This presentation will cover three examples of children who were referred for formal vestibular testing and a physical therapy evaluation. In determining a strategy for the evaluation, it's important to think about the reason for referral. Specificly, what is the question that you're trying to answer through the evaluation? A partnership among the members of the team is critical for success. Importantly, vestibular physical therapy is typically the key component for improving outcomes for pediatric patients with vestibular problems. One of the first children that we evaluated in our clinic was a four year old child with CHARGE Syndrome. We knew that he had serious abnormalities in his inner ear structures affecting both the cochlea and the semicircular canals. We also knew that he did not have an eighth cranial nerve on one side, and it wasn't really clear the status of the nerve on the other side. He did receive a cochlear implant on the side with the nerve, but remained functionally deaf. Parents requested this referral and they requested it because they were concerned that this child always played with toys lying on the floor. He has also had an older brother and they noticed a difference between KP and his older brother. So he presented to the room with a toy car in each hand, and he consistently sought out things to touch. For example, he would run the cars along the wall in the clinic. The question for KP really was, since we knew his inner ears were abnormal, the question wasn't whether he would have abnormal vestibular function. The question really was whether he had any vestibular function in either ear, and the answer to that question would help inform therapy strategies. So we were able to put him in the rotary chair with the camera attached to the pole which was attached to the chair. So we recorded just a video of his eye movements and it was clear that there were no eye movements for either clockwise or counterclockwise rotation, so the answer to the question was he did not appear to have any vestibular function in inner ear. He was started on vestibular physical therapy to work on both substitution exercises, So exercises training the other sensory systems to take over from an absent vestibular system, as well as improving core strength. When he sat in our clinic he really couldn't sit independently at all, and he tried to sit with his legs stretched straight out in front of him. So he went from that status to being able to sit on an exercise ball without support at all. The next case I'm going to review is a case of a 14 year old female competitive diver who sustained a concussion when she hit her head on a diving platform. She initially had symptoms of objective vertigo, so in other words the environment appeared to be spinning. She missed seven weeks of school, because of her symptoms before returning to normal. One year later she developed signs of feeling off-balance, and she reported as a sense of herself or their environment tilting to one side. She denied hearing loss but reported hypersensitivity to sound. She also had a history of intermittent sinus infection. Her hearing testing revealed normal hearing in both ears. When we saw her she had a DHI score of 28 out of a 100, which is in the mild disability range. In her formal vestibular test results revealed: spontaneous persistent left beating nystagmus, which typically suggests a right weakness; 44 percent right caloric weakness; and phase leads in chair for sinusoidal testing with otherwise normal chair and oculomotor test results. This testing was really important because she had a meet scheduled soon, and she needed to know if it would be safe for her to compete, and also she was missing school again. Weekly physical therapy was recommended for her with improvement noted. The third case I want to present is of an eight year old boy who had a recent onset of dizziness and car sickness. He had a known sensorineural hearing loss associated with enlarged vestibular aqueduct. Interestingly, he passed his newborn hearing screening. So he was born with normal hearing in both ears but developed hearing loss in the left ear only, which was initially quite mild. He was fit with a hearing aid in that ear and he reported frequent near falls and actual falls. He is very active playing both soccer and basketball. Importantly, he suffered a concussion the previous summer during a soccer tournament. He came to us because he had a recent speech and language evaluation where the speech therapist noted concerns about a change in his hearing, and his mother also noted in incident of dizziness a few days prior to that evaluation. He had repeat hearing testing which revealed increased hearing loss in the left ear which had progressed over time. He did not report headaches, he did report occasional nausea when symptomatic. His formal vestibular testing revealed results that are consistent with vestibular involvement. Specifically a relative left weakness with possible left otolith involvement, and a possible bilateral weakness affecting only very low frequency functioning. Specifically his caloric results were very minimal in both ears. Physical Therapy Evaluation noted a DHI score of 22 out of 84, abnormal balance, on the BOTT2 and the modified MCTSIB, and abnormal dynamic visual acuity. A physical therapist, recommended weekly Physical Therapy in the clinic as well as a home program. We also recommended that his hearing be monitored on a regular basis to see if there were any changes including more progressive hearing loss. So in summary, these three cases illustrate three different etiologies of vestibular loss. As well, the questions that were posed were different across the individuals reported. They really highlight the importance of a team approach. For each patient Physical Therapy was valuable and improving outcomes. Thanks for your attention.
