PT 7326 Case Study IV

1. PT 7326 Case Study IV Wayne Strube, SPT and Mariana Licata, SPT Fall 2008

2. Examination • Cathy Jenkins (CJ) • 29 y/o female • Full-time accountant • Lives with husband • 1st floor apartment • Recently recovering from flu • MOI: idiopathic, acute

3. Examination Sxs hx: • Day 1: • CJ c/o pain “all over” • ED releases CJ with Vicodin • Day 2: • husband finds CJ in fetal position on floor • admitted to hospital • pn not responding to narcotics • Day 3: • CJ unable to stand

4. Examination: Physical • A&O x 3 • BP: 140/85, HR: 100, RR: 22, Temp: 98.7ºF • Peripheral pulses intact: DP, Radial • Well nourished, appears stated age • Patient in obvious pain, in fetal position with distressed features; did not want to sit up • Pt requested, “take off the sheets, it hurts”

5. Examination: Neurological • Awake, distracted by pain • Normal cognitive and language function • Good long-term memory, but some deficits in short term memory • Cranial Nerves: Intact

6. Examination • MMT: • UE • L: 2-/5 spastic • R: 4-/5 normal tone • LE • L: 2-/5 spastic • R: 4-/5 normal tone • DTR (patellar, brachioradialis*) • L: hyperreflexia, 4+ • R: low normal, 2+ *Other reflexes NT 2º pn • Patient unable to stand, 2º pn and weakness

7. Examination: Sensory • Observed reduced postural stability in sitting, especially to L • Proprioception reduced, L>R both UE and LE • Pt reports ‘buring’ pn during test • Light Touch elicited a response of pain (L>R) on both UE and LE • No dermatomal pattern on sensory exams • Despite L>R, there was bilateral pn response • Further testing not done 2º pn, “all over” 10/10.

8. Evaluation: clues… • Excruciating, non-localized pain • Does not respond to narcotics • Any stimuli (e.g. sheets) elicit painful response  allydonia • DC/ML and STT elicit painful, altered reaction • Spasticity on left (UMN? LMN?) • Weakness on left implicate CST

9. Diagnosis: Thalamic Pain Syndrome aka Central Post-Stroke Pain (CPSP) • Lesion of Right Ventroposterolateral Nucleus (VPL) • Dysfunction of somatosensory of UE—body—LE  PAIN • VPM not involved because of normal head/neck • Lesion encroaches on Lateral Corticospinal Tract • Ventrolateral nucleus (VL) is involved in motor relay and houses CST  left hemiparesis • Close proximity to Posterior Limb of Internal Capsule also leads to CST involvement/hemiparesis • Short term memory relayed through thalamus • Unilateral lesion, right posterior thalamus

10. Probable Location of Lesion Motor Somatosensory Right Thalamus Probable Cause: CVA of PCA Figure from M.E. Parker’s Fall 2008 DPT Neuroanatomy Lecture: Thalamus

11. APTA Practice Pattern • Neuromuscular 5D: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous System—Acquired in Adolescence or Adulthood

12. Nagi Disablement Model • Pathology: thalamic pain syndrome • Acute with lasting effects, diffuse symptoms, nonprogressive • Impairment: altered painful sensation, left hemiparesis • Functional Limitation: cannot walk, manage pain • Disability: cannot go to work, cannot concentrate or socialize

13. Prognosis • Prognosis for this patient is fair. • Symptoms such as weakness can be addressed, but ultimate ability to pain control is highly individualized

14. PT Goals LTG: • In 6 weeks, pt to ambulate on carpet x 500 ft c AD for discharge home. • In 6 weeks, pt to short sit in chair c arms for 1 hr s LOB s fatigue to return to work. • In 6 weeks, pt to report overall pn 4/10 c ADLs to return home.

15. PT Goals STG: • In 3 weeks, pt to demonstrate L LE STR of 3/5. • In 3 weeks, pt to transfer sit stand x 2 s LOB c CGA.

16. Implication/Intervention • Motor Impairment & Sensory Dysfunction • Pt and caregiver education • Gait training (with AD as needed) • Transfer training • STR training • Balance training

17. Implications/Intervention Cont. Pain Control • PT: • Vestibular Caloric Stimulation • Exercise program to maintain ROM, tone, and general wellbeing • Multidisciplinary Intervention • Refer to Pain Clinic • Psychological evaluation for long term pain management • Pharmacological intervention • Tricyclic antidepressants or anticonvulsants can be more effective than narcotics

18. References • National Institute of Neurological Disorders and Stroke. Central Pain Syndrome Information Page. http://www.ninds.nih.gov/disorders/central_pain/central_pain.htm. Updated May 09, 2008. Accessed October 12, 2008. • Oh SK, Lee AY, Kim KI, Kim J, Kim JM. Central pain after thalamic stroke: clinical and radiological characteristics. J Korean Neurol Assoc. 1998;16(2):155-159. • Ramachandran V, McGeoch P, Williams L. Can vestibular caloric stimulation be used to treat Dejerine–Roussy Syndrome? Medical Hypotheses 2007;69(3):486 – 488. • Ramachandran VS, McGeoch PD, Williams L, Arcilla G. Rapid Relief of Thalamic Pain Syndrome Induced by Vestibular Caloric Stimulation. Neurocase. 2007;13:185-188. • Sodicoff, M. Neurological Exam: Diencephalon: Vascular Lesions: Thalamic Pain Syndrome. http://isc.temple.edu/neuroanatomy/lab/lesions/31.htm. Updated July 18th, 2004. Accessed October 7, 2008. • Tso DY. Thalamus. http://www.tsolab.org/nrjclub/070801/thalamus04.pdf. Updated July 27, 2008. Accessed October 12, 2008. • Verma AK, Maheshwari MC. Hypesthetic-ataxis-hemiparsesis in thalamic hemorrhage. Stroke. 1986;17(1):49-51.