Jolie Berke earned her Doctor of Physical Therapy degree from Northwestern University Feinberg School of Medicine in 2016. She is a physical therapist at NYU Langone Health Rusk Rehabilitation in New York, New York where she is currently treating patients with neurologic and vestibular disorders. She has successfully earned a certificate in vestibular physical therapy through the American Physical Therapy Association. She has presented posters at The International Society of Physical and Rehabilitation Medicine as well as at two separate Combined Section Meetings of the American Physical Therapy Association.
Sickle cell anemia (SCA) can result in ischemic crises effecting the blood flow to the inner ear. Sensorineural hearing loss (SNHL), tinnitus, vertigo, and disequilibrium are common symptoms post-SCA crisis. The purpose of this case report is to demonstrate the efficacy of Vestibular Physical Therapy (VPT) on residual vestibulopathy post-SCA ischemic crisis. A 46-year-old female, presenting 2 months after SCA crisis, with disequilibrium, vertigo, unilateral SNHL, and tinnitus. Examination revealed first degree right beating nystagmus, positive left head impulse test, and robust right beating nystagmus post horizontal head shaking. Findings were consistent with unilateral left peripheral hypofunction. Her dynamic balance was also impaired based on: functional gait assessment (FGA) score of 10/30; impaired gait speed (0.80 m/s); impaired balance self-efficacy via Activities-Specific Balance Confidence Scale (ABC) score (15%), and a severe level of disability related to dizziness and instability (Dizziness Handicap Inventory (DHI): 64). Patient completed 9, 45 minute sessions of VPT. Interventions incorporated: gaze stability x1 and x2; habituation for symptom provoking motions; adaptation training; and dynamic balance. Patient improved: dynamic balance (FGA 10 to 25/30); self-reported disability (DHI 0-64); balance self-efficacy (ABC 15%-98%); and habitual gait speed (0.80 m/2 to 1.31m/s). Patient was able to return to work and all leisure activities without symptoms. SCA crisis can affect the blood supply to cranial nerve VIII causing a vestibular hypofunction to develop. Traditional VPT was shown to be an effective measure to address the deficits associated with residual hypofunction due to SCA crises.
Rebecca Haigh BMBS studied medicine at Peninsula College of Medicine and Dentistry, graduating in 2014. On completion of her medical training she took up a Specialty Doctor post in neurorehabilitation with an interest in spasticity management
Rubral tremor more recently known as Holmes tremor is characterized by its onset a period of time following injury. Holmes tremor is described as a flexor-extension oscillation, present at rest and exacerbated by posture1. This tremor is further exacerbated by action. These characteristics have a profound effect on the patient, increasing lethargy and notably patient frustration, all of which negatively impact on a patient working towards rehabilitation goals. Multiple individual case reports have shown limited benefits of a range of medications including Levodopa and a few describing use of Benzodiazepine. Recent retrospective case study has found limited evidence to support use of Benzodiazepines and favors Levodopa as a pharmacologic agent2. It is important to consider that the majority of case reports and research suggest the only curative method is surgical. Case of 32 year old female initially presented with slow progression following spontaneous intra ventricular hemorrhage. Six weeks following initial injury she developed a global coarse tremor significantly limiting rehabilitation progress. On sitting out and particularly on intention the amplitude of the tremor greatly intensified making rehabilitation goals difficult to achieve particularly when taking into consideration associated lethargy. It was noted during this time that the tremor was improved significantly by use of tilt table. She initially showed a marked response to Lorazepam but this was difficult to titrate due to sedative affect and she was converted to Clonazepam. This input has caused a marked reduction in tremor with reduced lethargy and improved engagement with therapies.