Does vestibular rehabilitation optimize physiotherapy benefits in the early stages of PICA stroke recovery? A case series

Abstract

Introduction: The Posterior Inferior Cerebellar Artery (PICA) irrigates the inferior area of the vermis, the central nucleus of the cerebellum, the inferior area of cerebellar hemispheres, the medulla oblongata and the choroid plexus of the fourth ventricle (vestibular nuclear complex) [1]. After suffering a PICA stroke, patients present vertigo, dizziness, vomiting, headache, changes in gait, changes in postural control and horizontal nystagmus ipsilateral to the lesion [2]. These symptoms are related to a compromise of the vestibular afferent sensory input which impairs the motor output for the management/maintenance of balance [3]. Vestibular Rehabilitation (VR) aim at reestablish the function of the injured sensory system before introduced neuromotor exercises. Normally in these patients the standard intervention does not included this line of reasoning [3,4]. The main objective of this study is to understand the benefits of the vestibular intervention in the early stages of a PICA stroke.

Materials and methods: In this study, 5 patients who suffered a PICA stroke, 2♀ and 3♂, were assessed, between 6 to 10 days after the event and on the 15th session (with the respective informed consent according to declaration of Helsinki). Lateropulsion, gaze-evoked nystagmus and nausea were present. The regular protocol for evaluation was used, as well as the Mini Mental State scale (MMS), the Tinetti scale, the Dizziness Handicap Inventory (DHI) and the Functional Independence Measure (MIF). The clinical reasoning for the intervention included different VR tasks: gaze stabilization during the early, symptomatic phase, and sensory conflict tasks along with specific balance and gait exercises during a latter phase.

Results: After 15 sessions all patients improved. The greatest differences were noted on the ocular and postural stability, balance and gait’s quality, on the inhibition of balance visual compensation strategy and on the decreased rehabilitation time. Regarding the scales scores in the two moments of evaluation (1st assessment➔2nd assessment), there were no difference in the MMS (M = 25➔25.2; SD ±2.92➔2.77) but there were positive differences in all others outcome measures - Tinetti (M = 19.8➔27; SD ± 3.35➔1); DHI (M = 37➔11.6; SD ±15.48➔6,88) and FIM (M = 80.2➔118,8; SD ±18.29➔7.29). The degree of independence in functional tasks and activities of daily living also improved.

Discussion and conclusions: The main benefit of VR seems to be the optimization of the injured sensor (vestibular system), before promoting the correct sensorimotor integration with the typical physiotherapy interventions. These results suggest that Vestibular Rehabilitation may have a role in the recovery of PICA strokes, by optimizing the process, thus complementing the regular/standard physiotherapy approach. Little is written in the literature about this topic, so, in the future, more studies should seek to investigate it.