CRAIG MASON, ATC, SPT

ACOUSTIC NEUROMA RESECTION: A CASE STUDY

¡ 43 y/o female

¡ R acoustic neuroma

¡ Middle fossa craniotomy § Best preserves hearing

¡ R vestibular hypofunction

PATIENT HISTORY

¡ Complained of soreness, vertigo, and veering with gait

¡ Baseline 3/10 dizziness

¡  Increased dizziness with walking in visually rich environment

¡ Decreased when lying down

¡ Fear of falling

SUBJECTIVE FINDINGS

¡ Previous Level of Function: § Recreational outdoor

activities § Playing with children

¡ Current Level of Function § Difficulty walking and

negotiating stairs § Unable to drive § Unable to lift over 10

pounds

¡ Medications: § Tramadol: at night § Ibuprofen: as needed

SUBJECTIVE FINDINGS

¡ ROM/Strength: § UE/LE WFL

¡ Sensation: Intact

¡ Gait: § Slow paced § Path deviation § Decreased arm swing,

trunk and hip rotation § RW and SPC

¡ VOR: § Increased dizziness § Decreased speed

PT EXAMINATION

¡ Provoking Vertigo Test: § Head turns § Sit to stand § Bending

¡ DGI = 16/24 § Changes in speed § 180 turn § Stepping over obstacle § Quick stops

¡ Balance: § Increased postural sway

PT EXAMINATION

¡ Impairments: § Decreased VOR gain § Increased dizziness § Decreased balance § Fall risk

¡ Activity Limitations § Need for AD during gait § Unable to drive § Decreased independence

with ADL’s

¡ Participation Limitations § Unable to play with

children § Unable to work

¡ Prognosis: § Good!

PT EVALUATION

¡  In 1 week the patient will be independent with HEP.

¡  In 4 weeks, the patient will report decreased vestibular symptoms by 30%

¡  In 6 weeks, patient will improve DGI by 4 points in order to decrease risk for falls

¡  In 3 months patient will be independent with self-management of symptoms/final HEP and resume PFL with minimal symptoms.

GOALS

¡  Patient will be seen once per week for three months

¡  Interventions included: §  Therapeutic Exercise §  HEP §  Patient Education §  Safety Education §  Gait Training §  Neuromuscular Re-Education §  Functional Balance Training §  Vestibular Exercises

PLAN OF CARE

¡ 1st Treatment Session § VOR compensation § Corrective saccades § Gait training § Balance

¡ Wii at home??

PT INTERVENTION

¡ 2nd treatment session § Trunk rotation § Quarter Turns § Standing Head turns

¡ 3rd treatment session § Forward/Backward

Stepping § Sidestepping § 180 degree turns

during ambulation

INTERVENTION PROGRESSION

¡ In one month: § 50% decrease in symptoms (0/10 dizziness) § No fear of falling § Able to drive and shop § Amb without AD at home/with SPC in

community § DGI = 22/24

¡ Meet 3/4 of her PT goals

OUTCOMES

IS BALANCE EXERCISE WITH VISUAL FEEDBACK A SUPERIOR INTERVENTION

THAN CONVENTIONAL BALANCE EXERCISE TO

DECREASE RISK OF FALLS IN MY 43 Y/O PATIENT S/

P ACOUSTIC NEUROMA RESECTION?

CAKRT ET. AL

“The aim of this study was to evaluate the effect of a 2-week individualized visual feedback rehabilitation exercise on the

postural control in patients having undergone vestibular schwannoma surgical removal.”

¡ Seventeen subject randomly assigned before surgery

¡ Feedback versus standard therapy

¡ Both groups performed VOR x 1 viewing

¡ COP was measured before, post-op day five, and post-op day fourteen

METHODS

COP Parameter

Feedback Group

Control Group p value

AAP (cm) 6.2 ± 4.3 8.6 ± 6.6 0.227

AML (cm) 6.2 ± 4.5 11.9 ± 4.7 0.021

VAP (cm/s) 13.3 ± 4.2 19.2 ± 4.1 0.008

VML (cm/s) 5.7 ± 2.8 8.3 ± 1.4 0.059

TA (cm2) 133.3 ± 94.7 273.4 ± 73.2 0.011

¡ Significant differences in COP measures were observed between groups at 2 weeks.

RESULTS

RESULTS

¡ This prospective randomized clinical study suggests that exercises with visual biofeedback improve vestibular compensation in patients after vestibular neuroma removal.

¡ LIMITATIONS: § Small sample § Different setting

and treatment period

§ Did not explain the control treatment

§ No other measures of function

DISCUSSION

MELDRUM ET AL.

“The aim of this study therefore was to investigate whether the Wii Fit Plus as a form of virtual reality presented a superior method of rehabilitation of balance during

vestibular rehabilitation when compared with conventional balance exercises during vestibular rehabilitation, in adults with UVL.”

¡ Measured: § Gait speed § DGI § SOT § ABC

¡ At baseline, 8 weeks and 6 months

METHODS

¡ Seventy-one subject randomly assigned

¡ Conventional versus Virtual Reality

¡ Each group preformed gaze stabilization and a walking program

¡ Balance training differed

RESULTS

Baseline 8 weeks

Outcome Conv VR Conv VR p-value

Gait Speed (m/s)

1.28 ± 0.18 1.22 ± 0.22 1.38 ± 0.16 1.31 ± 0.20 0.23

DGI 19.4 ± 3.01 19.5 ± 3.67 22.4 ± 1.9 22.1 ± 2.33 0.59

SOT (%) 52.6 ± 12.3 55.8 ± 15.4 65.5 ± 14.7 68.2 ± 14.5 0.78

ABC (%) 64.5 ± 20.4 64.8 ± 18.7 81.5 ± 14.1 74.3 ± 21.3 0.08

No significant differences were observed in gait, balance or subjective outcome measures

¡ LIMITATIONS: § Other diagnoses § Could not isolate visual

feedback role due to multiple interventions

DISCUSSION

¡ No superior effect on balance, gait, and subjective outcome measures was found.

¡ Does visual feedback during balance exercise superiorly decrease fall risk?

§ Effective treatment, but can’t say it is superior

CONCLUSION

¡ Incorporate visual feedback during balance exercise. § DGI = 16/24 § Slow gait § Increased postural

sway § Decrease confidence/

fear of falling

¡ Wii for HEP § Able to play with

children § More enjoyment § Less fatigue and

difficulty

APPLICATION TO MY PATIENT

¡  Čakrt, O., Chovanec, M., Funda, T., Kalitová, P., Betka, J., Zvěř ina, E., . . . Jeřábek, J. (2010). Exercise with visual feedback improves postural stability after vestibular schwannoma surgery. Eur Arch Otorhinolaryngol European Archives of Oto-Rhino-Laryngology, 267 , 1355-1360.

¡ Meldrum, D., Herdman, S., Vance, R., Murray, D., Malone, K., Duffy, D., . . . Mcconn-Walsh, R. (2015). Effectiveness of Conventional Versus Virtual Reality–Based Balance Exercises in Vestibular Rehabilitation for Unilateral Peripheral Vestibular Loss: Results of a Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation, 96 .

REFERENCES

QUESTIONS