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Progression of Central-Peripheral Integration: A Sample Program using the 'Simplify Vestibular' Kit
We’re going to start with a 5-visit progression focusing on the patient’s symptoms of dizziness in busy visual environments, AKA: Visually Induced Dizziness (ViD).
Keep in mind that the sample treatment progressions are not a protocol, but activities customized to the patient. And the activities are based on impairments from the initial evaluation not the patient’s diagnosis of vestibular neuritis.
Quick Glance of Case History44-year-old female with dizziness post-vestibular neuritis
- PMH: previous concussions w/o LOC; migraines (not since mid 30’s); motion sickness as a child but not as an adult
- Denies otologic symptoms, previous spells of vertigo
- Rates health as excellent
- Previous Diagnostics: imaging normal in ED; hearing WNLs; VNG with 28% right caloric weakness
- Symptoms: no longer spinning but dizziness exacerbated by busy visual environments and quick head movements and turns; sometimes feels “drunk-like”; eye fatigue; decreased concentration
Summary of Initial Eval Findings
- DHI Screen: 22/40
- Neuro Screen: normal (tone; coordination; smooth pursuit and saccades)
- Gross MMT: WNLs
- Gross ROM: WNLs for UE/LE. Cervical ROM: WNLs with reports of “tightness” at end range rotation.
- Eye ROM: WNLs; Ocular Alignment: (+) esophoria bilat with right > left;
- Vergence: Impaired eye teaming (NP convergence) – left eye breaks at 14 cm
- Static Balance: normal for tandem, single leg stance, and Romberg on firm. Romberg on foam x 14 sec
- Functional Gait Assessment: 24/30
Clinical Rationale – specific to this patient
- 1st visit:
- Binasal Occlusion (BNO) glasses: to promote stimulation for eso (nasal) deviating eye(s) to turn out, decrease demand of binocular integration where the fields of both eyes overlap, increasing available processing & awareness in the periphery, and stabilizing visual-spatial perception (Gallop, 2013)
- Starting on a firm surface on a firm surface to promote increased use of somatosensory inputs for balance. Research shows a decrease in somatosensory inputs and an overreliance on visual cues in those with visually induced dizziness post-neuritis (Cousin et al, 2014)
- 2nd visit: stayed with BNO but decreased base of support & increased duration of activity
- 3rd visit: Discontinued BNO but added glow sticks to promote peripheral awareness. Continued to narrow base of support (BoS) but increased demand of multisensory processing by adding metronome
- 4th visit: Continued to narrow BOS but added cognitive task & increased duration of activity
- 5th visit: Continued with cognitive test and progressed to more unstable surface (on foam) and progressed difficulty of cognitive tasks
Lack of evidence on duration and frequency
- No clear direction of how long or how frequent exercises need to be performed
- It is generally agreed upon to start with more stable surface – don’t sacrifice quality of movement or posture.
- Neuro-rehabilitative vision therapy framework recommends starting with exercises in the peripheral (ambient) visual field.
Take Home Messages
- Keep in mind that studies related to ViD show a decreased use of somatosensory inputs (and sometimes vestibular) with an overreliance on visual cues, especially central (foveal) visual cues
- Think about initiating activities that in a more supportive environment (that promotes somatosensory and the cerebellum) and gradually increase the difficulty
- Consider starting therapies with an emphasis on what is happening in the periphery (ambient) vs central visual field (foveal)
- Share your story…research and clinical
Progression of Vestibular Ocular Reflex (VOR) Training: A Sample Program
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