The posterior fossa is an area near the back side of the base of the skull that contains parts of the brain called the brainstem and the cerebellum. After your child has surgery on an area in the posterior fossa, he may develop posterior fossa syndrome. Posterior fossa syndrome is most common after surgery to remove a medulloblastoma, but it sometimes is seen after surgery to remove an astrocytoma or ependymoma. Symptoms usually appear 1–5 days after surgery.
The symptoms of posterior fossa syndrome include problems with speech and language, motor skills, and mood changes. Symptoms can be different for each person. Most symptoms improve in weeks or months while some symptoms may continue for years following surgery. People who have more severe posterior fossa syndrome symptoms early in recovery are more likely to have symptoms that last longer.
If your child has posterior fossa syndrome, it is likely that he will be seen and treated by a physical therapist, occupational therapist, speech-language pathologist, and neuropsychologist. The physical therapist looks at balance, strength, and coordination. The occupational therapist looks at upper body movement, strength, coordination, and visual-motor skills. They also look at how well your child can do the tasks needed for daily life, known as activities of daily living. The speech-language pathologist looks at how your child speaks and how he swallows. The neuropsychologist looks at how your child thinks and behaves and helps prepare your child to go back to school.
The following is a list of problems you may notice if your child has posterior fossa syndrome. These are the most common problems, but there may be others. Please report all problems to your child’s doctor.
Speech and language
Apraxia of speech
This speech disorder may cause your child to have trouble saying what he wants to say correctly every time. It is caused by a reduced ability to plan and coordinate speech. If your child has apraxia of speech he may say the wrong word or require increased effort to produce sounds for speech. The speech-language pathologist may help your child speak better by practicing phrases he uses often.
Dysarthria is a motor-speech disorder that makes it difficult to use or control the muscles of the mouth, tongue, palate, and vocal cords, which are used to make speech. Dysarthria can cause these muscles to become weak, move slowly, or not move at all. The speech-language pathologist may teach your child some steps to help others better understand his speech. Some ways to improve this include having your child speak slower or use gestures to help listeners understand.
If your child has a language deficit, he may use or understand language at a lower level than he should for his age. Your child’s speech-language pathologist may help increase his vocabulary and improve grammar through targeted play.
The neuropsychologist will focus on thinking skills that can affect your child’s use or understanding of language. Examples of these thinking skills are attention, working memory, processing speed, planning, organizing, getting tasks started, and solving problems. The neuropsychologist and the speech-language pathologist will work together to find helpful ways for your child to communicate despite the mental and motor weaknesses that posterior fossa syndrome might cause.
A child who has mutism does not speak. Children with posterior fossa syndrome who do not speak, often want to communicate with others. The speech-language pathologist and neuropsychologist may help your child by giving him another way to communicate, such as pointing or using his eyes to look at multiple choices. This staff member may also help your child start to gain control over breathing, making sounds, and moving his mouth in the ways needed for speech.
A child with ataxia is less coordinated and has trouble moving and controlling movements. Ataxia causes problems with tasks that involve both large and small movements. If your child has ataxia he may shake or have tremors.
The physical therapist will help your child with large movements of his trunk (upper body), legs, and arms, called gross motor coordination. The occupational therapist will help with fine motor tasks, working with your child to control the small movements he makes with hands and fingers, including feeding himself, writing, dressing, and handling small toys and other objects. Both therapists work to help your child get back the most function possible. For example, your child’s therapist may suggest certain play activities and weight-bearing positions that involve controlled use of arms, legs, and trunk.
Sometimes activities may be hard for your child if he is having problems with motor planning. Motor planning is how the brain plans the steps needed to complete an action. Your child may need to be told which step comes next and may need many kinds of physical help to learn how to carry out the movement. All of your child’s care team will work to help your child break down a task into smaller, easier steps, to help him succeed.
If your child is not aware of his motor coordination problems, it will be harder to keep himself safe from everyday dangers. A neuropsychologist can work with your child to make him more aware of weaknesses that might cause safety concerns and will provide you with safety guidelines.
Change in muscle tone
Your child may have weakness on one side of the body (hemiplegia) or general changes in muscle tone (hypotonia or hypertonia).
Hemiplegia is when your child cannot move a group of muscles on one side of his body. This affects motor control and causes too much tension in muscles at rest.
Muscle tone refers to tension inside muscles, not strength. Muscle tone is the balance of muscle tension inside a muscle or group of muscles at rest allowing them to tighten and relax when needed. Muscle tone may change as your child heals after surgery. Two types of muscle tone that are often seen in patients with posterior fossa syndrome are hypotonia and hypertonia. Hypotonia is low muscle tone or floppy muscles. This means your child is less able to control and tighten a muscle to complete a desired task, which affects trunk control and posture. Hypertonia is when there is too much tension in the muscles and arms or legs might feel “tight.”
The occupational and physical therapists will have your child do certain activities to improve muscle use and tone in the affected arm and leg. They may have your child use both hands during activities and have him reach across the body while standing or sitting. They might also have your child complete tasks using only the affected arm and leg. They may have your child clap to music and squat to pick up a dropped item. The occupational therapist may give you different types of splints to help manage tone in your child’s arms and hands. If there is too much tone in an arm or hand, your child may need a splint to stretch the muscles or to position the hand so that he can use it.
Dysphagia is trouble swallowing. The speech-language pathologist may suggest ways to change your child’s diet to make it easier for him to swallow. Changing the texture of food may make swallowing easier. Changing head position may make swallowing safer for your child.
Muscle weakness is the loss of strength and power needed for normal movement. This usually affects your child’s posture and head control, and his arms and legs. The occupational and physical therapists will suggest play activities and exercises suited to your child’s age to help regain strength.
The occupational therapist will focus mostly on upper body strength, and the physical therapist will work mostly on lower body strength. For example, the therapist will encourage you to allow time for your child to take part in activities such as moving in and out of bed and engaging in play suited to his age. If your child has weak ankles or foot muscles that may cause him to trip or fall, his physical therapist may suggest orthotics. Orthotics are supports that make the ankle and foot stable. They are usually custom-made to fit your child.
Mobility and walking
Mobility is the ability to move around. One of the main goals of physical therapy is making sure that your child can move around from one area to another for play and other activities. Safety is the main concern when teaching a child to move around and walk. To keep from hurting weak muscles and to prevent falls, your child will need to have good strength and control of his trunk, arms, and legs before walking. The physical therapist will work closely with you to see if your child will need a walking aid when it is safe for him to move around on his own. By providing support, a walking aid helps your child walk safely while lowering the amount of effort it takes to walk. The types of walking aids most often used are:
- Forward-rolling walkers – used if your child has less strength and balance; and
- Posterior-rolling walkers – used if your child tends to lean too far forward or cannot safely control a forward-rolling walker.
Visual motor integration
Visual motor integration is how well your child’s hands (motor coordination) and eyes (visual perception) work together. It also involves how your child’s brain uses information from his hands and eyes to let him interact with the world. These skills are very important to helping him succeed in many childhood tasks, especially handwriting. Other thinking skills such as attention, motor planning, and your child’s sense of where his body is in space also help him to use his hands and eyes together.
The occupational therapist will help with problems your child has in this area. Activities your occupational therapist might do with your child include puzzles, drawing tasks where he needs to copy several shapes, connect-the-dots, mazes, handwriting, and building with blocks. The neuropsychologist will help determine how your child’s eyes and brain are taking in and using visual information to help him interact with his environment.
Mood and behavior
Mood swings and being irritable are common in people with posterior fossa syndrome. A neuropsychologist can find and help reduce or get rid of triggers that make your child upset, while helping to find activities or actions to calm him down. The neuropsychologist will also teach you and your child ways to better control his emotions and how he can show emotions in more helpful ways.
You may notice changes in how your child responds to different forms of touch or movement. He may seem to be bothered by certain textures, light touch, or quick changes in movement. These types of sensations may not have bothered your child at all before the surgery. On the other hand, your child might be comforted by pressure, deep touch, or gentle rocking. The occupational therapist will help you find the best ways to increase enjoyable sensations and avoid sensations that upset your child. Calming techniques include activities such as gentle swinging, using weighted m aterials to provide pressure, positioning techniques to help your child feel safe, or changes to lighting and sounds.
Attention and executive functioning
Posterior fossa syndrome and the effects of cancer treatments may shorten your child’s attention span and cause problems with focusing, shifting attention, and dividing attention between tasks. Executive functions are thinking skills that let your child organize his ideas and actions so he can problem-solve and work toward goals in the future. Executive functions include skills such as planning, getting started with tasks, and doing tasks quickly and correctly.
A neuropsychologist will help your child reach his highest level of attention and executive functioning possible, so that other symptoms of posterior fossa syndrome can be treated.
To learn more about posterior fossa syndrome and how the St. Jude team can help your child, call physical therapy, occupational therapy, or speech-language pathology in Rehabilitation Services at 901-595-3621. For neuropsychology, dial 901-595-3581. If you are outside the Memphis area, call toll-free 1-866-2ST-JUDE (1-866-278-5833).
This document is not intended to take the place of the care and attention of your personal physician or other professional medical services. Our aim is to promote active participation in your care and treatment by providing information and education. Questions about individual health concerns or specific treatment options should be discussed with your physician.
St. Jude complies with health care-related federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
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