Published online Nov 24, 2020. doi: 10.5306/wjco.v11.i11.945
Peer-review started: May 8, 2020
First decision: July 25, 2020
Revised: August 30, 2020
Accepted: September 22, 2020
Article in press: September 22, 2020
Published online: November 24, 2020
Patients in the acute phase of rehabilitation after vestibular tumor surgery usually experience vertigo, nausea, and a range of symptoms that include deficits in gaze stability, mobility, and balance. In addition to these problems, secondary problems such as vomiting, fatigue and reduced ability to focus or concentrate can occur. These symptoms can diminish the quality of life and impact all aspects of daily living and contribute to emotional problems sometimes causing anxiety or depression. Due to these symptoms, relatively short hospitalization, and the fact that they are left on their own, without the possibility of rehabilitation treatment, there is a need for such a vestibular rehabilitation treatment, including specific Functional Gait Assessment (FGA) activities during walking, and should be initiated in the hospital.
The purpose of our pilot study was to evaluate the improvement in functional balance in each patient and thus reduce the risk of falls. Experimental functional FGA exercises were chosen as a part of the vestibular rehabilitation program to regain patients’ ability to walk safely and to mimic their daily activities. Furthermore, this topic was chosen as the regular hospital rehabilitation program does not implement various postural tasks included in the FGA. We believe future research should focus on attempting to develop the most effective vestibular rehabilitation program for patients with vestibular loss in the early postoperative period.
The main goals of this study were to improve dynamic performance, to determine patients’ balance disorders; their susceptibility to falls, and to investigate the acceptability of the Berg Balance Scale (BBS) by reporting its score distribution. Most of the patients in the study, evaluated with the BBS showed statistically significant clinical progress in functional activities of daily living. The routine collection and reporting of BBS balance outcomes before and after surgery should be considered for all patients with vestibular loss, given the profound impact on the overall quality of life and for further quality studies in this area.
Our study was conducted at the Department of Neurosurgery in Ljubljana between January 2016 and June 2017. We included patients who underwent vestibular schwannoma surgery and scored higher than 25 points on the Mini-Mental State Examination and higher than 8 points on the Barthel index during the initial examination. We used the BBS for evaluation on the second day after surgery, during their hospital stay, at discharge, and three months after surgery. A vestibular rehabilitation program, focusing on multiple motor tasks included in the FGA scale was formed and implemented in the acute stage of rehabilitation. Before discharge, the patients were provided with instructions regarding balance-improving exercises in sitting and standing positions and during gait. Additionally, they were asked to keep a record of FGA-based exercise performance as well as falls in their home environment. Descriptive statistics were used for the variables considered. The non-parametric Wilcoxon test for paired samples was used to compare the mean value of the BBS scale at admission and discharge and three months after discharge. The statistical significance was set at P = 0.05. We used the R studio package (R version 3.6.1.).
Ten patients were included in the research: Six females and four males aged between 18 and 57 years (average 39.5 years). The average hospital stay was 10.5 d (minimum of 7 d, maximum 14 d). Analysis showed a statistically significant improvement in functional balance on the BBS scale at discharge from hospital (median = 11; P = 0.0059) and three months after discharge from hospital (median = 8; P = 0.0058) in these patients. The statistical analysis confirmed our hypothesis that the BBS scale is an appropriate functional balance assessment test in early rehabilitation, as it is also highly sensitive to changes that occur during rehabilitation programs and provides an adequate assessment of patients' postural instability. Statistical analysis also showed that the median progression in balance after BBS did not significantly differ at the time of hospitalization and after discharge (P = 0.2012). Larger numbers and more homogeneous cases in potential future studies would confirm or refute the results of our study.
Multitasking FGA exercises, as a part of the vestibular rehabilitation program for functional gait, proved helpful in the acute postoperative period as the functional independence of patients improved at the time of discharge and three months after discharge. However, given the small number of cases and lack of a control group, we cannot with certainty conclude that FGA scale tasks provide sufficient positive effects on early-stage rehabilitation in patients after vestibular tumor surgery. There are several key priorities for future research. Randomized controlled trials with larger sample sizes and more rigorous methodologies are needed to investigate the effects of each motor element of the FGA scale. Investigation of FGA intervention parameters, based on routine collection of balance outcomes, the timing and duration of FGA interventions, and the minimum or optimal "dosage" requirement to achieve effectiveness should be considered. The effects of education and social reinforcement also require further investigation.
Our study may be a good baseline for further research and to establish the Slovenian rehabilitation register for patients after surgical removal of vestibular tumors. The register should include a valid rehabilitation protocol for all Slovenian hospitals in primary care.