Journal of Neurologic Physical Therapy:
Guest Editor's Note
Schubert, Michael C. PT, PhD; Whitney, Susan L. PT, PhD, NCS, FAPTA
Vestibular rehabilitation has come a long way from Cawthorne and Cooksey exercises. Although revolutionary in their foresight and still in use today, the available options for rehabilitation of vestibular disorders has dramatically in recent years. Currently in our armamentarium are specific exercises to address gaze instability, postural instability (static and dynamic), motion sensitivity, and vertigo—all symptoms relative to pathology within the peripheral and central vestibular pathways. Cochrane studies have established that vestibular rehabilitation is effective for treating unilateral peripheral vestibular hypofunction. Recent treatment guidelines and systematic reviews suggest that repositioning maneuvers are the superior treatment for benign paroxysmal positional vertigo. Our knowledge of testing and treatment of pathologies affecting the peripheral vestibular labyrinth and/or the pathways mediating vestibular afference is exploding.
Just as optimal intervention for individuals with vestibular disorders commonly involves multiple disciplines, so are multiple disciplines conducting excellent research that demands vigilance in the practicing clinician. As clinicians who treat people with vestibular disorders, our interventions would be enhanced by examining data from other disciplines: emerging evidence suggests that new tests may isolate utricular from saccular function, migraines can be triggered by vestibular stimulation, and technical advances in oculomotor equipment now enable video monitoring and recording of rapid head and eye rotations. Today there are many tests that can be used by clinicians, which provide clinically meaningful information. In addition, as members of the vestibular team, physical therapists need to become more involved in other professional meetings to inform other clinicians about what we have to offer. Important opportunities for collaborating might involve the American Academy of Head and Neck Surgery, the Association for Research in Otolaryngology, and the biannual Barany Society meeting.
We are pleased to report that this Special Issue of the JNPT has and outstanding cadre of international authors and coauthors from the United States, the United Kingdom, Greece, Saudi Arabia, Jordan, and Australia. The topics covered are diverse and so is the authors' expertise. The authors include physical therapists, engineers, and physicians who work to enhance the care of persons with vestibular disorders. The authors were asked to contribute to this issue based on their novel work, and we hope that their recent findings help to improve care for your patients. Most of the articles in this Special Issue include advanced technology as part of their methods. The use of the vibrotactors (Wall), scleral search coils (Scherer and Schubert), uniquely applied measures of attention (Mohammad et al), and optokinetic stimulation (Pavlou et al) all involve some degree of innovative technology to assess treatment effectiveness, measurement of vestibular function, or reveal behavior in people with vestibular dysfunction. Other articles in this issue attempt to describe treatment effectiveness in interesting patient groups including mild traumatic brain injury related to blunt (Alsalaheen et al) and blast (Gottshall) trauma, patients with report of dizziness but normal caloric findings (Hall et al), patients with canal-only versus canal and otolith dysfunction (Murray et al), and differences between treatment paradigms (Clendaniel).
The future for vestibular rehabilitation is exciting and will involve interaction with multiple disciplines. In a recent survey of biomechanics laboratories, physical therapists who responded to an informal survey participated in projects in >75% of the laboratories. Physical therapists were the largest group represented at the 2010 International Gait and Mental Function meeting. In the future, we expect the merging of vestibular physical therapy with technical innovations to include virtual reality feedback/training, a vestibular prosthesis, even stem cell research to resolve pathophysiology within the labyrinth. These new technologies will need the skills and knowledge of physical therapists to help investigators determine whether the interventions are effective and/or to establish the behavioral implications of stem cell physiology to restore function. Most certainly, other clinicians/researchers will look to physical therapists for better understanding of movement problems of people with vestibular and other neuromotor disorders, and for optimal rehabilitation approaches to maximize the value of technology.
We encourage all readers to examine the foundational science and evidence for using new and innovative technologies before adopting the newest device for use with their patients. Material in this Special Issue was chosen to highlight some of the investigators around the world who are making a difference in the care of people with vestibular disorders. Many basic clinical questions remain, and we still struggle with issues such as optimal dose, optimal type of exercise, and the value of continuing a home exercise program after discharge. We hope that this Special Issue will help clinicians explore some new innovations and discoveries in physical therapist examination and treatment of persons with vestibular disorders.