june 1.245pm - memorial sloan kettering cancer center · – reedco posture score sheet: ... gait...

5/14/2013

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© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.

The presenter has no conflict of interest to report The presenter has no conflict of interest to report regarding any commercial product/manufacturer regarding any commercial product/manufacturer that may be referenced during this presentation.that may be referenced during this presentation.

Physiology of Balance 2,4,12

• 3 systems– Visual

– Somatosensory/Proprioceptive

– VestibularVestibular


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Visual System 1,2,4,12

• Assists in maintaining balance & orientation to space utilizing different properties & reflexes involving the visual perceptive system.

- Saccades

- Smooth pursuitp

- Optokinetic reflex

- Depth perception

- Vergence

• Visual cortex centers: allows to collect vertical & horizontal stimuli & process information for a particular motor output.

Somatosensory/Proprioceptive System1,2,4,12

• Provides kinesthetic and proprioceptive awareness to maintain and combat balance challenges

- Internal perturbations

- External perturbations

- Components of cervical proprioception assist to maintain balance through cervical ocular reflex

Vestibular System 1,2,4,12

• Maintains balance & stability through vestibular reflexes

- Semicircular canals- Respond to angular acceleration & are paired functionally

- Otolith organs- Respond to linear acceleration


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Vestibular System

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CASE PRESENTATIONCASE PRESENTATION

Case Description

• 37 yo male diagnosed w/melanocytoma of clivus in 6/2010 – s/p transnasal debulking with residual disease in 6/2010

– re-occurrence in 2012

– s/p L craniotomy with L mastoidectomy with resection of L middle ear & external auditory canal with fat graft in place over defect with a transtemporal approach & subtotal resection of recurrentwith a transtemporal approach & subtotal resection of recurrent clival meningeal melanocytoma in 2/2012

– L hemiparesis

– CN 7-10 deficits noted, L facial palsy, hoarseness, ↓ L hearing

– post-op course complicated with ICU admission due to meningitis

– s/p Cyber Knife surgery/RT x 5 sessions in 6/2012

– currently stable with no active disease


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Chief Complaint

• Initial visit (9/2012) – c/o “entire body in various states of paralysis” and “asleep”

– “terrible” balance with multiple falls

– “↑ disorientation & objects look shaky” with head turns contributing to ↓ ability to scan environment during community ambulation

– dizziness, disorientation, oscillopsia worse with long distance ambulation, head turns, ambulation in dark, positional changes

– ↓ symptoms: stationary head/neck, visual focus on object

– Unable to participate in community environment

Background 11,12

• Posterior Fossa Tumors– Meningiomas comprise 10-20% of PFT

• Clivus meningiomas (less than 1-2%)

• Classified as extra-axial

• Compress CN 7 & 8 due to its location resulting in ↓ hearing & ↓ sensation to face

– ↓ vision, headaches, nausea secondarily as a result of ↑ ICP from blockage of CSF or hydrocephalus

Oncological Considerations 8,9,11

• Radiation Therapy Field: Gamma Knife/Cyber Knife RT to treat large volume tumors can increase…

– Incidence of post-treatment edema

– Incidence of radiation necrosis to site

– Incidence of Blood Brain Barrier Breakdown resulting in potential brain hemorrhage

– Incidence of post-treatment inflammatory process resulting in neurological deficits & potential somnolence & cognitive deficits


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Patient History• PMH: HTN, recurrent meningeal melanocytoma with severe

brainstem compression

• PSH: Right knee arthroscopy

• Social History: lives alone apartment 1 flight of stairs worked FT• Social History: lives alone, apartment, 1 flight of stairs, worked FT as a banker, now on disability

• PLOF: independent with all ADL & ambulation

• Functional status: w/c immediately post-surgery; progress to ambulation with SC at initial outpatient PT visit

PT Initial Evaluation 5,10

• Subjective:

“I am constantly dizzy & the world appears shaky.”

– Dizziness Handicap Inventory: 64 (severe handicap)

– PSFS: ambulation with head turns: 2stair negotiation: 3reaching into cabinets while looking up: 5

grocery shopping: 3

Objective• Posture: FHP, protracted/anteriorly tipped scapulae, ↑ thoracic

kyphosis, ↓ lumbar curvature– REEDCO posture score sheet: 60/100

• Cervical ROM: limited cervical rot to 35° (R) & 30 ° (L)

• AROM: BUE/LE range within functional limits

• MMT: L hip flex 4-, hip abd/ext: 3+, knee ext 4, ankle DF 4-, ankle PF 4, great toe ext 4-

• Skin/Fascial Integrity: ↓ fascial integrity over L ear & at temporal region with ↑ scar tissue adhesions, ↑ suboccipital tightness


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Neurological Examination• CN: deficits in CN 6, 7,8, 9 and 10

• Myotomes: Intact

• Dermatomes: Decreased sensation to C2/C3 region with temporal region affectedregion affected

• Sensation: impaired vibratory sensation

• Reflexes: normal, brisk patellar & plantar reflexes

• Prioprioception: impaired

Standardized Testing 3,6,7,10

• TUG: 16 seconds with increased time at turns

• DGI: 15/24

• Berg Balance Test: 39/56

• 30 second sit to stand: 9 reps

• Modified CTSIB/Romberg/SOT

MCTSIB


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Cervical Proprioception

•

Towards Left: 16* discrepancy Towards Right: 5-8* discrepancy

>4.5 * discrepancy impaired

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Gait Assessment

• ↓ cadence & step/stride length

• Impaired smooth pursuit - shift to right

• ↓ speed of ambulation (61.7 cm/sec)

• Weight bearing asymmetry: 6-15% towards right

• ↓ smooth pursuit & balance with heel, toe, tandem walking

• Limited activation of hip & pelvic stabilizers in midline

Treatment 1,10

• VOR

– Gaze stabilization exercises

– VOR x1 & x2 exercises• stationary target with head mov’t

• target moving

• alternating target & head mov’t

• sequential mov’t of target & head

• Cervical proprioception with laser target & head mov’twith eyes closed

• Head-righting with mirror & cueing for midline alignment


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Somatosensory Exercises 1,13

• Static stance on firm, foam, grass, tarp, soft surfaces while maintaining balance– Adding head tilts up/down, rotation

– Adding trunk rotation

– Swaying forward, backward, side-to-side

• Performing reaching tasks with static stance progressing to dynamic stance with head & body mov’t outside BOS– Progressively adding external perturbations proximally & distally

with increased torque

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Balance Training

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Advanced Balance Training 10,13

• Advance VOR exercises with gaze stabilization, VOR x1 & x2 using Neurocom system

• Progress any variation of previous exercises with VOR x1 & 2 i d b i t l b k d h k b d& x2 viewed on basic neutral background, checker board pattern, on to varying degrees of busy patterns & distance – Perform in closed environment initially

– Progress to open environment with ↑ challenges to all balance systems

Advanced Activities

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Advanced Activities

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Advanced Activities

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Neurocom System

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Gait Training

• Change support surface– utilize simulated environment

• Changing speeds

• Changing inclines

• Negotiating obstacles

• Quick turns

• Sidestepping/carioca's – head steady

– head turns


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Gait Training

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Outcome ScoresInitial Evaluation

• DGI: 15/24

• DHI: 64/100

• PSFS:

• amb w/head turns: 2

• stair negotiation: 3

Reevaluation/Discharge• DGI: 20/24

• DHI: 45/100

• PSFS:

• Ambulation while turning head: 5

• stair negotiation: 5

• reaching into cabinets, looking up: 5

• grocery shopping: 3

• TUG: 16 seconds

• Berg Balance: 39/56

• Walk across/gait speed: 61.7cm/sec

• 30 sec sit to std: 9 rep, UE support

• Dynamic visual acuity: 4 line discrepancy

• reaching into cabinets, looking up: 7

• grocery shopping: 5

• TUG: 12 seconds

• Berg Balance: 46/56

• Walk across/gait speed: 85cm/sec

• 30 sec sit to std: 15 rep, no UE support

• Dynamic visual acuity: 2 line discrepancy

SOT

Pre- Test Post-Test

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Reorientation to Community

• Progress to community based activity

– Ambulation in busy Manhattan street

– Crossing the street in 10 seconds or less, multiple challenges to systemchallenges to system

Challenges and Special Considerations

• Limited improvement; pt to reach a plateau as functioning on right vestibular system only.

• Adaptation & compensation limited to right vestibular system.

• Progressive decline possibility secondary to radiation fibrosis, scar tissue & tumor progression.

• Increased treatment time, patient seen for 5 months to achieve above results.

Thank YouThank YouThank YouThank You


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References1. Herdman SJ. Role of vestibular adaptation in vestibular rehabilitation. Otolaryngol Head Neck Surg

1992; 119:49-54

2. Brown KE Whitney SL, Marchetti GF, Wrisley DM, Furman JM. Physical therapy for central vestibular dysfunction. Arch Phys Med Rehabil 2006;87:76-81

3. Rossier R, Wade DT. Validity and reliability: comparison of four mobility measures in patients presenting neurological impairment. Arch Phys Med Rehabil. 2001;82:9-13

4. Gillespie MB, Minor LB. Prognosis in bilateral vestibular hypofunction. Laryngoscope. 1999;109:35-41.

5. Jacobson GP, Newman CW. The development of the dizziness handicap inventory. Arch OtolaryngolHead Neck Surg. 1990;116:424-427.

6. Whitney SL, Marchetti GF, Shade A, Wrisley DM. The sensitivity and specificity of the timed “Up & Go” and the dynamic gait index for self reported falls in persons with vestibular disorders. J VestibRes 2004;14:397-409.

7.

Whitney S, Wrisley D, Furman J. Concurrent validity of the Berg Balance Scale and the Dynamic gait Index in people with vestibular dysfunction. Physiother Res Int. 2003;8:178-186.

References

8. Unger KR, Lominska CE, Chanyasulkit J, Randolph-Jackson P, White RL, Aulisi E, Jacobson J, Jean W, Gagnon GJ. Risk factors for posttreatment edema in patients treated with stereotactic radiosurgeryfor meningiomas. Neurosurgery. 2012;70:639-645.

9. Sato K, Baba Y, Inoue M, Omori R. Radiation necrosis and brain edema association with CyberKnifetreatment. Acta Neurochir Suppl. 2003;86:513-7.

d10. Herdman SJ. (2007). Vestibular Rehabilitation, 3rd Edition. Philadelphia, PA: F.A. Davis Company.

11. Greenberg HS, Chandler WF, Sandler HM. (1999). Brain Tumors. New York, NY: Oxford University Press Inc.

12. Noback Cr, Strominger NL, Demarest RJ. (1991). The Human Nervous System: Introduction and Review, 4th Edition. Malvern, PA: Lea & Febiger.

13. Mansfield A, Peters AL, Liu BA and Maki, BE. A perturbation-based balance training program for older adults: study protocol for a randomized controlled trial. BMC Geriatrics. 2007;7:12.


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