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Clinical Information

ASSESSMENT & TREATMENT

The goal in managing balance and mobility disorders is to minimize disability and improve functional performance. However, balance and mobility disorders are difficult to diagnose and treat using a traditional model of care, which focuses on localizing and treating specific pathology. The challenge lies in the fact that
  1. balance disorders do not represent a single disease, but occur in association with, or are a combination of multiple disorders; and
  2. balance problems can result from combinations of subtle degenerative, infectious, or injury processes, none of which are clinically significant in isolation.1

Patients with similar pathologies frequently present with significant differences in impairments and function. Because of these differences, patients with similar pathologies respond differently to a given treatment. The first task of the practitioner, therefore, is to determine whether a balance problem is sensory, integrative or motor in nature.2

Objective Clinical Tests of the Balance System

Because the interdependent systems that maintain balance control (stable gaze and postural control systems) are distinct, assessments of the individual systems play very different and complementary roles in management of balance disorders.

VOR tests such as electronystagmography (ENG) and rotary chair are frequently referred to as "vestibular function" tests. These VOR tests provide "site-of-lesion" information relative to the type and location of pathology. However, they provide little information relative the patient’s symptoms and functional problems.

Clinical tests of gaze and postural stability, such as Computerized Dynamic Posturography (CDP) and dynamic visual acuity (DVA) tests, provide clinical information specific to the patient's use of individual sensory inputs and motor reactions under a variety of daily life conditions. This information relates well with the patient's symptoms and functional complaints, but provides little by way of site-of-lesion information.

Why are both site-of-lesion VOR and postural stability tests clinically necessary? The answer lies in the fact that most chronic balance problems can be medically stabilized, but seldom cured by surgical and/or pharmacological treatments. Once a patient’s medical problems are stabilized, however, many of the associated functional problems can be reduced or eliminated by rehabilitation treatment. Site-of-lesion information is essential to planning medical treatments. Functional information about how the individual patient utilizes sensory information and motor reactions maximizes the effectiveness of rehabilitation by targeting exercises to the patient’s specific functional problems.

Managing Patients with Balance Disorders

The most effective strategy to managing these complex patients is an evidence-based multidisciplinary approach that focuses on impairments, functional limitations, and resultant disability,3-6 while taking pathological information into account. Highlights of this model include:
  1. Classification of patients based on pathology, impairments and functional limitations
  2. A care plan based on accurate patient classification, which includes progress indicators and expected outcome.
  3. Access to surgical, medical and rehabilitation treatments as appropriate.

Comprehensive Patient Management

Clinical outcome studies have demonstrated that management models utilizing impairment reduction treatment strategies customized to each individual patient’s impairments are cost-effective and provide better outcomes than models focusing on pathology alone.7-10

References:
  1. Tinetti, et al (2000). Dizziness among older adults: A possible geriatric syndrome. Annals of Internal Medicine 132:337-403)
  2. Goebel, JA ed. (2001) Practical Management of the Dizzy Patient. Lippincott, Williams & Wilkins.
  3. Managed Care Quarterly 4: 5-11
  4. World Health Organization (1999). ICDIH-2 International Classification of Function and Disability. Beta-2 draft. Short Version. Geneva, Switzerland.
  5. World Health Organization (1997). International Classification of Disease, 9th rev. Clinical Modification. New York, NY.
  6. Verbugge, L, Jette (1994). "A disablement process." Soc Sci Med. 38: 1-14.
  7. Black FO, Angel CR, Pesznecker SC, Gianna C (2000). "Outcome analysis of individualized vestibular rehabilitation protocols." American J Otology 21:543-551.
  8. Calder JH, Jacobson GP (2000). "Acquired bilateral peripheral vestibular system impairment: rehabilitative options and potential outcomes." J American Academy Audiology 11:514-521.
  9. Shepard NT, Telian SA (1996). Practical Management of the Balance Disorder Patient. Singular Publishing Group, Inc., San Diego, 221pp.
  10. Rose D, Clark S (2000). "Can the control of bodily orientation be significantly improved in a group of older adults with a history of falls?" JAGS 48:275-282.

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