I elected to go the habituation route to treat my patient, meaning I gradually exposed her to the tasks that induced her dizziness and graded those activities to her tolerance. In the beginning it was a lot of just being static, upright unsupported edge of bed and training her in some substitution strategies to help calm the symptoms. Then we transitioned into active bed mobility activities such as sitting up, lying down and rolling over. Then we really got moving with sliding board transfers, and pushing her wheel chair down hallways, progressing from dimly lit with little in the way of visual stimulation to normally lit hallways with lots of things and people moving through the field of vision. Then we started getting her used to being in the standing position again using a standing frame. We did all these activities in addition to gaze stability exercises to adjust her VOR: I typically had her do 2 sets with me and then asked her to do 3 additional sets– 1 around breakfast time, 1 around lunch and 1 around dinner– during the day at her leisure.
These interventions were slow going as with vestibular habituation, if the symptoms become more intense, you instruct the patient to slow the activity down to a pace that does not induce worsening symptoms. This also builds a great deal of patient-therapist trust and did wonders for my patient’s moral. The symptoms made her feel out of control of herself, but giving her that control back over what she was experiencing, and assuring her that I believed her complaints were real, improved her depression a great deal.
By the end of her approximately 3 weeks with me, she had progressed from middle severe into the lower end of the severe category of the Motion Sensitivity Quotient and self-reported that although she wasn’t back to herself, she felt like she was making improvements in the right direction. She was excited to move forward, continue progressing and see what the future held for her.
Functionally, she improved to stand by assist with transfers with a sliding board (some days minimum assist, depending on the severity of the symptoms) and tolerating up to 5 minutes in the standing frame. Since she continued to need assistance occasionally, it was not appropriate for her to discharge straight home alone from my inpatient rehab, but instead she went for a few more weeks of therapy intervention at a skilled nursing unit.
While at the nursing unit, although she did not regain the ability to walk, she did gain enough confidence in herself to transfer independently on the sliding board and return to living independently, just as a wheelchair user. She continues to be plagued by some dizziness, which limits her mobility, but she manages well enough to be independent.
So with as little literature as there is to go on out there for treatment strategies, I think I made the right choices for this patient’s case by meeting her exactly where she was (low low level), developing a strong patient-therapist trust relationship and easing her toward functional improvements at her own pace. In my reflection regarding her treatment, the only things I can think of that might have benefitted her for me to add would have been adding more postural challenges in sitting, such as head turns while I pushed her wheelchair, pushing the chair in a designated pattern, making sharp turns with the wheelchair, etc. I could have revisited the substitution activities later on the treatment program to check that those were being retained and utilized as well. Then I honestly had no idea how to train the cervical-ocular reflex at that point in my career, so I would incorporate those activities too, such as addressing any orthopedic restrictions in her neck soft tissues.
If you’ve made it this far, congratulations and thank you for coming with my on this journey of discovery. My literature review for this case review has been completed!
I have been doing a literature review in preparation to write a case report. This is the final post in this series, as my literature review is now complete. If you would like more background information on the case or information about the project, please click here. If you would like to see other article reviews related to this project, please click here.