Relationship among balance impairments, functional performance, and disability in people with peripheral vestibular hypofunction.

BACKGROUND AND PURPOSE: Physical therapy interventions are often based on assumed relationships among impairments, functional performance, and disability. The purposes of this study were (1) to describe balance impairments, functional performance, and disability in subjects with unilateral peripheral vestibular hypofunction (UVH) and bilateral peripheral vestibular hypofunction (BVH), (2) to examine the relationship among these factors, and (3) to determine whether disability can be explained by commonly used tests of balance and functional performance. SUBJECTS: Participants were 85 subjects (mean age=62.5 years, SD=16.5) with UVH (n=41) or BVH (n=44) diagnosed by vestibular function tests and clinical examination. METHODS: Each subject completed the Dizziness Handicap Inventory (DHI) to obtain a measure of disability. Functional performance was measured with a modified Timed Up & Go Test (TUG). Balance impairments were measured with computerized posturography and balance tests. Descriptive statistics, correlational analyses, and stepwise regressions were performed. RESULTS: Subjects with BVH had poorer balance but similar TUG scores and perceived levels of disability, as compared with subjects with UVH. Weak to moderate correlations existed among balance measurements, TUG scores, and DHI scores. Balance impairments and TUG scores together explained 78% of the variance in DHI scores of the subjects with BVH, whereas balance impairments alone explained 13% of the variance in DHI scores of the subjects with UVH. CONCLUSION AND DISCUSSION: Balance impairments and functional performance appear to be more closely related to disability in individuals with BVH as compared with those with UVH. Clinical tests of balance impairments and functional performance appear to be useful in explaining disability.

Posturography changes do not predict functional performance changes.

OBJECTIVE: Essentially no data exist to assess the utility of posturography, a frequently used test of standing balance in measuring change. The authors examined 1) how changes in posturography relate to functional balance changes as measured in the clinic and gait laboratory and 2) posturography's role and value in assessing patients with vestibular dysfunction. STUDY DESIGN: A correlational research design was used. SETTING: This study was conducted at a large, urban U.S. tertiary referral hospital. PATIENTS: Thirty-seven subjects (22 females and 15 males) with peripheral vestibular hypofunction and stable symptoms participated. Patients with central nervous system pathology were excluded from this study. INTERVENTIONS AND MAIN OUTCOME MEASURES: Subjects were tested before and after 6-8 weeks of vestibular rehabilitation with Equitest posturography sensory organization test (SOT), with timed quasistatic bilateral standing in tandem, on foam, and one leg; and with functional balance measures including gait velocity, a modified Timed Up & Go, gait with head rotation, gait with eyes closed, and tandem gait. RESULTS: Changes in SOT were not predictive of, nor often even directly correlated with, changes in quasistatic standing or functional performance. CONCLUSIONS: These data suggest that posturography SOT alone is not a useful tool to assess balance and functional changes in patients with vestibular hypofunction.

Relationship between standing posture and stability.

BACKGROUND AND PURPOSE: This study determined whether persons with stability impairments have postural aberrations. We investigated whole-body posture and its relationship to center-of-gravity (COG) stability. SUBJECTS: Data from 27 subjects with vestibular hypofunction and 26 subjects without vestibular impairment were analyzed. METHOD: An optoelectronic full-body system measured kinematics. Force plates measured ground reaction forces while subjects stood with their feet 30 cm apart and eyes open and with their feet together and eyes closed. RESULTS: The subjects with vestibular hypofunction demonstrated less stability than the subjects without impairment, but there were no postural differences. Subjects with vestibular hypofunction had more weight on the left lower extremity during standing with feet apart. In all subjects in both groups, during standing with feet apart, the COG was anterior to the ankle, knee, back, and shoulder and posterior to the hip and neck. Subjects had an anterior pelvic tilt, extended trunk and head, right laterally flexed trunk and pelvis, and flexed knees. With their feet together, subjects increased their anterior pelvic tilt; trunk, head, and knee flexion; and anterior COG position. CONCLUSION AND DISCUSSION: Posture and stability had a low correlation. Subjects with bilateral vestibular hypofunction did not demonstrate a forward head or backward trunk lean, as has been reported anecdotally. Changing from standing with feet apart to feet together increased whole-body movement patterns to control standing stability.

Rehabilitation of balance in two patients with cerebellar dysfunction.

The treatment of two patients with cerebellar dysfunction is described. One patient was a 36-year-old woman with a 7-month history of dizziness and unsteadiness following surgical resection of a recurrent pilocystic astrocytoma located in the cerebellar vermis. The other patient was a 48-year-old man with cerebrotendinous xanthomatosis (CTX) and diffuse cerebellar atrophy, and a 10-year history of progressive gait and balance difficulties. Each patient was treated with a 6-week course of physical therapy that emphasized the practice of activities that challenged stability. The patient with the cerebellar tumor resection also performed eye-head coordination exercises. Each patient had weekly therapy and performed selected balance retraining exercises on a daily basis at home. Measurements taken before and after treatment for each patient included self-perception of symptoms, clinical balance tests, and stability during selected standing and gait activities; for the patient with the cerebellar tumor resection, vestibular function tests and posturography were also performed. Both patients reported improvements in symptoms and demonstrated similar improvements on several kinematic indicators of stability during gait. The patient with the cerebellar tumor resection improved on posturography following treatment, whereas the patient with CTX improved on clinical balance tests. This case report describes two individualized treatment programs and documents functional improvements in two patients with different etiologies, durations, and clinical presentations of cerebellar dysfunction. The outcomes suggest that patients with cerebellar lesions, acute or chronic, may be able to learn to improve their postural stability.

Phase plane analysis of stability in quiet standing.

We analyzed the standing balance control of 11 healthy subjects and 15 subjects with bilateral vestibular hypofunction (BVH) using phase plane (velocity versus displacement) plots. We hypothesized that maintaining postural stability requires control of both the position and momentum of the center of gravity (CG) and infer that it is advantageous to use both velocity and displacement data to characterize balance control. Phase plane plots provide insight into this dynamic aspect of balance control. We evaluated phase plane plots based on whole body CG and center of pressure (CoP). We varied stability by altering the base of support and visual information. Three different foot placements were used: feet wide apart, feet together, and semitandem stance. Feet together standing was performed with eyes open and with eyes closed. The phase plane plots show changes in stability as base of support is altered or visual input is removed and reveal stability differences between the control and BVH groups. The root mean square variance of velocity and displacement was used to quantify the phase plane information. This parameter showed significant differences between activities and between groups. We conclude that phase plane plots that combine displacement and velocity information are more useful in characterizing balance control than displacement or velocity alone.

Physical therapy management of peripheral vestibular dysfunction: two clinical case reports.

We describe the treatment of two patients with peripheral vestibular dysfunction using a novel, staged exercise program. Response to treatment was documented. The first patient, a 62-year-old woman with unilateral vestibular dysfunction (UVD) and a 6-month history of disequilibrium following herpes zoster oticus resulting in damage to the right inner ear, was treated with an 8-week course of vestibular physical therapy. During the 8 weeks, the patient attended weekly physical therapy sessions and was trained to perform vestibular adaptation exercises on a daily basis at home. The second patient, a 53-year-old woman with progressive disequilibrium secondary to profound bilateral vestibular hypofunction (BVH), was treated with a 16-week course of vestibular physical therapy. During the first 8 weeks, the patient attended weekly physical therapy sessions and was trained to perform vestibular adaptation and substitution exercises on a daily basis at home. During the second 8 weeks, the patient continued performing vestibular physical therapy exercises at home independently. Vestibular function (sinusoidal vertical axis rotation testing), postural control (clinical tests and posturography), stability during the performance of selected activities of daily living (ADLs), and self-perception of symptoms and handicap were measured prior to and at the conclusion of treatment for both patients and at the midpoint of treatment for the patient with BVH. After 8 weeks of treatment, both patients reported improvements in self-perception of symptoms and handicap and demonstrated objective improvements in clinical balance tests, posturography, and several kinematic indicators of stability during the performance of selected ADLs. Further improvements were noted in the patient with BVH after 16 weeks of treatment. Improvements in postural control were noted after 8 weeks of treatment for the patient with UVD and after 16 weeks for the patient with BVH. Vestibular function improved during the course of treatment for the patient with UVD only. These case reports describe two different individualized treatment programs and document self-reported and laboratory-measured functional improvements in two patients with vestibular deficients--one with unilateral damage and one with bilateral damage.

Double-blind, placebo-controlled trial of rehabilitation for bilateral vestibular hypofunction: preliminary report.

Vestibular rehabilitation (VR) is increasingly popular, but few data exist to support enthusiasts' claims of efficacy in improving functional abilities of patients with bilateral vestibular hypofunction (BVH). A double-blind, controlled study of eight subjects (mean, 64 +/- 12 years; seven females, one male) with bilateral vestibular hypofunction was conducted. Subjects in group A received 8 weeks of VR followed by 8 weeks of home VR exercises, whereas those in group B received 8 weeks of control treatment (isometric strengthening exercises) followed by 8 weeks of VR. At the end of 8 weeks, group A walked 8% faster and, during paced gait and stair-climbing, with greater stability, evidenced by a 10% larger maximum moment arm and a 17% decreased double-support duration during gait and stair stance. Group B improved less than 1% during the control treatment. Self-reported Dizziness Handicap Inventory scores did not differ significantly between control and active VR. All subjects improved compared with baseline tests at the 16-week post-test on both functional testing and on the Self-reported Dizziness Handicap Inventory scale. We conclude that in this small sample, VR effectively improved functional, dynamic stability during locomotion, but even strengthening exercises result in self-reported symptomatic improvement.

Quantitative assessment of four men using above-elbow prosthetic control.

We studied the relationship between kinematically unconstrained activities of daily living (ADL) tasks and a kinematically constrained task in above-elbow (AE) amputee subjects using myoelectrically controlled prostheses. Four men, 24 to 49 years old, with unilateral AE amputation wore a prosthesis interfaced to a programmable controller to emulate two different elbow control schemes, conventional velocity and a new "natural" controller. Subjects were timed during three ADL tasks--cutting meat, donning socks, and rolling dough--with both controllers. The prosthesis emulator was then connected to a crank device with a handle, and the subjects turned the crank from bottom to top positions in a vertical plane using each controller. Synergistic shoulder-elbow joint coordination required for crank turning was quantified as the maximum slope of the change in elbow torque versus the change in crank-angle. Performance between the two controllers differed significantly for the crank test but not for ADL tasks. One subject did not complete all crank turning tests. Positive canonical correlation of 0.77 was found between time and crank domain measures. We conclude that biomechanical assessments should be integrated with time-based clinical tests to comprehensively evaluate performance of AE amputee subjects with a myoelectric device.