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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 93-94

Gaze-stability exercises incorporating physical activity on functional mobility and disability in unilateral peripheral vestibular hypofunction


Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal Hospital, Bengaluru Campus, Bengaluru, Karnataka, India

Date of Submission03-Oct-2019
Date of Decision03-Mar-2020
Date of Acceptance11-Mar-2020
Date of Web Publication17-Jul-2020

Correspondence Address:
Dr. Suruliraj Karthikbabu
Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal Hospital, Hal Airport Road, Bengaluru - 560 017, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_106_19

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  Abstract 


Dysfunction of one or both peripheral vestibular apparatus can manifest with gaze instability, balance, and mobility issues. This case report describes the role of vestibular rehabilitation along with a tailored physical activity regime on balance and disability in a 49-year-old female complaining of sense of losing the standing balance for the past 6 months' duration.

Keywords: Balance, gaze stability, habituation exercises, physical activity, vestibular hypofunction


How to cite this article:
Jayasree TJ, Karthikbabu S. Gaze-stability exercises incorporating physical activity on functional mobility and disability in unilateral peripheral vestibular hypofunction. Indian J Otol 2020;26:93-4

How to cite this URL:
Jayasree TJ, Karthikbabu S. Gaze-stability exercises incorporating physical activity on functional mobility and disability in unilateral peripheral vestibular hypofunction. Indian J Otol [serial online] 2020 [cited 2020 Aug 15];26:93-4. Available from: http://www.indianjotol.org/text.asp?2020/26/2/93/289942




  Introduction Top


Unilateral peripheral vestibular dysfunction is characterized by complaints of dizziness, gaze disturbances, and balance dysfunction. The secondary problems include a reduced level of physical activity, emotional distress, and poor health-related quality of life.[1] Rehabilitation strategies of gaze-stability exercises and balance retraining had shown to decrease the symptoms of dizziness, improve gaze stability, and postural stability in unilateral vestibular hypofunction.[2] The long-term benefits of functional mobility and disability following physical activity were understudied.


  Case Report Top


Mrs. JS, a tall female aged 49 years, was evaluated for severe neck pain and difficulty in balancing. She complained of neck pain and was much apprehensive to head-and-neck movements. While moving the head, she experienced dizziness lasting for several minutes of the waking hours. Her symptoms got exacerbated by sudden head movements in a busy environment. She was prescribed antivertiginous medications for the past 2 months by an otolaryngologist. She was emotionally distressed, and the majority of the daily self-care tasks were difficult, thereby a decline in her social participation.

On clinical examination, ocular motility and visual acuity were normal. The pursuit and saccadic eye movements were smooth, and no nystagmus was seen. An abnormal vestibulo-ocular reflex from the head-thrust test suggested a left-sided vestibular hypofunction.[3] Her neck range of movement was restricted in all directions. She could independently attain the sharpened/tandem Romberg's test position but was unable to maintain that posture for 5 s without having a corrective step. On a modified clinical test of sensory integration and balance, she could perform only the eyes open condition with fixed support. The score of 82 in the Dizziness Handicap Inventory indicated a severe disability. The difficulty in walking independently was reflected in the 6 points score of the Dynamic Gait Index. A gaze stabilization therapy was planned to address the poor eye–head coordination and balance issues. In addition, a tailored physical activity profile was incorporated to engage her in as many daily tasks as possible.

Mrs. JS was educated and explained the benefits and risks of vestibular rehabilitation. Her neck pain was treated using physical agents and neck movements. We initially taught her gaze-stability exercises in a seated position and then progressed to standing and walking as the balance capacity improved.[4] The condition 1 of gaze-stability exercise involved turning the head and neck in the horizontal and vertical directions while asking the lady to fix her gaze on the small letter written on the card. The condition 2 involved the movement of both the head and neck and visual targeting card. In condition 3, she practiced the gaze-stability exercise with the memory recall of the visual target. The dynamic balance exercises were taught to her with eyes opened and closed conditions while standing on stable and unstable support platforms. Multidirectional functional arm reach outs were also encouraged.

She was instructed to continue doing 30 min of exercises per se ssion, twice a day over 4 weeks duration. Following the outpatient vestibular rehabilitation regime, the Dynamic Gait Index improved to 22 points overcoming the cutoff score of fall risks. The score of 16 in the Dizziness Handicap Inventory indicated a mild handicap. We advised her practice gaze stability and balance exercises using different support surfaces in the following weeks at home. A structured physical activity profile was planned out for the next 3–6 months duration considering her priorities in daily chores and social participation. She gained confidence in performing household activities, gardening, and shopping outdoors. Eventually, she was much confident in her social roles at family function and public events. We telephoned twice a month to motivate and encourage her performing physical activity profile. We followed her up until 1 year, and the improvements had been retained.


  Discussion Top


The major focus of vestibular rehabilitation was to train Mrs. JS's brain through the repetitions of head-and-neck movements and balance performance. The interpretation of the vestibular input was more in agreement with that of the somatosensory and visual inputs in situ ations where the sensory conflict was absent. In gaze stabilization exercises, the head-and-neck movements against the small fixed and moving objects shall allow retinal slip due to abnormal vestibular-ocular reflex. The retinal slip possibly activates the indirect cerebellar pathway as an adaptation mechanism of recovery.[5]

Dynamic balance exercises in the altered visual and somatosensory situations and walking on level ground with head turns and clearing the obstacle might have helped her improving functional mobility.[6] The repeated use of visual, somatosensory, and/or vestibular modalities during gaze stabilization, balance exercises, and also engaging the female in physical activity profile might have habituated her postural control mechanism to cope up with challenging the environmental situations. A sense of well-being while successfully experiencing the daily needs with better balance confidence might be the reasons for improvements in the outcomes of walking and disability.[7]


  Conclusion Top


Gaze-stability exercises showed improvement in functional mobility and disability in a female with unilateral peripheral vestibular hypofunction. Moreover, incorporating physical activity and repeated practice of the daily tasks resulted in the retention of the therapy gains reflecting motor relearning benefits.

Declaration of patient consent

The authors certify that they had obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images, and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Weidt S, Bruehl AB, Straumann D, Hegemann SC, Krautstrunk G, Rufer M. Health-related quality of life and emotional distress in patients with dizziness: A cross-sectional approach to disentangle their relationship. BMC Health Serv Res 2014;14:317.  Back to cited text no. 1
    
2.
Hillier S, McDonnell M. Is vestibular rehabilitation effective in improving dizziness and function after unilateral peripheral vestibular hypofunction? An abridged version of a Cochrane Review. Eur J Phys Rehabil Med 2016;52:541-56.  Back to cited text no. 2
    
3.
Renga V. Clinical evaluation of patients with vestibular dysfunction. Neurol Res Int 2019;2019:1-8.  Back to cited text no. 3
    
4.
Arnold SA, Stewart AM, Moor HM, Karl RC, Reneker JC. The effectiveness of vestibular rehabilitation interventions in treating unilateral peripheral vestibular disorders: A systematic review. Physiother Res Int 2017;22: E1635.  Back to cited text no. 4
    
5.
Herdman SJ, Schubert MC, Das VE, Tusa RJ. Recovery of dynamic visual acuity in unilateral vestibular hypofunction. Arch Otolaryngol Head Neck Surg 2003;129:819-24.  Back to cited text no. 5
    
6.
Hall CD, Herdman SJ, Whitney SL, Cass SP, Clendaniel RA, Fife TD, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: From the American physical therapy association neurology section. J Neurol Phys Ther 2016;40:124-55.  Back to cited text no. 6
    
7.
Tjernström F, Zur O, Jahn K. Current concepts and future approaches to vestibular rehabilitation. J Neurol 2016;263 Suppl 1:S65-70.  Back to cited text no. 7
    




 

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Abstract
Introduction
Case Report
Discussion
Conclusion
References

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