Acute Care Rehabilitation for a Patient with Normal Pressure

ACUTE CARE REHABILITATION FOR A PATIENT WITH NORMAL PRESSURE

HYDROCEPHALUS

A Doctoral Project A Comprehensive Case Analysis

Presented to the faculty of the Department of Physical Therapy

California State University, Sacramento

Submitted in partial satisfaction of the requirements for the degree of

DOCTOR OF PHYSICAL THERAPY

Sara Mikesell

SUMMER 2017

Sara Mikesell

ACUTE CARE REHABILITATION FOR A PATIENT WITH NORMAL PRESSURE

HYDROCEPHALUS

A Doctoral Project

Sara Mikesell

Approved by:

______, Committee Chair Brad Stockert, PT, PhD

______, First Reader Toran MacLeod, PT, PhD

______, Second Reader Bryan Coleman-Salgado, PT, DPT, MS, CWS

______Date

iii

Student: Sara Mikesell

I certify that this student has met the requirements for format contained in the University format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the project.

______, Department Chair ______Michael McKeough, PT, EdD Date

Department of Physical Therapy

Abstract

ACUTE CARE REHABILITATION FOR A PATIENT WITH NORMAL PRESSURE

HYDROCEPHALUS

Sara Mikesell

A patient with normal pressure hydrocephalus was seen for physical therapy for 3 daily treatment sessions in an acute care setting as the patient underwent external lumbar drainage of cerebral spinal fluid. Treatment was provided by a student physical therapist under the supervision of a licensed physical therapist.

The patient was evaluated at the initial encounter with the Montreal Cognitive

Assessment-Basic, and the Tinetti Balance Assessment Tool. Main goals for the patient were to improve lower extremity strength, cognitive functioning of memory and attention, foot clearance, step length, step continuity, and functional independence. Main interventions were auditory and visual cues aimed at improving gait parameters and functional independence.

The patient improved his step continuity, base of support, and step length. The patient was discharged to home with a shower chair along with a recommendation for home health physical therapy. Patient was to return to the hospital a few weeks later for an elective ventriculoperitoneal (VP) shunt placement.

______, Committee Chair Brad Stockert, PT, PhD

______Date

ACKNOWLEDGEMENTS

I would like to acknowledge Community Regional Medical Center in Fresno for allowing me to learn about and treat patients with neurological disorders, as well as allowing me to use an acute care patient for my case study.

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TABLE OF CONTENTS Page

Acknowledgements...... vii

List of Tables ...... ix

Chapter

1. GENERAL BACKGROUND...... 1

2. CASE BACKGROUND DATA...... 3

3. EXAMINATION – TESTS AND MEASURES ...... 8

4. EVALUATION...... 12

5. PLAN OF CARE – GOALS AND INTERVENTIONS...... 15

6. OUTCOMES ...... 21

7. DISCUSSION...... 23

References...... 26

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LIST OF TABLES Tables Page

1. Medication Table………………… ...... ……………………………….4

2. Examination Table……………………………….……………………………11

3. Evaluation and Plan of Care… ..………….…………………………………. 15

4. Outcomes……………………………….……… ....………………………….21

ix 1

Chapter 1

General Background

There are several different types of hydrocephalus; two of those types primarily affect adults: hydroceplaus ex-vacuo and Normal Pressure Hydrocephalus

(NPH).1 Hydrocephalus ex-vacuo results from damage to the brain caused by a traumatic brain injury or a stroke.1 NPH is an abnormal increase in the cerebrospinal fluid (CSF) within the brain’s ventricles and may result from head trauma, tumor, infection, complications of surgery, subarachnoid hemorrhage, or from none of these factors.1-5 The term NPH is misleading as often many patients experience fluctuations in CSF pressure that are abnormal pressures.5,6

The exact pathophysiology of NPH is unclear, however most evidence supports that the increase in CSF is caused by an imbalance in the relationship between production and absorption of CSF.6-11 Typically CSF is absorbed into the arachnoid villi and this allows the CSF to drain into the venous sinuses, yet for reasons not understood the arachnoid villi do not maintain adequate removal of CSF in persons with NPH.6,7

Enlargement of the ventricles due to increased CSF is believed to cause compression of structures adjacent to the ventricles resulting in the clinical manifestations of the disease.6,12 The triad of signs associated with NPH are: gait disturbances, urinary incontinence, and dementia.1,2,4-9,13 The gait pattern in people with NPH is a hypokinetic pattern similar to patients with Parkinson’s disease, and include decreased stride length, step length, and step height.6,12

NPH can present at any age, however it is most common among the elderly population.4,5 Nearly 700,000 adults have NPH in the United States (U.S.), although less than 20% are properly diagnosed.2,5 Incidence of NPH range from 0.5 to 1.6%, but due to the lack of recognition by the medical community it is likely this number is an underestimate of those who have NPH.11,13 In cases of undiagnosed dementia, NPH is believed to cause 5-6% of the cases.9,13

There is no gold standard for the diagnosis of NPH.14 The combination of ventricular enlargement found on a computed tomography (CT) or magnetic resonance imaging (MRI) with the triad of typical signs leads to a diagnosis NPH.2,6,13 Prognosis worsens the longer NPH is untreated.9 Treatment often includes surgical insertion of a shunt that drains excess CSF into the abdomen, the lung, or the heart.2,14-16

Determining success of a shunt placement is often based on improvement of gait deficits following placement of an external lumbar drain (ELD).17,18 Gait is analyzed pre- and post-CSF drainage and an improvement of gait immediately following ELD is predictive of a positive outcome with the use of a VP shunt.18

Chapter 2 Case Background Data Examination – History

The Patient was a 68 year-old Spanish speaking male who was brought to the hospital following increased memory loss, worsening gait, and incontinence. During the patient’s evaluation, CT revealed enlarged ventricles within the brain and the patient was determined to have NPH. A lumbar drain was placed electively one day prior to initial physical therapy encounter, however the drain remained clamped until after the physical therapy evaluation in order to obtain baseline data.

Prior to the patient’s admission to the hospital, he had recently moved in with his daughter in the U.S. after living alone for several years in Mexico. The patient was a widower. Patient utilized a single point cane and/or “furniture walked” to ambulate around the house prior to onset of symptoms; patient’s daughter reported he owned a 4 wheeled walker with a seat. The residence was a single-story home with no stairs at the entrance and a walk in shower. The patient’s daughter provided assistance with ambulation when needed, however the patient reported being mostly independent in

ADLs and self-care tasks but he asked for assistance when required.

The past medical history includes a hernia repair in 2011, former tobacco smoker (quit ten years prior) with a 40-year pack history, hypertension, chronic kidney disease, benign prostatic hyperplasia, and dementia. He reported a worsening gait and the use of a urinary catheter over the prior 2 years. The patient’s chief complaints were his limited ability to ambulate outside of household distances and a fear of falling over

without something to hold onto while ambulating due to weakness in his lower extremities; no history of falls was reported.

Systems Review

The patient’s cardiopulmonary system was impaired as the patient reported a history of hypertension currently controlled by medication; blood pressure was measured at 140/68. The musculoskeletal system was impaired by bilateral lower extremity (LE) strength deficits determined by testing by the physical therapist. The neuromuscular system was impaired by the NPH with observable gait and balance impairments. The integumentary system was unimpaired based on observation and patient report. The urogenital system was impaired based on observation and long term urinary catheter use. The patient’s communication required a Spanish interpreter, yet was appropriate per interpreter and speech therapist report. The patient’s affect was unimpaired based on evaluation by speech language pathologist (SLP) and observation, however he displayed impaired cognition and learning.

Examination - Medications Table 1 Medication Table MEDICATION DOSAGE REASON SIDE EFFECTS Lisinopril 5 mg Hypertension Cough, dizziness, headache, (PRINVIL, excessive tiredness, nausea, ZESTRIL) 19 weakness, sneezing, runny nose, decrease in sexual ability, and rash. Serious side effects: swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles or lower legs; hoarseness; difficulty breathing or swallowing; fever; sore throat; chills; or other signs of infection; yellowing of the skin or eyes; lightheadedness; fainting or chest pain. Finasteride 5 mg Benign Depression, pain in testicles, problems

(PROSCAR)19 Prostatic with ejaculation, decreased sexual desire, Hyperplasia inability to have or maintain an erection. Serious side effects: rash, itching, hives, swelling of lips and face, difficulty breathing or swallowing, or changes in breasts. Donepezil 5 mg Dementia Vomiting, diarrhea, weight loss, loss of (ARICEPT)19 appetite, nausea, frequent urination, difficulty controlling urination, muscle cramps, joint pain, swelling, stiffness, pain, excessive tiredness, difficulty falling asleep or staying awake, dizziness, headache, depression, nervousness, confusion, changes in behavior or mood, hallucinations, abnormal dreams, red or scaling or itchy skin. Serious side effects: fainting, slow heartbeat, chest pain, new or worsening breathing problems, new or worsening stomach pain, black or tarry stools, bloody vomit, vomit that looks like coffee grounds, difficulty urinating or pain when urinating, lower back pain, fever, seizures, discoloration or bruising of the skin. Namenda 7 mg Dementia Dizziness, confusion, aggression, XR19 depression, headache, sleepiness, diarrhea, constipation, nausea, vomiting, weight gain, cough, pain anywhere in your body and especially in your back. Pneumococcal 0.5 mL Pneumonia Allergic reaction, high fever, or unusual Vaccine19 prevention behavior. Ceftriaxone 50 mL Post-op Pain or tenderness or hardness or Rocephin19 infection warmth at site of injection, pale skin or prevention weakness or shortness of breath when exercising, diarrhea. Serious side effects: rash, nausea or vomiting, stomach tenderness or pain or bloating, bloody or watery stools or stomach cramps or fever during treatment or for up to two months after treatment, heartburn, chest pain, severe pain in the side and back below ribs, painful urination, urinating more often than usual, pink or brown or red or cloudy or bad smelling urine, swelling in legs and feet, return of fever or sore throat, chills or other signs of infection, peeling or blistering or shedding skin, difficulty swallowing or breathing, swelling of throat or tongue, seizures. Lactulose 20gm/30 mL Constipation Diarrhea, gas, nausea. Serious side Chronulac19 prevention effects: stomach pain or cramps, vomiting.

Cefazolin 1 g UTI Genital itching, white patches in mouth, ancef LVPB19 prevention loss of appetite, heartburn, gas, nausea, vomiting, diarrhea, headache, dizziness, confusion, weakness, tiredness, drowsiness, pain or redness or bleeding at site of injection. Serious side effects: watery or bloody stools or stomach cramps or fever during treatment or up to two months post treatment, rash, hives, itching, difficulty breathing or swallowing, blistering or peeling or shedding skin, swelling in legs and feet, decreased urination, dark urine, yellowing or skin or eyes, pain in the upper right part of stomach, fainting, return of fever, sore throat, chills or other sign of infection. Bupivacaine / 0.25% Pain Itching or hives, swelling in face or Epinephrine20 hands, swelling or tingling in mouth/throat, chest tightness, trouble breathing, anxiety, depression, restlessness, drowsiness, ringing in ears, blurred vision, chest pain, fast or pounding or slow or uneven heart beat, trouble breathing, lightheadedness, fainting, nausea, vomiting, chills, metallic taste mouth, seizures, shivering, shaking, tremors, headache, back pain. Fentanyl 25 mcg Short duration Drowsiness, nausea, stomach pain, sublimaze19 pain vomiting, diarrhea, gas, heartburn, loss of appetite, weight loss, difficulty urinating, weakness, headache, changes in vision, anxiety, depression, hallucinations, unusual thinking or dreams, difficulty falling asleep or staying awake, dry mouth, sweating, sudden reddening of face, neck, upper chest, uncontrollable shaking of a part of the body, back pain, chest pain, sores or pain or irritation in the mouth, swelling of the hands, arms, feet, lower legs. Serious side effects: heartbeat is slower or faster than normal, seizures, hives, rash, itching. Labetalol 5 mg Hypertension Dizziness, tingling scalp or skin, trandate19 lightheadedness, excessive tiredness, headache, upset stomach, stuff nose. Serious side effects: shortness of breath or wheezing, swelling of the feet and lower legs, sudden weight gain, chest pain. Hydralazine 5 mg Hypertension Flushing, headache, upset stomach,

Apresoline19 vomiting, loss of appetite, diarrhea, constipation, eye tearing, stuffy nose, rash. Serious side effects: fainting, joint or muscle pain, fever, rapid heartbeat, chest pain, swollen ankles or feet, numbing or tingling in hands or feet. Ondansetron 4 mg Anti-nausea Headache, constipation, drowsiness, Zofran19 feeling cold or chills, pain or burning or numbness or tingling in hands or feet, fever, injection site pain or redness or swelling or warmth or burning. Serious side effects: rash, hives, itching, swelling of the eyes, face, lips, tongue, throat, hands, feet, ankles, lower legs, hoarseness, difficulty swallowing or breathing, chest pain, shortness of breath, dizziness, light headedness, fainting, fast/slow/irregular heart beat, blurred vision or vision loss, agitation, hallucinations, fever, excessive sweating, confusion, nausea, vomiting, diarrhea, loss of coordination, stiff or twitching muscles, seizures, coma. Lidocaine 1% soln 0.5mL Local Pain (at Itching, hives, swelling in face or hands, (PF)20 surgical site) swelling or tingling in mouth or throat, chest tightness, trouble breathing, redness or itching or burning or swelling or blisters where patch is applied.

Chapter 3 Examination – Tests and Measures

With regards to physical therapists treating patients with NPH, classifying the triad of symptoms using the International Classification of Functioning, Disability, and Health (ICF) model allows for a common language to be used in coordinating treatment.21 For body structure function impairments the Manual Muscle Test (MMT) and functional strength testing was used to assess lower extremity strength, and the

Montreal Cognitive Assessment Basic (MOCA-B) was used as a diagnostic tool to assess cognition. For activity limitations the Tinetti Performance Oriented Mobility

Assessment (POMA) was used to assess gait impairments. For participation restrictions a patient-specific self-report measure was used to assess ability to participate in family gatherings. The Tinetti POMA was also used as a prognostic indicator to assess favorability of responding to a shunt following CSF drainage at the lumbar spine and examined change in gait from baseline to post drainage.

The MMT is completed by providing manual resistance to a muscle to assess strength and is graded on a 5-point scale. There are no psychometrics established for people with NPH. However, in a literature review conducted on 100 studies related to

MMT, evidence for good reliability and validity in the use of MMT for patients with neuromusculoskeletal dysfunction has been shown.22 The results of several of the studies indicate that in order to be confident that a true change has occurred, minimal detectable change (MDC), the MMT score must change more than 1 full grade.22 The

MDC is based upon levels of agreement that were found: 82% to 97% for interrater reliability and 96% to 98% for test-retest reliability.22

The MOCA-B is a test divided into 8 categories that looks at: visuospatial or executive function, naming, memory, attention, language, abstraction, delayed recall, and orientation. The test has a total of 30 points and a score of below 26 indicates cognitive impairment.23 A SLP administered the test and continuity between SLP and physical therapy interventions provided the cognitive changes measured at discharge.

As a diagnostic tool for mild cognitive impairment, the sensitivity was found to be

90% and the specificity found to be 87%.23 The positive likelihood ratio (LR+) is 6.9 and the negative likelihood (LR-) ratio is 0.11. The LR+ indicates a moderate increase in the likelihood of mild cognitive impairment being present as compared to before the test was administered. The LR- indicates a moderate decrease in the likelihood of mild cognitive impairment being present as compared to before the test was administered.

The Tinetti POMA is an outcome measure that assesses balance and gait. In a cohort study of 87 patients with NPH undergoing CSF drainage, the Tinetti POMA was found to demonstrate sensitivity to change in patient’s undergoing CSF drainage and is an appropriate measure for physical therapists to use within the ICF model.3

There are 9 balance categories and 7 gait categories with a total score of 28 points being possible. A score of <19/28 indicates a high risk for falls for the elderly population.24 The minimal detectable change at a confidence interval of 95% was found to be 5.0 for older adults.25 This means a score needs to change more than 5 points to demonstrate that true change beyond measurement error has occurred.

Observation may be used to detect specific gait and balance deficits within each category when using the Tinetti POMA.

The impact of the ELD served as a prognostic indicator of the efficacy of VP shunt placement based upon a change in gait function [as measured by the Tinetti

POMA] following use of the ELD. An improvement of gait immediately following use of the ELD has a sensitivity of 95%, specificity of 64%, positive predictive value of 90%, and a negative predictive value of 78%.18 The LR+ is 2.64, indicating a small increase in the likelihood that improvements in gait following ELD will result in a favorable outcome following VP shunt placement.

Table 2 Examination Table BODY FUNCTION OR STRUCTURE Measurement Category Test/Measure Used Test/Measure Results Lower Extremity Manual Muscle Test Right Left Static Strength Hip Hip Ext: 4-/5 Ext: 4-/5 Flx: 4-/5 Flx: 4-/5

Knee Knee Ext: 4-/5 Ext: 4-/5 Flx: 4-/5 Flx: 4-/5

Ankle Ankle DF: 4/5 DF: 4/5 PF: 4/5 PF 4/5 Lower Extremity Functional Strength Functional Strength on Right and Left LE: Functional Strength Tests 2 heel raises out of 10 completed 2 squats out of 10 squats completed 1 set of 10 marches (5 on each leg) completed out of 2 sets Cognitive Functioning Montreal Cognitive 4/30. Assessment-Basic Patient is unable to maintain brief attention during testing and initial evaluation, requiring maximum cues 90% of the time. FUNCTIONAL ACTIVITY Measurement Category Test/Measure Used Test/Measure Results Gait & Balance Tinetti POMA 5/28. Patient found to have decreased step height, decreased step length, decreased step continuity, and a wide base of support. PARTICIPATION RESTRICTIONS Measurement Category Test/Measure Used Test/Measure Results Reduced participation Self Report Dependent on daughter to provide minimal in family social physical assistance with single point cane for gatherings. gait in complex environments outside of household distances once per week.

Chapter 4 Evaluation Evaluation Summary

The patient was a 68-year-old Spanish-speaking male who was one-day post

EDL placement following a diagnosis of NPH. For the past two years the patient has suffered from decreased cognitive functioning, worsening gait, decreased functional independence, and urinary incontinence. Upon evaluation the patient was found to have decreased lower extremity strength, cognitive deficits, gaze directed downward at feet during gait, and impaired gait in the form of: bilateral low foot clearance and shortened step length, decreased step continuity, and a wide base of support. He had an increased risk for falls, and he had limited ability to participate in family social gatherings outside of household distances in complex environments. The patient’s wide base of support, decreased step height and length, and lower extremity strength deficits are atypical of the typical pattern seen within the NPH population and suggest pre-existing impairments which required the need for skilled physical therapy.

Diagnostic Impression

The patient’s gait deviations were not consistent with the typical presentation of patients with a medical diagnosis of NPH. His lower extremity strength deficits, wide base of support and decreased step continuity during gait are not typically characteristic of NPH. He did, however, present with the typical NPH signs of urinary incontinence and cognitive deficits. The cognitive deficits were suspected to be related to the NPH diagnosis by both the SLP and the patient’s daughter. The patient’s body structure and function impairments of impaired cognition and decreased LE strength

contributed to his activity limitations of limited gait and an increased fall risk. His limited ability to participate in family social events stemmed from his lack of step height and step length, and wide base of support during gait. When combined with cognitive impairments, these gait deviations made him unable to negotiate complex environments for community distances.

Prognostic Statement

The patient’s positive prognostic indicators for rehabilitation included: good family support, controlled hypertension, and no adverse behavioral reactions. The patient had a positive response to the use of his ELD that was demonstrated by components of the Tinetti improving: step continuity and base of support. These findings predict a favorable outcome in response to a VP shunt to manage NPH.18

The patient’s negative prognostic indicators include: impaired cognition, increased fall risk, decreased compliance with using an assistive device and having an atypical presentation. An increase in lower extremity strength was not expected [due to the probable lack of validity of MMT to detect change in 3 days on a patient with an upper motor neuron problem], however the patient was expected to improve the quality of his gait and balance and therefore reduce his risk of falls. Improvement in participation was not expected to occur during his short duration of stay, however improved gait impairments could contribute to the patient’s decreased need for physical assistance during ambulation and contribute towards his long term goal of increased ability to attend family gatherings in complex environments.

G-Codes

Current with modifier: G8978-CM based on the Tinetti POMA score

Goal with modifier: G8979-CL based on the Tinetti POMA score

Discharge Plan

The patient was to be discharged home to the supervision and care of his daughter with a shower chair and a recommendation for home health physical therapy. The patient was to return in a few weeks for an elective surgical VP shunt placement.

Chapter 5 Plan of Care-Goals and Interventions Table 3 Evaluation and Plan of Care PLAN OF CARE Short Term Goals Long Term Goals Planned Interventions (Anticipated Goals) (Expected Outcomes) Interventions are Direct (3 days) (7 days) or Procedural unless they are marked: (C) = Coordination of care intervention (E) = Educational PROBLEM intervention BODY FUNCTION OR STRUCTURE IMPAIRMENTS Decreased Lower In 3 days patient will In 7 days patient will Interventions are aimed Extremity Strength be able to complete: complete at increasing lower • no changes • no changes in extremity strength to MMT: in manual manual assist with mobility. Right Left muscle muscle Exercises were Hip Hip strength strength performed 1x/day for 3 Ext: 4-/5 Ext: 4-/5 grades grades days. Flx: 4-/5 Flx: 4-/5 expected in expected in this time this time Heel raises, squats, and Knee Knee frame frame marches in place were Ext: 4-/5 Ext: 4-/5 because because performed while Flx: 4-/5 Flx: 4-/5 recovery of recovery of holding onto the motor motor control handles of a front- Ankle Ankle control is is occurring wheeled walker with DF: 4/5 DF: 4/5 occurring (MDC=1) contact guard PF: 4/5 PF 4/5 (MDC= 1) • 2 sets of 10 assistance. Initially 10 • 10 heel heel raises repetitions of each were Functional raises • 2 sets of 10 prescribed, as patient Strength Tests on • 10 squats squats was new to activities. Right and Left: • 2 sets of 10 • 3 sets of 10 Exercises were to be 2/10 heel raises marches in marches in performed initially 2/10 squats place (5 on place (5 on 1x/day during therapy. 1 set of 10 marches each leg per each leg per Progression in the form (5 on each leg) set) set) of increasing number of sets completed at discharge was completed. The goal of these strengthening exercises was to improve foot clearance during ambulation and improve the risk of falls after discharge.

(E): Instructed patient on proper form for

completing heel raises, squats, and marches. Stressed the importance of quality over quantity when performing exercises.

(C): Designated appropriate time to complete initial assessment before external lumbar drain was turned on; determined appropriate time to complete treatments when external lumbar drain was clamped.

Decreased SLP goal: Patient SLP goal: Patient will (C): Coordinated care Cognitive will maintain brief maintain brief of impaired cognition to Functioning: attention during attention during SLP. Memory and therapeutic activities therapeutic activities Attention (MOCA) requiring maximum requiring maximum (C): Designated cues 80-100% of the cues 60-75% of the appropriate time to time in 3 days. time in 7 days. complete initial • MOCA: 7/30 • MOCA: 10/30 assessment before external lumbar drain MDC: 6 points MDC: 6 points was turned on; (20% change) (20% change) determined appropriate time to complete treatments when external lumbar drain was clamped. ACTIVITY LIMITATIONS Impaired Gait as Patient will improve Patient will improve Interventions are aimed indicated by these their Tinetti POMA their Tinetti POMA at improving gait deviations: score of 5/28 to score to 20/28. parameters of gait. A) decreased 10/28. Treatment was foot MDC=5 points performed 1x/day for 3 clearance MDC=5 points days. B) decreased step length Gait training with a C) decreased front-wheeled walker step while using auditory continuity cues of a metronome on D) wide base a smart phone set at 100 of support beats per minute and tape on the floor set 60 cm apart. Distance E) Gaze turned walked was started at downward at feet 50 feet with minimal

during gait 50% of physical assistance the time. provided. Progress to increased distance walked with cues following discharge. External cueing in the form of auditory and visual allows the extraneous noise to be turned down and increase the focus of the patient on gait related tasks. Visual cues encourage corrected gaze while ambulating and facilitates correct postural alignment. Improved postural alignment helps to decrease the risk of falls, improve step length, step height, narrow the base of support, and improve step continuity.

(C): Designated appropriate time to complete initial assessment before external lumbar drain was turned on; determined appropriate time to complete treatments when external lumbar drain was clamped.

(E): Patient and Patient’s daughter taught importance of using an assistive device during ambulation to decrease risk of falls and to assist with balance.

PARTICIPATION RESTRICTIONS Decreased Patient will require Patient will require Gait training and Functional minimal physical Contact Guard therapeutic exercises as Independence assistance of one Assistance with a described above. A) Reduced ability person while using a front-wheeled walker Evaluation of front- to attend family front-wheeled to ambulate 100 feet wheeled walker use gatherings walker. during family during ambulation • Expect no gatherings outside of around stationary and change in household distances in mobile objects. level of complex Referral for Home assistance environments. Health Physical therapy required for and a shower chair ambulation upon return home. >100 ft. (C): Designated appropriate time to complete initial assessment before external lumbar drain was turned on; determined appropriate time to complete treatments when external lumbar drain was clamped.

(E): Proper guarding and physical assistance techniques training to daughter when patient is ambulating out of household distances in complex environments. Flx: flexion; Ext: extension; DF: dorsiflexion; PF: plantar flexion; SLP: speech language pathologist

Plan of Care – Interventions See Table 3. Overall Approach

Functional strengthening exercises were applied to improve motor control, and to improve preexisting and NPH-related gait abnormalities. External visual and auditory cues were applied in order to help the patient focus on the task of walking to address the hypokinetic gait pattern exhibited by patients with NPH. By focusing on

strengthening, the use of external stimuli, and patient and caregiver training to enhance the neuro-reeducation, the patient was expected to improve his gait and safety performance.

PICO question

For a patient with NPH (P) is rhythmic auditory stimulation in gait training more effective (I) than non-specific gait training (C) for improving gait parameters and increasing functional independence? (O)

A non-randomized study looked at the responsiveness to visual and acoustic cues for gait improvement in patients with NPH and Parkinson’s disease (PD) who were age and sex matched to healthy controls (level 2b evidence).26 An analysis was conducted for gait speed, cadence, and step length. Four trials were conducted pre and post CSF drainage in patients with NPH, and pre and post levodopa medication in patients with PD. Patients were instructed to pace their frequency to the beat of an electric metronome and asked to step on black stripes placed in a hallway; frequency and distance between stripes was determine by the control group: 110 steps/min and

60cm, respectively. Visual and acoustic cues improved the gait parameters of patients with PD, however significant improvement was not observed in the gait parameters for patients with NPH.26

The patient in this present case study matched the subjects of the study in age, sex, and diagnosis. However, the only gait parameter present in the patient that matched the subjects in the study was decreased step length. Although gait speed and cadence were addressed in the study, and base of support, step continuity, and step

height were addressed for the patient in this case study, the use of visual and acoustic cues can still be effective because the different parameters of gait impact one another.

For example, improvement in step length has positive implications for improving step height, step continuity, and base of support. By implementing the acoustic and visual cues the goal was to capture the focus of the patient on the functional task of gait and turn down the extraneous noise distracting from the task of gait. Although the results of the study are not strong to support the use of acoustic and visual cues on patients with NPH, the patient in this case study was atypical in presentation. This atypical presentation suggests additional impairments were present prior to the NPH diagnosis, and that those deficits require the need for follow-up skilled physical therapy services.

Utilizing acoustic and visual cues allowed for skilled physical therapy to address the impairments associated with NPH and the underlying pathological impairments, creating a beneficial rehab environment to enhance the focus of the patient and tune down the extraneous noise.

Chapter 6 Outcomes Table 4 Outcomes OUTCOMES BODY FUNCTION OR STRUCTURE IMPAIRMENTS Outcome Initial Follow-up (DC) Change Goal Met? Measure (Y/N) Manual Right Left Right Left Muscle Hip Hip Hip Hip Testing Ext: 4-/5 Ext: 4-/5 Ext: 4-/5 Ext: 4-/5 No Change N Flx: 4-/5 Flx: 4-/5 Flx: 4-/5 Flx: 4-/5

Knee Knee Knee Knee Ext: 4-/5 Ext: 4-/5 Ext: 4-/5 Ext: 4-/5 Flx: 4-/5 Flx: 4-/5 Flx: 4-/5 Flx: 4-/5

Ankle Ankle Ankle Ankle DF: 4/5 DF: 4/5 DF: 4/5 DF: 4/5 PF: 4/5 PF 4/5 PF: 4/5 PF 4/5 Functional 2/10 heel raises 10 heel raises Change Y Strength 2/10 squats 10 squats 1 set of 10 marches (5 2 sets of 10 marches in on each leg) place (5 on each leg per set)

Montreal 4/30; Patient is 7/30; Patient will +3 points Cognitive unable to maintain maintain brief attention MDC: 6 points N Assessment- brief attention during during therapeutic (20% change) Basic testing and initial activities requiring evaluation, requiring maximum cues 80-100% maximum cues 90% of the time in 3 days. of the time. ACTIVITY LIMITATIONS Outcome Initial Follow-up (DC) Change Goal Met? Measure (Y/N) Tinetti 5/28 14/28 +9 points Y POMA MDC: 5 points PARTICIPATION RESTRICTIONS Outcome Initial Follow-up (DC) Change Goal Met? Measure (Y/N) Reduced Dependent on Dependent on daughter ability to daughter to provide to provide minimal No Change N attend minimal assistance assistance with SPC for family with SPC for mobility outside of gatherings mobility outside of household distances household distances Flx: flexion; Ext: extension; DF: dorsiflexion; PF: plantar flexion; MDC: minimal detectable change; SPC: single point cane.

Discharge Statement: The patient received three daily acute care physical therapy visits while in the hospital. The patient was seen by speech therapy for cognitive deficits and seen by physical therapy for lower extremity strength impairments, gait impairments, decreased balance leading to increased risk of falls, and restricted ability to participate in family gatherings. The main interventions utilized were gait training and functional independence training that included auditory and visual cues. Exercises for lower extremity strength included squats, heel raises, and marches in place.

The patient achieved the goal of an improved Tinetti POMA score, yet his score still indicated a continued high risk for falls, as it was below the19/28 cutoff value, and improvements in functional strength. However, the patient did improve his base of support, step length, and step continuity during gait; other improvements on the Tinetti POMA were in the balance section. Goals were not attained for MMT strength increase, improved cognition as assessed by the MOCA, and ability to attend family gatherings. The patient was discharged home with a shower chair into the care and supervision of his daughter. Patient was to receive home health physical therapy while waiting to return in a few weeks for elective placement of VP shunt.

DC G-Code with modifier

G8980-CK based on the Tinetti POMA score

Chapter 7 Discussion

During the patient’s hospital stay, the patient displayed an improved gait performance as measured by the Tinetti POMA. Improvements in impairments typical to NPH correlated with drainage of CSF fluid relieving pressure in his central nervous system, and the other underlying pathological impairments improved from the skilled physical therapy interventions.27 The goals dealing with MMT strength increase, cognition, and reduced family gathering attendance were not met. Recommendations for treating similar atypical patients with NPH include longer duration of treatment times and/or increased number of therapy sessions, while using a similar approach in terms of coordinating care and working with auditory and visual cues for gait.

Overall the patient made improvements in step continuity, step length, and base of support during ambulation in response to the treatment provided. Balance components of the Tinetti POMA improved as well, accounting for the most increase in the overall score. Barriers included baseline dementia with no real cognitive changes during the episode of care, and a language barrier requiring the use of an interpreter. Positive attributes contributing to improvement included family support and an optimist demeanor. Reflecting on care provided, things that went well included: coordination of care with speech therapy, nursing [for drain clamp], and interpreter services, along with a focus on the patient’s goal of being able to walk with less assistance during family gatherings and patient education for using an assistive device to decrease risk of falls. Things that could have been done better included:

practicing ambulation with a single point cane and not just a walker during ambulation

[patient owns both pieces of equipment]; ambulation in an area with less space to simulate moving around at home; ambulation in an area with uneven surfaces and complex environment because hospital hallways do not carry over well to community ambulation; and utilizing functional strength measures to assess strength instead of

MMT as they are more appropriate for patient’s with upper motor neuron impairments.

In regards to the individual patient, he presented with the typical triad of signs for a patient with NPH; i.e. impaired gait, impaired cognition and urinary incontinence. However, his lower extremity strength deficits were atypical of patients with NPH as nothing in the literature describes lower extremity strength deficits. The

Tinetti POMA has been used for patients with NPH, but the Mini-Mental Exam has been used more frequently in the literature compared to the MOCA-B.3 The MOCA-B is an outcome measure used specifically by the hospital in which the care was provided. The interventions used can be applied to similar atypical patients with NPH as they focus on lower extremity strength, cognitive deficits, and gait impairments.

Continuity of cognition cues was coordinated with SLP and physical therapy, and can be applied to similar atypical patients with NPH.

Due to the limited amount of evidence available for the treatment of patients with NPH, better evidence would have enhanced the ability to treat this patient.

Further research needs to be done on this population to better understand optimum treatment options. Although patient’s with NPH present with hypokinetic gait similar

to patients with Parkinson’s disease, there are differences within the gait pattern that need to be investigated further in order to provide optimum care to this patient population.

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