Improvements in Balance, Vestibular-Ocular Response, Eye-Tracking, Cognitive Processing, Pain and Range of Motion After a 5-Day Intensive Rehabilitation Program.

Presentation: A 69-year-old male presented for a neurological evaluation with no subjective complaints. Patient history reported by a family membered revealed a recent decline in short term memory. The patient had a personal history of Benign Prostatic Hypertrophy and hypertension, and was on medication for both at the time of presentation. When asked, the patient stated that he had pain in his left shoulder and reduced range of motion. He stated he was scheduled for rotator cuff surgery.

Assessment: Upon standing, the patient’s blood pressure dropped 20 mmHg bilaterally. The patient had taken his blood pressure medication earlier that morning, and did report being nervous and anxious during intake testing. The patient fell backwards during perturbed eyes closed balance testing with the head turned to the right (4.2% stability score), and in extension (13.0% stability score), within 10 seconds each. The patient had high frequency horizontal square wave jerks in all gaze directions, horizontal and vertical pursuit, and after horizontal and vertical saccades. The patient also had decreased right optokinetic gain. The patient had a bilateral decreased gain of his vestibulo-ocular response after head-thrust testing. Trails A (TA), Trails B (TB), and Coding Tests (CT) were performed with the following results: TA (57.08 sec), TB (95.62 sec), CT (33 matches in 120 seconds). The patient had pain in his left shoulder in the distribution of the supraspinatus muscle, and had a decreased range of motion in extension, external rotation, internal rotation, abduction, and in the scaption plane.

Intervention: A treatment plan was implemented involving nerve stimulation of the tongue, vestibular-ocular rehabilitation exercises, multi-axis chair rotations, interactive metronome, and orthopedic rehabilitation on his left shoulder, performed 3 times daily, for 5 days.

Outcome: Following 5-day treatment, the patient experienced a near-complete resolution of this left shoulder pain, with only minimal pain at end ranges of motion at times. Range of motion of the left shoulder was within normal limits at the time of discharge. The patient had a significant improvement in rightward optokinetic gain and vertical pursuit following. The patient also had a dramatic decrease in the frequency of horizontal intrusions in all eye movements tested. The patient was able to complete all balance tests upon discharge. The patient’s stability score had improved on a foam surface with eyes closed and head turned to the right 1578.57% (4.2% to 70.5%). The patient’s stability score with head extended, eyes closed on a foam surface improved 435.38% (13.0% to 69.6%). Neurocognitive test had also improved with TA time improving 46.57% (57.08 sec to 30.5 sec), TB time improving 28.54% (95.62 sec to 68.33 sec)

Conclusion: 5-day, multi-sensory, intensive rehabilitation programs may be able to dramatically improve stability, cognitive performance, eye-tracking, and symptoms in the geriatric population.