The purpose of this presentation is to talk about the comprehensive evaluation of balanced function and dynamic visual acuity in children. So a vestibular physical therapist is a key member of the team who is responsible for an assessment of gross motor function, an assessment of postural control, an assessment of dynamic visual acuity, as well as positioning testing. The gross motor function assessment, of course, is variable based on the age and ability of the child, as are other parts. It includes thorough basic functionalal tasks, such as reaching for objects, or climbing stairs, as well as specific motor skills, such as throwing and catching a ball, and running and jumping. High-demand functional tasks would include things like walking in a serpentine fashion, or walking heel to toe. So the goal is to assess the contributions of each sensory system, including vision, the vestibular system, and proprioception or the somatosensory system. The conditions are varied systematically to be more challenging. There are some standardized assessments that are used by a vestibular physical therapist. One is called the BOT2, and that has been validated, and is appropriate for children four years and older, and it includes some more complex balance function tasks, such as standing on a balance beam on one foot, or tandem with eyes open and with eyes closed. The Peabody Developmental Motor Scales also provide information about balanced function and gross motor abilities. Normal cutoffs are available for children ages 4-15 years on tests of static balance. In addition to the two standardized assessments that are listed on the slide, there is an evaluation tool called the modified CTSIB. That test involves asking children to stand on firm surfaces with eyes open and eyes closed, feet together, tandem and on one foot, and then to make it more complicated by removing access to the somatosensory system, they are also asked to do the same tasks while standing on foam. So using that tool, the physical therapist is able to get a good handle on which sensory systems the child prefers to use, and which ones they're unable to use. Dynamic visual acuity testing is a simple way to look for evidence of vestibular loss, particularly bilateral vestibular loss. When your vestibular system is not working, you can have blurred vision with head movement, and that is called oscillopsia. Oscillopsia actually is the sensation that objects are moving in the opposite direction of head movement, but at the same speed. Changes in reading acuity with head still versus head moving is how we assess dynamic visual acuity. Specifically getting the best static vision, For kids who can read, you can use a Snellen chart, and have them read the smallest line that they can read with their head still, and then having the physical therapist rotate the child's head at a speed of 1-2 hertz. For children who cannot read, there are other optotypes that can be utilized, specifically the Tumbling E, which simply ask the child to point the direction that the open-end of that E is facing, or Lea symbols, which includes four optotypes: a stylized house and a stylized heart; as well as a circle and a square. So for those, as long as the child can identify the symbols, you can use that the same way you would the Snellen chart. What you're looking for is a significant change, a line change of 1-2 lines is considered to be normal, and anything greater than three or more lines is considered to be evidence of oscillopsia. Another role of the physical therapist is to look for evidence of positional or positioning vertigo. For that test, goggles with infrared cameras attached to them are utilized, and the condition is vision denied, meaning the patient is in darkness. There really are two tests that they complete. One is the Dix-Hallpike maneuver, which is intended to provide evidence of benign paroxysmal positional vertigo, and it involves taking the patient from a sitting position with the head turned to one side, and rapidly laying them down so that their head is slightly below their shoulders. What we're looking for, the abnormal result would be nystagmus that is torsional in nature. So the eye rotating. If there's evidence of BPPV, another test that can be utilized is the Roll Test, and in that case, the individual starts in the supine position, or are flat on their back, and their head is quickly moved to be right cheek on the pillow, or left cheek on the pillow. Again, we're observing to see if there's any evidence of eye movement. So the physical therapist is responsible for putting all of the pieces of this assessment together in order to determine whether therapy is appropriate, specifically, it's the gross motor assessment, the postural control assessment, and dynamic visual acuity testing, as well as positioning testing. Again, the purpose of putting all these pieces together is to determine whether a referral for therapy as appropriate, and what kind of therapy as appropriate. So in an ideal world, primary care providers and audiologists would screen for vestibular loss in all patients, especially those with hearing loss. Referral for vestibular testing and physical therapy would happen if there's evidence of delayed motor milestones, any failed clinic balance screens, or any other concerns about dizziness or balance. Thank you for your attention.
