Physical exercise and goal attainment after shunt surgery in idiopathic normal pressure hydrocephalus: a randomised clinical trial.

BACKGROUND: Rehabilitation in iNPH is suggested to be an important factor to improve patients' functions but there are lack of clinical trials evaluating the effect of rehabilitation interventions after shunt surgery in iNPH. The objective of this study was to evaluate the effect of a physical exercise programme and goal attainment for patients with idiopathic normal pressure hydrocephalus (iNPH) after surgery compared to a control group. METHODS: This was a dual centre randomised controlled trial with assessor blinding, intention-to-treat (ITT) and per protocol (PP) analysis. Individuals diagnosed with iNPH scheduled to undergo shunt surgery at the Linköping University Hospital in Linköping and Sahlgrenska University Hospital in Gothenburg, Sweden were consecutively eligible for inclusion. Inclusion was conducted between January 2016 and June 2018. The patients were randomised 1:1 using sequentially numbered sealed envelopes to receive either written exercise information (control group) or written information and an additional supervised high-intensity, functional exercise programme (HIFE) executed twice weekly over 12 weeks (exercise group). Preoperatively, the patients set individual goals. The primary outcome was change from baseline in the total iNPH scale score at the post-intervention follow-up. Secondary outcomes were goal attainment, and change in the separate scores of gait, balance, neuropsychology and continence and in the total score after 6 months. RESULTS: In total, 127 participants were randomised to the exercise group (n = 62) and to the control group (n = 65). In the ITT population (exercise group, n = 50; control group, n = 59), there were no between-group differences in the primary outcome, but the attrition rate in the exercise group was high. The exercise group improved more than the control group in the balance domain scores after 6 months. Post-intervention, the PP exercise population achieved their set goals to a greater extent than the controls. CONCLUSIONS: An additional effect of the 12-week HIFE-programme on the overall improvement according to the iNPH-scale after shunt surgery in iNPH was not shown. This could be due to high attrition rate. However, the long-term effect on balance and higher goal achievement indicate beneficial influences of supervised physical exercise. Trial registration clinicaltrials.gov, NCT02659111. Registered 20 January 2016, https://clinicaltrials.gov/ct2/show/NCT02659111.

Outcomes Following LSVT BIG in a Person With Idiopathic Normal Pressure Hydrocephalus: A Case Report.

BACKGROUND AND PURPOSE: There is no literature exploring physical therapy interventions for individuals with idiopathic normal pressure hydrocephalus (iNPH). There are parallels between symptoms of iNPH and Parkinson disease (PD), suggesting that similar interventions may be beneficial. An approach that promotes recalibration of movements to produce bigger motions (Lee Silverman Voice Treatment BIG [LSVT BIG]) is an evidence-based intervention for individuals with PD, which could potentially improve function in individuals with iNPH. This case report documents functional outcomes of LSVT BIG in an individual with iNPH. CASE DESCRIPTION: The participant was a 62-year-old man with a 16-year history of iNPH. He demonstrated hypokinesia, impaired balance, and cognitive deficits. These resulted in frequent falls and limited community ambulation. INTERVENTION: The participant completed the standardized 4-week LSVT BIG program in addition to 5 tune-up sessions 7 months later. Outcome measures included the Berg Balance Scale (BBS), Timed Up and Go (TUG), TUG cognitive and manual, Activities-Specific Balance and Confidence (ABC) scale, Five Times Sit to Stand (5TSTS) test, and a timed floor transfer. OUTCOMES: Improvements, exceeding minimal detectable change values, were noted on the BBS and the ABC scale immediately following intervention. Scores declined at 4-month follow-up, but BBS scores increased again after the tune-up sessions. Quicker floor transfer times were also noted. There were no changes in TUG, TUG cognitive and manual, or 5TSTS times. DISCUSSION: Therapists may wish to consider the use of the LSVT BIG program in persons with iNPH; however, a longer program and/or regular tune-up sessions may be necessary for best outcomes.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A315).

Home physical exercise program: analysis of the impact on the clinical evolution of patients with normal pressure hydrocephalus / Programa de exercícios físicos domiciliares: análise do impacto na evolução clínica de pacientes com hidrocefalia de pressão normal

ABSTRACT Objective: To present a program of home physical exercises for patients with normal pressure hydrocephalus (NPH) and to evaluate adherence, acceptance and applicability; to verify possible changes in patients with NPH in the home physical exercise program, comparing patients with, and without, a ventriculoperitoneal shunt, regarding gait, quality of life, activities of daily living, static and dynamic balance and its impact on the risks of falling. Methods: This was a controlled clinical trial, with assessments in three moments (0, 10 and 18 weeks) at the home, from October 2015 to November 2017. Fifty-two patients (30 women and 22 men) participated in the study. Results: There was a statistically significant improvement with 10 weeks of home physical exercises for the groups with and without ventriculoperitoneal shunt, respectively, in the sub-items: activities of daily living p = 0.032*, p = 0.003*; static balance p < 0.001*, p < 0.001*; functional capacity p < 0.001*, p = 0.027*; and dynamic balance and gait p = 0.009*, p < 0.001*. There was no statistically significant difference for the subitems: quality of life p = 0.695, p = 1.000; and NPH grading scale p = 0.695, p = 1.000, respectively. Conclusion: The developed program of home physical exercise was easily applied and there was good acceptance by most patients with NPH included in the research. There was a statistically significant improvement with the 10 weeks of home physical exercises in the sub-items: activities of daily living, static balance and functional capacity, for both groups. In the sub-item dynamic balance and gait, there was a statistically significant improvement for both groups, but with a higher score for the group with a ventriculoperitoneal shunt. There was no statistically significant difference for the sub-items: quality of life, NPH grading scale and risk of falls, based on the Berg scale.

RESUMO Objetivo: Apresentar um programa de exercícios físicos domiciliares para pacientes com hidrocefalia de pressão normal e avaliar a adesão, aceitação e sua aplicabilidade; verificar possíveis alterações nos pacientes com HPN com o programa de exercícios físicos domiciliares, comparando os pacientes com e sem derivação ventriculoperitoneal, no que diz respeito à marcha, qualidade de vida, atividades de vida diária, equilíbrio estático e dinâmico e sua repercussão nos riscos de queda. Métodos: Trata-se de um Ensaio clínico controlado, com avaliações em três momentos (0.10 e 18 semanas) em nível domiciliar, no período de outubro/2015 a novembro/2017 Participaram do estudo 52 pacientes (30 mulheres e 22 homens). Resultados: Houve melhora estatisticamente significante com as dez semanas de exercícios físicos domiciliares para os grupos sem e com derivação ventriculoperitoneal respectivamente, nos subitens: atividades de vida diária p = 0,032* p = 0.003*, equilíbrio estático p < 0.001*, p < 0.001*; capacidade funcional p < 0.001*, p = 0,027*; equilíbrio dinâmico e marcha p = 0.009*, p < 0.001*. Não houve diferença estatística significante para os subitens: qualidade de vida p = 0,695, p = 1,000 e escala de graduação de HPN p = 0,695, p = 1,000. Conclusão: O programa de exercícios físicos domiciliares desenvolvido mostrou-se de fácil aplicabilidade e houve boa aceitação para a maioria dos pacientes com Hidrocefalia de Pressão Normal inseridos na pesquisa. Houve melhora estatisticamente significante com as dez semanas de exercícios físicos domiciliares nos subitens: atividades de vida diária, equilíbrio estático e capacidade funcional para ambos os grupos. No subitem equilíbrio dinâmico e marcha houve melhora estatisticamente significante para ambos os grupos, mas com escore maior para o grupo com derivação ventriculoperitoneal. Não houve diferença estatisticamente significante para os subitens: qualidade de vida, escala de graduação de Hidrocefalia de Pressão Normal e risco de quedas baseado na escala de Berg.

Home physical exercise program: analysis of the impact on the clinical evolution of patients with normal pressure hydrocephalus.

OBJECTIVE: To present a program of home physical exercises for patients with normal pressure hydrocephalus (NPH) and to evaluate adherence, acceptance and applicability; to verify possible changes in patients with NPH in the home physical exercise program, comparing patients with, and without, a ventriculoperitoneal shunt, regarding gait, quality of life, activities of daily living, static and dynamic balance and its impact on the risks of falling. METHODS: This was a controlled clinical trial, with assessments in three moments (0, 10 and 18 weeks) at the home, from October 2015 to November 2017. Fifty-two patients (30 women and 22 men) participated in the study. RESULTS: There was a statistically significant improvement with 10 weeks of home physical exercises for the groups with and without ventriculoperitoneal shunt, respectively, in the sub-items: activities of daily living p = 0.032*, p = 0.003*; static balance p < 0.001*, p < 0.001*; functional capacity p < 0.001*, p = 0.027*; and dynamic balance and gait p = 0.009*, p < 0.001*. There was no statistically significant difference for the subitems: quality of life p = 0.695, p = 1.000; and NPH grading scale p = 0.695, p = 1.000, respectively. CONCLUSION: The developed program of home physical exercise was easily applied and there was good acceptance by most patients with NPH included in the research. There was a statistically significant improvement with the 10 weeks of home physical exercises in the sub-items: activities of daily living, static balance and functional capacity, for both groups. In the sub-item dynamic balance and gait, there was a statistically significant improvement for both groups, but with a higher score for the group with a ventriculoperitoneal shunt. There was no statistically significant difference for the sub-items: quality of life, NPH grading scale and risk of falls, based on the Berg scale.

Exercise-induced changes of cerebrospinal fluid vascular endothelial growth factor in adult chronic hydrocephalus patients.

Vascular endothelial growth factor (VEGF) is a growth factor demonstrated to be a key factor in cerebral angiogenesis and neurogenesis. It has been considered a critical component in hippocampus neurogenesis and memory formation and has been observed to increase in the rat hippocampus after exercise. We previously found increased VEGF levels in experimental chronic hydrocephalus in several brain areas and cerebrospinal fluid (CSF), suggesting a role in the adaption to chronic hypoxia. Here we investigate the ability of moderate exercise to increase CSF-VEGF levels in adult chronic hydrocephalus patients. Lumbar CSF samples were collected from 17 normal pressure hydrocephalus patients. During CSF collection, 11 patients (exercise group) underwent a standard in-room occupational therapy session; six patients (no-exercise group) did not undergo a physical therapy session. CSF-VEGF levels were evaluated for increase related to exercise and the clinical response to CSF drainage. CSF-VEGF levels in the exercise group demonstrated significant increases 1-3 hours post-exercise compared with the levels 1-2 hours pre-exercise (p=0.04), and also showed significantly higher levels than the no-exercise groups (p=0.03). The post-exercise CSF-VEGF level in the group that did not clinically improve was significantly higher than both their own pre-exercise level (p=0.02) and that seen in the clinically improving group (p=0.05) after exercise. We conclude that CSF-VEGF levels can increase after moderate exercise even in elderly hydrocephalus patients. This suggests that a potential benefit of exercise, especially in CSF drainage non-improved patients, may exist via a central VEGF mechanism.

Instrumented gait analysis for an objective pre-/postassessment of tap test in normal pressure hydrocephalus.

OBJECTIVE: To present an objective method to evaluate gait improvements after a tap test in idiopathic normal pressure hydrocephalus (INPH). DESIGN: Retrospective analysis of gait data. SETTING: Public tertiary care center, day hospital. The gait analysis was performed before and 2 to 4 hours after the tap test. PARTICIPANTS: Participants included patients with INPH (n=60) and age- and sex-matched controls (n=50; used to obtain reference intervals). From an initial referred sample of 79 patients (N=79), we excluded those unable to walk without walking aids (n=9) and those with incomplete (pre-/posttap test) gait data (n=10). Thirteen out of 60 patients were shunted and then reappraised after 6 months. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mahalanobis distance from controls, before and after the tap test. Eleven gait parameters were combined in a single quantitative score. Walking velocity was also evaluated because it is frequently used in tap test assessment. RESULTS: Patients were classified into 2 groups: tap test responders (n=22, 9 of them were shunted) and not suitable for shunt (n=38, 4 of them were shunted). In the tap test responders group, 9 out of 9 patients improved after shunt. In the not suitable for shunt group, 3 out of 4 patients did not improve. Gait velocity increased after the tap test in 53% of responders and in 37% of patients not suitable for shunt. CONCLUSIONS: The new method is applicable to clinical practice and allows for selecting tap test responders in an objective way, quantifying the improvements. Our results suggest that gait velocity alone is not sufficient to reliably assess tap test effects.

[Management of secondary normal pressure hydrocephalus and assessment of cortical reorganization using fMRI].

We assessed the motor recovery and cortical reorganization associated with intracranial pressure (ICP) control in a secondary normal pressure hydrocephalus (sNPH) patient. A 32-year-old man with sNPH resulting from a head injury presented with left hemiplegia. A ventricular-peritoneum shunt (VP shunt) was surgically inserted for the sNPH using a Codman Hakim Programmable Valve, and his ICP was controlled according to the ventricular size by CT scanning. The motor function of the patient was evaluated by functional MRI (fMRI) during ICP control in our hospital. The fMRI was performed at 3.0 T with timed dorsal flexion-extension movement of the foot. After 3 months of shunt valve pressure control, the primary sensorimotor cortex (SM1) was activated during the affected (left) foot movement, an area that had not been able to be activated just after admission. His walking ability also recovered markedly to the point of free independent walking. The motor function of the affected lower extremity appeared to recover to almost the some degree the original motor area after control of the ICP. This finding may reflect functional reorganization of the motor pathway following ICP normalization.

Rehabilitation combined with ventriculoperitoneal shunt for patients with chronic normal pressure hydrocephalus due to aneurysm subarachnoid haemorrhage: a preliminary study.

OBJECTIVE: The aim of this study was to compare activities of daily living and cognitive function after 6 months' rehabilitation training with or without ventriculoperitoneal shunt in patients with chronic normal pressure hydrocephalus following aneurysm subarachnoid haemorrhage. PATIENTS AND METHODS: Thirty-nine subjects diagnosed with chronic normal pressure hydrocephalus following aneurysm subarachnoid haemorrhage, based on clinical deterioration or non-improvement of gait ataxia, cognitive disturbance, and/or urinary incontinence during rehabilitation, were included in the study. A treatment group (n = 24) underwent ventriculoperitoneal shunt operation, and a control group (n = 15) did not undergo the operation. RESULTS: Following the operation there was a significant difference in Barthel Index scores between treatment and control groups at 1 month (p<0.01) and 6 month follow-ups (p<0.01) in the treatment group. CONCLUSION: Rehabilitation alone did not result in improvements in patients with chronic normal pressure hydrocephalus, but rehabilitation combined with ventriculoperitoneal shunt resulted in improvements in activities of daily living and cognitive function. The importance of early diagnosis of chronic normal pressure hydrocephalus is stressed.

Rehabilitation of patients with chronic normal-pressure hydrocephalus after aneurysmal subarachnoid hemorrhage benefits from ventriculoperitoneal shunt.

UNLABELLED: This study compares the effect and rehabilitation prognosis of 6-month combined ventriculoperitoneal shunt (VPS) versus rehabilitation training alone in chronic normal-pressure hydrocephalus patients. METHOD: After suffering from aneurysmal subarachnoid hemorrhage, 39 subjects were diagnosed with chronic normal-pressure hydrocephalus because of clinical deterioration or nonimprovement of gait ataxia, cognitive disturbance, and/or urinary incontinence during rehabilitation. Twenty-four subjects underwent ventriculoperitoneal shunt (VPS) placement, while 15 subjects did not undergo the procedure. RESULTS: Statistically significant increases in the Barthel Index (BI) were observed between the treatment and control groups 1 month (p < .05) and 6 months (p < .01) after VPS placement. Similar changes also were observed for the Mini-Mental State Examination (MMSE) at the 1-month (p < .01) and 6-month follow-up visits (p < .01). Significant differences in the change in MMSE and BI at admission, before VPS placement, and at 1 month and 6 months after VPS placement in the treatment group were demonstrated (p < .01). CONCLUSION: Chronic normal-pressure hydrocephalus after aneurysmal subarachnoid hemorrhage is an important issue to which clinicians should pay attention. It negatively influences the functional and behavioral outcome of rehabilitation but can be treated.

Sensitivity and predictive value of occupational and physical therapy assessments in the functional evaluation of patients with suspected normal pressure hydrocephalus.

OBJECTIVE: To examine effectiveness of standardized occupational therapy and physical therapy assessments in detecting functional changes and predicting clinical improvement in patients with suspected normal pressure hydrocephalus undergoing cerebrospinal fluid drainage. DESIGN: Cohort study. PATIENTS: Eighty-seven patients admitted to an inpatient neurology unit for elective cerebrospinal fluid drainage for suspected normal pressure hydrocephalus. METHODS: Before and after a protocol of continuous cerebrospinal fluid drainage via spinal catheter, patients were administered the Functional Independence Measure (FIMTM), Timed Up and Go (TUG), Tinetti Assessment Tool of Gait and Balance, 9-hole peg test, and Cognitive Assessment of Minnesota (CAM). Following cerebrospinal fluid drainage, changes in functional performance were compared for responders to cerebrospinal fluid drainage and non-responders to cerebrospinal fluid drainage. RESULTS: At baseline, CAM was more sensitive than the Mini Mental State Exam in predicting responders. Post-drainage: responders improved on 52% of tests while non-responders improved on only 11%. Assessments that differentiated magnitude of improvement in responders vs non-responders were: TUG (p<0.05), Tinetti total (p<0.001), Tinetti balance (p<0.001), Tinetti gait (p<0.001), FIM toilet transfer (p<0.001), and FIM lower body dressing (p<0.001). CONCLUSION: Specific occupational therapy and physical therapy assessments demonstrate sensitivity to change and predictive value with patients with suspected normal pressure hydrocephalus undergoing cerebrospinal fluid drainage.

Ventriculoperitoneal shunt dysfunction during rehabilitation: prevalence and countermeasures.

OBJECTIVE: We examined the prevalence of shunt dysfunction (e.g., overdraining or underdraining malfunctions) in patients with a ventriculoperitoneal shunt and elucidated effective countermeasures of a programmable valve shunt system in treatments for shunt dysfunction during rehabilitation therapy. SUBJECTS: Among 114 patients with a ventriculoperitoneal shunt for normal pressure hydrocephalus, underdraining appeared in eight patients during hospitalization for rehabilitation therapy, and seven patients experienced overdraining. RESULTS: We could treat underdraining noninvasively for all six patients with a programmable valve shunt system by decreasing the opening pressure, whereas the other two patients with a fixed valve pressure system required surgical replacement of the valve unit. We could also treat overdraining noninvasively in two cases with programmable valve shunt system by increasing the opening pressure. In two cases with fixed valve pressure system, however, chronic subdural hematomas had to be surgically treated. Either dysfunction interfered with a better functional outcome in rehabilitation therapy. Barthel index after the countermeasures and continuous rehabilitation therapies was significantly larger than the index before the countermeasures in both overdraining and underdraining groups. CONCLUSIONS: Shunt dysfunction appeared in approximately 13.2% of patients with a ventriculoperitoneal shunt during hospitalization for rehabilitation. The ventriculoperitoneal shunt using programmable valve shunt system was convenient and valuable for treating both overdraining and underdraining malfunctions in the rehabilitation ward.

[Evaluation of shunt therapy in normal pressure hydrocephalus-surgical results in neurological conditions (author's transl)].

This presentation is a study of 18 patients diagnosed as having normal pressure hydrocephalus and treated by CSF diversion procedures. Pre- and postoperative neurological conditions of these patients were evaluated, compared, and analysed. There were 56% of males and 44% of females and the number of patients under 60 and over 61 were equal. The histories and clinical findings in all suggested a diagnosis of normal pressure hydrocephalus. In 12, the two thirds of patients, showed progressive intellectual deterioration, ataxic gait and/or incontinence following subarachnoid hemorrhage. Similar neurological features were preceded by craniocerebral trauma in one, megadolichobasilar artery in one and superior sagittal sinus thrombosis in one. Three cases were idiopathic. 169Yb cisternography, transfer test of radioisotope to blood, angiography and in some cases pneumoencephalography were performed in the usual manner to confirm the diagnosis. Attempts have been made to correlate the surgical results with the ages of patients, the duration of symtoms, and the causes of hydrocephalus. Neurological symptoms were divided into three groups. Group "A" is composed of mental deterioration, lack of spontaneity and willingness, mutism and disorientation, groups "B" includes gait disturbance and group "C" incontinence. The results of surgical treatment were analyzed according to the three groups of symptoms not only in the percentage of cases who improved but also in the time interval from the time of shunting to the appearance of operative results. The results are as follows. The good surgical improvements were achieved in the cases of under 70 years old, in the case of NPH of known causes, such as subarachnoid hemorrhage, craniocerebral trauma, and in the cases operated on within three months after the onset of symptoms. Recovery of "A" symtoms was achieved not only sooner after the operation but also in more cases than those of "B" and "C" symptoms. The correlation was analyzed between the duration or symptoms and time interval after the shunting and the appearance of operative results. Although no correlation was obtained in "A" symptoms, the sooner was shunting performed, the earlier appeared the operative results in "B" and "C" symptoms. In conclusion, it appeared from the results of the present study, that in addition to the integration of the results of different examinations such as isotope cisternography, air study and angiography, the combination of the patient data such as ages, duration of symptoms and the cause of hydrocephalus are essential in selecting the patients for shunting operation. If the diagnosis of normal pressure hydrocephalus is confirmed and surgical improvement is predicted, the patient should be shunted as soon as possible to obtain a good surgical results especially in mental symptoms, which is the important factor in performing rehabilitation therapy.