I'm currently seeing a 60 y/o gentleman with normal pressure hydrocephalus (NPH) on an outpatient basis.
He
has been diagnosed for about 3 years now and was recently admitted
after his shunt malfunctioned and he had a revision done. The revision
helped significantly and now he's home. I've been seeing him for about
a month and I'm realizing that we are plateauing. I started researching
the literature for some guidelines on PT approach in this population
and there is very little. Most of the articles refer to acute care
management, gait characteristics of NPH vs. Parkinson's disease, and
NPH pre/post lumbar drain testing prior to shunt placement. Nothing I
can find really makes recommendations for chronic management.
As
for the specifics of his case, he demos fairly common gait
characteristics: small step length (festinating when fatigued) that
worsens in doorways and turns and in dynamic situations. Also reduced
arm swing unilaterally with ipsilateral pelvic protraction. He is
easily distractible, and like many of my PD patients, cannot multitask
very well. His carry over early on was good, most notably he was able
to stop himself at the first sign of festination and begin his gait
cycle again with focus on a good first step. This has cut down
significantly his furniture walking and wall grabbing tendencies. Now,
he always begins stepping well, including a fair amount of left arm
swing. But soon, he is taking short steps on the left again, the trunk
gets rotated anteriorly on the left, and he has to stop and start over
after about 75'...and that is when walking in a straight line on level
surface! Strength is near normal and tone is normal. There is mild
neuropathic sensory loss in the feet due to diabetes. Endurance seems
limited and has definitely been a target area. I've encouraged use of
the recumbent bike at home because his fear of falling and tendency for
increased instability with fatigue limit his ability to push himself
with walking distance for the purpose of increasing the stamina. So my
main goals are to improve his stability in a wider variety of
environments, improve functional endurance, and to improve his specific
ability to self-manage his home environment which is small and has lots
of turns. Mostly, I've used strategies that have been successful with
moderately impaired PD patients but we are hitting a wall and from what
I understand from the research I have found, the two diseases appear
similar, but probably impair motor planning in different ways.
Therefore, some say verbal cueing doesn't work well in this group (like
it does work fairly well in PD). We tried using a metronome in a couple
of sessions but I'm not formally trained with it. Pretty mixed results.
So again, 2 part question: 1) What evidence based (or expert
opinion based) guidelines exist for chronic management of NPH? Any
articles even that address this issue? 2) What do you think about this
particular patient as I've described him?
Thanks in advance for your feedback.
Jerram
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