Norcal Brain Center Rehab Manual PDF

REHAB MANUAL © 2023 NBC. All Rights Reserved. [email protected] TABLE OF CONTENTS SECTION 1: VIDEONYSTAGMOGRAPHY (VNG).................................................................... 4 1.1 VNG SET-UP............................................................................

REHAB MANUAL © 2023 NBC. All Rights Reserved. [email protected] TABLE OF CONTENTS SECTION 1: VIDEONYSTAGMOGRAPHY (VNG).................................................................... 4 1.1 VNG SET-UP...................................................................................................................................... 4 1.2 RUNNING VNG................................................................................................................................. 4 1.3 TROUBLESHOOTING TIPS................................................................................................................. 5 SECTION 2: VIDEO HEAD IMPULSE TESTING (vHIT)............................................................. 6 2.1 VHIT SET-UP..................................................................................................................................... 6 2.2 RUNNING VHIT................................................................................................................................. 6 2.3 TROUBLESHOOTING TIPS................................................................................................................. 7 2.4 FINISHING THE TEST......................................................................................................................... 7 SECTION 3: COMPUTERIZED ASSESSMENT OF POSTURAL SYSTEM (CAPS)........................... 8 3.1 CAPS SET-UP..................................................................................................................................... 8 3.2 CAPS TESTING.................................................................................................................................. 8 3.3 FINISHING THE TEST......................................................................................................................... 8 SECTION 4: QUANTITATIVE ELECTROENCEPHALOGRAPHY................................................ 10 4.1 SETUP............................................................................................................................................. 10 4.2 TESTING.......................................................................................................................................... 10 4.3 TROUBLESHOOTING....................................................................................................................... 11 4.4 CLEAN UP....................................................................................................................................... 11 SECTION 5: PHYSICAL EXAM............................................................................................ 12 5.1 BEDSIDE EXAM............................................................................................................................... 12 5.2 VITAL SIGNS.................................................................................................................................... 12 5.3 REFLEX APP.................................................................................................................................... 12 5.4 POST-EXAM.................................................................................................................................... 12 SECTION 6: STRUCTURE OF A VISIT.................................................................................. 13 6.1 REHAB VISIT’S FLOW...................................................................................................................... 13 6.2 DOCTOR VISIT’S FLOW................................................................................................................... 13 SECTION 7: WARM UP/CHARGE....................................................................................... 14 7.1 SSEP/CADWELL.............................................................................................................................. 14 7.2 GAMMACORE................................................................................................................................. 14 SECTION 8: ENERGY/HEALING......................................................................................... 15 8.1 VIELIGHT......................................................................................................................................... 15 8.2 RED LIGHT MAT.............................................................................................................................. 15 8.3 HYDROGEN GAS............................................................................................................................. 15 1 SECTION 9: PROPRIOCEPTIVE REHABILITATION................................................................ 16 9.1 CERVICAL PROPRIOCEPTION.......................................................................................................... 16 9.2 CERVICAL DECOUPLING................................................................................................................. 16 9.3 CORE STABILITY.............................................................................................................................. 16 SECTION 10: VESTIBULAR REHABILITATION.................................................................... 17 10.1 REPOSITIONING MANEUVER......................................................................................................... 17 10.2 CANAL STIMULATION..................................................................................................................... 18 SECTION 11: NEUROSENSORIMOTOR INTEGRATOR (NSI)............................................... 20 11.1 NSI SETUP....................................................................................................................................... 20 11.2 BASIC TRAINING............................................................................................................................. 20 11.3 ADVANCED TRAINING.................................................................................................................... 21 11.4 BALANCE TRAINING....................................................................................................................... 22 SECTION 12: TILT TABLE THERAPY.................................................................................. 23 12.1 TREATMENT................................................................................................................................... 23 SECTION 13: NEUROFEEDBACK...................................................................................... 24 13.1 RUNNING NEUROFEEDBACK.......................................................................................................... 24 SECTION 14: PRIMITIVE REFLEXES.................................................................................. 25 14.1 GRASP REFLEX REMEDIATION........................................................................................................ 25 14.2 MORO REFLEX REMEDIATION – STARFISH..................................................................................... 25 14.3 ROOTING REFLEX REMEDIATION................................................................................................... 25 14.4 TLR REMEDIATION – CORE............................................................................................................. 25 14.5 TLR REMEDIATION – SUPERMAN................................................................................................... 25 14.6 ASYMMETRICAL TONIC NECK REFLEX REMEDIATION – LIZARD.................................................... 25 14.7 SPINAL GALANT – ANGELS IN THE SNOW...................................................................................... 25 SECTION 15: MISCELLANEOUS....................................................................................... 27 1.1 4-4-8 BREATHING........................................................................................................................... 27 1.2 NORMATEC.................................................................................................................................... 27 SECTION 16: PATIENT INTERACTION.............................................................................. 28 1.3 INITIAL INTERACTION..................................................................................................................... 28 1.4 PATIENT QUESTIONS...................................................................................................................... 28 1.5 SOAP............................................................................................................................................... 28 SECTION 17: OBSERVATIONAL SKILLS............................................................................. 30 1.6 SIGNS OF FATIGUE......................................................................................................................... 30 1.7 OBSERVATIONAL SKILLS................................................................................................................. 30 2 SECTION 18: 10 WEEK TRAINING.................................................................................... 31 3 SECTION 1: VIDEONYSTAGMOGRAPHY (VNG) 1.1 VNG Set-Up 1. Start the OTOACCESS program on the computer. 2. Input the patient information, use first and last name, for ID use their first two letters of the first name, and first letter of their last name followed by their birth year. 3. Select “Micromedical VNG” at the top. 4. Patient sits in the chair 36 inches away from the TV (raise the TV and line chair up with the markers on the ground for accurate distance.) 5. Center the patient in front of the TV and keep the green dot at eye level. Adjust the height of the TV or the chair as needed. 6. Keep the googles clean, use an antibacterial wipe to maintain cleanliness. 7. Place the goggles on the patient and tighten the band so that it’s comfortable and snug. 8. Select “Start Testing.” The patient’s eyes will be on the screen. 9. Using the knobs on both sides of the goggles, adjust the clarity as clear as possible. Look at the TV and the patient’s eyes to ensure it is clear. 10. Center the eye and adjust the toggle so the cursor is on the pupil. 11. Select calibrate. Instruct the patient to keep their head still and only have their eyes follow the dot. Click calibrate to begin. If it is “stuck” on a dot, after about 7 seconds you can manually click approve. If there is a calibration error – the problem is usually the distance of the TV and patient, try adjusting the chair slightly. If problem persists - proceed by clicking default settings. 12. Periodically check in with the patient to see how they are feeling, give patient breaks as necessary throughout. 1.2 Running VNG 1. Ocular Counter Roll - Have the patient look at the green dot. Click “Calibrate”, “Torsion”, click “Autodetect”, then “Approve”. Ensure there is a cross grid on each eye. Instruct the patient that you will be moving their head for them. Have them focus on the green dot and tell them to keep their eyes wide and try their best to blink as little as possible. Click enter to begin the test, the voice will countdown. Every 10 seconds you will move – Stay middle, L tilt, middle, R tilt, middle. 2. For spontaneous nystagmus tests: Place the black goggle cover on. 3. Spontaneous Nystagmus Central – Instruct the patient to imagine a dot far away from them and focus on that dot without moving their eyes. 4. Spontaneous Nystagmus Vertical Saccades – Before you perform the test, show the patients the dots on the tv frame. Instruct them to look at the dots, “I’m going to cover your eyes and when I say up you look at where the top dot was and when I say down you look where the bottom dot was.” Do this 5 times in each direction, holding for 1.5-2 seconds before switching. Then direct them to look straight ahead for about 5 seconds. 5. Spontaneous Nystagmus Horizontal Saccades – “I’m going to cover your eyes and when I say left you look at where the left dot was and when I say right you look where the right dot was.” Do this 5 times in each direction, holding for 1.5-2 seconds before switching. Then direct them to look straight ahead for about 5 seconds. 4  6. Gaze Stability - “Keep your eye on the dot at all times, do not move your head.” Run all five tests with the same instructions. 7. Pursuits - “Follow the dot with your eyes, do not move your head.” For both horizontal/vertical 8. Random Saccade - “Follow the dots with your eyes, do not move your head.” For both horizontal/vertical 9. OPK - Ask the patient if they have a history of seizures. If they do, skip this test. “You’re going to watch the screen as the bars go by.” For both horizontal/vertical 10. Saccadometry - “Look at the center dot. When a new dot appears look at the new dot, then go back to the middle – with just your eyes not your head.” 11. Antisaccades - “Look at the center dot. A new dot will appear, when this happens look to where the dot would be if it was on the opposite side equal distance and then back to the center dot – with just eyes not the head.” 1.3 Troubleshooting Tips If the cursor is not staying on the pupil and is moving around, the patient’s eyelashes may be causing a disturbance. Have the patient keep their eyes open wide or pull the eyelid up a bit more before tightening the goggles. If you start the test at the exact same time a patient blinks, the data lines will split in two. Restart the test and make sure to start it without them blinking at the same time. If the data lines during a test are completely off, it may be because the goggles were moved. In this case, you will need to recalibrate it and redo that specific test. You do not need to restart from the very beginning of the VNG. If the patient is wearing mascara and this causes the sensor to not sense the pupil, instruct them to take it off with makeup wipes. If at any point, the patient gets dizzy or nauseous – PAUSE THE TEST and wait for them improve. If they improve and can continue testing then you can continue, if not then make a note of it and stop the test completely. During the VNG, check up on the patient to see if they need to take a break and feels ok to continue. 5 SECTION 2: VIDEO HEAD IMPULSE TESTING (vHIT) 2.1 vHIT Set-Up 1. Plug goggles into the computer before opening the OTOsuiteV program. 2. On the left side of the screen, click New Patient. Input the Last Name, First Name, Gender, and Birthdate, then click save. 3. Ensure that the goggles are recording, if they are not restart the program. 4. If foam cushion is dirty replace. Replace the foam weekly or if there are stains. 5. Clean the glasses with a microfiber cloth. 6. Position the patient at least 3 feet from the wall, turn on the wall lamp and make sure the light dimmer is all the way up. 7. Put the goggles to the patient’s eyes and ask them to hold it, then pull the strap back behind the patient’s ears. The strap needs to be very snug to get an accurate reading. Hair is tucked behind the ears and the straps are above the ears. The dot on the wall must be centered to the patient and eye level. Adjust accordingly. 2.2 Running vHIT 1. Select “Collect” on the left side of the Workflow Panel 2. Have the patient look straight ahead. 3. If the box is not centered on the pupil, on the top of the screen you can click directly on the pupil to center the green box on it. 4. The pupil should be white. If there is still some whiteness on the screen you can click the minus or plus signs to adjust. Throughout testing you want to make sure the pupil is white, and that the cursor is directly on the eye. 5. If the cursor is having trouble staying on the pupil, it may be because there are eyelashes covering the pupil. There are two ways to fix this. First, you can physically open the patient’s right eye wider and reposition the goggle so that the eye stays wide open. If this doesn’t work, you can use the eyelash curler on the patient’s right eyelashes. 6. Once the head is centered and the ROI (region of interest) is directly on the pupil, you can click the arrow on the right side of the screen. This takes you directly to the calibration tab. 7. Click the triangle to turn the red laser on the left side of the middle bar and instruct the patient move the laser so that it is on top of dot on the wall. Make sure their head is straight. Direct them look at the laser dot as it alternates flashing, only moving their eyes. 8. Click Run to calibrate. If the dots are slanted, adjust the goggles so that they are level. 9. Click next and complete the head check. Click Start Head Check and slowly turn the patient’s head left and right for 10 seconds. 10. Once the calibration is complete, give the patients instructions on how to complete the test. “Look straight ahead at the dot at all times and try to minimize blinking. I will hold your head and move it very slightly to the left and to the right. Please let me know if you need to take a break” 11. Stand behind the patient and hold the patient’s head above the strap without touching the strap. 6  12. Quickly move the patient’s head approximately 10 degrees to one side, in a very quick motion. It should feel like a fast but slight jerk. If the test was good, you will hear a high-pitched sound, and on the computer it will show that the test was accepted. If it was bad, you will hear a low- pitched sound, and it will give a reason as to why it was not accepted. a. There are two main reasons why the test will be rejected: if the patient’s head was moved too slowly, or if it was moved in the wrong direction. You will need a total of 20 accepted tests going to the left, and 20 accepted tests going to the right. 13. Once the testing is complete, move onto LARP. When you start the test, a laser will turn on. Have the patient match the laser up with the dot, and then push Center. 14. Turn the patient’s head 45 degrees to the right, until the diagram on the computer of the head turns green and have the patient keep their head in this angle. 15. Once here, click the pupil on the right side to center the eye, make sure the left side is adjusted and the pupil is white, then click the check mark on the right side of the screen. 16. Stand behind the patient, using your dominant hand on top of the head and the non-dominant hand cupping the chin. The fingers of the dominant hand should be facing towards the dot. Quickly move the head down or up for the remainder of the test until you have 20 accepted in the LA and the RP planes. Once finished, you can do the same with the RALP plane. 2.3 Troubleshooting Tips 1. If you are getting a lot of rejects during the test, there are two important areas to check. The first is your technique. Are you going too slow? Are you going out of plane? Are you keeping the patient’s head secure and stable after you move it? Are you touching the goggle strap? You can look at the program for additional feedback. Remember that the movement is a very short, quick, and stable jerk. Adjust as needed. 2. Check the display of the patient’s pupil. Is the whiteness on the pupil clean, especially when you move the patient’s head? You may need to play with the toggle and/or tape the patient’s eyelids up. Adjust as needed. Is the patient closing their eyes every time you move their head? Instruct as needed. 2.4 Finishing the Test After testing is complete, take the goggles off and put them on the placeholder. The test will automatically save. On the patient’s vHIT profile, click on “Report” on the left side column and save the report to Norcal Brain Center drive, naming it “First name” “Last name” “VHIT” “Test date”. Ex. Minh Tran VHIT 7-11-22. Then upload the report from the drive to the patient’s Jane. Remember to delete the report from the drive once uploaded. 7 SECTION 3: COMPUTERIZED ASSESSMENT OF POSTURAL SYSTEM (CAPS) 3.1 CAPS Set-Up 1. There are a total of 12 different tests, each one lasting 20 seconds long. 2. To get started, plug the USB into the computer. If the CAPS is not in use, make sure the USB is not plugged in. 3. Open up “CAPS EQ”. 4. Click New Test. 5. With existing patients click on Open Patient, then their name. With new patients click New Patient and input their information. 6. On the next page, there are 4 different testing sets. Only run the last three, ignore the first one. Click the second link, then next. 7. This will take you to a calibration page – make sure the foam pad is not on the unit. Click calibrate, once it is done have the patient step on. 3.2 CAPS Testing 1. Instruct patient “We are going to test your balance; I am standing behind you at all times to make sure you do not fall. When you step on, put your feet together as close as you can, keep your hands by your side and look straight ahead. Do not move and don’t talk during this test.” 2. Have them step on. The first two tests are looking straight ahead on the flat surface, first with eyes open then eyes closed. o It is essential that you are constantly monitoring the patient to ensure they do not fall. Never tell the patient to close their eyes when your arms are not poised and ready to catch them. 3. After the first two, instruct the patient to step off. 4. Gently put the foam pad on and recalibrate the test. o It is important to gently place the foam pad otherwise an error may occur. If an error does occur, you will have to restart and redo the first two tests. 5. Once the calibration is done, have them step back on in the same position, and test them with eyes open and closed. 6. After the second two tests, have them wait while holding onto the handles. 7. “Print” the results from the first four tests and save the file with their name and 1 (minh1). 8. Exit the test to the main page, then go onto the second test. Continue the next four tests with the patient on the foam pad with head rotated right, rotated left, flexed, and extended. o The patient’s eyes are closed during all these tests, but they open their eyes in between tests. 9. Once completed have them step off and go ahead and “Print” the second round of tests (labeled minh2). 10. Start the third test with the foam pad. Continue the last four tests with head right anterior, left posterior, left anterior and right posterior. Once done, save the file (minh3). 3.3 Finishing the Test 8 1. Disconnect the USB cable from the computer. 2. Combine all three of the CAPS file into a singular PDF report using Adobe. Make sure all parts of the test are in the report. 3. Save the PDF on Norcal Brain Center and upload it to the patient’s Jane as “First name” “Last name” “CAPS” “Test date”. Ex. Minh Tran CAPS 7-11-22. 4. Upload the report from the drive to the patient’s Jane. Delete the report from the drive once uploaded. 9 SECTION 4: QUANTITATIVE ELECTROENCEPHALOGRAPHY 4.1 Setup 1. Open the NeuroGuide program, go to “COLLECTION”, then “SET UP AND MONITOR”. 2. Click “OK” on the next screen and input patient information on “Subject Database screen”. 3. Input patient’s first name, last name, subject ID, DOB, Gender, Handedness, and put your name under Clinician. 4. Click on BROWSE to create a new subject folder formatting the patient folder (Last name, First name). From there create or select the folder that will be used for this session. 5. Push “Go” in the top left corner and there will be a map of each of the channels on the right side of the screen. 6. Measure the patient’s head, picking the corresponding cap size, and placing it on. o Ensure that the brain cap is placed on correctly with FP1 and FP2 slightly above the eyebrows, the cap is equidistant on both sides (not tilted more to the left or to the right of the head). o Place the ear clips with gel on with the metal side facing forward. Inject a small amount of gel in all of the points in the brain cap by slightly lifting a cap hole and inserting the tip of the syringe brazing the surface of the patient’s scalp. Then twist down on the cap hole to seal the gel 4.2 Testing 1. Two tests are needed, one with eyes open and one with eyes closed. Aim for 3 minutes of good data, for which you will need to record 6 minutes total time for eyes open and eyes closed. a. If the data looks as if it is poor quality (doesn’t look calm and normal) record for a few more minutes. 2. Instruct the patient to close their eyes and relax their face. Start recording but make sure the recording looks good with no artifacts. a. Sample phrase: “Go ahead and get in a comfortable position. Close your eyes and relax your whole body – your shoulders, neck, everything. Keeping your eyes closed, imagine looking at the tip of your nose. In addition, hold your tongue against the roof of your mouth. Stay relaxed in this position.” 3. After enough data is collected, click the red stop button to stop the recording and save the recording with “(First name) (Last name) (EC) (Date of the recording)” Ex. Minh Tran EC 7-11-22. a. If the scale is between 40-60, the data is good, and you can continue. If it is not, you will need to redo the test. 4. Open the patient’s file again, but this time change the setting to “Eyes open.” 5. Instruct the patient to look at the black dot on the orange post-it note below the TV. a. This ensures patient does not look up and move the cap. Begin recording again looking out for artifacts. b. Sample phrase: “Go ahead and get in a comfortable position. Please look at the black dot on the post-it notes below the TV and relax your whole body – your shoulders, neck, 10  everything. In addition, hold your tongue against the roof of your mouth. Stay relaxed in this position.” 6. Once enough data is recorded, stop the session, and save “(First name) (Last name) (EO) (Date of the recording)” Ex. Minh Tran EO 7-11-22. 7. If the scale is between 40-60, the data is good, and you can continue. If it is not, you will need to redo the test. 8. Take off the cap and hand the patient a tower to clean their head. 4.3 Troubleshooting Check the location of the artifacts. 1. For artifacts in the front ports, check if the cap is being tugged (instruct the patient to close their eyes and lift the cap to release tension) or eyes rolls (remind the patient to look at the direction of the tip of their nose). 2. For artifacts in the side ports, check for tight temples (massage the temporalis) or jaw clenching (remind the patient to hold their tongue against the roof of their mouth). 3. For artifacts in the back ports, check that the head is in a neutral position and not leaning forward or backwards (instruct the patient to return to neutral position. 4.4 Clean up The caps need to be cleaned at the end of each day. The main goal of cleaning the cap is to remove any gel within the electrodes, cap and to clear the ear clips. 1. Take the cap and ear clips to the break room with the waterpik. Be very careful when cleaning the cap as the wires are very delicate. 2. Use the waterpik to clean the gel out of the electrodes. 3. Run the cap over water and make sure the gel is out of the cap. Clean the conducting paste out of the ear clips. a. It is important to not let the other end of the cap into the water - that will damage the cap. 4. Once cleaned, squeeze the foams to get rid of residue water. 5. Hang the caps to let them dry overnight. 11 SECTION 5: PHYSICAL EXAM 5.1 Bedside Exam The doctors will be testing the patients in various ways while telling you their findings to write down. If you are unfamiliar with a word the doctor told you, but you can roughly pronounce the word, write it down as best as you can and ask the doctor after the exam. If you are completely unsure, respectfully ask the doctor to repeat it to you again. This will take practice. Ensure there are no contradicting statements. For example, if their finger tapping was G3 (grade 3), then WNL (within normal limits) should be deleted for that test. Scribing will be difficult at first but will become easier as you do more and become familiar with the vocabulary and the doctors’ methods. Bedside cheat sheet: https://docs.google.com/document/d/1lALcxhIP5jIsvRd- tyG106xTFJKd1MK7Cym9FvaLohY/edit?usp=sharing 5.2 Vital Signs During the patient’s exam day, you will also need a set of their vital signs. The vital signs include their blood pressure (left and right side, both sitting, supine and standing), heart rate (both sitting, supine, and standing), and oxygen saturation (left and right side). Record their height and weight. If they do not know their weight leave it blank temporarily. 5.3 Reflex App 1. On the iPad mini, open the Reflex app. 2. Create a new patient profile using the action button on the bottom right corner. 3. In a well lit room, instruct the patient to look at a point in the distance. Cover the left eye while you point the iPad towards the right eye. Stay off to the side to not occlude their vision. Capture the data, holding the iPad on the right eye. 4. Once prompted, switch sides to the left eye. Cover the right eye while the patient looks at a target. Capture the data. 5. Take the iPad into the exam to show the doctor. 5.4 Post-Exam After the patient has completed their physical exam, they will schedule the Report of Findings. The doctors will present the results of the diagnostics and recommend a treatment plan. If the patient is satisfied with the plan, we will begin the NeuroRestoration program. 12 SECTION 6: STRUCTURE OF A VISIT 6.1 Rehab Visit’s Flow 1. Warming up/charging the system – similar to stretching before a workout a. SSEP b. Gammacore 2. Energy/healing – giving the brain the resources it needs to change a. Vielight b. Red light mat c. Hydrogen Gas d. HBOT e. PEMF f. Gladiator 3. Rehabilitation – working on 1 system a. Proprioception i. Cervical Proprioception/Decoupling, halo ii. Core Stability b. Visual/vestibular Rehab i. Repositioning Maneuvers ii. Gaze Stability 4. Integration – working on multiple systems a. NSI b. Tilt table therapy 6.2 Doctor Visit’s Flow 1. Revisiting findings 2. Physical modalities a. Chiro/manual therapies b. Special electrical modalities 3. Fine Tuning 4. Integration a. Gyrostim b. Virtualis 13 SECTION 7: WARM UP/CHARGE 7.1 SSEP/Cadwell SSEP sites: V1 – medial top part of eye, on eyebrow V2 – an inch below zygomatic arch V3 – slightly to the side of the mandible Hypoglossal -directly on the tongue Median n – middle of wrist Common peroneal n – behind proximal fibular head Tibial n – posterior to medial malleolus of foot 1. Click the switch on at the bottom left of the base. 2. Open up the SierraXP program, on the bottom click select patient. Click on Tran, Minh. 3. On the top click on Test Protocol, and click Median SSEP. 4. You will see a Yellow icon with “Stim” on it. If that yellow icon is flashing, it means the stim is on. Use the probe, along with some ultrasound gel for the stimulation. 5. On the base there is a button on the bottom right “Run” that will turn on if you click it. 6. Start low and slowly build your way up. There is a turning mechanism on the prongs, turning to the right will increase strength and turning to the left will decrease strength. 7. Should be strong but not unpleasant or uncomfortable – the patient should never be in pain so make sure you follow up and continually check up on them to see if they are ok. 7.2 Gammacore 1. Turn the power on. It will display how many stimulations are left for the day. 2. Put a pea sized gel on each of the electrodes. 3. Find the vagus nerve on the neck – it should make a triangle with the sternocleidomastoid. 4. Put the device vertically on the patient’s neck and allow them to turn it up. The sensation should be strong and they should feel a pull in their neck. 5. After two minutes it will beep. Reapply gel and have them do another round on the same side. 14 SECTION 8: ENERGY/HEALING 8.1 Vielight There are two different controllers for the Vielight, Alpha and Gamma. The Alpha controller is used for calming down (anxiety, ADHD) while the Gamma is used for speeding up (focus, memory, concentration). Most of the time we will use Alpha on patients. Plug the headset into the controller and put the headset on the patient. Press the power button on the side of the white controller. Shift between Alpha or Gamma by clicking the blue button on the top of the headset. Press the yellow button to being the therapy. The headset will automatically turn off once complete (~20 minutes). Use the Vielight during active therapies for the patient. 8.2 Red Light Mat Inform the patient that the chair can recline forward/backwards by showing them the lever. The green protection glasses are optional. Turn on the mat on the remote and set the time to 20 minutes. 8.3 Hydrogen Gas Take a clean nose piece from the container in the drawer. Connect the nose piece to the end of the white tubes. Click the power button twice and have the patient wear the tubes. 15 SECTION 9: PROPRIOCEPTIVE REHABILITATION 9.1 Cervical Proprioception Place a chair 8 blocks away from the cervical proprioception poster. Have the patient take a seat, put a laser on their forehead and instruct the patient to keep the laser on the target. Have the patient close their eyes and move their head in a direction. Keeping their eyes closed, they must go back to the dot. Once they think they are there, they can open their eyes and if they are off, they can correct themselves back on the dot. Continue doing the exercise, if they are improving you can go further each time and if they are not doing well, you can go less of a distance. Repeat multiple times in all directions. Make sure you check in with them, this can be a very taxing exercise. 9.2 Cervical Decoupling Start in the same position as cervical proprioception but standing. Point the laser eye level on a dot placed on the wall. Instruct the patient to slowly shift their feet until their body and shoulders are facing the left wall. The patient should keep their head and laser on the dot the entire time. Then slowly move their feet and body back to the middle, then to the right side. Do 3-5 times. Halo Headband: The halo is a weighted headband that can be used during cervical proprioception, cervical decoupling, or other therapies to increase proprioceptive input to the head. 9.3 Core Stability 1. Instruct the patient to bring both legs up to a 90-degree angle without their knees touching. 2. Their arms are pointed towards the ceiling, with thumbs 45 degrees turned outwards. 3. The patient should consciously be pushing their low back into the table while doing this exercise as if there is a bead under their back to push against. 4. Hold the position for 15-60 seconds, ideally right before the patient fatigues. 5. To increase difficulty grab opposite leg and hand and slowly try to move them in opposing circles, while instructing the patient to resist any movement. Remind the patient to continue to big belly breathe and continue pushing down with their low back while doing this exercise. 6. Do for about 30 seconds, then check with the patient to see how challenging it was for them. Switch sides to ensure you do all 4 limbs, working opposite arm and leg at a time. Increase/decrease duration depending on difficulty. 16 SECTION 10: VESTIBULAR REHABILITATION 10.1 Repositioning Maneuver 1. Right posterior maneuver ⮚ Sit on the table and turn their head to the right 30 degrees ⮚ Lay on their back with head off the table (in extension) ⮚ Hold for ~30 seconds ⮚ Turn their head to the left. Hold for ~30 seconds ⮚ Turn onto their left shoulder with their head still turned to the left ⮚ Hold for ~30 seconds ⮚ Slowly get up 2. Left posterior maneuver (same as previous but opposite) ⮚ Sit on the table and turn their head to the left 30 degrees ⮚ Lay on their back with head off the table (in extension) ⮚ Hold for ~30 seconds ⮚ Turn their head to the right. Hold for ~30 seconds ⮚ Turn onto their right shoulder with their head still turned to the right ⮚ Hold for ~30 seconds ⮚ Slowly get up 3. Right anterior maneuver ⮚ Lay on their stomach with head off the table (in flexion) ⮚ Turn their head to the left 30 degrees and hold for ~30 seconds ⮚ Turn their head to the right and hold for ~30 seconds ⮚ Turn onto their left shoulder with their head still turned to the right ⮚ Hold for ~30 seconds ⮚ Slowly get up 4. Left anterior maneuver (same as previous but opposite) ⮚ Lay on their stomach with head off the table (in flexion) ⮚ Turn their head to the right 30 degrees and hold for ~30 seconds ⮚ Turn their head to the left and hold for ~30 seconds ⮚ Turn onto their right shoulder with their head still turned to the left ⮚ Hold for ~30 seconds ⮚ Slowly get up 6. Right horizontal maneuver > Lay on their back with head off the table but flexed > Turn their head to the right 30 degrees (still flexed) and hold for ~ 30 sec. 17  > Turn their head to the left 30 degrees (still flexed) and hold for ~ 30 sec. > Turn onto their left shoulder and have their head turned left > Hold for ~ 30 seconds > Turn onto their stomachs have their head straight across, hold for 30 sec. > Turn onto their right shoulder have their head turned right > Turn so they’re on their back again with head in initial starting position > Hold with their head to the right, flexed for ~ 30 seconds > Slowly get up 6. Left horizontal maneuver (same as previous but opposite) > Lay on their back with head off the table but flexed > Turn their head to the left 30 degrees (still flexed) and hold for ~ 30 sec. > Turn their head to the right 30 degrees (still flexed) and hold for ~ 30 sec. > Turn onto their right shoulder and have their head turned right > Hold for ~ 30 seconds > Turn onto their stomachs have their head straight across, hold for 30 sec. > Turn onto their left shoulder have their head turned left > Turn so they’re on their back again with head in initial starting position > Hold with their head to the left, flexed for ~ 30 seconds > Slowly get up 10.2 Canal Stimulation Right anterior (RA) – Have the patient seated (ideally in front of a blank wall). Rehab holds their thumb out centered and eye level (far enough from the patient so their eyes don’t converge). The rehab will move the patients head at a diagonal angle down and to the left. Instruct the patient to keep their eyes on the thumb. The thumb will move depending on if it’s x0, x1, or x2 viewing. Repeat. Do 2-3 sets of five reps, if this is too difficult decrease by 60%, if it is too easy increase to 8—10 reps per set. Right posterior (RP) – Have the patient seated (ideally in front of a blank wall). Rehab holds their thumb out centered and eye level (far enough from the patient so their eyes don’t converge). The rehab will move the patients head at a diagonal angle up and to the right. Instruct the patient to keep their eyes on the thumb. The thumb will move depending on if it’s x0, x1, or x2 viewing. Repeat. Do 2-3 sets of five reps, if this is too difficult decrease by 60%, if it is too easy increase to 8—10 reps per set. Left anterior (LA) – Have the patient seated (ideally in front of a blank wall). Rehab holds their thumb out centered and eye level (far enough from the patient so their eyes don’t converge). The rehab will move the patients head at a diagonal angle down and to the right. Instruct the patient to keep their eyes on the thumb. The thumb will move depending on if it’s x0, x1, or x2 viewing. Repeat. Do 2-3 sets of five reps, if this is too difficult decrease by 60%, if it is too easy increase to 8—10 reps per set. Left posterior (LP) – Have the patient seated (ideally in front of a blank wall). Rehab holds their thumb out centered and eye level (far enough from the patient so their eyes don’t converge). The rehab will 18 move the patients head at a diagonal angle up and to the left. Instruct the patient to keep their eyes on the thumb. The thumb will move depending on if it’s x0, x1, or x2 viewing. Repeat. Do 2-3 sets of five reps, if this is too difficult decrease by 60%, if it is too easy increase to 8—10 reps per set. LARP – Have the patient seated (ideally in front of a blank wall). Rehab holds their thumb out centered and eye level (far enough from the patient so their eyes don’t converge). The rehab will move the patients head to the right about 45 degrees. Then they will slowly move the head up and down equal distance, keeping the 45 degree turned angle. Instruct the patient to keep their eyes on the thumb. The thumb will move depending on if it’s x0, x1, or x2 viewing. Repeat. Do 2-3 sets of five reps, if this is too difficult decrease by 60%, if it is too easy increase to 8—10 reps per set. RALP – Have the patient seated (ideally in front of a blank wall). Rehab holds their thumb out centered and eye level (far enough from the patient so their eyes don’t converge). The rehab will move the patients head to the left about 45 degrees. Then they will slowly move the head up and down equal distance, keeping the 45 degree turned angle. Instruct the patient to keep their eyes on the thumb. The thumb will move depending on if it’s x0, x1, or x2 viewing. Repeat. Do 2-3 sets of five reps, if this is too difficult decrease by 60%, if it is too easy increase to 8—10 reps per set. x0 viewing – Have the patient look at their arm and move their head and arm in the same direction. x1 viewing – Have the patient look at the stationary target (such as their thumb or a dot) and move their head back and forth around 30 degrees. x2 viewing – Have the patient look at their arm and move their head and arm in opposite directions. Once the patient can do the exercise easily with no symptoms you may progress their positioning. Progression: Supine – Sitting – Standing – Standing on foam – Standing tandem Diamond gaze no/no stability pattern – There is a page of 5 dots in a diamond shape. Have the patient in front of the sheet looking at the middle dot, turn their head slowly left and right equally three times. Have the patient shift their eyes to the second dot with their head still in neutral position and move their head left and right. Repeat for each dot. Diamond gaze yes/yes stability pattern – Same as previous exercise but moving head up and down instead. 19 SECTION 11: NEUROSENSORIMOTOR INTEGRATOR (NSI) 11.1 NSI Setup Load the patient profile. If it is a new patient, create a new profile. The first name will be their birth year while the last name will be the first two letters of the first name and first letter of the last name. Turn on the headphones and hand it to the patient to wear. In addition, have the patient stand on a balance board that challenges the patient, but is not too difficult. To determine the distance the patient should be to the TV, have the patient try to touch the top two corners of the screen. They should be able to touch them without difficulty. Adjust as needed. 11.2 Basic Training Although there are many modules in NSI, there are four that are primarily used. These include proactive, reactive, saccade 1, and tachistoscope. 1. Proactive a. Number of stimuli – change depending on how long you want the session to be, generally between 25 to 35 b. Central Fixation – if enabled, patient will need to tap the middle if it is flashing. This causes a distraction c. Stimuli type – default is on circle. You can instruct the patient to tap the circle with same hands-on same side or opposite hands-on opposite side. We often like to do number/letter and instruct the patient to tap letters with one hand and number with the other hand d. Stimuli size – adjust if the patient has difficulty seeing or tapping the stimuli e. Location – generally this will be on both. Occasionally, the doctors will instruct you to choose a specific setting. With little kids, you may need to choose Central since some are unable to reach to the edges of the screen 2. Reactive a. Time – change to 0.1 to 0.2 seconds faster than the patient was able to do on proactive b. Rest of the settings are the same as Proactive. 3. Saccades 1 a. Number of stimuli – change depending on how long you want the session to be, generally between 20 to 30 b. Central fixation – if enabled, patient will need to tap the middle if it is flashing. This causes a distraction c. Stimuli persistence – if enabled, the stimuli will not disappear when tapped. Patient will only know they tapped correctly via the sound. d. Reverse sequence – if enabled, the stimuli order will be reversed e. Stimuli size – adjust if the patient has difficulty seeing or tapping the stimuli 20  4. Tachistiscope a. Time – adjust depending on how long you want the session to be. Generally, it will be 2 minutes b. Audio/verbal – generally we do one set of each After the top row of therapies, there are a few other modules that we use for more advanced patients. 11.3 Advanced Training Auditory/visual (aka NSI metronome) – Change settings to 1 minute, 60 BPM, auditory/visual, and level 2. Instruct the patient to alternatively tap the circles the same time they anticipate hearing the beat (not after the beat). A green circle would appear if they tapped at the beat, red circle if they tapped too late, and white circle if they tapped too early. Additionally, the patient will do this exercise while simultaneously doing 4-4-8 breathing (see Miscellaneous section for information). After the set, check the percent accuracy. If it is above 80%, you can change the BPM to 55. Repeat and continue to decrease the BPM by increments of 5 if percent accuracy is achieved. Once they get to 30 BPM, you can incorporate a balance board and start from 60 BPM again. Visual Motor – Geoboard 1-4 is what we use. For this exercise, the patient sees a diagram on the screen and has to reproduce it accurately by drawing it. Start with a simple one and work your way to more difficult ones. We typically flip the image horizontally or vertically to make it more difficult, and once you find their level you can slowly increase difficulty from there. Rotator 3 – this is similar to saccades 1, only with a spinning background. The main things you want to change are direction and speed. When instructed counterclockwise (CCW), the patient will do the exercise with their head tilted to the right. When instructed clockwise (CW), the patient will do the exercise with their head tilted to the left. Adjust the speed as desired. Memory Saccades – Memory saccades 1 is an exercise where they have to remember the location of either the first, second, or third dot. They will touch the dots until the red dot, which indicates that it is the last dot. Afterwards, they will have to touch where the first/second/third dot was. Memory saccades 2 has two parts. The first part has a dot that the patient has to memorize. The second part depends on which distractor is selected – auditory vs visual. For auditory, the patient has to listen to the number of clicks, and then has to select the dot location, then the number of clicks there were. For visuals, they are given a handful of numbers, then asked to remember the last one. They then have to select the location of the dot, then the last number. Quadrant loading – we can choose where the stimuli will go. Oftentimes we will let you know which quadrant to weight the stimuli, ie. 65 up and 65 right. 21 Dual tasking – Dual tasking refers to doing multiple things at once. To challenge patients, we will have them perform the task, and then stand on the balance board and ask them to do certain cognitive tasks, such as math problems, rhyming with words, or synonyms/antonyms. 11.4 Balance Training Vestibular Balance 1. Select “Exp. 1 – Vestibular-Balance” and then select the bottom option “Limits of Stability”. 2. Pull the Wii Balance board out from under the TV, far enough to give the patients room to move around comfortably without being too close to the TV. 3. The Wii Board should have a blue light signaling that it is on, connected, and ready for use. 4. On the TV select “Trails” to have a trail that shows the exact pathway of the patient while they do their exercise. 5. Choose your desired time for each patient to spend on each target before being able to move to the next target from the list of “Time on Target” options. 6. The patient should be slightly forward on the Wii balance board. 7. Select level 1, 2, or 3 in the bottom left of the screen to change the difficulty (1 being the hardest because you must be more precise as the targets will be closer together). 8. Inform the patient that they are the cursor, and their goal is to follow the red target and hold their balance on the red target until it moves to a new spot. 9. Pay attention to the patients’ posture and stand behind them to ensure they don’t fall when they go to the back targets. Balance Targeting 1. Select “Exp. 5 Balance Targeting” and then select the first option “Balance Targeting 1”. 2. On the TV, select “Trails” to have a trail that shows the exact pathway of the patient while they do their exercise. 3. Choose your desired time for each patient to spend on each target before being able to move to the next target from the list of “Time on Target” options. 4. Select the stimuli type from the options “Circles, Letters, or Numbers” in the bottom right of the screen. 5. Before starting, the rehab should click squares in a LARP or RALP plane (depending on the patient and their care plan). The stimuli that you chose will appear in the box as you press on it. Once you have selected all the boxes you want the patient to move to, you select “start” at the bottom of the screen. 6. The stimuli will either turn red one by one signaling which area you should target, or you selected numbers or letters it will go in sequential order and the turning red will signify that the patient has been on the target for the proper duration and is ready to move on to the next target. 22 SECTION 12: TILT TABLE THERAPY 12.1 Treatment 1. Have the patient lay on top of the tilt table while guiding their feet into the normatec boots. Their feet should touch the platform at the end of the table. 2. Using the table straps, place both straps over the patient’s hips and torso. 3. Place a pulse oximeter onto the patient's index finger and focus on the heart rate as you slowly tilt them upwards. 4. When you notice their heart rate spike up 10 points, record the tilt degree that it occurred, go down 10 degrees from where it spiked, and start therapy at this point. 5. Do 15 seconds of V3 stimulation and then a set of vestibular rehab (do it for them by holding their head). Ensure that the focal point is an arm length away to prevent convergence. 6. Raise the table 5 degrees and repeat doing a set of V3 stimulation and a set of No/No. Repeat this step until you notice a spike of 10 points in heart rate or if the patient expresses symptoms of discomfort. If either occurs, go down 10 degrees and repeat raising the table every 5 degrees with a set of V3 stimulation and No/No gaze stability in between. 7. The goal is to prevent the heart rate from spiking up when mimicking the patient standing up with the tilt table. Do this therapy for 10-15 minutes and document how long you did it for. 8. If the patient does not feel good during this therapy, stop, and do not continue. 23 SECTION 13: NEUROFEEDBACK 13.1 Running Neurofeedback 1. Set up the patient as you would for an eyes open QEEG. 2. Lower the TV to its lowest level. Make sure the brain waves look clean. It does not have to be as clean as you would want it for a QEEG. 3. Go to “COLLECTION”, then “NEUROFEEDBACK”, then “swLORETA NEUROFEEDBACK”. The neurofeedback main page will pop out. 4. There are a couple of settings to adjust. Change the “Z Threshold” to 5.00, “Method” to Z-Tunes, “Sound” to WAV File, “Display” to Ani-Streamer. Under the Session Rounds tab on the top of the page, change “Number of Rounds” to 1, “Round Duration” to 20, and Intra-Session Data Type to “Percent Reward”. 5. Go back to the Protocol tab and click “Apply”. The ANI Streamer Settings page will pop out. 6. Open Netflix on Google Chrome and have the patient choose a show to watch (something that will not make them anxious). 7. Once they have chosen, click the Netflix tab and return to ANI Streamer Settings. The word Netflix should now be displayed under “Window to Stream”. 8. If so, click “Dock”. The Netflix show should now be displayed on the TV screen. 9. Maximize the show on the TV screen and full screen the show on the computer. We will now change two settings on the ANI Streamer Settings page. 10. Change “Sound” to Fixed Volume and “Transition Range” to 75%. Now you can click Begin Session on the bottom of the neurofeedback main page. The session has now begun. The neurofeedback session is dynamic, meaning the difficulty of the session is adjusted depending on how the patient is doing. 1. Go to the “Progress” tab on the main neurofeedback page. 2. The graph on the percent reward should hover between 40 and 80. If it is consistently above 80, the session is too easy. 3. Go back to the Protocol tab and lower the Z Threshold to 4.75. If the percent reward is still too high, continue to lower it by 0.25 until it is within the desired range. 4. If the percent reward is below 40, the session is too hard. Increase the Z Threshold until it is within the desired range. 5. Make sure to save the session after it’s done using the date of the session. Ex. 7-11-22. If the patient has a history of seizures change the “Display” on the neurofeedback main page to Cz-Head instead of Ani-Streamer and the “Sound” tab to Bell. The rest of the settings will remain the same as it would for a Netflix neurofeedback session. Move the Cz-Head to the TV screen and maximize it. Click Begin Session. Adjust the percent reward as you would for a Netflix neurofeedback session. Save the session. 24 SECTION 14: PRIMITIVE REFLEXES 14.1 Grasp Reflex Remediation 1. Take the patients’ hand, make sure they are fully relaxed 2. Take an object and stroke it across the hand 3. Do this 25 times on the affected hand 14.2 Moro Reflex Remediation – Starfish 1. Have patient start seated with one arm over the other, Ex: Right arm over the left, right leg over the left 2. Have them bend slightly, then open up both arms and legs fully (they should feel like they are almost falling without actually falling) and then come back to original position just switched 3. When they return to the position it should now be left arm over right, left leg over right 4. Do this 50 times 14.3 Rooting Reflex Remediation 1. Grab an object, brush works best 2. Stroke the cheek along towards the corner of the patient’s mouth 3. Do each side 25 times 14.4 TLR Remediation – Core 1. Have the patient lay flat on their back 2. Have them curl up and hold on to their legs with their head up 3. Have them hold position for about 15 seconds and then rest 14.5 TLR Remediation – Superman 1. Have the position lay on their stomach 2. Bring arms and legs up at the same time 3. Try to make an arch with their back 4. Hold for about 15 seconds then rest 14.6 Asymmetrical Tonic Neck Reflex Remediation – Lizard 1. Have the patient lay on their stomach with head neutral 2. Have them start on the right by turning their head to the right 3. Have them bring their right arm and right leg up 90 degrees and slowly back 4. Then do the opposite direction and back 5. Do this slowly and get as much drag as you can from the ground on both their arm and their leg 6. Do this 50 times 14.7 Spinal Galant – Angels in the snow 1 Have the patient lay flat on their back with arms and legs straight down 25 2 Have them do a snow angel movement slowly, while timing it so their legs and arms open fully at the same time 3 Slowly return to the starting position 4 Aim to have as much feedback from the ground as possible 5 Repeat process 50 times 26 SECTION 15: MISCELLANEOUS 1.1 4-4-8 Breathing Instruct the patient to breathe in for 4 seconds, hold their breath for 4 seconds, and then exhale for 8 seconds. If they are unable to do so for the entire duration, they are either inhaling/exhaling too fast or slow. 1.2 Normatec Have the patient lay down and place each of their legs in a boot sleeve. Plug the sleeve ports to the control unit. Adjust sleeve zones according to the patient's height through advanced settings, adjust intensity level, and begin the therapy. Adjust and monitor as needed throughout the session. 27 SECTION 16: PATIENT INTERACTION 1.3 Initial Interaction To have consistency across providers, all staff are instructed to have the same initial visit greeting. When seeing a patient, use the following script. Salutation – It’s good to see you! Assessment – How have you been doing since the last visit? (during this, shift attention over to computer and be attentive, writing down any notes) You-We-I Statement – Ok so you have __symptom____ going on, we’re going to start by doing treatment , and I’ll do my best to make you feel better. Questions – Any questions before we begin? Begin – Ok, let’s begin. 1.4 Patient Questions If you get asked a question that you don’t know or are not completely sure how to answer, redirect them to the doctor. Do not try to make things up. Otherwise, when they ask the doctors and are given a different answer, they will no longer trust you with their treatments. However, if you are sure you know the answer, feel free to explain! SAMPLE: “That’s a good question, I could try to answer it, but I want to make sure you get the absolute correct answer and my explanation might not be as good, so please ask the doctor when you see them today.” Another option is to give a generalized explanation. SAMPLE: “The brain has a lot of maps, visual maps of the environment, vestibular maps of where your head is and where it moves, and proprioceptive maps so you know where your body is. This exercise is designed to fix the _____ map.” 1.5 SOAP SUBJECTIVE The subjective refers to what the patient tells you during their therapy session. While it is generally important to get a good summary of how the patient has been doing since the previous session, it is especially the case for person injury (PI) patients. In the event that the patient is called into court, our charts may be audited. Documenting the patient’s symptoms and how they are impacting the patient’s life is critical to uphold that treatment was necessary for the patient. Below is a guideline to obtain an accurate subjective. 1. Write chief complaint down, their intensity, and anything that has changed since last visit 2. Write another sentence about what their pain is preventing them from doing 3. Intensity – do not use numbers. a. Mild – 1-2/10 28  b. Moderate – 3-5/10 c. Severe – 6-10/10 d. Focus on ADL (activities of daily living), pain, and suffering. What can they not do? e. Don’t say “Patient feels good” or “Patient had one headache today”. Justify our care. OBJECTIVE The objective refers to what we as provider see. Copy & paste from the Pertinent Findings listed in the Diagnosis and Plan chart. ASSESSMENT The assessment refers to the diagnosis. Copy & paste the bullet points listed in the Diagnosis section in the Diagnosis and Plan chart. PLAN The plan refers to the specific treatments done on the patients during the therapy session. It is important to increase the difficulty of exercises from one session to the next in order to challenge the patient. 29 SECTION 17: OBSERVATIONAL SKILLS 1.6 Signs of Fatigue 1. Increased dilation of pupil 2. Patient doesn’t look good/says they don’t feel good 3. Increase in symptoms 4. Increased heart rate, sweating 5. Watery eyes 1.7 Observational Skills 1. Pupil size 2. Pursuit smoothness 3. Noting differences between their relaxed appearance to signs of fatigue, distress and discomfort. 30 SECTION 18: 10 WEEK TRAINING 1. Everyone needs to be everything the same exact way from the rehabs to the doctors 2. The goal is to systematize in the practice 3. Ask questions if you are unsure of something 4. Improve knowing how to update exercises throughout care plan and when to do new exercises Week 1: Structure of a Visit Week 2: Warmup/charging, Energy/healing Week 3: Proprioceptive Rehabilitation Week 4: Repositioning Maneuvers Week 5: Vestibular Rehabilitation Week 6: NSI Week 7: Tilt Table Week 8: Neurofeedback Week 9: Misc, SOAPS, Patient Interaction, Transformation Statements Week 10: Fatigue 31