Her areas of special interest include elderly fall

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14 Νοε 2013 (πριν από 3 χρόνια και 5 μήνες)

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Donna received her B.S in Physical Therapy from Bradley
University in 1997. She has completed numerous
continuing education courses related to vestibular and
balance disorders including completion of the coveted
Vestibular Rehabilitation: A Competency
-
Base Course in
2012 co
-
sponsored by the APTA and Emory University.


Her areas of special interest include elderly fall
prevention/rehabilitation and post
-
concussion care of all
ages. She has worked for St.Vincent since 2006.

Speaker: Donna Shotton, PT

St. Vincent Outpatient Rehab Manager

ddshotto@stvincent.org



PT in the area of balance and vestibular rehabilitation for over 10 years


Completed Susan Herdmann vestibular rehabilitation training at
Emory University 2012


Patients With
Balance
Problems


Sensory System Deficits

-

Vestibular, Vision, Proprioception


Geriatric Fall Risk

-

Chronic Non
-
Specific

-

Sensory, CNS, Orthopedic Disorders



Traumatic Brain Injury & Concussion


Medical
-
Legal/Worker Comp


Parkinson’s Disease/Multiple Sclerosis


Neuro
-
Developmental


Equipment


Natus

Medical Inc. (previously
NeuroCom
®


Balance Manager Systems)


Bertec

Balance


Biodex

Balance System


The
SmartStep
™ Gait System


HUR
iBalance

SmartCard



AlterG


Wii

Fit?


PT Practices with
NeuroCom®


St. Vincent Indianapolis

located on W. Carmel Dr.


St. Vincent Anderson Regional Hospital (St. John’s)


St. Joseph
--
Kokomo


Balance Point


Balance Institute of Indiana


Minds in Motion (for children)


Otolaryngology Associates


Indianapolis VA Medical Center


Rehabilitation Hospital of Indiana


Healthplex

Rehabilitation Services


IU Health Neuroscience Center


NeuroCom®

NeuroCom
®

Balance Manager Options


Short force plate


(Basic Balance Master)




Long force plate


(Balance Master)



NeuroCom®


Smart EquiTest

NeuroCom®


inVision



HS
-
SOT (head
-
shake)


PTT (perception time)


DVA (dynamic vision)


GST (gaze stability)






Gaze Stability

Postural Stability

Balance Control

The ability to maintain
gaze or visual focus on
an external target during
movement .


A function of an intact
VOR (vestibulo
-
ocular
reflex) at speeds > 85
degrees/second.

The ability to maintain the
body’s
center of gravity

(COG) over the
base of
support

(BOS) in a given
sensory environment
.


Gaze Stability

Postural Stability

Visual

System

Vestibular

System

Somato
-

Sensation

Lighting;

movement of self or
environment



Gravity;

Linear & Angular

Head and Eye
Movement


Surface changes &
irregularities; BOS
changes

Environmental

Interaction

Sensory weighting is task
-
dependent in
normal

individuals

WEIGHTING

Stable Surface


70% SOM


20% VEST


10% VIS

RE
-
WEIGHTING

Unstable Surface


60% VEST


30% VIS


10% SOM

Peterka, R. and P. Loughlin (2004). "Dynamic regulation of sensorimotor integration in human postural control."
J
Neurophysiol

91: 000
-
000; adopted from Horak 2003

NeuroCom®

Computerized Dynamic Posturography

(CDP) was developed
by NeuroCom
®

with initial support from NASA to evaluate
the effects of space flight on
vestibular

function and
balance control in astronauts.


A scientific framework for understanding the control of
balance & postural stability



Objective method for quantifying impairments in use of
sensory inputs, use of motor patterns, and central
adaptation





NeuroCom Tests



CDP (Computerized Dynamic Posturography)


SOT

Sensory Organization Test


MCT
---
Motor Control Test


ADT


Adaptation Test



Limits of Stability


HS
-
SOT

head shake


Rhythmic Weight Shift


Unilateral Stance


Fixed


Surface

Sway
-
Referenced


Surface

Normal

Vision


Eyes

Closed

Sway
-
Referenced


Vision

Sensory Organization Test

(SOT)

1

2

3

4

5

6

SOT Information


Is there a sensory
balance problem?


Which sensory
system(s) are impaired?


Are there secondary
problems?


Movement strategies


COG awareness

“Patient presents with dizziness and imbalance


all diagnostic testing is normal”















69 year old librarian

s/p successful CRP

Inability to safely perform his
volunteer job duties

Problems on unstable
surfaces (4,5,6)

Problems when
vision

absent or
conflicted (2,3,5,6)

26 year old female s/p whiplash

In the medical system for neck pain

Working full time















75 year old skier

Frustrated that he is unable to
return to his sport

Problems on unstable surfaces with
vision absent (5)

Problems on unstable surfaces with
altered or absent vision (5,6)

35 year old pilot

Dizziness after flight; Grounded
from the flight schedule


“Patient presents with dizziness and imbalance


all diagnostic testing is normal”

Generation of

Body Movement

Voluntary Movements

Intentional & Self
-
initiated
Movement




Slow
(> 200 milliseconds)



Slower if task is complex or if
novice



Improved by instruction




Variable performance



Given patient



Given group of patients

Safe limits & control

Generation of

Body Movement


Reflexes

Vestibulo
-
Ocular Reflex

What it is
: The vestibular ocular reflex
(VOR) system reflexively drives eye
movements in a direction that is
equal & opposite those of the head

The
purpose
: maintain gaze on an
external target during movement
(dynamic visual acuity)

The
problem
: when the VOR system is
impaired, gaze stability is impaired,
and visual acuity degrades during
head movements.


DVA
: Is visual acuity maintained during active head
movement?


GST
: At what head movement velocity does gaze
stabilization break down?


Is the problem isolated to one movement direction?


Can the patient simultaneously maintain balance &
gaze stability?

Dynamic Visual Acuity (DVA)

Gaze Stabilization Test (GST)

Examining VOR
Function

Dynamic Visual Acuity (DVA) test

Gaze Stabilization test (GST)


Stimuli
:

1.
Variable target size at a defined head speed

2.
Variable head movement speeds while
viewing defined visual target (optotype)




Response
:


Accurate recognition of optotype
orientation/direction (visual acuity)



Findings
:

1.
Static and dynamic visual acuity measures for
right/left and vertical head movements

2.
Speeds to which subjects can maintain
accurate visual acuity for function


Synthesis of

Multiple Examination items

Horak FB. Postural orientation and equilibrium: what do we need to know about
neural control of balance to prevent falls?
Age and Ageing.
2006;35(Suppl 2):ii7
-
ii11.

Clinical Examination of Balance:

Bertec Balance


Virtual reality is being used to disrupt vision during SOT
conditions 3 and 6. Visual flow is being used to disrupt
vision during training.


Images at CSM were a virtual islands, piloting an airplane
and a black/white checkerboard room.


Standard software for visual flow on the production units
will be grocery store aisles, busy street corners and other
real life environments that clinicians tell us their patients
struggle with (possibly stepping onto a down escalator,
glass walled elevator, etc.). Systems will also allow for some
freedom to


create or add visual environments in the clinic.

Bertec Balance


Features will include a 4” platform for easy, safe access by
patients; operator touch screen, a clean, dedicated patient
monitor to improve compliance by low vision and visually
sensitive patients, good audio cues during testing and
treatment, safety harness and a wireless printer.


Software will include
SOT/MCT/ADT/RWS/LOS/Unilateral Stance/WBS.
Training includes seated, weight shifting, mobility, closed
chain. There are no levels to training so setting up a session
for a patient is quick and easy. Patient history files are
found on the patient record for easy access during any
session.


Biodex Balance

Biodex Balance


Static and Dynamic (SD)



Offers twelve levels of platform control as well as static force
setting


allows testing, training and rehabilitation programs for diverse populations.


Six Training Modes and Five Testing Protocols



Standardized testing for true
progress assessment.


Standardized Fall



Screening and Athlete Knee Injury Screening


Tests


Test results are compared to age
-
based normative data to help identify fall
candidates and athletes predisposed to knee injury.


Normative Data



Healthy populations stored for test comparison of older adults for fall
screening and student athletes for concussion management.


Large Display



Features 12.1" touch
-
screen display, powered by a Windows CE
operating system.


Expanded Connectivity



Allows connection to larger monitors and LCD projectors to
enhance interaction for visually impaired patients.


Adjustable Support Handles



Lock in place for safety or swing away for an
unobstructed, open environment for a variety of training activities.


Mobility



Transport wheels allow easy relocation between clinic and community for fall
screening programs and health fairs.


The SmartStep Gait System


Andante Medical Devices

Ltd., an Israeli company,
provides the following info about its technology:


The SmartStep™ is composed of three main
components:



A force
-
sensing insole that is flexible, lightweight,
ergonomically designed.



A miniature microprocessor control unit



Computer software for analysis, display and storage
of patient performance.


The SmartStep Gait System

The SmartStep Gait System

The SmartStep Gait System


Gait Pattern Analysis
: The SmartStep application
graphically displays an analysis of patient’s data,
including weight bearing, velocity, cadence, and the
correct timing of gait.

The SmartStep Gait System


Feedback training
: The control unit can be
programmed to provide the patient with real
-
time
auditory indications of correct or incorrect gait
performance according to the specific patient’s
prescribed regime. Feedback training in the clinic or at
home guides patients as they strive for correct posture,
motion and function.

HUR iBalance Smart Card


HUR Health And Fitness Equipment
provides

strength exercise machines

and
balance testing platforms
to implement
effective and measurable active aging
programs to promote independence,
mobility,

fall prevention
and

incontinence

reduction.

HUR iBalance Smart Card


HUR iBalance Smart Card
: Smart Card virtual
testing/training system


Smart Card technology acts as


a "Virtual Trainer"


Interface with HUR Smart Card


Strength Equipment


Easy
-
to
-
use touch screen


Designed for senior housing or


physical therapy centers with HUR


SmartCard machines


Standardized Balance Tests & 5 Interactive Training modes


They have a portable unit that weighs 18 lbs.

2 balance tests








AlterG

AlterG
--
locations


St. Vincent Physical and Occupational Therapy


1185 Carmel Drive, Carmel


St. Vincent Sports Performance


8227 Northwest Blvd, Indy


Kindred Rehab at Bridgewater


Carey Road, Carmel


Indiana Orthopedic Hospital


6040 W. 84
th

St., Indy


Hendricks Regional Hospital


Avon


Heritage Healthcare


West Lafayette


Canterbury Nursing

Fort Wayne


Ashton Creek Healthcare

Fort Wayne



AlterG


Originally conceived by Dr. Whalen to design effective exercise
regimens for NASA’s astronauts
--

Differential Air Pressure (DAP)
technology has been adapted by
AlterG

for use in training and
rehabilitation. Cleared by the FDA in 2008, the
AlterG

M320 Anti
-
Gravity Treadmill is a medical device that can be used for:


Rehabilitation of lower extremity injuries


Treatment of neurological conditions


Weight reduction


Aerobic conditioning


General training to combat the diseases of aging


Unweighting

is achieved in the
AlterG

by using air in a pressure
-
controlled chamber to gently lift the user. Precise calibration using our
patented technology allows for very specific
unweighting

from 100
-
20%
of the users body weight in 1% increments.

Something no other
unweighting

modality can do.


AlterG


The AlterG LiftAccess



Shorts

AlterG


Endurance

-

walking strengthens muscles and
improves the health of the heart and circulatory
system


Strengthening

-

increase muscle tissue mass and
decrease age
-
related muscle atrophy


Range of Motion



keep the body flexible and
maintain good joint health


Balance



reduces the likelihood of falls by training in
a controlled environment



Wii Fit/Fit Plus

Wii Fit/Fit Plus

References:


NeuroCom
:


www.resourcesonbalance.com


Click on Bibliography for their extensive references.


Bertec

Balance:


www.bertec.com


Click on Documents, then select Research Papers.


Biodex

Balance:


www.biodex.com


Under Products, select Balance then Balance System SD. On
the right hand side under Resources, select
Biobliography
,
Balance System SD.

References:


The
SmartStep

Gait System:


www.andante.co.il


Click on Clinical Studies



HUR
iBalance

SmartCard


www.hurlabs.com


Couldn’t find list of resources on the site



AlterG


www.alterg.com


Click on Clinical Data from the menu on the left



Wii

Fit