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Background: Asymmetric vestibular function, decreased plantar sensation, postural control and functional ability have been associated with fall-related wrist fractures., Objective: To investigate whether multi-sensory training (MST) improves postural control, vestibular function, foot sensation and functional ability among people with fall-related wrist fractures compared to wrist stabilization training (WT)., Methods: This was an assessor-blinded, randomized controlled trial. Ninety-eight participants, age 50-75 years, were randomized to MST or WT. Pre- and post-training measurements: Head Shake Test (HST), Video-Head Impulse Test (vHIT), Semmes-Weinstein Monofilaments (SWF), Biothesiometer (BT), Sensory Organization Test (SOT), 10-m Walk Test (10MWT), Five Times Sit to Stand Test (FTSTS), Activities-Specific Balance Confidence (ABC) and Dizziness Handicap Inventory Scales (DHI). The training period was 12 weeks, with six supervised sessions by a physical therapist and daily home exercises for both groups., Results: There were significant endpoint differences in SOT (p = 0.01) between the two groups, in favor of the MST group, but no changes were seen in other outcome variables. Subgroup analysis with participants below normal baseline SOT composite scores indicated that the MST was more effective in improving 10MWT fast (p = 0.04), FTSTS (p = 0.04), SWF (p = 0.04) and SOT scores (p = 0.04) than the WT., Conclusions: MST improves postural control among people with a fall-related wrist fracture. The results further suggest that the program is more effective for those with SOT balance scores below age-related norms.

Background: Standardized instruments for measuring the intensity of balance exercises in clinical environments are lacking., Objective: The objective of this study was to develop a method for quantifying the perceived intensity of standing balance exercises., Design: A test-retest study design was used, with repeated evaluations within the same visit and between visits 1 week later., Methods: Sixty-two participants who were healthy and 18 to 85 years old (with a mean age of 55 years [SD = 20 years]; 50% women) were enrolled. On each of 2 visits, they performed 2 sets of 24 randomized static standing exercises consisting of combinations of the following factors: surface, vision, stance, and head movement. Postural sway was measured with an inertial measurement unit, and ratings of perceived difficulty (RPD) were recorded using numerical and qualitative scales. The RPD scales were validated against the quantitative sway measures using a general linear model approach. The test-retest reliability of the RPD scales was examined using a weighted kappa coefficient., Results: Both RPD scales were associated with postural sway measures with correlation coefficients > 0.6 for the whole sample. The test-retest reliability of the ratings varied considerably across the different balance exercises, and the highest weighted kappa values occurred for RPD scores on the numerical scale within the second visit, as moderate agreement was achieved in 18 of the 24 exercises., Limitations: The limitations are that the RPD scales need to be validated for other types of balance exercises and in individuals with balance disorders., Conclusions: The RPD scores correlated with the magnitude of postural sway, suggesting that they can be used as a proxy measure of perceived intensity of balance exercises., (© 2019 American Physical Therapy Association.)

Background and Purpose: Many interventions to improve mobility in older adults often include exercises to address underlying impairments such as strength deficits. Task-oriented exercise interventions that focus more on walking and stepping tasks that may be encountered in the community have been considered for improving mobility in older adults. The main purpose was to examine the effect of task-oriented and impairment-based group exercise interventions on standing balance and lower extremity muscle strength., Methods: This is an ancillary study to a cluster-randomized clinical trial. Participants included 107 older adults. Participants were randomized by facility to 1 of 2 different interventions, or a waitlist control group. The On the Move (OTM) task-oriented intervention consisted of warm-up, timing and coordination (stepping and walking patterns), strengthening, and stretching exercises. The standard of care impairment-based exercise intervention (STD) consisted of warm-up, strength, endurance, and stretching exercises. Postural sway and balance measures were recorded before and after the 12-week interventions. An accelerometer was used to collect postural sway for 6 different standing balance conditions. A portable load cell was used to assess lower extremity muscle strength for 3 muscle groups., Results and Discussion: The OTM group had a significant reduction in sway acceleration during most of the balance conditions over the 12-week period, whereas the STD had smaller, nonsignificant reductions. Both exercise interventions had a significant reduction in sway compared with the waitlist control group in at least 1 balance condition. The OTM and STD groups had significant increases in hip abduction strength during the intervention and the STD group also had an increase in knee extension strength. The waitlist group had a significant reduction in strength in all muscle groups during the 12-week period. Strength changes in both exercise groups were significantly different from the waitlist group but not from each other., Conclusion: Both exercise intervention groups had an improvement in standing balance and lower extremity strength when compared with a waitlist group that did not receive exercise. Although the exercise groups did not significantly differ from each other, the OTM exercise group showed a trend toward improvement in static standing balance conditions.

Frequent falls in people with cerebellar ataxia (CA) is a significant problem Therefore, an intervention that could improve balance and reduce the number of falls is of paramount importance from the patients' perspective. Combining cognitive training with physical training to improve balance is a new approach for reducing the risk of falls in patient populations who are at risk for falls. To determine if adding structured cognitive demands to conventional balance and coordination training we designed the Cognitive-coupled Intensive Balance Training (CIBT) program. We found that the more intensive and focused CIBT intervention reduced dual-task cost, improved balance, and reduced the number of falls in a sample of individuals with CA. We hypothesize that (1) CIBT will improve balance and reduce falls; and (2) CIBT will be a cost-effective treatment option for improving balance and reduce falls. To test these hypotheses, we propose conducting a randomized controlled trial (RCT) with economic evaluation . This paper reports the findings of our study testing the feasibility of the CIBT program, rationale for testing our hypothesis and an overview of our future study design to test the effectiveness and cost-effectiveness of the CIBT program., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Compared to in-clinic balance training, in-home training is not as effective. This is, in part, due to the lack of feedback from physical therapists (PTs). In this paper, we analyze the feasibility of using trunk sway data and machine learning (ML) techniques to automatically evaluate balance, providing accurate assessments outside of the clinic. We recruited sixteen participants to perform standing balance exercises. For each exercise, we recorded trunk sway data and had a PT rate balance performance on a scale of 1-5. The rating scale was adapted from the Functional Independence Measure. From the trunk sway data, we extracted a 61-dimensional feature vector representing the performance of each exercise. Given these labeled data, we trained a multi-class support vector machine (SVM) to map trunk sway features to PT ratings. Evaluated in a leave-one-participant-out scheme, the model achieved a classification accuracy of 82%. Compared to participant self-assessment ratings, the SVM outputs were significantly closer to PT ratings. The results of this pilot study suggest that in the absence of PTs, ML techniques can provide accurate assessments during standing balance exercises. Such automated assessments could reduce PT consultation time and increase user compliance outside of the clinic.

Purpose of Review: Rehabilitation for persons with vertigo and balance disorders is becoming commonplace and the literature is expanding rapidly. The present review highlights recent findings of both peripheral and central vestibular disorders and provides insight into evidence related to new rehabilitative interventions. Risk factors will be reviewed to create a better understanding of patient and clinical characteristics that may effect recovery among persons with vestibular disorders., Recent Findings: Clinical practice guidelines have recently been developed for peripheral vestibular hypofunction and updated for benign paroxysmal positional vertigo. Diagnoses such as persistent postural-perceptual dizziness (PPPD) and vestibular migraine are now defined, and there is growing literature supporting the effectiveness of vestibular rehabilitation as a treatment option. As technology advances, virtual reality and other technologies are being used more frequently to augment vestibular rehabilitation. Clinicians now have a better understanding of rehabilitation expectations and whom to refer based on evidence in order to improve functional outcomes for persons living with peripheral and central vestibular disorders., Summary: An up-to-date understanding of the evidence related to vestibular rehabilitation can assist the practicing clinician in making better clinical decisions for their patient and hopefully result in optimal functional recovery.

Vestibular rehabilitation is an exercise-based program that has been in existence for over 70 years. A growing body of evidence supports the use of vestibular rehabilitation in patients with vestibular disorders, and evolving research has led to more efficacious interventions. Through central compensation, vestibular rehabilitation is able to improve symptoms of imbalance, falls, fear of falling, oscillopsia, dizziness, vertigo, motion sensitivity and secondary symptoms such as nausea and anxiety. Early intervention is advised for falls prevention and symptom management; however, symptomatic patients with chronic vestibular disorders may still demonstrate benefit from a course of vestibular rehabilitation. Recent advances in balance and gait training, gaze stability training, habituation training, use of virtual reality, biofeedback, and vestibular prostheses are discussed in this chapter in the context of unilateral and bilateral vestibular disorders., (© 2019 S. Karger AG, Basel.)

Balance problems and frequent falls are common among clients with Cerebellar Ataxia (CA). CA is not a disease by itself but a collection of symptoms due to the involvement of cerebellum or its pathways. Presently the treatment for balance problems for CA is not standardized. Interventions available to improve balance are not specific to symptoms presentation. Functionally the cerebellum is divided into the spinocerebellum, vestibulocerebellum and corticocerebellum. Each functional zone has a distinct role in maintaining balance. Therefore, the presentation of symptoms will vary according to the functional zone involved. Pre-screening clients with CA for identifying the part of cerebellum involved will facilitate clinicians to provide tailor-made interventions for targeting specific symptoms for better outcomes. Pre-screening clients with CA according to the part of cerebellum involved is not in practice and our study will introduce this concept. We hypothesize pre-screening participants with spinocerebellar ataxia (SCA) for the involvement vestibulocerebellum followed by prescribing vestibulocerebellum targeted exercises will have better outcomes when compared to conventional balance training. We plan to conduct two related studies. In study 1 we will screen participants with CA for the involvement of vestibulocerebellum. In study 2, the effects of vestibulocerebellum targeted balance exercises on balance will be studied. We will assess the Subjective Visual Vertical (SVV) deviation and postural sway pattern to screen participants into people with and without vestibulocerebellar involvement. SVV deviation will be estimated using a computerized Subjective Visual Vertical (cSVV) device and postural sway pattern will be assessed using the limits of stability program of the Bertec© Balance system. The obtained SVV deviation scores will be used to derive at cut-off scores to discriminate clients with and without vestibulocerebellar involvement. The second study will test the treatment effects of conventional exercises plus vestibulocerebellum targeted exercises to improve balance by correcting SVV deviation in SCA with vestibulocerebellar involvement. The intervention is planned as 12 one-to-one sessions over three months period. Participants will be reassessed after the intervention and 3 months post-intervention. The findings of this cutting-edge research are extremely important to the clinicians, researchers and clients with SCA., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Sensory augmentation has been shown to improve postural stability during real-time balance applications. Limited long-term controlled studies have examined retention of balance improvements in healthy older adults after training with sensory augmentation has ceased. This pilot study aimed to assess the efficacy of long-term balance training with and without sensory augmentation among community-dwelling healthy older adults., Methods: Twelve participants (four males, eight females; 75.6 ± 4.9 yrs) were randomly assigned to the experimental group (n = 6) or control group (n = 6). Participants trained in their homes for eight weeks, completing three 45-min exercise sessions per week using smart phone balance trainers that provided written, graphic, and video guidance, and monitored trunk sway. During each session, participants performed six repetitions of six exercises selected from five categories (static standing, compliant surface standing, weight shifting, modified center of gravity, and gait). The experimental group received vibrotactile sensory augmentation for four of the six repetitions per exercise via the smart phone balance trainers, while the control group performed exercises without sensory augmentation. The smart phone balance trainers sent exercise performance data to a physical therapist, who recommended exercises on a weekly basis. Balance performance was assessed using a battery of clinical balance tests (Activity Balance Confidence Scale, Sensory Organization Test, Mini Balance Evaluation Systems Test, Five Times Sit to Stand Test, Four Square Step Test, Functional Reach Test, Gait Speed Test, Timed Up and Go, and Timed Up and Go with Cognitive Task) before training, after four weeks of training, and after eight weeks of training., Results: Participants in the experimental group were able to use vibrotactile sensory augmentation independently in their homes. After training, the experimental group had significantly greater improvements in Sensory Organization Test and Mini Balance Evaluation Systems Test scores than the control group. Significant improvement was also observed for Five Times Sit to Stand Test duration within the experimental group, but not in the control group. No significant improvements between the two groups were observed in the remaining clinical outcome measures., Conclusion: The findings of this study support the use of sensory augmentation devices by community-dwelling healthy older adults as balance rehabilitation tools, and indicate feasibility of telerehabilitation therapy with reduced input from clinicians.

Background and Purpose: Unwarranted variation in practice is among the principal contributors of suboptimal outcomes in health care. This variation can be minimized via quality improvement initiatives. However, quality improvement projects focus mostly on assessing processes, and less attention is given to the effect of the variation on clinical outcomes. An effective implementation of a clinical treatment algorithm (CTA) could improve care for individuals with balance and vestibular disorders. The first aim of this quality improvement project was to examine adherence to a CTA developed by physical therapists who treat persons with balance and vestibular disorders. The second aim was to examine the effect of adherence on patient outcomes., Methods: Twenty-three physical therapists who provided rehabilitation for individuals with balance and vestibular disorders participated in the quality improvement project. All physical therapists worked for the same health care provider, and developed the minimum data set and CTA. The physical therapists were cluster randomized into 2 groups; both groups received educational training and reminders regarding adherence to the CTA. The first group received the training and reminders after an 8-week baseline period (initial group), and the second group (delayed group) after a 12-week baseline period. The prescribed interventions were classified as being adherent or nonadherent to the CTA. Clinical outcomes, including the Activities-Specific Balance Confidence (ABC) scale, Dizziness Handicap Inventory (DHI), and the Global Rating of Change (GRC), were recorded at the initial evaluation and discharge for 454 individual with balance or vestibular disorders., Results: Across the 16-week project, adherence rates improved significantly by 9% and 12% for the initial and delayed groups, respectively (P = 0.008), but there was no difference between groups related to the timing of the educational training and adherence reminders. Clinical outcomes improved for individuals, with balance or vestibular disorders but there was no differences in the change in ABC, DHI, and GRC scores based on whether the interventions were or were not adherent to the CTA., Discussion and Conclusions: This quality improvement project was effective in increasing the adherence to the CTA in both groups. Although on average individuals with balance and vestibular disorders showed improvement on the clinical outcomes, there was no additional benefit in the clinical outcome for adherent interventions.Video abstract is available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A125).

Background and Purpose: Individuals with concussion often complain of persistent dizziness and imbalance, and these problems have been treated with vestibular rehabilitation exercises. The purpose of this study is to describe the vestibular rehabilitation exercise prescriptions provided to individuals after concussion., Methods: A retrospective chart review of vestibular rehabilitation home exercise programmes prescribed by physical therapists for 104 participants who were diagnosed with concussion was conducted. Each of the exercises was classified by exercise type, duration and frequency. Frequency counts of the most common exercise types were recorded. Exercise progression patterns were examined by determining how exercise types were modified from visit to visit., Results: Eye-head coordination exercises were the most commonly prescribed exercise type (in 95% of participants), followed by standing static balance exercises (in 88% of participants), and ambulation exercises (in 76% of participants)., Conclusions: Understanding the prescription patterns of expert clinicians may elucidate the vestibular-related impairments of individuals after concussion and may provide a resource for therapists who may be starting vestibular rehabilitation programmes for management of individuals with concussion. To improve quality of care, future research should be directed to relate outcomes to the exercise prescription patterns., (Copyright © 2012 John Wiley & Sons, Ltd.)

The use of vestibular rehabilitation for persons with balance and vestibular disorders is used to improve function and decrease dizziness symptoms. Principles of a vestibular rehabilitation program are described including common exercises and outcome measures used to report change. A review of negative and positive predictive factors related to recovery is also provided.

Background and Purpose: Management of dizziness and balance dysfunction is a major challenge after concussion. The purpose of this study was to examine the effect of vestibular rehabilitation in reducing dizziness and to improve gait and balance function in people after concussion., Methods: A retrospective chart review of 114 patients (67 children aged 18 years and younger [mean, 16 years; range, 8-18 years]; 47 adults older than 18 years [mean, 41 years; range, 19-73 years]) referred for vestibular rehabilitation after concussion was performed. At the time of initial evaluation and discharge, recordings were made of outcome measures of self-report (eg, dizziness severity, Activities-specific Balance Confidence Scale, and Dizziness Handicap Inventory) and gait and balance performance (eg, Dynamic Gait Index, gait speed, and the Sensory Organization Test). A mixed-factor repeated-measures analysis of variance was used to test whether there was an effect of vestibular rehabilitation therapy and age on the outcome measures., Results: The median length of time between concussion and initial evaluation was 61 days. Of the 114 patients who were referred, 84 returned for at least 1 visit. In these patients, improvements were observed in all self-report, gait, and balance performance measures at the time of discharge (P < .05). Children improved by a greater amount in dizziness severity (P = .005) and conditions 1 (eyes open, fixed support) and 2 (eyes closed, fixed support) of the Sensory Organization Test (P < .025)., Discussion: Vestibular rehabilitation may reduce dizziness and improve gait and balance function after concussion. For most measures, the improvement did not depend on age, indicating that vestibular rehabilitation may equally benefit both children and adults., Conclusions: Vestibular rehabilitation should be considered in the management of individuals post concussion who have dizziness and gait and balance dysfunction that do not resolve with rest.

Background and Purpose: Vestibular dysfunction has been shown to be associated with altered cognitive function. The purpose of this study was to examine changes in cognitive function in participants with vestibular disease during the course of vestibular physical therapy., Methods: Twenty-two participants (mean age = 52, standard deviation = 11) with previously diagnosed vestibular disorders were tested at the beginning and end of rehabilitation. The Motor and Perceptual Inhibition Test (MAPIT) was used to assess manual reaction times when responding to various stimuli presented on a computer screen. Additional physical performance measures and questionnaires related to dizziness, fear of falling, and activities of daily living were used to quantify change during the 6-week intervention period. The repeatable battery for the assessment of neuropsychological status (a measure of memory and executive function) was used to ensure that participants did not have memory or executive function deficits., Results: Overall, there were no significant differences in MAPIT score before versus after physical therapy intervention, however there were some participants who demonstrated improvements in motor inhibition (MI) and perceptual inhibition (PI) scores. Interstingly, 8 of the 9 participants with abnormal caloric test findings had improvements on 2 of the PI scores. Overall 50% to 64% of the participants demonstrated improvement in the 4 different MAPIT scores. There were improvements in physical performance and self-report measures at the end of the 6-week physical therapy intervention program., Discussion/conclusion: Individuals with vestibular disorders may show improvement in MI and PI after a 6-week physical therapy intervention program; those with abnormalities on caloric and rotational chair tests appear especially likely to experience improvement in PI. Additional study is needed to determine whether individuals with vestibular disorders have remediable deficits in MI and PI.