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Neuroanatomical Case Study: Mr. Richards and the Challenges of ALS

This case study evaluates Mr. Richards, a 40-year-old speech therapist diagnosed with Amyotrophic Lateral Sclerosis (ALS). Symptoms include dysphagia, motor weakness, and difficulties in balance and ambulation, impacting his daily activities and profession. The neurological examination reveals motor impairments and flaccid paralysis, typical of ALS pathology. The study highlights the importance of interventions for maintaining independence, addressing strength deficits, and education for Mr. Richards and his family regarding disease management. Prognosis indicates a progressive decline, necessitating ongoing evaluation and adaptive strategies.

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Neuroanatomical Case Study: Mr. Richards and the Challenges of ALS

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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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