unilateral vestibular deafferentation syndrome. In this manner, the term “well compensated” is used to describe the “fully functional,” while “poorly compensated” is applied to describe a partial recovery. The term “decompensation” is adopted to describe a near-total relapse [19]. If patients describe a severe vestibular crisis at onset, with continuous dysequilibrium or motion-­ provoked vertigo persisting or recurring, they are probably uncompensated. This is true even though specific abnormalities are not apparent during vestibular testing [2]. The goals of VRT are (1) enhancing gaze stability, (2) enhancing postural stability, (3) decreasing vertigo, and (4) improving daily living activities [20]. Following are principles of VRT based on the goals of VRT:

1.4.1 Enhancing Gaze Stability

1.4.1.1 Vestibular Adaptation Gaze instability is due to the decreased gain of the vestibular response to head movements [20]. The best stimulus to increase the gain of the vestibular response is the error signal induced by retinal slip [18]. Retinal slip is the image motion on the retina during head motion [21]. A good example of an exercise to induce retinal slip is horizontal or vertical head movements while maintaining visual fixation on a target. The target can be placed either within the arm’s length or across the room [16] (Fig. 1.1a). Repeated periods of retinal slip induce vestibular adaptation. 1.4 Principles of VRT Not all head movements result in the VOR gain The overall mechanisms of recovery are vestibu- change. Horizontal (yaw plane) and vertical lar adaptation and vestibular substitution. The (pitch plane) head movements are effective vestibular adaptation approach is similar to that whereas head movements in the roll plane do not described by Cawthorne for patients with persis- sufficiently induce changes in the VOR gain [18]. There are several ways to increase the effectent disequilibrium [17]. Vestibular adaptation refers to readjusting the gain of the vestibulo-­ tiveness of vestibular adaptation during head

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a

1  Vestibular Rehabilitation Therapy: Review of Indications, Mechanisms, and Key Exercises

b

Fig. 1.1  Exercises for enhancing gaze stability: (a) Head turns. (b) Head–trunk turns

movements. First, various amplitudes of retinal slip should be applied. Training with progressively increasing retinal slip errors is more ­effective than that with sudden, large errors [22]. To increase the magnification factor and the duration of exposure to the retinal slip, patients should view a target that is moving in the opposite direction of the head while moving their heads either horizontally or vertically [18]. Second, a wide range of head movement frequencies should be applied, because the greatest changes in the VOR gain occurs at the training frequencies [20, 23]. The training frequencies should not be changed abruptly. Adaptive changes in the VOR gain to retinal slip are greater when the error signal is gradually incremented than presented in its entirety [24]. Third, various directions of head movement should be tried, because head orientation during the training is a factor, presumably because the otolithic input influences the training effects [20, 25]. Patients should perform the exercises for gaze stability 4 to 5 times daily for a total of 20 to 40 min/day in addition to 20 min of balance and gait exercises [26]. During the exercises to induce retinal slip, good visual inputs, such as bright room lights or curtains open, should be encouraged [27]. There are also other ways to induce retinal slip such as position error signals, imagined motion of the target, strobe light, and tracking of images stabilized on the retina (flashed after images) [22]. Although retinal slip is probably the most effective means to stimulate VOR adaptation, other error signals may also contribute [22]. The

optokinetic visual stimulus also induces retinal slip [18], because smooth pursuit eye movement itself is a part of the error signal [28]. The benefit is that the optokinetic visual stimulus does not need head movements, and can be driven by the oscillation of an optokinetic drum or of a light-­ emitting diode stimulus [18]. Unidirectional optokinetic training enhances vestibular responses in the corresponding direction. Thus, optokinetic or combined vestibular–optokinetic training may improve the VOR gain in unilateral peripheral vestibular dysfunction [29]. During the optokinetic visual stimulus, a foveal and a full-field stimulus works equally in inducing adaptation [28]. Even in the absence of a visual stimulus, the VOR gain can be raised to near-unity by asking the subject to imagine an earth fixed target in darkness while moving the head. The VOR suppression can be trained by asking the subject to slowly rotate the upper body (head, arm, and torso together) (en block) side to side while maintaining the gaze on the thumb of the forwardly extended arm [30] (Fig. 1.1b).

1.4.1.2 Substitution by Other Eye Movement Systems Substitution by other eye movement systems can effectively cancel the vestibular deficit and so protect the patient from receiving smeared retinal images during head movements. Such substitution is possible when the patient has active control of the response [19]. The other eye movement systems are described. (a) Saccade Modification Corrective saccades become a part of an adaptive strategy to augment the diminished slow-phase component of the VOR [22]. Two kinds of saccades may be found in patients with vestibular deficits. One is a saccade of insufficient a­ mplitude (undershoot). When the patients follow a target with the eyes and head, a saccade to the target of decreased amplitude (undershoot) is initially generated, and then the eyes drift to the target. This keeps the eyes still during the head rotation [31]. The other is a saccade back toward the target (preprogrammed saccade); during an ipsile-

1.4  Principles of VRT

sional unpredictable head rotation (yaw) away from a centrally positioned target, the saccade is generated in the opposite direction to the head rotation back toward the target [32]. (b) Enhancing Smooth Pursuit Eye Movement Smooth pursuit eye movement becomes a means of substitution for the deficient VOR. One study revealed that patients with a deficient vestibular system show an enhancement in the pursuit system, with the open- and closed-loop pursuit gains that were about 9% higher than those in the controls [33]. Patients with severe bilateral vestibular loss also use smooth pursuit eye movements to maintain gaze stability during head movements while fixating on a stationary target [18, 34] (Fig. 1.2). (c) Central Preprogramming Eye movements occur before the onset of the head rotation when the movement is anticipated. These are not vestibular origin but result from central preprogramming and efferent copy of the motor command [35]. Visual acuity and VOR gains are better during predictable head movements toward the defect than those during unpredictable ones. This infers that, when the required movement is anticipated, central preprogramming is more effective for maintaining gaze stability [18]. Patients with bilateral vestibular loss use central programming of eye movements to maintain gaze stability more than do healthy subjects or patients with unilateral vestibular loss [35]. (d) Eyeblink During Saccade Both normal subjects and patients with unilateral vestibular deficits perform a blink during gaze saccades. This may prevent smear of the retinal image and cancel a VOR inadequacy [36]. (e) Cervico-ocular Reflex During low-frequency head movements (e.g., lower than 0.5 Hz), cervico-ocular reflex (COR) induces a slow eye rotation opposite to the head movement [18]. The COR makes no significant contribution to eye movements in the normal subjects [37]. However; in patients with bilateral

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vestibular loss, the COR takes on the role of the VOR in head–eye coordination (1) by initiating the anticompensatory saccade which takes the eyes in the direction of the target, and (2) by generating the subsequent slow compensatory eye movements [37]. COR has been known to contribute to gaze stability only in patients with bilateral vestibular loss, at least during low-­ frequency head movements (e.g., lower than 0.5  Hz) [18]. However, a recent study revealed that the COR is also potentiated in patients with unilateral vestibular loss [38].

1.4.2 Enhancing Postural Stability Postural stability recovers more gradually than that of gaze stability [15]. The primary mechanisms of postural recovery are increasing reliance on the visual and somatosensory cues (substitution) and improving the vestibular responses (adaptation) [20]. In patients with temporary deficits, recovery of normal postural strategies is required. In cases of permanent vestibular deficits, compensatory strategies such as relying on alternative somatosensory cues are needed [39]. The goals of VRT especially for postural stability are to help patients (1) to learn to use stable visual references and surface somatosensory information for their primary postural sensory system, (2) to use the remained vestibular function, (3) to identify efficient and effective alternative postural movement strategies [40], and (4) recovering normal postural strategies. For these, the therapist should assess whether the vestibular deficit is unilateral or bilateral, whether there is remaining vestibular function, whether the patients over-rely on particular sensory modalities such as vision or proprioceptions, and whether there is any other sensory impairments present [41]. To assess how sensory information from the vestibular, visual, and somatosensory system is utilized for postural stability, the Clinical Test for Sensory Interaction in Balance (CTSIB) was designed [42]. This test examines the patient’s body sway while the subject stands quietly for 20  s under the six different sensory conditions which alter the availability and accu-

1  Vestibular Rehabilitation Therapy: Review of Indications, Mechanisms, and Key Exercises

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a

b

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2

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1

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Fig. 1.2  Exercises for enhancing eye movements: (a) Exercise for saccade and VOR: 1. Look directly at a target, being sure that your head is lined up with the target. 2. Look at the other target. 3. Turn your head to the other target. (b) Exercise for imagery pursuit: 1. Look directly at a target, being sure that your head is lined up with the

target. 2. Close your eyes. 3. Slowly turn the head away from the target while imagining that you are still looking directly at the target. 4. Open your eyes and check to see whether you have been able to keep your eyes on the target. If not, adjust your gaze on the target

racy of visual and somatosensory inputs for postural orientation [42]. Somatosensory information is altered by having the patients stand on a foam [42]. Vision is eliminated with eye closure or blindfold [42]. Vision is altered by having patients view the inside of the dome (a modified Japanese lantern with vertical stripes inside) attached to their heads [42]. Nowadays, instead of the dome, moving visual surround is used to alter vision during the CTSIB.

example, trucks passing in front of the patients in the street) can be misinterpreted as a self-motion and corrective postural adjustments are produced which can cause postural instability [41]. Therefore, it is not optimal to foster visual dependency (e.g., by teaching patients to fixate on a stationary object and to decrease their head movements while walking) [20].

1.4.2.1 Substitution by Vision or Somatosensory Cues The patients rely on somatosensory cues from the lower extremities during the acute stage, and on visual cues during the chronic stage [18]. The most powerful visual inputs come from the peripheral visual motion cues, rather than from the central (foveal) visual motion [40]. Although visual cues become increasingly important, those can be very destabilizing as a postural reference in patients with vestibular loss. If visual cues to earth vertical are slowly moving or not aligned with the gravity, patients may align their bodies with the visual cues and destabilize themselves, particularly when the surface reference is unstable or unavailable [40]. This phenomenon is called visual dependency. When the patients are visually dependent, a moving visual scene (for

Exercises for Visual Dependency For the patients who are visually dependent, exercises can be devised whereby the patient must balance with reduced or distorted visual input but good somatosensory inputs (for example, in bare feet) [41]. The patients should practice to maintain balance during exposure to optokinetic stimuli such as moving curtains with strips, moving discs with multicolored and differently sized circles, or even moving rooms [43]. Exposure to optokinetic stimuli in the home environment may be accomplished by having the patient watch videos with conflicting visual scenes, such as high-speed car chases either on a video screen, busy screen savers on a computer, or moving large cardboard posters with vertical lines [43]. Patients may watch a video showing visually conflicting stimuli while performing head and body movements in sitting, standing, and walking [43].

1.4  Principles of VRT

Exercises for Somatosensory Dependency Somatosensory dependency may occur during the vestibular recovery especially in patients with bilateral vestibular deficit. Those patients, differently from the patients with unilateral vestibular deficit, rely on visual cues during the acute stage, and somatosensory cues during the chronic stage [18, 44]. For those, vestibular compensation would not be expected to rely solely on visual inputs. In this instance, somatosensory cues are more important and could provide the requisite error signals leading to the static rebalancing of the vestibular nuclei [11]. This phenomenon is somatosensory dependency. To overcome this, the patients should practice to perform tasks while sitting or standing on surfaces with disrupted somatosensory cues for orientation, such as carpets, compliant foam, and moving surfaces (e.g., tilt board). An example is catching a ball while standing on carpets [43]. Nevertheless, visual and somatosensory cues cannot fully substitute for lost vestibular function [18].

1.4.2.2 Adaptation: Improving the Remaining Vestibular Function If a patient is unstable when both visual and somatosensory cues are altered, a treatment plan should be designed to improve the remaining vestibular function [45]. Although the remaining vestibular function has not fully recovered, the patients who are most confident in their balance ability and able to increase vestibular weighting the most are the best compensated [40]. Thus, the ultimate goal for regaining postural stability is to help patients learn to rely upon their remained vestibular function as much as possible, and do not depend upon their vision and somatosensory function only to substitute for the vestibular loss [40]. In order to teach patients to rely on their remaining vestibular function, gradual reduction or alteration of visual and somatosensory cues is needed [15, 41]. Patients should practice with the eyes open and closed, on firm or compliant surfaces, learning to maintain a vertical position in

7

the absence of visual or somatosensory cues. The patients need the practice of walking in different environments, such as on grass, in malls, and during the night [15]. Therefore, the exercises designed to improve postural balance are usually performed on a cushion with the eyes closed. The following exercises may be also included, e.g., walking and turning suddenly or walking in a circle while gradually decreasing the circumference of the circle, and walking on a floor while a therapist orders to turn to the right or left [15]. Exercises to improve balance in sitting or other positions are usually not necessary [15].

1.4.2.3 Recovering Postural Strategies Controlling the body position and orientation requires motor coordination processes that organize muscle throughout the body into coordinated movement strategies [43]. These processes are postural strategies. (a) Normal Postural Strategies There are three main postural strategies mobilized to recover balance in standing. Ankle strategy is the postural strategy in a wide stance that uses ankle torques in a bottom-up, inverted pendulum-­type sway. Hip strategy is the postural strategy in a narrow stance involving quick torques around the trunk and hips in a top-down control [46]. Ankle strategy is more dependent on somatosensory than vestibular function [46], while hip strategy is more dependent on vestibular function [47]. Ankle strategy is a pattern of postural strategy where the upper and lower bodies move in the same direction or in phase whereas hip strategy requires that the upper and lower bodies move forward or backward in the opposite direction or out of phase. Step strategy is a stepping movement when the stability limits are exceeded. (b) Abnormal Postural Strategies in Vestibular Dysfunction Patients with vestibular loss use the ankle strategy, but not the hip strategy, even when the hip

8

1  Vestibular Rehabilitation Therapy: Review of Indications, Mechanisms, and Key Exercises

strategy is required for postural stability such as standing on one foot, across a narrow beam, or in heel–toe stance [46]. Sometimes, vestibular deficits may result in abnormally coordinated postural movement strategies that would give rise to excessive hip sway [48]. This can cause a fall when the surface is slippery [41]. (c) Identifying Efficient and Effective Postural Strategies For patients using abnormally coordinated postural strategies, alternative postural strategies should be identified. Therefore, patients should be retrained to utilize the redundancy within the balance system to promote alternative postural strategies [41]. Because the postural strategies are centrally programmed and can be combined according to the postural conditions, subject expectations, and prior experiences [47], the patient should practice to perform a given strategy during self-initiated sway, or during tasks involving voluntary limb movements, or in response to perturbations [41]. (d) Recovering Normal Postural Strategies Ankle strategy can be practiced by swaying back and forth, and side to side within small ranges, keeping the body straight and not bending at the hips or knees [43]. Small perturbations, such as a small pull or push at the hips or shoulders are used. Patients carry out a variety of tasks, such as reaching, lifting, and throwing [43]. Hip strategy may be practiced by maintaining balance without taking a step and using faster and larger displacements (Fig. 1.3). This can be facilitated by restricting force control at the ankle joints by standing across a narrow beam, standing heel to toe, or in single-limb stance. Patients practice both voluntary sway and response to external perturbations on altered surfaces [43]. Stepping strategy can be practiced by passively shifting the patient’s weight to one side and then quickly bringing the center of mass back toward the unweighted leg, or in response to large backward or forward perturbations [43]. Patients also practice stepping over a visual target or obstacle in response to the external perturbations [43].

a

b

Fig. 1.3  Swaying back and forth: (a) Bend forward and move your center of body backward with your toe up. (b) Bend backward and move your center of body forward with your heels up. Repeat several times

*Other Things to Know The authors experienced a patient with chronic vestibular loss who can ride bicycles well although he had vertigo and imbalance while walking. This may be an example of the description by Brandt et  al. [49]. Patients with acute vestibular disorders can maintain balance better when running than walking slowly. This might suggest that the automatic spinal locomotor program suppresses destabilizing vestibular input [49].

1.4.2.4 Using Assistive Devices Light touch that provides a somatosensory cue without mechanical support is a powerful sensory reference for postural control. Thus, the use of a cane, which acts as an extended haptic “finger” for orientation to an earth reference, is an important tool for postural rehabilitation [40]. Fall is an important consequence of bilateral vestibular hypofunction, and patients should be counseled about the increased risk of falling. Assistive devices should be considered, especially for persons aged older than 65 years with bilateral vestibular loss [50]. Patients with bilateral vestibular deficits, unlike most patients with unilateral disorder, may require a walking aid, especially in the early stages. But care should be taken for the patients not to become dependent on such an aid [41].

1.4  Principles of VRT

The authors experienced a blind man who did not wear caps or gloves even in cold weather because he had a feeling of losing balance when he wore those. This indicates that Somatosensory information from the face may serve some function in compensation [51]. Therefore, the patients with balance disorders may be recommended not to wear caps or gloves when they are walking. Common Mechanisms for Gaze and Postural Stability There are mechanisms commonly applicable to both gaze and postural stabilities. 1. Decreasing head movements Patients with peripheral vestibular lesion have compensatory strategies that decrease their trunk and neck rotation in an effort to improve stability by avoiding head movements [52]. Patients typically turn “en bloc” and may even stop before they turn. This can lead to secondary musculoskeletal impairments including muscle tension, fatigue, and pain in the cervical, and sometimes in the thoracolumbar region [52]. The patients may not be able to actively achieve full cervical range of motion owing to dizziness, pain, or co-­ contraction although passive range with the head supported against gravity is possible [52]. Patients use excessive visual fixation and therefore have increased difficulty if asked to look up or turn their heads while walking [52]. However, this strategy is not useful because it results in a limitation of normal activity and does not provide a mechanism for seeing clearly during head movements [18]. 2. Spontaneous cellular recovery in ipsilesional vestibular function There are evidences of spontaneous cellular recovery in animal studies. Complete functional recovery of the vestibular function was observed after streptomycin treatment [53]. Single-neuron studies also demonstrated that a significant recovery of resting activity has occurred in the vestibular nuclei ipsilateral to the lesion by the time the spontaneous nystagmus and roll head tilt have largely disappeared [51]. However, it is unclear whether

9

cellular recovery is a significant factor in the restoration of vestibular function in human beings [18]. 3 . Substitution by unaffected vestibular function If the peripheral lesion is extensive, the ipsilateral vestibular nucleus will become responsive to changes in the contralateral eighth nerve firing rate by activating the commissural pathways [2]. There may be adaptive substitution or compensation within the central vestibular system of the unaffected side. A beneficial result is the suppression of input from the affected modality and the restoration of adequate spatial orientation by the contralateral, unaffected vestibular nucleus complex [54]. Corrective saccades occur at latencies suggesting that they could be triggered from neck proprioception or from changes in activity on the intact, contralateral vestibular afferents in the case of unilateral vestibular hypofunction [22].

1.4.3 Decreasing Vertigo For most patients with provoked positioning vertigo without definite diagnosis but benign etiology, decreasing vertigo should be the primary goal [2]. It can be achieved by habituation of abnormal vestibular responses to rapid movements [1]. The therapist identifies the typical movements that produce the most intense symptoms and provides the patient with a list of exercises that reproduce these movements [2]. Motion sensitivity test (MST) is used to assess the positions and movements that provoke symptoms. This test is associated with consecutive movements and positions such as turning the head or body during lying, sitting, or standing [15]. Habituation is a decrease in response magnitude to repetitive sensory stimulation. Habituation occurs through repetitive exposures to a provocative movement [43]. Habituation is specific in the type, intensity, and direction of the eliciting stimuli. In most cases, the provoking movement is the less frequently executed movement during daily activities. Repetition of the originally abnormal signal will stimulate compensation [55]. Sometimes,

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1  Vestibular Rehabilitation Therapy: Review of Indications, Mechanisms, and Key Exercises

the therapist should distinguish pure benign paroxysmal positional vertigo (BPPV) from positional vertigo resulting from poor compensation after a labyrinthine injury [2]. Provoked vertigo disappears when central compensation stimulated by the exercise develops sufficiently [43, 56]. After habituation, the spatial disorientation becomes the usual one and then begins to be integrated into the normal mechanism of processing [55]. If the patients can persevere with their program, most patients will begin to notice dramatic

relief of positional vertigo within 4 to 6  weeks [21]. The habituation effect is slower for the aged and the end result is not a complete success in a number of them [56]. The habituation effect remains for a very long time after the application of the stimulus [55]. Brandt–Daroff exercise is also a habituation therapy [57]. Authors experienced many patients who experience vertigo induced by bending over their neck or trunk. The exercise for those patients is presented in Table 1.1 and Fig. 1.4.

Table 1.1  Key exercises for VRT 1. Exercises for enhancing gaze stability  (1) Head turns: rotates the head side to side horizontally with gaze fixed on a stationary target. Do the same exercise with vertical head turns [15, 17, 52].  (2) Head–trunk turns: rotates the head and trunk together (en block) horizontally with gaze fixed on the thumb while the arm moving together with the trunk (modified from Zee’s exercise [58])  (3) Head turns while walking: while walking in a straight line, the patient rotates the head horizontally to the left and right with gaze fixed on a stationary target. Do the same exercise with vertical head turns [58]. 2. Exercises for enhancing eye movements  (1) Saccade: Keeps the head still and moves only the eyes. Imagine horizontally placed two targets close enough together that while looking directly at one. Look at one target and quickly looks at the other target, without moving the head. These movements are repeated several times (one of the Cawthorne–Cooksey exercises [58])  (2) Pursuit: Keep the head still and moves only the eyes. Extends one arm forward and make the thumb (target) up, and turn the arm side to side while focusing on the thumb (modified from one of the Cawthorne–Cooksey exercises [58])  (3) Saccade and vestibulo-ocular reflex: Horizontally placed two targets are imagined. For example, two arms are extended forward with two thumbs (target) up. Look at a target, being sure that the head is lined up with the target. Then, look at the other target and turn the head slowly to the target. Repeat in the opposite direction. Repeat both directions several times [52].  (4) Imagery pursuit (remembered target exercise). Look directly at a target, being sure that the head is lined up with the target. Close the eyes, and the head is slowly turned away from the target while imagining that one is still looking at the target. Then, open the eyes and whether the target is kept in focus is checked. If not, adjust the gaze on the target. Repeat in the opposite direction. It should be as accurate as possible. Repeat both directions several times [52]. 3. Exercises for enhancing postural stability.  (1) Stand on one leg. Stay for 15 s. Switch to the other leg (one of the Cawthorne–Cooksey exercises [58])  (2) Standing with the feet heel-to-toe with both arms extended. Stay for 15 s. Switch to the other leg [15, 17].  (3) Sway back and forth. Locate the patient behind a chair and before a wall. This prevents the patient from falling. The patient starts by bending low and moves the center of the body backward with the toes up. Next is bending backward and moving the center of the body forward with the heels up. Repeat ten times (one of the authors’ exercises)  (4) March in place [17]. 4. Exercises for decreasing vertigo  Stand with one arm elevated over the head, with the eyes looking at the elevated hand. Bend over and low the arm diagonally with the eyes continuously looking at the hand until the hand arrives at the opposite foot. Repeat 10 times (one of the authors’ exercises) 5. Exercises for improving activities of daily living  (1) Gait with sharp or wide turns to the right and left [17]  (2) Go from a seated to a standing position, then return to sitting (one of the Cawthorne–Cooksey exercises [58]) Key exercises for enhancing gaze stability, enhancing eye movements, enhancing postural stability, decreasing vertigo are described

1.5  Factors Affecting Recovery

a

b

Fig. 1.4  Exercises for decreasing vertigo: (a) Stand with one arm elevated over the head, with the eyes looking at the elevated hand. (b) Bend over and low the arm diagonally with the eyes continuously looking at the hand until the hand arrives at the opposite foot. Repeat with the other arm

Habituation exercises are inappropriate for patients with bilateral vestibular loss, because the exercises are designed to decrease unwanted responses to vestibular signals rather than to improve gaze or postural stability [52]. However, for patients with bilateral vestibular deficits, the theoretical benefit to the eye–head habituation activities (although not specifically tested) involves a reduction in oscillopsia [1]. Certain exercises for habituation such as rising quickly should not be performed in the elderly, because it may produce orthostatic hypotension [15].

1.4.4 I mproving Activities of Daily Living The final goal of vestibular recovery should be to return to all activities of daily living. Therefore, VRT is not completed until the patients are returned to their normal work or satisfactorily resettled. Patients who are unable to return to their normal work and in whom the disability is likely to last at least 6 months are considered as disabled persons [4]. To achieve the final goal of vestibular recovery, normal activity such as walking is integrated into the exercise, rather than being performed with the patient sitting or standing quietly [59]. Various games can be introduced to vary the

11

monotony of purely remedial exercises [14]. By exposing patients gradually and safely to a wide variety of sensory and motor environments, they are teaching the nervous system to identify strategies to accomplish functional goals [40]. All patients who receive customized VRT programs are also provided with suggestions for a general exercise program that is suited to their age, health, and interests. For most persons, this would involve at least a graduated walking program. For many, a more strenuous program is suggested that may include jogging, walking on a treadmill, doing aerobic exercises, or bicycling. Activities that involve coordinated eye, head, and body movements such as golf, bowling, handball, or racquet sports may be appropriate. Swimming is approached cautiously because of the disorientation experienced by many vestibular patients in the relative weightlessness of the aquatic environment [2]. The older adults who talk as they walk with assistive devices are more likely to fall than those who do not talk as they walk [60]. Therefore, the old patients should be instructed that when a conversation is started they should stop walking in order to prevent falling [60]. If rapid head movements cause imbalance, the patients should be advised not to drive [58].

1.5

Factors Affecting Recovery

(a) Medications: The use of centrally acting medications such as vestibular suppressants, antidepressants, tranquilizers, and anticonvulsants has no adverse effect on the ultimate therapy outcome. But the mean length of therapy in patients using medication is significantly longer before the ultimate outcome is achieved [1, 2, 9]. (b) Visual and somatosensory inputs: Recovery is delayed if the visuomotor experience is prevented during the early stage after unilateral vestibular loss [27]. Avoidance of movements and body positions that provoke vertigo also retards recovery [2]. (c) Time to begin treatment: It was believed that the earlier the patients commence exercises, the quicker and better the results [4, 16, 29].

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1  Vestibular Rehabilitation Therapy: Review of Indications, Mechanisms, and Key Exercises

However, the lack of an adverse effect on therapy outcome by length of symptoms argues against a critical period. To date, it is accepted that there is no critical time period within which some individuals achieve significant functional improvement [9, 26]. (d) Daily exercise duration: Brief periods of unidirectional optokinetic stimulation (30 s, 10 times daily for 10  days) can produce VOR gain changes after unilateral vestibular loss in human beings [29]. Therefore, we can postulate that even brief periods of stimulation can induce the recovery of vestibular function. (e) Symptom intensity: Symptom intensity does not influence therapy outcome [1]. However, if the lesion is unstable, for example fluctuating vestibular deficit (e.g., Meniere’s disease), incomplete damage, positional phenomenon (BPPV), ongoing labyrinthine pathology, and slowly progressive tumors, it is difficult for the central nervous system to compensate, and exercise therapy is generally fruitless [9, 39]. Patients with spontaneous or continuous symptoms of disequilibrium, a head injury history, permanent disability, and severe postural control abnormalities perform the poorest in the current therapy program [9]. (f) Site of lesion: Patients with central lesion or mixed lesion have a prolonged period of therapy, but there is no difference in the final outcome [9]. Therapy was longer for those with mixed lesion sites [9, 58]. Pure central lesion patients demonstrated a trend for a more successful therapy outcome compared with the mixed lesion group [2]. A lesion of the cerebellum delays recovery [61]. Patients with head injury and associated vestibular deficit show less improvement with treatment [62] and demonstrates a significantly poorer therapy result [1]. (g) Age: Age does not affect the final level of recovery, but sometimes prolongs the length of time required to maximize the benefit from therapy [1, 2, 9, 26, 63]. (h) Psychogenic factor: Complicating features of anxiety, depression, or excessive depen-

dence on medications may hinder vestibular compensation [2].

1.6

Practicing Exercise

1.6.1 Principles of the Exercises Before commencing exercises, simple techniques for reducing neck tension may be needed (e.g., shoulder shrugging, shoulder/arm rotation, and gentle stretching exercises specific for the neck region) [43]. Head movements must be encouraged both to induce vestibular adaptation and to habituate the symptoms provoked by movement [15]. Patients should practice a wide collection of functional tasks in a variety of contexts. These include maintaining balance with a reduced base of support, maintaining balance while changing the orientation of the head and trunk, and maintaining balance while performing a variety of upper extremity tasks [43]. The exercises for vestibular rehabilitation therapy include general strengthening and flexibility exercises, voluntary eye movements and fixations (visual stabilization exercises), active head movements (recalibration of the vestibulo-­ ocular reflex), active body movements (improvement of vestibulospinal regulation), substitution exercises for utilization of varied senses, particularly somatosensory cues and vision, visual dependence exercises, somatosensory dependence exercises, habituation exercises, education for using assistive devices, and safety awareness techniques to avoid falls [64].

1.6.2 Components of the Exercises Key exercises for enhancing gaze stability, enhancing eye movements, enhancing postural stability, decreasing vertigo are described in Table 1.1.

1.6.3 Exercise Modification The exercises can be modified with various conditions (Table 1.2).

1.6  Practicing Exercise

13

Table 1.2  Exercise modifications Conditions Eye Head movement Speed Movement amplitude Target location

Target distance Posture Foot position

Arm position

Base hardness

Base width Gait

Exercises Open Closed Horizontal Vertical Slow Fast Small Large Fixed Moving Imaginary Far Near Sitting Standing Shoulder width apart Together Tandem Single leg Outstretched Close to the body Across the chest Hard Soft Cushion Wide Narrow Static Walking

Gaze stability o o o o o o o o o o o o o o o o o

Eye movements o o o o o o o o o o o o o

Postural stability o o

o o o o

o o o

o o o o o o o o o o o

o o

The exercises can be modified with various conditions

1.6.4 Exercise Frequency and Duration Patients perform exercise for gaze stability 4 to 5 times daily for a total of 20 to 40  min/d plus 20 min/d of balance and gait exercises [26]. Each exercise may be done at least twice per day beginning with 5 repetitions each and increasing to 10 repetitions [17].

1.6.5 How to Progress (i) Follow-up visit: Patients are typically seen once every 1–2 weeks and are provided with a specific daily home program. During the visit, the therapist addresses the specific

problems and goals of the individual patient. As the progress in therapy plateaued, patients are switched from customized exercises to a maintenance program comprising a wide variety of motion-orientated activities [1]. (ii) Progressing to the next session: Performing specific exercises without dizziness means that the patient has improved and those particular exercises have become easier [43]. As the patient improves, more difficult and demanding tasks should be introduced using varying speeds of movements [43]. (iii) Maintaining compensation: Once all the exercises can be performed without dizziness, patients should maintain a high degree of physical activity (e.g., playing ball games,

14

1  Vestibular Rehabilitation Therapy: Review of Indications, Mechanisms, and Key Exercises

dancing, or other activities) in order to sustain compensation [43]. It should be kept in mind that after compensation is achieved, periods of stress, fatigue, or illness may result in a temporary recurrence of vertigo [43].

1.6.6 Special Situations (i) In acute period: In the first several hours from the acute vestibular lesion, the patients may have nausea or vomiting. This can be relieved by adequate medications. After nausea or vomiting is subsided, the patient quietly lies down and turns the head very slowly while looking at a target on the ceiling. If the patient can sit up, initially a few key exercises may be started. (ii) Nausea: When nausea or emesis occurs during exercises, patients are advised to return to the previous exercise on their program and continue until nausea becomes prohibitive [1]. At that point, they are to stop the program and begin again at the next scheduled time. When symptoms cannot be handled in this manner, anti-emetic medication is used simultaneously. This same approach is also used when the exercises stimulate prolonged periods of increased vertigo following the exercise activity, thereby disrupting daily routines. In this case, vestibular suppressants may be simultaneously required [1]. (iii) Glasses: Although good visual inputs are recommended, eyeglasses reflect the vision and can aggravate vertigo during head oscillation. Authors recommend removing the glasses during the exercise if eye–head exercise with glasses exaggerates vertigo. (iv) Safety concern: The environment must be modified to allow a patient to practice the exercises safely and without the continual supervision of a therapist [43]. Therefore, patients that are very unsteady or fearful of falling should practice movements while wearing a harness connected to the ceiling, in parallel bars, standing close to a wall or corner, or with a chair or table in front of them [43].

1.7

Summary

Exercises related to eyes and head movements are the key practices to improve gaze stability, whereas exercises while standing on a narrow base or a cushion with eye closed are the key performances to improve postural stability. VRT is applicable to patients with stable vestibular lesions whose vestibular function is poorly compensated regardless of age, cause, symptom duration, and symptom intensity. The use of centrally acting medications and visual/somatosensory deprivation should be avoided. Safety is a major concern so that therapists always should pay attention to the patients during the treatment session. Education and instruments for safety should be always accessible to the patients. VRT reduces the cost of treating vertigo by reducing unnecessary medication and studies, and by shortening the recovery period. Indeed, VRT is safe and effective without reported adverse effects and would be the most useful tool in the alleviation of protracted vertigo.

References 1. Shepard NT, Telian SA, Smith-Wheelock M. Habituation and balance retraining therapy. A retrospective review. Neurol Clin. 1990;8:459–75. 2. Shepard NT, Telian SA.  Programmatic vestibular rehabilitation. Otolaryngol Head Neck Surg. 1995;112:173–82. 3. Cawthorne T.  Vestibular injuries. Proc R Soc Med. 1946;39:270–2. 4. Cooksey FS.  Rehabilitation in vestibular injuries. Proc R Soc Med. 1946;39:273–8. 5. Hall CD, Heusel-Gillig L, Tusa RJ, Herdman SJ. Efficacy of gaze stability exercises in older adults with dizziness. J Neurol Phys Ther. 2010;34:64–9. 6. Shepard N, Asher A.  Treatment of patients with nonvestibular dizzienss and disequilibrium. In: Herdman SJ, editor. Vestibular rehabilitation. 2nd ed. Philadelphia: F. A. Davis Company; 2000. p. 534–44. 7. Seok JI, Lee HM, Yoo JH, Lee DK. Residual dizziness after successful repositioning treatment in patients with benign paroxysmal positional vertigo. J Clin Neurol. 2008;4:107–10. 8. Blatt PJ, Georgakakis GA, Herdman SJ, Clendaniel RA, Tusa RJ. The effect of the canalith repositioning maneuver on resolving postural instability in patients with benign paroxysmal positional vertigo. Am J Otol. 2000;21:356–63.

References 9. Shepard NT, Telian SA, Smith-Wheelock M, Raj A. Vestibular and balance rehabilitation therapy. Ann Otol Rhinol Laryngol. 1993;102:198–205. 10. Hain TC.  Vestibular rehabilitation therapy (VRT). [cited 2010 October 3]. Available from http://www. dizziness-and-balance.com/treatment/rehab.html 11. Zee DS. Vestibular adaptation. In: Herdman SJ, editor. Vestibular rehabilitation. 3rd ed. Philadelphia: F.A. Davis Company; 2007. p. 19–31. 12. Halmagyi GM, Weber KP, Curthoys IS.  Vestibular function after acute vestibular neuritis. Restor Neurol Neurosci. 2010;28:37–46. 13. Kim HA, Hong JH, Lee H, Yi HA, Lee SR, Lee SY, Jang BC, Ahn BH, Baloh RW. Otolith dysfunction in vestibular neuritis: recovery pattern and a predictor of symptom recovery. Neurology. 2008;70:449–53. 14. Brandt T, Huppert T, Hüfner K, Zingler VC, Dieterich M, Strupp M. Long-term course and relapses of vestibular and balance disorders. Restor Neurol Neurosci. 2010;28:69–82. 15. Herdman SJ, Whitney SL. Intervention for the patient with vestibular hypofunction. In: Herdman SJ, editor. Vestibular rehabilitation. 3rd ed. Philadelphia: F.A. Davis Company; 2007. p. 309–37. 16. Herdman SJ, Clendaniel RA, Mattox DE, Holliday MJ, Niparko JK. Vestibular adaptation exercises and recovery: acute stage after acoustic neuroma resection. Otolaryngol Head Neck Surg. 1995;113:77–87. 17. Krebs DE, Gill-Body KM, Riley PO, Parker SW.  Double-blind, placebo-controlled trial of rehabilitation for bilateral vestibular hypofunction: preliminary report. Otolalyngol Head Neck Surg. 1993;109:735–41. 18. Herdman SJ.  Role of vestibular adaptation in vestibular rehabilitation. Otolaryngol Head Neck Surg. 1998;119:49–54. 19. Curthoys IS, Halmagyi M.  Vestibular compensa tion: clinical changes in vestibular function with time after unilateral vestibular loss. In: Herdman SJ, editor. Vestibular rehabilitation. 3rd ed. Philadelphia: F.A. Davis Company; 2007. p. 76–97. 20. Herdman SJ. Advances in the treatment of vestibular disorders. Phys Ther. 1997;77:602–18. 21. Gauthier GM, Robinson DA.  Adaptation of the human vestibuloocular reflex to magnifying lenses. Brain Res. 1975;92:331–5. 22. Schubert MC, Zee DS.  Saccade and vestibular ocular motor adaptation. Restor Neurol Neurosci. 2010;28:9–18. 23. Lisberger SG, Miles FA, Optican LM.  Frequency-­ selective adaptation: evidence for channels in the vestibulo-ocular reflex? J Neurosci. 1983;3:1234–44. 24. Schubert MC, Della Santina CC, Shelhamer M.  Incremental angular vestibulo-ocular reflex adaptation to active head rotation. Exp Brain Res. 2008;191:435–46. 25. Tiliket C, Shelhamer M, Tan HS, Zee DS. Adaptation of the vestibulo-ocular reflex with the head in differ-

15 ent orientations and positions relative to the axis of body rotation. J Vestib Res. 1993;3:181–95. 26. Herdman SJ, Hall CD, Schubert MC, Das VE, Tusa RJ.  Recovery of dynamic visual acuity in bilateral vestibular hypofunction. Arch Otolaryngol Head Neck Surg. 2007;133:383–9. 27. Fetter M, Zee DS, Proctor LR.  Effect of lack of vision and of occipital lobectomy upon recovery from unilateral labyrinthectomy in rhesus monkey. J Neurophysiol. 1988;59:394–407. 28. Shelhamer M, Tiliket C, Roberts D, et al. Short-term vestibuloocular reflex adaptation in humans II. Error signals. Exp Brain Res. 1994;100:328–36. 29. Pfaltz CR. Vestibular compensation. Physiological and clinical aspects. Acta Otolaryngol. 1983;95:402–6. 30. Barnes GR.  Visual-vestibular interaction in the control of head and eye movement: the role of visual feedback and predictive mechanisms. Prog Neurobiol. 1993;41(4):435–72. 31. Kasai T, Zee DS.  Eye-head coordination in labyrinthine-­ defective human beings. Brain Res. 1978;144:123–41. 32. Tian J, Crane BT, Demer JL.  Vestibular catch-up saccades in labyrinthine deficiency. Exp Brain Res. 2000;131:448–57. 33. Bockisch CJ, Straumann D, Hess K, Haslwanter T.  Enhanced smooth pursuit eye movements in patients with bilateral vestibular deficits. Neuroreport. 2004;15:2617–220. 34. Leigh RJ, Huebner WP, Gordon JL. Supplementation of the human vestibulo-ocular reflex by visual fixation and smooth pursuit. J Vestib Res. 1994;4:347–53. 35. Herdman SJ, Schubert MC, Tusa RJ.  Role of central preprogramming in dynamic visual acuity with vestibular loss. Arch Otolaryngol Head Neck Surg. 2001;127:1205–10. 36. Black RA, Halmagyi GM, Curthoys IS, Thurtell MJ, Brizuela AE.  Unilateral vestibular deafferentation produces no long-term effects on human active eye-­ head coordination. Exp Brain Res. 1998;122:362–6. 37. Bronstein AM, Hood JD.  The cervico-ocular reflex in normal subjects and patients with absent vestibular function. Brain Res. 1986;373:399–408. 38. Schubert MC, Das V, Tusa RJ, Herdman SJ. Cervico-­ ocular reflex in normal subjects and patients with unilateral vestibular hypofunction. Otol Neurotol. 2004;25:65–71. 39. Shumway-Cook A, Horak FB, Bronstein AM. Rehabilitation of balance disoders in the patient with vestibular pathology. In: Bronstein AM, Brandt T, Woollacott M, editors. Clinical disorders of balance posture and gait. London: Arnold Publishers; 1996. p. 211–35. 40. Horak FB. Postural compensation for vestibular loss and implications for rehabilitation. Restor Neurol Neurosci. 2010;28:57–68. 41. Foord G, Marsden J.  Physical exercise regimes-­ practical aspects. In: Luxon LM, Vavies RA, edi-

16

1  Vestibular Rehabilitation Therapy: Review of Indications, Mechanisms, and Key Exercises

tors. Handbook of vestibular rehabilitation. London: Whurr Publishers; 1997. p. 101–15. 42. Shumway-Cook A, Horak FB.  Assessing the influence of sensory interaction of balance. Suggestion from the field. Phys Ther. 1986;66:1548–50. 43. Pavlou M, Shumway-cook A, Horak FB, Yardley L, Bronstein AM. Rehabilitation of balance disorders in the patient with vestibular pathology. In: Bronstein AM, Brandt T, Woollacott MH, Nutt JG, editors. Clinical disorders of balance, posture and gait. 2nd ed. London: Arnold Publishers; 2004. p. 317–43. 44. Bles W, Vianney de Jong JMB, de Wit G. Compensation for labyrinthine defects examined by use of a tilting room. Acta Otolaryngol. 1983;5:576–9. 45. Whitney SL, Herdman SJ.  Physical therapy assessment of vestibular hypofunction. In: Herdman SJ, editor. Vestibular rehabilitation. 3rd ed. Philadelphia: F. A. Davis Company; 2007. p. 272–99. 46. Horak FB, Nashner LM, Diener HC.  Postural strategies associated with somatosensory and vestibular loss. Exp Brain Res. 1990;82:167–77. 47. Horak FB. Role of vestibular system in postural control. In: Herdman SJ, editor. Vestibular rehabilitation. 3rd ed. Philadelphia: F.  A. Davis Company; 2007. p. 32–53. 48. Shupert CL, Horak FB, Black FO. Hip sway associated with vestibulopathy. J Vestib Res. 1994;4:231–44. 49. Brandt T, Strupp M, Benson J. You are better off running than walking with acute vestibulopathy. Lancet. 1999;354:746. 50. Herdman SJ, Blatt P, Schubert MC, Tusa RJ.  Falls in patients with vestibular deficits. Am J Otol. 2000;21:847–51. 51. Smith PF, Curthoys IS. Mechanisms of recovery following unilateral labyrinthectomy: a review. Brain Res Brain Res Rev. 1989;14:155–80. 52. Herdman SJ, Clendaniel RA.  Assessment and interventions for the patient with complete vestibular loss. In: Herdman SJ, editor. Vestibular rehabilitation. 3rd ed. Philadelphia: F.  A. Davis Company; 2007. p. 338–59.

53. Jones TA, Nelson RC. Recovery of vestibular function following hair cell destruction by streptomycin. Hear Res. 1992;62:181–6. 54. Dieterich M, Brandt T.  Imaging cortical activity after vestibular lesions. Restor Neurol Neurosci. 2010;28:47–56. 55. Norre ME, De Weerdt W.  Treatment of vertigo based on habituation. I.  Physio-pathological basis. J Laryngol Otol. 1980;94:689–96. 56. Norré ME, Beckers A.  Vestibular habituation training for positional vertigo in elderly patients. Arch Gerontol Geriatr. 1989;8:117–22. 57. Brandt T, Daroff RB.  Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol. 1980;106:484–5. 58. Keim RJ, Cook M, Martini D. Balance rehabilitation therapy. Laryngoscope. 1992;102:1302–7. 59. Das VE, Leigh RJ, Thomas CW, et  al. Modulation of high frequency vestibuloocular reflex during visual tracking in humans. J Neurophysiol. 1995;74:624–32. 60. Lundin-Olsson L, Nyberg L, Gustafson Y. “Stops walking when talking” as a predictor of falls in elderly people. Lancet. 1997;349:617. 61. Furman JM, Balaban CD, Pollack IF. Vestibular compensation in a patient with a cerebellar infarction. Neurology. 1997;48:916–20. 62. Telian SA, Shepard NT, Smith-Wheelock M, Kemink JL.  Habituation therapy for chronic vestibular dysfunction: preliminary results. Otolaryngol Head Neck Surg. 1990;103:89–95. 63. Norre ME, Beckers A. Benign paroxysmal positional vertigo in the elderly. Treatment by habituation exercises. J Am Geriatr Soc. 1988;36:425–9. 64. Brandt T, Dieterich M.  Postural imbalance in peripheral and central vestibular disorders. In: Bronstein AM, Brandt T, Woollacott MH, Nutt JG, editors. Clinical disorders of balance, posture and gait. 2nd ed. London: Arnold Publishers; 2004. p. 146–62.

2

Vestibular Rehabilitation in Central Dizziness

2.1

Introduction

Vestibular rehabilitation therapy (VRT) has been considered a mainstay to manage patients with peripheral dizziness rather than central dizziness [1]. That might be because the length of time involved with VRT is usually significantly longer for these patients when compared to those with peripheral lesions [2]. Central dizziness is responsible for nearly 25% of the dizziness experienced in patients [3]. It is caused by lesions along the vestibular pathways in the brainstem, which extend from the vestibular nuclei in the medulla oblongata to the ocular motor nuclei and integration center in the rostral midbrain and to the vestibulocerebellum, the thalamus, and multisensory vestibular cortex [3, 4]. The vestibular nuclei process and relay vestibular signals, and the vestibulocerebellum modulates vestibular responses and allows the vestibular system to adapt to injury, disease, and changes in sensorimotor demands [1]. In the majority of cases, central dizziness is caused by dysfunction or deficit of sensory input induced by a lesion, while in a small proportion of cases, they are due to pathological excitation of various structures, extending from the peripheral vestibular organ to the vestibular cortex. Most central This chapter is refer to a published paper: Han BI, Ko PW, Lee HW, Kim HA, Lee H. Vestibular Rehabilitation in Central Dizziness. Res Vestib Sci. 2015 Dec;14(4): 97–100. © Springer Nature Singapore Pte Ltd. 2021 B. I. Han, Simplified Vestibular Rehabilitation Therapy, https://doi.org/10.1007/978-981-15-9869-2_2

dizziness have a specific locus, but not a specific etiology [5]. The disorders occurring with central dizziness are migraine-associated dizziness, the sequelae of trauma, ischemic diseases, multiple sclerosis plaques, degenerative neurologic disorders that affect the cerebellum [1, 4], inflammatory diseases, neoplasms, intoxications, and traumatic lesions [5]. Vestibular migraine is a transient condition and is not a candidate for VRT, so that is beyond the scope of this chapter. Basal ganglia may be considered to be a central dizziness because postural instability in Parkinson disease (PD) was found to be related to abnormalities in the processing of afferent inputs from the vestibular, proprioceptive, and visual system [6, 7]. Central vestibular disorders are more likely to cause imbalance, and to be associated with other neurologic symptoms than peripheral vestibular ailments [1]. Regarding natural course, central dizziness may not improve or may do so more slowly [3]. Nonetheless, VRT speeds up the process of improvement [8] so that patients with a stable central lesion should be considered candidates for VRT [2]. The mechanisms underlying central compensation of central lesions may be similar to those of central compensation of peripheral vestibular lesion and VRT may facilitate this central compensation [5]. Possible mechanisms of recovery after central nervous system lesions may include neural sprouting, vicarious functions, functional reorganization, substitution, and plasticity [9, 17

2  Vestibular Rehabilitation in Central Dizziness

18

10]. Central dizziness may be classified into five subgroups: central vestibulopathy; mixed central and peripheral vestibulopathy; post-traumatic central disorders; stroke (excluding cerebellar stroke); and cerebellar dysfunction. Among these, patients with cerebellar dysfunction improve the least after VRT, while the other groups improve significantly, although most in all subgroups continue to exhibit gait dysfunction and continue to be at risk of falling [8].

2.2

Usefulness of VRT for Selected Central Dizziness

Migraine is considered as either a central dizziness or mixed central and peripheral dizziness is a common central dizziness [11]. Migraine may also play a role in chronic nonspecific vestibulopathy [12]. Treatment for patients with vestibular migraine does not usually include physical therapy [12]. Brain trauma can induce damage to the inner ear, vestibular nerve, or central structures and pathways. Because functional deficits after brain trauma are usually due to a combination of many interacting factors, sorting out the relative contribution of vestibular system pathology to overall loss of function can be difficult [13]. The treatment of patients experiencing post-traumatic dizziness must be planned with the realization that both the peripheral and central vestibular systems may be involved simultaneously with or without concomitant neck problems. Intervention will vary depending on the individual patient's presentation [1]. In most instances exercises are designed to facilitate central nervous system compensation rather than alter underlying vestibular disease [13]. In spite of vigorous exercise interventions, many patients with traumatic vestibular dysfunction show persisting symptoms of dizziness and disequilibrium several years after trauma [13]. In the ischemic disease of central vestibular disorders, most signs and symptoms resolve spontaneously within weeks to months owing to either recovery of the lesion or central compensation and substitution [5]. Patients with infarction

of the vestibular nuclei might be expected to have a very poor prognosis and respond poorly to physical therapy. Despite these obvious potential limitations, such patients often respond well to physical therapy. The reason for this somewhat paradoxical finding may be that patients with brainstem strokes are likely to have unilateral lesions, with preserved function contralaterally. In addition, there may be sufficient redundancy in central vestibular pathways to allow partial recovery of balance function [1].

2.3

Cerebellar Degeneration

Cerebellar degeneration is progressive and is associated with imbalance and falls [14]. Because the cerebellum is considered to be crucial to motor learning, the patients with cerebellar degeneration were believed to be less responsive to physical rehabilitation [9]. However, there is some evidence that treatment programs improve function in patients with cerebellar dysfunction; if the cerebellum is not totally destroyed, neighboring areas of the cerebellum can adapt or compensate for the impaired region [9]. A randomized clinical trial revealed that an intensive rehabilitation program for patients with pure cerebellar degeneration who were able to ambulate 10 m independently or with the assistance of one person can significantly improve functional gains in ataxia, gait, and activities of daily living. The program included 2 h of inpatient physical and occupational therapy, focusing on coordination, balance, and ADLs, on weekdays and 1 h on weekends for 4 weeks. Improvement of truncal ataxia was more prominent than limb ataxia. Some level of improvement was shown to be maintained 24 weeks post treatment [15]. Patients with cerebellar dysfunction have problems with both the vestibulo-ocular system and postural control system [1]. Except spinocerebellar ataxia (SCA) type 3 that have bilateral vestibulopathy, other patients with SCA have normal vestibular function but are not able to cancel their vestibulo-ocular reflex owing to a defect in the cerebellar vermis [14]. The patients

2.5 Conclusion

with cerebellar dysfunction have hypermetric responses to unexpected perturbations, causing them to sway more and for a longer time before returning to an equilibrium point [9]. Despite postural hypermetria, cerebellar patients showed preserved postural adaptation [16]. Therefore, cerebellar patients can use vision to help achieve postural stability, and they should be encouraged to improve gaze stability to improve postural stability [9]. In that process, visual cues become increasingly important, but it is also likely to foster visual dependency. Fortunately, such patients are able to suppress visual cues over time and rely more on their vestibular and proprioceptive inputs [7]. Repetition of balance and gait activities may help utilize somatosensory feedback to scale the magnitude of the postural responses [17]. Treatment regimens for such patients should include equalizing step lengths, narrowing step width, balance exercises on complaint surfaces, and enhancing somatosensory inputs to the lower extremities [1]. Intermittent home-based therapy as well as systematic self-exercise may be necessary to preserve functional status [15]. It should be cautioned that patients with cerebellar dysfunction, in general, should not receive vestibular suppressant medications because most of these medications will act to worsen the cerebellar function [1], and exercise may precipitate attacks in SCA6 patients [18]. The disease has a progressive nature so that postural instability may deteriorate continuously if physical therapy intervention is not practiced [8]. Then, providing an assistive device such as a cane or walker may be helpful [1].

2.4

Parkinson Disease (PD)

Postural instability is a common feature of PD, becoming a clinical concern in the middle stage of the progressive illness. Postural instability is resistant to improvement with dopamine replacement medications, so that it may not be related to dysfunction of dopamine systems [6, 19, 20]. Postural instability is assumed to be related to an abnormal choice of postural strategies under dif-

19

ferent surface conditions [21]. Recently a number of studies assessed the effect of balance rehabilitation to PD patients [6, 19, 20, 22]. The balance training designed by Smania et  al. improved postural stability, improved the level of confidence perceived while performing daily activities that require balance, and reduced the frequency of falls in patients with PD.  The training effects were maintained for at least 1 month after the end of treatment [6]. Zeigelboim BS et  al. reported that the VR following the Cawthorne and Cooksey protocol administered for 3 months, twice a week, followed by an assimilation of repetitions at home were shown to be useful in managing subjective complaints of physical, functional, and emotional aspects evaluated by dizziness handicap inventory (DHI) [20]. Hirsch and the colleagues reported that balance training under altered visual and somatosensory sensory conditions, 3 times a week for 10 weeks, improved postural balance in persons with PD, and the effect was larger if high-­ intensity resistance training (knee extensors and flexors, ankle plantarflexion) is added to balance training [22].

2.5

Conclusion

In central dizziness, postural instability may improve slowly or not improve with VRT. Furthermore, in some degenerative cases, it may progress even with vigorous rehabilitation treatments. Nevertheless, much can be done to improve postural stability or offset the deterioration by having the patients engage in balance trainings. Environmental setting and practice at home is also important. However, at the advanced stages, treatment is aimed at maintaining mobilization and avoiding falls. When instability becomes a major risk for falls, walking aids can decrease the risk and preserve mobility. In the same manner, when walking becomes extremely difficult and dangerous but does not substantially improve the quality of life, it is time to switch the patient’s mindset to regard walking as an exercise without any mobilization goal. This is the time to use a wheelchair for mobilization and represents

20

the end of the fight for ambulatory independence [23]. Nevertheless, VRT is effective in central dizziness so that VRT is a rational and conservative approach that is useful in the treatment of these patients [24]. Conflict of Interest  No potential conflict of interest relevant to this chapter was reported.

References 1. Furman JM, Whitney SL. Central causes of dizziness. Phys Ther. 2000;80:179–87. 2. Shumway-Cook A, Horak FB.  Rehabilitation strategies for patients with vestibular deficits. Neurol Clin. 1990;8:441–57. 3. Karatas M.  Central vertigo and dizziness: epidemiology, differential diagnosis, and common causes. Neurologist. 2008;14:355–64. 4. Brandt T, Dieterich M, Strupp M. Central vestibular structures. In: Brandt T, Dieterich M, Strupp M, editors. Vertigo and dizziness. 2nd ed. London: Springer; 2012. p. 112–4. 5. Dieterich M, Brandt T. Assessment and management of disorders affecting central vestibular pathways. In: Herdman SJ, editor. Vestibular rehabilitation. 3rd ed. Philadelphia: F.  A. Davis Company; 2007. p. 409–32. 6. N S, Corato E, Tinazzi M, Stanzani C, Fiaschi A, Girardi P, Gandolfi M.  Effect of balance training on postural instability in patients with idiopathic Parkinson’s disease. Neurorehabil Neural Repair. 2010;24:826–34. 7. Bronstein AM, Hood JD, Gresty MA, Panagi C. Visual control of balance in cerebellar and Parkinsonian syndromes. Brain. 1990;113:767–79. 8. Brown KE, Whitney SL, Marchetti GF, Wrisley DM, Furman JM.  Physical therapy for central vestibular dysfunction. Arch Phys Med Rehabil. 2006;87:76–81. 9. Gill-Body KM, Popat RA, Parker SW, Krebs DE.  Rehabilitation of balance in two patients with cerebellar dysfunction. Phys Ther. 1997;77:534–52. 10. Bach y Rita P. Central nervous system lesions: sprouting and unmasking in rehabilitation. Arch Phys Med Rehabil. 1981;62:413–7. 11. Brandt T, Dieterich M, Strupp M. Vestibular migraine/ Migraine of the basilar type. In: Brandt T, Dieterich M, Strupp M, editors. Vertigo and dizziness. 2nd ed. London: Springer; 2012. p. 132–43.

2  Vestibular Rehabilitation in Central Dizziness 12. Cass SP, et  al. Migraine-related vestibulopathy. Ann Otol Rhinol Laryngol. 1997;106:182–9. 13. Shumway-Cook A.  Assessment and management of the patient with traumatic brain injury and vestibular dysfunction. In: Herdman SJ, editor. Vestibular rehabilitation. 3rd ed. Philadelphia: F. A. Davis Company; 2007. p. 444–57. 14. Tusa RJ.  Non-vestibular dizziness and imbalance: from disuse disequilibrium to central degenerative disorders. In: Herdman SJ, editor. Vestibular rehabilitation. 3rd ed. Philadelphia: F. A. Davis Company; 2007. p. 433–43. 15. Miyai I, Ito M, Hattori N, Mihara M, Hatakenaka M, Yagura H, Sobue G, Nishizawa M, Cerebellar Ataxia Rehabilitation Trialists Collaboration. Cerebellar ataxia rehabilitation trial in degenerative cerebellar diseases. Neurorehabil Neural Repair. 2012;26:515–22. 16. Mummel P, Timmann D, Krause UW, Boering D, Thilmann AF, Diener HC, Horak FB.  Postural responses to changing task conditions in patients with cerebellar lesions. J Neurol Neurosurg Psychiatry. 1998;65:734–42. 17. Horak FB, Diener HC. Cerebellar control of postural scaling and central set in stance. J Neurophysiol. 1994;72:479–93. 18. Yu-Wai-Man P, Gorman G, Bateman DE, Leigh RJ, Chinnery PF.  Vertigo and vestibular abnormalities in spinocerebellar ataxia type 6. Neurol. 2009;256:78–82. 19. Dibble LE, Addison O, Papa E. The effects of exercise on balance in persons with Parkinson’s disease: a systematic review across the disability spectrum. J Neurol Phys Ther. 2009;33:14–26. 20. Zeigelboim BS, Klagenberg KF, Teive HA, Munhoz RP, Martins-Bassetto J. Vestibular rehabilitation: clinical benefits to patients with Parkinson’s disease. Arq Neuropsiquiatr. 2009;67:219–23. 21. Horak FB, Nutt JG, Nashner LM.  Postural inflexibility in Parkinsonian subjects. J Neurol Sci. 1992;111:46–58. 22. Hirsch MA, Toole T, Maitland CG, Rider RA.  The effects of balance training and high-intensity resistance training on persons with idiopathic Parkinson’s disease. Arch Phys Med Rehabil. 2003;84:1109–17. 23. Giladi N, Balash Y, Ruzicka E, Jankovic J. Disorders of gait. In: Jankovic J, Tolosa E, editors. Parkinson’s disease and movement disorders. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 436–58. 24. Telian SA, Shepard NT, Smith-Wheelock M, Kemink JL.  Habituation therapy for chronic vestibular dysfunction: preliminary results. Otolaryngol Head Neck Surg. 1990;103:89–95.

3

Implementing the Exercises

3.1

Assessments for VRT

The VRT assessments are comprised of obtaining medical information, estimating the severity of dizziness using questionnaires, and a series of tests that help evaluate the individuals’ overall physical status and balance function. These assessments are considered the starting point for designing an appropriate exercise program: • Obtaining medical information: The therapist should assess whether individuals about to perform VRT are experiencing dizziness or pain. Any medical condition that may impair the patient’s ability to exercise should be evaluated. • VOR testing: VOR can be tested using the rapid head impulse test, in which the head is rapidly moved to the side with force, while the eyes are evaluated to assess whether they remain fixated on a target. • Body posture assessment: Good posture is important in maintaining balance. By standing up straight, you center your weight over your feet. This helps you maintain the correct form while exercising, which results in fewer inju-

© Springer Nature Singapore Pte Ltd. 2021 B. I. Han, Simplified Vestibular Rehabilitation Therapy, https://doi.org/10.1007/978-981-15-9869-2_3

ries and greater gains. The most common example of a bad posture is the forward head posture. Forward head posture is produced when muscles that are responsible for good posture are weakened or tightened from continuous exposure to suboptimal positions, as in hours of sitting. • Flexibility testing: Flexibility is the ability of a joint to produce a fluid motion through its complete range of motion. Since shoulder and neck flexibility is a crucial part of keeping good posture and balance, most exercise regimes have a set of isolated stretches that target these muscle groups. • Lower body strength testing: Lower body strength relates to articulation of motion and the ability to safely balance and maintain equilibrium. The leg strength test evaluates the lower body’s ability to generate maximal force. The hip complex, quadriceps, and core muscles all contract in unison to generate force that can be measured using a dynamometer. • Core muscle strength testing: Core stability is the ability to control the position and motion of the trunk over the pelvis and legs. Imbalances due to asymmetric patterns of trunk rotation may contribute to unstable posture and gait.

21

3  Implementing the Exercises

22

3.2

Exercises for VRT

The VRT exercises include gaze stability exercises, postural stability exercises, and habituation exercises. Gaze stability exercises include (1) head–eye exercises and (2) eye exercises. Postural stability exercises include (1) standing balance exercises and (2) postural strategy exercises. Habituation exercises utilize sensory signals such as visual, vestibular, and somatosensory inputs. General exercises, including warming ups, stretches, strengthening, and cooling down exercises should be performed as well during the therapy session. The exercise program should be introduced as soon as it can be tolerated by the patients. Start warming up with light stretches before conducting the VRT. Then proceed to the VRT exercises by performing one or two exercises for gaze stability as well as for postural stability. Habituation exercises may be added if necessary. Start the exercises slowly and increase the intensity over time. Adjust the intensity by increasing the number of repetitions, duration, frequency, and speed of exercises. Vary the exercise program to keep the patients engaged and keep from becoming bored. Do not exercise for more than 30 minutes without rest. Slow down or stop the exercise if dizziness worsens or if the patient becomes nauseated. There is no need for the exercises to be performed perfectly. Allow the patients to complete the exercise at their own pace. For patients with BPPV, habituation exercises alone may be sufficient. In patients with weaker lower body strength, accompany VRT with strengthening exercises that target the lower extremity. Be sure to perform cooling down exercises after conducting the VRT. During the VRT, a therapist should remain in close proximity and/or use adequate safety measures to prevent a fall. The use of a chair as a support for patients with a high risk of falling is recommended. After the VRT session ends, take-home exercises should be recommended. One or two VRT sessions a week is ideal. The Simplified VRT offers an alternative solution to the traditional VRT for primary care clinics without a specialized therapist, equipment, and/or space.

# Simplified VRT The simplified VRT (sVRT) is a streamlined version of the VRT, designed for use in primary healthcare facilities with limited space and equipment. sVRT only requires readily accessible resources: a display monitor, one instructor, and a chair. The movements for VRT can be recorded in footage in a way that is easy for the patients to follow along. Then, the footages can be displayed on a monitor and the patients follow on. The movements can be performed while standing or sitting, or simply using a chair without other equipment. The sVRT exercises are for ambulatory patients. For individuals with musculoskeletal problems or for individuals who cannot stand alone, the exercises should be modified to accommodate their situation. The setup for sVRT exercises are shown in the picture 1. The worksheet for sVRT exercises is shown in the Table 1.

Picture 1: sVRT Exercise–The patient is imitating the VRT exercises on the screen while the therapist stands close by in case of a fall (photo model: Hyun-jin Goo, Byung In Han)

3.2 Exercises for VRT

sVRT Exercises and YouTube Link 3.2 Exercises for VRT    3.2.1  Gaze Stability Exercises       1. Head-Eye Exercises https://youtu.be/zAHasIMgK7Y       1.1  Horizontal Head-Eye exercise        1.2  Vertical Head-Eye exercise        1.3 Circular Head-Eye exercise       2. Eye Movement Exercises https://youtu.be/JcAEvoic4TY         2.1 Pursuit Eye Movement         2.2 Saccade Eye Movement          2.3 Imagery Pursuit Movement (Remembered Target Exercise)       3. Visual Habituation Exercises by Utilizing VOR Suppression         3.1 Head-Trunk Turns       4. Head-Eye Exercises While Walking https://youtu.be/mgKs887weJQ          4.1 Horizontal Head-Eye Exercise with Gaze Fixed on a Target While Walking         4.2  Looking Around While Walking    3.2.2 Postural Stability Exercises       1. Standing Balance Exercises       (a)  Static Standing with Feet Together        a1.  Standing on a Firm Surface        a2. Standing on a Cushion       (b)  Standing with the Feet Heel-to-Toe       (c)  Stand on One Leg       (d)  Sway Back and Forth       (e) Marching in Place       2. Postural Strategy Exercises       (a)  Ankle Strategy Exercises https://youtu.be/TuVjXsHe7jo        a1.  Ankle Oscillation        a2. Sideway Sway        a3. Pivot on Heels or Toes        a4.  The Skier        a5.  The 360-Degree Turn       (b)  Hip Strategy Exercises        b1.  Hip Strategy Exercises with the Legs Fixed https://youtu.be/VSJhawd2a4Q          (i)     Hip Oscillation with In-Phasing Arms          (ii)      Hip oscillation with Out-Phasing Arms          (iii)   Sideway Sway          (iv)    Sideway Counter-Sway          (v)   Waist Rotation          (vi)   Torso Rotation          (vii)    Arm Stretch  – Forward          (viii)  Arm Stretch - Sideway        b2.  Hip Strategy Exercises with One Leg Moving https://youtu.be/HNLQaEJbK3k          (i)    Forward and Backward Leg Swings          (ii)     Front Side to Side Leg Swing          (iii)      Rear Side to Side Leg Swing          (iv)      Circle of the Leg       (c)  Stepping Strategy Exercises https://youtu.be/JbGc6-Rn5kg        c1. Forward Step        c2. Sidestep

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       c3.  Sideway Front Cross-Step        c4.  Sideway Back Cross-Step        c5.  Stepping Over an Object   3.2.3 Habituation Exercises       1. Habituation Exercises while Sitting https://youtu.be/wEZNGPJo48o         1-1.  Horizontal Head Turn while Sitting          1-2. Vertical Head Exercise while Sitting          1-3. Diagonal Head Exercise while Sitting          1-4. Seated Body Rotation with Fixed Gaze (With Instructor)           1-5. Seated Body Rotation with Fixed Gaze (Without Instructor) https://youtu.be/dM1WXJfOl6g       2. Habituation Exercises while Standing https://youtu.be/RoieRXmxpNc          2-1. Standing Body Rotation with the Head in a Stationary Position         2-2. Head Rotation while Standing          2-3. Standing Trunk Rotation with the Head in a Stationary Position         2-4.  Standing Head and Trunk Rotation          2-5. Turning with Head Being Stationary and Fixed Gaze https://youtu.be/1Puaj7y1qO4         2-6. Bent Chest Rotation          2-7. Diagonal Head Movement while Standing       3. Habituation Exercises for Sensory Dependency         3-1.  Exercises for Visual Dependency         3-2.  Exercises for Somatosensory Dependency 3.3 General Exercises    3.3.1 Warming Up Exercises https://youtu.be/GMIG0ofs1ts       1. Weight Shifting Exercise      2. The Folder      3. Windmill    3.3.2 Cooling Down Exercises https://youtu.be/u40x0HErFtc       1. Bending Forward       2. Arm and Leg Raises While Standing      3. Back Twist   3.3.3 Shoulder Stretch https://youtu.be/zLlk8VyPwvU       1. Shoulder Rolls       2. Cross-Body Shoulder Stretch       3. Opening Chest       4. Cow-Face Pose       5. Standing Side Stretch       6. Horizontal Shoulder Rotation       7. Single Shoulder Twist       8. Double Shoulder Stretch    3.3.4 Upper Cross Syndrome Exercises https://youtu.be/PBf3Hnc-vfk       1. Neck Flexor Strengthening and Upper Chest Flexor (Pectoralis) Stretch       2. Neck Extensor (Upper Trapezius) Stretch       3. Lower Chest Extensor (Lower Trapezius) Strengthening       4. Chest Flexor (Pectoralis) Stretch    3.3.5 Leg Stretches Using a Chair https://youtu.be/c5BuXzjj3Bg       1. Standing Hamstring Stretch       2. Heel Pivot       3. Cross Curtsy Lunge       4. Standing Leg Raise       5. Standing Rear Leg Lift (Standing Quadriceps Stretch)       6. Standing Front Leg Grab (Hip Internal Rotation)

3.2 Exercises for VRT

  3.3.6 Leg Stretching https://youtu.be/0tszx30VLs0       1. Standing Hamstring Stretch       2. Standing Rear Leg Lift (Standing Quadriceps Stretch)       3. Standing Front Leg Lift (Hip Internal Rotation)       4. Standing Front Knee Lift       5. Deep Side Lunge       6. Standing Calf Stretch (Gastrocnemius and Soleus Stretch)    3.3.7 Leg Strengthening Exercises Using a Chair https://youtu.be/3JopAdY6MWc       1. Standing Forward Leg Lift       2. Standing Side Leg Lift       3. One-Legged Bicycle       4. Standing Lunge       5. Heel Lift      6. Toe Lift    3.3.8 Leg Strengthening Exercises https://youtu.be/QedVU6HlGJ0       1. Standing Forward Leg Lift       2. Standing Side Leg Lift       3. One-Legged Bicycle       4. Standing Lunge       5. Heel Lift      6. Toe Lift    3.3.9 Lower Cross Syndrome Exercises https://youtu.be/HyypyMEDQ1w       1. Seated Back Flexor Strengthening       2. Seated Back Extensor Stretch       3. Standing Hip Flexor Stretch (Forward Lunge with a Chair)       4. Standing Hip Extensor Strengthening

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Table 1: Worksheet for sVRT–The worksheet includes the name of exercises in the leftmost column and the dates on which the VRTs were conducted in the topmost row. The selected exercises are marked with checkmarks. Three to five exercises are undertaken per VRT session General exercises

Warming up Upper body

VRT exercises

Gaze stability

Postural stability

Habituation

General exercises

Lower body

Cooling down

Warming up Shoulder stretching Upper cross syndrome exercises Head-eye exercises Eye exercises Visual habituation exercises Head-eye exercises while walking Standing balance exercise Ankle strategy Hip strategy with leg fixed Hip strategy with leg moving Stepping strategy Exercise, sitting Exercise, standing Exercises for sensory dependency Leg stretching with chair Leg stretching Leg strengthening with chair Leg strengthening Lower cross syndrome exercise Cooling down

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v v v v v v v v v v v v v v

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*) The sVRT exercises are available in YouTube, the link are listed at the Table: sVRT Exercises List. (or you may search on YouTube using keyword : "do neurology vrt", or following with the exercise name such as "do neurology vrt head-eye", "do neurology vrt warming", "do neurology vrt postural", etc.)

3.2.1 Gaze Stability Exercises Gaze stability exercises include (1) head–eye exercises, (2) eye movement exercises, (3) visual habituation exercises, and (4) head–eye exercises while walking. Head–eye exercises are effective in promoting gaze stability because horizontal or vertical head movements while maintaining visual fixation on a target are the best stimuli to induce retinal slip and to recover the VOR reflex. The target can be placed either within an arm’s length to the patient or across the room. Varying degrees of the amplitude, direction, and frequency of the head movements should be used in the exercise. These variations should be implemented gradually. In order to optimize the induction of retinal slip, the exercises should be performed in a brightly lit room [Photograph 1-1, 1-2, 1-3]. Eye movements exercises was designed on the following principle. Eye movements such as saccades and pursuits can compensate for the decrease in VOR.  Therefore, stimulating these compensatory eye movements can improve gaze stability [Photograph 2-1, 2-2]. Utilizing the central programming of eye movements can improve gaze stability [Photograph 2-3]. Visual habituation exercises utilize vestibulo-­ ocular reflex (VOR) suppression to enhance gaze stability during head movement, by producing eye movements in the direction opposite to the head movement. However, VOR should be suppressed when both the eyes and the head are moving actively, on a fixed body, or when the eyes are moving actively and the head passively on a fixed body. Therefore, actively suppressing VOR can also enhance overall gaze stability [Photograph 3-1].

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Head–eye exercises while walking enhance the recovery of gaze and postural stability because the exercises engage the vestibular system that controls posture and stabilizes eyes during head motion. In a hallway or open space, practice walking in a straight line while turning your eyes and head left and right. Look left when stepping with your left foot and vice versa. Head and eye movements can be performed in different directions and either with the gaze fixed or moving [Photograph 4-1, 4-2].

 . Head–Eye Exercises 1 *Exercise link on YouTube: https://youtu.be/ zAHasIMgK7Y 1-1 Horizontal Head–Eye Exercise Rotates the head side to side with the gaze fixed on a stationary target. Start slowly but speed up as you get used to the exercise. Repeat 5 to 10 times. If you become dizzy or nauseated, slow the speed or stop this exercise. (Photo model: Eun Hye Shin)

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1-2 Vertical Head–Eye Exercise Slowly move the head up and down with a gaze fixed on a stationary target. Start slowly but speed up as you get used to the exercise. Repeat 5 to 10 times.

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1-3 Circular Head–Eye Exercise Draw a circle with the head while keeping the gaze fixed on a stationary target.

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 . Eye Movements Exercises 2 *Exercise link on YouTube: https://youtu.be/ JcAEvoic4TY 2-1 Pursuit Eye Movement This is a gaze pursuit exercise for a continuously moving object. Keep the head still and moves only the eyes. Extends one arm forward and put your thumb up. Slowly move the arm side to side and follow your thumb with your eyes while keeping the head still.

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2-2 Saccade Eye Movement Hold both your thumbs up to eye level and extend your arms. Without moving your head, quickly alternate your gaze from one thumb to the other. Repeat 5 to 10 times. Keep the head still and move only the eyes.

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2-3 Imagery Pursuit Movement (Remembered Target Exercise) Look directly at a target, and make sure you are looking straight ahead when looking at the target. Close your eyes, and slowly turn your head away from the target but imagine that you are still looking at the target. Then, open the eyes to check whether you successfully kept your gaze on the target. If not, adjust your gaze on the target and repeat in the opposite direction. Repeat in both directions several times until you can accurately maintain your gaze on the target.

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3. Visual Habituation Exercises by Utilizing VOR Suppression 3-1 Head–Trunk Turns Extend your arm forward, hold your thumb up, and fix your eyes on the thumb. Slowly rotate your upper body (head, arm, and torso together) (en block) side to side while maintaining your gaze on the thumb. Repeat 5 to 10 times (Photo model: Hyun-jin Goo).

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 . Head–Eye Exercises While Walking 4 *Exercise link on YouTube: https://youtu.be/ mgKs887weJQ

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4-2 Looking Around While Walking While walking, look left and right without keeping your eyes fixed on an object. Then practice moving your head up and down.

4-1 Horizontal Head–Eye Exercise with Gaze Fixed on a Target While Walking Perform this exercise in an open area that is large enough to take at least 10 steps. Begin walking with your eyes fixed on an object ahead of you. With every step, move your head in the direction of your stepping foot (i.e., look left when stepping with your left foot and vice versa). Try to walk in a straight line. Then practice moving your head up and down. (Photo model: Hyun Ah Kim).

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3.2.2 Postural Stability Exercises Postural stability exercises are designed to enhance the use of stable vvisual and somatosensory information and remained vestibular function. The exercises also help to identify efficient and effective alternative postural strategies. Postural stability exercises include (1) standing balance exercises and (2) postural strategy exercises.

 . Standing Balance Exercises 1 Standing balance exercise is the most elementary exercise that helps you maintain a good balance. While any activity that keeps you on your feet and moving is beneficial in maintaining balance, specific exercises are designed to increase the efficiency and effectiveness of the therapy. The following are the steps for standing balance exercises: (1) start with a stable stationary position (static balance); (2) progress to a less stable position by reducing the base of support (see the figures below), changing head/trunk orientation, and adding movement (dynamic balance); (3) stretch your arms out to the sides then cross them in front of you; and (4) progress to practicing with altered somatosensory or visual information. Try to avoid looking down at the ground during balance exercises.

(a) Static Standing with Feet Together The goal of this exercise is to maintain good posture (standing tall) and to minimize sway while decreasing stiffness and tension. Somatosensory information can be altered by having the patients stand on a foam, and by eliminating vision with eye closure. For safety, stand in a corner with your back close to the wall but not touching. Place a firm chair in front of the patient. An instructor should remain in close proximity to the patient. a1. Standing on a Firm Surface Stand on a firm surface with the feet together. Focus on keeping equal pressure between the heels and the balls of the feet. Perform this with arms outstretched, with eyes open, and eyes closed. If this movement becomes easy, perform with arms across the chest (Photo model: Hyun-­ jin Goo, Hye-min Jung).

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a2. Standing on a Cushion Stand on a cushion or pillow in a corner. Try to stand still without touching the wall for 30 seconds. Practice with eyes open. When this is easy, practice with eyes closed. You may make this more challenging by bringing your feet closer together. Crossing arms across your chest also makes this more challenging. Progressively attempt to perform this exercise in the most challenging position possible.

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(b) Standing with the Feet Heel-to-Toe Practice standing “heel to toe” (one foot in front of the other with the heel of one foot touching the toe of the other foot) with both arms extended and eyes open for 5 to 15 seconds. Switch to the other leg. You may make this more challenging by crossing arms across the chest. If this is too hard at first, try standing “almost heel to toe” (with feet touching at big toes and ankles). Once you have mastered this exercise with eyes open, practice with eyes closed. When this is easy, practice while standing on a thin cushion.

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(c) Stand on One Leg Stand with your feet together. Make sure both feet are firmly planted. Stand straight, with your head level and arms outstretched. Then, transfer your weight to your one foot and slowly lift your opposite leg off the ground. Maintain balance on one foot while keeping the other leg off the ground and slightly bent. Hold the position for 5 to 10 seconds. Gently place your foot back on the floor. Perform several times on each side.

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(d) Sway Back and Forth Stand close to a wall or next to a chair to prevent a possible fall. Starts by swinging both arms forward and with your hips, with the heels up. Repeat 5 to 10 times. Perform this exercise again but move your arms and hips in the opposite direction (e.g., swing your arms forward as you pull your hips backward with toes up). Repeat 5 to 10 times. When this is easy, practice with eyes closed. These movements are similar to one of the hip strategy exercises.

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This illustration depicts “Sway Back and Forth” movement.

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(e) Marching in Place Stand straight. March in place and lift your knees as high as you can. When this becomes easy, practice with eyes closed or on a cushion.

 . Postural Strategy Exercises 2 There are three main postural strategies mobilized to recover balance while standing. “Ankle strategy” uses ankle torques in a bottom-­up, inverted pendulum-type sway. Once the imbalance goes beyond the range of a small perturbation that the ankles can correct, the hip strategy is mobilized.

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“Hip strategy” involves quick torques around the trunk and hips in a top-down control. This comes into play when the perturbation is too large for the ankles to control, but yet not big enough yet to force a step to correct the imbalance. Ankle strategy is a type of a postural strategy where the upper and lower bodies move in the same direction or in phase. On the other hand, the hip strategy requires the upper and lower bodies to move in the opposite direction or out of phase. By standing on a narrow surface that does not support the heels and forefoot, the ankle strategy is negated. By putting the ankles at a disadvantage, the hips and core are emphasized for balance. “Stepping strategy” is a stepping movement that kicks in when the stability limits are exceeded. This strategy is the last resort and only kicks in when the perturbation is so large that the ankle or the hip cannot help. The principal steps for postural strategy exercises are as follows: (1) Start in a stable stationary position, (2) stretch your arms out to your sides then fold them across your chest, and (3) practice with altered somatosensory or visual information. (a) Ankle Strategy Exercises *Exercise link on YouTube: https://youtu.be/ TuVjXsHe7jo An ankle strategy maintains balance by utilizing a small group of muscles that produce four types of actions that occur at the ankle joint; dorsiflexion, plantar flexion, inversion, and eversion. When performing the following exercises, stand in a corner or close to a wall for safety and use a chair for support.

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a1. Ankle Oscillation Stand with your feet shoulder-width apart. Sway back and forth by the ankles without moving your feet or your hips. The toes or the heels may be lifted during oscillation. Do not bend your knees or back. Repeat 5 to 10 times (Photo model: Hyun Ah Kim).

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a2. Sideway Sway Stand with your feet shoulder-width apart. Shift your weight from one foot to the other, swaying sideways. Do not bend your knees or back. Repeat 5 to 10 times. a1-1

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a3. Pivot on Heels or Toes Stand with your feet shoulder-width apart. Fan your feet out using your heels as support and back. Repeat 5 to 10 times. Then, stand comfortably. Fan your heels out using your toes as support and back. Repeat this movement 5 to 10 times.

a4. The Skier Stand with your feet shoulder-width apart and slightly bend your knees. Jump to the side while swinging your arms to create momentum. Then jump to the other side and back in the same fashion. Repeat 5 to 10 times.

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a5. The 360-Degree Turn In a standing position, turn your head at a 90-degrees angle to the left. Pivot your left foot by the heel in the same direction following through with your right foot. Complete a whole circle in 90-degree intervals and then in the opposite direction.

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(b) Hip Strategy Exercises When balance is lost going backward, hip and back extension is required to redirect the center of mass (COM) forward and recover balance. Strong hip flexors, hip abductors, hip extensors, and trunk extensors are the keys to effective balance recovery movements. Hip strategy exercises involve rhythmically shifting the center of gravity by moving the body back and forth in any direction while keeping the feet in place. Weight shifts can be performed from side to side, forward and back, and with hip/trunk rotation. When performing the following exercises, stand in a corner or close to a wall for safety and use a chair for support. a5-7

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b1. Hip Strategy Exercises with the Legs Fixed *Exercise link on YouTube: https://youtu.be/ VSJhawd2a4Q

ii. Hip Oscillation with Out-Phasing Arms Stand comfortably with your feet shoulder-width apart. Swing your hips back and forth with both arms swinging in the opposite direction (out-­ phase direction). Repeat 5 to 10 times.

i. Hip Oscillation with In-Phasing Arms Stand comfortably with your feet shoulder-width apart. While keeping your eyes fixed on an object in front of you swing your hip back and forth with both arms swinging in the same direction (in-phase direction). Start small then swing further in increments. Repeat 5 to 10 times.

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iii. Sideway Sway Stand comfortably with your feet shoulder-width apart. Swing both your arms in front of your body. Sway with hips in the same direction as your arms. Repeat 5 to 10 times.

iv. Sideway Counter-Sway Stand comfortably with your feet shoulder-width apart. Swing both your arms in front of your body. Sway your hips in the opposite direction of your arms.

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v. Waist Rotation Stand comfortably. Draw a big circle with your waist in one direction. Repeat 5 to 10 times. Repeat in the opposite direction.

vi. Torso Rotation Stand comfortably. Draw a big circle with the upper part of your body without moving your legs. Repeat 5 to 10 times. Repeat in the opposite direction.

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vii. Arm Stretch - Forward Stand comfortably. Stand with your feet shoulder-­ width apart. While keeping your legs straight, stretch out your hand to the front as far out as possible as if you are reaching for a faraway object simultaneously bending forward at your waist. Maintain balance by stretching your other hand in the opposite direction. Hold for 5 to 10  seconds and return to the standing position. Switch hands.

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viii. Arm Stretch - Sideway Stand comfortably. Stretch out your hand to the side as far out as possible as if you are reaching for a faraway object. Do not move your feet. Hold for 5 to 10 seconds and return to the standing position. Switch hands.

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b2. Hip Strategy Exercises with One Leg Moving *Exercise link on YouTube: https://youtu.be/ HNLQaEJbK3k i. Forward and Backward Leg Swings Stand with your feet together. While maintaining balance on one leg, swing the other leg forward and back without bending your knees. Repeat 5 to 10 times then switch legs. If this exercise is too strenuous, drag your feet along the floor without lifting it up. A chair can be used for support and for safety.

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ii. Front Side to Side Leg Swing Stand with your feet together or shoulder-width apart. Lift your right leg slightly forward without bending the knee. Swing your leg side to side as far out as possible without moving your upper body. Swing 5 to 10 times then switch legs. If this exercise is too strenuous, drag your feet along the floor without lifting it up.

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iii. Rear Side to Side Leg Swing Stand with your feet shoulder-width apart. Lift your right leg slightly toward the back Swing your leg side to side as far out as possible without moving your upper body. Repeat 5 to 10 times then switch legs. If this exercise is too strenuous, drag your feet along the floor without lifting it up.

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iv. Circle of the Leg This movement is like “Rond de Jambe” which is a classical ballet movement. Stand with your heels together. Lift one leg forward then draw a half-circle creating the letter “D.” Return to the standing position after each rotation. Repeat 2 to 4 times and again in the opposite direction. Your heel may slightly touch the heel of the standing leg. Repeat with the other leg. If this exercise is too strenuous, drag your feet along the floor without lifting it up.

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(c) Stepping Strategy Exercises *Exercise link on YouTube: https://youtu.be/ JbGc6-Rn5kg The ability to take a quick and controlled step is key to preventing a fall, particularly during larger disruptions to balance. To perform this exercise, start by taking steps forward. Once the patients’ coordination, steadiness, and confidence improve, proceed to stepping in different directions. Various elements can be introduced to this exercise such as randomization (e.g., stepping in any direction based on random cues), increased speed (e.g., cures appear quicker), increased step distance (e.g., targets are further away), and/or stepping over obstacles (e.g., place an object between the patient and the target). c1. Forward Step Stand with your feet together. Take a single step forward, starting with your right foot. Step back into your original position, starting with your right foot. Repeat, 5 to 10 times. Switch to starting with the left foot.

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c2. Sidestep Stand with your feet together. Take a single step out to the right as far as you can. Then step back to your original position. Repeat, starting with the opposite foot.

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c3. Sideway Front Cross-Step Stand with your feet together. Take a step to your left with your right leg crossing over your left leg. Complete the step by taking a step with your left foot. Return to the original position. Repeat 5–10 times and switch sides.

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c4. Sideway Back Cross-Step Stand with your feet together. Take a big step to your left with your right leg crossing behind your left leg. Complete the step by taking a step with your left foot. Repeat 5 to 10 times and switch sides.

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c5. Stepping Over an Object Stand with your feet together or shoulder-width apart. Take a step out to the side over an imaginary object. Bring your other leg over, assuming the original standing position on the other side of the object. Repeat the exercise by starting with the opposite leg.

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Habituation occurs through repetitive exposures to a provocative movement. After finding the specific type, intensity, and direction of the eliciting stimuli, the patient can repeat the provoking movement. The provoking movements can be performed in various ways (i.e., up and down, and gaze fixed or moved). Generally, dizziness is provoked by the head or upper body movements than the lower body, so that habituation can be achieved mostly by the movement with the head or upper trunk. Those body movements mainly induce somatosensory and vestibular habituation if those are with gaze fixed or eye closed. However, if the movements are performed with the gaze moved, visual habituation also can be achieved.

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The “diagonal head exercise” invented by the author is a universal habituation exercise which can be performed if a specific eliciting stimulus cannot be found. This exercise stimulates all semicircular canals as well as the neck structures so that extensive sensory habituation can be achieved. The habituation exercises should be performed while sitting for inexperienced patients to prevent any falls. Once the patients are comfortable with the exercises, proceed to stand.

 . Habituation Exercises While Sitting 1 *Exercise link on YouTube: https://youtu.be/ wEZNGPJo48o 1-1 Horizontal Head Turn While Sitting Sit on a chair. Look left and right by turning your head slowly. Repeat 5 to 10 times (Photo model: Hyun Ah Kim).

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1-2 Vertical Head Exercise While Sitting Sit on a chair. Look up and down while simultaneously moving your head up and down slowly. Repeat 5 to 10 times.

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1-3 Diagonal Head Exercise While Sitting Sit on a chair with your back straight. Lift your arm up and fix your gaze on your hand. Bring your lifted arm down diagonally to the opposite foot while keeping your gaze on your moving hand. Repeat 5 to 10 times. Switch arms.

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1-4 Seated Body Rotation With Fixed Gaze (with Instructor) This exercise requires a swivel chair or a stool that can spin on its axis. Sit comfortably on the chair. The instructor should gently hold the patient’s head in place. With the head held in place, and with gaze fixed on an object, turn your body side to side using your feet. Repeat 5 to 10 times. At first, an instructor may help first-timers perform this exercise, but not when the patient is confident enough to do perform the exercise alone (Photo model: Hyun-jin Goo, Hye-min Jung).

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1-5 Seated Body Rotation with Fixed Gaze (Without Instructor) *Exercise link on YouTube: https://youtu.be/ dM1WXJfOl6g Sit comfortably on a swivel chair. Hold your head in place and fix your gaze on an object. Turn your body and chair side to side by using your feet. Repeat 5 to 10 times. 1-5-4

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2. Habituation Exercises While Standing *Exercise link on YouTube: https://youtu.be/ RoieRXmxpNc

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2-1 Standing Body Rotation with the Head in a Stationary Position This is a turning exercise while standing up. Stand straight. The instructor should gently hold the patient’s head in place while the patient’s whole body turns from one side to the other. Repeat 5 to 10 times (Photo model: Hyun-jin Goo, Hye-min Jung).

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2-2 Head Rotation While Standing Stand with your feet shoulder-width apart. Look from one side to the other by turning your head slowly from side to side. Repeat 5 to 10 times (Photo model: Hyun Ah Kim).

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2-3 Standing trunk rotation with the head in a stationary position Stand with your feet shoulder-width apart. While looking forward, turn your trunk from one side to the other without moving your feet. Holding your fists up to the chest will make this easier. Repeat 5 to 10 times.

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2-4 Standing Head and Trunk Rotation Stand with your feet shoulder-width apart. Turn both your head and trunk from one side to the other without moving your feet. Repeat 5 to 10 times. 2-3-1

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2-5 Turning with Head Being Stationary and Fixed Gaze *Exercise link on YouTube: https://youtu. be/1Puaj7y1qO4 Stand comfortably. Without the help of an instructor, turn your body from one side to the other by only using your feet. Your head should remain stationary and your gaze fixed. Repeat 5 to 10 times. 2-5-4

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2-6 Bent Chest Rotation Stand with your feet wide apart. Stretch out your both arms and bend your upper body forward by the hip joints. Rotate your chest from one side to the other by touching your left foot with your right hand and vice versa. Your free arm should be stretched backward. Repeat 5 to 10 times. 2-5-3

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2-7 Diagonal Head Movement While Standing Stand with your feet wide apart. Turn your trunk slightly toward the direction you will be turning. Raise your arm up over the head and slightly out (about 30 degrees from your central axis). Turn your head to look at the raised hand. Your gaze should be fixed on the hand during this exercise. Bend over your trunk at the hip joints and bring your arm down diagonally to your foot on the opposite side with the eyes continuously looking at the hand throughout the movement. Repeat 5 to 10 times. Switch sides.

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3. Habituation Exercises for Sensory Dependency Habituation exercises also include exercises for sensory dependency. In order to overcome visual dependency, the patient should attempt to balance with good somatosensory inputs but reduced or distorted visual input such as moving curtains with strips, moving discs with multicolored and differently sized circles. In order to overcome somatosensory dependency, the patients should practice to perform tasks while sitting or standing on surfaces with disrupted somatosensory cues for orientation, such as carpets, compliant foam, and moving surfaces. For safety, stand in a corner or close to a wall. If necessary, a chair may be placed in proximity for support.

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3-1 Exercises for Visual Dependency This exercise requires an umbrella with a complex pattern. This exercise needs two instructors. The exercise is more effective when the patient is not wearing shoes. The patient stands on a firm surface. The first instructor stands beside the patients to prevent a fall. The second instructor and the patient stand facing each other. While leaving enough distance between the patient and the umbrella, the second instructor opens an umbrella and spins it in front of the patient without the tip being too close. While looking at the spinning umbrella which disrupts visual input, the patient practice to stand still for approximately 30 seconds. The two photographs below show the umbrella in motion and when stopped (Photo model: Hyun-jin Goo, Hye-min Jung). 3-1-2

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3-2 Exercises for Somatosensory Dependency The patient stands on a cushion and fix his/her gaze on an immobile object. The instructor should stand close to the patient (without physical contact) in case of a fall. The patient tries to stand still for approximately 30  seconds. When this is easy, proceed to perform this exercise with arms folded across the chest.

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1. Weight Shifting Exercise Stand with your feet wide apart and point your toes outward. Raise your arms to the side, palm down until they are at shoulder level. Slowly shift your weight to one side by bending your knee. Switch sides. Repeat 5 to 10 times.

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3.3

General Exercises

General exercises, including warm-ups, stretches, strengthening, and cool-down exercises should be performed appropriately throughout the therapy session.

3.3.1 Warming-Up Exercises *Exercise link on YouTube: https://youtu.be/ GMIG0ofs1ts The main purpose of warming up is to optimize the physiological efficiency of the body to prepare for the strenuous workout. The warmingup exercises should involve large muscle groups that will be used during the therapy session.

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2. The Folder Raise both your arms above your head. Slowly bend forward from your hips while keeping your legs straight until your arms are pointing straight forward. Repeat 5 to 10 times.

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3. Windmill Raise your arms up and lock your fingers. While keeping your legs straight, draw a big circle from the hips with the upper part of your body. Switch directions. Repeat 3 to 5 times.

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3.3.2 Cooling-Down Exercises *Exercise link on YouTube: https://youtu.be/ u40x0HErFtc Cooling down after an exercise may prevent dizziness and even fainting by gradually reducing heart rate and the respiratory rate to resting levels, and preventing the blood from pooling in the legs. It also removes metabolic waste products such as lactic acid that have accumulated in the muscles. Cooling-down exercises should include taking deep breaths and consist of less strenuous versions of the preceding exercises. 1. Bending Forward Stand with your feet shoulder-width apart. While keeping your legs straight, slowly bend from the hips. Touch the floor with your hands then recover. Repeat 5 to 10 times.

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2. Arm and Leg Raise While Standing Stand with your feet shoulder-width apart. Put your hands up and lock your fingers. Stretch upward as you stand on your toes then recover. Repeat 5 to 10 times.

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3. Back Twist Stand with your feet shoulder-width apart. Slowly twist to the right from your waist without moving your hips. Put your right hand on your back and the left on your right waist. Turn your head in the same direction with your trunk. Twist further, if possible. Hold the position for 10–30 seconds. Slowly return to face forward. Repeat on the left side. Repeat 3-5 times.

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3.3.3 Shoulder Stretch *Exercise link on YouTube: https://youtu.be/ zLlk8VyPwvU Shoulder stretches help relieve muscle tension, pain, and tightness in the neck and shoulders. The exercises shown below are intended for use in primary healthcare facilities for ambulatory patients. Consequently, exercises that require tools or ample space are excluded. Therapists who intend to develop a more sophisticated exercise regime should modify the following exercises to better suit their patients.

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1. Shoulder Rolls Let the arms hang down at the sides of the body. Breathe in and lift the shoulders up toward the ears. Move the shoulders back, squeezing the shoulder blades together. Exhale and drop the shoulders back. Move the elbows forward, feeling the stretch at the back of the shoulders. Repeat 5 to 10 times.

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2. Cross-Body Shoulder Stretch Stretch the right arm out to your side. Bring the right arm across the body without bending at the elbow. Hook the left forearm under the right arm, supporting the right arm above the elbow. Use the left forearm to pull the right arm further in and across the body, stretching the back of the right shoulder. Hold this for 10 seconds, then repeat the stretch on the other side.

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3. Opening Chest Stretch both arms backward and lock your fingers together in the back. Pull the shoulders back by squeezing the shoulder blades together. Inhale as you open your chest and extend your neck. Exhale as you release the shoulders.

4. Cow-Face Pose Reach the above hand over the head and down the back. Reach the lower hand behind and up the back. Bring the left and right hands close together, clasping them if it feels comfortable. Lock your fingers behind your back with your one elbow pointed toward the ceiling and the other elbow pointed toward the floor. If you cannot lock your fingers, use a towel. Take three or four deep breaths. Release your fingers and alternate arms.

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5. Standing Side Stretch Stand with your feet shoulder-width apart. Slowly bend to the side and bring one arm of the other side overhead. Exhale as you lengthen the arm over the head. Continue to bend the body gently to the side. Inhale to return arms overhead to center. Repeat 5 to 10 times. Switch sides.

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6. Horizontal Shoulder Rotation Stand with your feet shoulder-width apart. Hold your one arm out to the side and draw a circle 5 to 10 times while keeping the arm straight. Switch sides

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7. Single Shoulder Twist Stand with your feet shoulder-width apart. Slightly bend your knees. Place your one hand on your knee on the same side. Twist your upper body to the opposite side as you extend your opposite arm toward the ceiling and beyond your back. Repeat 5 to 10 times. Bring back the stretched arm onto your knee. Do the same movement with the other arm.

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8. Double Shoulder Stretch Stand with your feet shoulder-width apart. Bend your knees and place your hands on your knees. Push one hand against the knee and twist your shoulder and body to the one side. Hold for 5 to 10 seconds. Switch sides. 7-1

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ors, serratus anterior, and the lower trapezius are weakened. On the other hand, the postural muscles such as the chest flexors (pectoralis major and minor) and neck extensors (suboccipital muscles, upper trapezius, and sternocleidomastoid) are tightened and shortened. 1. Neck Flexor Strengthening and Upper Chest Flexor (Pectoralis) Stretch In a standing position, put both your hands on the small of your back. Pull your shoulders back as you push against your back with your hands. Inhale during this step and tuck your chin in. Move both shoulder blades together, as if trying to hold a tennis ball between them. Hold this for 5 to 10 seconds. Repeat 2 to 4 times. 8-1

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3.3.4 U  pper Cross Syndrome Exercises *Exercise link on YouTube: https://youtu.be/ PBf3Hnc-vfk Forward head-and-neck posture is common in patients with dizziness. The patients with the forward head-and-neck posture are likely to have upper crossed syndrome. In the upper crossed syndrome, the phasic muscles such as neck flex-

2. Neck Extensor (Upper Trapezius) Stretch Stretch the right arm out to your side. Bring the right arm across the body without bending at the elbow. Hook the left forearm under the right arm, supporting the right arm above the elbow. Use the left forearm to pull the right arm further in and across the body, stretching the back of the right shoulder. Hold this for 5 to 10 seconds. Repeat 2 to 4 times on each side.

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4. Chest Flexor (Pectoralis) Stretch Bend one arm over your head. Grab the arm by the elbow with your other hand and pull toward the back. Hold this for 5 to 10 seconds. Repeat 2 to 4 times. Switch sides.

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3. Lower Chest Extensor (Lower Trapezius) Strengthening Put your hands on your waist. Open your chest by pulling your shoulders back. Press down on your waist with both hands. Hold for 5 to 10 seconds. Repeat 2 to 4 times.

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*Exercise link on YouTube: https://youtu.be/ c5BuXzjj3Bg Use a chair that does not have arms or wheels. The chair should have a back to be used as a support and balance. To start each exercise, lightly grip the back of the chair from behind and slightly bend your knees. The following movements are intended for use in primary healthcare facilities with limited space. These exercises are also intended for ambulatory patients. For patients with musculoskeletal problems or for those who cannot stand alone, the exercises should be modified to better accommodate their needs.

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1. Standing Hamstring Stretch Assume starting position. Spread your legs to about twice the length of your shoulders. Push your hip out to one side as you shift your weight onto one leg. Bend the weight-bearing knee and stretch your other leg. Hold for 5 to 10 seconds. Repeat 2 to 5 times on each side.

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2. Heel Pivot This movement rotates your back and hips. From the starting position, stand on your heels by lifting your toes. Pivot on your heels by turning your hip and knees. Pivot to both sides. Repeat 5 to 10 times. Alternatively, this exercise can be performed by pivoting on your toes.

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3. Cross Curtsy Lunge Assume starting position. Take a lunge to the right side of the chair with your left foot without losing your grip on the back of the chair. Bend both knees as you drop into a curtsy lunge position. Hold for 5 to 10 seconds. Repeat 2 to 5 times on each side.

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4. Standing Leg Raise Stand next to a chair with one hand on its back for support. Bring your other hand up to your ear. As you swing your hand back down, raise your knee as high as you can. Repeat 5 to 10 times on each side.

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5. Standing Rear Leg Lift (Standing Quadriceps Stretch) Stand next to a chair with one hand on its back for support. Bend your knee back and grab your ankle with your free hand. Bend your knee back and pull the ankle up as far as possible. Hold for 5 to 10 seconds. Switch sides.

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6. Standing Front Leg Grab (Hip Internal Rotation) Stand next to a chair with one hand on its back for support. Raise your knee opposite to your free hand, and grab the ankle by rotating your shin inward. Pull on your ankle as far up as you can and hold for 5–10 s. Switch sides.

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3.3.6 Leg Stretching *Exercise link on YouTube: https://youtu. be/0tszx30VLs0 Among the extensive list of leg stretches, the following were designed specifically for ambulatory patients at primary care clinics where space is limited. These exercises should be undertaken for patients with their balance intact. Nonetheless, an instructor should always remain in close proximity to prevent a fall especially because these exercises do not involve a chair for support. 1. Standing Hamstring Stretch Stand with your feet shoulder-width apart. Shift your weight onto one foot by pushing your hip 1-2 out to the side and straighten your non-weight-­ bearing leg. Hold for 5 to 10 seconds before returning to a standing position. Repeat 3 to 5 times then switch sides.

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2. Standing Real Leg Lift (Standing Quadriceps Stretch) Stand comfortably while maintaining balance. Bend your knee back and grab your ankle with your free hand. Bend your knee as far back as possible for 5 to 10 seconds. Repeat 3 to 10 times then switch legs.

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3. Standing Front Leg Lift (Hip Internal Rotation) Stand comfortably while maintaining balance. Raise your leg and grab your shin by the ankle and the knee. Pull on your shin as far up as you can and hold for 5 to 10 seconds. Repeat several times then switch sides.

4. Standing Front Knee Lift Stand comfortably while maintaining balance. Raise your leg up and bring your knee close to your chest using both hands. Lift your knee as high as you can without tilting your pelvis. Hold for 5 to 10 seconds. Repeat 3 to 5 times on each side.

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5. Deep Side Lunge Stand with your feet wide apart and toes pointing forward. Crouch down to one side by shifting your body weight onto one foot. Straighten your non-weight-bearing leg. Switch sides by shifting your weight to the opposite side without fully standing up. Hold the position for 4 to 10 seconds on each side.

6. Standing Calf Stretch (Gastrocnemius and Soleus Stretch) Stand comfortably while maintaining balance. Stand in a split stance with one foot forward and the other leg back, making sure both your toes are facing forward. Keep your heels on the ground and lean forward while keeping your back knee straight. Rotating the toes in and out will target the medial and lateral parts of this muscle separately. Try not to bend your back knee because bending the back knee while keeping your heel on the ground will take the tension off the gastrocnemius and place it on the soleus. Holding your hands up will stretch your thigh flexors. Hold for 5 to 10 seconds then switch sides.

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your leg is perpendicular to the central axis. Hold for a second before returning to the start position. Complete the suggested number of repetitions then switch sides.

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3.3.7 L  eg Strengthening Exercises Using a Chair

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*Exercise link on YouTube: https://youtu. be/3JopAdY6MWc These exercises enhance the strength and balance of the lower body. Using a chair prevents the patients from falling and reduces the burden of the weight-bearing leg. The instructor should remain in close proximity and/or use adequate safety measures to prevent a fall. To start each exercise, stand beside or behind a chair and lightly grip the back of the chair. 1. Standing Forward Leg Lift This movement strengthens hip flexors. While standing straight and one hand holding onto the chair, swing your one leg forward while keeping it straight. Your upper body should remain upright. Raise your leg as high as you can or until 1-2

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2. Standing Side Leg Lift This movement strengthens hip abductors. Stand straight beside the chair, with your hand holding onto the chair. Lift one leg out to the side while keeping it straight without moving your upper body. Hold for a second before returning to a standing position. Complete the suggested number of repetitions then switch sides.

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3. One-Legged Bicycle While standing straight beside a chair with your hand holding onto the chair, lift your knee up then straighten your leg by kicking forward. Flex your ankle then slowly bring your leg down to the standing position without bending your knee. The entire movement should resemble a pedaling motion. Repeat 5 to 10 times and then reverse directions. Switch sides.

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about 90-degree angle. Keep your toes pointing in the same forward direction and keep your back leg straight. The weight should be evenly distributed between both legs. Hold for 5 to 10 seconds then recover by pushing on your front foot. Alternate legs and repeat 5 to 10 times

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4. Standing Lunge Stand straight beside the chair with your hand holding onto the chair. Move one foot forward and the other foot straight back. Make sure your torso is straight and bend your forward knee to

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5. Heel Lift This exercise strengthens the muscles of the ankles and foot flexors. Stand straight behind a chair and put your both hands on the chair. As you inhale, raise your heels as high as you can and stand on your toes. Exhale as you come back down. Repeat 5 to 10 times.

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6. Toe Lift This exercise strengthens the muscles of the ankle and foot extensors. Stand straight behind a chair with your both hands holding onto the chair. Lift your toes up and down while keeping balance on your heels. Repeat 5 to 10 times.

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3.3.8 Leg Strengthening Exercises *Exercise link on YouTube: https://youtu.be/ QedVU6HlGJ0 Lower body strength plays a crucial role in maintaining balance and overall physical fitness. The following movements are intended for use in primary healthcare facilities with limited space. These exercises are also intended for ambulatory patients. For patients with musculoskeletal problems or for those who cannot stand alone, the exercises should be modified to better accommodate their needs. The instructor should remain in close proximity and/or use adequate safety measures to prevent a fall. 1. Standing Forward Leg Lift This movement strengthens hip flexors. While standing straight, swing your right leg forward while keeping it straight. Your upper body should remain upright. Raise your leg as high as you can or until your leg is perpendicular to the central

3.3 General Exercises

axis. Hold for a second before returning to the start position. Complete the suggested number of repetitions then switch sides.

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Lift one leg out to the side while keeping it straight without moving your upper body. Hold for a second before returning to a standing position. Complete the suggested number of repetitions then switch sides.

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3. One-Legged Bicycle While standing straight, lift your knee up then straighten your leg by kicking forward. Flex your ankle then slowly bring your leg down to the standing position without bending your knee. The entire movement should resemble a pedaling motion. Repeat 5 to 10 times and then reverse directions. Switch sides.

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2. Standing Side Leg Lift This movement strengthens hip abductors. Stand straight and keep both your hands on your waist.

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4. Standing Lunge Stand in a split stance with one foot forward and the other foot straight back. Make sure your torso is straight and bend your forward knee to about 90-degree angle. Keep your toes pointing in the same forward direction and keep your back leg straight. The weight should be evenly distributed between both legs. Hold for 5 to 10 seconds then recover by pushing on your front foot. Alternate legs and repeat 5 to 10 times.

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5. Heel Lift This exercise strengthens the muscles of the ankles and foot flexors. Stand straight and put your arms on the waist. As you inhale, raise your heels as high as you can and stand on your toes. Exhale as you come back down. Repeat 5 to 10 times.

6. Toe Lift This exercise strengthens the muscles of the ankle and foot. Lift your toes up and down while keeping balance on your heels. Repeat 5 to 10 times.

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3.3.9 L  ower Cross Syndrome Exercises *Exercise link on YouTube: https://youtu.be/ HyypyMEDQ1w Lower crossed syndrome is characterized by anterior pelvic tilt and lumbar hyperlordosis (swayback). While the hip flexors and the back extensors are tightened and shortened, the hip extensors (glutes/hamstrings) and back flexors (abdominals) are weakened and lengthened. 1. Seated Back Flexor Strengthening Sit on the edge of the chair with your back straight and not against the back of the chair. Lift your foot and straighten your leg. Hold still for 5–10 s. Repeat 3 to 5 times on each side.

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2. Seated Back Extensor Stretch Sit on the edge of the chair with your back straight and not against the back of the chair. Lift your knee and pull toward your chest using both hands. Relax your back and hold still for 5 to 10 seconds. Repeat 3 to 5 times on each side.

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3. Standing Hip Flexor Stretch (Forward Lunge with a Chair) Stand next to the chair and put your hand on its back for support. Stand in a split stance with one foot forward and the other foot straight back. Make sure your torso remains straight and bend your forward using your knee. Lower your body until your hip flexors are fully stretched. Hold for 5 to 10 seconds then recover by pushing on your front heel. Alternate legs and repeat 5 to 10 times.

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3.4 Software “Do Smart®” and the Equipment “Balance Pro®” for sVRT

4. Standing Hip Extensor Strengthening Stand next to the chair and put your hand on its back for support. Slowly lift one leg back while keeping your upper body straight. The straighter the upper body, the greater the effects of this exercise. Hold for 5 to 10 seconds then recover. Repeat several times on each side.

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 oftware “Do Smart®” and S the Equipment “Balance Pro®” for sVRT

The sVRT was developed into a software: “Do Smart ®,” which is an exercise program for therapists to implement easily.1 This software displays the whole list of exercise movie clips on the screen so that the therapist can quickly select the exercises for their patients. The selected exercise clips can be made as a sequence. A therapist can click the start button to start the sequence. The speed of the individual exercise clip as well as the sequence can be adjusted. The sequences made from selected movie clips can be stored under the name of designated patients for the next uses. Exercise sequences for specific conditions can be created and stored by the users; for example: visual blurring, neck stiffness, forward head protrusion, leg muscle weakness, visual or somatosensory dependency habituation, etc. Therefore, Do Smart® allows therapists to customize the exercises for their patient’s individual needs. The software makes it easy for the patient to mimic the movements shown by the instructor. The Balance Pro® (Man&tel Co. Ltd) is a posturography equipped with an interactive balance control training function.2 The Balance Pro® is intended for use in rehabilitation to restore balancing functions in patients with balance problems. This product consists of a balancing board, which senses the horizontal shifts in weight, a computer system, including posturography and game software that processes incoming movement data. It also includes a screen to help with visual feedback, body harnesses for stability, and a safety bar. The pressure sensors in the balancing board process the patient’s pressure center then the software translates it into a horizontal cursor movement on the screen. Posturography is carried out by placing the patient in a standing posture on a fixed balancing The Do Smart® is a computerized exercise software developed by the author. E-mail us to inquire sVRT or this product to [email protected]. 2  The Balance Pro® is a medical equipment functioning as posturography as well as a balance trainer. Inquire about this product by e-mail to [email protected], or visit the website http://www.manntel.com 1 

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board that is connected to sensitive detectors. This measures the moving range and moving area of the center of gravity (COG), back and forth, and side-to-side wobbles. Balance control training is carried out by interacting with the games displayed on the monitor. One of the games is “Picking fruits.” The level of difficulty can be tailored to the patient’s preferred skill level. When the patient moves a cursor (hand-shaped) on the screen, they can “pick” the fruit in a fruit harvesting game. The game changes the scenery and type of fruit every time a patient finishes picking all the fruits. The Do Smart® software can be installed into Balance Pro®, which gives the therapist the ability to integrate the exercises into the games utilizing visual stimulation and feedback. This leads to greater improvement in balance ability and also achieves higher participation and compliance.

Picture 1  Playing Games and Performing Exercises. A patient is playing games with the Balance Pro® (left) while another patient is following the Do Smart® program exercises by mimicking the instructor’s movements on the screen (right)

3  Implementing the Exercises

Picture 2  The screen of Do Smart®. It displays a list of exercise clips, a sequence (left), and speed adjusting button (bottom middle)