Synapse AUTUMN 2004 - acpin

Syn’apse ● AUTUMN/WINTER 2004
LETTERS
■ YORKSHIRE
Caroline Brown
Regional Representative
Other topics have included Fiona
Jones on ‘Whose confidence is it
anyway?’ in relation to the treatment
these have been organized at
different venues around the region
(York, Leeds and Huddersfield).
If you have any ideas for future
lectures or venues please contact me
on 01904 725747. It will be great to
Letters
good referral diagnosis. But it rests mainly on good knowledge of vestibular
anatomy, physiology and pathology, combined with a willingness to listen to the
patient’s description of their problems.
Another six months have flown by,
of stroke patients, and Anna Jones
The committee continues to
hear from you. As always all the
Commonly it is left to the physiotherapist to determine the physiotherapy
and Yorkshire ACPIN continues with a
few new faces on the committee.
They were thankfully recruited at our
(not related!) on the Rescue Project.
By the time this goes to print we will
also have held a day on ‘Incomplete
beaver away to finalise the
programme for the next six months,
which we hope will include both
details of Yorkshire ACPIN events will
be sent to each member and
advertised in Frontline.
VESTIBULAR REHABILITATION: A REJOINDER
Dr Andrew King Senior Lecturer, Physiotherapy and Diatetics Subject Group, Coventry University
diagnosis, after medical staff have referred a patient with a medical label in the
hope that the patient will benefit from rehabilitation. In Greenaway’s audit for
example, there were patients with ocular melanoma, tinnitus, and hyperacusis,
AGM, where Ray Tallis delivered some
spinal injuries’ with Lynne Fletcher.
lectures or practical sessions on the
none of which are normally indications for physiotherapy. Sometimes it may be
excellent lectures.
To help with travelling for members,
MS Guidelines and FES.
A knowledge of the vestibular contribution to balance is vital in neurological
necessary for the physiotherapist to refer back to medical staff patients for whom
rehabilitation. For this reason I welcome Caroline Greenaway’s audit of a
vestibular rehabilitation is inappropriate. This tension between the medical and
vestibular rehabilitation programme in the last edition of Synapse (Greenaway
physiotherapy diagnosis is perhaps present through the whole spectrum of
2004). That article raised a number of issues which deserve further attention. I
physiotherapy, and is an inevitable corollary of the physiotherapist’s unique role in
would like to focus briefly on three areas: first, physiotherapy diagnosis in balance
recovery and of the physiotherapist’s status as an autonomous professional. (But it
disorders; secondly, the appropriate components of a vestibular rehabilitation
does make audit using referral diagnoses very difficult indeed.)
programme and thirdly, the relevance of vestibular rehabilitation to people with
neurological conditions.
2. Components of vestibular rehabilitation
Greenaway’s rehabilitation programme used the Cooksey-Cawthorne exercises.
1. Diagnosis
At the Leicester Balance Centre we incorporate elements of these exercises to
In her invaluable book Vestibular Rehabilitation Susan Herdman (Herdman 2000)
encourage adaptation and habituation. The choice of movements used are
makes an important distinction between the medical diagnosis and the
determined less by the original rigid order, and more by the patient’s specific
physiotherapy diagnosis in balance disorders. The medical diagnosis focuses on
problems, as revealed by subjective assessment and posturography.
the specific pathology. The physiotherapy diagnosis is concerned more with the
In addition there will almost always be an element of retraining through
vestibular system as a functioning unit, which is directly relevant to its
exercises involving the vestibulo-ocular reflex (VOR). These were not a part of the
rehabilitation needs. These diagnoses may not map specifically to the old ICIDH’s
Cooksey-Cawthorne programme (Cawthorne 1944 and Cooksey 1946), and were
terms of ‘impairment’ and ‘disability’, but they perhaps stand in the same
not mentioned by Greenaway, but are fully described by Herdman (Herdman
relationship to each other as those terms. For example, a patient with unilateral
2000). Controlled feedback of error signals resulting from a faulty VOR appears to
vestibular hypo-function will require a programme of physiotherapy and
be a potent driver for rapid adaptation and recovery (Herdman 1998). It is a vital
vestibular rehabilitation with the aim of restoring function by encouraging CNS
part of modern vestibular rehabilitation.
adaptation to new levels of signalling from vestibular receptors. That is a
physiotherapy diagnosis. The vestibular hypofunction will result from one of
3. Vestibular rehabilitation in people with neurological conditions
several conditions, such as an attack of vestibular neuronitis, of Ramsay-Hunt
Vestibular rehabilitation is most immediately effective in people with an intact
syndrome, or even subsequent to an attack of Meniere’s disease. These are
CNS who have incurred some insult to the vestibular end organs in one inner ear.
medical diagnoses. (Figure 1)
Recovery is slower and often less complete in people who have a damaged,
On the other hand a patient with one medical diagnosis could present with one
fluctuating or progressively deteriorating CNS, such as in cases of cerebellar
of several physiotherapy diagnoses, depending on the stage of the pathology and
ataxia, or MS. Patients who have ‘vestibular’ symptoms following one-off damage
MISMATCH OF MEDICAL AND PHYSIOTHERAPY DIAGNOSIS 1
Medical diagnosis Physiotherapy diagnosis Treatment
Vestibular neuronitis
Unilateral
Rehabilitation
Ramsay-Hunt syndrome
May lead to
vestibular
using
hypofunction
adaptation
Meniere’s syndrome
Figure 1
the patient’s reorganisation of their systems in response to it. For example, a
patient with Meniere’s disease might present in several ways, ranging from a state
in which rehabilitation would be inappropriate, to a condition requiring vestibular
rehabilitation working through adaptation and habituation, or a state requiring
advice and recommendations to adopt substitutive strategies. (Figure 2)
The ability to make such diagnoses requires good assessment skills and in some
cases some good equipment, and it is usually (but not always) facilitated by a
to the CNS such as in CVA or TBI, may have better prospects for successful
outcomes to a programme of vestibular rehabilitation.
I would like to highlight here the need for accurate differential diagnosis, and
the possibility of a secondary vestibular condition overlying a primary
neurological condition. I remember very well a lady with MS who presented at the
Leicester Balance Centre. She had a long history of vague unsteadiness, a fine
resting nystagmus, and she performed poorly on posturography. But in addition
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