First MRI since radiotherapy with cyber knife

[photog1]

Hello,
I am writing again to the forum in hopes of finding out more about life, post-radiotherapy with the cyber knife.  I am not an AN patient, but do have a dear boyfriend far away from me (he lives in the UK), whom I think if having a lot of difficulty since his 2 radiotherapy treatments, the first was in February this year and his second was 4 weeks ago today.  We used to be in contact with each other quite a lot, either by e-mail or by phone.  Now, I don't hear from him at all.  My e-mails go unanswered.  I called him 2 weeks ago and he sounded happy to hear from me, but he was not having an easy time with the side effects.  He was very fatigued but had started going back to work, on a limited basis.  I care about him a lot but I think it could be too much of a burden on him for me to be calling him.  He may need all his strength to heal.  He is 56 years old.  He did say his doctors are unsure if it is safe for him to have any further treatments.

His AN was about 1.7 cm in size at diagnosis in February this year.  I am very concerned about how he is doing, mentally and physically.  He suffered many of the usual side effects after the first treatment, which was larger than this second treatment.

I need to know, has anyone out there had their first MRI, post-radiotherapy with CK, just 4 months later?   How were the results?  I read that 6 months is the usual time before the first post-treatment MRI.   He said he is having his first MRI next month (June).  That's only 4 months since first treatment.  Has anyone's AN shown signs of shrinking/dying after only 4 months?

I'm curious to know.  I am sorry to have to turn to the discussion forum for answers which I can't seem to get from my friend.  He has been so shy with me about his situation.  Could this be a guy thing with him, attitude-wise?  I've never known anybody with an AN before, never heard of an AN before my boyfriend.

Thank you so much for any comments and answers to my questions and concerns.
Tina

[Ruthie Mac]

Hi Tina,
I'm sorry your friend is not communicating more with you, as you sound very supportive, and god knows anyone dealing with an AN needs as much support as possible. I'm surprised his treatments were so far apart - but maybe they have a different approach in the UK. Usually radiation is either done in a one dose treatment (Gamma Knife) or fractionated in 4-5 sessions (Cyberknife or Linear Accelerator ( which I had) or 30 sessions with Cyberknife or Proton.

Regardless of the choice, the recovery time and process is completely different for everyone, so it's hard to know what to expect. I had a tough time with fatigue for the first 4 months. And the dizziness and wonky headed feeling is so hard to describe, I gave up trying to find analogies and just said "I'm miserable" which everyone can relate to on some level.

For a few months, I needed to use all my energy to just get through work and daily errands with nothing extra to give to relationships with friends. Even returning emails could seem overwhelming. I wasn't depressed, but found I needed to withdraw from social activities because it was too hard to engage in conversation especially if it required processing other people's problems. Since relationships require give and take, I just couldn't be a good friend until I felt better. Sometimes I feel like my friends are getting impatient with how long it's taking me to feel better and why don't the doctors don't have better solutions, etc. So, in a way I feel like I'm letting them down. Maybe that's how your friend feels.

If so, the best thing might be to keep communicating your support in whatever way requires the least amount of responsibility on his end. It sounds like phone calls worked better than email - maybe because they're more spontaneous.
Sending a care package of some favorite items might be well received.

As far as the MRI, there's not much to see in the first year. I had one at 6 months, mostly out of curiosity. It showed swelling of approx 4 mm, which is not unexpected, and only justified my feeling miserable!
But at 6 mos. my energy is much better and I'm back to my regular schedule. Physical Therapy is helping with balance.
Don't give up on your friend...we need more caring people like you in the world!
Ruthie

[john1455]

Tina,

You are correct when you state that the first post treatment CyberKnife MRI is taken at 6 months. I suspect the reason your friend's is being done at 4 months is because of all the problems he is having. I was very surprised to read your post because CK sessions are supposed to be painless and CK is supposed to have the least impact on the quality of life. From my online research, your friend's problems are the exception rather than the rule and I feel badly that he is going through this nightmare. Here are some things about CK that I have found out and may help you understand your friend's situation better-

It is normal for tumors to swell after being hit with radiation; swelling may take place from 2 months to over 2 years after CK treatment; side effects from CK may take up to 2 years to appear; it may take 2 or more years before any shrinkage is seen on a MRI and sometimes there is never any shrinkage at all; the main goal of CK is to kill the tumor cells and stop further growth and if shrinkage happens (due to necrosis) then that is an added bonus. Necrosis or cell death causes the tumor to shrink but that takes time, lots of time (as in years), so patience is needed. Just because there is no shrinkage does NOT mean CK failed but continued growth is a sign of failed treatment. That is why ANs must be monitored post CK treatment. It will be extremely unlikely to see any shrinkage after 4 months since the AN will probably still be swelling from the radiation. If anything, most AN patients will see an increase in tumor size within the first year post treatment but if one realizes that it is normal for tumors to swell from radiation treatments, that should allay any fears that the increase in size is pathologic and is common.

Almost all AN patients will still have the same symptoms that existed prior to CK. Some may go away, some may improve, some may become worse, but most will remain.

[photog1]

Thanks so much to both you, Ruthie and John.  I tried to print up the replies to my post, but don't seem to find an icon to click on to get them printed up.  I will try to remember the most important points you both made.  I can see both of your points.  Since this guy is a good friend of m  mine, I have made it my mission to learn all I can about acoustic neuromas and all they can entail, so that I can understand his situation better and offer any help that I can.  I have introduced him to the ANA.ORG site and the ANA has sent him a large information packet like they sent to me, too.  Last time I spoke to him on the phone I mentioned it to him and he looked forward to receiving it.  I hope he received it okay and is reading through the material now.   

Going into his first treatment in February, he had a positive attitude.  We were talking about his coming here to the U.S. to visit me.  It would be the first time we met in person (we met online, of all places, early this year) and have gotten to know each other well enough that we both greatly anticipated our first meeting and being together to see what that would be like.    And, see where things go from here.

After his first CK treatment in February, he initially had the fatigue, felt bad he couldn't go to the gym.  He is also an engineer, now the director of his own company that manufactures  steel products for the construction industry.  He lamented over not knowing how much work he would miss.  He is the only person directing the company.  His work and his company, which he founded, means the world to him.  If there were any other side effects, he didn't tell me of them. 

About 10 days after that first treatment (larger than the second treatment 4 weeks ago), his spirits picked up, he began to return to return work  and was calling me again.  We spoke again about our meeting for the firsts time.  About a month after that first treatment, the swelling started and it was very difficult for him to tolerate, plus he had difficulty tolerating the steroids he was having to take.  We continued to be in touch, however.  Then, suddenly, in the space of only 2 days or so, he e-mailed me (April 4th), saying our relationship couldn't continue, that he had nothing he could contribute to it anymore, he said he can't travel anywhere rest of this year and that I shouldn't wait for him.  It was like pulling teeth trying to get him to tell me what had happened that compelled him to come to this shocking decision!!!  I was horribly  devastated!!!  The most I could get out of him was that he had made this decision after meeting with his doctor that morning and that he was shattered!   Shattered about what???  He wouldn't tell me. 

I could only guess and speculate (so much speculating  has exhausted me) that the doctor had decided to do surgery to remove the AN (it's in his right ear.)  After much e-mailing back and forth that day, my friend and I did decide that we will remain just friends and keep in contact.  He didn't really want to lose me, I surmise. 

So, we have been just friends since.  After that e-mail, I started finding out as much as I could about AN's, online and communicating with the ANA.  With all that I have learned about AN's since, I have learned enough to get a better understanding of what he is going through, knowing what all the side effects can be.  I would assume he has had some balance issues, although being the avid gardener that he is, he did mow his lawn the day before Easter.  And, he has a huge backyard, 64 ft. by 300 ft.  I know that because we spoke on the phone that day (I called him.)  It was during that conversation that he told me of his upcoming, 2nd CK treatment on April 24th.  I could tell he wasn't looking forward to it.  He was to have it on March 31st, but somehow it got pushed back to April 24th. 

It was the day before that 2nd treatment that I got an e-mail from him and I could tell he was having the head wonkiness big-time (head wonkiness is something new to me), in that he was unable to focus (he had always prided himself on being a focused individual), he was absent-minded, couldn't concentrate, he couldn't appreciate things and felt very tired and unhappy about how he was feeling at that time.  He said he wished he could escape.

When I called him 2 weeks ago, he seemed glad to hear from me, but sounded like all the life had drained out of him.  He was able to stay on he phone with me for as long as an hour, which is good.  A couple of days later, he wrote to thank me for calling him and it was good talking to me.  He also thanked me tor my efforts in learning about his medical situation and understanding it.  He truly appreciates it.  HE actually said he hopes one day he can be of help and support to me, as I have been to him.  So, at least he is looking in a forward direction saying this. 

Ruthie, thanks for the suggestion that I call him instead of e-mailing.  I will call him again this weekend and find out how he is doing at this point. 

Yes, it does surprise me that he has had 2 treatments so far apart from each other.  He has had to go through all this hell, one after the other.  I know that the CK treatments are usually given over the course of only a few days.  I told him this and he seemed to know that, too.  He told me more about how he is doing in this most recent phone conversation than I have been able to find out from him in e-mails.  So, I will continue calling him.  I know he needs the support, he doesn't get any of it from family.  His father passed away 30 years ago and that was very devastating for him.  He is divorced with 2 adult kids, his ex took a lot from him, financially, in the divorce, 8 years ago.  He started again from scratch and built up his assets to where they were prior to the divorce.  He is a very hard and dedicated worker.  His son works in his company, but I don't yet know in what capacity.  So, I can imagine how freaked out he could get if he can't be at work running his company.  I know how much that means to him.  So, I have tried to give him all the space he needs to heal and slowly get back to better health.  I know it takes time and a lot of patience.  Maybe he has not had much patience.  I have a lot of it.  I'm wondering now if what his doctor told him, prior to that April 4th e-mail, was how long it could take for the tumor to die off and he be back to good health.  Maybe he had been thinking it would be only a matter of a month or two.  I know it could take at least a year, 2 years or more, however long it takes.  I told him no two patients are alike in their experiences with this nasty little thing.  I think he understands this. 

He lives alone in his own house, has no domestic help.  He takes care of everything himself, even cooks for himself.  I don't know how he could do this with all the side effects from his treatments.  He said he has lost all his hearing in his AN ear.  I don't know if that is due to the nerve being completely severed.  Can CK radiotherapy cause the hearing nerve to completely sever?   I would bet he had some hearing loss prior to his diagnosis in early February.  I understand that is one of the first symptoms of an AN.           

So, that's as things are for now.  I will be interested in speaking to him again this weekend to get an update.  He knows that he has my total support.  Just wish I could be the one to go there to be with him, but I know that would be too much for him right now.   I told him that someday, he will look back on all this and realize he is stronger because he made it through this nightmare.  I'm doing all that I can to help him have only positive thoughts and a positive attitude.

I'm thinking probably nothing will show up in the way of improvement from his MRI next month.  To me, that's too early.  I hope he won't get terribly discouraged if there are no positive changes. 
 
I'm sorry that I've gone on for so long here, but I'll keep you posted.  Thanks so much again for your input and I wish you both the best in your healing processes, as well!
Tina         

           

[PaulW]

I read your post with great interest..
At first when I read about two treatments 1 month apart.... my first thoughts were "what the F" That doesn't sound right.

I have been very interested in the debate between Single Session Radiosurgery versus Fractionated Stereotactic Radiotherapy and the science behind it. Two sessions one month apart may actually be the best of both worlds..

FSR exposes patients to many times the radiation of single session radiosurgery. It is theorised that this exposes the patient to a small risk of non related cancer. This is in addition to the chances of malignant transformation.

Having two sessions one month apart may in fact be the perfect compromise between Radiosurgery and FSR for AN's
Having spoken to a number of radiation oncologists in the past I see the logic of two sessions one month apart.

As for your friends symptoms... have a read of this website.

www.myacoustic.org

Most of us have problems on our journey.

I can certainly relate to your friends symptoms and behaviour.
The first 6 months in particular can be tough.

While I did go back to work straight away I found month 5 the most difficult.
At the time I was the owner of a business with about 35 staff.

While I was functional I was not driving the business, or providing the same leadership that I had before the AN.
I got tired easily and distracted

I thought I was all good at 12 months, but I was even better at 24m and 36m

There is light at the end of the tunnel, but the journey is typically 2 years or more.

Don't expect anything from the MRI, the tumour will probably be bigger.. It may have a darker centre, but that doesn't mean much either, because often the 12m one shows an even bigger tumour with no dark centre...
Its all normal, don't panic when it happens.

The most important thing is that the tumour shrinks after the 2 year MRI.
The 2 Year MRI typically marks the end of the swelling period for the majority of AN's

Steroids do make some people feel awful, including depression when you stop taking them.
I would take the doctors advise, but certainly consult with them to take a minimal dose and try and get off them as soon as practical again strictly following doctors orders. Stopping long term steroid medication against medical advice, suddenly can be very dangerous.

I found Ginger travel sickness tablets to be of use to reduce dizziness and that foggy head.
Getting up and getting active also made me feel worse initially but better the next day.

I hope that helps



Taking steroids as an optional extra is probably a bad idea.

[photog1]

 ^-^Wow, Paul W, I read your response with great interest, as well!!!  First, I recognized the website you gave me, in that I have read the  incredible story of your AN journey after the single session of CK radiotherapy that you had at Stanford in 2007, and the story spanned 5 years.  You must have had a large dose of it, having only 1 session.   It is a fascinating story which I believe all AN patients, who have had the same treatment, should read!  I printed up your story, highlighted many areas of interest and used it as a general guide when I last spoke to my friend on the phone 2 weeks ago, mainly, trying to instill in him the positive attitude he needs to help him get through his ordeal and have a good outcome.  I still read through it from time to time.  I see you were able to travel a great distance a couple of times throughout your recovery, gives me hope that my friend can still travel here for us to meet and see each other.  I live in southeast Florida, by the way.

His 2 CK radiotherapy treatments were actually 2 months apart, so whichever side effects he had gotten over in between are back, all over again, following the 2nd treatment April 24th.  One month ago today.  So, your thinking that the treatments that far apart, even a month apart, is the better way to go?  That is fascinating. 

I know you had great help getting treatment at Stanford.  I have heard from my dentist, who knows someone who had the surgery a few decades ago and has facial paralysis and deafness in the AN ear, that Stanford is the best place in the U.S. for AN treatment.  His friend was not treated at Stanford. 
By the time I heard this information, though, my friend had already had his 1st treatment (February 20th this year).  It was a larger dose of CK radiotherapy than the dose he got in April.       

My friend, by the way, lives in Birmingham, England.  Born and raised and educated there. 

I don't think there will be any changes showing up in his upcoming June MRI, so soon after the 2 treatments.  I just hope he doesn't have to end up having surgery to remove the AN, because when he first told me about his diagnosis and the treatment options, I could tell he definitely didn't want to go through the surgery.  So, he was aware then of those risks.   

I do have a feeling, too, that he is becoming more accepting of the true reality of his situation and the timeline ahead for recovery (how long it could take for recovery.)  Time does heal wounds and shattered expectations.     

I'll be interested in speaking to him again on the phone tomorrow and get an update from him.  I'm ready for the real possibility that there won't be much change from 2 weeks ago.  It is different for him this time around because after the first treatment in February, he was back e-mailing me fairly regularly about 5 days later and resumed calling me about 2 weeks later.  Oh yes, he had to be hospitalized a couple of days after the first treatment in February, before he could be released to go home.  At home all by himself, he called his doctor daily to report to him how he was doing.  I think when the AN started swelling the first time, from then on, that is when his situation became something out of his control and it had freaked him out since.  I could tell that from the wording of his e-emails.  Now, since the 2nd treatment, he seems more calm and accepting of his limitations, but I think he believes he'll be that way forever.  That is when I told him of the ANA organization and asked them to send him the same great information packet they sent to me.  I hope he is reading through the materials and getting a more firm hold on his situation and not feeling so hopeless.  ANA can give AN patients so much hope!

Thanks again for your response!  It is great to meet you!   I may have more questions for you as time goes on, but I clicked on your link "e-mail me", but nothing came up.

Thanks so much,
Tina

[PaulW]

Hi Tina,
The website

www.myacoustic.org

That isn't me....

However some of the problems we had, and the timelines are similar and talking with others who have had radiation whether that be gamma knife, cyberknife, novalis etc the theme of what happens after radiation is not uncommon.

The people that seem to have the least side effects from radiation are the ones that are completely deaf and their balance is already gone.

I would be interested in knowing where he had Cyberknife, was it at the Harley st Clinic in London.
What were the doses he received ?

I think it is easy to blame cyberknife and swelling for the problems..

Have a read of this website in particular these two pages

http://vestibular.org/understanding-vestibular-disorder

http://vestibular.org/understanding-vestibular-disorder/symptoms#cognitive

I already had some of these problems before CK.
After CK they just got worse....

A lot of what your friend is experiencing in my opinion is problems with his vestibular system.
It maybe well worth getting him to see a vestibular therapist.
We had a vestibular therapist come and talk with our AN group
So many light bulbs went off in the room, when she discussed symptoms and experiences.
She recommended regular walking over uneven ground to help retrain the brain.
Walking along the beach was one suggestion, although a little hard in Birmingham.
She also taught vestibular exercises, however she felt that walking everyday helped people more and was easier to comply with.

I had problems with typing and speech BEFORE Cyberknife
Words just didn't come out right.
Typing was also hard it would take me hours to write a simple email as words and letters were frequently jumbled.

As for travel, that should not be a problem.
He will feel the same sitting in a chair at home or sitting on a plane

I actually live in Australia, and was treated in Munich Germany.
I travelled to Germany because in July 2010 Australia didn't have a Cyberknife or Gamma knife.

I flew home 36 hours after the CK treatment. a little more dizzy and deaf than before treatment but otherwise OK.

I drove 400 miles in a day for work, 3 weeks after treatment... I wont say it was easy, but I felt I did it safely

Flew a total of 6000km  1 month after CK as well, no problem. other than the ones I already had.

At 5 months I felt pretty crappy so I decided to jump in the car and drove 1200 miles over three days across the outback.

7 months after CK I flew to China, and Taiwan for work and play... The travel was fine, but had to push myself to do many things.
Coming down the great wall of china was very slow, I just had no balance, felt like I was totally drunk, but I hadn't touched a drop. My brain had to do so much work on the way up, coming down it sort of shut off..

I think it is fair to say that I could do anything I wanted to after CK, but it was not always easy.

Keeping a positive attitude is 90% of the battle..

Things do get better, much better.

At 5 months after driving the 1200 miles I had my first day where I felt normal. That feeling lasted about an hour.
But slowly the normalness increased and the living in the cloud sensation disappeared.

The first 6 months are often the most difficult.
Every person that I have ever met that has had radiation and had symptoms has always had them improve very significantly within two years... But it does take that long

I really enjoy snow skiing with the family and went skiing just before I was treated.
Basically I had trouble skiing due to poor balance it just wasn't pleasurable any more.
Went skiing again 12 months later and again did not enjoy it, I could do it.. but my poor balance made it hard.

At 2 years I could ski again and enjoyed it again. My balance problems had improved very significantly.

I am nearly at the 4 year mark now,
I don't think about my tumour much at all, life goes on just like it did before my AN
My hearing remains, and I can do everything again.

Your friend right now is probably thinking this will never end... It will.
The hump month is month 6.... things nearly always improve after that.

   

[PaulW]

Please keep in mind that it takes time for radiaton to show results

The overall success rates of radiation is around 98%

Many tumours that swell even for more than 3 years eventually shrink.

Its important that radiation is given the time and every opportunity to work before a surgery is planned.

Some surgeons have been known to operate too soon without letting the radiation take its course.

The chances of needing an operation especially at this early stage are very low

[photog1]

  I apologize, Paul W, I mistook you for the author of the myacoustic.org site.  That was quite a story he wrote, though,  about his experience, which actually lasted longer than yours.  So, you are pretty much back to normal after 4 years?  That is great if you are.  I failed to read the small print info. at the bottom of your post.  The author's diagnosis occurred in 2007 and had his CK radiotherapy treatment only once.  His first 6 months were very similar to yours. 

I have a rare medical condition myself, of which there is no known cause, and I have to take oral chemotherapy for it, which has made me anemic and feeling varying degrees of fatigue.  So, I can relate to the AN people regarding that side effect.  I have been on  this very strong medication for over 2 years.  My blood has to be checked every 2 months for any renal and hepatic changes.  I also work full-time in a very stressful environment and my job responsibilities have increased due to downsizing at the place where I work.  I have a condition called parapsoriasis.  It is mainly confined to my lower legs.  There is no cure for it, it can only be managed with medication and the medication itself could eventually cause me to get something called T-cell lymphoma.  So, for me, it is also a one-day-at-a-time thing.   

Again, sorry for the misunderstanding and thank you so much for the valuable information you shared with me.
Tina   

[photog1]

    Thanks for the additional, valuable information you just wrote to me.  I was in the midst of writing my previous post when it came in.  Our posts crossed.

To answer your question, I don't know for sure where my friend had his CK treatment, but I would guess it was at Queen Elizabeth Hospital in Birmingham.  I haven't asked him yet the name of the hospital, but I found it when I was Internet searching about the CK treatment and came upon a site showing CK locations.  I was glad to find there is even one in my former hometown in the state of northern Indiana!   The town where I was born (Ft. Wayne, Indiana).  At Parkview Memorial Hospital, and it's the only facility in northern Indiana that has the CK treatment.
Tina

[photog1]

Well, I tried to reach my UK friend this afternoon but there was no answer.  It was at about 4:00 PM, my time.  9:00 PM, his time.  Maybe he had just gone to bed for the night.  Hoping to reach him again sometime tomorrow or Tuesday.  I really hope that he is okay.  If he is still plagued with a lot of fatigue, then I would presume 9:00 isn't too early to turn in for the night.  Maybe he will be going in to work early tomorrow.

Hoping for the best for him, as always.
Tina

[photog1]

 
I still wasn't able to reach my UK friend at home yesterday, either, by phone.  I tried calling several times, always got his voice mail.   Still no e-mail from him, either, in response to my voice message I left him when I called on Sunday. 

I don't know what to think.  Trying not to think the worst!
Thanks,
Tina

[photog1]

   I gave it one more try this afternoon and I reached my UK friend at home!!!  He is doing as well as possible, managing day by day, but of course, still has some mental confusion and great fatigue by day's end, especially after a day of being at work, managing his company.  He is mostly bothered by the complete deafness in his right (AN) ear.  He said he does have a buildup of earwax in that ear and thinks that might help a bit if it could get all cleared out.  He is not adept at doing it my himself, he's tried but it only pushes it farther into his inner ear.  His doctor knows of this.  I suggested he have his ear doctor to that.  He has had the deafness in that ear since last September (5 months before his diagnosis.)  His doctor said he doesn't think his hearing will come back in that ear. 

He also has balance issues.  I asked him if he has heard of vestibular exercises.  He said no.  This was a surprise!  It also shocked me that there is little to no communication between him and his doctor, on his own part.  I tried to stress to him the importance of open communication between him and his doctor, that he needs to tell his doctor as much as he is telling me!  He hardly talks to his doctor at all!  It's been almost 5 weeks since his second CK treatment.  When is it time to start vestibular exercises?  I tried to explain to him how beneficial they can be for him.   Can he start them even while still having fatigue?

He is back at work, some days he is there all day.  It is on those days that he feels the most fatigue at day's end, of course. 

So, I was so glad to have reached him today and that he is okay.  He was at the office yesterday, that is why I was unable to reach him at home.  I never call him at his office.  He still believes he will be the way he is now, for the rest of his life.  I told him I am trying to help him because I like him very much and I deeply care about him.

Oh yes, to Paul W --- he did have his CK treatment at Queen Elizabeth Hospital in Birmingham (UK.)  He said it is a teaching hospital.

Life feels good.  Just trying to get my guy friend to think that, too.  But, as I told him, he will feel much better before too long.  I will keep telling him this!
Thanks!
Tina

[PaulW]

If your friend is deaf in one ear, and it is bugging him, he should look at getting a cros hearing aid or Baha. Both types of hearing aids help significantly with communication.
One thing I leaned recently is that getting a cros hearing aid, even if you are completely deaf on one side gives you some ability to pick up the direction of sound.. At first I thought this was impossible..
But the sound coming from the hearing aid is slightly different...allowing you to get back some direction of where sound is coming from...
There are a number of studies showing a significant improvement in quality of life when a hearing aid is fitted to a person who has lost their hearing on one side.
Assure your friend that he will feel a lot better. He will notice the difference over the next few months.
As for vestibular therapy.. Definitely worth doing something... Even regular walking is good... The vestibular exercises are great for some... Others find them too tedious

[photog1]

Thank you, PaulW for the hearing aid information.  He is wearing a hearing aid, said it isn't helping at all.  I will definitely tell him of the 2 types you mentioned.  His knowing that he will feel better for it has got to help him get into a better frame of mind.

If he is still having the fatigue, is it too soon to start the vestibular exercises? 

I would like to invite him to come here (Miami) for some R&R when his fatigue and other bothersome side effects dissipate.  Hopefully, that could be by late this fall or around the Christmas and New Year's holidays later this year.  Keeping my fingers crossed.  He asked me, yesterday, how the weather is here these days.

Thanks so much for your help!
Tina