A Habituation Approach: To Treating Vertigo in Occupational Therapy
A Habituation Approach: To Treating Vertigo in Occupational Therapy
C:be History
A 42-year-old woman with multiple sclerosis of 12 years'
duration, which resulted in a residual weakness in all four
extremities, sought treatment at the Rehabilitation Insti-
tute of Michigan in Detroit, complaining of Iight-headed-
ness and marked ataxia. The physician ordered a com-
plete oculomotor examination, with emphaSiS on
labyrinthine function. The tests ordered were as follows:
1. Use of Frenzels lenses to observe subtle sponta-
neous or positional nystagmus.
2. Caloric tests to examine the function of the semi-
circular canals individually, by stimulating one ear
at a time with warm and cold water, with the head
in various pOSitions.
3. Rotary chair tests to examine the vestibuloocular
reflex under controlled parameters, with sinu-
soids and velocity steps of various frequencies
and velOCities.
4. Other tests of eye movements to examine the
various oculomotor subsystems.
These tests were performed whiJe eye movements
were recorded objectively with the use of electroocu-
lography, a)so known as electronystagmography. These
tests of oculomotor function give information about the
locus of the lesion, because lesions in different locations
cause different kinds of deficits in oculomotor control
(Cohen & Keshner, 1989).
The audiologist gave the patient a hearing test to
screen for middle ear problems; tumors of the eighth
nerve that could cause both auditory and vestibular symp-
toms; or Meniere disease, which also affects both audi-
tory and vestibular sensation.
The test results showed nystagmus, or rhythmic
Patricia Ann Morris, Ol~, is Senior Clinician at the Rehabilita-
movements of the eyes, on upward gaze. The patient was
tion Institute of Michigan, 7551 Wykes Street, Detroit, Michi-
unable to hold this eye position and became extremely
gan 48210
nauseated. She was also impaired in her ability to use
This article was accepted/or publication June 30, 1990 smooth eye movements to watch a moving target bilater-
increase in movement, either while seated or while stand- Sequence Direction From To
ing, increased her anxiety.
Possible causes for the patient's symptoms were ex- Ml J'vlidIine Silting Supine
plored during a team meeting and through a review of the M2 Left Supine Left side
M3 Right Left side Right side
literature on vertigo. FollOWing the literature review,
M4 Midline Supine Sitting
treatment was instituted.
STA;,\,DINC'I
M5 Turning to right
Lireraulre Review M6 Turning to left
Slnl"G
Cawthorne (1945) and Cooksey (1945, 1946) developed a
set of exercises for vertigo to cause the patient to learn to M7 Right Nose on left knee Right ear on right
shoulder
habituate or adapt to the vertiginous stimulus. Patients M8 Left Nose on right knee Left ear on left
perform gradual exercises to increase the range of mo- shoulder
tion through which they can tolerate head movements. MOVEMENTS
This exercise program, called vestibular habituation M9 Tuming head counter-
training, consists of a series of 19 maneuvers that are clockwise
repeated to gradually inhibit the vertigo. Vestibular ha- MlO Turning head clock-
wise
bituation training is carried out for at least 5 min, three Mll Bending forward
times daily for as long as the vertigo continues. Both M12 Going from silting to
Cawthorne and Cooksey recommended emphasis on the erect standing
posilion
head positions and movements that cause vertigo. They M13 Moving head forward
claimed that the earlier and more regularly the exercise and hack
regimen is carried out, the faster and more complete the M14 Ldl SiIring Head hanging and
turned to the left
return to normal actiVity.
M15 Left Sitting
McCabe (1970) developed a similar habituation ap- M16 Right Silling Head hanging and
proach to treating vertigo. He encouraged patients to turned to the right
M17 Right Sitting
stimulate their vertigo whenever they could. He reported
M18 Midline SiIring Head hanging in
that by doing so, the patients could build a tolerance to midline
and eventually inhibit the symptoms of vertigo. Like M19 Midline Sitting
Cawthorne (1945) and Cooksey (1945, 1946), McCabe
believed that if the vertigo is related to certain head posi- Note. From "Vestibular Habituation Training: Exercise Treatment for
Vertigo Based Upon the Habituation Effect"' by M.E. Norn~ and A.
tions, then the patient should place his or her head in that
Beckers, 1988, Archiveso/Otolmyngo!ogy, 114, pro 883-886. Copyright
position repeatedly. The positions found to be the most 1988 by Marcel E. Nom::, Adapted by permission.
the standing activities, she began ambulating on level Gray, Ph[), Rhonda Stewart, Oll<. La Donn People, MS. OTR. Sue
Nimlin, "IS, OTR. and my family for their editorial assistance.
surfaces with a standard walker.
Picking up objects. The final step in the patient's ha-
References
bituation program was for her to lean over to pick up
lightweight objects from the floor. Barber, H. 0., & Sharpe,). A. (1988). Vestibular disorders.
Chicago: Year Book.
Cawthorne, T. (1945). Vestibular injuries. Proceedings of
Results the Royal Society of i1;[edicine, 39, 270.
Cohen, H., & Keshner, E. A. (1989). Current concepts of
After 4 weeks of daily occupational therapy sessions of 1 the vestibular system reviewed: 2. Visual/vestibular interaction
to 2 hr in duration, the patient's movements became and spatial orientation. American journal of Occupational
more spontaneous, which was reflected in her activities Therapy, 43, 331-338.
Cooksey, F S. (1945) Rehabilitation in vestibular injuries.
of daily living. She was independent with transfers, with Proceedings of the Royal Society of Medicine, 39, 220.
hygiene and dressing, and in using adaptive devices. She Cooksey, F S. (1946). Rehabilitation in vestibular injuries.
performed light kitchen tasks independently and safely. Proceedings of the Royal Socie/v of Medicine, 39, 273-275.
Her fearfulness abated and she stated, "It feels good to be Dix, M. R. (1979). The rationale and technique of head
able to do things myself instead of depending on my exercises in the treatment of vertigo. Ac/a Oto-Rhino-Laryngo-
logica Belgica, 33, 370-384.
mother." The patient's mother was taught how to work Dix, M. R, & Hood, j. D. (1984). Vertigo. New York: Wiley.
with her daughter in the home to maintain the patient's McCabe, B. F. (1970). Labyrinthine exercises in the treat-
skills and reinforce her positive behavior. I recommend- ment of disease characterized by vertigo. Laryngoscope, 80,
ed that the patient perform activities of daily liVing at the 1429-1433
appropriate times, be allowed additional time to com- Norre, M. E. (1987). Rationale of rehabilitation for vertigo.
American journal of Otolaryngolo[!y, 8, 31-35
plete activities before being assisted, and be given praise Norre, M. E., & Beckers, A. (1988). Vestibular habituation
for her accomplishments. training. Exercise treatment for vertigo based upon the habitua-
tion effect. Archives of Otolaryngolo[!y, 114, 883-886.
Norre, M. E.. & DeWeerdt, W. (1980). Treatment of vertigo
Summary based on habituation: Techniques and results of habituation
training. journal of Laryngology and OtologV, 971-977.
Before occupational therapy, the patient's basic and ad-
vanced activities of daily liVing were hindered by her ver-
Editor's No/e. To continue the Case Report department, we need
tigo, causing her to become housebound and to believe and welcome reporlS that document the practice of occupational
that she would never walk again. These feelings brought therapy for speCIfic clinical situations Guidelines for writing case
on a sense of insecurity and helplessness. Vestibular ha- reports are available from the Editor.