Vertigo and vestibular rehabilitation.MK Konnur
Department of Occupational Therapy, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai-400 012, India., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 11298478
Source of Support: None, Conflict of Interest: None
The role of rehabilitation in the management of vertigo is limited to a very specific group of conditions. An Occupational therapist who is a part of the multidisciplinary team treating the vertiginous patient, with the knowledge of physiology and therapeutic benefit of vestibular rehabilitation can widen the rehabilitation spectrum for various diseases producing vertigo and dysequilibrium, to resolve or minimise these symptoms. The present article reviews the need for vestibular rehabilitation and the different conditions needing the same along with its characteristics, physiology and various exercises prescribed.
Keywords: Activities of Daily Living, Exercise Therapy, Female, Human, Male, Occupational Therapy, methods,Prognosis, Severity of Illness Index, Treatment Outcome, Vertigo, diagnosis,rehabilitation,Vestibular Diseases, rehabilitation,
Vertigo is spinning feeling of self-motion and surrounding visual scene, which can go to the extent of causing disability in the day-to-day life of an individual. Sudden simple movements or change of posture may provoke vertigo, which may be accompanied by dysequilibrium. Frequent recurrence of vertigo curtails outdoor activities of the individual, which is obvious from the absentia at workplace in case of an employed individual and hesitancy to go even for a walk in case of others. Activities like crossing roads is not only difficult but also hazardous as there are blackouts due to giddiness. This negative feedback hampers the psychological status of the individual. More so if it concerns geriatric individual it predisposes the person to falls and secondary injuries, which may make him disabled or shorten the life expectancy.
Such vertiginous patients have common adaptations like avoidance of usually the neck movements causing or provoking vertigo and hesitancy to change postures., This not only amounts to restriction of range at the particular joint but also leads to the vicious cycle by decreasing the threshold for vertigo and increasing the vertiginous attacks. Vertiginous patients are commonly observed to take over to dependency on others who are mostly the family members.
Antivertiginous drugs, antihistaminics or vasodilators, are known to give temporary relief but literature suggests the counterproductive effects of these drugs. Once the severe acute symptoms subside the anti-vertiginous drug therapy should be stopped and the patient should be considered for vestibular rehabilitation therapy (VRT).,
VRT deals with the management of vertiginous patient by alleviating the symptoms and increasing the threshold to vertigo. Activities of daily living (ADL) are also a part of the therapy which eases their performance.
Cawthorne - Cooksey primarily charted the vestibular exercise proforma. Since then there have been modifications in the exercise pattern adopted for these patients put forth by various researchers.,,,,, These studies were done on patients with variable otolaryngological, vascular, neoplastic conditions giving rise to central and peripheral vertigo. Different tailored exercise proformas like University of Michigan VRT and Zee’s exercises have been used. ,
VRT has therapeutic and diagnostic utilities. The patients who do not exhibit vertigo and postural abnormalities when provocative movements are performed should not be considered as candidates for vestibular therapy. VRT as a therapeutic modality can be used in the following conditions:,,,, otological conditions like labyrinthitis, neuronitis, benign paroxysmal positional vertigo; vascular conditions e.g. vertebral artery compression secondary to cervical spondylosis; post-tumour resection e.g. acoustic neuromas, cerebello-pontine angle lesions, cerebellar, temporal and frontal tumours; Meniere’s disease if severe spontaneous attacks do not occur more than once a month; head injuries; post vestibular surgery like vestibular nerve section, labyrinthectomy; panic and anxiety attacks; and dysequili-brium due to aging.
Other than the therapeutic uses, VRT can be used as an evaluatory tool to decide the actual need for vestibular training and as a diagnostic method to differentiate malingering from true vertigo.
The concept of CNS and vestibular plasticity and compensation forms the physiological rationale for VRT. The compensatory process of CNS results from active neuronal and neurochemical processes in the cerebellum and brain stem in response to sensory conflicts produced by vestibular pathology. This is used in the form of training which is done through accurate adjustive responses to head movements (input) which aim at reinstalling symmetric tonic firing rates in the vestibular nuclei. The training is later on replaced by habituation that is by maintaining a consistency in these sensory inputs.
There are different exercise formats described in literature but they are all primarily centred around the following exercises which are tailored according to individual needs. The intensity of exercise is regulated according to individual tolerance and the resolution of the symptoms. The energy-dependent nature of the vestibular exercises is always to be considered, as abrupt stopping of exercise, period of inactivity, extreme fatigue or intercurrent illness may trigger off the symptoms.
Head and neck exercises: They are given in various positions like supine, sitting, standing and during performance of ADL which include vertigo provoking movements of the neck in different planes e.g. flexion, extension, etc. They make use of cervical-ocular reflex.
Visuo-vestibular interaction exercises like ocular exercises, eye-hand coordination exercises like dexterity kits, bead exercise. The vestibulo-ocular reflex is therapeutically used here.
Exercises to improve static and dynamic postural stability. They are designed to promote postural stability in a variety of sensory environments involving the manipulation of the visual, somatosensory, vestibular cues and use of prior experiences in single progressing to combinations. This includes the different surfaces on which the patient stands, head orientation and head movements and the performance with visual changes like eyes open with full field, moving stimuli or eyes closed. The static exercises, which are more of weight bearing types, move on to dynamic ones which include trunk rotation, small amplitude low frequency head rotations in the gait exercises.
Along with exercises are given general precautions against falls, use of protective adaptations like walkers, grab-bars, and suggestions to decrease mechanical barriers, especially in elderly patients.
After the patient completes initial phase of treatment, the exercises that no more produce vertigo are replaced by others which were on lower priority before, till the improvement is plateaued. Later on counselling and maintenance programs are provided.
The efficient management and resolution of disabling symptoms depends on diagnostic and rehabilitative planning which requires a multidisciplinary team approach comprising of neuro-otologists, occupational therapists (rehabilitation therapists), psychiatrists and medical social workers. The discretion of the therapist is of a special concern as therapist besides rehabilitating the patient functions to educate the patient about the condition (as motivation of the patient is the utmost requirement for therapy), supports the patient and counsels him in conditions with less favourable outcome. The patience and time investment during the therapeutic procedure pays dividends by making the passive patient go into an active role to aid his recovery from vertigo and dysequilibrium.