0:06

Good afternoon, and Welcome to our first am Awareness Week webinar. Thank you for joining us today. We're excited to welcome Ben Vasquez who is going to present acoustic neuroma and your balance the role of vestibular therapy in your treatment. I'm Melissa Baumbick manager of Outreach and development for the acoustic neuroma Association, and I'll be your moderator today just a couple of quick notes before we get started. Everyone is in listen-only mode. So if you have questions, you can type them into the questions box on your dash.0:35

Or and we'll spend about 20 or 30 minutes at the end of the presentation getting to as many as we can. If you're having any trouble with your audio using your computer speakers, you can certainly call in using the phone number and access code on your control panel. We are recording this webinar and it should be available on the website in the next day or two. We're also sending out it out to have captions added but that takes about a week all of this week's webinars all of our an awareness week webinars and Facebook live.1:05

Eggs can be found on our Awareness Week landing page, which is at a and a usa.org backslash awareness since today is the first day. There's no not there yet, but they will be up there in the next day or two. I want to thank all of our annual sponsors who spawned help Advance acoustic neuroma education and support as well as increase awareness, and then I'd like to give a special. Thank you to our presenting sponsor UC San Diego health and now I'd like to introduce our speaker.1:35

Benjamin Vasquez is a board-certified physical therapist who specializes in neurology. He treats people with neurologic dysfunction and individuals with acoustic neuroma. Dr. Vasquez completed his residency in neurology at Northern Arizona University in Flagstaff and earned a doctorate in physical therapy from Loma Linda University. He holds a neurology specialist certification from the American Board of the school therapy specialty. It is now my pleasure to get started and turn the webinar.2:04

over 2 And so let me get your presentation up and we will.2:17

word from there Okay.2:25

Awesome. You see that? Yeah, I could see a perfect. Great. Okay. All right. Well, hello everyone. I'm excited to be here presenting the you guys from UC San Diego campus here. Just appreciate the introduction Melissa. Just I'm a physical therapist here at UCSD and I see many individuals for preoperative assessments. 2:53

I see them during the All after they've had surgery and I see individuals post-op once they are discharged from the hospital and are ready to go home. So I see a lot of individuals here for and after surgeries and I'm here to talk to you a little bit about physical therapy and the role that it plays with acoustic.3:15

Neuroma, not just with individuals having surgery, but for those doing watching the weight and also radiation treatments and you can head to the next slide.3:30

And then there's a few objectives are you can just kind of Click through them as a bullet point show up just some objectives. It's and things will go over some common deficits and how they are dressed by therapy quick explanation of the anatomy and vestibular system function some current research that's out there after after surgery and kind of what to expect and then some tips on finding an outpatient.3:59

Physical therapist with knowledge of the vestibular system and somebody can help you out with any dizziness or balance issues you'd be having.4:15

Alright, so some common deficits that would be more in the realm of dizziness and balance Saudis associated with acoustic neuroma or vertigo dizziness impaired gaze stabilization will tal explain that a little bit and just general balance issues excessive retinal slip with head and eye movement causing a feeling of being off.4:40

So I've had so many people describe to me their symptoms and so many Ways and I've learned so many new additives is wonkiness and I just feel off or I don't feel dizzy people keep saying I'm dizzy, but I don't feel dizzy and so many different ways people experience these symptoms, but oftentimes they're caused from people not being able to focus on an object is they're up and moving around and that's the ability to have that focus is gay State stabilization.5:14

And and then if you are having issues with your eyes focusing while you're moving they call that retinol slip so this can happen before a surgery like even just watching weight. It can start to happen after irradiation. It can happen pretty much indefinitely after surgery. It can happen pretty much anywhere on the on the timeline of having an acoustic. Neuroma.5:42

And I think there's a couple more bullets on there. And then that last bullet just says due to the unique nature of each tumor and everyone's Anatomy people experience it different ways and I'm only talking about dizziness and balance things not even in regards to like hearing things or tinnitus or things are any kind of facial numbness or headaches? It's just such a wide variety because everyone is so different.6:12

And all everyone's tumors are so different.6:15

And we can go ahead and go to that first Anatomy slide there.6:21

So just a real quick bit on the anatomy here so that cranial nerve seven.6:28

The facial nerve is labeled in two different places because it kind of goes through and and hooks down there and that muscle are them sorry that nerve controls the muscles of your face and your facial expression and it also has a role in some taste actually right where that Label for the internal auditory canal is that's actually pointing to the the stock of cranial nerve 8 there. So as it says the whole vestibulocochlear nerve before it splits then splits into a Cochlear branch, which is labeled cochlear nerve there. Then goes to the cochlea which plays a role in your hearing.7:14

There's also a split into the the vestibular branch, which is labeled vestibular nerve and then that Vestibular nerve then splits into a superior and inferior branches. So like a higher one and a lower one. And those are responsible for feeling different ways. Your head might be moving and telling your brain and the rest of your body that your head is moving and we can go to the next slide there that shows a neuroma so that space that the tumor is sitting in is such a small space.7:50

at cerebellopontine angle and everyone's Anatomy is so different but normally something that's a matter of one two, three, four centimeters wouldn't be causing as much problems, but it's in this really sensitive spot next to all these cranial nerves and it has the ability to cause a lot of

issues and a lot of symptoms because it's in this spot another nerve that shown on this slide is actually the trigeminal nerve which also plays a role in taste but primarily is is Sensation for your face on that side so individuals that might be having like facial numbness tingling that sort of thing and then the cochlear nerves their facial nerves there and you can show how they can you can see how they're impacted by the tumor and then the one you can't see is that actually that vestibular nerve because it's pretty much engulfed in the tumor the nature of the tumor is it is out of the nerve sheath is extra nerve cells there go to the next slide here.8:57

And then there's a couple bullets that will show up there.9:00

So this you have three major systems for your balance. You have your vision everything you see you have your somatosensation so things that you feel and your hands and feet and then you have your vestibular system, all of these things get put together and organized in your cerebellum the back part of your brain, which is responsible for coordination and it makes up your balance in that little diagram there.9:30

It says proprioception, which is a little bit more specific that Actually more joint position sense, but it's part of the that somatosensation and your body as in a well-oiled machine and it's working everything's working the way it's supposed to is all of these things are taking in input telling your brain what's going on and your brain is having the output to make certain adjustments be it with your eyes be it with your balance be with your muscles. And then if it is a well working as a well-oiled machine, then you wouldn't be dizzy.10:03

If there is an issue with one of these systems, like if you have an acoustic neuroma, then that vestibular system gets impaired and then there's becomes like a disagreement of what's happening or not happening.10:17

So the vision may still work in the somatosensation may still work but this tubular systems giving like faulty or skewed information and that error signal kind of makes makes a dizziness and makes for having somebody feel not not very good or not, very And then I think there might be another. Yeah, so yeah, it gets organized by the cerebellum. We get a next slide there.10:47

And then there's a bunch of bullets on this one. So which brings me to my next point about the vestibulo-ocular reflex. So if you're talking about acoustic neuromas and dizziness, this guy is

kind of like the star of the show and this is what I spend a good portion of my week dealing with so the VOR we call it for short is what stabilizes your gaze. So as you're up and around and moving up and down and turning your head. It's telling your eyes.11:17

Hey, you need to adjust for these head movements so that you can track images appropriately and things aren't getting out of focus and you're not feeling dizzy.11:28

If there is an impairment with the VOR you have like I mentioned earlier that retinol slip so that means that the eyes are adjusting but it takes them some time and then while people are moving their head, they're having like a feeling of like whoa, like I feel so dizzy because it's taking them a second or two to to have their eyes catch up essentially and that's the mechanism of feeling dizzy or wonky or offer.11:58

Other people are describing their symptoms. It's a deficit in this VOR.12:06

And one of the things I think there's one more bullet here. One of the things I love about the VOR as it's a super rehab bubble reflex.12:18

So be it watching wait be it gamma knife, especially especially post-op this reflux can heal and I can improve and it can utilize and There are things and to make you not as dizzy anymore or not dizzy.12:42

I can go to the next slide here. So this is a this is kind of a technical slide. I'll kind of briefly go over it. Basically what it's showing here is this person's head is rotating to the left. So they're they're having a left head turn and the muscles the two muscles on the right side of this person's eyes are letting their eyes go, right. So if you all at home look straight ahead and you turn your head to the left and the whole time you're turning your head.13:11

You keep your Eyes focused straight ahead.13:14

You're using your VOR.13:16

So the to like seashell kind of looking things at the bottom of the screen are your inner ear picking up that sense that you're moving the your head is moving and it's telling your eyes that they need to move equally and opposite in the other way so that you can still focus on whatever you're focusing on and if anywhere on that chain something gets affected it presents is you feeling Feeling dizzy essentially are even if it's just for a second or two go to the next slide here.13:54

So what is my job do how does physical therapy help so we focus on treating the deficits rather than the the tumor itself? So well, that means everybody's rehab is is different essentially. So there are some common things and we do see quite a few individuals with neuromas here at UCSD.14:19

So we've seen the common things and we've been able to compare Rules and we have these tools that we can use to treat these symptoms.14:29

Especially dizziness is primarily dizziness and balance is primarily but symptoms that I'm treating in my clinic and essentially after so a neuroma knocks out one side service to Bueller function. So if you have the worst thing I can do the Stabler wise is make your nerve not function on that side. Even if you're in that worst-case scenario, you have the other side your other vestibular nerve on the other side of your head, which is working fine. You have your eyes working for you and then you have your somatosensation working for you.15:09

So Vestibular rehab uses your all of your other intact systems to kind of compensate and to make you in the end of things not feel as dizzy. So it's kind of like you have a new set up now and it's and you have to break it in and you have to learn it and you have to train it so that you're not having that retinol slip in that feeling dizzy. So it's essentially like a new Anatomy that you have especially if you have something as acute as like a removal surgery.15:43

Go to the next slide here.15:48

And so a lot of people have had physical therapy for other things, maybe some shoulder pain or knee replacement or something like that. So they're kind of curious on what the therapy consists of and what how long is it take and how it when are they going to be done with it?16:08

So it's a very homework based rehab so it's tends to be different than a lot of those Orthopedic issues that you would Treat and nobody's really putting their hands on you or doing anything to you. Physically.16:23

It's just really a program that's customized to you too that you will progress yourself through and the therapist will give you newer difficult more difficult exercises and upgrade your program until you're not really feeling dizzy in your regular life. It's essentially a way of building your threshold for getting dizzy so high that normal things and moving around and all of your hobbies and sports and exercise and things are not making you dizzy.16:52

So it's training yourself to get to that high of a level and everyone is so different and everyone's tumors are so Print that it's so hard to put a timeline on it. But I have people ask me that question because people have lives and people have jobs and they need to plan for these things.17:12

So in my experience like it to make a full recovery, and this is just a Nick meet anecdotally speaking I'd say about three to six months so it starts off your Going from kind of Ground Zero as I call it where you're even just walking down a hallway is very challenging to like about a couple weeks out where you're able to walk safely enough and nobody has to like hold on to you or anything like that. And then and you're going along the progression there, but you're still not normal by any means they're still having these symptoms when I say like 6 months. I'm talking about being back to of your back to functioning normally.17:55

Like to not having these issues that you're having to deal with daily. Like I said everyone's different and that's kind of an umbrella statement. I just that's a common question I get so I wanted to address that and then that bottom line says doing the home exercises at ski, so all of these timelines and things that I'm talking about for Recovery only apply to those who are really doing what they're supposed to be doing.18:19

There are people that have not done any exercises are not done any therapy and Rehab totally fine and I told me hey Ben. I'm doing your stuff and I'm feeling great and great idea how much that's so good for those people. I just with my own patients. I don't like to take that chance and I want to really make sure people heal is completely in it and quickly as possible as they can. So it's again, it's not one where you would have to come three times a week or anything like that. I

even see my locals about once every other week as long as I trust them that they're doing their thing. They're exercises.18:55

Every single day so they can kind of get this over with and get to where they need to be go to the next slide there.19:04

So it's kind of a wordy slide a lot of it as the same. So I'll kind of talk you through what what kind of what is this therapy even look like like what kind of the exercises are they? So VOR exercises. I'll start with the watching weight column. So if somebody is having dizziness from a tumor, they're not sure if they want to get treatment for it, or maybe they don't need to get treatment for it, but they want to not be dizzy anymore. They want to do therapy to treat.19:34

Those issues VOR exercises are pretty much where we are pretty much for everybody. The this is like the main the meat and potatoes of the rehab and what they are is essentially testing your VOR and building it up like you would build up any other muscle or or reflex like or anything like that.19:56

So so it's essentially moving your head in different directions while keeping your eyes focusing on nothing. So this starts off as simple as having x on a Post-It note and putting it in front of you and turning your head side to side and keeping your focus there and then it gets more complicated as you get better. So we make it harder to build your threshold higher and higher or using metronomes to integrate speed and make it faster because fast head movements make you more crazy than slow head movements to so it's a whole progression since Riri.20:34

Waiting exercises are exercises that are very systematically weighing in and weighing out you're different you're different systems between the vision vestibular and sensation. So there's a lot of things like with your eyes closed so that you can't use your eyes so much to balance usually people's eyes. They they often complain of ocular fatigue or I tiredness or headaches or something like that.21:04

After staring at screens things like that, you're often times people's eyes are trying to do so so much way more than they should normally have to do so on top of seeing and reading and focusing on things that they're having to basically give you that input for your balance, which is like them working overtime. So you want to Hype up your other systems so that they don't have

to do that. You can give them a somewhat of a break so they can just do I work and not balance work as much.21:34

You feel in the end of it feel feel better and feel more balanced and not as dizzy General balance and coordination exercises lower extremity strengthening exercises. So we can do VOR exercises and all these things until we're blue in the face. But if you especially for some of my senior citizen patients, if you are don't have the muscular capacity or the strength to like step with your legs and correct your balance and that becomes an issue as well. So yeah.22:05

Hip and hip and lower extremity exercises can be pretty helpful. The last bullet there I have is Task specific or designer exercises. So a lot of times people say I do this thing.22:18

I like to I play tennis and I look up and when I serve and that makes me dizzy every time so then we're designing exercises and we're simulating things in the clinic to that you can take home and practice so it's Working on what you having issues with directly but also in a safe controlled environment and something that will put you in control and get you back to being able to do those things and practice them so that you're ready to do those things. So all the bullets under the radiation or or gamma knife column. There are all the same except for one other one.23:00

So facial rehab is not my specialty, but we do have Right here at UCSD. We have therapists that specialize more in that but if there's any kind of facial weakness, we can employ that more after the tumor is radiated. It's it tends to be harder to rehab the face. If you're watching wait in the tumor still there pressing on the on the nerve that tends to be a harder rehab process some sometimes it's different.23:27

Some people have recovery and ends up being more like a like a Bell's Palsy situation, but definitely after radiation or surgery and then the last column there is more my specialties is post-surgery so We're in the neuro ICU the day after surgery and we're ambulating people. We don't use Walker's or canes or anything like that. We get people up and we put a gait belt around that or their waste to keep them safe and they start walking the first day after surgery and they start their VOR exercises the first day after surgery, you know walking after surgery is so so important so it and what that means is Maybe.24:16

Going like just down the hallway the first day or maybe halfway down the hallway and then somebody's kind of holding on you as you kind of lose your balance and then progressing each day stronger and stronger and more and more able to tolerate more and more and until the point where you're walking around outside.24:38

Here the hospital you're discharged you're doing you're managing your own walking program and you're going to get it in your grading like head-turning and things like that and making it more high level as you start to get better and stronger since reroute re-weighting exercises. Again.24:52

Those are those work very well and then General balance coordination task specific stuff like we talked about and then also also facial rehab so everyone presents different everyone has different Surgery approaches, everyone has different symptomatology afterwards and then we're just essentially customizing these things to to fit what you're having issues with and we can go to the next slide there and then here are some articles and these are all these are all articles based on excision surgery. So it kind of puts everyone on even playing field. So to speak after an excision. I know everyone.25:38

Everyone's unique and it's kind of hard to put people on that playing field. But of that nerve is is essentially taking out on that side. Then you have zero functionality on that side and it kind of it starts everyone similar spot and then with variation on how much they've compensated before surgery.25:59

So the first article by passier and colleagues says after Excision Demonstrated favorable favorable results with posture ography gay stability subjective complaints of disequilibrium oculomotor function and standing balance. So posture ography is a big machine that measures your balance essentially and so they were able to find some objective objective improvements with that gay stability. We talked about that and then subjective complaints that people just explaining how their how they're feeling and how dizzy they are. So they improved in all these categories Susan Hardman and colleagues found.26:37

That the use of adaptation exercises after acoustic neuroma removal results in improved postural stability stability with ambulation and perceived disagree Librium. So adaptation exercises another name for VOR exercises. So they utilize those and people are getting better

because Shard at all found that individuals or physically active prior to excision surgery demonstrated better patterns of postural compensation or balance than those that were sedentary prior to surgery.27:07

A lot of people ask me if they're here for a consult. They say then I'm not dizzy. I have no dizziness. I have my problems are hearing the related or they found my tenure by incidentally. What should I do? Should I do vestibular therapy before my surgery and I tell them no, you don't you don't have to just be a healthy person try and try and be active try and keep your cardio up contouring keep your strength up.27:37

All of those things like General Wellness things are going to help you so much on the back end of surgery. If somebody sedentary in they're not really leaving the house and they have really low endurance. Those are all things that are going to possibly complicate recovery or just make for a little bit longer recovery. So just being in just good Wellness things or will help a ton. I think there's a one or two more bullets there. I guess just one.28:17

So the vereeke are ago that every cat all found that patients aged 50 or older May benefit from an early customized vestibular rehab after surgery.28:29

So This is a good study. But it was also kind of a very crude study. There's only 53 people included and somebody who's 50 is included with somebody who's like 90. So it's a very crude study. I I do this tabular Rehab on pretty much everybody after after the surgery. There's a small minority that end and a lot of them end up being children that I don't put them on put them on a plan.29:00

Because they're doing so so well.29:05

It's not like oh, I'm 49. I don't need this tubular therapy some sometimes people end up being fine without it. I'm I just want P. I don't like to take that chance. So I put everyone on a program until they're feeling normal then they don't have to do it anymore and they're essentially done after that. So that's what that study found.29:25

I think yep, and then it is kind of a unique therapy that not a lot of people know about so I just kind of have some some issues that are really not addressed by physical therapy because I

have some questions about about things and people are maybe asking me if I can help them with this. So tinnitus ringing we don't have anything that we can do to treat that hearing loss or decrease.29:54

During physical therapy's not really going to help with that headache. I say directly there because I mean people have headaches that's like especially after surgery that's pretty normal. And I'm not going to leave people hanging so to speak when I say we can't address it directly.30:13

I mean like we can't dress address it like a medicine where we have something that was going to make it go away, but I'm absolutely putting people on a program where they can Increase their aerobic activity and they can I want them being hydrated as much as they can. I want them to not be dizzy. So they're not having as high of a frequency of having these headaches. So there's things that I can do to indirectly address that or that a physical therapist can do but just not directly like to turn it off like maybe like a medication what that are surgical team is doing more of that that kind of treatment and then I have facial weakness.30:54

For treatment so just kind of how I said before before if you have it in the tumor still there. It's kind of it can be tricky to rehab from that.31:06

Facial Pain or numbness caused by trigeminal nerve issues. We can't really help that with with physical therapy as much that's more pharmacological.31:18

Same with the change in taste.31:22

Anxiety, so that's that's in the realm of like the headache. So I'm not telling people who have anxiety. There's such a high percentage of individuals who are dizzy neuroma or not that also have anxiety and that has caused them to have anxiety some they had it before some are having it now because they're dizzy.31:45

I am absolutely going to help people and talk to them and explain them and educate them exactly what's going on and And tell them about the process and what they need to do to get better and I'm not gonna force them or be. I'll definitely talk to them slowly and be patient with

them like if they have anxiety and then also if you do the exercises and you get better and you're not busy that can help as well.32:16

But I can't address it like a drug would all right. So how do you find a therapist? How do you find a therapist that knows how to do this stuff? So I've got a couple resources here. Luckily, even though neuromas are so so rare as you all know the type of therapy you would get is not as rare.32:40

So there's there are a lot of inner ear conditions that can cause more dizziness and balance type issues that are treated effectively with the same types of exercises and Rehab protocol which is which is nice neuro PT dot org is a website that I very frequently used to find clinics for people so many of you that are familiar with the UC San Diego acoustic neuroma program a lot of our most of our patients fly in and then I will consult them and help them find somebody that is closer to home after they return back home that they can continue on their therapy with so this is my actual favorite website to go and you just go home and special interest groups vestibular rehab and then that'll show you a map and there's not a ton of providers on there because it's only people who have volunteered their names to be on there but it's a it's a good place to start and if you live anywhere near any kind of a major city or even like a somewhat major city, there's often some somewhere. That's that's close.33:46

home in the next slide some of you may be familiar with vita the vestibular disorders Association.33:54

They have a website and they have a tool that if you go to the homepage go to finding help and support find a vestibular specialist and then within that Select Physical Therapist, they have that tool and you can essentially type in a city or an area code or something like that and it'll say like these people are listed and this is how Are they far away they are from your location?34:27

and then I don't have a slide for this but those are both if you use those two together, you'll probably come up with about 5% of total people who have that skill and that special to you that can help you out. The next one is just to Google local therapy places and then just give them a call and say hey, do you guys do vestibular rehab there and they should be able to help you out.34:55

And then what to expect after if you do get the surgery Tamara wall in our physician assistant here is going to give a great talk tomorrow. If you guys have time to tune into that about the symptoms and expectations afterwards, but just very briefly Headache nausea and dizziness. So a lot of times you'll have an incisional headache just from where the incision was you did have surgery there and that's totally normal and it's going to not feel good and it's going to get better with time and you'll have medication.35:24

To deal with it and that in the meantime.35:27

Nausea does not happen with everybody but it's I would say a majority people have nausea acute nausea for a period of time. And again that's addressed with medicines and things like that and then the dizziness and is where we come in. So we are the you actually there's certain dizziness medications that you want to stay away of stay away from and in recovery, like meclizine and things like that that can kind of impede recovery a little bit.35:56

So that's more If he thing that's affecting dizziness and therapy and the ambulation program. So just walking around.36:05

Balance just to give you an idea a lot of times people end up kind of like walking very slowly like almost like a like a very cautious like a like some people would say like a drunken drunken gate kind of on the first few days and then improves from there and then the therapy we kind of we kind of spoke about already.36:27

And then this is a research study that just shows some things that that would complicate a recovery, or at least lengthen it or make it more not so normal. So Central vestibular Sir Bill orders is disorders are like something like a stroke brain stem trauma. If you have constant dizziness, like every second of every day pre-op. ER preoperatively. That's something that would be a complicating Factor.36:57

Visual impairment is more along the lines of not not I wear glasses more along the lines of complete blindness because then you don't have that visual input to help with your balance and then depression and then another one that's not listed on there is if you have neurofibromatosis type 2 and you've already had the others surgery on the other side and you're going in for surgery on the second side, then that can be a tougher recovery as well as well.

37:30

I just got a couple pages of references here. If any of you guys want to look at those research studies. The first few are just the pictures and there's another slide of references.37:43

And then the next slide has my email on it. So if you have any therapy or rehab related questions, I mean, I'm going to I'm going to answer some questions here with you all now, but if you're watching this maybe later, you can absolutely email me anytime. There's my email and I'd love to help you out or answer your questions to the best of my ability.38:07

And then Chris I wake who many of you may I may know who she is is our program coordinator here at UC San Diego and that's her email if you have more general questions about surgery or maybe you want to get a consult or have anything that's maybe not as rehab related, but still about our program here at UCSD. And yeah, that's my that's my presentation.38:37

Well, that's great. That was a lot of really good information. Thank you so much for all of those slides. We do have a lot of questions. So I'll jump right in there if you're ready. Perfect. Yeah, I'm ready. Okay. So one of the things you talked a lot about was was staying active and and you talked a little bit about what we've heard from patients as like prehabilitation, but even with that we had a question about if somebody was to do like weekly or daily.39:06

Lee Tai Chi or something like that some kind of balance that necessarily therapy. But but you know something that that would probably work and help your balance.39:17

What what is I'm assuming that that's not the same exactly as this tabular therapy. So what kind of what additional benefits would vestibular therapy offer in comparison to doing something like riding your bike or doing Tai Chi or something like that that does require balance walking. That's a that's a great question. So the vestibular therapy is more like a little bit more specific to like that.39:50

The the inner ear and just like making those Pathways and kind of like force use of head motion.39:57

So all of those things I would categorize as more like General balance things which are so great and so helpful and going to help anybody who does them the Idea of vestibular therapy is

almost like exposure therapy where you're exposing yourself at graded rates and exposing your vestibular system to to more movement in a controlled environment and just having a lot of like measurable things attached to that that you can scale yourself up and build your threshold that way. So I guess it's more specific to the vestibular recovery than just total full body.40:40

Like full balance and even like mental health as mental like meditation and things like that that also come with Tai Chi and yoga and things like that. Yeah, and we had a question about about really pushing yourself during physical therapy. So will the person asked will they get better results if they push themselves more in PT, even if they get dizzier, but they really want to see that.41:10

Improvement so if that is the case and that's something that people should be doing. How do you you know, how do you kind of manage through that and how do you find the balance?41:22

That is a great question for whoever wrote that question. I'm glad they ask that. So the goal of these exercises is actually to make yourself somewhat dizzy. The keyword is somewhat or in and it's a controllable amount of dizziness. So what I mean by that is that you're you're doing the exercises you're in the exercise, you're feeling that dizziness.41:45

You're still able to still focus on the on the Target that you're focusing on and then when you stop doing them A minute or so and things calm back down if you're doing them. So intensely that you spike your dizziness through the ceiling and you're still 5-10 minutes after you did that exercises exercise and you're in a world of hurt or still and you can't function and you can't go throughout the rest of your day or if you feel like oh man, I did my exercises and I had to sit down the rest of the day. That's that's going to be more do more harm than good. So good. You push yourself.42:21

And do them yes, but one of the things I work with people on is not doing them too hard too fast because that's going to be more detrimental even then. It'll it'll be not not good for you.42:36

Yeah, and I work with a lot of really motivated great patience here that want to they wanted to really go a hundred ten percent and that's not always always indicated. That's I can understand I can imagine that.42:51

Okay, so we have another question about about time frames somebody who had surgery or was treated a long time ago and and was interested in knowing, you know, if there's if it's if there's Is a time frame that's too long and I wanted to share a separate comment that came in from a woman who said she didn't have a question, but she did recommend that people take advantage of this tubular therapy. She said that last year she did it for 12 weeks after being post-op for 30 years.43:24

And even after that many decades she really improved during those 12 weeks and she received exercises that are now part of her everyday life and because of them, you know, she's still June to improve so she had a great comment, but I just wanted to see if you know what your thoughts were on that and if that's typical what a what a great testimonial from that person and I think that kind of answered the question for me. Absolutely. I have some people that that have come come back after sometime or maybe they were had their excision surgery and a time or in a place where therapy wasn't where it is today.44:01

We've come a long long way in the last 10 15 five years even to the point where we're doing things differently and more aggressively and giving people therapy. There's time where people didn't get any therapy or are didn't have that opportunity for them and absolutely people can recover for after a long time of not doing these exercises. There's not really an expiration date and I think 12 weeks is such a good example to they say acute issues are can be resolved a little sooner.44:35

It's like your Awakenings systems that weren't even being used. So they're still there. He's still have them you just have to do these really specific things and and to kind of utilize this some systems and be better to furthermore. They've even done research. I don't have this in my my presentation that VOR reflex that vestibulo-ocular reflex. They've done studies on normal people who do not have disabilities.45:05

Venus who have no tumors who have no issues and they've still done those exercises and they were two they were able to improve themselves even Beyond normal like to to raise their scores. So just as a testament to how well that reflex rehabilitates.45:21

That's amazing while you're talking about that VOR. There was a question about someone who might have visual motor or visual spatial deficits to begin with that. You know that have were not

necessarily part of the part of the acoustic neuroma. Is that does that make recovery more difficult when that's the case more challenging? Hmm. I think that's a good question.45:47

I haven't I mean I've had people with with pretty pretty involved in my experience like visual issues to the point where they have like visual field cuts and like scotoma has and like black spots in their vision and like and like really involved prescriptions and that in my experience has not impaired their recovery at all or put them on a different timeline or complicated things. So that would be my closest experience with with something like that.46:19

I haven't had anybody who specifically Meg I mentioned visuospatial visual spatial issues, but I don't anticipate that that would put a burden on somebody's recovery and we had a couple people ask questions specifically about different activities that they were doing riding a bike or even being in the ocean and having, you know even having grown up near the water and then but now with the after recovering from treatment for acoustic neuroma really struggling to be In the ocean or or to ride a bike and this person said they had to get off the bike and look left and right to be able to you know across the street as opposed to just being able to maybe turn your head the way that they did before. Is that what suggestions do you have there?47:10

So that on my end of things is where rehab tends to get kind of kind of fun and we have to get kind of creative and that's more talking about like those designer exercises.47:23

So if Somebody's having issues with say those two things like riding a bike or being in the ocean. If you are experiencing those things out in an open environment and you're like you're riding a bike next to a car or next to the street with cars and there's people around and it's a very open environment that where you're not as in control. So bike riding is a common thing that I hear.47:52

So what I do in my clinic is I put them on a stationary And I like in a great head movements that way so a safe environment where you can start moving your head start looking around and trying all of those things and then from there moving onto like a beach cruiser type of error like a sturdier like a mountain bike or something and then if they're like a like got like there Lance Armstrong like road bike then they can with clip it pedals and all that stuff then they can that'd be kind of the final stage. So that's when I that's what I mean by those designer.48:25

Sizes more if they're having issues with these specific things will cater an exercise program so that they can deal with those same thing with the ocean with the ocean. It's kind of an uncontrolled environment kind of an open environment, but I would figure out exactly what about being in the ocean if it's just like the rocking or if it's the swimming or the dunking of the head and the moving of the head and I kind of have them tease out what exactly it is kind of rate everything and then maybe it's just time.48:56

It's like an integrated like you need to do 5 minutes in and then take a break and then just you need to do five minutes of swimming and then take a break or whatever put them on a plane where they're going to be the ones that are in control and then can remove themselves from a situation when they're in that period of their building themselves back up.49:15

Okay, and we are from a lot of particularly radiation patients where the balance nerve is not cut and sew them the you know, the other side does more of the compensation but there's additional swelling that takes place after treatment. And so this particular question is from someone who had radiation back in 2014 is and is continuing to see their balance worsen.49:40

So is that is that something that inquiry experience would You their expectation for improvement or how does that work? Just without seeing this patient. I would say that they do have the capacity to get better.49:59

So the one tricky thing with watching weight and radiation as opposed to surgery is if you think about both sides operating at a hundred percent of functionality of vestibular nerve and then use have the Lan side where it's decreasing to eighty percent 50 percent 40 percent. So that's so they're having a decline in on their vestibular functionality of that side just to kind of put it in perspective.50:32

If somebody who typically has surgery post after post op, there's 0% And functioning vestibular nerve on that side at least at least here at UCSD, but you can still rehab it's just you might have to dip back into rehab if you continue to see more further degradation of that nerve. So a lot of inner ear infections will also gradually knockout function. So it's like a gradual thing over time or if it's a swelling thing from radiation.51:05

So we're to where the point where it's Not complete but sometimes your body will adjust and kind of compensate for it. And sometimes it won't and sometimes you need to do rehab and then every time it kind of degrades you you have like a new setup and you need to like dip back into that rehab be it. You already know the exercises and you have to do them again, or you should visit a therapist and they can kind of reassess see where you are at now and then kind of get you our program, but I wouldn't say that that person is doomed to suffer.51:36

Worsening balance without hope for the for the rest of their life. Okay, and that sort of answers.51:43

Another question that we had where somebody was asking about when to go back to this tabular therapy likes that they had treatment and had to see me with therapy and did well and then is having balance issues again, so this can be like something that is is, you know ongoing I guess or you know, how do you know when you should go back and It sounds like it's something that you know can potentially be adjusted based on what's going on currently, even if that's a little bit different than what was going on before. Yeah, so you can definitely I mean if you have questions or if you're dealing with new onset dizziness, that's worsening or balance problems that are that are worsening. That's definitely justifiable to go at least be seen again.52:30

I know people can be hesitant because they're like, oh man, they're gonna sign me up for like 6 months of like How many times a week or whatever like it can be more especially like if somebody's familiar with these exercises it can be more of just like a couple visits to get you back on track. And then the person can the patient can just be on their own with the vestibular exercises. That's when I discharged people actually is is not often times not sometimes it's when they're all the way back to themselves and they're not having issues with things anymore.53:04

But sometimes it's they're like, hey Ben, I got this like I know what I'm doing. I know how to progress myself and I and they absolutely do so I have them stop physically coming to see me. Like I said, it's a very homework based rehab sure and any quick question come in they can come anytime. Well that leads me to my next question. Next question is what are there exercises to do pre-surgery and how they differ from what you do posts.53:35

Let's even not even Necessarily defined it as surgery but post-treatment maybe.53:44

So that's more again like those General General Wellness type things. If someone yoga Tai Chi cardiovascular exercise just walking if you have Orthopedic issues in the past that are that have limited you like you can you can treat those things so that your low back pain.54:06

Is it going to is it going to then interfere with your Stabler like your rehab from your treatment so different things just like Total Wellness things. I would say are going to be the best for or prehab. A lot of people ask me. Do I need to do VOR exercises before surgery and and I don't really think so. You're kind of a new person in regards to your vestibular nerve functionality after a treatment radiation or surgery.54:39

So I I tell them not not as much that but just more just whole body Wellness things.54:46

Okay, and we had a question. I haven't had this one before but it's interesting to me because I do read a lot about this technique it how does this tabular therapy differ from the Epley maneuver great question. So the most common cause of dizziness or vertigo is bppv, which stands for benign positional paroxysmal vertigo. That's like displaced.55:16

Calcium carbonate crystals in your inner ear that get into the semicircular canals as big loopy things that you get that are seen in those diagrams and they cause you to have the spins. So the room is spinning spinning spinning spinning that one of the Maneuvers to treat that bppv. That vertigo is is termed the Epley maneuver or now. There are a lot of times.55:45

Going at the kennel with repositioning maneuver, but that is more of like a one and done like you or not one and done. It's very treatable to where you put somebody's head in different positions and then their vertigo's gone and I do that my clinic as well. I do that individuals in the emergency department admitted to the hospital that is a lot of individuals who have gone through the Journey of being diagnosed with an acoustic neuroma. They probably have been asked a million questions.56:15

About trying The the person thinking it's vertigo because that's the most common cause of that. Uh-huh. Okay, I really was within her gotcha. Okay, and we're getting close to the end of our time here. So I had one last question and that is how important is it that the physical therapist that somebody is recovering from acoustic. Neuroma treatment.56:45

Important is it that the physical therapist is board certified in vestibular therapy.56:52

So It helps if somebody is like had some course work on it. But luckily the type of therapy that you would receive this kind of like vestibular therapy 101.57:08

So I see individuals that maybe live in more rural areas that have people therapists that are more generalist by Nature that kind of treat different things. They might treat some shoulder pain here and they might treat some vestibular stuff here in oftentimes. That is good enough like it's like and I hate to use the words good enough but like this, I've seen really good outcomes with just really basic therapy.57:37

So and then as far as like the board certification thing so I have like The neuro clinical specialist things if you are like in a area like Seattle or Los Angeles or New York and you really get to be choosy with you with who you have and you have an abundance abundance of resources and NCS doesn't doesn't hurt. Those are some individuals who have taken some time in their career to do some self study and to really get to know their craft.58:09

However, I've seen I've seen amazing results from therapists that do not have that certification.58:16

Gotcha. Okay. Well, we're at the end of our time today. So that will have to be the last question and I just want to thank Ben and everyone who was able to attend today. Please check out the A and Awareness Week page on our website and that web address is AMA usa.org backslash awareness and there you can find a full schedule of all of the events that we have coming up this week. You can also see our and Warrior wall you guys have been really sending in lots of pictures and we love them.58:45

So keep them coming we will post them on our wall as well as on our social media Pages throughout the week. We're also housing all of the presentations that we're doing this week are going to be there on that page as well and tomorrow been mentioned Tamara Wallen who's going to discuss immediate post treatment for acoustic neuroma and what to expect during that time. She will be presenting tomorrow 1 p.m. Pacific.59:15

4 p.m. Eastern time and it'll be a Facebook live. So there's no need to register for that way you did for this today. You can just go to our Facebook page at the correct time. Check your time

zone, and it'll stream live from there. So, thank you. Again Ben. That was really awesome. And thank you to everyone that attended and you guys have a great afternoon.59:36

Awesome. Thank you for having me.59:40

Why did?RE-GENERATE TRANSCRIPT

SAVE EDITS