Hydrocephalus is a condition in which an abnormal amount of cerebrospinal fluid (CSF) accumulates in the brain’s ventricles due to various factors. This excess fluid causes the ventricles to enlarge, increasing pressure on the brain tissue, which can be dangerous and even life-threatening. Hydrocephalus can negatively impact coordination, balance, mobility, and walking, often affecting daily activities. Therefore, physical therapy (PT) is crucial for promoting motor and cognitive functions, helping individuals maintain mobility, improve coordination, and enhance overall quality of life. 

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What are the types and causes of hydrocephalus?

Hydrocephalus can occur at any age but is most common in infants and adults over the age 60. Hydrocephalus in young and middle-aged adults presents differently and can be more challenging to understand compared to cases in infants or older adults with normal pressure hydrocephalus (NPH), as it also involves psychological, social, emotional, and occupational issues. 

 The main types of hydrocephalus include: 

• Congenital hydrocephalus: Present at birth, this type may result from genetic abnormalities or complications in fetal development, such as birth defects in the brain, spine, or spinal cord. Complications of premature birth, like bleeding in the ventricles, or infections such as rubella during pregnancy, may cause inflammation in the brain tissue of the fetus
• Acquired hydrocephalus: A type that can develop at any age, often caused by neurological illness or injury, such as brain or spinal cord tumours, bacterial meningitis, or stroke
• Normal pressure hydrocephalus (NPH): A type of communicating hydrocephalus often diagnosed in individuals aged 60 and older. It occurs when the flow of CSF is blocked in the brain due to secondary complications such as past injury, bleeding, infection, brain tumours, or brain surgery. In some cases, the cause is idiopathic, meaning it is not known. NPH causes a distinctive set of three symptoms, often referred to as a triad: difficulty controlling urination (wet), problems with walking or balance(wobbly), and changes in thinking and memory (wacky). These symptoms were first identified in 1965 when doctors observed these mild issues in individuals with hydrocephalus, even when the fluid pressure in their brains was normal²
• Communicating hydrocephalus: Occurs when the flow of cerebrospinal fluid (CSF) is obstructed after leaving the brain's ventricles, preventing it from being properly absorbed into the bloodstream. The term "communicating" indicates that cerebrospinal fluid (CSF) can still move between the ventricles, which remain open
• Non-communicating hydrocephalus: This is also known as obstructive hydrocephalus and occurs when the flow of CSF is blocked along one or more of the narrow passages connecting the ventricles

Hydrocephalus ex-vacuo: Occurs due to complications such as stroke, degenerative diseases like Alzheimer’s or other dementias, or traumatic injury causing damage to the brain, leading to brain tissue shrinkage.

What are the common symptoms in individuals with hydrocephalus?

The symptoms of hydrocephalus can vary greatly from person to person and are primarily influenced by age.³

Infants

• Seizures
• Enlargement of head size
• Poor eating
• Vomiting
• Irritability
• Problems sucking or feeding
• Sleepiness 

Children and young adults

• Headache
• Blurred vision
• Trouble with balance
• Poor coordination
• Poor appetite
• Irritability
• Change in personality
• Decline in concentration affecting school or job performance
• Decline in thinking or reasoning skills
• Frequent urination (incontinence) 

Older adults 

• Problems walking, commonly described as feeling like the feet are "stuck"
• Progressive mental impairment and dementia
• General slowing of movements
• Loss of bladder control and/or frequent urination
• Poor coordination and balance

How physical therapy helps in hydrocephalus management?

Nowadays, surgical intervention is the most common method of treatment, in which a device or valve (shunt) is inserted from the cavities of the head to the abdomen, allowing cerebrospinal fluid to be absorbed into the bloodstream. However, physical therapy is crucial for both preoperative and postoperative individuals in various ways to reduce or delay the signs and symptoms of the condition. 

Strengthening exercises

If an individual is inactive for a period of time postoperatively, muscle wasting, also known as muscle atrophy, can occur. Strengthening exercise can help prevent muscle wasting and improve functional abilities, such as walking or climbing stairs.

Balance and coordination training

Exercises designed to enhance stability and prevent future injuries or falls.

Mobility training

Gait training is a type of physical therapy that helps improve walking patterns and may involve the use of assistive devices for walking.

Flexibility and range of motion

Stretching exercises help maintain joint flexibility, reduce muscle tightness due to prolonged immobility, and improve the range of motion in affected areas.

Posture and alignment correction

Hydrocephalus can impact posture, leading to injuries or falls. Physiotherapists incorporate exercises and techniques to improve posture, prevent musculoskeletal issues, and enhance core strength.⁸

How is hydrocephalus diagnosed?

• Neurological examination includes assessing muscle strength and reflexes, coordination and balance, vision, eye movement, hearing, mental functionality, and mood
• Computed tomography (CT) scans and magnetic resonance imaging (MRI) scans are commonly used as initial tests to diagnose hydrocephalus in adults
• These scans reveal the build-up of excess fluid in the brain, the enlargement of the ventricles, and structural abnormalities due to increased pressure on brain tissue
• During pregnancy, ultrasound scans can detect congenital hydrocephalus before birth in infants
• Additional tests, such as a lumbar puncture, lumbar drainage test, or lumbar infusion test, may be conducted to determine if surgery would be beneficial^3,5 

What are the surgical treatment options for individuals with hydrocephalus?

There are two surgical treatment options available: 

• Ventriculo-peritoneal (VP) shunt: This is the most common type of shunt. It works by diverting cerebrospinal fluid (CSF) from the brain's ventricles to the abdomen.
• Endoscopic Third Ventriculostomy (ETV): ^4,7

What are the benefits of physical therapy?

• Promotes functional mobility such as crawling, standing, or walking in infants.
• Enhances mobility and independence, leading to an increased ability to perform daily activities.
• Reduces the risk of complications by preventing secondary conditions like contractures and pressure sores.
• Improves quality of life through better physical function, which contributes to improved social interaction and emotional well-being.

What are the challenges and considerations?

• Varied treatment plans tailored to individual needs based on age, severity, and progress.
• Multidisciplinary approach for better coordination with other therapies (occupational, speech, medical).
• Involvement of family support and caregivers with proper knowledge of home exercises.

Summary 

Hydrocephalus is a condition characterised by the abnormal accumulation of cerebrospinal fluid in the brain, leading to increased pressure on the brain tissue. This can result in difficulty with balance, mobility, and other aspects of daily activities and functions. Although surgery is the most common treatment option for this condition, physical therapy is crucial both before and after surgery . to promote recovery and enhance quality of life..

Physical treatment improves mobility, balance, coordination, and muscle strength in individuals with hydrocephalus. These activities are essential for maintaining flexibility, minimising muscle weakness, and enhancing gait, all of which are commonly affected by the condition. In order to reduce the risk of injury and enhance core strength, therapists also focus on alignment and posture correction.

Physical therapy offers numerous benefits, including improved mobility, increased independence, and a lower risk of falls. Additionally, it enhances quality of life by making it easier for individuals to perform daily tasks. Early intervention and consistent therapy are key to achieving the best results for those with hydrocephalus.