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Compenso vestibolare
Attivazione di funzioni complementari che si sovrappongono alle funzioni di equilibrio compromesse. Comporta la scomparsa delle asimmetrie statiche e dinamiche nelle risposte oculari e spinali indotte dalla lesione. Possono intervenire interazioni sostitutive visive e propriocettive.
Recupero funzionale
Restituzione: riparazione completa del danno
Adattamento: modificazione della sensibilità dei recettori
periferici da parte del SNC
Assuefazione: riduzione dell’intensità e della durata delle
reazioni vestibolari soggettive provocate da mismatch
sensoriali. E’ un fenomeno centrale di inibizione della
percezione di stimoli che non hanno significato per il
controllo dell’equilibrio o che sono dannosi
Recupero Funzionale Vestibolare:scopi
n Indurre sostituzione sensoriale aumentando l’input visivo e propriocettivo e modificando il gain del riflesso vestibolare
n Supportare il compenso centrale attraverso la plasticità del sistema vestibolare
n Incoraggiare la mobilizzazione dei segmenti corporei e l’equilibrio statico e dinamico
n Promuovere l’habituation alle vertigini e all’instabilitàn Rimuovere le componenti psicologiche
Esempio compenso lesione acuta monolaterale
ü Inibizione internucleareü Shut-down cerebellareü Ricalibrazione dei sottosistemiü Sostituzione sensoriale (sostituzione saccadica, COR, ecc.);
dipende dalla preferenzialità sensoriale del soggettoü Ristrutturazione comportamentale (se lasciata a se stessi spesso
patologica con evitamenti, fobie, ecc.)
Compenso vestibolare
Porta a diversi livelli di recupero:
ü Sostituzione funzionale: stesso sottosistema riorganizzato, stesso pattern motorio
ü Sostituzione sensoriale: cambia il sottosistema senso-motorio, stesso pattern motorio
ü Sostituzione comportamentale: nuovi comportamenti motori (ristrutturazione)
Evoluzione della lesione
n Danno primario (lesione iniziale)
n Danno secondario (in caso di compenso patologico)
n Danno terziario (cronicizzazione dei fenomeni adattativi patologici)
PERCHÈ ALCUNI SOGGETTI COMPENSANO E ALTRI NO, ANCHE A RELATIVA PARITÀ DI DANNO?
Restor Neurol Neurosci. 2010;28(1):83-90.Management of the patient with chronic dizziness.Bronstein AM, Lempert T.Neuro-otology Unit, Division of Neuroscience and Mental Health, Imperial College London, Charing Cross Hospital, London, UK. [email protected]
In this review we present a pragmatic approach to the patient with chronic vestibular symptoms. Even in the chronic patient a retrospective diagnosis should be attempted, in order to establish how the patient reached the current situation. Simple questions are likely to establish if the chronic dizzy symptoms started as benign paroxysmal positional vertigo (BPPV), vestibular neuritis, vestibular migraine, Meniere's disease or as a brainstem stroke. Then it is important to establish if the original symptoms are still present, in which case they need to be treated (e.g. repositioning manouvres for BPPV, migraine prophylaxis) or if you are only dealing with chronic dizzy symptoms.
Restor Neurol Neurosci. 2010;28(1):83-90.Management of the patient with chronic dizziness.Bronstein AM, Lempert T.Neuro-otology Unit, Division of Neuroscience and Mental Health, Imperial College London, Charing Cross Hospital, London, UK. [email protected]
In addition the doctor or physiotherapist needs to establish if the process of central vestibular compensation has been impeded due to additional clinical problems: - visual problems (squints, cataract operation), - proprioceptive deficit (neuropathy due to diabetes or alcohol), - additional neurological or orthopaedic problems, - fear of falling or psychological disorders. - neurological gait disorder. Treatment of the syndrome of chronic dizziness is multidisciplinary but rehabilitation and simple counselling should be available to all patients. In contrast, vestibular suppressants or tranquilisers should be reduced or, if possible, stopped.
Curr Med Res Opin. 2006 Sep;22(9):1651-9.Restoration of vestibular function: basic aspects and practical advances for rehabilitation.Lacour M.Université de Provence/CNRS, Marseille, France. [email protected]
FINDINGS: Static deficits, following the loss or disruption of vestibular functions, are fully compensated; this is explained by the vestibulo-centric theory that suggests different plastic changes occurring in the vestibular nuclei complexes. In contrast, dynamic deficits remain poorly compensated; the restoration of dynamic vestibular functions results from substitution processes and vicarious strategies. The practical advances in the rehabilitation of vestibular defective patients are as follows:
(1) perform rehabilitation at an early stage;
(2) favour active retraining;
(3) do not use stereotyped rehabilitation programs but adapt exercises to the patients;
(4) examine patients in standardized environments;
(5) use both static and dynamic tests;
(6) avoid drugs with sedative effects (or limit them to the very acute stage only) and prescribe those accelerating the recovery process (e.g. betahistine dihydrochloride).
CONCLUSION: Recovery of vestibular function is greatest when early active retraining and adequate pharmacological treatments are used in combination.
J Neurol. 2008 Oct;255(10):1479-82. Epub 2008 Jul 11***Vestibular neuritis: vertigo and the high-acceleration vestibulo-ocular reflex.Palla A, Straumann D, Bronstein AM.Neurology Department, Zurich University Hospital, Frauenklinikstrasse 26, 8091 Zurich, Switzerland.
. Patients after vestibular neuritis (VN) often report persistent dizziness and disequilibrium. We correlated persistent symptoms with sustained impairment of the high-acceleration horizontal vestibulo-ocular reflex as determined by quantitative searchcoil head-impulse testing (qHIT). In 47 patients, qHIT was recorded 0-60 months and symptoms assessed with the Yardley Vertigo Symptom Scale short form > or = 18 months after VN onset. No correlation between the magnitude of high-acceleration vestibular impairment and the severity of vertigo symptoms was observed. The lack of a symptom-qHIT correlation suggests that defective compensation at a more rostral level in the central nervous system may be responsible for protracted symptoms in VN patients.
Different opinions about weight, body image and physical exercise
MOTIVAZIONE!!!
It is never too late to start playing!
Laryngoscope. 2002 Oct;112(10):1785-90.The effect of age on vestibular rehabilitation outcomes.Whitney SL, Wrisley DM, Marchetti GF, Furman JM.Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, USA. [email protected]
RESULTS: During the initial evaluation, older adults reported having statistically greater space and motion discomfort and more severe symptoms on a scale of 0 to 100. Younger adults had more impaired DGI scores and a higher proportion of caloric testing abnormalities. After rehabilitation, overall improvement was seen in both the younger and older populations. There were no statistical differences between the two groups on the DHI, the DGI, reported symptoms at discharge, or number of falls. When only the complete matched-pair data were analyzed, there were no statistically significant differences between the age groups in the proportion of patients demonstrating clinical improvement.
CONCLUSION: Age does not significantly influence the beneficial effects of vestibular rehabilitation for persons with vestibular disorders.
Balance disorders caused by vestibular deficit
“Given the high prevalence among the elderly, and the extraordinary costs associated with falls (exceeding $20 billion annually), screening for vestibular dysfunction could be a life-saving and cost-effective practice.”
Se sintomi vestibolari: rischio di caduta aumenta di 12 volte
Rieducazione Vestibolare
Definizione:
Quando la disabilità è provocata da una disfunzione (danno quantitativo ma organizzazione centrale efficiente) l’intervento terapeutico è finalizzato alla sua correzione riorganizzando le funzioni residue del paziente.
Riabilitazione Vestibolare
Definizione:
Quando la disabilità è provocata da una lesione periferica o centrale del SNC l’intervento terapeutico è finalizzato alla ristrutturazione completa del sistema ottenendo il recupero funzionale attraverso il superamento della disabilità, anche mediante ausili protesici e correzioni dell’ambiente.
Indicazioni al training vestibolare
üLesioni vestibolari stabili con compenso assente o incompletoüLesioni centrali o miste (periferiche e centrali)üTraumi cranici (esiti)üVertigine psicogena lieve (approccio somato-psichico)üPresbiastasia, prevenzione delle caduteüDisturbi dell’equilibrio di ndd (approccio empirico)üLabirintolitiasi (residual dizziness persistente)üLesioni vestibolari instabili (prehab, habituation)
Scopi del training vestibolare
üAumentare la stabilità dello sguardoüAumentare la stabilità posturale statica e dinamicaüRidurre i sintomi vertiginosi propriamente dettiüMigliorare lo svolgimento delle ADL
VESTIBULAR TRAINING
Basics of vestibular training exercises:
Rapid head movements in yaw, roll and pitch, eyes open/closed, with fixation or not Standing and walking on firm or uneven surfaces, head still or moving, eyes open/closed, fixating or not
Standing on steady or sway-referenced platform, eyes open with sway-referenced moving landscape
Saccadic, smooth pursuit and/or full-field optokinetic stimulation on firm or unstable surfaces
Principi di terapiaPostural Compensation for Vestibular LossFay B. Horak
Vestibular rehabilitation should focus on: n decreasing hypermetrian decreasing an overdependence on surface
somatosensory inputs n increasing use of any remaining vestibular function n substituting or adding alternative sensory feedback
related to trunk swayn practicing challenging balance tasks on unstable
surfaces (mid freq.)
