Original Cawthorne Cooksey Rehabilitation Exercises 1946

CAWTHORNE, T. COOKSEY, FS. (1946) Proc Roy Soc Med 39:270.

These are provided for historical interest. Please refer to the modified exercises for current practice.

Source: Some observations on the pathology and surgical treatment of labyrinthine vertigo of non-infective origin. Hunterian Lecture delivered at the Royal College of Surgeons of England on 2nd February, 1949 by Terence Cawthorne, F.R.C.S. Surgeon for Diseases of the Ear, Nose and Throat, King’s College Hospital, Aural Surgeon, National Hospital for Nervous Diseases, Queen Square. CAWTHORNE, T. Ann R Coll Surg Engl. (1949) Jun;4(6):342-59.

Rehabilitation after Operation or Injury

“ The most disturbing sequel of a labyrinthine injury is vertigo. In its acutest form it has been vividly compared with being simultaneously seasick and in an earthquake. Fortunately such sensations quickly subside but, if the vestibular labyrinth has sustained permanent injury, there will remain, possibly for a long time, some instability of balance. This is particularly noticeable after sudden movements of the head, walking up or down stairs, or on an uneven or inclined surface, or moving about in the dark, or watching rapidly moving objects. There is also a tendency to tire easily on exertion.

The significance of these symptoms and their relief can be better understood if we consider the mechanism of the sense of balance; for it is one of the senses though not included in the traditional five. Balance is maintained as the result of impressions received from the eyes, the skin muscle-joint sense, and the vestibular labyrinth. In everyday life man is accustomed to rely on his eyes and skin-muscle-joint sense for ordinary balance, while the activity of his vestibular labyrinth is available to take command of skeletal muscular movements if necessary. Any impairment of vestibular activity will upset the pattern and disturb balance; though if the impairment is constant as in a labyrinthine injury rather than fluctuating as in hydrops, then it is possible gradually to adjust the balancing mechanism to the altered circumstances. In the same way partial or complete failure of one engine in a twin or multi-engined aeroplane can, after the initial disturbance, be compensated by a suitable adjustment of the controls by the pilot, though thereafter the steadiness of the flight is more easily disturbed by outside influences.

Lack of appreciation of the sequelae of a labyrinthine injury particularly if it is unsuspected as in post-concussive conditions may lead the patient to fear a more serious cause; and the doctor, in the absence of any familiar and easily demonstrable signs of disorder, to overlook the organic cause and lay the blame on a psychological disturbance. This combination of circumstances leads naturally to a neurotic state that may further complicate the picture.

The first step, then, in any scheme of rehabilitation is to see that the patient understands the true nature of the disturbance and, in the case of deliberate operative injury, to warn him beforehand of what is going to happen. Recovery of balance is hastened by the use, preferably in a class, of graduated exercises designed to encourage eye, head, and body movements.

A graduated series of exercises was developed in the Physiotherapy Department of King’s College Hospital and they play a leading part in restoring patients who have sustained a labyrinthine injury to a normal life. A definite scheme of progression is followed, the exercises being done first of all in bed, then sitting, then standing, and then moving about on the flat, and finally up and down stairs and inclined planes. Exercises are done first with the eyes open, then closed and the following scheme includes a specimen series of the exercises.



(1) To loosen up the muscles of the neck and shoulders; to overcome the protective muscular spasm and tendency to move “in one piece.”
(2) To train movement of the eyes independent of the head.
(3) To practise balancing under everyday conditions with special attention to developing the use of the eyes and muscle and joint sense.
(4) To practise head movements that cause giddiness and thus gradually overcome the disability.
(5) To become accustomed to moving about naturally in daylight and in the dark.


Following operation of the labyrinth these exercises may be started in bed on the third day. By the sixth post-operative day most patients can join the gymnasium class for sitting exercises in a wheel-chair, progressing to standing exercises on the eighth day. For other cases progress will be governed by the general condition of the patient. All exercises are started in slow time and gradually progress to quick time. The rate of progress from bed to sitting and then to standing exercises depends upon each individual case, and the times mentioned for post-operative cases represent the average. It has been found that class exercises encourage a steady rate of progress.


(A) In Bed:
      (1) Eye movements-at first slow, then quick
             (a) Up and down
             (b) Side to side
             (c) Focusing on finger moving from 3 feet to 1 foot away from face
      (2) Head movements at first slow, then quick. Later with eyes closed.
             (a) Bending forwards and backwards
             (b) Turning from side to side
(B) Sitting (in class):
      (1) and (2) (a)
      (3) Shoulder shrugging and circling
      (4) Bending forwards and picking up objects from the ground
(C) Standing (in class):
      (1), (2) and (3)
      (4) Changing from sitting to standing position with eyes open and shut
      (5) Throwing a small ball from hand to hand (above eye level)
      (6) Throwing ball from hand to hand under knee
      (7) Change from sitting to standing and turning round in between
(D) Moving About (in class):
      (1) Circle around centre person who will throw a large ball and to whom it will be returned
      (2) Walk across room with eyes open and then closed
      (3) Walk up and down slope with eyes open and then closed
      (4) Walk up and down steps with eyes open and then closed
      (5) Any game involving stooping or stretching and aiming such as skittles, bowls and basket-ball

Detailed exercises in the scheme outlined above can be varied or extended according to need. The order in which the exercises are carried out should not as a rule be changed.

The stimulating effect of example and competition that is seen when these exercises are done in a class further hastens recovery, and it is usually found that two or three weeks of exercises are sufficient to set most patients well and truly on their feet again. They are not intended for cases of Meniere’s Disease except after operation, not for other forms of fluctuating vertigo. When, however, there is some constant loss of function in one or other labyrinth, then the exercises hasten the restoration of balance and encourage the patient to overcome the slight momentary dizziness provoked by sudden head movements. They form part of the routine after treatment of every labyrinthine operation, and any case of head injury followed by vertigo. They can also be used with advantage for any case of permanently impaired vestibular function, whether the result of operation, injury or disease. ”