V.H. is a 60-year-old female who was involved in a “minor” car accident in 1993. Although she did not hit her head in the accident, she was eventually diagnosed with a brain stem injury on MRI. Mrs. H had always been very socially active, she worked full time, she was president of her Red Hat Club, attended church, and many social functions. After this injury, she found herself unable to tolerate noisy or crowded environments. She would begin to feel ill, have difficulty maintaining her balance and would need assistance leaving such an environment. She would often have a headache for many hours to days afterwards. These “spells” often had the look of pre-seizure activity, however this was ruled out on EEG. Mrs. H’s world became much smaller as a result of her physiological responses to noise. At the time of assessment in October of 2010, Mrs. H was being treated with 17 different prescription medications for additional conditions of asthma, high blood pressure, fibromyalgia, reflux, and depression.
Initial Assessment: Using the Scan-A: Filtered Words 1%, Auditory Figure-Ground – patient was unable to tolerate the background noise and began having symptoms as described above. Competing Words 2%, Competing Sentences 37%.
Balance: Patient was unable to maintain her balance on two feet with her eyes closed for any length of time. She was unable to maintain one foot balance for more than one second. She was independent walking on level surfaces but lost her balance easily especially if there was movement in her peripheral field of vision, for example walking on the sidewalk with cars going by.
Vision Screening: The patient wears prescription glasses full time. Visual pursuits were normal but patient was found to be convergence insufficient.
Goal of Treatment: Patient would like to be able to return to group activities such as going to a restaurant, church, and family gatherings.
Treatment: Treatment began November 29, 2010 using the sensory motor protocol with bone conduction at zero. We needed to progress extremely slowly with this patient as setting off one of her “spells” would take several days to recover. We initially began with the iLs program on for 15 minutes only while sitting. We then took a walk outdoors for 14 minutes with close guarding as she lost her balance easily. We chose walking outside because patient was unable to walk and turn around or even walk in a large circle without symptoms of nausea. Treatment frequency was 3 times a week with gradually increasing complexity of activities. We attempted to move the bone conduction up to just the very first notch, however this resulted in bad headaches and nausea. The patient’s balance quickly improved so that she could walk independently outdoors and I felt comfortable giving her the Kick-Start Unit to use at home to increase the frequency of her program to 5 times a week. The patient returned every 7-10 days for follow-up to increase the exercises she was performing with the iLs.
Retesting of the Scan-A in March of 2011 revealed these improvements: Filtered Words 16%, Auditory Figure-Ground: patient still unable to tolerate the test. Competing Words 50%, Competing Sentences 75%. The patient reports that her balance has improved enough that she was able to take a Zumba class and was able to keep up with the rhythm. She also noted, “I think I’m hearing better. I haven’t had any episodes recently where I misunderstood what someone said and gave them an inappropriate answer.” Mrs. H was also able to tolerate noisy environments better. She occasionally used noise reducing headphones in restaurants or at a party. We took a break for several months from therapy.
In July of 2011, the patient returned to see if she could gain further improvements. At this point we utilized the Total Focus Unit using the Reading/Auditory Comprehension Protocol as a home program. We asked the patient to control the bone conduction and increase it as she felt able. The patient returned for follow-up every 3-4 weeks to adjust the home program.
In September of 2011, she happily reported that she was able to go to church and tolerated organ music for the first time. She has gone to several weddings, and numerous restaurant outings all without incident. She occasionally uses the noise reducing headphones to dampen the volume at some events. She has not had any of her previous “spells” where she felt like she would pass out and was overwhelmed by the noise. She reports that at her last optometry visit she needed a new prescription for her glasses because her vision had improved. Retesting on the SCAN-A will have to wait until she returns from her trip to Nepal. She reports “I’m doing great! I feel like I have my life back.”
by Diane Droescher, PT
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