DOI Number: 10.5958/j.0973-5674.7.4.

139
Indian Journal of Physiotherapy & Occupational Therapy. October-December 2013, Vol. 7, No. 4 147

The effect of Cawthorne and Cooksey Exercises in

Patients, affecting Balance Following Vestibular Problem
in Elderly
Neeraj Ruhela1, Pankaj Gupta2
1
Lecturer Department of Rehabilitation Sciences Bundelkhand University Jhansi, 2Sr. Physiotherapist TLM
Community Hospital Nandnagri Delhi-93
ABSTRACT
Background: Vestibular rehabilitation is an increasing popular treatment options for patients with
persistent dizziness or vertigo. Cawthorne and Cooksey exercises in form of habituation exercises
are a simple, inexpensive treatment that may be suitable for home based exercise program.
Objective: To determine the benefit of Cawthorne and Cooksey exercises with standard medical care
given in case of chronic vertigo as vestibular suppressant, using a brief intervention for vertigo patients
in a home based exercises program given by a trained professional.
Method: Elderly people consulting their general practitioner with dizziness or vertigo were randomly
assigned to treatment or control group. Patients in both the group received the same evaluation at
baseline, midsession and four week latter comprising the assessment of balance and vertigo symptoms.
At base line and mid-term follow up all the patients were stimulated with habituation as Cawthorne
and Cooksey exercises comprising of Eye, Head Trunk exercises designed to promote vestibular
compensation and enhance skill and confidence in balance and reducing the symptoms of vertigo.
While the control group as well the study group were allowed to take regular medication prescribed
by their physician for their presenting symptoms.
Result: Result were calculated for the subjects who completed the study excluding patients which
did not complete the study (n=10) .The treatment group (n=15) with mean age and standard deviation
was 57.13 + 6.33 where as the control group (n=15) with mean age and standard deviation 56.2 + 4.47.
Result calculated using paired t test demonstrated significant result in both the group but when
comparison was done it was more significant ( P <0.05) for the study group. When result was compared
in group A from the baseline, midsession follow up and with final evaluation in term of balance and
vertigo symptoms was significant (P<0.05).where as in the control group which was on medical care
it was observed that at mid-term and final follow up the result was significant for vertigo symptom
(P<0.05) and not significant for balance (P>0.05). Where as at final result of comparison of means
between different session for SRT (Sharpened Romberg test for standing)and VSS (vertigo symptom
scale) showed group A showed more significance (P<0.05) than Group B.
Conclusion: Cawthorne and Cooksey exercises are simple, inexpensive and beneficial form of
habituation exercise used to improve balance and vertigo symptoms in a home based treatment
program.
Keywords: Vertigo, Balance, Cawthorne And Cooksey Exercises, Vertigo Symptom Scale, Sharpened Romberg
Test, Vestibular Rehabilitation

INTRODUCTION
Balance is a complex process involving the
reception and integration of sensory inputs and the

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147

planning and the execution of movements to achieve

a goal requiring upright posture.. Within an individual
there are two component of balance function, the

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148 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2013, Vol. 7, No. 4

peripheral component and the central component

interaction of these two are involved in the cycle.1

Patients diagnosed chronic vertigo due to

vestibular causes or unknown origin

Vestibular rehabilitation (VR) has been

recommended as a treatment of choice for the patient
with persisting dizziness due to vestibular
dysfunction. The central element of VR is a set of
exercise that promote central compensation by
providing the central nervous system with repeated
exposure to a range of eye, head & body
movement.14The physical exercise are designed to
restore balance as far as possible and to train eyes and
muscles and joint sense to compensate for the per
demand and vestibular dysfunction. 15For many
patients a single home program of vestibular
rehabilitation, head movement exercise is related to
reduce symptoms of balance during stance and gait.
16
Cawthorne and cooksey were the first clinician to
advocate exercise for persons suffering from dizziness
and vertigo. 17

Vestibular neuritis.

Labyrinthitis.

Menieres disease.

Benign paroxysmal positional vertigo.

METHODOLOGY
The present study is aimed to find the effectiveness
of Cawthorne and Cooksey exercises affecting the
balance caused due to vestibular problems in elderly.
Research approach
Experimental approach is chosen for conducting
the present study. A pre-test and post-test group design
was chosen for conducing the present study.
Population
A population is defined as the group of people to
whom the research results are generalized. All patients
who are suffering from chronic vertigo were universal
population of the present study.
Setting of the study
The study was conducted in different hospital OPD
and clinics such as Doon hospital, Kala hospital and
other ENT diagnostics clinics and Sai sparsh OPD in
Dehradun ,Uttarakhand.
Inclusion criteria:
All patients were required to fulfill the following
criteria.

Patients between age group 50 to 69 years of either

sexes.

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148

Exclusion criteria

Suffering from chronic illness where exercise

therapy contraindicated.

Life threatening or progressive central disorder

Propriceptions and joint problems

Vestibular insufficiency syndrome

Diabetes mellitus

Protocol:
All the patients diagnosed and referred for
physiotherapy were selected following the inclusion
and exclusion criteria and were assessed for 20-30
minutes by me using a assessment performa the
patients was explained about the study and the consent
of the patient was taken by explaining the procedure.
Symptoms of vertigo were assessed using a short form
of the vertigo symptom Scale (VSS) ranging from (0
60). With choice as 0, 1 ,2, 3,4 depending upon the
severity of the symptoms against each question to
answer ,ranging from never(0) to very often as (4).For
balance sharpened Romberg tests standing (SRT)for
up to 60 second with feet placed heel to toe position
with eyes closed, eyes open with a total score (240)
sec at the baseline test for balance.
The study comprises of 40 samples 20 were
randomly taken in the experimental group for whom
the exercise were included in the program. Other 20
were included in the control group this group were
not given the Cawthorne and Cooksey exercises.
The experimental group patients was the
group selected for vestibular stimulation through
Cawthorne and Cooksey exercises and the other group
was kept away from the vestibular stimulation. While
the study both the group were on the medication for
their symptoms prescribed by the clinician also the
patient were free to consult their physician or specialist.

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Indian Journal of Physiotherapy & Occupational Therapy. October-December 2013, Vol. 7, No. 4 149

All the patient were instructed by the therapist

explaining all sets of exercises verbally and followed
by demonstration by the me in front of the patients
and their relatives .All the patients were explained
about printed material and its instruction and also
detail of the Cawthorne and Cookery exercise, its
duration, time, care and mentioning the rest period
between the exercises .The printed material was made
available in both languages Hindi & English and
also audio / video C.D. was given for the patient for
audio visual support at home for exercise program.
Cawthrone and Cooksey Exercises.

Turning on spot left to right.

Eyes closed

From standing, bend to touch the floor and back

to standing.From standing, bend forward to touch
the floor, turn to left to touch the Chair behind;
turn to right to touch the chair, back to front.

From standing, drop shoulders and head sideways

to right and left.

From standing, touch floor, reach high into air.

Change sit to stand, turning one way sit down,

stand up, turn opposite way sit down.

Turning on spot place right and then to left.

A) Eyes (Movement of eyes, keeping your head still).

Up and down, then side to side following your

finger.

Focusing on your finger moving 3 feet to 1 foot

from your face.

D) Lying down (If possible do not use the pillow).

Eye open

B) Head

Rolling head from side to side

Eyes open

Rolling whole body from side to side

Sitting up straight forward.

From lying roll on to your side, sit over the edge

of the bed lie down on opposite side and roll on to
your back

Bending forward and backwards

Turning from side to side

Eyes closed

Bending forward and backward

Eyes closed

Turning from side to side

Rolling head from side to side

C) Trunk (Eyes and head must follow the object)

Rolling whole body side to side

Eyes open

Sitting up straight forward

From standing; bend forward to pick up an object

from the floor and back Up to standing.

From standing, bend forward to pick up an object

from the floor, turn to left to place the object behind,
leave the object, and turn to right to pickup the
object, now place the object back in front.

From lying, roll on to your side sit over edge of

the bed, lie down on opposite and roll onto your
back.

From standing drop the shoulder and head

sideways to left and then to Right.

From standing reach with the object up into the

air then left and then to Right.

From standing pick object from the floor then and

reach high into air.

Change sit to standing, turning one way sit down,

sit up, turn opposite way, then sit down.

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149

RESULT
Statistics were performed by using SPSS 11. Results
were calculated by using 0.05 level of significance.
Table 1: Mean and SD of SRT at different session for
Group A and Group B
Start
Mean + SD

15th day
Mean + SD

30th day
Mean + SD

Group A

105.87 + 28.01

116.33 + 27.64

136.27 + 31.95

Group B

118.8 + 39.87

122.33 + 42.77

122.53 + 42.74

Table 2 describe Mean and SD of SRT at different

session ,start of the treatment, after 15th day and on
30th day , for Group A and Group B as follows. Group

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150 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2013, Vol. 7, No. 4

A 105.87 + 28.01,116.33 + 27.64 and 136.27 + 31.95.

Where as group B was 118.8 + 39.87, 122.33 + 42.77
and 122.53 + 42.74.
Table 2: Mean difference and SD of VSS between
different session for Group A and Group B
Groups

15th day-start
Mean + SD

30th day 15th

day Mean + SD

30th day start

Mean + SD

Group A

-3.4 + 2.08

-4.93 + 2.54

-8.33 + 4.27

Group B

-1.26 + 1.16

-3.26 + 1.27

-4.53 + 1.99

Table 2 describes compression of the Mean

difference and SD of VSS between different session
for Group A and Group B at start day - 2nd week and
4th week as follows. Group A -3.4 + 2.08, -4.93 + 2.54
and -8.33 + 4.27. Group B as -1.26 + 1.16, -3.26 + 1.27
and -4.53 + 1.99.
Table 3: Comparison of means between different
sessions for SRT and VSS between Group A and
Group B
Group A Vs Group B

SRT

VSS

t value

P value

t value

P value

15th day - Start

2.07

P < 0.05

-3.44

P < 0.05

30th day 15th day

5.57

P < 0.05

-2.26

P < 0.05

30th day - Start

4.64

P < 0.05

-3.12

P < 0.05

P < 0.05 Significant

P > 0.05 Not-significant

Table 3 describes the compression of the mean

between different session of SRT and VSS between
group A and B on 15th Vs start day,30th Vs 15th day,30th
Vs start day .t value for SRT ,Group A Vs Group B was
2.07(P<0.05), 5.57(P<0.05),4.64(P<0.05) where as for
VSS was -3.44(P<0.05),-2.26 (P<0.05) and -3.12(P<0.05)
respectively.
DISCUSSION
Balance is an important component of functional
activity, it is a complex mechanism involving various
component of sensory input and planning and the
execution of movement to perform goal performing
posture .1 Primary concern of early rehabilitation is
reducing fall by improving balance with a home based
multidirectional exercise program to reduce the
physical impairment and fear of falling.25
The clinical importance in these studies lies in the
fact that falls are one of the factors causing disability
some time morbidity in elderly. Thus preventing fall
by improving balance provide basic condition for the

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150

maintenance of physical independence. Vestibular

rehabilitation exercise have shown reduction in fall risk
VR(P<0.05) in younger and older adults26. Vestibular
rehabilitation and exercise therapy is found beneficial
in improving balance in healthy elderly women when
stimulated with Cawthorne and Cooksey exercises.11
Cawthorne and Cooksey exercise feature gross
head and trunk movement such movements produce
anticipating postural adjustment and also trigger reflex
postural adjustment.27Early initiation of Cawthorne
and Cooksey were significant correlated with low
disability and questionnaire scores.28 It was observed
the activity of daily living and balance significantly
improved in unilateral vestibular deficiency patients
with Cawthorne and Cooksey exercises.18
The outcome of the study for the study and the
control group who all completed the study (n=15)
group A and n= (15) group B, whereas those patients
who either left the study, didnt come for any one
follow up or came before or after the follow up
schedule time for their problem were not included in
the study (n=10) for both group. Results clearly
indicated a potential role of the delivery of the
Cawthorne and Cooksey excersise as a home based
program .There was significant (P<0.05) improvement
in the treatment grouping virtually on every index
from objective measures of postural control to
subjective reports of the symptoms. Improvement was
evident on the 15 day of the treatment was significant
(p<0.05) more improvement was observed in 15th to
30 day schedule, it was observed that the final result
was significant in both the group but in group A it was
more significant. Where as in Group B at 15th day and
30 th day there was significance improvement in
symptoms of vertigo (P<0.05) but not significant
((P>0.05) for balance. The patients had relief of the
symptoms in end of the study in group A and vertigo
symptoms in group B but not for balance, as in primary
care when VR was given for three month compared to
usual medical care improvement was seen significant
in the experimental group and was maintained at six
month an in expensive and first stage of treatment of
dizziness in primary care.6
CONCLUSION
The balance problem resulting due to chronic
vertigo in elderly is a normal ageing phenomena as
these changes cannot be reversed but balance related

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Indian Journal of Physiotherapy & Occupational Therapy. October-December 2013, Vol. 7, No. 4 151

problem due to vertigo can be managed

symptomatically by increasing the coordination and
adaptation to the changing external environment
affecting the balance so that an improvement can be
achieved and avoid further deterioration. However
medication also proved to be beneficial in patients with
chronic vertigo in improving the vertigo symptoms
but is not that helpful in improving the balance
problem. The possibility of using both interventions
was explored in the study and showed a significant
result.

11.

REFRENCES

14.

1.
2.

3.

4.

5.

6.

7.

8.

9.

10.

Darcy A. Umpired. Jeb Burton, edition 2001, page

(618-622).
Maria stokes, Physical management in
neurological rehabilitation reprinted 2005, page
(413419).
Susan B.OSullivan, EdD, PT and Thomas J.
Schmitz. PhD, PT. Physical rehabilitation
assessment and treatment, fourth edition. .
2001,822-24
Terence Cawthorne. Vestibular injuries
proceeding of the royal society of medicine,
December 7, 1945, (270-273).
Persons F. Hanssen. Assessment and
management of vertigo and dizziness among
older Cambridge University publications, 2004;
14: 229-234,
Lucy Yardley et al. Effectiveness of primary
casesbased vestibular rehablitation for Chronic
Dizziness. Ann intern
med, 2004; 141,
598605.
Yardley, Shard a beech et al. A randomized
controlled trial of exercise therapy for dizziness
& vertigo, British journal of practice, 1998.48,
1136 -1140.
Kollen, Lena. Evaluation and treatment in benign
paroxysmal positional vertigo (BPPV). Advances
in physiotherapy volume 8, No 3, September.
2006, 106-115(10).
Erna Kentala, Steven D. Rauehia A practical
assessment algorithm for diagnosis of dizziness.
Otolaryngology head neck surgery .2003; 12854-59.
Hain TC Uddin M. Pharmacological treatment of
vertigo. CNS Drugs, 2003; 17(2):85- 100.

28. pankaj Gupta--147-152.pmd

151

12.

13.

15.
16.

17.

18.

19.

20.

21.

22.

23.

24.

Angela dos Santos Bersot. Balance improvement

& reduction of likelihood of falls in older women
after Cawthorne &Cooksey exercise. Rev Bras
Otorinolaryngol, 2005; 71(1):38-46.
F.B Horak et. al. Effect of vestibular rehablitation
on dizziness and imbalance. Otolaryngol Head
and neck Surgery 1992; 166-175.
Helen S Cohen et al .Decreased ataxia and
improved balance after vestibular Rehabilitation.
Otolaryngology head, neck surgery 2004; 130:
18-25.
Weiss LS, Amedee RG. Vestibular rehabilitation.
La State Med Soc.1993 May 145 ;( 5); 187-9.
Davis LE, J. Dizziness in elderly men. Am
Geriatric soc 1994 NOV 42(11); 1184-8.
Magnus Johansson et al. Randomized controlled
trial of vestibular rehabilitation combined with
Cognitive Behavior therapy for dizziness in older
people. Otolaryngology head, neck surgery 2001;
125-151-6.
F.S.Cooksey. Rehabilitation in vestibular injuries.
Proceedings of royal societies of medicine. 1945;
273-78.
Stefano Corna et al .Comparison of Cawthorne
& Cooksey exercise & sinusoidal support surface
translation to improve balance in patient with
unilateral vestibular deficit. .Arch Phys Med
Rehabilitation: 2003; 84; 1173-84.
Cohen H .Vestibular rehabilitation reduces
functional disability, Otolaryngeal Head Neck
Surgery .1992Nov; 107(5):638-43.
Hansson EE et. al. Effect of specific rehabilitation
for dizziness among patients in primary health
care .A randomized controlled trial. Clinical
Rehabilitation 2004, Aug; 18 (5):558-65.
B. Mendel et. al. The sense of coherence: a tool
for evaluating the patients with peripheral
vestibular disorder. 2001, clinical Otolaryngol 26,
19-24.
Sales N, Kressig R ,et al. Management of chronic
dizziness in elderly people.. Z Gerontol Geriatr ,
2003 Feb 36(1) 10-5.
Prasansuk.S (et. al ) .Balance disorder in the
elderly and the benefit of balance exercise. J Med
Assoc Thi 2004; 87(10):1225-33.
Barona De Guzman, et. al. Vestibular
compensation. Rehabilitation of a patient with

11/26/2013, 4:48 PM

152 Indian Journal of Physiotherapy & Occupational Therapy. October-December 2013, Vol. 7, No. 4

25.
26.
27.

Vertigo .Acta Otorrinolaringol Esp. 1994, NovDec, 45(6):401-5.

Schmal F, Stoll W, drug treatment for vertigo.
Laryngorhinootologic. 2003; 82(1):44-61.
Stakk W. Otogenic vertigo .Differentiation and
therapy, Laryngorhinootologic.1993; 72(6):311-5.
Fitzgeiald B. A review of the sharpened Romberg
test in diving medicine. SPUMS 1996; 26(3):
142-146.

28. pankaj Gupta--147-152.pmd

152

28.

29.

Brigg RC et. al .Balance performance among non

institutionalized elderly women. Phy Ther 1989;
69(9):748-56.
Badke MB et. al .Outcome after rehabilitation for
adults with balance dysfunction .Arch Phys Med
rehabilitation .2004,85;(2)227-33.

11/26/2013, 4:48 PM

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