Treatment of attention deficit disorder using vestibular and gaze therapy
Background: A 9-year-old patient presented to a functional neurology clinic for assessment, because her mother reported that the child was experiencing “a delay in processing” in school. The mother reported concern that her daughter’s delay would continue and degrade her school performance. The patient was inattentive, oppositional and dyslexic, consistent with that of a child with delayed processing.
Methods: During the physical exam an anisocoria was evidenced, with pupils that did not constrict with light stimulation. Pursuit testing revealed saccadic interruptions bilaterally. Saccadic testing showed an increase in latency with rightward saccades along with difficulty in gaze fixation bilaterally, left worse than right. There was an increased sensitivity to pinwheel sensation to her right upper and lower extremity along with trigeminal ophthalmic and maxillary dermatomes bilaterally on her face. The patient reported an increase in the intensity of the color red in her right eye more than in her left eye, upon color saturation testing. All primitive reflexes were assessed: rooting, moro’s, spinal galant, asymmetrical and symmetrical tonic neck responses, palmer grasp, spinal perez, and plantar reflex. They were all were noted as absent. A course of treatment including vestibular rehabilitation, gaze stability with head movements, eye exercises, somatosensory evoked potential simulation, complex non-linear limb movements, balance training, hand-eye coordination activities, and off vertical axis rotations were implemented. For 5 days the following treatments were performed three times per day: Trigeminal somatosensory evoked potential stimulation over the ophthalmic, maxillary and mandibular branches were performed bilaterally for 30 seconds each with 3 repetitions. Passive vestibular rehab was given with 4 sinusoidal oscillations around the z-axis and 4 sinusoidal oscillations around the y-axis at approximately 15 degrees per second at 0.5 Hz. Neuromuscular re-education was performed by passive movements in a figure 8 pattern with the upper right extremity and the lower left extremity, ten times, before switching to the upper left and lower right. Sensorimotor and balance training were performed using the interactive metronome. Patient performed the sessions at 54 beats per minute on a difficult level of 300 for 1 minute, by standing on the left leg alternating clapping and stomping with her right arm and right leg. Hand-eye coordination was performed utilizing a neurosensory integrator, the patient had to recall a series of verbally stated words in the reverse order, and touch them using her right arm on a touch screen TV. Vision therapy was delivered utilizing a computer program of saccades up and to the right and pursuits down and to the left. Multi-axis whole body rotation consisted of an alternating pattern of yaw right with anterior pitch for 4 revolutions and yaw right and posterior pitch for 4 revolutions.
Results: At the end of four consecutive days of treatment the patient showed significant improvements. Video nystagmography testing showed saccadic latency decreased from 270ms to 150ms along with a diminished anisocoria. Optokinetic testing showed an improved nystagmus response, especially in the vertical plane. Symptom severity improved from 22 to 1, with scores of sleep disturbance, trouble falling asleep, sleeping soundly and emotions, all decreased from a 3 on a 0-6 scale to 0 upon discharge. The only reported symptom after treatment was fatigue, which scored a 1 on a 0-6 scale. Other improvements were shown in processing speed, cognitive testing, recall memory, and hand-eye coordination. In addition, extensor strength improved bilaterally.
Conclusion: The improvements that were evidenced by the use of clinical neurological treatment strategies in this case point to a need for further research in this area for the future.