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Nancy - France September 22-24, 2011

Marcel Norres V.H.T. An old and very good technic of vestibular habituation training
R. BONIVER

Introduction
Vestibular rehabilitation is essentially a physical therapy program for persons with symptomatic lesions of the vestibular system. When applied early after the insult it can hasten compensation and reduce symptoms resulting from permanent deficits caused by vestibular injury. It has been shown to be effective when applied to patients with either unilateral or bilateral losses. Compensation occurs through tonic rebalancing at the level of the vestibular nuclei by substitution of vision, proprioception, and peripheral sensation for the missing vestibular input, and by the use of behavioral strategies to deal with the residual deficits. The latter two mechanisms can be facilitaded with vestibular rehabilitation exercises.

Treatment methods must be varied based on the patients underlying disorder. The best prognosis for full recovery is for individuals with acute unilateral vestibular injury. Patients with bilateral lesions will show improvements but will have permanent deficits. Rehabilitation includes vestibular exercises, management of vestibular suppressant medications, general conditioning, and patient instruction. Treatment of symptomatic dizziness is based upon habituation to the provoking stimulus, usually head or eye movement.

Indications of vestibular rehabilitation

Unilateral vestibular dysfunction or weakness on one side of the vestibular system


Bilateral vestibular dysfunction Benign Paroxysmal Positional Vertigo (BPPV) in cases of failure of liberatory procedure

Rationale of Rehabilitation Treatment


There is obvious clinical and experimental evidence that compensation develops progressively in a rather fast way for the static components, in a slower and sometimes incomplete way for the dynamic components. Compensation appears to be a complex mechanism, which includes the intervention of several structures, uses different strategies and evolves at a different rate for the several manifestations of imbalance. It is an active process and it is subject to decompensation. It has been shown that the several signs expressing balance disturbance can have a separate evolution not only concerning their static and dynamic aspects but also concerning VOR and VSR. The development of compensation obviously is dependent on sensory input and needs many central functions from the VNlevel on. If they are lesioned or disturbed (e.g. by drugs), a delay of development of compensation has to be expected.

Multisensory input as well as sensorimotor activity has been proved indispensable for developing compensation. Moreover, repeated confrontation of the centers with the disturbing situation is the very stimulus for adequate re-organization. Indeed adaptation functions as an error-controlled process. A normal functioning of the centers is postulated for successful application of REHAB. Habituation is manifestly a basic mechanism for developing this compensation. - the use of specific exercises adapted to the exact dysfunctional situation in the particular patient; - The very stimulus is repetitive presentation of the situation, which has to be corrected and adapted, to the centers. This means, e.g., that activation is advised as soon as possible after a sudden loss; - It is important to withdraw inhibiting drugs; - Reservations have to be made if central signs are present.

MANOEUVERS OF THE VHT-TESTBATTERY


SEQUENCE
DIRECTION OF MANOEUVER

DESCRIPTION
change of position from sitting supine left side supine standing turning to the right turning to the left sitting, change of position from nose closed to left knee nose closed to right knee sitting, movements turning head CCW ** turning head CW *** bending forward from sitting to erect standing position moving head forwards/backwards change of position from sitting return to sitting position sitting return to sitting position sitting return to sitting position to supine left side right side sitting

M1 M2 M3 M4 M5 *

middle left right middle

M7 M8

right left

to right ear closed to right shoulder left ear closed to left shoulder

M9 M10 M11 M12 M13

* * * * *

M14 M15 M16 M17 M18 M19 * ** ***

left left rignt right middle middle

to

to head hanging and turned to the left head hanging and turned to the right head hanging in midline

to

to

Manoeuvers where nystagmus never occured Counter-clockwise Clockwise

- Application of VHT and follow-up: The Ms found positive (M+) for each particular patient are used as his adequate exercises. Each exercise is repeated five time successively with elicitation of vertigo. The patient maintains the vertigo-eliciting position as long as vertigo is persisting. Two sessions a day are advised. The exercises are executed in an active way, preferably without assistance, except in very elderly people. The therapy is applied at home.

The patients evolution is monitored by weekly repeating the testing on the testbattery. If his total score becomes 0, the end-evaluation is planned approximately two months after onset. If after one week the score is still positive, the patient is re-motivated and encouraged. Application of exercises is corrected, if necessary. The patient is further followed weekly until his score becomes 0. For each patient an end-evaluation is done two months after onset.

How to use the table of score


a) For each manuvre it is noted: - typical vertigo TV - dizziness AV - without vegetative signs TV- or AT- with vegetative signs TV+ or AT+ - intensity +/-, +, +++ - time of symptoms in sec. b) First consider the time and secondly the adequate column.

Your obtain a score and you add the scores of each manuvre to obtain a total score.

V.H.T. EVALUATION (FROM MARCEL NORRE).


+/t= Time in sec. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

+
TV+
6.0 7.8 8.9 9.6 10.2 10.7 11.1 11.4 11.7 12.0 12.2 12.5 12.7 12.9 13.1 13.2 13.4 13.5 13.7 13.8 13.9 14.1 14.2 14.3 14.4 14.5 14.6 14.7 14.8 14.9 14.9 15.0 15.1 15.2 15.3 15.3 15.4 15.5

++
TV9.0 11.7 13.3 14.4 15.3 16.0 16.6 17.1 17.6 18.0 18.4 18.7 19.0 19.3 19.6 19.8 20.1 20.3 20.5 20.7 20.9 21.1 21.3 21.4 21.6 21.7 21.9 22.0 22.2 22.3 22.4 22.5 22.7 22.8 22.9 23.0 23.1 23.2

AV1.0 1.3 1.5 1.6 1.7 1.8 1.8 1.9 2.0 2.0 2.0 2.1 2.1 2.1 2.2 2.2 2.2 2.3 2.3 2.3 2.3 2.3 2.4 2.4 2.4 2.4 2.4 2.4 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.6 2.6 2.6

AV+
2.0 2.6 3.0 3.2 3.4 3.6 3.7 3.8 3.9 4.0 4.1 4.2 4.2 4.3 4.4 4.4 4.5 4.5 4.6 4.6 4.6 4.7 4.7 4.8 4.8 4.8 4.9 4.9 4.9 5.0 5.0 5.0 5.0 5.1 5.1 5.1 5.1 5.2

TV3.0 3.9 4.4 4.8 5.7 5.3 5.5 5.7 5.9 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.8 6.9 7.0 7.0 7.1 7.1 7.2 7.2 7.3 7.3 7.4 7.4 7.5 7.5 7.6 7.6 7.6 7.7 7.7 7.7

AV3.0 3.9 4.4 4.8 5.1 5.3 5.5 5.7 5.9 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.8 6.9 7.0 7.0 7.1 7.1 7.2 7.2 7.3 7.3 7.4 7.4 7.5 7.5 7.6 7.6 7.6 7.7 7.7 7.7

AV+
6.0 7.8 8.9 9.6 10.2 10.7 11.1 11.4 11.7 12.0 12.2 12.5 12.7 12.9 13.1 13.2 13.4 13.5 13.7 13.8 13.9 14.1 14.2 14.3 14.4 14.5 14.6 14.7 14.8 14.9 14.9 15.0 15.1 15.2 15.3 15.3 15.4 15.5

TV+
18.0 23.4 26.6 28.8 30.6 32.0 32.2 34.3 35.2 36.0 36.7 37.4 38.1 38.6 39.2 39.7 40.1 40.6 41.0 41.4 41.8 42.2 42.5 42.8 43.2 43.5 43.8 44.0 44.3 44.6 44.8 45.1 45.3 45.6 45.8 46.0 46.2 46.4

AV9.0 11.7 13.3 14.4 15.3 16.0 16.6 17.1 17.6 18.0 18.4 18.7 19.0 19.3 19.7 19.8 20.1 20.3 20.5 20.7 20.9 21.1 21.3 21.4 21.6 21.7 21.9 22.0 22.2 22.3 22.4 22.5 22.7 22.8 22.9 23.0 23.1 23.2

AV+
18.0 23.4 26.6 28.8 20.3 32.0 32.3 34.3 35.2 36.0 36.7 37.4 38.1 38.6 39.2 39.7 40.1 40.6 41.0 41.4 41.8 42.2 42.5 42.8 43.2 43.5 43.8 44.0 44.3 44.6 44.8 45.1 45.3 45.6 45.8 46.0 46.2 46.4

TV27.0 35.1 39.9 43.3 45.9 48.0 49.8 51.4 52.8 54.0 55.1 56.1 57.1 57.9 58.8 59.5 60.2 60.9 61.5 62.1 62.7 63.2 63.8 64.3 64.7 65.2 65.6 66.1 66.5 66.9 67.3 67.7 68.0 68.3 68.7 69.0 69.3 69.7

TV+
54.0 70.3 79.8 86.5 91.8 96.0 99.6 102.8 105.5 108.0 110.2 112.3 114.0 115.9 117.5 119.0 120.4 121.8 123.0 124.0 125.0 126.0 127.0 128.0 129.0 130.0 131.1 132.0 133.0 133.8 134.0 135.0 136.0 136.0 137.0 138.0 138.0 139.0

From the formula f (A) g (I) log 10 . (t) (M. Norr)

Comparison with sinusodal support surface translation (Corna et al. 2003)

Measures
- body sway and subjective score of sway during quietstana EO or EC.
- Standard deviation of the A.P. displacement of the malleolus, hip and head during A.P. platform translation.

Results
both intervention are effective with the some results.

Advantages of Marcel Norre V.H.T.


- Lost cost furnitures:
- One examination table - One chair

- One cushion for the neck


- Easy to realize, after discussion with the specialist, for the patient at home or with the physiotherapeut

- Easy to evaluate with the score table.

CONCLUSION
Marcel Norres V.H.T. is still up to date for the rehabilitation of vertigo. Marcel Norres V.H.T. is, according to our experience, one of the best treatments for permanent labyrinthine lesions and facilitates quickly the mechanisms of central compensation. This technique is cheap, easy to carry out . We also use V.H.T. with success in failure of liberatory manoeuvers in cases of benign paroxysmal vertigo.

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