Lymphedema, also known as lymphoedema and lymphatic edema, is a condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system, which normally returns interstitial fluid to the bloodstream. The condition is most frequently a complication of cancer treatment or parasitic infections, but it can also be seen in a number of genetic disorders. Though incurable and progressive, a number of treatments can ameliorate symptoms. Tissues with lymphedema are at high risk of infection.
Traumatic brain injury, often referred to as TBI, is most often an acute event similar to other injuries. That is where the similarity between traumatic brain injury and other injuries ends. One moment the person is normal and the next moment life has abruptly changed.
In most other aspects, a traumatic brain injury is very different. Since our brain defines who we are, the consequences of a brain injury can affect all aspects of our lives, including our personality. A brain injury is different from a broken limb or punctured lung. An injury in these areas limit the use of a specific part of your body, but your personality and mental abilities remain unchanged. Most often, these body structures heal and regain their previous function.
Brain injuries do not heal like other injuries. Recovery is a functional recovery, based on mechanisms that remain uncertain. No two brain injuries are alike and the consequence of two similar injuries may be very different. Symptoms may appear right away or may not be present for days or weeks after the injury.
One of the consequences of brain injury is that the person often does not realize that a brain injury has occurred.
MS symptoms are variable and unpredictable. No two people have exactly the same symptoms, and each person’s symptoms can change or fluctuate over time. One person might experience only one or two of the possible symptoms while another person experiences many more.
Explore the list below to find more information about the symptoms you or someone you care about may experience. Most of these symptoms can be managed very effectively with medication, rehabilitation and other management strategies. Effective symptom management by an interdisciplinary team of healthcare professionals is one of the key components of comprehensive MS care.
Occurs in about 80% of people, can significantly interfere with the ability to function at home and work, and may be the most prominent symptom in a person who otherwise has minimal activity limitations.
Related to several factors including weakness, spasticity, loss of balance, sensory deficit and fatigue, and can be helped by physical therapy, assistive therapy and medications.
Numbness of the face, body, or extremities (arms and legs) is often the first symptom experienced by those eventually diagnosed as having MS.
Refers to feelings of stiffness and a wide range of involuntary muscle spasms; can occur in any limb, but it is much more common in the legs.
Weakness in MS, which results from deconditioning of unused muscles or damage to nerves that stimulate muscles, can be managed with rehabilitation strategies and the use of mobility aids and other assistive devices.
The first symptom of MS for many people. Onset of blurred vision, poor contrast or color vision, and pain on eye movement can be frightening — and should be evaluated promptly.
People with MS may feel off balance or lightheaded, or — much less often — have the sensation that they or their surroundings are spinning (vertigo).
Bladder dysfunction, which occurs in at least 80% of people with MS, can usually be managed quite successfully with medications, fluid management, and intermittent self-catheterization.
Very common in the general population including people with MS. Sexual responses can be affected by damage in the central nervous system, as well by symptoms such as fatigue and spasticity, and by psychological factors.
Constipation is a particular concern among people with MS, as is loss of control of the bowels. Bowel issues can typically be managed through diet, adequate fluid intake, physical activity and medication.
Pain syndromes are common in MS. In one study, 55% of people with MS had “clinically significant pain” at some time, and almost half had chronic pain.
Refers to a range of high-level brain functions affected in more than 50% of people with MS, including the ability to process incoming information, learn and remember new information, organize and problem-solve, focus attention and accurately perceive the environment.
Can be a reaction to the stresses of living with MS as well as the result of neurologic and immune changes. Significant depression, mood swings, irritability, and episodes of uncontrollable laughing and crying pose significant challenges for people with MS and their families.
Studies have suggested that clinical depression — the severest form of depression — is among the most common symptoms of MS. It is more common among people with MS than it is in the general population or in persons with many other chronic, disabling conditions.
Speech problems, including slurring (dysarthria) and loss of volume (dysphonia) occur in approximately 25-40% of people with MS, particularly later in the disease course and during periods of extreme fatigue. Stuttering is occasionally reported as well.
Swallowing problems — referred to as dysphagia — result from damage to the nerves controlling the many small muscles in the mouth and throat.
Tremor, or uncontrollable shaking, can occur in various parts of the body because of damaged areas along the complex nerve pathways that are responsible for coordination of movements.
Seizures — which are the result of abnormal electrical discharges in an injured or scarred area of the brain — have been estimated to occur in 2-5% people with MS, compared to the estimated 3% of the general population.
Respiration problems occur in people whose chest muscles have been severely weakened by damage to the nerves that control those muscles.
Pruritis (itching) is one of the family of abnormal sensations — such as “pins and needles” and burning, stabbing or tearing pains — which may be experienced by people with MS.
Although headache is not a common symptom of MS, some reports suggest that people with MS have an increased incidence of certain types of headache.
About 6% of people who have MS complain of impaired hearing. In very rare cases, hearing loss has been reported as the first symptom of the disease.
Parkinson’s disease (PD) is a neurodegenerative disorder that affects predominately dopamine-producing (“dopaminergic”) neurons in a specific area of the brain called substantia nigra.
Symptoms generally develop slowly over years. The progression of symptoms is often a bit different from one person to another due to the diversity of the disease. People with PD may experience:
- Tremor, mainly at rest and described as pill rolling tremor in hands. Other forms of tremor are possible
- Slowness of movements (bradykinesia)
- Limb rigidity
- Gait and balance problems
Stroke is one of the leading causes of long-term adult disability, affecting approximately 795,000 people each year in the U.S. The very word “stroke” indicates that no one is ever prepared for this sudden, often catastrophic event. Stroke survivors and their families can find workable solutions to most difficult situations by approaching every problem with patience, ingenuity, perseverance and creativity. Early recovery and rehabilitation can improve functions and sometimes remarkable recoveries for someone who suffered a stroke
After a serious injury, illness or surgery, you may recover slowly. You may need to regain your strength, relearn skills or find new ways of doing things you did before. This process is rehabilitation.
Rehabilitation often focuses on
- Physical therapy to help your strength, mobility and fitness
- Occupational therapy to help you with your daily activities
- Speech-language therapy to help with speaking, understanding, reading, writing and swallowing
- Treatment of pain
The type of therapy and goals of therapy may be different for different people. An older person who has had a stroke may simply want rehabilitation to be able to dress or bathe without help. A younger person who has had a heart attack may go through cardiac rehabilitation to try to return to work and normal activities. Someone with a lung disease may get pulmonary rehabilitation to be able to breathe better and improve their quality of life.
Physical therapists (PTs) are highly-educated, licensed health care professionals who can help patients reduce pain and improve or restore mobility – in many cases without expensive surgery and often reducing the need for long-term use of prescription medications and their side effects.
Physical therapists can teach patients how to prevent or manage their condition so that they will achieve long-term health benefits. PTs examine each individual and develop a plan, using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability. In addition, PTs work with individuals to prevent the loss of mobility before it occurs by developing fitness- and wellness-oriented programs for healthier and more active lifestyles.
Physical therapists provide care for people in a variety of settings, including hospitals, private practices, outpatient clinics, home health agencies, schools, sports and fitness facilities, work settings, and nursing homes. State licensure is required in each state in which a physical therapist practices.
Cognitive rehabilitation therapy
Cognitive rehabilitation is a program to help brain-injured or otherwise cognitively impaired individuals to restore normal functioning, or to compensate for cognitive deficits. It entails an individualized program of specific skills training and practice plus metacognitive strategies. Metacognitive strategies include helping the patient increase self-awareness regarding problem-solving skills by learning how to monitor the effectiveness of these skills and self-correct when necessary.
Cognitive rehabilitation therapy (offered by a trained therapist) is a subset of Cognitive Rehabilitation (community-based rehabilitation, often in traumatic brain injury; provided by rehabilitation professionals) and has been shown to be effective for individuals who suffered a stroke in the left or right hemisphere. or brain trauma. A computer-assisted type of cognitive rehabilitation therapy called cognitive remediation therapy has been used to treat schizophrenia, ADHD, and major depressive disorder.
Cognitive rehabilitation, in its narrow training of the client sense, builds upon brain injury strategies involving memory  and in the community, Executive functions, activities planning and “follow through” (e.g., memory, task sequencing, lists).
It may also be recommended for traumatic brain injury, the primary population for which it was developed in the university medical and rehabiltation communities, such as that suffered by U.S. Representative Gabrielle Giffords, according to Dr. Gregory J. O’Shanick of the Brain Injury Association of America. Her new doctor has confirmed that it will be part of her rehabilitation. Cognitive rehabilitation may be part of a comprehensive community services program and integrated into residential services, such as supported living, supported employment, family support, professional education, home health (as personal assistance), recreation, or education programs in the community.
According to the standard text by Sohlberg and Mateer:
Individuals and families respond differently to different interventions, in different ways, at different times after injury. Premorbid functioning, personality, social support, and environmental demands are but a few of the factors that can profoundly influence outcome. In this variable response to treatment, cognitive rehabilitation is no different from treatment for cancer, diabetes, heart disease, Parkinson’s disease, spinal cord injury, psychiatric disorders, or any other injury or disease process for which variable response to different treatments is the norm.
Nevertheless, many different statistical analyses of the benefits of this therapy have been carried out. One study made in 2002 analyzed 47 treatment comparisons and reported “a differential benefit in favor of cognitive rehabilitation in 37 of 47 (78.7%) comparisons, with no comparison demonstrating a benefit in favor of the alternative treatment condition.”
An internal study conducted by the Tricare Management Agency in 2009 is cited by the US Department of Defense as its reason for refusing to pay for this therapy for veterans who have suffered traumatic brain injury. According to Tricare, “There is insufficient, evidence-based research available to conclude that cognitive rehabilitation therapy is beneficial in treating traumatic brain injury.” The ECRI Institute, whose report serves as the basis for this decision by the Department of Defense, has summed up their own findings this way:
In our report, we carried out several meta-analyses using data from 18 randomized controlled trials. Based on data from these studies, we were able to conclude the following:
- Adults with moderate to severe traumatic brain injury who receive social skills training perform significantly better on measures of social communication than patients who receive no treatment.
- Adults with traumatic brain injury who receive comprehensive cognitive rehabilitation therapy report significant improvement on measures of quality of life compared to patients who receive a less intense form of therapy.
The strength of the evidence supporting our conclusions was low due to the small number of studies that addressed the outcomes of interest. Further, the evidence was too weak to draw any definitive conclusions about the effectiveness of cognitive rehabilitation therapy for treating deficits related to the following cognitive areas: attention, memory, visuospacial skills, and executive function. The following factors contributed to the weakness of the evidence: differences in the outcomes assessed in the studies, differences in the types of cognitive rehabilitation therapy methods/strategies employed across studies, differences in the control conditions, and/or insufficient number of studies addressing an outcome.
Citing this 2009 assessment, US Department of Defense, one of the federal agencies not responsible for health care decisions in the US, has declared that cognitive rehabilitation therapy is scientifically unproved and should refer their concerns to the US Department of Health and Human Services, US Budget and Management, and/or the Government Accountability Office (GAO). As a result, it refuses to cover the cost of cognitive rehabilitation for brain-injured veterans. Cost-benefit and cost-effectiveness studies, together with an analysis of personnel and veterans’ services for new our emerging groups in head and brain injuries, are recommended.
- Rehabilitation (neuropsychology)
- Cognitive remediation therapy
- Rehabilitation: Community-based
- Rehabilitation: Hospital-based units
- “Cognitive Rehabilitation Therapy for Traumatic Brain Injury: What We Know and Don’t Know about Its Efficacy” (PDF). ECRI Institute. 2011-01-21. Retrieved 2014-04-17.
Approaches to cognitive rehabilitation therapy are generally separated into two broad categories: restorative and compensatory.
- Keith D. Cicerone; Cynthia Dahlberg; James F. Malec; Donna M. Langenbahn; Thomas Felicetti; Sally Kneipp; Wendy Ellmo; Kathleen Kalmar; Joseph T. Giacino; J. Preston Harley; Linda Laatsch; Philip A. Morse; Jeanne Catanese (August 2002). “Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002”. Archives of Physical Medicine and Rehabilitation. xxx: Elsevier. 86 (8): 1681–1692. doi:10.1016/j.apmr.2005.03.024. PMID 16084827. Retrieved 2011-01-22.
The overall analysis of 47 treatment comparisons, based on class I studies included in the current and previous review, reveals a differential benefit in favor of cognitive rehabilitation in 37 of 47 (78.7%) comparisons, with no comparison demonstrating a benefit in favor of the alternative treatment condition.
- Soderback I.; Ekholm J. (1992). “January–March). Medical and social factors affecting behavior patterns in patients with acquired brain damage: a study of patients living at home three years after incident”. Disability and Rehabilitation. 14 (1): 30–35. doi:10.3109/09638289209166424.
- Elgamal S, McKinnon MC, Ramakrishnan K, Joffe RT, MacQueen G (Sep 2007). “Successful computer-assisted cognitive remediation therapy in patients with unipolar depression: a proof of principle study”. Psychol. Med. 37 (9): 1229–38. doi:10.1017/S0033291707001110. PMID 17610766.
- Wykes T (May 2007). “Cognitive remediation therapy in schizophrenia: randomised controlled trial”. Br J Psychiatry. 190: 421–7. doi:10.1192/bjp.bp.106.026575. PMID 17470957.
- Wykes T (Aug 2007). “Cognitive remediation therapy (CRT) for young early onset patients with schizophrenia: an exploratory randomized controlled trial”. Schizophr Res. 94 (1-3): 221–30. doi:10.1016/j.schres.2007.03.030. PMID 17524620.
- O’Connell RG, Bellgrove MA, Dockree PM, Robertson IH (Dec 2006). “Cognitive remediation in ADHD: effects of periodic non-contingent alerts on sustained attention to response”. Neuropsychol Rehabil. 16 (6): 653–65. doi:10.1080/09602010500200250. PMID 17127571.
- Stevenson CS, et al. (Oct 2002). “A cognitive remediation programme for adults with Attention Deficit Hyperactivity Disorder”. Aust N Z J Psychiatry. 36 (5): 610–6. doi:10.1046/j.1440-1614.2002.01052.x. PMID 12225443.
- Zencius A.; Wesolowski M.; Burke W.H. (1990). “January–March). A comparison of four memory strategies with traumatically brain-injured clients”. Brain Injury. 4 (1): 33–38. doi:10.3109/02699059009026146.
- Burke W.H.; Zencius A.H.; Weslowski M.D.; Doubleday F. (1991). “Improving executive function disorders in brain-injured clients”. Brain Injury. 5 (3): 241–252. doi:10.3109/02699059109008095.
- Ben-Yishay, Diller L (1993). “Cognitive remediation in traumatic brain injury: Update and issues”. Archives of Physical Medicine and Rehabilitation. 74: 204–213.
- Crowley J.; Miles J. (1991). “Cognitive remediation in pediatric head injury: A case study”. Journal of Pediatric Psychology. 16 (5): 611–627. doi:10.1093/jpepsy/16.5.611.
- Gordon W.; Hibbard M.; Kreutzer J. (1989). “Cognitive remediation: Issues in research and practice”. Journal of Head Trauma Rehabilitation. 4 (3): 76–84. doi:10.1097/00001199-198909000-00011.
- Kreutzer, J. & Wehman, P. (1991). Cognitive Rehabilitation for Persons with Traumatic Brain Injury: A Functional Approach. Baltimore, MD: Paul H. Brookes.
- Thomas M. Burton (2011-01-10). “Brain at Risk Despite Quick Aid”. Wall Street Journal. Retrieved 2011-01-21.
“The rapid treatment she received needs to be matched by a seamless course of rehabilitation such as cognitive rehabilitation,” Dr. O’Shanick said.
- “‘Intensive Rehabilitation’ Is Next for Giffords, New Doctor Says”. ABC News Radio. 2011-01-21. Retrieved 2011-01-29.
The key is get into intensive rehabilitation…Bringing in lots of different people from different specialties to work as a coordinated team, speech, cognitive, physical rehabilitation.
- Watson, S. (1991). PAS and head injury. In: J. Weissman, J. Kennedy, & S.Litvak, Personal Perspectives on Personal Assistance Services. (pp. 72-75). Oakland, CA: Rehabilitation Research and Training Center on Public Policy and Independent Living, World Institute on Disability.
- Ulciny, G. & Jones, M. (1985). Enhancing the attendant management skills of persons with disabilities. American Rehabilitation, 18-20.
- McKay Moore Sohlberg; Catherine A Mateer (2001). Cognitive rehabilitation: an integrative neuropsychological approach. Guilford Press. p. 4. ISBN 1-57230-613-0.
- Andrew Tilghman (2011-01-01). “Military insurer denies coverage of new brain injury treatment”. USA Today. Retrieved 2011-01-21.
In an internal 2009 study, the Tricare Management Agency found that cognitive rehabilitation therapy is scientifically unproved and does not warrant coverage as a stand-alone treatment for brain injuries.
Vestibular Rehabilitation Therapy (VRT)
Evidence has shown that vestibular rehabilitation can be effective in improving symptoms related to many vestibular (inner ear/balance) disorders.1,2 People with vestibular disorders often experience problems with vertigo, dizziness, visual disturbance, and/or imbalance. These are the problems that rehabilitation aims to address. Other problems can also arise that are secondary to vestibular disorders, such as nausea and/or vomiting, reduced ability to focus or concentrate, and fatigue.
Symptoms due to vestibular disorders can diminish quality of life and impact all aspects of daily living. They also contribute to emotional problems such as anxiety and depression. Additionally, one of the consequences of having a vestibular disorder is that symptoms frequently cause people to adopt a sedentary lifestyle in order to avoid bringing on, or worsening, dizziness and imbalance. As a result, decreased muscle strength and flexibility, increased joint stiffness, and reduced stamina can occur.
Treatment strategies used in rehabilitation can also be beneficial for these secondary problems.
WHAT IS VESTIBULAR REHABILITATION?
Vestibular rehabilitation (VR), or vestibular rehabilitation therapy (VRT) is a specialized form of therapy intended to alleviate both the primary and secondary problems caused by vestibular disorders. It is an exercise-based program primarily designed to reduce vertigo and dizziness, gaze instability, and/or imbalance and falls. For most people with a vestibular disorder the deficit is permanent because the amount of restoration of vestibular function is very small. However, after vestibular system damage, people can feel better and function can return through compensation. This occurs because the brain learns to use other senses (vision and somatosensory, i.e. body sense) to substitute for the deficient vestibular system. The health of particular parts of the nervous system (brainstem and cerebellum, visual, and somatosensory sensations) is important in determining the extent of recovery that can be gained through compensation.
For many, compensation occurs naturally over time, but for people whose symptoms do not reduce and who continue to have difficulty returning to daily activities, VRT can help with recovery by promoting compensation.3
The goal of VRT is to use a problem-oriented approach to promote compensation. This is achieved by customizing exercises to address each person’s specific problem(s). Therefore, before an exercise program can be designed, a comprehensive clinical examination is needed to identify problems related to the vestibular disorder. Depending on the vestibular-related problem(s) identified, three principal methods of exercise can be prescribed: 1) Habituation, 2) Gaze Stabilization, and/or 3) Balance Training.4
Habituation exercises are used to treat symptoms of dizziness that are produced because of self-motion3 and/or produced because of visual stimuli5,6. Habituation exercise is indicated for patients who report increased dizziness when they move around, especially when they make quick head movements, or when they change positions like when they bend over or look up to reach above their heads. Also, habituation exercise is appropriate for patients who report increased dizziness in visually stimulating environments, like shopping malls and grocery stores, when watching action movies or T.V., and/or when walking over patterned surfaces or shiny floors.
Habituation exercise is not suited for dizziness symptoms that are spontaneous in nature and do not worsen because of head motion or visual stimuli. The goal of habituation exercise is to reduce the dizziness through repeated exposure to specific movements or visual stimuli that provoke patients’ dizziness. These exercises are designed to mildly, or at the most moderately, provoke the patients’ symptoms of dizziness. The increase in symptoms should only be temporary, and before continuing onto other exercises or tasks the symptoms should return completely to the baseline level. Over time and with good compliance and perseverance, the intensity of the patient’s dizziness will decrease as the brain learns to ignore the abnormal signals it is receiving from the inner ear.
Gaze Stabilization exercises are used to improve control of eye movements so vision can be clear during head movement. These exercises are appropriate for patients who report problems seeing clearly because their visual world appears to bounce or jump around, such as when reading or when trying to identify objects in the environment, especially when moving about.
There are two types of eye and head exercises used to promote gaze stability. The choice of which exercise(s) to use depends on the type of vestibular disorder and extent of the disorder. One type of gaze stability exercise incorporates fixating on an object while patients repeatedly move their heads back and forth or up and down for up to a couple of minutes. The following pictures demonstrate examples of this type of gaze stability exercise.
The other type of gaze stability exercise is designed to use vision and somatosensation (body sense) as substitutes for the damaged vestibular system. Gaze shifting and remembered target exercises use sensory substitution to promote gaze stability. These exercises are particularly helpful for patients with poor to no vestibular function, such as patients with bilateral (both sides) inner ear damage.4
Balance Training exercises are used to improve steadiness so that daily activities for self-care, work, and leisure can be performed successfully. Exercises used to improve balance should be designed to address each patient’s specific underlying balance problem(s).7 Also, the exercises need to be moderately challenging but safe enough so patients do not fall while doing them. Features of the balance exercises that are manipulated to make them challenging, include:
- Visual and/or somatosensory cues
- Stationary positions and dynamic movements
- Coordinated movement strategies (movements from ankles, hips, or a combination of both)
- Dual tasks (performing a task while balancing)
Additionally, balance exercises should be designed to reduce environmental barriers and fall risk. For example, the exercises should help improve patients’ ability to walk outside on uneven ground or walk in the dark. Ultimately, balance training exercises are designed to help improve standing, bending, reaching, turning, walking, and if required, other more demanding activities like running, so that patients can safely and confidently return to their daily activities.
For patients with Benign Paroxysmal Positional Vertigo (BPPV) the exercise methods described above are not appropriate. First a clinician needs to identify the type of BPPV the patient is suffering from, and then different repositioning exercises can be performed.8,9 For more details about BPPV, including diagnosis and treatment, see VeDA’s article on this topic.
After BPPV has been successfully treated and spinning symptoms resolved, some patients will continue to report non-specific dizziness (symptoms other than spinning) and/or imbalance. In these cases, treatment using habituation exercise and/or balance training may be indicated.4
WHAT SHOULD PATIENTS EXPECT FROM VESTIBULAR REHABILITATION?
VRT is usually performed on an outpatient basis, although in some cases, the treatment can be initiated in the hospital. Patients are seen by a licensed physical or occupational therapist with advanced post-graduate training.
VRT begins with a comprehensive clinical assessment that should include collecting a detailed history of the patient’s symptoms and how these symptoms affect their daily activities. The therapist will document the type and intensity of symptoms and discuss the precipitating circumstances.
Additionally, information about medications, hearing or vision problems, other medical issues, history of falls, previous and current activity level, and the patient’s living situation will be gathered.
The assessment also includes administering different tests to more objectively evaluate the patient’s problems. The therapist will screen the visual and vestibular systems to observe how well eye movements are being controlled. Testing assesses sensation (which includes gathering information about pain), muscle strength, extremity and spine range of motion, coordination, posture, balance, and walking ability.
A customized exercise plan is developed from the findings of the clinical assessment, results from laboratory testing and imaging studies, and input from patients about their goals for rehabilitation. For example, a person with BPPV may undergo a canal repositioning exercise for the spinning s/he experiences, whereas, someone with gaze instability and dizziness due to vestibular neuritis (a deficit from a weakened inner ear) may be prescribed gaze stability and habituation exercises, and if the dizziness affects their balance this may also include balance exercises.
An important part of the VRT is to establish an exercise program that can be performed regularly at home. Compliance with the home exercise program is essential to help achieve rehabilitation and patient goals.
Along with exercise, patient and caregiver education is an integral part of VRT. Many patients find it useful to understand the science behind their vestibular problems, as well as how it relates to the difficulties they may have with functioning in everyday life. A therapist can also provide information about how to deal with these difficulties and discuss what can be expected from VRT. Education is important for patients because it takes away much of the mystery of what they are experiencing, which can help reduce anxiety that may occur as a result of their vestibular disorder.
ARE VESTIBULAR REHABILITATION EXERCISES DIFFICULT TO DO?
VRT exercises are not difficult to learn, but to achieve maximum success patients must be committed to doing them.
Since the exercises can sometimes be tedious, setting up a regular schedule so that the exercises can be incorporated into daily life is very important.
Exercises may, at first, make symptoms seem worse. But with time and consistent work, symptoms should steadily decrease, which means participation in activities of daily life will be easier for patients to do.
FACTORS THAT CAN IMPACT RECOVERY
When patients participate in VRT different factors can impact the potential for recovery. For example, the type of vestibular disorder affects recovery. Patients that have a stable vestibular disorder, such as vestibular neuritis or labyrinthitis, have the best opportunity to achive a satisfactory resolution of their symptoms. When patients have a progressive vestibular disorder, like multiple sclerosis, or a fluctuating condition, like migraine and Meniere’s, which cause spontaneous attacks of dizziness or vertigo, compensation can be difficult to achieve, and therefore, success with VRT is more difficult.
To improve the chance for success with VRT for patients with progressive or fluctuating disorders it is important to manage these disorders medically. Patients with vestibular migraine may benefit more from VRT by implementing behavioral changes (reduction of migraine triggers and participation in cognitive behavioral treatment) and/or using pharmacological therapy to help reduce or eliminate the headache attacks. Although VRT does not treat the attacks of vertigo that patients with Meniere’s disease experience, if the frequency of these attacks is reduced with diet and medication, or if indicated, with a more aggressive chemical or surgical type of intervention, then VRT can possibly help reduce symptoms that occur between attacks. The goal of medical management is to help stabilize the disorder as best as possible to allow for compensation to occur. As a consequence, the exercise strategies used in VRT will have a better chance to promote compensation and reduce vestibular-related symptoms.10,11,12,13
There are differences in potential recovery depending on the vestibular disorder. If patients have a unilateral lesion (only one ear affected by a vestibular disorder) they generally have a better chance of recovery as compared to those with bilateral lesions (both ears are affected). VRT does assist with recovery in patients with bilateral lesions, just not the same amount and not as quickly as in patients with unilateral lesions.14,15
For patients with central vestibular disorders, the structures of the brain that allow for compensation are affected. This limits the amount and speed of recovery. However, research has shown that patients with central vestibular disorders can make gains with VRT.3
Other factors that can potentially limit recovery:
Being inactive can lead to suboptimal levels of health and fitness, which can cause secondary problems. Also, this lifestyle can further decrease the tolerance to movement by decreasing the threshold that it takes to aggravate the symptoms of dizziness and unsteadiness. In turn, desire to be active is reduced even more, thus creating a vicious cycle. Slowly and progressively, training the body to increase tolerance to movement and promote physical fitness is a goal of VRT and can address this factor.
In general, pain contributes to imbalance and is associated with increased risk of falls in older adults.16 People also restrict their movement and activity level to avoid pain, which leads to a more sedentary lifestyle and the negative consequences of this lifestyle. Additionally, to avoid pain patients may not be able to do the prescribed exercises, which restricts full participation in VRT and limits VRT’s effectiveness. For these reasons, pain should be routinely assessed and managed with physical therapy and medical interventions as needed so that results can be maximized.
Presence of Other Medical Conditions
It is more difficult to accomplish the goals set out in VRT when patients have to deal with multiple medical conditions. In fact, any condition that reduces the ability to perform the exercises will lessen the chances of achieving success. Additionally, just as pain is a factor that increases the risk of falling, certain medical conditions (cardiovascular, arthritis, foot problems, vision problems, neurological diseases, cognitive impairments) are also factors that increase fall risk.17 Assessment and proactive, comprehensive management of these conditions should be done.
Certain Medications and/or Multiple Medications
Use of medication is a “double edged sword” because on one side it provides needed benefits that are necessary for managing disease, but on the other hand it can cause side effects like dizziness, sedation, muscle fatigue and weakness, and unsteadiness and falls, which magnifies the problems that already exist due to the vestibular disorder. Additionally, when multiple medications are prescribed, the side effects are compounded. Tinetti and colleague’s work17 has revealed that not only is taking four or more medications a factor that increases a patient’s risk of falls, but also that certain types of medications like psychoactive medications (sedatives, antipsychotics, and antidepressants), anticonvulsants, and antihypertensive mediations are strongly associated with an increased risk of falling.
In particular, when it comes to medication usage for vestibular disorders, frequently patients are prescribed medication like meclizine (Antivert) and diazepam (Valium) for acute symptoms. The goal of these medicines is to act on the brain so that the intensity of dizziness and/or nausea is not as strong. Because these medications suppress brain function they can be counter-productive with promoting compensation, so it is best to not use them for extended periods of time.3
Since there can be a tradeoff between the benefits and risks of using medications, decisions about usage should be made on an individual basis and should include the priorities of each patient. For instance, certain medications that reduce blood pressure can cause lightheadedness, which can potentially lead to unsteadiness and/or falls. Determining which is more important, the risk of heart disease and stroke or the risk of falling and therefore causing injury, causes a dilemma in patient management. Physicians take into consideration which patients are at greater risk of having a stroke – in which case it would be in their best interest to control their blood pressure – as compared to patients who are at more risk of falling, in which case taking medication that lowers blood pressure too much may not be indicated.
Patients can be helpful with making decisions about medication usage by knowing what their medications are supposed do for them and understanding the possible side effects. This can lead to more effective discussions between patients and physicians about symptoms that might be experienced from as a result of taking a particular medication. From these conversations, physicians can work toward achieving the intended benefit of the medication while minimizing potential side effects by taking different actions:
- Make sure medications are being taken correctly
- Adjust medication dosage
- Eliminate unnecessary medications
- Prescribe a different medication
Anxiety, panic, and depression occur frequently with vestibular disorders and can cause difficulty with managing symptoms.
Frequently, patients will restrict their activity to avoid increasing their vestibular related symptoms. While this coping strategy may reduce the anxiety a patient experiences as a result of their symptoms, it limits compensation that is necessary to promote recovery.
With slow, progressive exposure to movement and activity patients can experience improvement in their vestibular symptoms, which help reduce their anxiety. However, for many patients, it may be helpful to seek counseling to deal with the difficult emotional challenges that often accompany life with a chronic illness. Cognitive behavioral and/or pharmacological therapy can help address a patient’s underlying anxiety so they can achieve the goals of VRT.18,19
With compensation, vestibular symptoms will decrease as the brain recalibrates and fine tunes incoming signals from the inner ear. However, when damage to the vestibular system is permanent there is the potential for symptoms to return.
Symptomatic relapses can occasionally occur because the brain de-compensates. This can be due to different emotional and/or physical stressors, like personal or job-related pressures, periods of inactivity, a bad cold or flu, extreme fatigue or chronic lack of sleep, changes in medication, or sometimes surgery.3 Although it is important for patients to consult with their physician to make sure nothing new has occurred, returning to the exercises that promoted the initial compensation can help promote recovery again. Additionally, recovery after de-compensation usually occurs more quickly as compared to the initial compensation.
Where can I find a vestibular rehabilitation specialist?
The Vestibular Disorders Association (VeDA) provides a directory of health professionals who are specially trained to assess and treat vestibular disorders. This online directory offers users the ability to search for providers according to specialty and geographical location.
Author: Lisa Farrell, PT, PhD, AT,C; Clinical Faculty, Department of Physical Therapy, Nova Southeastern University, Fort Lauderdale, FL
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