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Rehabilitation of a Complex Patient with Autoimmune Disease and ARDS

Rehabilitation of a Complex Patient with Autoimmune Disease and ARDS. Katherine Leuck, PT, DPT Cori Cohen, OTD, OTR/L Main Campus, Acute Care December 07, 2016. CASE DESCRIPTION.

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Rehabilitation of a Complex Patient with Autoimmune Disease and ARDS

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  1. Rehabilitation of a Complex Patient with Autoimmune Disease and ARDS Katherine Leuck, PT, DPT Cori Cohen, OTD, OTR/L Main Campus, Acute Care December 07, 2016

  2. CASE DESCRIPTION • HPI- Patient is a 41 y/o male presenting to CCF MICU on 8/19 with recent diagnosis of Adult-onset Still's disease and ARDS. • History • 5/9/16 presents to OSH with chest pain, outpatient workup negative • Pt is followed as an outpatient by multiple specialists; continued to have multiple nonspecific symptoms as seen in ROS • Outpatient workup included imaging demonstrating ground glass opacities and was recommended for admission to OSH for continued workup • But he was admitted for worsening symptoms including muscle/joint pain, vomiting, cough, and diarrhea. • Review of Symptoms • Respiratory: non-productive cough • Gastrointestinal: vomiting, diarrhea • Musculoskeletal: arthralgia/myalgia • Integumentary: non-specific, pruritic rash grossly on UE/LE

  3. Case continued • Imaging and testing • CT positive for enteritis & mesenteric lymphadenopathy, enlarged fatty liver • WBC elevated, LFTs elevated, negative tests: RSV, strep, HIV, fungal serologies, EBV and CMV • Bronchoscopy with BAL showed inflammatory changes, began antibiotics • CT chest shows progressive ground glass infiltrates • ANA negative, RF negative (autoimmune inflammatory markers) • Inpatient course • 8/6: Pt intubated 2/2 respiratory distress (AC 50%, PEEP 12) • 8/10: Pt extubated • 8/11: Rheumatology suspected adult onset Still's Disease and was started on Anakinra (pulse dose steroids) • 8/16: Re-intubated for possible transfer, asynchronous and tachpyneic to 50s. Required proning (FiO2 100%; PEEP 15) • 8/19: arrival to CCHS. Pt is paralyzed, sedated on propofol, fentanyl and paralyzed with atrocurium. Patient on dopamine and norepinephrine • 8/20: spontaneous pneumothorax, chest tube placed • 8/29: Physical and Occupational therapy are consulted

  4. Literature Review • Adult Onset Still’s Disease (AOSD) is a constellation of symptoms and is a dx of exclusion. Presents as several non-specific symptoms and is often preceded by infection triggering immune response. Can have involvement with heart, lungs and kidneys. • Acute Respiratory Distress Syndrome (ARDS): occurs quickly, within a few hours or up to a few days following the initial disease/trauma.  ARDS occurs when fluid builds up in the alveoli and results in hypoxemia. • Patients present with respiratory distress, tachypnea, tachycardia and use of accessory muscles for respiration. This patient population requires high concentrations of supplemental oxygen, mechanical ventilation with low tidal volumes and high PEEP. • Cardioinhibitory vasovagal response

  5. Ventilator Management • Research shows that managing the vent with low tidal volumes and a higher than normal PEEP maximizes alveolar recruitment. • These two factors together may decrease the risk of ventilator associated lung injury. This is referred to as open lung ventilation, which may help improve mortality and other clinical factors. • Low tidal volumes are a protective mechanism for the lungs (avoiding alveolar overdistention).

  6. ARDS vs Typical Vent Settings • Typical parameters which indicate proceeding with PT and OT • FiO2 <60% • PEEP <12 • Respiratory Rate <30 • When treating ARDS patients daily discussion must take place between PT, OT,RT and medical team • A patient with ARDS will often have an increased RR secondary to a low tidal volume to ensure the patient is receiving the entire minute ventilation. Reasonable SpO2 saturation is 88-95%. The typical ARDS patient will desaturate at a moderate rate requiring extended rest breaks and increased supplemental O2 for therapy • Relevance for therapy: ventilator settings for ARDS patients may contradict proposed guidelines for progression of therapy.

  7. EXAMINATIONSubjective Measures Patient Goals Short Term: tolerate out of bed tasks Long Term: Go to rehab, Return home and regain baseline function Home Set Up Patient Lives With: Significant Other Assistance Available: PRN Number Of Stairs Into Home: 2 Number Of Stairs To Bed/Bath: 0 Equipment Owned:  None Prior Functional Level: Within Functional Limits - patient is a police officer, independent with ADL/IADL tasks. Wife and family at bedside throughout hospital stay, very involved family

  8. EXAMINATIONObjective • MMT/ROM • Evaluation on 8/30/16 (limited exam, focus on function to EOB this session) • R knee extension 2-/5 • L knee extension 2/5 • L ankle DF 1/5 • R ankle DF 1/5 • R and L shoulder <50% ROM; 2-/5 • MMT BUE 2-/5, exam limited by sedation/weakness

  9. THERAPY DIAGNOSIS & PROGNOSIS Acute Care PT diagnosis included reduced mobility and generalized muscle weakness Acute Care OT diagnosis included decreased activities of daily living (ADL) and reduced mobility Problem list: Occupational Therapy Problem List: Impaired Self Care; Decreased Activity Tolerance; Functional Mobility Impairment; Balance Impaired Physical Therapy Problem List: Education Deficit; Impaired Self Care; Decreased Activity Tolerance; Decreased Range Of Motion; Decreased Strength; Functional Mobility Impairment; Balance Impaired Early physical and occupational therapy intervention look similar in the ICU working toward very different goals

  10. Challenges and Complications • Medical complications • Pneumothorax (2 instances) • Hypoactive delirium • High amounts of sedation • Difficulty controlling BP/HR/SaO2 and volume status • High anxiety requiring OT for relaxation training during physical function tasks per PT • Vasovagal response (atypical) • High oxygen requirements and difficulty weaning from ventilator • Poor tolerance of transition from IV to PO steroids (respiratory distress, shock)

  11. INTERVENTION

  12. Therapy Goals • Physical Therapy Goals • Transfer supine to/from sit with contact guard • Transfer sit to/from standing to be assessed when deemed safe • Pt will improve seated balance to contact guard in preparation for transfers • Pt will tolerate BLE/BUE exercise > 20 reps to facilitate strength • Occupational Therapy Goals • Feeding with: Set Up • Grooming with: Set Up • Upper Body Bathing with: Modified Independent • Upper Body Dressing with: Modified Independent • Lower Body Bathing with: Modified Independent • Lower Body Dressing with: Modified Independent • Chair Transfer with: Contact Guard Assistance • Toilet Transfer with: Contact Guard Assistance • Tolerate (minutes of functional activity): 30 • Functional Activity with: Contact Guard Assistance • Demonstrate Positive Coping Strategies with: Independent • Demonstrate Competence With Education with: Independent 

  13. Pt not seen again until 9/6 due to multiple reasons: illness requiring pressors, vent weaning, tracheostomy (9/2).

  14. Transfer out of ICU (yay!)

  15. Patient discharged to Acute Rehab on 9/26 via ambulance

  16. OUTCOMES • Treatment on 9/15/16 updated • BLE 3/5 • Treatment (last tx) on 9/25/15 • >/= 4/5 measured through function, ambulating with RW • BUEs at least 4/5 noted by ADL UE/LE dressing performance • Oxygen requirement at 30% FIO2 via trach collar • Discharged home from acute hospital following pleurodesis on 10/22 • Patient ambulating with walker (MIN assist) • Patient performing ADLs w/ MIN assist

  17. CONCLUSION • Complex case combining autoimmune disease with ARDS • Combination of cognitive management with physical progression • Skilled cotreatment required to maintain hemodynamic monitoring during slightest mobility and exercise • Skilled cotreatments can significantly benefit complex patients while addressing separate goals

  18. Where he is now… • Patient discharged to Acute Rehab in Louisville, KY. • Patient re-admitted to Jewish hospital with pneumothorax (3rd) requiring chest tube re-insertion, VATS, and pleurodesis. • Patient required PEG tube 2/2 decreased swallow reflex, poor esophageal sphincter contractility, now resolved and patient tolerating PO, full diet! • Patient ambulating without adaptive equipment, assisting with coaching daughter's basketball team • Physical therapy outpatient 3x/wk • Discharged from home OT

  19. REFERENCES 1)Pearmain L , and Herridge MS . Outcomes after ARDS: a distinct group in the spectrum of disability after complex and protracted critical illness. Minerva Anestiologica; 2013. 79:793-803  2)Putman, M.S. and Du, A.B. Adult Onset Still's Disease Complicated by the Acute Respiratory Distress Syndrome. Lupus: Open Access. 1/2016; 1:111. 3) Siegel, M. D., MD, & Hyzy, R. C., MD. (2016, June 16). Mechanical Venitlation of adults in acute respiratory distress syndrome. Retrieved November 29, 2016, from www.uptodate.com •  Patient provided HIPAA release for photos and privacy information.

  20. Spinal Manipulation & Sport-Specific Strengthening in a Collegiate Baseball Player with Thoracolumbar Junction Syndrome • Alli Burfield, SPT & Eric Jankov, PT, DPT, C-OMPT, CSCS • University Hospitals St. John Medical Center • Outpatient Rehabilitation

  21. Thoracolumbar Junction Syndrome Case Report Purpose • Outline the patient/client management of thoracolumbar junction syndrome (TLJS) using an evidence-based, manual therapy and therapeutic exercise approach. • Explain the clinical signs and symptoms of TLJS. • Provide treatment strategies to effectively manage TLJS. • Provide rationale for clinical decision making process in the treatment of TLJS.

  22. Thoracolumbar Junction Syndrome Case Report Patient History • 19 y/o M with complaints of left-sided low back pain with radicular symptoms, groin pain, and lateral hip pain following batting practice. • Medical Diagnosis: Acute Lumbar Disc Herniation • Pain: 4/10 at rest, 8/10 during baseball • Aggravated by batting, throwing, forward bending, & prolonged sitting. • Relief with prone press ups & stretching before and after practice. • Radiological Impression: Unremarkable, except hypoplastic ribs at T12.

  23. Thoracolumbar Junction Syndrome Case Report Examination • Posture: Excessive lumbar lordosis + anterior pelvic tilt in standing • Palpation: Hypertonicity and tenderness of the L lumbar paraspinals & hypersensitivity to the L greater trochanter and the inguinal region. • Spinal Palpation: Painful at L4-L5 and at TLJ with PA pressure. M/L glides to SP at TLJ reproduced symptoms in lateral hip & groin. • Lumbar ROM: Grossly WNL with LBP pain in all directions, extension being the worst.

  24. Thoracolumbar Junction Syndrome Case Report Examination • Repeated Movements: Prone lumbar extension centralized LBP, but no effect on lateral hip or groin pain. • Hip ROM: Limited hip extension bilaterally, otherwise WNL. • Hip & Core MMT: WFL except gluteus medius & maximus 2/5.

  25. Thoracolumbar Junction Syndrome Case Report Maigne R. Low Back Pain of Thoracolumbar Origin. Arch Phys Med Rehabil. 1980; 61 (9): 389 – 95. • TLJS is caused by compression or entrapment of the dorsal rami at T11-L1 and/or the thoracolumbar fascia. • Diagnosed by clinical symptoms or by periapophyseal joint injection. • Referral Areas: • 1. Inguinal/Groin Area • 2. Posterior Iliac Crest • 3. Greater Trochanter

  26. Thoracolumbar Junction Syndrome Case Report Clinical Presentation • Symptoms reproduced by: • PA or lateral pressure at the TLJ • Contralateral Sidebending • Ipsilateral Rotation • Skin rolling test • Deep palpation along posterior iliac crest • Commonly seen in individuals who perform repetitive/overuse activities with rotational components.

  27. Thoracolumbar Junction Syndrome Case Report Clinical Impression • TLJS • Lumbar Paraspinal Strain • Acute Lumbar Disc Herniation

  28. Thoracolumbar Junction Syndrome Case Report Interventions Spinal Manipulation to TLJ

  29. Thoracolumbar Junction Syndrome Case Report TLJ Rotation & Self Mobilization

  30. Thoracolumbar Junction Syndrome Case Report Resisted Baseball Swings & Core Stabilization

  31. Thoracolumbar Junction Syndrome Case Report Outcomes • Plan of Care: 2x/week for 3 weeks, then 1x/week for next 3 weeks • At discharge and at a 3 month follow up, patient was pain-free with full athletic participation. • Rated +6 (a great deal better) on the 15-point Global Rating of Change Scale • Oswestry Disability Index 0% disability at discharge, from 26% at initial evaluation.

  32. Thoracolumbar Junction Syndrome Case Report Anatomy http://www.wollaston-chiropractic-clinic.co.uk/assets/images/Lateral__Side_.jpg https://upload.wikimedia.org/wikipedia/commons/thumb/a/a3/Sobo_1909_35.png/201px-Sobo_1909_35.png

  33. Thoracolumbar Junction Syndrome Case Report Anatomy http://higheredbcs.wiley.com/legacy/college/tortora/0470565101/hearthis_ill/pap13e_ch07_illustr_audio_mp3_am/simulations/figures/vertebrae.jpg

  34. Thoracolumbar Junction Syndrome Case Report Singer KP, Breidahl PD, Day RE. Variations in Zygapophyseal Joint Orientation and Level of Transition at the Thoracolumbar Junction. SurgRadiol Anat. 1988; 10: 291 – 295. Level of Evidence: 2b • CT scans through superior endplates of T11, T12, L1, and L2 (N = 214) • Joint angles calculated using computeraided digitiser • Coronally oriented superior & sagittallyoriented inferior joint processes • Articular tropism (> 20°) most frequentat T11-12 (21%), then T12-L1 (9%)

  35. Thoracolumbar Junction Syndrome Case Report Anatomy http://drmorgan.info/attachments/Image/Image1_edit_William-E.-Morgan-c.png?template=generic http://file.scirp.org/Html/9-2400120/b3c5afd3-5aa8-4350-9ecc-22fe3e3cc027.jpg

  36. Thoracolumbar Junction Syndrome Case Report Maigne JY, Maigne R. Trigger point of the posterior iliac crest: painful iliolumbar ligament insertion or cutaneous dorsal ramus pain? An anatomic study. Arch Phys Med Rehabil. 1991; 72 (10): 734-7. Level of Evidence: 2b

  37. Thoracolumbar Junction Syndrome Case Report Biomechanics http://images.slideplayer.com/22/6351881/slides/slide_18.jpg

  38. Thoracolumbar Junction Syndrome Case Report Hansen L, de Zee M, Rasmussen J, Anderson TB, Wong C, Simonsen EB. Anatomy and Biomechanics of the Back Muscles in the Lumbar Spine with Reference to Biomechanical Modeling. Spine. 2006; 31 (17): 1888-99. Level of Evidence: 2a

  39. Thoracolumbar Junction Syndrome Case Report Biomechanics • Normal (neutral) mechanics • TLJ = higher degree of rotation available compared to lumbar spine • Orientation of the facet joints • Floating ribs https://www.researchgate.net/figure/6428554_fig3_Figure-3-Movements-of-the-lumbar-spine-A-side-lateral-flexion-B

  40. Thoracolumbar Junction Syndrome Case Report Biomechanics • Abnormal (non-neutral) mechanics • Excessive lumbar lordosis + ant. pelvic tilt further limits lumbar rotation, thus increasing stress to TLJ • Also increases risk of extension overload at TLJ http://www.muscleimbalancesyndromes.com/wp-content/uploads/2012/01/fig04_03b.jpg https://s-media-cache-ak0.pinimg.com/236x/f3/03/93/f30393c4b07ce64bb0d2c9a204a67ee1.jpg

  41. Thoracolumbar Junction Syndrome Case Report Fortin JD. Thoracolumbar Syndrome in Athletes. Pain Physician. 2003; 6: 373 – 375. Level of Evidence: 4. • Sports with repetitive spinal loading with hip flexion & cervical extension concentrate forces at TLJ (i.e. equestrian, hockey, football, golfing, baseball, etc.) • Limited cervical extension when head is already tilted upwards • Limited thoracic extension available due to biomechanical limitations (i.e. ribs) • No extension available at LSJ due to hip flexion • TLJ becomes pivotal region for further extension loading

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