The Indian Journal of Occupational Therapy : Vol. XXXIII : No.

1, April-July 2001

VESTIBULAR REHABILITATION THERAPY IN NEUROSURGICAL PATIENTS : AN OCCU-

PATIONAL THERAPY PERSPECTIVE
KONNUR M.K., BHATJIWALE M.G., NAVALAKHE M.M., KHANDELWAL P.S.
Deptts. of Occupational Therapy, Neurosurgery and E.N.T., Seth G.S. Medical College and K.E.M. Hospital, Parel, Mumbai.

INTRODUCTION Symptoms
1. Vertigo :
Occupational Therapy deals with the rehabilitation of the In post operative cases, nonsubdued within 24-
psycho-physical handicap to return them to their possible 72 hours.
functional status and ease performance of activities of daily 3. Balance and Gait Dysfunction.
living (ADL). Residual vertigo (giddiness), balance and gait
dysfunction in (1) Post surgical management of tumor cases, Assessment and investigations
(2) Vertebrobasilar insufficiences, (3) Head injuries, pose a
threat to effective rehabilitation using traditional techniques2,3. 1. Occupational Therapy evalution in terms of
Since the advent of vestibular exercises (Cawthorne- physical capacity, vertigo8,9, Tinetti Assessment
Cooksey) there have been modifications, variations and Battery for gait and balance10.
adaptation of these exercises to have a more individualised 2. Neurosurgical Assessment : Investigations-
approach4,5. Vestibular Rehabilitation Training (VRT) has MRI, CT Scan
basically 2 components i.e. habituation and training which 16 cases of unilateral lesion
exhibits impressive results in management of vertigo and 1 case of midline lesion
balance dysfunction.
Type of Tumor
Literature of vestibular rehabilitation reveals evidences to Meningiomas, Low Grade Astrocytomas,
the success of these strategies in different conditions involving Haemangioblastoma, Medulloblastoma
the central and the peripheral vestibular system but do not
quantify its effect in the above mentioned cases which Mean Size
became the basic aim of the study3,5,6,7. For posterior fossa Tumors : 3 x 3.5 cms.
For Basal Ganglia Tumors : 6.5 x 4.8 cms.
METHODOLOGY ENT : Audiometry - Reported normal hearing.

Selection of patients Intervention

A population of 25 patients (11 females, 14 males) of age Patients were to follow VRT, ten times each, thrice a day
group 20-60 years were included in the study, the criteria and were evaluated prior to the start of VRT and at 2, 3, 4, 6
being. weeks post VRT4,5,11. Individualized exercise schedule was
followed. VRT broadly consisted of :
Diagnosis
1. 14 cases of posterior fossa tumors and 3 cases 1. Head and Neck Exercises in
of basal ganglia tumors. Variable positions like supine, sitting (with eyes
2. 5 cases of cervical spondylosis with no open and closed.)
neurological deficit. Activities of Daily Living (ADL) which require
3. 3 cases of precipitant head injury with no head movements.
residual neurological deficit. Walking.
2. Visual - vestibular interaction exercises, e.g. eye-hand
CORRESPONDENCE : Dr. (Miss) Moushumi K. Konnur, coordination exercises.
Occupational Therapist, 113, Saraswati Niwas, Hindu 3. Postural control exercises, e.g. weight bearing
Colony, Road No. 4, Dadar, Mumbai-400014.
exercises.
Paper was presented at 37th Nat. Conference of AIOTA, 4. Precautions regarding falls, walking aids.
EMCON'2000, at Mumbai in Jan. 2000.

17
Patients requiring surgery carried out exercises on indoor
basis till discharge from the hospital with 2 sessions in O T
Department and post discharge at home, and visit to the
therapist on followup date. Rest of the patients were initially
supervised thrice in the first week in the O T Department to
later on follow a home programme and report for followup
session.
DISCUSSION
Vertigo and maladaptive postural control strategies have for
long posed problems and hesitancy in the therapists to institute
rehabilitation schedule. In conditions like posterior fossa and
cerebellopontine angle tumors which are progressive, VRT
can only give a diagnostic trail preoperatively4. But after

Table I

Parameters VRT P
Before F.U.-I. F.U. 2 F.U. 3 F.U. 4
(2 wks) (3 wks) (4 wks) (6 wks)
VERTIGO
a) Intensity 4.36±0.489 3.08±0.759 2.04±0.734 1.60 ± 0.707 1.36± 0.568 P<0.001 highly significent

b) Duration 2.92 ± 0.276 1.48 ±0.962 1.36± 0.568 1.00±.007 1.00±0 P<0.01 highly significant

TAB
a) Group A 6.71±3.42 15.5±5.76 22.71±4.98 25.98±2.69 26.95±1.328 P<0.001 highly significent

b) Group B 23.27 ±4 26.18 ±2.60 27.72 ±0.904 28.00±.0 28.0±0 P<0.005 significant

RESULTS resection in many a cases there exist symptoms of vertigo

As per Table 1, the VRT was found to be very effective to
decrease vertigo (in terms of intensity and duration), to
negligible in all cases and showed high statistical significance
on gait and balance improvement.
For statistical case the patients were divided into 2 groups,
namely A and B, for evaluation on the Tinetti Assessment
Battery (TAB) as Group B patients did not report for gross
alterations/dysfunctions in the gait and balance parameters.
Inclusions in Groups were :
Group A
14 patients with posterior fossa and Cerebello pontine angle
tumors
(giddiness) and imbalance inspite of normal hearing which
provided the authors with a baseline to carry out the study.
Moresoever, cases with vertebrobasilar insufficiency in
cervical spondylosis and precipitant head injuries noted
symptomatic similarity. It was seen that due to these
symptoms ADL also becomes uncomfortable although the
voluntary control and power of the appendages and axis
remains intact, thereby explaining the inclusion of ADL in
VRT2.
VRT puts forth the unique feature of vestibular plasticity or
compensation of the CNS. A flowchart of the compensatory
process can be referred to in fig. 1 This process results from
active neuronal and neurochemical processes in the
cerebellum and the brainstem in response to sensory conflicts
produced by vestibular pathology. To achieve this VRT uses
the physiologic rationale of :

Group B Training
11 patients, 5 with cervical spondylosis, 3 with head injury, 1. Reestablishing symmetric tonic firing rates in vestibular
nuclei.
and 3 patients with basal ganglia tumors.
2. Accurate adjustive responses to head movements.
All the patients followed up after a month from the last follow
up and kept consistent with the findings recorded at the 6th
Habituation
week.
1. Consistency in sensory inputs

IJOT : Vol. XXXIII : No. 1 18 April - July 2001

The basic and common techniques of VRT are elaborately
discussed in literature and only in individualised programme
following these was used in the study details discussed before.
Motivation of the patient to perform and participate in the
therapy is the key to the efficacy and success of the therapy
as the initial phase might be irritable for the patient6.
The therapist-assessed Tinetti Assessment Battery can be
used to evaluate gait and balance dysfunction more so in
posterior fossa and cerebellopontine angle tumors. Although
Computerized Posturography is the global indicator of patient
candidacy for therapy, literature states that non computerized
versions of Balance and Gait batteries are gaining wide
acceptance and can be administered efficiently2. Our study
also supports this view. This was evident in the group A
patients for TAB as they pursued cerebellar dysfunction.
Whereas the group B patients had dysfunction on TAB mainly
due to vertigo.
As the patient gets trained to become gradually habituated,
relief of symptoms is noticeable in 1-4 weeks from start of
therapy. As this is an energy dependent process, the VRT
should not be abruptly stopped. The symptoms may be
triggered by a period of inactivity, extreme fatigue, change in
medications or an intercurrent illness.
Fig. I
VRT : The Physiologic Rationale.
Pathology of Vestibular System
(Cerebellum, Brainstem, Vestibular Tracts)
Vertigo, Dysequilibrium (Gait/Balance)
Acute Compensation De-compensation
(24-72 hours) (Relapse of symptoms)
Residual Symptoms
Chronic Compensation
V.R.T. in Occupational Therapy
Relief of Symptoms
CONCLUSIONS
1. VRT can be used in management of residual vertigo
and postural control strategies and comfort ADL in
post operative neurosurgical, vascular and head injury
IJOT : Vol. XXXIII : No. 1
cases. Confirming validity of the study with wider
sample is a futuristic aim.
2. Non computerized versions of balance and gait
assessment batteries can be used by therapists for
patient candidacy and follow up assessment.
ACKNOWLEDGEMENT
We wish to thank Dean, Seth G.S. Medical College and
K.E.M. Hospital for allowing us to conduct the study and
extend our thanks to Professor (Mrs.) I.R.Kenkre, H.O.D.
(OT) and Dr. Atul Goel, HOD (Neurosurgery).
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19 April - July 2001