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PHYSIOTHERAPEUTIC ASSESSMENT AND REHABILITATION
STRATEGIES OF THE SEQUELAE OF SURGICAL REMOVAL IN A IV
VENTRICULUM’S TUMOR: A CASE STUDY
Sandro João Pereira Martins1
Abstract: Introduction: Tumor surgeries in the IV ventricle are challenging and hairsplitting due to
the risk of injury in adjacent structures, such as, the cerebellum and vestibular nucleus, which can
cause movement disorders, aecting balance and gait, resulting in a decrease in functional capacity
and quality of life. Objectives: Find the most eective assessment and rehabilitation process, taking
into account a whole bio-psycho-social that is the patient of this case study. Methodology: Subjecti-
ve and objective assessment were performed, as well as a treatment plan to the patient in question.
Results: Good results were recorded on the Berg Scale and Timed Up & Go (Tug). Discussion: A
lot of literature talks about isolated treatments to treat sequelae of surgical procedures close to the
cerebellum, however in this case study it is demonstrated that, supported by the existing scientic
evidence, with the aid of clinical reasoning and critical thinking, it is possible to adapt and execute
a assessment and rehabilitation process for those patients, in a safe and eective way. Conclusion:
Physiotherapy, namely therapeutic massage, re-education of the gait pattern, namely facilitating the
semi-step with handling in the foot, ankle and knee, balance training inspired by the Berg Scale,
functional training with the promotion of dynamic instability and aerobic training, result in good
strategies to decrease postural instability, maximize functional capacity and minimize complications
in this kind of surgeries.
Keywords: physiotherapy, surgery, IV ventricle, ataxic gait, vestibular rehabilitation
1 Degree in Physiotherapy at ESSUA - School of Health of the University of Aveiro
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Introduction
Intraventricular tumors represent 2% of intracranial lesions , however, lesions of the fourth
ventricle constitute only a small portion of these lesions (Ferguson S. et all , 2018). These tumors are
found more frequently in the posterior portion of the lateral ventricles in pediatric cases, while in
adults they are found more frequently in the IV ventricle, namely in the supra-tentorial zone ( Koeller
K. et all , 2002).
The IV ventricle is a pyramidal-shaped space that forms the cavity of the metencephalon and
myelencephalon. The apex of this ventricle extends to the base of the cerebellum and tapers caudally
into a narrow canal that continues into the cervical cord. Laterally, the fourth ventricle extends over
the surface of the medulla as the lateral recess, to open in the area of the pons-bulb-cerebellum junc-
tion, the pons-cerebellum angle. Although the lateral recess is composed of the choroid plexus, the li-
mits of this space are formed by cerebral structures, including the cerebellum, the superior cerebellar
peduncles, and also the superior and medial vestibular nucleus (Haines D. et all , 2018).
Intraventricular lesions represent a great surgical challenge, since tumor surgery, particularly
in the fourth ventricle, is quite detailed due to the proximity, and possible injury, of vascular structu-
res, adjacent cranial nerve nuclei, cerebellar peduncles, vestibular nuclei and cerebellum. ( Tomasello
F. et all , 2015). The cerebellum plays an essential role in controlling limb movements, eye move-
ments, balance and gait, varying with the extent and location of the lesion. Balance and gait decits
reect the important role that the cerebellum plays in coordination, sensory integration, coordinate
transformation, learning, and motor adaptation ( Marsden , J., 2018). Cerebellar ataxia is a movement
disorder that can aect balance, gait, limb movement, oculomotor control, as well as cognition and
emotions. These symptoms signicantly aect functional capacity and quality of life ( Zhang L. et
all , 2017). In a cohort study , it was reported that the most common sequelae in tumor surgery on the
fourth ventricle were: headaches (45%), nausea and vomiting (38%), walking diculties (33%), visual
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changes (29%), dizziness (24%), cranial nerve decits (16%), fatigue (13%), and memory impairment
(11%). Several patients presented multiple symptoms, which is why the total does not give 100% (Fer-
guson S. et all , 2018).
The objective of this case study is to nd the most eective evaluation and rehabilitation
process, to maximize functional capacity and minimize secondary complications of surgical removal
of a tumor in the IV ventricle, always taking into account the entire bio- psychological being . which
is the patient in this study.
Methodology
Patient’s story
After several episodes of forgetfulness, namely where he parked his car, in 2018 he unde-
rwent a Computerized Axial Tomography (CAT), where a tumor was detected in the IV ventricle,
resulting in cranio-cerebellar surgery to remove that same tumor on the 3rd of October 2018, starting
a rst period of rehabilitation one and a half months after surgery lasting 3 months. On February 11,
2020, the patient says that she is forgetful, reports having changes in her vision and that when she
turns her neck “she becomes confused/dizzy”, falling frequently (2 to 3 times a day without severity
so far), and that due to their imbalance they nd it very dicult to carry out most of the activities of
daily life ( avd’s ). To perform these avd’s he spends a lot of time on his knees, and when in an upright
position and when walking, he needs a cane to support himself and move around outside the house,
since, inside the house he says that his cane is the furniture.
Assessment
On February 11, 2020, the patient presented to the hospital with an ataxic gait assisted by a
cane. The muscle test on the main muscle groups of the lower limb (mi) resulted in a 5, except for the
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tibiotarsal dorsal exors ( tt ) on the right side ( drt ) resulting in a 4+. Osteotendinous reexes rotulian
drt and left ( esq ) existing, but not very expressive. Feel fatigue and pain in the dorso-cervical region.
Below are the tables with the assessment carried out using the Berg scale and the Tug .
a) Berg scale item number
b) Berg scale score
Assessment instruments
The Berg scale was used to assess functional balance. It has a maximum score of 56 points,
with each item having an ordinal scale of 5 alternatives ranging from 0 to 4 points. The test is simple,
easy to administer and safe for evaluating elderly patients. It only requires a stopwatch and a ruler as
equipment and its execution takes around 15 minutes (Berg K. et all , 1992). This scale was subjected
to a process of cultural and linguistic adaptation, as well as verication of content validity, simulta-
neous/concurrent validity (n=20, r=0.93 (0.42) and n=33, Kendall=0.574 to 0.530 (0.000) ), longitudi-
nal validity/sensitivity to change (n=20 and n=33) and inter-observer reliability (n=20, r=0.94 (0.42)
and n=33, Kendall=0.88 to 0.82 (0.000)) (Santos et al., 2005).
The Tug was created to test balance ( Podsiadlo D. et al, 1991). The protocol for the Tug was
administered according to the description by Podsiadlo D. et al, 1991.
The patient’s main problems and treatment objectives
Berg Scale (11-02-20)
a) 12345678910 11 12 13 14
b) 44444333232301
Timed Up & Go (11-02-20)
TUG
(cone at 3 meters)
27 seconds
25 seconds
21 seconds
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Considering the results of the subjective and objective assessment, the patient’s main pro-
blems are: pain in the dorso-cervical region, ataxic gait, decreased balance and fatigue. In this sense,
the objective of the rehabilitation process was: to reduce pain in the dorso-cervical region, re-educate
the gait pattern, increase balance and physical conditioning, thus preventing and reducing the risk of
falls.
Rehabilitation process
The rehabilitation process is described in the table below:
Date Treatments
11-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (15 minutes)
facilitation to re-educate the gait pattern with plantar proprioceptive stimulation (sponge mat and feet only in
socks) (30 minutes depending on the patient’s tolerance, with rest breaks)
12-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (15 minutes)
facilitation to re-educate the gait pattern with plantar proprioceptive stimulation (sponge mat and feet only in
socks) (30 minutes depending on the patient’s tolerance, with rest breaks)
13-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (15 minutes)
facilitation to re-educate the gait pattern with plantar proprioceptive stimulation (sponge mat and feet only in
socks) (30 minutes depending on the patient’s tolerance, with rest breaks)
14-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (15 minutes)
facilitation to re-educate the gait pattern with plantar proprioceptive stimulation (sponge mat and feet only in
socks) (30 minutes depending on the patient’s tolerance, with rest breaks)
17-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
facilitation to re-educate the gait pattern with plantar proprioceptive stimulation (sponge mat and feet only in
socks) (20 minutes depending on the patient’s tolerance, with rest breaks)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 6. Standing with
your eyes closed, 7. Standing with your feet together, 8. Leaning forward with your arm stretched out, 10. Turn to
look behind you, 12. Place your feet alternately on a step (20 minutes depending on the patient’s tolerance, with
rest breaks)
aerobic training on cycle ergometer (60% HR) (10 minutes)
18-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
facilitation to re-educate the gait pattern with plantar proprioceptive stimulation (sponge mat and feet only in
socks) (20 minutes depending on the patient’s tolerance, with rest breaks)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 6. Standing with
your eyes closed, 7. Standing with your feet together, 8. Leaning forward with your arm stretched out, 10. Turn to
look behind you, 12. Place your feet alternately on a step (20 minutes depending on the patient’s tolerance, with
rest breaks)
aerobic training on cycle ergometer (60% HR) (10 minutes)
19-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
facilitation to re-educate the gait pattern with plantar proprioceptive stimulation (sponge mat and feet only in
socks) (20 minutes depending on the patient’s tolerance, with rest breaks)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 6. Standing with
your eyes closed, 7. Standing with your feet together, 8. Leaning forward with your arm stretched out, 10. Turn to
look behind you, 12. Place your feet alternately on a step (20 minutes depending on the patient’s tolerance, with
rest breaks)
aerobic training on cycle ergometer (65% HR) (10 minutes)
20-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
facilitation to re-educate the gait pattern with plantar proprioceptive stimulation (sponge mat and feet only in
socks) (20 minutes depending on the patient’s tolerance, with rest breaks)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 6. Standing with
your eyes closed, 7. Standing with your feet together, 8. Leaning forward with your arm stretched out, 10. Turn to
look behind you, 12. Place your feet alternately on a step (20 minutes depending on the patient’s tolerance, with
rest breaks)
aerobic training on cycle ergometer (65% HR) (15 minutes)
21-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
facilitation to re-educate the gait pattern with plantar proprioceptive stimulation (sponge mat and feet only in
socks) (20 minutes depending on the patient’s tolerance, with rest breaks)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 6. Standing with
your eyes closed, 7. Standing with your feet together, 8. Leaning forward with your arm stretched out, 10. Turn to
look behind you, 12. Place your feet alternately on a step (20 minutes depending on the patient’s tolerance, with
rest breaks)
aerobic training on cycle ergometer (65% HR) (15 minutes)
24-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 9. Pick up an object
from the oor, 11. Turn 360 degrees, 13. Stand with one foot in front of the another, 14. Standing on one leg (20
minutes depending on the patient’s tolerance, with rest breaks)
“8” circuit with chairs (20 minutes depending on the patient’s tolerance, with rest breaks)
aerobic training on the treadmill (2.5 km/h 15 minutes)
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18-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
facilitation to re-educate the gait pattern with plantar proprioceptive stimulation (sponge mat and feet only in
socks) (20 minutes depending on the patient’s tolerance, with rest breaks)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 6. Standing with
your eyes closed, 7. Standing with your feet together, 8. Leaning forward with your arm stretched out, 10. Turn to
look behind you, 12. Place your feet alternately on a step (20 minutes depending on the patient’s tolerance, with
rest breaks)
aerobic training on cycle ergometer (60% HR) (10 minutes)
19-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
facilitation to re-educate the gait pattern with plantar proprioceptive stimulation (sponge mat and feet only in
socks) (20 minutes depending on the patient’s tolerance, with rest breaks)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 6. Standing with
your eyes closed, 7. Standing with your feet together, 8. Leaning forward with your arm stretched out, 10. Turn to
look behind you, 12. Place your feet alternately on a step (20 minutes depending on the patient’s tolerance, with
rest breaks)
aerobic training on cycle ergometer (65% HR) (10 minutes)
20-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
facilitation to re-educate the gait pattern with plantar proprioceptive stimulation (sponge mat and feet only in
socks) (20 minutes depending on the patient’s tolerance, with rest breaks)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 6. Standing with
your eyes closed, 7. Standing with your feet together, 8. Leaning forward with your arm stretched out, 10. Turn to
look behind you, 12. Place your feet alternately on a step (20 minutes depending on the patient’s tolerance, with
rest breaks)
aerobic training on cycle ergometer (65% HR) (15 minutes)
21-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
facilitation to re-educate the gait pattern with plantar proprioceptive stimulation (sponge mat and feet only in
socks) (20 minutes depending on the patient’s tolerance, with rest breaks)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 6. Standing with
your eyes closed, 7. Standing with your feet together, 8. Leaning forward with your arm stretched out, 10. Turn to
look behind you, 12. Place your feet alternately on a step (20 minutes depending on the patient’s tolerance, with
rest breaks)
aerobic training on cycle ergometer (65% HR) (15 minutes)
24-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 9. Pick up an object
from the oor, 11. Turn 360 degrees, 13. Stand with one foot in front of the another, 14. Standing on one leg (20
minutes depending on the patient’s tolerance, with rest breaks)
“8” circuit with chairs (20 minutes depending on the patient’s tolerance, with rest breaks)
aerobic training on the treadmill (2.5 km/h 15 minutes)
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Results
On March 2, 2020, the user walked without a walking aid (cane). The muscle test on the main
muscle groups of the MI results in a 5, except for the tt dorsal exors drt , resulting in a 4+. Osteoten-
dinous reexes rotuliano drt and esq existing, but not very expressive. Below are the tables with the
results of the nal assessment made using the Berg and Tug scale .
26-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 9. Pick up an object
from the oor, 11. Turn 360 degrees, 13. Stand with one foot in front of the another, 14. Standing on one leg (20
minutes depending on the patient’s tolerance, with rest breaks)
“8” circuit with chairs (20 minutes depending on the patient’s tolerance, with rest breaks)
aerobic training on the treadmill (2.6 km/h 15 minutes)
27-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 9. Pick up an object
from the oor, 11. Turn 360 degrees, 13. Stand with one foot in front of the another, 14. Standing on one leg (20
minutes depending on the patient’s tolerance, with rest breaks)
“8” circuit with chairs , throwing a ball (front, left side and left ) (20 minutes depending on the patient’s tolerance,
with rest breaks)
aerobic training on the treadmill (2.7 km/h 15 minutes)
28-02-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
balance training (use of the Berg scale as an intervention with a sponge mat and feet in socks) – 9. Pick up an object
from the oor, 11. Turn 360 degrees, 13. Stand with one foot in front of the another, 14. Standing on one leg (20
minutes depending on the patient’s tolerance, with rest breaks)
“8” circuit with chairs, throwing a ball (front, left side and left ) (20 minutes depending on the patient’s tolerance,
with rest breaks)
aerobic training on the treadmill (2.8 km/h 15 minutes)
02-03-20 dorsocervical parafango (15 minutes)
dorso-cervical massage (10 minutes)
“8” circuit with chairs, throwing a ball (front, left side and left ) (20 minutes depending on the patient’s tolerance,
with rest breaks)
Berg Scale (02-03-20)
a) 1 2 3 4 5 6* 7* 8* 9** 10* 11** 12* 13** 14**
b) 4 4 4 4 4 4* 4* 4* 4** 4* 3* 4* 3*** 4***
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a) Berg scale item number: *that was used in the rehabilitation process from 02-17-20 to 02-
21-20 and **that was used in the rehabilitation process from 02-24-20 to 03-02-20
b) Berg scale score: *which increased by 1 point, **which increased by 2 points and ***whi-
ch increased by 3 points, since the rst assessment
Discussion
In the rehabilitation process of this patient, parafango and massage were used with the aim of
reducing pain in the dorso-cervical region. It is suggested that the pain-relieving property of massage
therapy is attributed to the reduction of substance P and increase in serotonin. There is evidence that
massage therapy increases serotonin and decreases cortisol, providing relief from negative emotional
symptoms such as depression and anger, thereby increasing positive mood (Field, 2010).
In facilitating gait pattern retraining with plantar proprioceptive stimulation (sponge mat and
socked feet), neurorehabilitation research on locomotor intervention suggests that specic rehabilita-
tion training leads to increased improvements in gait outcomes ( Bayona N. et all , 2005) ( Hubbard
I. et all , 2009), since these results indicate that patients’ postural sway is reduced and the gait move-
ment pattern becomes more consistent during locomotion, suggesting improvements in gait stability
( Seung-Jin Im et all , 2016).
Vestibular rehabilitation techniques have evolved in recent decades and there is reliable re-
search on the eectiveness of vestibular exercises in peripheral vestibular dysfunction. Personalized
treatment programs focus on decreasing symptoms of dizziness, oscillopsia , postural instability, and
treating the patient’s functional decits . The aim of the exercises is to promote central compensation
for vestibular dysfunction ( Sulway S. et all , 2019).
Timed Up & Go (02-03-20)
TUG
(cone at 3 meters)
12 seconds
11 seconds
10 seconds (minus 11 seconds, 47.6%
improvement since the rst evaluation)
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The “gure 8” circuit disturbed by throwing a ball, from the front and side, to the patient
makes sense because, when exposed to repeated disturbances, the neuromotor system is stimulated to
develop the necessary neurophysiological changes and sensorimotor skills. to prevent falls ( Grabiner
M. et all , 2014). Perturbation-based balance training has been reported to be potentially eective
for populations with balance disorders, promoting greater postural stability ( Chien and Hsu , 2018;
Handelzalts S. et all , 2019; Klamroth S. et all , 2019), reducing the incidence of falls ( Gerards M. et
all , 2017; Manseld A. et all , 2017) and improving functional performance in individuals with neu-
rological conditions ( Steib S. et all , 2017).
Solid experimental evidence suggests that physical exercise can promote brain plasticity
through activation of neurotrophin , synaptogenesis , angiogenesis and neurogenesis signaling pa-
thways . Furthermore, the benecial eects of aerobic exercise may be mediated by reducing the
oxidative stress of neuroinammation and improving intracellular calcium homeostasis ( Ferrazzoli
D. et al. all , 2020), and in a review of 42 randomized and controlled studies, it is demonstrated that
exercise is a safe and eective intervention to reduce fatigue and improve mobility in adult cancer
survivors ( Dennett A. et all , 2016).
This case study has some limitations mainly in the evaluation, as more scales should be used,
namely the Scale for Assessment and Classication of Ataxia (SARA) and the Fatigue Severity Scale
(FSS). And in the intervention process, more coordination exercises should be carried out.
Conclusion
After analyzing this case study, it is possible to conclude that physiotherapy, specically:
therapeutic massage, re-education of the gait pattern, namely facilitation of half-step with handling
on the foot, ankle and knee, balance training inspired by the Berg Scale, functional training with the
promotion of dynamic instability and aerobic exercise result in good strategies to reduce postural
instability, maximize functional capacity and minimize sequelae of surgical removal of tumors in the
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fourth ventricle.
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