5/14/2013
1
© 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
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
2
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
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
3
Vestibular System
MS
KC
C p
ho
to
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
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
4
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
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
5
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
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
6
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
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
7
Cervical Proprioception
•
Towards Left: 16* discrepancy Towards Right: 5-8* discrepancy
>4.5 * discrepancy impaired
MS
KC
C p
ho
to
MS
KC
C p
ho
to
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
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
8
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
MS
KC
C p
ho
to
MS
KC
C p
ho
to
MS
KC
C p
ho
to
MS
KC
C p
ho
to
Balance Training
MS
KC
C p
ho
to
MS
KC
C p
ho
to
MS
KC
C p
ho
to
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
9
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
MS
KC
C p
ho
to
MS
KC
C p
ho
to
Advanced Activities
MS
KC
C p
ho
to
MS
KC
C p
ho
to
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
10
Advanced Activities
MS
KC
C p
ho
to
MS
KC
C p
ho
to
Neurocom System
MS
KC
C p
ho
to
MS
KC
C p
ho
to
Gait Training
• Change support surface– utilize simulated environment
• Changing speeds
• Changing inclines
• Negotiating obstacles
• Quick turns
• Sidestepping/carioca's – head steady
– head turns
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
11
Gait Training
MS
KC
C p
ho
to
MS
KC
C p
ho
to
MS
KC
C p
ho
to
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
MS
KC
C p
ho
to
MS
KC
C p
ho
to
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
12
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
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.
5/14/2013
13
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.
© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.