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1, April-July 2001
VESTIBULAR REHABILITATION THERAPY IN NEUROSURGICAL PATIENTS : AN OCCUPATIONAL THERAPY PERSPECTIVE
KONNUR M.K., BHATJIWALE M.G., NAVALAKHE M.M., KHANDELWAL P.S. Deptts. of Occupational Therapy, Neurosurgery and E.N.T., Seth G.S. Medical College and K.E.M. Hospital, Parel, Mumbai.
Occupational Therapy deals with the rehabilitation of the psycho-physical handicap to return them to their possible functional status and ease performance of activities of daily living (ADL). Residual vertigo (giddiness), balance and gait dysfunction in (1) Post surgical management of tumor cases, (2) Vertebrobasilar insufficiences, (3) Head injuries, pose a threat to effective rehabilitation using traditional techniques2,3. Since the advent of vestibular exercises (CawthorneCooksey) there have been modifications, variations and adaptation of these exercises to have a more individualised approach4,5. Vestibular Rehabilitation Training (VRT) has basically 2 components i.e. habituation and training which exhibits impressive results in management of vertigo and balance dysfunction. Literature of vestibular rehabilitation reveals evidences to the success of these strategies in different conditions involving the central and the peripheral vestibular system but do not quantify its effect in the above mentioned cases which became the basic aim of the study3,5,6,7.
Vertigo : In post operative cases, nonsubdued within 2472 hours. Balance and Gait Dysfunction.
Assessment and investigations
1. Occupational Therapy evalution in terms of physical capacity, vertigo8,9, Tinetti Assessment Battery for gait and balance10. Neurosurgical Assessment : InvestigationsMRI, CT Scan 16 cases of unilateral lesion 1 case of midline lesion
Type of Tumor
Meningiomas, Low Grade Astrocytomas, Haemangioblastoma, Medulloblastoma
METHODOLOGY Selection of patients
A population of 25 patients (11 females, 14 males) of age group 20-60 years were included in the study, the criteria being.
For posterior fossa Tumors : 3 x 3.5 cms. For Basal Ganglia Tumors : 6.5 x 4.8 cms. ENT : Audiometry - Reported normal hearing.
Patients were to follow VRT, ten times each, thrice a day and were evaluated prior to the start of VRT and at 2, 3, 4, 6 weeks post VRT4,5,11. Individualized exercise schedule was followed. VRT broadly consisted of : 1. Head and Neck Exercises in Variable positions like supine, sitting (with eyes open and closed.) Activities of Daily Living (ADL) which require head movements. Walking. Visual - vestibular interaction exercises, e.g. eye-hand coordination exercises. Postural control exercises, e.g. weight bearing exercises. Precautions regarding falls, walking aids.
1. 2. 3.
14 cases of posterior fossa tumors and 3 cases of basal ganglia tumors. 5 cases of cervical spondylosis with no neurological deficit. 3 cases of precipitant head injury with no residual neurological deficit.
2. Colony, Road No. 4, Dadar, Mumbai-400014.
CORRESPONDENCE : Dr. (Miss) Moushumi K. Konnur, Occupational Therapist, 113, Saraswati Niwas, Hindu
Paper was presented at 37th Nat. Conference of AIOTA, EMCON'2000, at Mumbai in Jan. 2000.
Reestablishing symmetric tonic firing rates in vestibular nuclei.0±0 P<0. 4 (6 wks) P b) Duration TAB a) Group A 1.276 3.U.568 P<0. 3 (4 wks) F.0 28. the VRT was found to be very effective to decrease vertigo (in terms of intensity and duration).00±. DISCUSSION Vertigo and maladaptive postural control strategies have for long posed problems and hesitancy in the therapists to institute rehabilitation schedule.904 25.July 2001 .04±0. But after Table I Parameters Before VERTIGO a) Intensity 4. 3 with head injury. In conditions like posterior fossa and cerebellopontine angle tumors which are progressive. and visit to the therapist on followup date.92 ± 0.76 26. thereby explaining the inclusion of ADL in VRT2. Rest of the patients were initially supervised thrice in the first week in the O T Department to later on follow a home programme and report for followup session.60 ± 0.U.001 highly significent F. VRT can only give a diagnostic trail preoperatively4. 5 with cervical spondylosis.36± 0. Inclusions in Groups were : Group A 14 patients with posterior fossa and Cerebello pontine angle tumors Group B 11 patients. to negligible in all cases and showed high statistical significance on gait and balance improvement.71±3. Moresoever. 1 18 April . It was seen that due to these symptoms ADL also becomes uncomfortable although the voluntary control and power of the appendages and axis remains intact.18 ±2.72 ±0. 2 (3 wks) F. (2 wks) VRT F. resection in many a cases there exist symptoms of vertigo (giddiness) and imbalance inspite of normal hearing which provided the authors with a baseline to carry out the study. Habituation 1. To achieve this VRT uses the physiologic rationale of : Training 1.01 highly significant 6.U. For statistical case the patients were divided into 2 groups. VRT puts forth the unique feature of vestibular plasticity or compensation of the CNS.98±2.962 2.36± 0.5±5.489 2.568 1.98 27.734 1.27 ±4 15.005 significant RESULTS As per Table 1. namely A and B.328 P<0.00±. All the patients followed up after a month from the last follow up and kept consistent with the findings recorded at the 6th week. Consistency in sensory inputs IJOT : Vol.U. 1 This process results from active neuronal and neurochemical processes in the cerebellum and the brainstem in response to sensory conflicts produced by vestibular pathology. XXXIII : No.60 22.95±1. for evaluation on the Tinetti Assessment Battery (TAB) as Group B patients did not report for gross alterations/dysfunctions in the gait and balance parameters.36±0.-I.48 ±0.001 highly significent b) Group B 28. cases with vertebrobasilar insufficiency in cervical spondylosis and precipitant head injuries noted symptomatic similarity.Patients requiring surgery carried out exercises on indoor basis till discharge from the hospital with 2 sessions in O T Department and post discharge at home.69 26. 2.71±4.00±0 P<0. and 3 patients with basal ganglia tumors. A flowchart of the compensatory process can be referred to in fig.759 1.007 1.08±0. Accurate adjustive responses to head movements.42 23.707 1.
Rhinology and Laryngology. 1 19 April . 42:1441-44. Brainstem. 3-12. Smith -Wheelock .. 1996. Vestibular Tracts) cases.Physical Therapy program for vestibular rehabilitation. Keim R. relief of symptoms is noticeable in 1-4 weeks from start of therapy. 1992 (102) : 1302-7. 48 (10) : 919-25. 217 : 919-24.Physiologic basis and practical value of head exercises in the treatment of vertigo. the VRT should not be abruptly stopped.T. JAGS.. 1989. Neurology 1992.Vestibular Rehabilitation Improves daily life function : Am. Annals of Otology. Hospital for allowing us to conduct the study and extend our thanks to Professor (Mrs. 1976.T. Vertigo.Balance Rehabilitation Therapy. H. Tinetti M.. 29(2) : 359-371. Medical College and K. Although Computerized Posturography is the global indicator of patient candidacy for therapy.. Dysequilibrium (Gait/Balance) 7. .B. Telian. XXXIII : No.R.. 1991. Residual Symptoms Chronic Compensation V. . Moffat.Posterior fossa vestibular Neurectomy. As this is an energy dependent process.A.O.Performance Oriented Assessment of mobility problems in Elderly patients. 6. 10. 12 (13) : 218-225. Shepard .R. Catherine Trombly . extreme fatigue.Otolaryngologic Clinics of North America. Otolaryngologic Clinics of North America. 7 (1): 23-33.J. This was evident in the group A patients for TAB as they pursued cerebellar dysfunction.Update on Vestibular Rehabilitation Therapy. Confirming validity of the study with wider sample is a futuristic aim. Seth G.Patton J.D. 11. Hecker H. The therapist-assessed Tinetti Assessment Battery can be used to evaluate gait and balance dysfunction more so in posterior fossa and cerebellopontine angle tumors. (OT) and Dr.Kenkre. ACKNOWLEDGEMENT We wish to thank Dean.. 1986. 3.S..Treatment planning process : In Occupational Therapy for Physical Dysfunction.Treatment of vertiginous patient using Cawthorne's Vestibular Exercises.Vestibular and Balance Rehabilitation Therapy. Catherine Trombly Baltimore Williams and Wilkins.J. Cook M. REFERENCES 1. 1974.The basic and common techniques of VRT are elaborately discussed in literature and only in individualised programme following these was used in the study details discussed before. VRT can be used in management of residual vertigo and postural control strategies and comfort ADL in post operative neurosurgical. . vascular and head injury IJOT : Vol. 102 : 198-205. 1991. Telian S. Atul Goel. Laryngoscope. Non computerized versions of balance and gait assessment batteries can be used by therapists for patient candidacy and follow up assessment. Toher et al . Fig. Presistent Vertigo . 12. Ruben R. HOD (Neurosurgery). 2. Herndon J.M. Exercise therapy for positional vertigo. Motivation of the patient to perform and participate in the therapy is the key to the efficacy and success of the therapy as the initial phase might be irritable for the patient6. Whereas the group B patients had dysfunction on TAB mainly due to vertigo. I VRT : The Physiologic Rationale. Dix M. 5. 4. CONCLUSIONS 1. Acute Compensation (24-72 hours) De-compensation (Relapse of symptoms) 8. The American Journal of Otology. . 34(2) : 119-26. Cohan H .E. Hang C. 1974. in Occupational Therapy Relief of Symptoms 9. As the patient gets trained to become gradually habituated.M. Laryngoscope. Journal of Laryngology and Otology. Shepard N. Journal of Occupational Therapy 1994.R. change in medications or an intercurrent illness. Troost T.July 2001 . Pathology of Vestibular System (Cerebellum. 11: 2065-72.E. The practitioner. Martini D. Our study also supports this view. 2. 1993. The symptoms may be triggered by a period of inactivity.) I. literature states that non computerized versions of Balance and Gait batteries are gaining wide acceptance and can be administered efficiently2. 105 (12) : 1002-3.
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