People with impairments of the vestibular system often have subtle problems that have profound ramifications for their ability to engage in daily life tasks and activities at home and to participate in society outside the home. Vestibular impairment often restricts an individual’s ability to participate in everyday occupations, affecting not only that individual but also significant others, including family members, friends, coworkers, and caregivers. Occupational therapy facilitates increased independence in daily life tasks and participation in work and social occupations. For these reasons, occupational therapy is an appropriate intervention for clients needing vestibular rehabilitation to decrease symptoms and increase independence in all aspects of their lives. Thus, vestibular rehabilitation is within the scope of practice for occupational therapists and occupational therapy assistants1 who have specialized knowledge and skills in this area. This document provides an understanding of the essential knowledge and skills needed by practitioners working with individuals with vestibular impairments and will be of interest to payers, practitioners, or consumers who wish to know more about occupational therapy practice using vestibular rehabilitation techniques.
People with vestibular disorders may present with symptoms including vertigo, oscillopsia, nausea, disequilibrium, spatial disorientation, visual motion sensitivity, decreased dynamic visual acuity, decreased concentration, and decreased skill in dual task performance. Spatial orientation deficits and disequilibrium may be manifested as head and body tilt while sitting or standing, perception of tilt while sitting or standing, veering or drifting to the side while walking or steering a vehicle, or a sense of not knowing which way is up. These problems may result in fear of falling. These symptoms may affect occupational performance and can result in social withdrawal and depression. For example, visual motion sensitivity may cause disequilibrium, vertigo, nausea and disorientation, leading to slower or more awkward performance of self-care skills, decreased participation in social activities, and decreased ability to perform home management tasks outside of the home, such as grocery shopping. Vertigo, disequilibrium, and other symptoms may interfere with job skills as they cause difficulty standing, reaching, walking, turning the head to scan the environment, or making social gestures with the head such as nodding.
The term vestibular rehabilitation refers to intervention to decrease symptoms and increase independence, safety, and participation in people with specific disorders of the peripheral vestibular apparatus, the central vestibular pathways, and age-related disequilibrium. Interventions include, but are not limited to, exercise and activity programs to reduce vertigo and oscillopsia, repositioning interventions for positional vertigo, exercises and activities to improve standing and walking balance during activities, and safety training at home and at work. A client receiving occupational therapy including vestibular rehabilitation techniques may also receive occupational therapy using other interventions. For example, a client with a head injury may also receive perceptual, motor, or life skills training. Vestibular rehabilitation is used to treat the sequelae of specific medical conditions, and provides an alternative or adjunct to pharmacologic and surgical intervention by the physician. Clients who receive vestibular rehabilitation have specific medical conditions that can be demonstrated with objective diagnostic tests or otherwise medically determined. Most people who are referred for vestibular rehabilitation are adults. They have a wide variety of health conditions including, but not limited to, benign paroxysmal positional vertigo (BPPV); acute, chronic, and recurrent labyrinthitis; vestibular neuronitis; some autoimmune disorders; postconcussion vertigo; postoperative vertigo; Ménierè’s disease; bilateral vestibular weakness or total vestibular loss due to ototoxicity; presbystasis or disequilibrium of aging; some cases of strokes, some cases of multiple sclerosis, some cases of Parkinson’s disease, some Parkinsonian syndromes, and some cases of migraine.
Although the focus of this document is on adult vestibular rehabilitation, we note that the same or similar vestibular impairments may occur in children. The literature has few papers on the efficacy of vestibular rehabilitation in children. These disorders are difficult to diagnose because children may not be able to describe their symptoms and because, for technical reasons, young children cannot always be tested with standard objective diagnostic tests. Vestibular disorders that occur in childhood that may respond to vestibular rehabilitation include childhood paroxysmal vertigo, which may be related to migraine; BPPV; labyrinthitis; vestibular neuronitis; bilateral impairment due to ototoxicity; some autoimmune disorders; and congenital malformations of the inner ear. In pediatric vestibular rehabilitation, treatment activities must be age appropriate.
Clients with vestibular disorders have a complex combination of physiological and psychological problems. The effects of vestibular impairments are subtle and pervasive. Many people with these problems are not able to describe the sensations they have or the motions that elicit vertigo or disequilibrium. Therefore, rehabilitation of most individuals with vestibular impairments requires skills beyond entry-level competence. The specialized nature of this intervention requires specific, advanced-level knowledge. Intervention may require specific techniques that focus directly on the vestibular impairment. Advanced skills build on earlier competencies in knowledge, performance, critical reasoning, interpersonal abilities, and ethical reasoning and additional competencies developed during independent study of the literature, continuing education coursework, and additional practice. An in-depth understanding of the structure and function of the vestibular system, visual/vestibular/proprioceptive interactions, and the principles of motor control is essential when providing vestibular rehabilitation. Occupational therapy entry-level education provides a foundation in functional anatomy, neuroscience, and motor control that assists the practitioner in understanding the types of complex problems experienced by clients with vestibular impairments. Practitioners need further training, however, to address the subtle problems of clients with these disorders. Advancedlevel skills are necessary for evaluation of the deficits and specific manipulations that alter vestibular function. This knowledge and these skills are not provided to occupational therapists at the entry level. Appendix 1 outlines the basic science knowledge necessary for advanced practice. Occupational therapists use knowledge of vestibular system anatomy and physiology when determining underlying problems that affect occupational performance. An individual’s central nervous system uses information about head movement to help control four classes of behavior: (a) postural reflexes for control of balance, (b) vestibulo-ocular reflexes to stabilize gaze so the individual can see clearly, (c) coding of spatial coordinates for object orientation and navigation, and (d) some autonomic responses to prepare for “fight-or-flight” behavior. Appendix 2 outlines the applied science knowledge necessary for advanced practice.
The occupational therapist must be highly skilled at evaluating the consequences of subtle vestibular deficits, such as balance disturbances due to head movements while sitting, standing, walking, reaching, and performing transfers between positions.
Understanding the potential impact of vestibular impairment on participation in healthy occupations requires knowledge of the effect of vestibular impairment on the life of the person. See Appendices 3–8 for specific examples of how vestibular impairments impact performance in occupation (AOTA, 2002). Refined skills in activity analysis are essential for evaluation of and intervention planning for these clients. The occupational therapist uses knowledge of body structure and function in conjunction with observation and activity analysis when evaluating subtle decrements in performance during typical daily activities. At the entry level, occupational therapists and occupational therapy assistants are familiar with the location of the vestibular labyrinth and know that the symptoms of vestibular disorders include vertigo, poor balance, and fear of falling. Their use of the occupational profile helps to determine which tasks elicit those symptoms. They are able to determine if clients would benefit from adaptive safety equipment; to recommend equipment appropriate for the home; and to educate clients about other safety concerns, such as appropriate clothing and shoes.
They also are able to evaluate many activities of daily living directly to determine if training is needed and provide training when necessary. Appendix 9 outlines the essential evaluation skills for the advanced practitioner. Appendix 10 outlines specific information on intervention using vestibular rehabilitation methods. Occupation therapy practitioners who do vestibular rehabilitation may seek reimbursement through Medicare and other third-party payers. Examples of possible Current Procedural Technology (CPT) codes include, but are not limited to, codes for neuromuscular reeducation of movement, balance, coordination, and/or posture for sitting and/ or standing activities (97112); manual therapy (97140); and therapeutic activities to improve functional performance (97530) (American Medical Association, 2006).
The occupational therapist assumes the ultimate responsibility for the delivery of occupational therapy services, including evaluation of the person and development of the intervention plan. The advanced occupational therapist may delegate certain selected interventions to an entry-level occupational therapist or to an occupational therapy assistant who has demonstrated service competency in those interventions. All practitioners should know when and how to refer clients to other health professionals when needed, including but not limited to: specialty physicians, certified driving rehabilitation specialists, psychologists, physical therapists, audiologists, and social workers.
Vestibular rehabilitation in occupational therapy practice is supported by the literature, although considerable research remains to be done. This section is not an exhaustive review of the research but gives an overview of the research on vestibular impairment and vestibular rehabilitation that is relevant to occupational therapy. Suggested readings not cited here are listed in the “Additional Reading” list.
In the first paper describing the use of exercises for vertigo, Cawthorne (1944) indicated that some patients with postconcussion vertigo are rendered “helpless and immobile,” preceding later work by occupational therapists and their collaborators showing that patients with disorders that cause vertigo have significantly reduced independence in activities of daily living (Cohen, 1992; Cohen, Ewell, & Jenkins, 1995; Cohen & Jerabek, 1999; Cohen & Kimball, 2000; Cohen, Kimball, & Adams, 2000; Cohen, Wells, Kimball, & Owsley, 2003; Farber, 1989; Morris, 1991).
In Cooksey’s first paper describing vestibular rehabilitation exercises (Cooksey, 1945), he mentioned the need for teamwork by rehabilitation staff, including occupational therapists. Cooksey specifically noted the role of occupational therapy in the early resumption of purposeful activity. In his 1946 paper, Cooksey indicated that purposeful activity should be incorporated into the daily exercise program for these patients. Structured, purposeful activity is an effective treatment modality for reducing vertigo, improving balance, and increasing independence in activities of daily living (Cohen, Kane-Wineland, Miller, & Hatfield, 1995; Cohen, Miller, Kane-Wineland, & Hatfield, 1995). Vertigo habituation exercises are also effective in decreasing symptoms, improving spatial orientation skills, and increasing independence and ability to perform purposeful activity that involves repetitive head movements (Cohen & Kimball, 2002, 2003, 2004b, 2004c). Thus, exercises and purposeful activities may be components of a successful rehabilitation program for many patients with vertigo. For a critical review of more recent studies on vertigo habituation treatments and other issues, see Cohen’s 2006 review paper.
A series of studies has shown that patients with vestibular disorders also have high rates of anxiety and other psychosocial problems (Eagger, Luxon, Davies, Coelho, & Ron, 1992; Yardley & Hallam, 1996; Yardley, Luxon, & Haacke, 1994; Yardley & Putman, 1992). Many of these kinds of problems might be appropriate for intervention by occupational therapists, combining our understanding of physical and psychosocial disorders. Patients with benign paroxysmal positional vertigo are best treated with passive maneuvers of the head that are thought to reposition otoconial particles that have become displaced from one compartment to another. Occupational therapists and their collaborators have been in the forefront of investigators showing that these repositioning maneuvers are effective treatments (Cohen & Jerabek, 1999; Cohen and Kimball, 2004a, 2005; Macias, Lambert, Massingale, Ellensohn, & Fritz, 2000; Steenerson & Cronin, 1996; Steenerson, Cronin, & Marback, 2005).
The following Appendixes outline the basic knowledge needed to understand and treat vestibular disorders, the effects of vestibular disorders on occupational performance, and the types of interventions occupational therapists use. The appendices are not exhaustive. Further knowledge of specific conditions may be needed in some circumstances, particularly when clients have more than one diagnosis or health condition. Also, by the nature of growth in clinical skills, the division between entry-level and advanced knowledge is somewhat fluid as the practitioner learns more and advances in clinical knowledge and skill. Furthermore, the knowledge base listed here is not absolute. Research in basic and applied science continues to expand the available knowledge base. Therefore, practitioners continue to read the literature, attend continuing education courses, and otherwise engage in activities to maintain and improve their knowledge and understanding of intervention in this area, to support their evidence-based practice. Vestibular disorders decrease the ability to be independent in many activities of daily living. In general, tasks that require rapid or repeated head movements, tasks that require good postural control especially while standing or walking, and tasks that require good spatial orientation may be affected. Clients who have fallen or who are at risk for falls may severely restrict their movements and may actually increase their risk of falling as a result.
Many clients deliberately constrain their lives, becoming less active within and outside the home. So, they may abandon activities that they consider to be nonessential and reduce their participation in essential tasks. Many people stop driving or drive only within their neighborhoods and avoid highway driving. They may even change jobs to reduce travel or to avoid other job-related requirements that elicit vertigo or disequilibrium.
Many people with vestibular disorders stop socializing or attending worship services because they are embarrassed by their ataxic gaits and do not want to give the appearance of intoxication. Some clients, who have vertigo when they bow during required prayers or who are unable to kneel while praying, may feel spiritually bereft. These problems can affect relationships with family, friends, and coworkers. Even the most understanding spouses may become upset when intimate sexual activity is interrupted by vertigo, quiet time together while taking a walk is made unpleasant due to repeated stumbling or drifting back and forth, and the affected individual may no longer be able to participate in shared sports or other exercise activities.
See Appendixes 3–8 for further examples. Specific evaluation and intervention skills are used in vestibular rehabilitation. The occupational therapy practitioner who works in this specialty must be familiar with the evaluation skills in Appendix 9 and the intervention skills in Appendix 10.