CASE STUDY VI

1. CASE STUDY VI Lizette Luna, SPT Doreen Ruiz, SPT PT 7326 Neuroanatomy

2. Patient Background • Ms. Stultz • 72 y/o female • Retired nurse • Loves to travel • Lives alone in a one-story house

3. Patient Scenario • Pt suspects she has the flu—weakness • Increasingly difficult to take care of herself and home • Unable to get out of bed • 911 is called when her sister finds that she has fallen out of bed trying to get to the phone and her respiration is labored.

4. Examination • MOI: Unknown • MH: Admitted to ED 2 days ago, attending MD orders blood work, CT scan and a lumbar puncture (spinal tap) • Lab work results: spinal tap shows elevated level of protein without an increase in the number of WBC in the CSF

5. Examination Cont. Physical Examination • A&O x 3 • Appears overwhelmed and fatigued • BP &HR slightly elevated • Respiration labored • Administered O2 • Peripheral pulses intact Neurological Exam • No memory deficits found • Cranial Nerves—intact

6. Examination Cont. Motor System • Bilateral LE weakness: 2/5 • Bilateral UE weakness: 3/5 • DTRs: LE absent; UE diminished Sensation • Paresthesia—toes (bilaterally) • UE—N

7. Follow Up Examination Same • DTRs • LE—absent • UE—diminished • Sensory—diminished distally Different • Motor system • Bilateral LE: 1/5 • Bilateral UE: 2/5

8. Pathology • GuillainBarre Syndrome (GBS) • Demyelination disease that affects the peripheral nervous system • Autoimmume disease • Symptoms are characterized by: • Ascending symmetric motor weakness • Progressive weakness >1 extremity, usually stops progressing within four weeks. • Mild sensory signs and symptoms • Usually distally • Loss of deep tendon reflexes

9. Pathology Cont. • Cause of the disease is unknown • Frequently occurs after an infectious illness • Surgery, viral infection, immunization • Diagnosed: • Lumbar Puncture - Elevated Albumin in CSF after 1 week - Without an increase in the number of WBC in the CSF • Electrodiagnostic tests • Nerve conduction velocity(NCV)—slowed • Electromyogram (EMG)—loss of nerve impulse

10. Differential Diagnosis • Myasthenia Gravis • Condition where antibodies block receptors in muscles that receive signals of acetylcholine thus impairing muscle function • Clinical signs and symptoms • Muscle weakness and fatigability • Commonly in mms involved in eye mvt, chewing, swallowing and facial expression • Proximal muscles affected more than distal muscles • Diagnosed with: • Blood test • Tensilon

11. Evaluation: Disablement Model • Pathology: Guillain-Barre Syndrome (GBS) • Impairment: Progressive weakness • Functional Limitation: Pt is unable to take care of herself & her home • Disability: Pt will not be able to live independently

12. 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

13. Pt Prognosis Factors influencing Px: • Mortality rates 5 % or higher • Age • Time before recovery • Need for artificial respiration • 67 % patients completely recover in 1 year • 20 % sustain disabilities • The prognosis for this patient is fair/poor.

14. Pt Goals • LTG 1: Pt to maneuver powered WC through hallways, doors, and bathroom independently to allow DC to home in 6 weeks. • STG 1: Pt to transfer min. assist from bed to WC with sliding board in 4 weeks. • LTG 2: Pt to increase muscle strength 3+/5 in UE & 3/5 LE to be more functional at home in 6 weeks. • STG 2: Pt to demonstrate increased muscle strength 2+/5 UE & 2/5 LE in 2 weeks.

15. PT Implications • Patient may be easily fatigued & overwhelmed • Care in ICU requires monitoring arterial blood gases • Loss of control of respiratory muscles • Meticulous skin care • Overstretching & overuse of muscles • Recovery could take years

16. PT Intervention • Ascending Phase (2 – 4 weeks) • Pt & family education • ROM • Monitoring muscle strength • Skin Care • Careful watch of respiration

17. PT Intervention • Stable Phase (after 2- 4 weeks) • Aquatic Therapy • Gentle Stretching • AROM, Assisted AROM

18. PT Intervention • Descending (Recovery) Phase • Hot Packs • Gentle Massage • Pt education on AD, WC, home modifications • Proprioceptive Neuromuscular Facilitation Techniques

20. Medical Treatment • Plasmapheresis – plasma removed and filtered to dilute circulating antibodies - 4 to 6 exchanges / week - Can improve GBS impairments • Intravenous injections of immunoglobulins

21. Andy Griffith

22. FDR http://www.cnn.com/2003/HEALTH/10/31/roosevelt.polio.reut/index.html

23. References 1. Goodman CC, Fuller KS, Boissonnault WG. Pathology, Implications for the Physical Therapist. 2nd ed. Philadelphia, PN: Saunders; 2003. 2. Goodman CC, Snyder TE. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th ed. St. Louis, MO: Saunders; 2007. 3. Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science. 4th ed. New York, NY: McGraw Hill; 2000. 4. Griffith A. Journey to Health. Guideposts: a Practical Guide to Successful living. [serial online]. 1996; 51(9). Available at: http://www.mayberry.com/tagsrwc/wbmutbb/anewsome/private/guidpost.htm. Accessed: October 19, 2008.