Recovering and Maintaining Functionality

Symptom improvement after shunt surgery to treat normal pressure hydrocephalus (NPH) is impacted by a number of variables. It’s estimated that more than 80% of those properly diagnosed with NPH and screened for shunt responsiveness will experience rapid improvement in their condition, although it may take weeks or months to see the full benefits of the procedure. After surgery, physical therapy, occupational therapy, and other rehabilitation strategies may be advised to help you or your loved one attain as much resolution of symptoms as possible. Some healthcare professionals prescribe inpatient therapy immediately after surgery; others prescribe one or more therapies on an outpatient basis. You should talk with your neurosurgeon about his or her particular protocols following surgery. Listed below are the different healthcare professionals you’ll interact with as well as therapies and precautions frequently used.

Therapies

Physiatrist, who is a doctor specializing in physical medicine and rehabilitation, can perform functional assessment including an individual’s gait and cognitive status as well as a general medical examination before and after surgery, and make a decision whether multidisciplinary/interdisciplinary inpatient rehabilitation or outpatient rehabilitation is indicated postoperatively. If it is noted that someone will be a candidate for acute inpatient rehabilitation, the physiatrist continues to observe medical status throughout inpatient stay, since certain pre-existing medical conditions may affect exercise tolerance and progressive gait training. After surgery, some individuals may develop acute neurologic changes during inpatient rehab stay, and the physiatrist with the assistance of multidisciplinary rehabilitation members identify acute changes and communicates with their neurosurgeon immediately. If outpatient rehabilitation is considered to be appropriate after surgery, it is advisable for having a physiatrist to order appropriate rehab therapies and follow progress rather than asking a neurosurgeon or a neurologist to prescribe rehabilitation therapies. In rehabilitation, interdisciplinary communication is of paramount importance, and the physiatrist leads and coordinates the rehabilitation team, and communicates with the person with NPH, their family, neurologist, neurosurgeon, and, if necessary, other medical specialists, in order for the person to undergo rehabilitation smooth with the achievement of anticipated functional outcomes.

Physical Therapy (PT) is the most common form of therapy following shunt or ETV surgery. PT is used to help individuals recover their ability to stand and walk. Individuals with NPH should make sure they are scheduled with a therapist who treats neurological disorders as opposed to being scheduled with a therapist who only treats orthopedic issues. Physical therapy will assist the person in regaining their strength, balance reactions, endurance, and restore their walking to a more normal walking pattern. Clients need to be educated about the importance of following through on their home program and understand that the treatment method is managing the NPH not restoring their ability to function – it takes hard work and follow through to maximize the benefit of undergoing the surgery to treat NPH. Therapists will assess the individual’s needs and design a program that will assist them in achieving their mobility goals.

Many PT facilities have specialized equipment to help patients safely regain their ability to walk. For instance, the AlterG treadmill uses NASA technology and biofeedback to retrain you; the ZeroG harness is another tool.

Attention should be given to identifying those situations that lead to balance and walking problems so those scenarios can be addressed specifically. One that is common to individuals with NPH is walking downhill. Most therapists give their patients maintenance exercises to continue after formal PT has ended. Incorporating these into a daily exercise routine is important.

Occupational Therapy (OT) may be prescribed to help individuals with NPH with everyday activities like getting dressed, taking medications, and preparing meals; frequently the goal of OT is to enable the patient to live independently. Occupational therapists also are able to assist with memory strategies as well as cognitive activity.

Cognitive Therapy may be prescribed to help patients who have experienced cognitive impairment. For example, for memory loss, trouble with multitasking, or executive functions. Cognitive therapy combines exercises done during office visits with homework assignments to increase short-term memory, attention, and decision-making skills. Homework can include web- or phone-based brain exercises. Discussion of compensating strategies and tools is also included.

Neuropsychological Therapy may be prescribed to help patients deal with the emotional issues that NPH causes. The NPH population experiences three times the normal rate of anxiety and depression; neuropsychologists are trained to help NPH patients deal with these conditions.

Typically, a prescription is needed to initiate any of these therapies. Your neurosurgeon, physiatrist, or primary care physician can be consulted for both the therapy prescription and to help you find local providers. Frequently the first appointment includes an assessment of the patient’s current impairments with an estimate given on the frequency and duration of the therapy needed.

Awareness and Prevention

Some individuals expect that once they are recovered from surgery they will be completely back to “normal” and they may suffer new injuries if preventative measures are not taken or continued. These preventative measures can include:

• Fall-proofing the home: removing throw rugs, installing night-lights, and grab bars particularly in the bath.
• Assessing driving readiness: depth perception and coordination may be impaired as may the ability to multitask that is required to drive.
• Assessing the ability to swim: many individuals with NPH who were strong swimmers have shared that they lost the ability to swim after shunt surgery. It is important to check for this possibility in a safe setting.
• Taking extra care when turning or changing head levels: many of us think nothing of putting an object on the floor and then straightening up quickly and going about our business. Some individuals have shared this kind of movement can cause dizziness and even falls severe enough to break bones.
• Regular exercise is very beneficial: the elliptical machine at the gym offers stability for exercisers with balance issues; walking is wonderful but may be very difficult at first. Walk with a sturdy cane and/or friend.

Assistive tools and techniques:

• Handicapped parking placards/licenses – ask your neurosurgeon for approval
• Canes (especially the footed kind that can stand on its own)
• Walkers
• Shopping Carts (so helpful for maintaining balance at the store)
• Nightlights (especially between bed and bath)
• Grab Bars
• Reminders: in email calendar or on the phone
• GPS

Information you can trust! This article has been written by HA volunteer, Trish Bogucki. We would like to thank the following individuals for their valuable contributions and expert input: James B. Golomb, MD, Jung H. Ahn, MD, and Sharon Hayden, PT.