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PT 7326 Neuroanatomy Case Study VI

PT 7326 Neuroanatomy Case Study VI. Zach Ibarra, SPT Brittney Spengler, SPT. Patient Background. Mrs. Stultz 72 y/o female Retired Nurse Was widowed recently and now lives alone in one-story home Loves to travel Plays bridge once a week with church friends. Patient Symptoms.

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PT 7326 Neuroanatomy Case Study VI

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  1. PT 7326 NeuroanatomyCase Study VI Zach Ibarra, SPT Brittney Spengler, SPT

  2. Patient Background • Mrs. Stultz • 72 y/o female • Retired Nurse • Was widowed recently and now lives alone in one-story home • Loves to travel • Plays bridge once a week with church friends

  3. Patient Symptoms • Mrs. Stultz suspected she had the flu because of feeling weak • Several days later, she found it difficult to take care of herself and was unable to get out of bed • Her sister enters Mrs.Stultz’s home to find that she has fallen out of bed trying to answer the phone • Respiration is labored • 911 is called and Mrs. Stultz is admitted to the ED • Physician orders blood work, CT scan, and a lumbar puncture • MOI is unknown

  4. Physical Examination • A & O x 3 • BP and HR slightly elevated with a decreased RR • Temperature of 98.7° F • Peripheral pulses in tact • Pt appears weak and fatigued

  5. Neurological Examination • No memory deficits found • Normal cognitive function • Cranial Nerves are intact

  6. Examination Cont. • Motor Systems • R UE & L UE- STR 3+/5 with normal tone • R LE & L LE – STR 2/5 with normal tone • Deep Tendon Reflexes • Bilaterally LE is absent • Bilaterally UE is WNL

  7. Examination Cont. • Sensation • Bilateral paresthesia in feet • UE WNL • Coordination/Balance • WNL

  8. Follow Up Visit • Same • DTR’s- Bilaterally • LE is absent • UE is WNL • Different • Motor System • R UE & L UE- STR 3-/5 • R LE & L LE – STR 2-/5 • Sensation • Paresthesia spread to knees

  9. Any guesses as to what this patients pathology might be?

  10. Pathology • Guillain-Barré Syndrome (GBS) • Demyelination and autoimmune disorder where the body’s immune system attacks part of the peripheral nervous system • Rare disorder that can develop over the course of hours, days, or even weeks • Cause is unknown, but has occasionally been seen to occur post surgery or vaccination administration • If intensity of symptoms continually increase, can be considered life-threatening

  11. Pathology Cont. • Symptoms: • Decreased RR • Normal temperature • Progression from LE to UE- Bilaterally • Weakness • Loss of DTR’s • Paresthesia • Usually distal to proximal

  12. Evaluation: Disablement Model • Pathology: Guillain-Barré Syndrome (GBS) • Impairment: Decreased RR, progressive weakness and paresthesia from LE to UE • Functional Limitation: Pt is unable to take care of herself • Disability: Pt cannot travel, go to bridge once a week, or live by herself

  13. APTA Practice Patterns • 5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated With Peripheral Nerve Injury • 5G: Impaired Motor Function and Sensory Integrity Associated With Acute or Chronic Polyneuropathies • 6E: Impaired Ventilation and Respiration / Gas Exchange Associated with Ventilatory Pump Dysfunction of Failure. • 7A: Primary Prevention / Risk Reduction for Integumentary Disorders

  14. Prognosis • Outcomes vary from fair-poor & depend on several factors: • Age • Time between onset & recovery • Need for artificial respiration • Progression of sxs (Ascending Phase)decreases within 4 wks for 90% of pts • Pts undergo a period of stasis lasting 2-4 wks before recovery begins in proximal to distal progression

  15. Prognosis Continued • Full recovery may take months or years 67% fully recovery within 1 yr • 20% sustain significant disability • 8% unable to recover within 2 yrs • Recurrent in 10% of cases

  16. Goals • LTG #1: Pt to operate pwr assist WC up and down WC accessible ramps and through assimilated 32” doorway I at home prior to DC in 8 wks. • STG: Pt to demonstrate mod assist transfer from bed to WC c min assist c sliding board in 4 wks. • STG: Pt’s sister to demonstrate transfer of pt from bed to WC c min assist c sliding board in 4 wks.

  17. Goals Continued • LTG # 2: Pt to increase MMT 4/5 UE & 3/5 in LE in order to restore function for ADLs prior to DC in 8 wks. • STG: Pt to increase MMT 3+/5 UE & 2/5 LE in 4 wks.

  18. Intervention • Ascending Phase (first 2-4 wks) • Focus on complications associated with immobilization • Monitor mm STR • Skin care • ROM • Monitor fatigue with activity • Monitor respiration and Po2 levels • Pt & family education

  19. Intervention Continued • Stable phase (2-4 more wks) • Aquatic therapy • AROM or AAROM • Prevention of overstretching and mm overuse • Descending phase (when sxs begin to subside) • PNF • Pt and family education with WCs, ADs, and transfers • Thermotherapy to alleviate deep mm & jt pn

  20. PT Implications • Monitor pt’s RR closely • Muscle strength will progressively decrease: • Strengthening • Stretching • ROM • **Pt may fatigue easily** • Monitor skin integrity

  21. Interesting Story About GBS

  22. References • Goodman CC, Fuller KS, Boissonnault WG. Pathology, Implications for the Physical Therapist. 2nd ed. Philadelphia, PN: Saunders; 2003. • Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science. 4th ed. New York, NY: McGraw Hill; 2000. • American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Alexandria, VA: APTA; 2003.

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