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325
References
1. Ghez C (1991) Posture. In: Kaendel ER, Schwartz JH, Jessell TM (eds) Principles of neural
sciences, 3rd edn. Elsevier, New York/Amsterdam/London/Tokyo, pp 596–607
2. Angel RW, Hofmann WW (1963) The H refl ex in normal, spastic and rigid subjects. Arch
Neurol 8:591–596
3. YaM K (1979) The organization of voluntary movement. Neurophysiological mechanisms, vol
II. Plenum Press, New York/London, pp 27–503
4. Alpini D, Cesarani A, Barozzi S (1992) Non pharmacological treatment of acute vertigo. In:
Claussen CF, Kirtane MV, Schneider D (eds) Diagnostic procedures and imagining techniques
used in neurotology. Proceedings of the XVI NES Congress. Werner Rudat & Co, Nachf ed
m + p, Hamburg, pp 337–340
5. Thompson AK, Chen XY, Wolpaw JR (2013) Soleus H-refl ex operant conditioning changes the
H-refl ex recruitment curve. Muscle Nerve 47(4):539–544
6. Oliveira MI, Machado AR, Chagas VG, Granado TC, Pereira AA, Andrade AO (2012) On the
use of evoked potentials for quantifi cation of pain. Conf Proc IEEE Eng Med Biol Soc
2012:1578–1581
7. Shields RK, Dudley-Javoroski S (2013) Fatigue modulates synchronous but not asynchronous
soleus activation during stimulation of paralyzed muscle. Clin Neurophysiol
11:S1388-2457(13)00278-2
8. Okuma Y, Bergquist AJ, Hong M, Chan KM, Collins DF (2013) Electrical stimulation site
infl uences the spatial distribution of motor units recruited in tibialis anterior. Clin Neurophysiol
18: S1388-2457(13)00315-5
9. Lagerquist O, Mang CS, Collins DF (2012) Changes in spinal but not cortical excitability following combined electrical stimulation of the tibial nerve and voluntary plantar-fl exion. Exp
Brain Res 222(1–2):41–53
31 The Neurophysiological Basis of Vestibular Electrical Stimulation
327
D.C. Alpini et al. (eds.), Whiplash Injuries,
DOI 10.1007/978-88-470-5486-8_32, © Springer-Verlag Italia 2014
32.1 Introduction
Reeducation of the proprioceptive refl exes is especially indicated in posttraumatic
disequilibrium. This method uses the theoretical premises of the method known as
“proprioceptive neuromuscular facilitation” by (1) the use of nervous information
of surface origin (tactile data) and (2) coordination of the information of deep origin
(joint place, stretching of tendons, and capsuloligamentous complexes).
This peripheral information stimulates the nervous system, which triggers the
muscle. In this way the patient may relearn to balance on his foot or knee via recoordination of the refl exes in unstable positions. He thus learns progressively to
admit and understand the unstableness after an accident and is guided to fi ght
against this residual unstableness through an improved muscular interplay [ 1 , 2 ].
Skitter is a ski trainer platform comprised of an oscillating plate on which two
foot pads are placed. Each foot pad is able to move anteroposteriorly (toes up and
toes down) and lateral senses also allow torsional movement of each foot. The plate
on which the two foot pads are placed is able to surf on an oscillating small table
(Fig. 32.1a ).
The oscillations of the table are slowed by elastic cords that regulate the resis-
tance with which the device opposes the patient’s movements. These movements of
M. Savini
Istituto Clinico Città Studi , via Jommelli 17 , Milan , Italy
D. C. Alpini (
*)
ENT-Otoneurology Service , IRCCS “Don Carlo C. Gnocchi” Foundation , Milano , Italy
e-mail: dalpini@dongnocchi.it
A. Cesarani
Department of Clinical Sciences and Community Health ,
University of Milan , Milano , Italy
Audiology Unit , IRCCS “Ca’ Granda” Ospedale Maggiore Policlinico , Milano , Italy
e-mail: antonio.cesarani@unimi.it
3 2
Ski Trainer Oscillating Platform: Proprioceptive Reeducation
M. Savini, D. C. Alpini, and A. Cesarani
328
the feet and, especially, surfi ng and oscillating of the body simulate the movements
performed during skiing (Fig. 32.1b ).
We usually employed Skitter for proprioceptive reeducation of posttraumatic
unsteadiness and dizziness because it allows the use of cognitively involved exercises and improvement of sensorial coordination when visual feedback is
a
b
Fig. 32.1 Skitter ( a ) and
skier ( b )
ab
Fig. 32.2 Forward ( a ) and backward ( b ) leg extensions
M. Savini et al.
329
associated in order to improve head-to-trunk dynamic stabilization [ 3 ]. To success-
fully reeducate refl exes by this method, active cooperation of the subject is needed.
The careful activity of a reeducator or of a physiotherapist offers better chances of
success [ 4 ].
In whiplash patients we standardized a protocol that has been used in patients
ranging from 18 to 45 years of age. According to the obvious limits of age, Skitter
can be employed (with the constant help of the reeducator) also in older subjects,
but usually it is not possible to perform the entire protocol. To achieve a good result,
it is crucial that the articulations of ankle, knee, and hip are complete and that the
muscular tone, especially of the thigh, is good. Sometimes previous tonifi cation of
the muscles is in fact necessary before starting reeducation of the proprioceptive
refl exes.
32.1.1 Forward Leg Extensions (Fig. 32.2a )
1. With one foot on the end cap and the other across the foot pad, the patient keeps
his weight forward and extends the front leg in a controlled manner, then he
returns slowly and repeats. It improves quads and trunk muscles and stabilizes
ankles and knees.
2. The patient maintains the leg extension position, and the therapist destabilizes
him by moving the platform during visual fi xation of a point.
3. The patient performs a leg extension with closed eyes to improve self-perception
of muscle tone.
ab
Fig. 32.3 Ankle-hip lateral strategies ( a ) and with oscillations ( b )
32 Ski Trainer Oscillating Platform: Proprioceptive Reeducation
330
32.1.2 Backward Leg Extensions (Fig. 32.2b )
This is similar to forward leg extensions except the focus is on the rear leg. With a
stable, controlled movement, the patient extends the leg back to the end and repeats
on both legs. It improves gluts and quads, hamstrings, and trunk muscles, and stabi-
lizes ankles and knees.
According to the neuro-otologic and equilibriometric characteristics of the
patient, leg extensions should be performed for both legs or only for one leg.
32.1.3 Ankle-Hip Strategies (Fig. 32.3a )
The patient steps on the foot pads with feet centrally positioned. Then he concen-
trates on proper posture using a mirror to see his refl ection and transfers his weight
from one foot to the other with a smooth fl owing motion.
During this smooth and rhythmic weight transfer, the therapist induces body
movements according to ankle or hip strategies.
32.1.4 Visual Feedback
The patient is comfortably stable on the foot pads. With his thumbs and extended
limbs, he tries to touch some visual targets placed in different positions on a mirror
in front of him.
32.1.5 Oscillations (Fig. 32.3b )
The patient steps on foot pads with feet centrally positioned. Then he concentrates
on proper posture using a mirror to see his refl ection. With eyes closed he transfers
his weight from one foot to the other with a smooth fl owing motion. During this
smooth and rhythmic weight transfer, the therapist pushes the bumpers at one end
of the Skitter inducing a sudden and unpredictable inclination of the device.
32.1.6 One Leg
The patient maintains equilibrium on one leg with the other extended (Fig. 32.4a ) or
fl exed (Fig. 32.4b ) or with one leg lateral (Fig. 32.5 ). The therapist helps the patient
either to maintain equilibrium or to correct his posture. A mirror facilitates postural
equilibrium strategies correction.
32.1.7 Slalom (Fig. 32.6 )
The patient steps on the foot pads with feet centrally positioned. Then he concentrates on proper posture using a mirror to see his refl ection and begins to transfer
his weight from one foot to the other with a smooth fl owing motion. As his rhythms
M. Savini et al.
331
increase he will get closer to the bumpers at each end, always maintaining good
upright posture with eyes focused in the mirror and paying attention to his balance.
If the exercise is performed with limited upper body movement (such as in slalom),
it improves hip rotators, quads, and calves, while it stimulates abdominal stabilizers and gluts when the patient includes upper body motion (such as in giant slalom). Exercises have to be performed concentrating on proper edge setting
techniques.
a
b
Fig. 32.4 Extended ( a ) or fl exed ( b ) exercises with one leg
Fig. 32.5 One-leg exercise
32 Ski Trainer Oscillating Platform: Proprioceptive Reeducation
332
32.1.8 Ankles Stability
The patient keeps his knees straight pushing the skate forward with his toes and
pulling back with his heels. He has to concentrate on using only the ankles and
calves, while all the other muscles are relaxed. It improves calves and ankle stability
and balance proprioception.
References
1. Corna S, Nardone A, Prestinari A, Galante M, Grasso M, Schieppati M (2003) Comparison of
Cawthorne-Cooksey exercises and sinusoidal support surface translations to improve balance
in patients with unilateral vestibular defi cit. Arch Phys Med Rehabil 84(8):1173–1184
2. Nardone A, Godi M, Artuso A, Schieppati M (2010) Balance rehabilitation by moving platform and exercises in patients with neuropathy or vestibular defi cit. Arch Phys Med Rehabil
91(12):1869–1877
3. De Nunzio AM, Nardone A, Schieppati M (2005) Head stabilization on a continuously oscillating platform: the effect of a proprioceptive disturbance on the balancing strategy. Exp Brain
Res 165(2):261–272
4. Fairburn PS, Palmer R, Whybrow J, Fielden S, Jones S (2000) A prototype system for testing
force platform dynamic performance. Gait Posture 12(1):25–33
Fig. 32.6 Slalom exercise
M. Savini et al.
333
D.C. Alpini et al. (eds.), Whiplash Injuries,
DOI 10.1007/978-88-470-5486-8_33, © Springer-Verlag Italia 2014
33.1 Introduction
Maintaining postural stability is a complex process [ 1 ] involving the coordinated
actions of biomechanical, sensory, motor, and central nervous system components.
A relatively simple biomechanical defi nition for postural stability can be formulated
in terms of the position of the body center of gravity relative to the base of support.
The body movements used to maintain postural stability, however, are complex
because of the number of joint systems and muscles involved. The center of gravity
(CoG) is the point at which the whole weight of a body may be considered to act. In
humans who are standing quietly and vertically erect, the CoG is located at the level
of the hips and slightly forward of the ankle joints. CoG height is 0.5527 of total
height. CoG and center of mass (CoM) are equivalent points in space when the
gravitational fi eld is uniform and gravity is the only force under consideration.
Shumway-Cook et al. [ 2 ] conducted the fi rst study that used objective visual
feedback (VFB), based on symmetry of postural sway (movement of the CoG), for
training purposes.
D. C. Alpini (*)
ENT-Otoneurology Service , IRCCS “Don Carlo C. Gnocchi” Foundation , Milan , Italy
e-mail: dalpini@dongnocchi.it
A. Cesarani
Department of Clinical Sciences and Community Health , University of Milan , Milan , Italy
Audiology Unit , IRCCS “Ca’ Granda” Ospedale Maggiore Policlinico , Milan , Italy
e-mail: antonio.cesarani@unimi.it
M. De Bellis
ENT Department , Desio Hospital (Mi) , Milan , Italy
R. Kohen-Raz
The school of Education, The Hebrew University of Jerusalem, Har ha-Tsofi m , Jerusalem , Israel
D . R i v a
International Society of Proprioception and Posture , via Valgioie 87 , 10146 Torino , Italy
3 3
Visual Feedback Postural Control Re-education
D. C. Alpini , A. Cesarani , M. De Bellis ,
R. Kohen-Raz , and D. Riva
334
Nowadays, a lot of different posturographic equipments are available and VFB is
frequently used to improve postural stability control.
For the scope of the chapter, even if nowadays for postural visual feedback reha-
bilitation [ 3 – 5 ], examples are based on the Balance Master System (Neurocom,
Clackamas, OR, USA, http://resourceonbalance.com ), Tetrax FB System (Tel Aviv
Israel, www.tetraxfb.com ), and the Delos System (Turin, Italy, www.delos-
international.com ).
Balance Master is an equipment that allows, by means of a dual footplate, a
visual feedback of CoG position, projected on a computer screen facing the patient
standing on the platform [ 6 – 8 ] (see also Chap. 15 ).
Tetrax system is based on recording of separate CoG of the anterior and posterior
part of the 2 ft [ 9 – 16 ] (see also Chap. 15 ).
Delos System is an equipment constituted by a unstable and oscillating platform
and two accelerometers, one on the trunk [ 17 ] and one on the head (see also Chap.
16 ). In this way the visual feedback projected on the screen may regard the move-
ments of the table or the trunk or the head or a combination of the three.
33.2 Balance Master
When normal subjects maintain a vertically erect position, the CoG is located
directly over the area of the feet support, slightly forward of the ankle joints. This
position can be maintained without stepping or reaching for support if sway does
not exceed the subject’s limits of stability (Fig. 33.1 ).
Functional stability limits (limits of stability, LoS) have been calculated to be
6.25″ anteriorly and 4.45″ posteriorly for the average adult subject. The angular
limits of stability are very nearly the same for all adults regardless of height. The
biomechanical properties that determine the LoS are similar for standing in place,
walking, and sitting without trunk support. For these reasons reeducation of the
limits of stability in standing in place can be used to rehabilitate the patient to regain
normal LoS during walking, too.
LoS test and exercise require the subject to be able to actively move his/her CoG
away from the center toward a visual target and maintain that position for the
required time. The correct execution of the LoS test requires normal combined and
integrated ankle-hip strategies (Fig. 33.2 ).
LoS parameters to be considered are:
Movement time , how many seconds the patient takes to reach the desired target
(including the reaction time).
Path sway , that refers percentage of path length.
Target sway , percentage of maximum CoG area maintained on the target.
Patient position , value given in polar coordinates that represents the average position of
the COG during the period of target sway assessment. If the target was not reached,
the patient position score refl ects the point of closest approach to the target.
Distance error , difference between the patient’s average position and the center of
target. This parameter allows one to see how far away from the center the patient
is willing and able to move in a given direction.
D.C. Alpini et al.
335
LoS misperception is common fi ndings in whiplash patients. In these cases train-
ing aimed at teaching the appropriate conditions for using ankle movements can
have a positive impact. In contrast, weakness of ankle joint muscles, loss of ankle
sensation, reduced mobility about the ankles, or combinations of these factors prevent the patient from generating effective ankle movements and might be an abnormal adaptation used by a dizzy patient to minimize head movements and associated
stimulation of the neck and vestibular system.
By means of the Balance Master it is possible to treat patients ranging from 76 to
203 cm in height and from 18 to 138 kg in weight. Each treatment session can be
performed according to the LoS, ranging from 25 to 100 % of the predictable LoS,
in 5 % increments. The target pacing is 1, 3, 5, 7, 10, 15, and 20 s. If trying to promote faster movement, then low pacing settings (1, 2, 5 s) are appropriate. If stability at points in space is desired, then higher pacing settings (10 s or higher) are
appropriate so that the patient must “hold” a position (Fig.
33.3 ).
The duration of each session treatment is 20 min. The frequency generally varies
from twice a week to every day treatment. The frequency of training sessions is
dependent on a combination of other rehabilitative treatments such as physical
therapy and vestibular electrical stimulation.
Fig. 33.1 Balance Master
equipment
33 Visual Feedback Postural Control Re-education