Spanish translation of CC exercises courtesy of Maria Busso. One of the first "general" interventions for vestibular problems were the Cawthorne-Cooksey CC exercises, as shown below. Although some authors state that the CC exercises are outmoded, this is not true. The CC exercises are still in common use see numerous references at bottom of this document. The CC exercises are mainly used as a home program This document is one page handout of activities that progress from simple head movement to complex activities such as throwing a ball.
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This medical information is provided to enhance and support, not replace, individual advice from a qualified medical practitioner.
Definition of vertigo Vertigo is a particular form of dizziness or giddiness. Rather than just feeling faint or light headed, it is an illusion of motion.
The sufferer feels as though they, or their surroundings, are turning, spinning, falling, or some other form of movement when in fact they are not. Like sea-sickness, vertigo is often accompanied by nausea and vomiting. After acute vertigo settles, it is often followed by dysequilibrium diss-eck-will-IB-ree-um , an uneasy feeling of imbalance, as though one might be about to fall over.
Vertigo and dysequilibrium can be very frightening, but do not usually signify any serious or life-threatening disease.
How damage to the inner ear causes vertigo Inner ear balance organ: vestibule, semicircular canals, cochlea and audio-vestibular nerve Vertigo can result from many causes, but is most often caused by damage to the balance organ of the inner ear. As well as the cochlea for hearing, the inner ear contains a very sensitive organ, the vestibular labyrinth, designed to help maintain balance.
The vestibular labyrinth is made up of three semicircular canals — lateral, posterior and superior. They join together at the vestibule. The semicircular canals are arranged at right angles to one another.
They can detect and measure movements and acceleration in all three planes of space. The inner ear balance organ can also detect the direction of gravity.
The right and left balance organs work together, constantly sending signals via the audiovestibular nerves to the brain, telling you which way up you are, whether you are moving, turning, etc. When your inner ear balance organ is damaged, it sends a false signal to the brain. Vertigo results when the brain believes the false signal and acts accordingly. The commonest condition to affect the inner ear is labyrinthitis, which means inflammation of the labyrinth and causes severe rotatory vertigo.
Labyrinthitis often causes permanent and irreversible damage to the inner ear. The recovery that follows is not because the inner ear gets better, but because the brain learns to ignore, adjust to or compensate for the false signal. The brain learning to make allowances for the faulty information coming from the inner ear is known as central compensation. Carrying the pole amplifies any sway and gives better feedback to the sense organs in her joints. The inner ear is not the only source of information to help you balance.
You also receive information from: The eyes — you can see which way up you are, whether you are moving and in which direction. The soles of your feet if you are standing or the seat of your pants if you are sitting down. You can feel where you are. All of your joints and muscles — including the joints in your neck, back, legs, feet, arms and hands — have sense-organs in them which send signals up the nerves and spine, telling the brain what position they are in.
This position-sense is known as proprioception. Proprioception is reduced in various medical conditions including arthritis and diabetes. The information comimg from the eyes, skin, muscle and joints is integrated with the information coming from the inner ears and processed in the brain. If there is plenty of information coming from the eyes, skin and joints, you do not really need to rely on information from the inner ear to help you balance. If the information coming from the other sources is reduced, lost or confused — for example in the dark, on soft or uneven ground — your brain has to rely more on the information coming from the inner ears.
This is why your balance will be worse in the dark, on soft or uneven ground, if you have a problem with your inner ear. Your inner ear — an aeroplane instrument. Like the signals from the damaged inner ear, faulty aircraft instruments can be ignored in good conditions, but must be relied upon in cloud The balance control area of your brain acts like the pilot of an aeroplane. It is constantly making adjustments to the controls, to keep your body in balance. The pilot of an aeroplane does not need instruments to fly straight and level if the weather outside is good, and he can see the horizon.
He will always find it much easier if he has other independent sources of the necessary information If, however, the aeroplane has faulty instruments and the pilot tries to fly through cloud, he is then forced to rely on those faulty instruments.
If he then takes those false readings at face value, believes them to be true, and makes adjustments to the controls accordingly, he will almost certainly end up crashing. This is what happens to a person with false signals from a damaged inner ear who tries to walk in the dark across uneven ground. Central processing of information in the brain is essential for balance It is obvious you need brain power to keep your balance.
The two-legged human is not inherently stable. If your brain stops working, you will collapse into a heap on the ground. To be able to sit, stand, keep your balance, walk, run and jump, are learned skills. Even sitting up straight requires an immensely complex series of calculations, carried out microsecond by microsecond. Instructions are sent from the brain down the nerve fibres to the muscles which control your head position, neck and spine, allowing you to stay stay upright.
The instructions are constantly updated by feedback from the joints and muscles themselves proprioception from the skin which feels the pressure of the seat, from the eyes which can see where you are, and from the inner ear which knows whether you are tilted backward, forward, sideways or moving.
A newborn baby cannot even turn himself over from back to tummy. First, the baby will learn to turn his head and look at things. Then he will learn to roll over. After a few months, he will learn to sit up. Even aged three, motor skills are incomplete — not many three year olds could run the hurdles, even if they were made low enough.
All these learned skills are stored in the brain, they become automatic sub-routines so that the five year old can run without having to think about it.
By the time we are adults, we have all forgotten how we ever learned to walk — we just take it for granted. But there is an immense amount of skill to it, and an immense amount of computing power used by the brain in achieving it. The problem with damage to the inner ear is that one of the inputs into these automatic subroutines is now false. Garbage in, garbage out is a well known adage in the computer world.
The computer — your brain — is now receiving garbage information from the damaged inner ear. It is not surprising that the instructions sent out to the muscles will be wrong, and your balance will be affected. If the damage to the inner ear is permanent, your brain will have to re-programme all the previously learned subroutines.
The subroutines for movement and balance that you learned as an infant are stored at a low level in the brain. That storage space is high speed rapid access memory, and is mostly used up. Newly learned skills and that will include the re-programmed subroutines are generally stored in the higher centres of the brain, where there is spare memory capacity. Access to subroutines stored in the higher centres is considerably slower than the lower levels, so even if you succeed in the reprogramming, your brain might not be able to keep up with very rapid movements.
Nystagmus — eye movements associated with labryinthine vertigo One of the reflexes connected with balance is not learned, it is present at birth. That is the automatic control of eye movements during head turns, known as the the vestibulo-ocular reflex.
In health, if you turn your head, your vision does not normally turn into a blur. You will focus very briefly on one view, then another, then another, until you have completed the head turn. To do this requires rapid, accurately controlled eye movements. Eye movements are controlled by muscle activity, under the control of an image stabilization system which receives information from the inner ear.
There are good survival reasons why we have evolved this system. If you are a monkey swinging through the trees, you need to keep the ability to focus on the next branch while moving. The control of eye movements is assisted by predictive reflexes from the inner ear balance organ. If the brain receives a signal that you are turning rapidly to the right, it will automatically trigger a series of reflex actions designed to keep your vision in focus. Your eyes will sweep across from right to left, at the same rotational speed as the surroundings, helping them to fixate on one point in the rotating view.
Just before the eyes reach their limit of movement within the eye socket, they are then sent flicking very fast to the right — much faster than the speed of rotation. For this split second only instead of the whole length of time of the head turn vision would be blurred.
The eyes then start another sweep to the left. This repetitive horizontal jerking movement of the eyes, with a slow phase to one side and a fast phase to the opposite, is called nystagmus.
Nystagmus can be seen in normal life if you are sitting on a roundabout. Nystagmus is usually seen in patients suffering acutely from vertigo. If you have nystagmus, it will look to you as though your surroundings really are moving. As well as the inner ear telling you that you are spinning, if you look at your surroundings with nystagmus, your eyes confirm that either you or the world around you is spinning.
Because the reflex control of eye movements is built in to the brainstem at such a low level, it can be difficult to stop nystagmus and vertigo from happening during very rapid head turns in someone with a damaged inner ear. Cawthorne-Cooksey exercises modified Important note: Please make sure it is safe to do these exercises.
There should be nothing in the room that might get in the way, or for you to trip over. You might find it helpful to have another person with you. A labyryinthectomy is the deliberate destruction of the inner ear. It nearly always causes severe vertigo. The idea behind the exercises is a graded series of steps to help the brain compensate, or work around, the false information coming from the labyrinthectomised ear. The lack of any signal from one side, with normal signal from the other, is interpreted as a severe rotation.
The brain has to re-programme itself to allow for, offset, and adapt to this defective signal. The exercises start with simple eye movements, and progress to complex activities. A patient following labyrinthectomy would normally have the exercises supervised by a physiotherapist. You should aim to spend about an hour a day doing the exercises.
Vertigo Rehabilitation Exercises
Gardarisar Although some authors state that the CC exercises are outmoded, this is not true. Adapted from Dix and Hood, and Herdman, ; References: This document is one page handout of activities that progress from simple head movement to complex activities such as throwing a ball. June 20, Return to VRT pag e. The CC exercises are still in common use see numerous references at bottom of this cookse. Ideally these activities should be done with a supervised group. Sitting Eye movements and head movements as above Shoulder shrugging and circling Bending forward and picking up objects from the ground Standing Eye, head and shoulder movements as before Changing from sitting to standing position with eyes open and shut Throwing a small ball from hand to hand above eye level Throwing a ball from hand to hand under knee Changing from sitting to standing and turning around in between Moving about in class Circle around center person who will throw a large ball and to whom it will be returned Walk across room with eyes open and then closed Walk up and down slope with eyes open and then closed Walk up and down steps with eyes open and then closed Any game involving stooping and stretching and aiming such as bowling and basketball Diligence and perseverance are required but the earlier and more regularly the exercise regimen is carried out, the faster and more complete will be the return to normal activity. Spanish translation of CC exercises courtesy of Maria Busso.
COOKSEY CAWTHORNE PDF