Let’s look at the progression of multisensory balance training. 

Click here if you missed the Progression Central-Peripheral Integration and click here if you the Progression of VOR Training

Clinical Rationale – specific to this patient

• 1st visit: Started with Romberg due to decreased use of vestibular inputs for balance. Added head movements in horizontal & vertical planes with eyes open on firm surface to increase multisensory demands. Repeated activities on a rocker board. In walking, focused on not being “guarded” then added head movements in horizontal & vertical planes. Focused on quality of movement
• 2nd visit: Progressed standing on foam while performing head movements – alternating between eyes open (EO)/eyes closed (EC) to increase difficulty. Added A-P tilts on tilt board with EO/EC for limits of stability training. In walking, increased speed & size of head movements. Also added 180 pivot turns.
• 3rd visit: Continued with head movements on foam EC w/feet apart, metronome at 120 bpm to increase vestibular demands during postural stability task. Used head lamp to facilitate eye-head alignment. Performed Infinity Walking – using the JPET target as her visual reference point – to navigate turns while challenging visual & vestibular systems.
• 4th visit: Standing on foam w/feet together while watching optokinetic stripes (Pavlou, 2010) in VR glasses. Continued with Infinity Walking while wearing BNO glasses.
• 5th visit: Cont. w/VR glasses scene of driving on curvy, snow-covered road in the mountains. Changed gait to walking while looking over shoulder and saying aloud numbers being held up by clinician.

Our Challenges

Determining which sensory system to focus on first and how plus lack of research for optimal frequency and duration

• No clear understanding of what is best approach to improve somatosensory cues: working on a firm surface for more feedback or starting on unstable surfaces to increase awareness of using ankle strategies
• More recent research recommending a multi-sensory approach vs single system approach and need to consider hearing as an important sensory system in balance as well as the negative impact of hearing loss in postural stability

Typically, think of starting in less busy environments then progressing to more visual stimulation and optokinetic stimulation

• Research has shown a faster improvement in symptoms (in the beginning of vestibular rehab) when patient is exposed to OPK stimulation early vs later (Pavlou, 2010)

Take-Home Messages

• Multisensory processing activities result in best outcomes but ensure that patient has a good use of somatosensory inputs in postural control as a working foundation
• Minimize time of patient using central visual cues in postural stability – challenging use of visual periphery and optimize vestibular with eyes closed, rapid head movements, & confusing visual cues
• When working on balance, if the task is easy then the activity isn’t producing enough error messages to “learn” or if it’s too difficult, the error messages are too big to change responses
• Monitor quality of movement, quality of sway – quality shouldn’t be compromised to be successful at the task and sway quality should be an expected “sway” response…not excessive use of upper extremities or producing a startle response
• Share your story…research and clinical