Synapse AUTUMN 2004 - acpin

Syn’apse ● AUTUMN/WINTER 2004
ARTICLE 4
APPENDIX 1
PD stage classification (from Pilot Questionnaire)
In the absence of any uniform or reliable method of disease
classification or impairment measures for PD patients, we are using
generalised categories of early, middle and late PD stages (Jones and
Godwin-Austen, 1998) as patient groupings. In our opinion, these
groupings respectively approximate to the scale categories of 1, 2 and
3 of the Parkinson’s Disease Rating Scale [Webster Scale] 1968 (Carr
and Shepherd, 1998). They are intended as a guide only.
EARLY
• Some Bradykinesia
• Beginnings of flexor pattern
• Mild rigidity
• In walking, one arm shows decreased swing. Stride length 30-45cm.
Unequal L-R heel strike. Turning around slow, requiring several
steps.
MIDDLE
• Moderate Bradykinesia
• Slow performance of most activities
• Moderate rigidity
• In walking, restricted arm swing. Stride length 15-30cm. Forceful
L and R heel strikes. Some balance difficulties.
LATE
• Severe Bradykinesia
• Marked flexor posture in standing
• Severe resting rigidity in trunk and limbs
• In walking, no arm swing. Gait shuffling and festinating, stride
length between 8-15cm. Severely impaired balance. Freezing
episodes common.
Effect of a functional
electrical stimulator
on a patient with decompression sickness
INTRODUCTION
A young patient who was suffering from decompression
sickness presented with weakness in her left dorsiflexors,
and with sensory changes in her left lower limb.
Despite a course of physiotherapy including gait reeducation
and strengthening exercises there was no
objective or subjective change in her condition for eight
months. She was then referred to the neurology outpatient
department and was given a trial of a functional
electrical stimulator to the weak evertors and dorsiflexors
and an improvement was seen within three
weeks. Improvement continued rapidly and the patient
was walking normally within a month. Six months after
starting this treatment Sarah was able to run a half
marathon in 2 1 ⁄2 hours.
THE PATIENT
Sarah was a previously fit and well 21-year-old student
who was an experienced diver. She had been diving on
a regular basis without any previous problems and was
fit and regularly exercised. Past medical history
included fractures of left ankle, fingers and left wrist
from an earlier diving accident. She was living in a
shared house and had no disabilities.
In May 2001 she experienced problems on coming
out of the water, and was unable to carry the boat with
her other crew members. Three to four days later she
noticed increased weakness in her left shoulder. She
vomited and felt light-headed. There was numbness
and tingling in her left arm and leg. She had weakness of
her left hand grip and a left foot drop. Her problems
increased with malaise and ‘cognitive problems’: she felt
unable to process information.
Two weeks later she underwent hyperbaric oxygen
therapy in Plymouth, and her memory improved. The
treatment lasted up to six hours a day for two weeks. On
discharge she felt less fatigued but still had numbness
and tingling. Other problems now were a left foot drop,
left arm weakness, left shoulder weakness, pins and
needles and occasional pain in her left side. She also
complained of extreme fatigue. In June 2001 Sarah’s
symptoms became worse with increasing weakness. She
had increased fatigue and numbness again. She was rereferred
to Plymouth where she had a further week of
hyperbaric oxygen treatment.
Two months later she again had problems of foot
drop, with pain in her left upper and lower limbs. She
was seen as an outpatient by the neurologists.
In November 2001 she went climbing in the student
union on a metal rope ladder, which she had done
previously without any problems. She went for a drink
afterwards and felt tired and nauseous in the pub. She
walked home and had a shower. She lay on the
bathroom floor and was unable to get up due to pain
and weakness. She attended casualty and was admitted
to hospital for one month. All medical tests proved
negative.
INTERVENTION
Sarah was referred to physiotherapy and seen in a
musculosketetal outpatient department. Treatment
included exercises to increase strength in the affected
muscles, and gait re-education. She was able to walk at
this stage with one stick and a hinged ankle foot
orthosis. There was constant pain down the weaker left
side for which she was taking gabapentin 600mg three
times a day. Progress was slow, with no improvement in
the strength of her ankle muscles.
Sarah was referred to the neurology outpatient
department, Bristol General Hospital, in January 2002.
She was only able to walk two or three steps without her
splint, as her foot constantly inverted and planterflexed.
She felt shocked and depressed at having been told that
she may not walk again.
Sensation was decreased on her left side over the
lateral aspect of her left thigh with numbness in her left
foot. Co-ordination was also reduced on the left. She was
found to have weakness and reduced range of motion in
her left upper limb (generally grade 4, Oxford scale), and
had difficulty holding objects in her left hand. Her left
lower limb had more marked weakness, with only a
flicker of activity in her foot and ankle. There was poor
control of her left knee with a tendency for it to either
hyperextend or flex uncontrollably during gait. Planter
reflex was positive on the left and reflexes were brisk.
Problems were:
1. Weak eversion of the ankle and flexion of her left
knee.
2. Reduced stability and control of her left knee, with
some hyperextension in walking.
3. Altered sensation in her left leg.
4. Instability and weakness in her shoulder.
The use of electrical stimulation to improve control of
her dorsiflexors was discussed and Sarah was very keen
Melanie Ann Falk Grad Dip
Phys MCSP
Physiotherapy Department,
Bristol General Hospital,
Bristol BS1 6SY
KEY WORDS
Decompression sickness
Functional Electrical
Stimulator
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