Help! cerebellar pontine angie meningioma

[Aussyy]

Just recently qualified and have to treat and manage a 63yr old lady who has just had surgery for cerebellar pontine angie meningioma. A benign tumour removed from brain. She has dec trunk control, proprioception loss global ataxia. she is motivated and compliant. she can stand unsupported for 20sec. I have been seeing her for 3 wks doing lots of trunk control, proprioception exercises. when I first met her the whole half hour her head was side flexed to the right and she was w/b > to the left. She can correct her posture when prompted. stg was to be able to sit unsupported whilst recruiting knee ext this she can now do. What she wants is to be able to walk using a wwf. She can transfer using banana board but needs A01. When she stands and you ask her to step with the r foot forward and back the ataxia, dec co-or is making this mvt very unsteady and pt struggles to plantigrade her foot precisely where I ask. Happy with what I am doing and why but to get someone who has treated a pt like this before would be a huge benefit to my rx.

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[gcoe]

Hi Aussyy

It sounds like you have got some good ideas for treating this patient. I think you have to go off the presenting impairments as everyone is different. From an evidence point of view there isn’t much out about cerebellar management let alone a mixture of brainstem+ cerebellar signs which seems what your patient has. Have you looked at this systematic review? This might give you some ideas:

Effectiveness of physiotherapy for adults with cer... [Clin Rehabil. 2009] - PubMed result

My comments would be:

If ataxia is a big component then this really is a huge dexterity issue. Applying task-oriented training is the way to go. Utilise your motor learning principles as much as you can - particularly task specificity, repetitious practice, and intrinsic learning.

These patients are often motor learning disabled so they need to really get the practice in to compensate for this problem

These patients often have some ability to balance statically but if all goes to seed when they start walking. Obviously your patient does has difficulty with static standing so good idea to work on it. However building up her static standing may have not real transference to balance in walking.

I would therefore not delay walking practice if you possibly can set up safe walking. Body weight support treadmill training may get around this if you have access to the equipment. This may be an ideal way for your patient to build up skill of walking while her balance is still so atrocious. If you don’t have access then may be she might manage walking with an Arjo frame or even a gutter frame. For any of these techniques you may need more than one pair of hands to start off with.


Best of luck!

[Aussyy]

Many thanks that is really useful.

One more isssue with this lady is the surgery seems to have affected r > L arms, both limited in rom active and passive,

pt says mvt stopped by stiffness - passive hard end range feel and stiff

no p/n, no numbness, no pain, has sensation to light touch, performed some tests eg speed, empty can, neers all -ve,

given active assisted and gravity assisted and pendulum x's but bit puzzled with arms
but decided to work on trunk first as without that she isn't going far?

[gcoe]

Hi Aussii

Glad that you found it useful.

About the arms particularly the right arm: Hmm a bit hard to work that one out. Based on what you have said sofar I am not sure. choices that come to mind are that she has contracture (sounds most likely) but she may also have spasticity or rigidity - spasticity possibly from the pontine involvement. If she has contracture then then it is most likely to have been preceded by spasticity, rigidity or weakness. Here is a scenario:


She has developed contracture already. How long is she post surgery? I wonder how long she had arm problems prior to the surgery? If there was a long lead-up of gradually worsening symptoms from the growing tumour she may have had lost power, spasticity or rigidity.


So is the loss of range in both directions (agonist & antagonist). Which direction(s) is the loss of range - most commonly loss of flexion at the shoulder and extension at the elbow wrist and hands.

Does she have increased resistance through range? If so is it velocity dependent (spasticity and more likely one direction) or is it not velocity dependent and in both directions (rigidity).

If the symptoms came on quickly prior to surgery and she isn't long after surgery, and she doesn't have spasticity or rigidity I would be at a loss to explain it. Possibly she could have some concurrent musculoskeletal problem like a frozen shoulder.

One other question:

What is her function like?. Could you capture that with the Upper limb MAS or wolf motor function test?