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Nasretdinova Mahzunova Tahirovna, Karabaev To Hurr Asankulovich, Department of Otorhinolaryngology, the city of Samarkand Uzbekistan Tashkent Pediatric Medical Institute Department of children's Otorhinolaryngology, dentistry course Tashkent Uzbekistan
Samarkand Medical Institute E-mail: luna1088@mail.ru
THE USE OF VESTIBULAR REABILITATION IN PATIENTS WITH VIOLATIONS OF THE VESTIBULAR ANALIZER
Abstract: Vestibular rehabilitation is a simple and effective method of treatment of patients with diseases of peripheral and central parts ofvestibular analyzer. The diagnosis ofvestibular disorders, estimation of severance and dynamics of patient's state is conducted with use of clinical tests with high level of significance. Among such tests there are investigation of spontaneous and end-position nistagmus, Halmagy test, test "to stand up and go for time", test "on one leg equilibration" and so on. Vestibular gymnastic is composed of exercises for visual stabilization and balance training. The results of observation research the purpose of which was to estimate the optimal duration of vestibular rehabilitation in patients with unilateral nonprogressive peripheral vestibular disorder are presented. The optimal duration of treatment was established to be as little as two months.
Keywords: dizziness; vestibular disorders; vestibular rehabilitation.
Vestibular rehabilitation is a relatively simple and effec- dizziness, instability in old age. The most effective vestibular
tive method of treatment of vestibular diseases caused by damage to the vestibular system at the peripheral or Central level. Damage to the vestibular system is common in clinical practice. Thus, according to a recent study conducted in the United States, the prevalence of obvious and hidden vestibular disorders in people over 40 years reaches 35.4% [1]. According to another study, up to 4% of American adults experience chronic balance disorder [2].
The vestibular system performs two main functions: it ensures the stability of the image on the retina, so that objects remain stationary when moving the head, and takes part in maintaining balance. Consequently, diseases of the vestibular system are manifested by dizziness (i.e., a sense of imaginary movement or rotation of obj ects around the patient or the patient in space) and instability. Vestibular disorders, both acute and chronic, significantly limit the daily activity of patients. The impact of chronic vestibular disorders on the quality of life is comparable to the consequences of paresis or amputation of the limb [3].
The goal of vestibular rehabilitation is to reduce visual disorders associated with vestibular dysfunction and restore balance, thereby reducing the risk of falls.
Indications for vestibular rehabilitation are non-progressive peripheral vestibular disorders, diseases with damage to the Central parts of the vestibular analyzer, the consequences of craniocerebral trauma, when disorders of the Central and peripheral vestibular system are often combined, psychogenic
rehabilitation is in non-progressive unilateral peripheral vestibular disorder, for example, due to vestibular neuronitis or labyrinthitis [4]. Rehabilitation in Central vestibulopathies is less effective, but is widely used in the treatment of various diseases of the Central nervous system. Vestibular rehabilitation is impractical in cases of progressive vestibular disease. Diseases manifested by recurrent dizziness, in cases where patients do not experience instability and dizziness between attacks, also usually do not require the appointment of vestibular gymnastics [5].
The study of the vestibular system includes the study of spontaneous and systemic nystagmus, as well as samples that help to establish damage to the vestibular system and determine the level of this damage. The study of nystagmus is an important indicator of the safety of the vestibular system. Nystagmus invariably occurs when the vestibular-ocular reflex is damaged. To detect nystagmus, the patient is offered to monitor the movement of the object located in front of his eyes, in the horizontal and vertical planes. The study of the eye in extreme positions it is not informative, because in this case may appear physiological installation nystagmus, occurring in healthy people.
Peripheral vestibular disorders are accompanied by horizontal and / or torsion nystagmus, which does not change direction when looking in different directions. Vertical nystagmus indicates a lesion of the vestibular nuclei or cerebellar worm. So, nystagmus when looking down ("nystagmus
beating down") occurs at the craniocervical junction anomalies (Chiari anomaly, placebase). It is also possible with stem and cerebellar stroke, lithium poisoning or antiepileptic drugs and multiple sclerosis. Nystagmus when looking up due to the defeat of the tires of the Pons caused by stroke, tumors.
The diagnostic value of the nystagmus test is significantly increased when using Fresel glasses. These simple devices are equipped with lenses with a refractive power of + 16 diopters and a built-in light source. Lenses, on the one hand, prevent the fixation of the eye, which can suppress spontaneous nystagmus caused by damage to the peripheral vestibular system, and on the other - facilitate the visualization of the eye due to the effect of a magnifying glass.
Sample Hallmagi - another way to diagnose damage to the vestibular system. Surveyed offer to fix the eyes on the bridge of the nose situated in front of him the doctor and quickly turn your head alternately in one and the other side by about 15° from the midline. Normally, due to the compensatory movement of the eyes in the opposite direction, the eyes remain fixed on the bridge of the nose and do not turn after the head. In case of damage to the vestibuloocular reflex due to the loss of the function of the vestibular system, the turn of the head towards the lesion can not be compensated by a one-time rapid transfer of the eyes in the opposite direction. As a result, the eyes return to their original position with a delay - after turning the head there is a corrective saccade that allows you to return the eye to its original position. This saccade is easily identified in the study. Positive test Hallmagi indicate damage to the vestibular system. Negative proof Hallmagi suggests that dizziness is due to damage to the cerebellum or, rarely, some departments of the big hemispheres of the brain, and not the vestibular system.
Methods of clinical study of balance and determining the risk of falls include the use of special scales that allow to quantify the severity of existing disorders in the patient. The most common and available in everyday practice for screening assessment of stability and risk of falls are the test "stand and walk for a while", the test of stability on one leg, the test ofwalking speed (preferred and maximum).
Test "get up and walk for a while": the Examinee is offered to get up from a standard chair (seat height 46 cm, armrest height 65 cm), go 3 m, turn around, go back and sit in the chair again. The test is performed in normal everyday shoes; the patient can use a cane or other AIDS that he usually uses when moving. Before performing the test, it is recommended to offer the patient to try to do what will need to be done on time. Normative data for the test "get up and walk for a while" are shown in the (table 1) [6; 7].
In General, a time of less than 10 seconds is considered normal. When you run the test for more than 10 seconds increases the risk of falls. If the patient spends more than 20
seconds on the test, we can talk about a significant limitation of mobility. Performing the test for more than 30 seconds indicates the existence of dependence on outside help in the performance of any daily activities.
Table 1. - Normative data for the test "get up and walk for a while" for different age groups
Age, years Men, with Women, with
40-49 6 7
50-59 7 9
60-69 8 10
70-79 10 11
Stability test on one leg: the Subject is asked to stand at a distance of one meter from the wall or other fixed object. It is better to perform the test without shoes. The test is performed first with open and then with closed eyes. The patient is offered to cross his arms on his chest so that the hands lie on his shoulders, and stand on one leg. It is important that the legs do not touch each other during the study. Measure the time during which the patient can keep his balance. The countdown is stopped if the leg on which the patient rests moves on the floor, if the legs touch each other, the raised leg touches the floor or the patient changes the location of the hands. The second step is asking the patient to perform this test with his eyes closed. In this case, another reason to stop the countdown is the opening of the examined eye. Normative data for the resistance test on one leg for different age groups are given in (table 2.)
Table 2.- Regulatory data for the resistance test on one leg for different age groups
Age, years with open eyes with closed eyes
40-49 29.7 ± 1.3 24.2 ± 8.4
50-59 29.4 ± 2.9 21.0 ± 9.5
60-69 22.5 ± 8.6 10.2 ± 8.6
70-79 14.2 ± 9.3 4.3 ± 3.0
Thus, normally a person over the age of 60 years should be able to stand on one leg with his eyes closed on average at least 5 seconds.there should be no significant difference between stability on the right and left leg.
Apparently, the stability test on one leg has insufficient reproducibility [2] and is hardly applicable for the diagnosis of postural disorders. Nevertheless, it can be used to monitor the effectiveness of rehabilitation [6].
Walking speed test (preferred and maximum): the Subject is asked to walk a distance of 6 m at first with the normal and then with the maximum possible speed. Normative data for the walking speed test are given in table three.
Table 3.- Regulatory data for the walking speed test-preferred and maximum, m/s
Age, years Preferred speed Maximum speed
men women men women
20-29 1.09 1.06 1.95 1.96
30-39 1.27 1.16 1.83 1.65
40-49 1.13 1.08 1.74 1.57
50-59 0.94 1.09 1.17 1.49
60-69 0.95 0.87 1.21 1.27
70-79 0.94 0.85 1.35 1.19
Selection of vestibular gymnastics exercises: Despite the large variety of exercises for vestibular rehabilitation, gymnastics usually includes two groups of exercises: eye stabilization and balance training [7; 8]. The most common exercise to stabilize the gaze is that the patient is offered to fix the gaze on the object located at arm's length, and turn the head from side to side in horizontal and vertical planes. The exercise is performed for 30-60 2-3 times a day. The criterion for the correct speed of head movements is the ability to clearly see the object in the outstretched hand.
As training exercise is complicated: if the patient first performs this exercise sitting, then in the next stage-standing, then-standing in the position of "feet together", then - standing in a tandem position, then - standing on a soft Mat, inclined surface, etc.In addition, the eye can be fixed not only on closely spaced objects, but also on objects located, for example, at the other end of the room.
Another exercise is that in the face of the patient at arm's length have two objects. Objects are usually located 50-60 cm apart so that, looking directly at one of these objects, the patient can see:
1. another. The patient is first offered to keep his head straight and turn his eyes to one of these objects. Then followed the eyes of the patient turn
2. head. After asking the patient to transfer the eye to a second object. Then the patient turns behind the eyes and head. These movements repeat 1-2 min 2-3 times a day.
There are no strictly defined exercises for postural stability and balance training. Walking itself, especially on rough terrain, is already a balance training. As one of possible options of exercise on balance training there can be the following. The patient is offered to walk between several chairs placed in the room. You should move at maximum speed, avoiding the chairs on perhaps a more complex trajectory. Exercise should be performed 2-3 times a day for 1 min.
A total of 46 patients took part in the observational study. Of these, 18(39%) were men and 28(61%) were women. The
median age was 47 years, 95% confidence interval (42.9-51.1) (19 to 70 years).
As a cause of dizziness, 44 (95.6%) of 46 examined patients were diagnosed with vestibular neuronitis; one (2.2%) -herpes zoster with lesions of the cranial ganglia (Ramsey-hunt syndrome), one (2.2%) - labyrinthitis. The observation program lasted 3 months, and all patients were examined 4 times with an interval of 1 month. Objectification of symptoms of dizziness was carried out using the scale of assessment of dizziness (SHOG) (Dizziness Handicap Inventory - DHI) and a 5-point Scale of subjective assessment of the severity of dizziness. Shogh is developed byJacobson and co [9] in 1990 and it is widely used to objectify the severity of dizziness in various clinical studies. The scale includes 25 questions with three answers to each ("Yes", "no", "sometimes"). The answer to the question " Yes "was estimated at 4 points," sometimes " - 2 points," no " - 0 points.
Thus, the total score for the SHOG can be from 0 (no dizziness) to 100 (very pronounced dizziness). SOG has 3 pods-kali: function (assesses the extent to which dizziness disrupts daily activity of the patient), emotional (assesses the extent to which dizziness violates the emotional state of the patient) and physical examination (assesses the extent to which movement of the head and body affect the dizziness). In General, this scale allows you to quantify the impact of vestibular diseases on the physical and emotional state of the patient, which is especially important in the dynamic monitoring of the course of treatment.
Immediately after the diagnosis, patients were selected exercises for vestibular gymnastics.
The results of the observation program indicate that in most cases (71.7%) the best therapeutic effect in patients with acute non-progressive peripheral vestibular disease occurred after 2 months of treatment. At the same time, after 3 months of treatment, the condition of patients continued to improve somewhat, but these differences were not statistically significant.
The improvement in the patients who participated in observational study, were observed in all podskalak SOG. This indicates that vestibular rehabilitation in combination with drug treatment improves the daily activity of patients with damage to the peripheral part of the vestibular analyzer, reduces the dependence of dizziness on movements in General and the head in particular, which is very characteristic of vestibular dysfunction, and also improves the emotional state of patients.
Thus, vestibular rehabilitation is an important component of treatment of patients suffering from various vestibular diseases. Selection of vestibular gymnastics is relatively simple, and observation of changes in the state of patients and ob-jectification of indicators reflecting the degree of severity of vestibular disorders
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