The head and eye movements initially provokes dizziness.

To improve patient adherence,

adaptation exercises should start with minimal stimuli and gradually be made more challenging.
An adaptation response can be triggered by as small a stimulus as a retina slip, the movement of a
visual image across the retina. This can be progressed by varying visual input and/or head and
body Movement and continually reorienting to one's head position in space. Adaptation exercises
can incorporate movements called X 1 (times one) and X 2 (times two) viewing. X1 viewing
involves keeping the eyes fixed on a stationary visual target while the subject moves the head back
and forth, and up and down (Fig. 13-20, A). x 2 viewing involves maintaining visual fixation on a
visual target when head and target move in the same or opposite directions (Fig. 13-20, B). These
these exercises can be performed sitting,standing, or walking and may involve horizontal or
vertical movements progressing from small to large and from slower to faster.
Tips for adaptation Exercises
Exercise 1-2 minutes to patient tolerance but provoke symptoms.
Change the frequency of the movement and the range of head movement.
Exercise can be completed in the dark using mental imagery-gains will occur, but not to
the same extent s with actual head and eye movement.
Exercises should stress the patients ability and be guided by the patients ability to
manage symptoms and keep the target in focus.

When the vestibular system is not working well, balance can require compensation with
increased use of the other sensory systems, either vision or somatosensation or both, as discussed
in the section on sensory training. Compensation specifically directed toward dysfunction of the
VOR includes use of a number of possible strategies (Table 13-6).
Gaze stabilization exercises can be used to help patients learn to keep an image on the fovea
during head movements. These exercises are designed to decrease eye saccades during head
movement and to compensate by moving the eyes either before or after the head moves. Different
patients will prefer different strategies so it is best to provide situations and gaze stabilization
exercises and let patients choose their own strategy. Gaze stabilization strategies are appropriate
for both training and compensation. They can be used if the VOR is unlikely to return, as with
bilateral vestibular loss, as well as in the initial stages of an acute unilateral lesion when a patient
is too symptomatic to tolerate adaptation exercises. Exercises may start with X 1 viewing (see Fig.
13-20), as in adaptation exercises, for less than a minute with the client sitting, and the visual
target placed on a plain background. Exercises can be progressed by increasing the distance
between targets or the complexity of targets. Only a few patients with bilateral vestibular loss may
eventually tolerate X 2 viewing.
Table 13-6 Compesantory Strategies for Vestibulo-Ocular Reflex Dysfumction
Alternative Strategy

Technique

Cervico-ocular reflex

Very slow head movements, may allow eyes to

compesate

Saccade modification

Using saccades as a compesantory strategy,

move eyes then head between 2 targets.

Create predictable task

Central preprogramming is possibel if it is a

predictable task.
Visual tracking

Use visual tracking to mantain gaze stability

during head movement.

Visual fixation

While salking, patient fixates on object 20-30

feet away. Once past the object, the patient
picks another object and continues to mantain
visual fixation.

Move eyes first

When turning, teach patinet to move eyes first,

focus on object, then turn the head, and then the
body, all in the target direction.

Stop

When dizziness strats or imbalance begins, stop

and focus an object. Let symptoms pass before
moving.

Progression of Gaze Stabilization Exercises

Start with a simple target, single letter, or plain business card taped on the wall. While
sitting, have the patient move the head in the direction that it is easiest to focus (side to
side OR up and down) progress to include both motions. If you note corrective saccades
with the exercise, slow the movement.
Using two targets have the patient focus on one with eyes and head aligned, and then
move eyes to the other target without moving the head, focus, then move the head,
keeping the target in focus. Keep targets close enough together that when focusing on one
the other can be seen using peripheral vision.
Use an imaginary target. Have the patient focus on a real target then close the eyes. Teli
the patient to keep the eyes on that target as visualized, have the patient move the head
slightly, still looking at the target. Then have the patient open the eyes and check to see if
he or she has stayed with the target.
Habituation exercises involve repeated exposure to asymptom-causing stimulus or movement
to reduce the pathological response to that movement. These exercises can help with balance in
patients with vestibular hypofunction or BPPV. In contrast to adaptation exercises that use mostly
head and eye movements to learn what altered signals mean, habituation generally focuses on
whole body movements and repeats these until the patient no longer reacts adversely to the
stimuli. The patient is provided with a list of functional motions to rate according to which
motions trigger symptoms: none, some lot The clinan picks a few of the motions that trigger
moderate symptoms. The patient then repeats motions with the goal of eventually generalizing the
lack of symptoms to all functional motions.
Tips for Habituation Exercises
No more than four motions should be selected
Motions should be completed 2 times twice per
Movements should be quick enough and through enough range to produce mild to
moderate but not severe symptoms. Progress speed and range as symptoms resolve
Rest between each mouon for symptoms to stop or calm Symptoms should diminish after

a minute or at least within 5-10 minutes of the routine, if not, regress speed and range
Habituation exercises typically show results within 4 weeks, but are generally continued
for 2 months
orthostatic hypotension should be checked before starting exercises incorporating rapid
changes in height of the head in relation to the heart.

CANALITH REPOSITIONING TREATMENTS OR MANEUVERS

If examination reveals a unilateral vestibular problem consistent with BPPV, the most
effective intervention maybe a canalith repositioning treatment or maneuver. Examination should
reveal which canal requires intervention. Correct canal identification and determination of stability
of the debris, whether it is free-floating, as in canalithiasis or adhering to the cupula, as in
cupulolithi asis, can affect the success tions and speeds of movement should be used for these
different situations. Three basic bedside interventions are used: Canalith repositioning treatments
liberatory maneuvers, and Brandt-Daroff habituation exercises.
Canalith repositioning treatment (CRT also known the Epley maneuver) is used for
canalithiasis of the anterior or posterior canals. The Hallpike-Dix is first performed in the
direction that provokes symptoms, ending in a supine position with the head turned toward the
affected side. This position is maintained for 1-2 minutes, and the clinician slowly rotates the
patient's head through moderate neck extension toward the unaffected side and keeps it there
briefly. Finally, the clinician rolls the patient into side lying with the head turned 45 degrees (nose
down) and then helps the patient slowly sit up.the patient is then fit with a soft neck collar and told
not bend over, lie back, move their head up or down, the head for the rest of the day. Patients are
encouraged to sleep on an extra pillow that evening to keep the head elevated and prevent the
debris from moving back into canal. A modification of CRT designed for the horizontal canal
keeps the patients head in the plane of the horizontal canal. Level with the table; this manuever is
sometimes reffered to as the barbecue roll.
The liberatory manuever developed by Semont et al can be used to treat posterior or anterior
canalithiasis or cupulolithiasis. After the provoking positions is determined the patient is moved to
provoking sidelying position with head turned up and kept in the position for 2-3 minutes. The
patient is then turned to the opposite eardown position with the therapist maintaning the alignment
of the neck on the body; the speed of the movement depends on whether the initial nystagmus
indicated canalithiadis or cupulolithiasis, determined by length of the initial nystagmus. if the
examination suggests the presence of cupulolithiasis, the movement should be rapid to jar the
debris from the cupula. if canalithiasis is suspected, the movement may be slow. To treat the
posterior canal the head is turned toward the uninvolved side and the patient is laid on the
involved side (nose up); to treat anterior canal the head is turned toward the involved side and the
patient laid on the involved side (nose down). Following the maneuver, patients should remain
vertical for the rest of the day and sleep with multiple pillows that might. Initially, individuals
were to remain vertical for 48 hours, including while they slept, and avoid the provoking position
for a week after traetment; such rigid restrictions are now thought to be unnecessary. The
liberatory maneuver is typically preferred over Brandt-Daroff exercises, since it often requires
only single treatment. It is believed this maneuver will float the debris through the canal system to
the common crus.

Brand-Daroff exercises were developed as a particular type of habituation exercises, but now are
thought to help dislodge or refloat debris out of the semicircular canals. They have the advantadge
that patients can perform them on their own as a home program, perhaps after a liberatory
maneuver is performed in the office. For these exercises the patient moves rapidly from sitting
into the semi-sidelying potitions that causes their vertigo and holds that position until the vertigo
stops or diminishes. The patient then sits up again rapidly and stays sitting for 30 seconds (Fig 1321). Patient are generaly instructed to performed these movements ten times every 3 hours until
patients have no episodes of vertigo for 2 consecutive days.
Tips for Canalith Repositioning Treatment
Identify involved canal.
Determined if the patient has canalithiasis or cupulolithiasis
Consider any precautions for neck movement or joint protection.
Instruct the patient on what to expect during and after treatment.
MULTIDIMENSIONAL OR MULTIFACTORIAL TRAINING
Multiple risk factors and multiple problems contribute to most individuals' falls. Therefore it
can be important to target interventions toward multiple factors simultaneously. Multifactorial
interventions normally include gait training, strengthening programs, balance training, training in
appropriate assistive device use, review of health management (monitoring blood pressure,
numbers and types of medications, vision correction, and assessment of dementia) and
environmental assessment or modification, including a home safety evaluation and patient and/or
caregiver education regarding fall risk. Programs are targeted to the specific areas identified in the
examination. Several studies have shown that falls can be prevented through appropriately
targeted examination and implementation of multidimensional interventions. These interventions
have been tested in individual and group settings, with community-dwelling elderly, home bound
elderly, and nursing home residents and in care settings. Most of the studies report similar
components to their interventions (Table 13-7).
To assess the effects of a multidimensional exercise program on balance and mobility, ShumwayCook and colleagues conducted a prospective clinical investigation with 105 community-dwelling
older adult jects were divided into 3 groups: Control group, fully adherent exercise and a partially
adherent exercise group. Although both exercise groups showed a reduction in fall risk, the fully
adherent exercise group decreased their fall risk by 33% compared to the partially adherent
exercise group, which reduced their fall risk by 11%. The control group showed an 8% increase in
fall risk.
Table 13-7 Components of multidimensional Balance training
Exercises and Progression
Balance exercises
Sitting
Standing
Walking

Activities
Balance recovery
Using sensory information for postural
orientation (center alignment)
postural
adjusment
Anticipatory
activities

Mobility retraining
Unperturbed gait
Perturbed gait
Transfers
Stail Climbing
SPESIFIC EXERCISES AS DETERMINED
BY THE THERAPIS BASED ON
IMPAIRMENT
Weakness
Fatigue
Limited ROM

Integration of sensory and motor

strategies for posture and balance
control
Functional activities
Various light conditions
No distractions-distractions
Variety of surfaces
With and without head movements
With and without cognitive tasks

Strengthening
Endurance training
Stretching

Interestingly, these researches found that age, gender, number of medications, number of comorbidities, living situation, performance of clinical measures of balance and mobility (other than
Tinetti's POMA), frequency of imbalance, and fall history did not limit their subjects' positive
responses to exercise. A multidimensional intervention can thus reduce falls and improve balance
for a variety of patients. The only variable that emerged as a predictor for exercise adherence was
the type of assistive device used for gait: Patients who used a walker as the primary assistive
device for gait were less likely to follow through with exercises than those who used a cane or no
assistive device.
Rose noted the importance of fostering problem-solving skills to achieve balance and
function versus training specific transfer and gait skills to improve balance and reduce falls Her
program focused on manipulating task goals and performance environments to develop a
repertoire of postural strategies that could be adapted to various demands. Three core ingredients
were (1) COG control training, (2) strategy training, and (3) multisensory training. This
intervention primarily focused on a technology based activities utilizing a support surface that
could be computer programmed, but similar situations can be set-up in a standard clinic as
evidenced in other studies.
Hart-Hughes et al conducted a study in which a "Fall Clinical Team" provided an
interdisciplinary, specialized, and individualized care plan to 57l veterans at-risk for falls and fallrelated injuries. At the time of discharge and at 3-month follow-up a statistically significant
reduction in the number of falls was reported. In regard to fall prevention, at the start of the study,
19% reported no falls in the 3 months prior; at the end of the study 64% reported no fails in the 3
months prior. It is important to note that in this study, grab bars, shower chairs, and other devices
were recommended to provide a safe home environment. These may have contributed to a reduced
fall rate but are common in multifactorial interventions.
Tinetti et al conducted a study with 301 community dwelling individuals over 70 years of age
with risk factors for falling in which the control group received usual health care plus social visits.

The experimental group received a combination of adjustment in their medications, behavioral

instructions, and exercise programs targeted to their specific risk factors. At a 1-year follow-up,
35% of the intervention group had fallen compared to 47% of the control group (p=0.04). The
execises programs in this interventions consisted of gait or gait or transfer training, as needed, and
a progressive, competency-based balance and strengthening exercise program. Subjects were
instructed to perform the exercises twice a day for 15-20 minutes per session. Intervention lasted 3
months.
Chang et al completed a systematic review and metaanalysis of 61 RCTs on interventions for
the prevention of falls in older adults and concluded that the most effective intervention was a
multifactorial falls risk assessment and management program. They also concluded that
strengthening and balance specific exercise programs were effective in reducing the risk of falling.
The goals of a multidimensional program are (1) to resolve, prevent, or reduce underlying
impairments; (2) to utilize effective and efficient task-specific sensory and motor strategies, and
(3) to adapt and train task spesific strategies allow fucntional tasks to be performed in changing
environmental situations. Challenging multiple systems at the time by challenging the individual
(taking them to the outer limit of stability), changing the environment (darker, uneven surface,
movement around the individuual), adding complexity to the task (reading while walking, doing
multiplication tables while balancing on a Dyna-disc) simulates "lifelike" situations and provides
opportunity for the therapist to train the patient in integration of postural control.
PATIENT. OR CLIENT-RELATED
INSTRUCTION: EDUCATION AND SAFETY
Even if patients have the potential for improving their postural control over time, the risk for
falls may be so great that compensatory strategies will be required. Teach patients to stop, hold
onto a stable surface, and refocus if they feel dizzy or unbalanced. When turning, they should
move their eyes first, focus, and then turn their head and body to help minimize dizziness.
All individuals should be taught to identify safety hazards at home and in the community, for
people poor balance, hazards might include poor lighting uneven surfaces, and visually conflicting
environments. Compensation for such hazards might include using night lights, carrying pocket
flashlights. securing throw rugs, and safely using extension cords. A home safety checklis should
be used to assess environmental hazards and help educate the patient, client, care provider, and/or
family. Safety checklists typically include external factors that impact fall risk but should review
internal factors to heighten awareness of risks.
INJURY PREVENTION OR REDUCTION
A primary focus of fall prevention and balance intervention is to reduce or prevent injury
from falls. The previously mentioned interventions strengthening, ROM general conditioning, use
of assistive devices, sensory and multisensory training, vestibular rehabilitation and patient
education, as well as environmental modification-can all be used to reduce or prevent injury from
falls. Research regarding the effect of external hip protectors on reducing injuries from falls is
equivocal, with some studies suggesting that these are helpful and others reporting no benefit. A
RCT with 561 subjects in the Netherlands, including individuals residing in nursing home as well

as those residing in the community, found that hip protectors did not prevent hip fracture: 4 out of
18 fractures in the intervention group occurred while hip protectors were being worn.
The most important considerations in making home modifications to reduce falls are
modifications of surface lighting, obstacles, and activity in the home (see Chapter 35). Adding
grab bars and other safety devices to bathrooms may help reduce the risk of falls. However, some
evidence suggests that changging a familiar environment may increase the risk of falls for the
elderly, particularly they are used to using furniture in its current location for maintaining balance.