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Our patient • Donald Jones • Retired Carpenter • Lives with wife • Hobbies includes carpentry • Right hand dominant
MOI • Working on cabinetry and felt weakness in left side, went home had tea with his wife and strength returned • Next day while taking out garbage, Mr. Jones lost consciousness and fell. • Taken to ER and promptly given tPA (Tissue Plasminogen Activator)
Physical Examination • Medically stable, referred to PT to address L hemiplegia • A&O x 3 • BP 130/88 (with Rx), HR 75, RR 15 • Pulses intact • STR on non-affected side is normal • Pt is anxious/eager and unrealistic of capabilities
Neurological Examination • No memory deficits found • Cranial Nerves were intact • Sensation diminished on affected side
L side MMT - 0/5 UE - 1/5 LE DTR - absent in UE and LE Tone - flaccid paralysis of whole left side Balance - 20 on Berg Balance Scale R side MMT - 4/5 UE - 4/5 LE DTR - normal for UE and LE Tone - normal tone Motor Examination
Cognitive/Perceptual Examination • Patient response to questions about affected limbs includes denial of impairment and states “his arms and legs are fine.” • Patient unable to describe or recognize familiar routes. • Patient shows difficulty with localizing objects in space and gauging distance
Evaluation Disablement Model • Pathology: Acute CVA affecting non-dominant Right hemisphere • Impairment: Left hemiplegia, spatial relations disorders, and anosognosia • Functional Limitation: Patient unable to safely care for himself • Disability: Patient unable to return to carpentry hobbies and perform ADLs independently
Differential Diagnosis • Initial TIA with Left hemiparesis and quick recovery • CVA to non-dominant Right Hemisphere within 24 hours of TIA • Left Hemiplegia • Anosognosia – pathogenesis unclear, but associated with damage to supramarginal gyrus • Topographical Disorientation – the majority of cases present with lesions to Brodmann’s Area 30 • Visual-Spatial Agnosia – Usually due to lesions of the right parieto-occipital-temporal junction • These sxs are most likely due to occlusion of the MCA
APTA Practice Pattern • 5D: Impaired motor function and sensory integrity associated with non-progressive disorders- acquired in adolescence or adulthood.
Prognosis • Mr. Jones’ prognosis is fair • Considering: • He received tPA within the first 3 hours. • Anosagnosia typically resolves spontaneously within the first 3 months • Topographic disorientation usually resolves in 2 months or less • Recovery can be accelerated with therapy • Visual-Spatial Agnosia can be addressed with therapy • Patients generally regain some motor function spontaneously within 3 months and can also be further facilitated with therapy
PT Intervention • Safety education regarding anosognosia for pt and caregiver • Spatial recognition and topographic orientation training Ex) Pt positioning, mazes, following directions, Left hemisphere sequencing • Improve strength and motor performance of the affected side Ex) Constraint induced, biofeedback, e-stim, gait training
Goals • LTG 1: Pt to amb from PT gym to room (~100 ft) with hemi-walker independently in order to safely navigate home in 3 weeks. • STG 1: Pt to amb 20 ft with hemi-walker with mod assist following dot sequence in 1 week. • LTG 2: Pt hammer 20 nails while standing without hitting thumb in order to return to carpentry hobbies • STG 2: Pt to pick up 10 pegs and place them in peg-board while standing with min-assist in 1 week.
References • Goodman CC, Fuller KS, Boissonnault WG. Pathology, Implications for the Physical Therapist. 2nd ed. Philadelphia, PN: Saunders; 2003. • O’Sullivan S, Schmitz T. Physical Rehabilitation. 5th ed. Philadelphia, PA: F.A. Davis Co; 2007