OT Takes Leading Role in Vestibular Treatment By Claudia Stahl ADVANCE- March 13, 1995 Assistant Editor When people speak of imbalance in their lives, they are usually referring metaphorically to lifestyle issues: But for people with vestibular disorders, imbalance is literal. The world spins at an alarming rate, causing fear, dizziness- even physical injury. Rehabilitation is now widely accepted in the treatment of vestibular disorders, preferable even to drugs (ADVANCE, "Stopping the Spin," Dec.12, 1994), What many people in the health care field don't realize, however, is that occupational therapists have contributed to the success of vestibular rehab. Helen Cohen, EdD, OTR, co-director of the Center for Balance Disorders at Baylor College of Medicine in Houston, partially attributes this lack of recognition to the scarcity of literature on OT in vestibular rehabilitation. Vestibular rehab also is described in terms of exercise, and- therefore- physical therapy. Given these obstacles and the absence of information on vesti- bular rehab in the OT curriculum, it is no wonder that only "a handful of occupational therapists are involved in vestibular rehabilitation," Dr. Cohen said. Those who are, she added, "discovered it on their own." But the tables are turning. Research and patient testimonials are rapidly validating the need for an occupational component in traditional vestibular exercise programs. "There is a vital role (here) for OT because a number of patients don't comply with exercise programs," said Dr. Cohen. "I believe it is better to incorporate the Cawthore-Cooksey exercises in their daily activities." The current protocol of vertigo treatment-a series of exercises formulated to de-sensitize patients to their dizziness-was developed by Drs. T. Cawthorne and F.S. Cooksey in 1944. At that time, occupational therapists were included in the rehabilitation process only for diversionary therapy. Today, the OT's role in vestibular rehabilitation is much broader. In fact, a recent study funded by the American Occupational Therapy Foundation (AOTF) has revealed that purposeful activity is an extremely effective modality for treatment of vertigo and balance problems. Dr. Cohen served as principal investigator of that research, which was co-conducted by occupational therapists Maureen Kane-Wineland, MEd, OTR, of the Medical College of Ohio, and Laura V. Miller, MA OTR, of the Detroit Receiving Hospital. The therapists found that the Cawthorne-Cooksey exercises could easily be incorporated into activities which require specific head movements, such as games of catch, bean bag toss, and Frisbee. The movements used in such actions correspond with daily activities that commonly provoke vertigo, such as putting away groceries. The researchers compared individuals who were treated in the traditional Cawthorne-Cooksey exercise regimen with those whose exercises were embedded in activity. "The data suggested that both groups improved. But the activity-based group had less vertigo than the others and were more independent in ADL," said Dr. Cohen. Thomas Patullo, OTR/L, owner of Florida Balance Centers, Inc., Dania, FL, is not surprised by those findings. For five years he has enjoyed great success with using activity to treat patients with vestibular disorders. Patullo said OTs bring a new perspective to vestibular rehabilitation because they are not only dealing with the physical components, but the emotional and psychological, as well. These issues are just as relevant to the individual's ability to resume normal activities. According to Patullo, people with vestibular problems learn to avoid activities that will lead to the onset of vertigo. Ironically, this hinders them in the long run because the central nervous system never learns to respond properly to the signals causing the condition. Vertigo occurs when the vestibular labyrinth in the inner ear, responsible for our sense of balance, sends asymmetric signals to the brain. The CNS does not know how to respond to the signals, and produces conflicting information about the positioning of the head and body; the result is dizziness. Cawthorne and Cooksey theorized that the best way for individuals to recover from vertigo is to move their heads and make themselves dizzy. Eventually, the CNS learns to interpret the signals correctly and adjusts to the imbalances. Avoidance of these activities only complicates the problem and leads to increased disability. "They fall into a chronic cycle of limiting activity. As they do their systems become even more sensitive to movement, leading to a downward spiral of inactivity," explained Patullo. Activities such as driving, getting into or and out of the bathtub, food shopping, or dining in a restaurant can become difficult to impossible if vertigo isn't treated. Secondary psychological issues, such as anxiety, panic and depression are almost inevitable. Patullo said acknowledging these issues with clients creates an almost immediate rapport. "They find enormous relief when someone can relate to how these problems are limiting their lifestyle," he said. "It raises their level of confidence in the practitioner." Individuals are referred for vestibular rehabilitation when the condition has been diagnosed as chronic (typically if the symptoms persist for more than a month). Dizziness is not the only symptom of a vestibular problem. Sometimes sequelea are limited to disequilibrium or blurred vision. Patullo uses a sensory integrative mix of graded activities to gradually retrain his clients' vestibular systems, focusing on how their conditions limit ADL. Patients are evaluated standing, lying down, sitting and rolling. Patullo finds The Balance Master System by Neurocom International, helpful for assessment of balance and position, as well as his patients' visual-vestibular interaction skills- the head and eye movements they need to perform common activities in a variety of patterns and conditions. "I may have them use the computer for visual scanning and targeting, or walk on both static and uneven surfaces with their eyes open and closed," he said. With the aid of postural biofeedback, Patullo is able to show patients how to correct sway on their own. Patients can also use their body movements to control a downhill skiing computer game. "It makes therapy more interactive and related to real life," Patullo said. Finally, Patullo assists patients in dealing with the emotional symptoms of their conditions. Fear, depression, and anxiety related to their disorder can be just as incapacitating as its physical symptoms. "I give them coping strategies," Patullo said. "For example, if going to a restaurant may be difficult due to background noise and the constant movement of passing waiters and patrons, I may recommend that they sit in a quiet area, away from the wait station. Or that they sit where they can face people, rather than having to constantly turn their heads," Patullo said. Grocery shopping can be another dizzy task for people with vestibular disorders due to the need to scan the aisle for items. Patullo helps his patients to write out grocery lists and organize them according to item type. That way, they are not searching for random items and have less running around to do. Patullo said it takes an average of six to 10 weeks for patients with vestibular dysfunction to recover. In Cohen's experience, individuals with peripheral vestibular disorder take no more than two-to-three weeks to recover. "It may take longer if they have experienced significant trauma or if there is CNS involvement," he said. Patullo said vestibular rehabilitation in OT is highly specialized much like hand therapy. He became involved in vestibular rehab when a physician inquired about it. "I began researching and going to courses on vestibular disorders," he said. "It made sense to me that OT's were ideally suited for helping to correct these (problems)." Patullo believes heightening publicity may be one solution to raising awareness of OTs role in vestibular rehabilitation. It wasn't until he read an article on the subject, written by Gaye Cronin MHE, OTR/L (ADVANCE, Oct. 22, 1990) that he realized he wasn't alone. Patullo has now specialized in vestibular rehabilitation for five years. His practice was recently featured on the local news in Florida. "There has been a lot of media attention lately about vestibular disorders," he said. According to the NIH, 76 million people suffer from inner ear disorders, so there is a great need for vestibular rehabilitation." Dr. Cohen's research will be appearing in the April 1995 issue of AJOT. She is hoping her article, too, will generate interest in this area within the occupational therapy community. "This is an accessible specialty and it would benefit patients if more OT's were to get involved in vestibular rehabi-litation," said Dr. Cohen. "We have a unique role in this arena and special skills to offer."