Dear Physical therapist, Back to contents I had one of the fortunate chances of treating this woman in the nursing home I worked . That was about a year and half ago when I was working in Grand rapids, Michigan. This woman was admitted to the nursing home from her residence. She was in her late 50's. She had been hospitalised thrice during the last 6 years, according to her history. Apparently her major concern was loss of balance while walking. She together had multiple associated problems and as a result, PT, OT and speech services were very much indicated. The patient's family was really concerned as her husband, son and the rest kept visiting on a regular basis. It showed that they truly cared for this poor woman. When I was assigned this patient in Physical therapy, I as usual ,did some routine tests as part of my initial evaluation. I knew the medical diagnosis well ahead. But inspite of knowing it,I was puzzled and did not know what exactly to look for. The woman seemed co-operative and could recall her history, but with a very slow thought process and slurred speech. She wore glasses and there was something about her eyesight . She did not seem to make any eye contact at all during our conversation. Her husband gave me finally ,her pre-morbid status and the details of the progression of disease. The initial findings were not too significant at least for me. She had been suffering from this for almost 6 years. It had taken years of battle to arrive at her current diagnosis. Her primary physician had been treating her with a misleaded diagnosis , until she was referred to a Neurologist. In the next few days, her clinical features were baffling me. There seemed to be no muscle weakness in both upper & lower extremities. However she showed a distinct tendency to fall backwards in unsupported standing. Her cadence was less using a roller walker and slightly better with 2 person hand held assistance. Either way she would stop after 15-20 ft as she complained of stiffness in her Lt.big toe.When examined, she presented evidence of a hyperflexed great toe which was of spastic type. It took several minutes to relax to normal. The patient appeared very frustrated and would quit the session when this occurred. In the effort to fasten her recovery I increased her Tx frequencies to BID. This is when I found that she had very poor receptiveness one time and strikingly better indulgence the next time. I would go to see her in her room in the afternoons, and I would find her cuddled in her blanket .As I knock the door and push open, she would call out my name and attempt to get up in bed pushing up from her elbows. The next moment she would fall back in her bed due to lack of balance . She kept her room dark. Even the visitors were sometimes sitting next to her in that darkness. During many occassions, I will find her in her bed with tears in her eyes. It was obvious that she was under depression .She had a decent memory and would know my times of visit. Sometimes it would take a half hour to put on her Lt.shoe due to the spastic big toe. I had then instituted Frenkel's exercises for her in-coordination and balance deficits. The main limitation in her progress came from her visual defects. By now she had fallen at least twice as she had attempted to stand and ambulate in her room. Later I recognised that this occurred due to her inability to focus and aim her eyes. The speech therapist who was working with her told that she had difficulty in shifting her eyes from one line to another line. She had also swallowing difficulties and was at risk for aspiration pneumonia. She showed gradual personality changes including loss of interest in pleasuraable activities and increased irritability. Sadly , over the next several weeks, this patient did not make any outstanding progress. Helplessly we tried in all means to encourage this poor woman. The outcome was not too successfull. There was very little to no progress.She had to be discharged from Physical therapy to restorative nursing. She had to however continue medication with Levadopa and anti -depressants. Within my inner mind I had a hopeless feeling. What prevented this woman from not recoverring partially or fully ? As I read a lot of literature on this disease, I was clear with most of the answers and yet left with a few queries of this mysterious disease. Note: Readers are encouraged to write to the EDITOR ONLY , the answers to the following. Whoever FIRST gives all the answers right , will recieve a gift in their mail. Please include your address without fail. The winner's name shall be honored by the editor in the next issue and the answers will be discussed in the same. 1 )What is the cause of this disease ? 2) What is the name of the disease ? 3) What does the name mean and signify ? 4) Which otherdisease does this resemble ?, Good luck. Raveen, PT Rochester, NY USA.
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