Functional Neurological Disorder Case Study: Difference between revisions
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Revision as of 21:18, 24 March 2015
Author/s[edit | edit source]
Whitney Greene, Kayla Foster, Scott Gwinn, Jesse Koerner from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.
Abstract
[edit | edit source]
In patients diagnosed with conversion disorder, physical therapy can be an important part of a quick recovery from conversion disorder through experiencing improvement in physical function. During physical therapy the focus should be on what the patient is doing correctly and emphasis is placed upon the physical gains of the patient. The patient must be progressively challenged while integrating behavior modifications among functional mobility programs. Research shows the most productive interventions include gait training, strengthening, neuromuscular re-education and balance training, with a full recovery expected for most patients. Conversion disorder may also be referred to as functional gait disorder, hysterical paralysis, psychomotor disorder, conversion reaction, or chronic neurosis.
Patient Characteristics
[edit | edit source]
Demographic Information: (occupation/vocation, gender, age, etc.)
• Student
• Female
• 20 years old
• Caucasian
Medical diagnosis if applicable
Diagnosed with high anxiety
Co-morbidities
None in medical hx or pt reported
Previous care or treatment
Examination[edit | edit source]
Subjective:
Patient History:
A 20 year old female reported to physical therapy with numbness and severe weakness on the left side of her body, specifically her leg. The patient was recently involved in a bicycle collision with a motor vehicle 3 days ago when she was on her way home from school at a small community college. The patient reports the vehicle clipped the front of her bike while crossing an intersection, causing her to crash hard on her left side. The patient doesn’t remember if she hit her head, but she was wearing a helmet. She only recalls feeling very startled and dizzy after the collision with a couple of scrapes on her left leg from the pavement. The patient was taken to the local, rural hospital to screen for a concussion, which came back negative, where she was then released from the hospital. Since the injury 3 days ago, the patient reports her dizziness has converted to double vision and difficulty swallowing like there is a lump in her throat. Patient reports having increased stressed and difficulty completing school work in the past couple of weeks.
Systems Review:
Cardiac
• Shortness of breath
• Chest pain
Gastrointestinal
• Difficulty swallowing
• Nausea
Musculoskeletal
• Pain in the legs or arms
Neurological
• Headaches
• Dizziness
• Diplopia
• Tinnitus
• Muscle weakness LLE
• Paresthesia in LLE
Urogenital
• None to report
Medical History:
No medical history to report
Chief Complaint:
Difficulty walking and loss of balance
Prior or Current Services Related to Current Episode: (use relative date days, months, years)
MRI, labs, and EMG reports all normal
'Self Report Outcome Measures
LEFS
FABQ
Outcome measures
• 4 Square Balance Test:
• BERG: 26/56
• 10MWT: 1.04m/sec (Normative for female 20yo: 2.47m/sec)
• STS x 5: 14.2sec(Normative for 19-49yo: 6.2 +/- 1.3 sec)
Objective : Physical Examination Tests and Measures
slurred speech, trouble hearing PT during eval while speak at normal volumes; patient presented with difficulty walking with decreased gait speed, a limp on her left side, during questioning pt grinded teeth and gave very painful expressions during MMT
Physical Exam
Neurological: negative, however patient complains of agitation with wearing long pants
Vitals: normal
No reproduction of symptoms
DTR: normal
ROM: WNL passively, but difficulty with full hip & knee ROM to march in place
MMT:
Left quadriceps, hamstrings, gluteal muscle group, dorsiflexors: 4/5
Note: During MMT of quadriceps, hamstring contracted in opposition and vice versa with hamstring MMT
All of other muscles on left side and right side: 5/5
Clinical Impression[edit | edit source]
Based upon the exam findings, the clinical impression would lead to conversion disorder.
Summarization of Examination Findings[edit | edit source]
There are inconsistencies among repeated testing of sensation and muscle strength, the MMT ranges are not reflected in functional abilities, and sensation deficits are inconsistent with anatomical patterns. Because of these inconsistencies, it is important that we are able to rule out any other possible diagnoses that may reflex these signs and symptoms. Some of the other possible differential diagnoses, but not limited to, are multiple sclerosis, SLE, Guillain-Barre, post-encephalitis syndrome, and brain/spinal tumors. These, as well as any other possible diagnoses identifying an organic cause for the signs and symptoms, must be ruled out in order to assume the patient is suffering from conversion disorder. It is important that the patient understands that the other tests were negative without confrontation, and that a full recovery can be expected.
Plan of Care[edit | edit source]
Intervention
Balance/Coordination:
Tandem Stance
Balloon Volley Ball
Wobble board
Gait:
Parallel bars
Weight shifts A/P, M/L
Walking around objects
Strengthing of LE:
STS
4-way hip with TBw
Phases of Interventions (e.g. protective phase, mobility phase, etc.)
Treatment Progression:
Build Rapport
Let the patient know you think they have a problem
Make the pt want to work with you and take ownership of the problem
Reward wanted behaviors and give positive reinforcement
Ignore unwanted behavior, but do not punish
Emphasize quality over quantity
Develop goals in collaboration with the patient
Don't focus on their deficits, focus on their positives
Introduce patient to full collaborative team involved in their care
Pre-gait and strengthening
Weight shifting
Balance
STS
Transfer training
Decrease BOS
Dynamic sitting balance
Tandem stance
SLS
Bed mobility
Gait
Standing and gait in parallel bars
Step over objects
Side stepping and backwards stepping
General Mobility
Gait outside of parallel bars
Maneuvering obstacles
Endurance training
Multitasking
Seated weight shifting
Community Integration
Walking outside
Curb management
Uneven terrain
Ascending/descending stairs
Architectural barriers
Community/job/recreation incorporated
Walking while carrying books
D/C planning
Dosage and Parameters
3x per week for 4 weeks
Rationale for Progression
A patient with conversion disorder needs to see improvements in physical therapy to help the pt believe they are getting better. The progression follows the progression of someone with neurological disease with known origins because research shows conversion disorder follows similarly to the progress of a neurological disorder. Research suggests following PT Practice Pattern 5A: Primary Prevention/Risk Reduction for Loss of Balance and Falling for this diagnosis.
Co-interventions if applicable (e.g. injection therapy, medications)
Outcomes[edit | edit source]
Patient was able to completely recover and integrate back into everyday life with normal function and gait.
Discussion[edit | edit source]
Add Discussion Here.
Related Pages[edit | edit source]
References[edit | edit source]
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