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PT 7326 Neuroanatomy Case Study II

PT 7326 Neuroanatomy Case Study II. Kristen Martin, SPT Megan Legault, SPT. Patient Background. Mr. Richards 40 y/o male, speech therapist Lives with wife and young son Lives in two story home with 15 steps. Symptoms. Choked on a piece of meat during lunch Pt c/o dysphagia

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PT 7326 Neuroanatomy Case Study II

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  1. PT 7326 NeuroanatomyCase Study II Kristen Martin, SPT Megan Legault, SPT

  2. Patient Background • Mr. Richards • 40 y/o male, speech therapist • Lives with wife and young son • Lives in two story home with 15 steps

  3. Symptoms • Choked on a piece of meat during lunch • Pt c/o dysphagia • Noticed difficulty picking up his son off of the floor • Wife noticed Mr. Richards having problems walking up the stairs as he is relying on the handrails to assist • 1 wk ago needed help rising from a low sofa • Referred by Chiropractor to Neurologist

  4. Physical Examination • A & O x 3 • BP, HR, and RR normal • Peripheral pulses intact • Dysarthria noted

  5. Neurological Examination • No memory deficits found • All cranial nerves intact, however Mr. Richards demonstrates tongue fasciculations upon testing of hypoglossal nerve.

  6. Examination Continued • Motor Systems • RUE & LUE- MMTs of the UE 4/5 • RLE & LLE- MMTs of the LE 4/5 • DTRs- LE reflexes diminished

  7. Examination Continued • Sensation • All sensory tests WNL • Coordination/Balance • Romberg, Tandem Stance, SLS all negative

  8. Re-Evaluation at 30 days • Motor Systems • RUE & LUE- MMTs of the UE 3+/5 • RLE & LLE- MMTs of the LE 3+/5 • DTRs- UE & LE reflexes diminished • Coordination and balance have worsened 2° decreased mm tone in LE.

  9. SO WHAT DO YOU THINK??

  10. A L S

  11. Pathology • Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease) • Bilateral lower motor neuron damage • Neurodegenerative disease • Flaccid paralysis, decreased DTR’s, mm atrophy • Sensory remains intact

  12. Pathology Continued • Will also affect UMN/Corticospinal tract with time due to degeneration leading to sclerosis of the lateral spinal cord (i.e. lateral sclerosis) • Lou Gehrig was a famous baseball player who died of ALS.

  13. Evaluation: Disablement Model • Pathology- ALS • Impairment- decreased overall strength and mm atrophy, difficulty generating words • Functional Limitation- Slightly decreased independence in ADL, difficulty speaking • Disability- Pt cannot return to his job as a speech therapist

  14. Diagnosis • Practice Pattern 5E: Impaired motor function and sensory integrity associated with progressive disorders of the central nervous system. • Stage II of ALS

  15. Prognosis • Average lifespan from diagnosis is 3-5 yrs • Pt is young with family support and high motivation. However, disease is progressive and will most likely move through these stages…

  16. Stages of ALS • Stage I: Mild weakness, clumsiness, ambulatory, and independent in ADL • Stage II: moderate, selective weakness; slightly decreased independence in ADL, ambulatory • Stage III: Decreased independence in ADL, pt no longer ambulatory-requires wheelchair

  17. Stages of ALS • Stage IV: Pt requires a motorized wheelchair for mobility • Stage V: Severe LE weakness, mod to severe UE weakness, increasingly dependent in ADL, possible skin breakdown 2° poor mobility • Stage VI: Bedridden, completely dependent in ADL

  18. Goals • LTG 1: Pt will maintain a STR of 3+/5 in UE mms in 4 wks in order to pick up his son from the floor • STG 1: Pt will perform 20 reps of bicep curls bilaterally with a red thera-band in 2 wks. • STG 2: Pt will perform 20 reps of shoulder abduction bilaterally with a red thera-band in 2 wks.

  19. Goals • LTG 2: Pt will amb >100 ft over even and uneven surfaces without an AD in 4 wks. • STG 3: Pt will maintain a STR of 3+/5 in bilateral quadriceps and ankle dorsiflexors in 2 wks.

  20. Intervention (for Stage II) • Stretching to avoid contractures • Cautious strengthening of mms, monitoring fatigue • Consider orthotic support • Walking • Pt and family education • Note: Intervention changes as pt progresses through the stages

  21. PT Implications • Mm strength progressively decreases. • Regular exercise will help ease fatigue and improve overall well being. • Gait analysis is necessary. • Falls from mm weakness are common. • Braces, ADs, and WCs should be considered for future necessity.

  22. PT Implications • Heat and e-stim can help with the pain associated with mm shortening, cramping, and jt stiffness. • Respiratory impairments become an issue and will eventually lead to death.

  23. References • Pathology: Implications for the Physical Therapist, 2nd edition. Goodman, Fuller, Boissonnault • The ALS Association official website- www.alsa.org

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