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Case VIII Deborah Landreth and Chris Rogers

Case VIII Deborah Landreth and Chris Rogers. Our patient. Donald Jones Retired Carpenter Lives with wife Hobbies includes carpentry Right hand dominant. MOI. Working on cabinetry and felt weakness in left side, went home had tea with his wife and strength returned

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Case VIII Deborah Landreth and Chris Rogers

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  1. Case VIIIDeborah Landreth and Chris Rogers

  2. Our patient • Donald Jones • Retired Carpenter • Lives with wife • Hobbies includes carpentry • Right hand dominant

  3. MOI • Working on cabinetry and felt weakness in left side, went home had tea with his wife and strength returned • Next day while taking out garbage, Mr. Jones lost consciousness and fell. • Taken to ER and promptly given tPA (Tissue Plasminogen Activator)

  4. Physical Examination • Medically stable, referred to PT to address L hemiplegia • A&O x 3 • BP 130/88 (with Rx), HR 75, RR 15 • Pulses intact • STR on non-affected side is normal • Pt is anxious/eager and unrealistic of capabilities

  5. Neurological Examination • No memory deficits found • Cranial Nerves were intact • Sensation diminished on affected side

  6. L side MMT - 0/5 UE - 1/5 LE DTR - absent in UE and LE Tone - flaccid paralysis of whole left side Balance - 20 on Berg Balance Scale R side MMT - 4/5 UE - 4/5 LE DTR - normal for UE and LE Tone - normal tone Motor Examination

  7. Cognitive/Perceptual Examination • Patient response to questions about affected limbs includes denial of impairment and states “his arms and legs are fine.” • Patient unable to describe or recognize familiar routes. • Patient shows difficulty with localizing objects in space and gauging distance

  8. Evaluation Disablement Model • Pathology: Acute CVA affecting non-dominant Right hemisphere • Impairment: Left hemiplegia, spatial relations disorders, and anosognosia • Functional Limitation: Patient unable to safely care for himself • Disability: Patient unable to return to carpentry hobbies and perform ADLs independently

  9. Time for a Differential Diagnosis

  10. Differential Diagnosis • Initial TIA with Left hemiparesis and quick recovery • CVA to non-dominant Right Hemisphere within 24 hours of TIA • Left Hemiplegia • Anosognosia – pathogenesis unclear, but associated with damage to supramarginal gyrus • Topographical Disorientation – the majority of cases present with lesions to Brodmann’s Area 30 • Visual-Spatial Agnosia – Usually due to lesions of the right parieto-occipital-temporal junction • These sxs are most likely due to occlusion of the MCA

  11. Topography

  12. Topography

  13. Topography

  14. Blood Supply

  15. APTA Practice Pattern • 5D: Impaired motor function and sensory integrity associated with non-progressive disorders- acquired in adolescence or adulthood.

  16. Prognosis • Mr. Jones’ prognosis is fair • Considering: • He received tPA within the first 3 hours. • Anosagnosia typically resolves spontaneously within the first 3 months • Topographic disorientation usually resolves in 2 months or less • Recovery can be accelerated with therapy • Visual-Spatial Agnosia can be addressed with therapy • Patients generally regain some motor function spontaneously within 3 months and can also be further facilitated with therapy

  17. PT Intervention • Safety education regarding anosognosia for pt and caregiver • Spatial recognition and topographic orientation training Ex) Pt positioning, mazes, following directions, Left hemisphere sequencing • Improve strength and motor performance of the affected side Ex) Constraint induced, biofeedback, e-stim, gait training

  18. Goals • LTG 1: Pt to amb from PT gym to room (~100 ft) with hemi-walker independently in order to safely navigate home in 3 weeks. • STG 1: Pt to amb 20 ft with hemi-walker with mod assist following dot sequence in 1 week. • LTG 2: Pt hammer 20 nails while standing without hitting thumb in order to return to carpentry hobbies • STG 2: Pt to pick up 10 pegs and place them in peg-board while standing with min-assist in 1 week.

  19. References • Goodman CC, Fuller KS, Boissonnault WG.  Pathology, Implications for the Physical Therapist.  2nd ed.  Philadelphia, PN:  Saunders; 2003. • O’Sullivan S, Schmitz T. Physical Rehabilitation. 5th ed. Philadelphia, PA: F.A. Davis Co; 2007

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