The "2024 Academic Annual Meeting of the Vertigo Medicine Branch of the China Association for the Promotion of International Exchange in Health Care and the 5th China Vertigo Medicine Forum" was held in Zhuhai, Guangdong Province from May 10 to 12, sponsored by the Vertigo Medicine Branch of the China Association for the Promotion of International Exchange in Health Care and undertaken by Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine and Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology. This conference invited a number of experts from all over the country to conduct in-depth discussions on new concepts, new technologies and new products in the field of vertigo medicine, bringing a feast of academic gluttony with various forms and rich contents. At this conference, Professor Xiong Binbin from Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine gave a wonderful sharing on the theme of "Vestibular Compensation and Rehabilitation Principles".
The author of this article is the report team of the Yimaitong Vertigo Conference
Yimaitong collated the report, please do not reprint without authorization.
Effects of vestibular dysfunction
The effects of vestibular dysfunction are usually the neglect of the symptoms of "dynamic decompensation" after the spontaneous vertigo of acute vestibular dysfunction disappears, with dizziness, a sense of imbalance, unsteady gait, visual shaking, head-induced vertigo, and vibratory visual hallucinations. Chronic, progressive vestibular impairment can lead to more persistent symptoms, such as a sense of imbalance, decreased dynamic visual acuity, and visual vertigo. Treat with exercise, not drugs – the concept of "vestibular rehabilitation (VRT)" was thus proposed.
History of vestibular rehabilitation
➤ In the 40s of the 20th century, Cawthome & Cookscy introduced a training-based physical therapy to treat vestibular impairment caused by trauma or surgery --
图1. Cawlhorne-Cookscy Exerciscs
➤ In 2016, the American Physical Therapy Association (APTA) issued guidelines for vestibular rehabilitation for peripheral vestibular dysfunction, which were updated in 2021. Guidelines suggest that vestibular rehabilitation is of significant benefit in patients with acute or subacute unilateral vestibular dysfunction, as well as in patients with chronic unilateral or bilateral vestibular dysfunction who remain symptomatic (level of evidence: I., level of recommendation: Strong)
➤ In July 2021, the first "Expert Consensus on Vestibular Rehabilitation" in China was published. It is the first to put forward the formulation strategy of vestibular rehabilitation program, the common dynamic monitoring indicators for evaluating efficacy, and the grading criteria for rehabilitation effect.
Indications for vestibular rehabilitation
· Impaired stable vestibular function
· Central or mixed vestibular lesions
· Vestibular symptoms due to head trauma
· Functional dizziness
· Senile dizziness and balance disorders
· Unexplained vertigo
· Contraindications to vestibular rehabilitation
Contraindications to vestibular rehabilitation
· Cervical spondylosis causes significant restriction of head and neck movement
· The fracture of the body did not recover
· Combined with severe organ insufficiency
· Stroke involves the motor system, resulting in limited mobility
· Severe mental disorder
· The acute phase of vertigo and the period of severe fluctuations in blood pressure
Flow of vestibular rehabilitation
Figure 2
Baseline assessment is an important part of vestibular rehabilitation: medical history + bedside examination + vestibular function examination + scale assessment + imaging examination
Mechanisms of vestibular rehabilitation
前庭康复机制主要是静态代偿和动态代偿，包括前庭毛细胞的复原（Recovery）、中枢对静态前庭张力平衡的重建（Rcbalancc）、残余前庭功能的适应（Adaplion）、前庭功能丧失后的替代（Subslilution）和对不适刺激与感官的习服（Habituation）。
Figure 3
· Adaption: The readjustment of the vestibulo-ocular reflex (VOR) or vestibulospinal reflex (VSR).
· Substilution:(1) the use of other eye movements (saccades, tracking) to replace VOR eye movements; and (2) the use of other sensory (visual, proprioceptive) information to replace the missing vestibular sense
· Habilualion: Repeated exposure to stimuli that trigger symptoms, such as rapid head movements (vertigo induced by head movements), complex visual environments, and fixation on fast-moving objects (visual vertigo).
The goal of vestibular rehabilitation
· Enhanced gaze stability
· Improvement of vertigo symptoms
· Improves postural stability
· Improves ability to perform daily activities
Basic principles of vestibular rehabilitation and related methods
(1) A Strengthen gaze stability (gaze stability training)
· Repetitive false visual signal (rclina slip) stimulation can induce vestibular adaptation, which increases VOR gain
· Different amplitudes, frequencies, directions, and distances of head movements should be used, depending on the strength tolerated by the patient
· Acute vestibular injury is initiated within 2 weeks in the form of weekly follow-up visits + daily home training
· According to the course of the disease, train 3-5 times/day, 20-40min/day, and the course of treatment ≥ 4 weeks
(1) bStrengthen gaze stability (VOR substitution training)
· The enhancement of saccade and tracking eye movements is an adaptation and replacement for the decrease in the speed of slow to slow eye movements of the VOR
· For predictable head movements, the center can pre-encode eye movements (prcprogramming) even earlier than head movements, thereby increasing VOR gain and visual acuity (note: eye movement only, head immobility is not effective)
(2) Improve postural stability (static and dynamic balance training)
· Normal balance strategies: ankle strategy (mainly relying on proprioception), hip strategy (mainly relying on vestibular sense), stride strategy
· Patients with vestibular dysfunction tend to use ankle rather than hip strategies to maintain balance
· Static and dynamic balance training is at least 20min/day, and the course of treatment ≥ 4 weeks
(3) Reduce symptoms of vertigo (uniform training)
· Habit training is performed through repeated exposure to symptom-inducing stimuli
· Training is designed according to the specific action/scenario that induces symptoms, and symptoms can be reduced or disappeared after practice
(4) Improve the ability of daily activities
· In addition to individualized vestibular rehabilitation, activities that require coordination of the head, eyes, and trunk can be performed
· In daily activities, head movement is encouraged; Before training, relax your neck muscles
· Recovery is a long-term process, and establishing a home training program and consistency is key
Evaluation of the efficacy of vestibular rehabilitation
According to the Expert Consensus on Vestibular Rehabilitation, the commonly used indicators that can represent the state of vestibular compensation were screened out from the three levels of subjective scale, physical examination and objective test, and the rehabilitation effect of patients was graded and evaluated. A grading standard for evaluating the effect of vestibular rehabilitation was established, which was helpful to quickly judge the effect of vestibular rehabilitation.
Table 1 Scoring criteria for vestibular rehabilitation
summary
Professor Xiong Binbin concluded that the emphasis on vestibular rehabilitation is to pay attention to the decompensated symptoms (postural instability/imbalance, visual shaking/decreased visual acuity, head-moving positional vertigo, visual vertigo, etc.) after vertigo has stopped, so it is important to assess the patient's current state and daily situation. The basic principle is to allow patients to quickly return to their daily lives through gaze stabilization training, static and dynamic balance training, and uniform training. Individualized rehabilitation treatment should also be developed according to the patient's symptoms and functional impairment. In addition, it is necessary to pay attention to the treatment of comorbidities such as anxiety, depression, and sleep disorders, communicate fully and effectively with patients, pay attention to patient education, and improve patient compliance.
A special report on the 2024 Academic Annual Meeting of the Vertigo Medicine Branch of the China Association for the Promotion of International Exchange in Health Care and the 5th China Vertigo Medicine Forum
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