1

Management of balance disorder cases is

challenging and controversial

A lot of conflicts and unresolved issues raised by
clinicians and researchers on the diagnosis and
treatment of vestibular disorders

If untreated, the quality of life balance disordered
patients can be greatly impaired.



2
Selection of appropriate treatment of Central and
Peripheral Vestibular Disordered is undoubtedly
important to assist them to reach the desired
recovery.

Physical exercises have been shown to help
patients with balance disorders especially
peripheral vestibular disorders cases


3
WHAT IS VESTIBULAR
REHABILITATION?
4
5
Vestibular rehabilitation :
an exercise based therapy
in order to eliminate the
balance disorder and
dizziness a/w vestibular
disorder
Treatment
technique
which involves
structured
physical
movement
Benefits of balance
exercise
Reduce the symptoms: dizziness, nausea and
vomiting.
Increasing postural controlling system.
Could help patient to accept all weakness or
disease that they faced (familiarized and
adaptation).
6
Cont..
Prevent from any accident or fall
Avoid to get psychology signs; palpitation, panic
and others, like those to be faced by chronic
vestibular patient.
Enhance personal confidence level and increase
quality of life (QOL).
Knowledge sharing Malaysia-Pakistan 7
Indications for therapy
1. General interventions for vestibular loss
- Unilateral loss-vestibular neuritis
or acoustic neuroma (Topuz et al. 2004; Hall et al, 2004;
Enticott et al, 2005).
- Bilateral loss-gentamicin toxicity and related conditions.


2. Fluctuating vestibular problems.
To prepare for anticipated dizziness rather
permanent change in their present
vestibular situation.
- Meniere's syndrome
- Perilymphatic fistula

Knowledge sharing Malaysia-Pakistan 8
CONT..
3. Empirical treatment when the diagnosis is unclear.
- Post-traumatic vertigo
- Multifactorial disequilibrium of the
elderly

4. Psychogenic vertigo for desensitization
Psychological counseling (CBT), with vestibular
rehabilitation may be helpful in patients who
have no significant emotional disorder that
aggravates their vestibular problems (Andersson,
2006; Holmberg, 2006).

9
Vestibular rehabilitation reduces severity of
agoraphobia in persons with agoraphobia and
vestibular dysfunction (Jacob et al, 2001).

5. Acoustic neuroma

5. A stroke, head injury or concussion

5. A history of inner ear problems

5. Diabetes

10
11
- Mal de Debarquement or
"MDD or MdDS
- Vertigo and imbalance that
occurs after getting off of a
boat.
http://www.dizziness-and-balance.com/disorders/central/mdd.html
12
VIDEO
Types of balance
exercises?
Cawthorne cookseey exercise (CCE) (Adapted
from Dix and Hood, 1984 and Herdman, 1994;
2000)

Customised CCE

Bal Ex : Homebased video module for balance
exercises = customised CCE +Prayer movement

Wii games

Optokinetic stimulation

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Cawthorne Cooksey Exercises
(Adapted from Dix and Hood, 1984 and Herdman, 1994; 2000)

In bed or sitting
o Eye movements -- at first slow, then quick
up and down
from side to side
focusing on finger moving from 3 feet to 1 foot away from face
o Head movements at first slow, then quick, later with eyes closed
bending forward and backward
turning from side to side
Sitting
o Eye movements and head movements as above
o Shoulder shrugging and circling
o Bending forward and picking up objects from the ground
Standing
o Eye, head and shoulder movements as before
o Changing form sitting to standing position with eyes open and shut
o Throwing a small ball from hand to hand (above eye level)
o Throwing a ball from hand to hand under knee
o Changing from sitting to standing and turning around in between
Moving about (in class)
o Circle around center person who will throw a large ball and to whom it will be returned
o Walk across room with eyes open and then closed
o Walk up and down slope with eyes open and then closed
o Walk up and down steps with eyes open and then closed
o Any game involving stooping and stretching and aiming such as bowling and basketball
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Customized Cawthorne-Cooksey Exercise (CCE)
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DISCO
BALL
A mirrored "disco ball" to
provide optokinetic
stimulation for patients
with vestibular disorders.

All of these techniques
"involve some degree of
innovative technology to
assess treatment
effectiveness,
measurement of vestibular
function, or reveal
behavior in people with
vestibular dysfunction,"
Drs. Schubert and Ryan
write.
16
Wii games
Alternative and recent innovative of vestibular
rehabilitation
Nintendo Wii


17


Home-based Video Module
for Balance Exercises
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Arabic
Malay
English
Nigeria
Hokkien
Indonesian
Mandarin Persian Tamil
Japan
France

Experiences with National
Hospital for Neurology and
Neurosurgery, Central London
2006
20
21

Home-based and video guide
Nine different languages (Malay, English,
Mandarin, Tamil, Hokkien, Nigeria, Parsian and
Arabic) to help patients with various balance
disorders
Consists of 20 movements (divided into 3 levels)
targeting specific functions of balance organs
Adaptation from Customized Cawthorned
Cookseey Exercise and prayer movement


- Head & neck
- Eye focusing
- Heaviness of the neck

Knowledge sharing Malaysia-Pakistan 22
- Positioning
- Daily activities i.e
prayer, up and
down
Return to normal
daily activities

LEVEL 1 LEVEL 2
LEVEL 3
22
- Postural
- Increase the postural
control
- Return to normal walk,
running and use a stair
23
TECHNIQUES HOW TO USE
BAL EX
24
Under family supervision
Start the exercise according to doctor or
physiotherapist advice or start the Bal Ex
exercises from the level 1 till level 3
Advicely do the exercise 3-4 times per day
(morning, afternoon and evenng)
Repeat the movement 20 times for every
movement
Start the Bal Ex exercises slowly and structuredly
according to your capabilities
Early session patients normally will experience
balance disorders symptoms i.e nausea,
vomiting, vertigo, unsteadiness and others
uncomfort symptoms
Same exercise ne to be done if the symptom
persistancely there till the symptoms resolved

25
Once that exercise success (no symptoms of
vertigo, nauea and vomiting), patients can
proceed with the second step 1b and so on till the
end.
In the begining please aviod from doing the full
step ( 1-20) at the same session.
Once all the 1-20 movement succussfully done,
you can practice the whole 20 movement at the
same time.
This Bal Ex modul can be completed after 2 weeks
till 5 months.
Please dont do the exercise or
session if you have the symptom of :
- Chest pain
- Shortness of breath
- Felling fainting
- Severe neck or back injury


Contraindication for this therapy
Low blood pressure
Medication reactions (other than ototoxicity)
Migraine associated vertigo (although it has been
reported to be helpful nonetheless, e.g. Whitney et
al, 2000)
Transient ischemic attack -- TIA
Benign Paroxysmal positional vertigo (BPPV)
(chronic cases only)
26
Knowledge sharing Malaysia-Pakistan 27

A STUDY OF THE NEUROCOGNITIVE STATUS IN PATIENTS
WITH PERIPHERAL VESTIBULAR DISORDERS (PVD) USING
SELECTED NEUROLOGICAL TESTS
(BAL EX MODULE & Customized Cawthorne Cookseey
Exercise)

2 year project 2009-2011 (RESEARCH UNIVERSITY GRANT
99,000
In general, MVVSS and MMSE did not change after
the exercise .
P300 and late latency response (P1 and N1) did
show some improvement after using Bal Ex.
It is common that the physiological changes happen
first before the patients can actually notice the
improvements (as reflected by MVVSS & MMSE).
VESTIBULAR
COMPENSATION

28
Patient 1
Video before tx
Video after tx
Video after tx
Patient 2
Video before tx
Video after tx
Process occurred during therapy
29
1. Plasticity
2. Formation of internal models

3. Learning of limits
4. Sensory weighting
Factors that lead
to poor
compensation ?
30


-drugs with action upon the central nervous system (importantly including vestibular suppressant drugs),
and co-morbid systemic disorders.

PLEASE BE TOO SELECTIVE AND CONFIRM BEFORE YOU THINK TO START ANY MEDICATION
SOMETHING IT NOT HELP.
Luxon LM, Davies RA, eds. Handbook of vestibular medicine. London: Whur Publishers,1997.

Knowledge sharing Malaysia-Pakistan 31
Knowledge sharing Malaysia-Pakistan 32
http://bal-exercise.blogspot.com/
http://balexstroke2011.blogspot.com/
VIDEO
Presented by BALEX Researchers
BALEX Research Group
Current and future innovations

1. Bal Ex : Home-based
Video Module for Balance
Exercises
2. Bal Ex Stroke: Home-based training
Module for Stroke rehabilitation
3. Bal Ex Zuraida-shah rotatory chair
4. STAND UP
5. Wheelsaver
6. Bal Ex Foot
7. Bal Ex AUTOFIS

36
GOLD MEDAL MALAYSIA
TECHNOLOGY EXPO 2012
Bal Ex Homebased Training
Module for Stroke
Rehabilitation
Home-based Video Module for Balance Exercises
BAL EX VIRTUAL ROOM
Bal Ex Stroke : Home based training Module
for Stroke Rehabilitation
MALAYSIA
TECHNOLOGY
AWARD 2012(GOLD
MEDAL AWARD)
The ONLY home-based and video guided stroke rehabilitation available in 15 different
languages(Malay, English, Mandarin, Tamil, Indonesian, Japanese, Thailand, Korean,
Cambodia, Arabic, Persian, France, Russia, Sindhi and Urdu) to help patients with
stroke problem
Bal Ex Stroke GES 2013 (KLCC)
Global
Entrepreneurship
Summit 2013, Kuala
Lumpur Convention
Centre, Malaysia.






Visited by:
Malaysia Prime
Minister
ZURAIDA-SHAH ROTATORY CHAIR- ITEX
2013 (KLCC)
GOLD MEDAL
AWARD - 24
TH

International Invention,
Innovation &
Technology Exhibition
2013 Kuala Lumpur
Convention Centre,
Malaysia.
STAND UP- Manual Footplate for
Balance Rehabilitation
The ONLY manual
footplate balance with
structure manual book,
protocol and video guided to
help patients with various
balance disorders

Was developed by doctors,
scientists specializing in the
vestibular engineering field

Consists of 11 movements
(divided into 7 steps)
targeting specific functions of
balance organs (Prayer
Movements)

SPECIAL
AWARD
BY -
Association
of Polish
Inventors
Rationalize
s Poland
STAND UP-
ACHIEVEMENT
PECIPTA 2013
PECIPTA 2013 GOLD WINNER AWARD
INNOVATION & INVENTION COMPETITION

On 25 & 26 August, 2013 Perpustakaan Negeri
Kelantan. Organized by PETRONAS

Awards:
1) Open Category Special Jury Award
2) Invention Award
STAND UP
I-INOVA 2013 - Bronze Awards
STAND UP
WHEELSAVER- AUTOMATED
CONTROLLER FOR WHEELCHAIR
WHAT IS WHEELSAVER?

Wheelsaver is an automatic
control device that can be used in
any existing wheelchair or a new
wheelchair. With low cost,
patients are able to own an
electric wheelchair or automated
to facilitate their movement. As we
note an electric wheelchair very
high price and some fetch more
than RM 10,000.
ACHIEVEMENT-
BIO MALAYSIA 2013
GOLD WINNER AWARD
Bio Malaysia,
PERSADA, Johor Bahru,
Johor.
Bal Ex Foot
49
A modified shoes for this stroke patient to
improve their gait and avoid further
complication
ACHIEVEMENT-
1. Zuraida Z, Mohd Normani Z, Dinsuhaimi S, Mohd Darimi Y, Zamri H.
Silver Medal for BAL-EX; Home based video module for balance
exercises in MALAYSIAN TECHNOLOGY EXPO 2010, 26 February
2010 PWTC, KL (INTERNATIONAL)

2. U BALANCE ANUGERAH SANGGAR SANJUNG BAGI KATEGORI
KUALITI for BAL-EX; Home based video module for balance
exercises 17 March 2010 USM Pulau Pinang

3. Zuraida Z, Mohd Normani Z, Dinsuhaimi S, Mohd Darimi Y, Zamri H.
ANUGERAH SANGGAR SANJUNG BAGI KATEGORI
PENGKOMERSIALAN for BAL-EX; Home based video module for
balance exercises 17 March 2010 USM Pulau Pinang


4. Winner ( 1st place) for management categories BAL-EX; Home
based video module for balance exercises HEALTH CAMPUS ICC
CENVENTION 2010

5. Gold Medal award for BAL-EX; Home based video module for
balance exercises Konvensyen ICC Wilayah Pantai Timur 2010 di
Hotel Renaissance Kota Bharu pada 26 - 27 Julai 2010

6. 2 star for BAL-EX; Home based video module for balance
exercises MPC ICC National
Convention 7-9 October 2010 in Genting Highland

7. Silver Medal & 3rd place for the Management category BAL-EX;
Home based video module for Balance exercises Bal 7th IPTA ICC
Convention hosted by Universiti Putra Malaysia

8. SILVER MEDAL Intelligent balancing system for patients with
balance disorder for clinically used EKSPO REKACIPTA DAN
PAMERAN PENYELIDIKAN UNIMAP11 JANUARI 2012

9. Gold Medal award for Zuraida z et al. BAL-EX STROKE; Home
based training module for stroke rehabilitation Home based video
module for balance exercises in MALAYSIAN TECHNOLOGY EXPO
2012, February 2012 PWTC, KL (INTERNATIONAL)

10. Winner ( 1st place) for management categories BAL-EX STROKE;
Home based training module for stroke rehabilitation HELATH
CAMPUS ICC CENVENTION 2012 Gold Medal award for BAL-EX
STROKE; Home based training module for stroke rehabilitation 2012
Gambang Resort City Pahang pada 4 - 5 Julai 2012

11. Gold Medal award with three star for BAL-EX STROKE; Home
based training module for stroke rehabilitation KIK National Level
KLCC Kuala Lumpur October 2012

12. Top 10 Finalished for ANUGERAH INOVASI NEGARA (Service
category) KLCC, Kuala Lumpur 5-7 November 2012


13. ITEX Gold Medal For BAL-EX ZURAIDA-SHAH ROTATORY CHAIR
24
th
International Invention & technology exhibition ITEX 2013, Kuala
Lumpur Malaysia,
9
th
11
th
May 2013.

14. Jury Awards And Gold Winner For STAND UP- MANUAL
FOOTPLATE FOR BALANCE REHABILITATION in Pustaka Negeri
Kelantan Innovation and design competition 2013 Organize By Petronas

15. Gold Winner for AUTOMATED CONTROLLER FOR WHEELCHAIR,
Biomalaysia, Bioeconomy Asia Pacific | 21 23 October 2013, Persada
Johor International Convention Centre.

16. Bronze Medal Award, For STAND UP- MANUAL FOOTPLATE FOR
BALANCE REHABILITATION in I-Innova13 Ekspo Inovasi Islam
1434 H, Stadium Tertutup Nilai Negeri Sembilan.

17. Gold Winner For STAND UP- MANUAL FOOTPLATE FOR
BALANCE REHABILITATION in Pecipta13 Transforming Research &
Innovation Towards Commercialisation, 7- 9 Nov 2013 | Kuala
Lumpur Convention Centre Malaysia.

18. Special Awards By Association of Polish Inventors Rationalizes
Poland. For STAND UP- MANUAL FOOTPLATE FOR BALANCE
REHABILITATION in Pecipta13 Transforming Research &
Innovation Towards Commercialisation, 7- 9 Nov 2013 | Kuala
Lumpur Convention Centre Malaysia


THANK YOU