This online series of 4 sessions was recorded at Inger Brueckner’s live course.
COURSE DESCRIPTION:
This course was created out of frustration with the way children respond to traditional vestibular rehabilitation. Children are not “just smaller adults” and they have unique presentations and responses to intervention. Current literature finds that children have similar rates of vestibular dysfunction as adults. This has created the need for specialization intervention.
This course will present current understanding of the scope of the problem, best practice, systematic evaluation and treatments to address vestibular deficits in the school-aged child and adolescent. The course combines lecture, hands-on lab, and case study to accurately and efficiently address dysfunction. This course is updated as new information and guidelines are published. The primary goal is to challenge therapists to re-think movement and stillness in their practice, using a comprehensive understanding of the vestibular system. Principles presented can be applied across the lifespan and with a multitude of disability levels.
LEARNING OBJECTIVES:
- Describe developmental anatomy and physiology related to the vestibular system, including related reflexes, and balance
- Choose the most relevant, time efficient evaluations specific to functional deficits and be able to take these findings to create and modify a treatment program
- Recognize dysfunction that can be addressed and red flags that signal the need to referral to other medical provider
- Be able to educate patients, caregivers and other medical team members about the identified vestibular involvement in the child’s functional complaints
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SCHEDULE:
I. Understanding the Vestibular System in Children and Adolescents – 2 hours (95 minutes plus 15 minutes to watch the YouTube video plus 15-minute posttest=2 hours):
0-15 minutes:
• Introduction to Evidence based practice. Functional implications of the child with dizziness. Impact of interruptions in the development of a vestibular in children. The anatomy and physiology of semicircular canals.
16-30 minutes:
• Motions detected by the vestibulocochlear system and head orientations. The significance and functions of the otoconia and otoliths.
31-45 minutes:
• Treatment significance of velocity detections within the vestibulocochlear system, vestibular physiology. Cranial nerves and vascular systems associated in relation to treatment considerations and trauma incidences.
45-60 minutes:
• Children v. the adult brain. Crucial vestibular reflexes including ocular motor, postural reflexes, spinal/cervical involvement implications. Central nervous system processing. Outward symptoms of dysfunctions.
60-75 minutes:
• Development of the vestibular system and reflexes related to the different presentations of children and adults. Guides for development of each reflex. Balance, weight shifting, and the cerebellum.
75-95 minutes:
• Hippocampus development and impact on the brain, adolescent brain development, pruning of the grey and white matter, evidence-based research study on ocular motor skills in children (fixation, smooth pursuits, saccades, visual drift), functional impairments.
• Review of evidence-based research on prevalence of dizziness in children, how children report symptoms of dizziness, epidemiology, signs that vestibular system isn’t developing properly.
II. Pathology: The Child with Vestibular Symptoms (2.5 hours including a 15 minute post-test):
0-15 minutes
• Nystagmus-peripheral v. central, red flags to look for, anatomy of the vestibulocochlear system and the effect on nystagmus, and vestibular neuritis.
16-30 minutes:
• Implications for otitis media (ear infections), sensorineural hearing loss (SNHL), cochlear implants, labyrinthitis, bilateral vestibular loss, cystic fibrosis, ototoxicity: Streptomycin, Cancer Therapy,
30-45 minutes:
• Chemo toxicity, BPPV and its effect on children’s functioning and vestibular system
45-60 minutes:
• BPPV after trauma, Meniere’s disease, peri lymphatic fistula, cranial trauma, mTBI, central vestibular syndrome, vertigo and headache relationship
60-75 minutes:
• Migraine and its relationship to the vestibular system including symptoms and interactions.
75-90 minutes:
• Central dysfunction related to concussions, lesions and tumors, cervical vertigo, whiplash, TMJ, Canalithiasis, Cupulolithiasis
90-105 minutes:
• Cervical trauma/considerations, trauma/falling and related pathology, vertebral artery complications after trauma, Concussion/TBI
105-120 minutes:
• Cellular changes after concussion/TBI, extended healing times for children, cardiovascular symptoms from TBIs, risk factors for longer recovery times in children (learning disabilities, anxiety, migraines). Review of literature.
120-135 minutes:
• Brain resiliency, literature on brain injuries and the effects on the body autonomic nervous system related to vertigo and related symptoms, visual sensitivity an dependence, ocular motor related to increasing use of technology.
135-150 minutes:
• Vestibular considerations for children with CP, anxiety, DBR syndrome, Adolescent drug use, ADHD, autism, idiopathic scoliosis.
III. Pediatric Vestibular Screening and Assessment: Evaluation and Testing – 4.5 hours (including a 30 minute post test):
0-15 minutes:
• How to pare down assessments to tailor to the pediatric population. Importance of history to understand dysfunction. Overview of how to start: Observe posture, ocular motor, positional changing modified, movement tolerance/effect on functioning. Subjective reports, visual complaints, hearing, pain, clumsiness, school functioning, social functioning. Other considerations (secondary gain, use open ended questions). What is the complaint, time of day, and what are the functional ramifications?
15-30 minutes:
• Non verbal signs. How to explain treatments and they WHY behind symptoms and treatment. Plan to give them something to walk away with on first day. Screens: neck AROM, movement screen. Video: understanding doctor’s screens in ER and neurologic screens. Cervical rotation and vertebral artery functioning screen and contraindications.
30-45 minutes:
• Demonstration of cervical rotation and what to look for. Smooth pursuits, saccades, accommodation – the difference of what therapists look for vs. doctor,
45-60 minutes:
• Video to understand what doctors look for in ocular motor testing. Demonstration of how therapists can test more functionally to assess ocular motor functioning. – What to look for and sequence of tests.
60-75 minutes:
• Ocular motor modifications for testing children. Developmental optometrist interview with functional implications for ocular motor dysfunction. Options for BPPV testing demonstration with modifications for children and what to look for.
75-90 minutes:
• Answered questions about BPPV testing and demonstration on table as opposed to the floor and possible reported symptoms. Horizontal canal testing and what to look for. VOR testing, and testing of vertical and horizontal planes and what to look for. Head thrust test and why it is difficult for children. Head impulse test, which is only for very complaint patient.
90-105 minutes:
• Dynamic visual acuity with vestibular component. Head shaking. Imaginary target testing to test for cervico-cephalic kinesthesia and VOR. Balance testing and screening (static, dynamic and movement) the progression and what to look for.
105-120 minutes:
• Static sitting screen with wedge, dynamic tilt assessment, cervical stability with balance assessment – looking at their ability to take in feedback to change movement patterns and signs of dysfunction. Spinning assessment, activities and what to look for. Motion sensitivity quotient to see what movements trigger dizziness and design HEP. Red flags to look for.
120-135 minutes:
• Rotational chair, cVEMPs. Findings related to functions, head stability and ways to explain this to children. Games with laser pointer and head mount. Importance of staying still and modification on exercises.
135-150 minutes:
• Variety of Bal-a-vis-x exercises (grading up and down, incorporating crossing midline, coordination, and ocular motor skills etc…) and functional implications. Bean bag activities to incorporate ocular-vestibular skills
150-165 minutes:
• Bean bag activities continued incorporating coordination, ocular motor skills, movement, bilateral coordination, diagonal planes,
165-180 minutes:
• Activities in multiple planes with prone, side lying, and moving. Substitutions/compensations to watch for. How to assess postural changes with ocular motor skills, Note which eye muscles work, if the eyes work together and what the children are avoiding Smooth pursuits, visual convergence, saccades and note any symptoms from ocular movements. Peripheral nervous system -parasympathetic and sympathetic nervous system impact on functioning in children.
180-195 minutes:
• Autonomic nervous system components with standing. Orthostatic reactions and symptoms reported. Incidence of syncope in varying ages of children and triggers. Dysautonomia and ANS related dizziness signs and symptoms in children. Orthostatic hypotension anatomy, physiology. Signs and symptoms and variations.
195-210 minutes:
• Populations with POTS and precursors. mTBI and ANS dysfunction. GI symptoms associated with sympathetic nervous system. Associated conditions. POTS signs, symptoms and recommendations. ANS exercises while lying down, endurance training and efficacy. Vestibular system with ANS functioning. Stress and the vestibular system. Exercises and treatment considerations to improve ANS dysfunction.
210-235 minutes:
• Considerations for psycho-somatic issues and how therapists can help. Vestibular variations in adolescents and women. Interplay of vestibular system with estrogen/hormones. Vestibular warm up.
235-250 minutes:
• Components of balance to consider. Dynamic Gait Index. Functional reach. Timed floor to stand. Timed up and go with child norms. Pediatric berg balance scale and considerations of how the child follows verbal directions. Four-square test.
250-265 minutes:
• High level balance tests: Community balance and mobility scale. Star excursion and Y subtest. Sensory organization test. Dynamic activity. Convergence insufficiency. Objective measures and variations.
IV. Practical Treatment Techniques for the child with Vestibular Symptoms to Improve Function and Participation (includes lab)-4.5 hours (including a 30 minute post test):
0-15 minutes:
• Overview of how to explain important lifestyle changes to children and the effect it can have on their health. Importance of sleep and precautions with supplements such as melatonin. Exercise and implications for mTBI and recovery from dizziness. Importance of hydration and good nutrition.
15-30 minutes:
• Treatment Principles: Adaptation, habituation, sensory substitution, repositioning maneuvers, balance, gait, conditioning, and maintenance programs. Evidence behind treatment principles. When to refer out. Effect of stress on vestibular disorders. Home exercise program (HEP) guidelines for best compliance rates (duration and time of day)
30-45 minutes:
• Importance of re-evaluating after 4 sessions. Manual technique principles. BPPV limitations, precautions, and best practices. BPPV clinical guidelines and treatment. Foster self treatment. Home Epleys treatment. Semont treatment.
45-60 minutes:
• BPPV lab demonstration. Tests and treatments that cause minimal side effects for children. What to look for during treatment and how to document treatment in notes..
60-75 minutes:
• Time for practice technique for 20 minutes. School considerations: saccadic movements in reading, smooth pursuits, balance in school, convergence. School psychologist/case study on how to support children with concussions in school. Return to learn. How long to wait before athletes can return to school sports.
75-90 minutes:
• Adaptations in 504 plans vs. IEP with children with vision and vestibular changes. FL-41 filter glasses for migraine glasses. Vision changes related to the neck. Glare and vision. Importance of eye rest.
90-105 minutes:
• How to improve posture, ergonomics, and other considerations for vision. How to vary and grade treatments. Visional motion sensitivity – children need to work on fixation and fun treatment ideas. Gaze stability with VOR treatment intensity and duration considerations for children. Treatment ideas to improve VOR reflex.
105-120 minutes:
• Multiple treatment ideas and video demonstrations, ways to use meaningful and functional activities. How to grade intensity and duration of treatment.
120-135 minutes:
• Continued treatment ideas lab with indications, what to look for (increasing symptoms, and compensations etc.), and finding appropriate variations. How to treat utricle, saccule, and different semi-circular canals. How to improve accuracy in children to effectively treat symptoms. Low cost treatment ideas.
135-150 minutes:
• More low cost and minimal equipment interventions. How and what to document. Gradations and modifications for children. Auditory sensitivity modifications.
150-165 minutes:
• How to effectively use swing treatments. Sensory considerations and how to structure treatment sessions. Lab: case studies and what treatment ideas to include, progression, and HEP to assign.
165-180 minutes:
• Case studies continued with treatment progressions and other considerations for complex cases. How to apply treatment to children’s everyday functioning and school performance.
180-195 minutes:
• Putting it all together: applying anatomy, theory, evaluation and treatment to children with vestibular issues. Answers to complex questions from participants.
195-210 minutes:
• Motion sickness. Relieving symptoms with manual therapy and kinesio tape. Associative awareness technique (mindful-based technique) to calm the autonomic nervous system. Other symptom relieving techniques: manual therapy, cervical pillows, breathing techniques, and empowerment to overcome symptoms.
210-235 minutes:
• Lab for symptom relief therapies. Feedback from instructor. Intercostal release for improved breathing and decreased dizziness upon standing. How to talk to parents about vision. Treatment progression: end with symptom relief.
235-241 minutes:
• Where/when to refer patients. How to incorporate function into treatment. How to modify treatments. Wrap up.
