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Disturbing case
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Disturbing case - March 12, 2008 10:35:10 PM
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PTupdate.com
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Joined: October 8, 2001
From: Pittsburgh, PA USA
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This past week I saw a physician, 40-something years old (won't say what type of MD, and please this is not the place to bring up issues as to why this lasted this long) at his request, for what he told me on the phone was UE weakness, and he wanted me to help with his home gym strengthening routine.
I had seen him 4 years ago for neck pain and shoulder weakness on the right. He had, from playing ball, strained his neck and had a lot of neck pain. 5 days later underwent kidney surgery. They radiographed the neck at the hospital, and all was clear. I saw him after the kidney recovery, finding limitation with RR, RSB, extension, and C4-5 weakness. We fixed the majority of these issues, and he went on his own. Saw him a year later for knee pain, and no neck issues.
So, he presents this past week describing severe UE weakness, now both sides, and difficulty even performing 5lb weighted biceps curls. Works out in his basement nightly "to fatigue". Symptoms began worsening 6 months ago, getting even crappier 3 months ago.
As he demonstrated things with his shirt on, I knew I was dealing with something bad. Had him take his shirt off, revealing severe supraspinatus, infraspinatus, and deltoid atrophy on both sides. Right shoulder so weak that active elevation was below 120, yet PROM easily to 160. Both shoulders fine for PROM, but 3/5 at best for all groups, and bi/tri not much better. Supination/pronation/wrist 4/5, fingers and hand normal..... no hand atrophy, no tremors, no dyskinetic movements. In fact, no neck, shoulder, or back pain.
While seated, muscle fasiculations in right infraspinatus and right triceps. Negative Hoffman, no LE issues, no visual, breathing, balance, coordination issues.
Reflexes close to normal, but if dealing with LMN, they actually would have been considered to be too reactive.
I told him he does not need to see me, but rather a neurologist, and fast. I personally am thinking brachial amyotrophic diplegia type problem, but would be interested to see what others are thinking before I get the neuro results. Please note I could have checked for a bunch of other things, but we got talking about music and Jerry Garcia....which is always more important. My other diagnosis possibilty is a severe central disc herniation or congenital stenosis, which may have compromised portions of the cord.
Obviously, I told him to stop exercising to "fatigue" for now
But, I had a stomach ache all day over this, my second (possibly) ALS-type syndrome pick-up in the past year. Being in the same age range, and a father myself, to me this just sucks really bad.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Disturbing case - March 12, 2008 10:47:32 PM
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annpsu25
Posts: 80
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From: PA
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Wow. This is really sad. Only in his 40's and he has had this many problems. I don't know what this would be because I have not had experience like you have, but I am interested to know the results and what treatment would be for him. Make sure to post and update when you find out.
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RE: Disturbing case - March 12, 2008 10:57:13 PM
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kamryn
Posts: 27
Joined: February 23, 2008
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Thanks for sharing this case - very unfortunate. Who knows what happened here - maybe he was in monster denial and simply turned to someone he could trust.
I would agree with your thoughts of ALS.
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RE: Disturbing case - March 13, 2008 6:22:53 AM
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Dr.Wagner
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From: Indianapolis
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Extremely intelligent move to refer to the neurologist. Very insightful. There are many that would wait just to see what they could do. I think you may be right on with the thoughts.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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RE: Disturbing case - March 13, 2008 9:27:53 AM
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jma
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From: NY
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Indeed a very unfortunate case. Let us know what was the outcome from the visit to the neurologist.
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RE: Disturbing case - March 15, 2008 3:00:46 AM
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chita229
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What about myasthenia gravis or Lambert eaton syndrom? Myasthenia gravis presents as proximal weakness. Does the strength testing diminish rapidly with repetition? Any mild facial drooping or asymmetry? Eye twitching? Just a guess off the top of my head. I know that doesnt perfectly fit with the reflex findings...
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RE: Disturbing case - March 15, 2008 10:50:41 AM
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annpsu25
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From: PA
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I thought MG also, but then i re-read his post:
"While seated, muscle fasiculations in right infraspinatus and right triceps. Negative Hoffman, no LE issues, no visual, breathing, balance, coordination issues."
No visual and breathing issues- 10-15% usually present with vision problems in the first year.
Also, MG presents with no atrophy and neurological findings are usually WNL.
Hope this helps.
_____________________________
Allisha
LPTA
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RE: Disturbing case - March 15, 2008 2:23:40 PM
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chita229
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Good points allisha; helps if I read more thouroughly right before bed when Im sick. ;)
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RE: Disturbing case - March 17, 2008 2:42:20 PM
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Nicole Matoushek PT MPH CSHE CEES
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From: St. Petersburg, FL
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Very interesting post. Please tell us what the neuro finds if you become aware of the results. I happen to have myasthenia gravis and I can say it is the snow flake disease, no 2 people have the same presentation. Severe proximal weakness in UE and LEs, even trunk is common, as are balance/dizziness issues, eye fatigue and drooping and swallowing/breathing challenges. Muscle fasciculations can occur with MG and not all MG patients have eye problems, breathing or swallowing problems. Some just have generalized fatigue and with time there could be disuse atrophy.
My biggest issue MG is generalized fatigue, I do not have any of the other problems listed, MG is not always text book and can be difficult to diagnose b/c the symptoms don't always fit the text book signs. You did the right thing by discouraging him from exercising to fatigue.... that is not wise with MG or other NM disorders. MG kicked my butt for several years. But there is treatment and hope.
The neuro should hopefully be able to find out what is going on, but I agree with you, it sounds a bit serious and hopefully treatable. If it is MG, let me know and I can point him in the direction of some resources.
_____________________________
Nicole Matoushek, PT, MPH, CSHE, CEES
http://www.ErgoRehabinc.com
http://www.ErgoRehabBlog.com
http://www.ComputerAccessoriesOnlineStore.com
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RE: Disturbing case - April 26, 2008 8:13:18 AM
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PTupdate.com
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An update: 2 weeks ago, the MRI of the neck revealed significant degenerative changes at multiple levels, esp. C4-5-6, the levels noted above. He felt very optomistic and even happy, I did not.......to see that kind of muscular wasting, fasciculations, fairly good reflexes, yet no neck pain or sensation of stiffness did not blend well with me. I have seen some with a good amount of single nerve root atrophy that cannot even remember any neck/scapular pain, but not this large scale. So, I held my opinion and breath as other test results came in
Yesterday, I discovered it has been diagnosed as an anterior horn disease, exact type not yet known.
Overall, this really sucks. But, it serves as a reminder to PT's that they will often be the front runners in evaluating persons with conditions such as this. Those too ignorant to know what they are viewing, or those too arrogant to do what's best for the patient, will do nothing but cause harm to the populace and our professional image. Crevidence notes in another post just how many don't read yet are working full time.
There are so many disease processes to learn, that can be picked up early in the PT environment, yet will be missed due to the laziness of the typical PT. Just last night I was reading a large list of case studies in the journal Orthopedics (Blue) detailing the early signs of conditions such as pediatric acute leukemia and bleeding complications in TKA, reminding me how much I still have to learn and retain
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Disturbing case - April 26, 2008 8:30:10 PM
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jma
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From: NY
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Thanks for the update. Definitely one of many that one may come across. Yes, I do agree that we have much to learn.
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RE: Disturbing case - April 27, 2008 10:02:42 AM
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rwillcott
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From: Canada
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This is a great lesson to all of us about the significance of PT. All of us our trained to pick up on these red flags and take the appropriate action to refer them on. If we all can do the right thing as Duffy has our profession will continue on the right track.
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RE: Disturbing case - April 30, 2008 1:35:02 PM
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TMondale
Posts: 131
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From: Newton-Wellelsley Hospital
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John,
Certainly too bad for that gentleman, and nice pick up by you. But I must take exception with what I felt the tone of your last post was. It's the same nonsense that legislators are bombarded with from self serving opposition groups to PT direct access talks on a regular basis. Our qualifications and results of direct access in many states for years speak for themselves.
Good for you for being such a good adult learner; we all should for our profession and patients. However we don't have to know what the signs and symptoms are for pediatric acute leukemia, or any other medical condition. What we have to be highly skilled at is knowing what lies within our unique body of expertise, and what doesn't.
Are diagnoses missed? Of course, mostly by medicine and probably not infrequently. Again John you seem like a very contientious, hard working, and probably very good therapist. That said, I would fully expect a new grad to know that that presentation you described in this case was dramatically not someone that needs our services primarily, and they would be referred out.
I very much agree that this responsibility in our practice will only grow.
No disrespect meant.
Tim
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RE: Disturbing case - April 30, 2008 9:45:18 PM
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PTupdate.com
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Tim,
I disagree with some of your points. First, we DO need to know the signs and symptoms of pediatric lukemia. What are they? 40% present with musculoskeletal pain, age range 7 months to 17 years, 12% may limp, 10% may have swelling, 6% may have joint effusion. These are all common orthopaedic signs/symptoms seen every day, often as direct access patients, or sent by a PCP that may not have even seen the child. Pallor and listenessness are the 2 more exact signs that need picked up. Not knowing these points, and not having radiographs to show positive findings, the condition could easily be brushed off (and treated as) "growing pains", shin splints, PFPS, etc. The crucial early detection period could be lost.
Perhaps I have the good (?) fortune of working with and around many PT's for many years, and can safely say over 80% don't read anything, nor do they take the time to learn anything. Some even brag about the fact, thus the "tone" in my above post. And, I often get to mop up the disasters and blatant misses by other PT's that should have been picked up.
I don't think anybody even reading this needs to take my comments as offensive....they are here.... either participating or lurking, but are still taking the time to learn something. It's the other 60,000+ PT's that I worry about.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Disturbing case - May 1, 2008 12:34:02 AM
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TMondale
Posts: 131
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From: Newton-Wellelsley Hospital
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John,
As I said I think you are one of the good ones for sure. I've read your inciteful and humerous posts for years now, and almost always agree with you. However in this case I think you're selling the profession short. There is no doubt that some diagnoses/medical conditons would be missed by us just as they are by medicine, and everyone else who sees patients at the entry point. What I am saying is that our training is as good or better than anyone else, save medicine for differentiating serious medical pathology from standard neuromusculoskeletal care. I completely disagree that we need to know what the condition is called, or exactly what the medical diagnosis is for any patient that we recognize as not fitting our care model. Again in your example above if that is brushed off as acceptable from our standpoint, then someone isn't practicing even to entry level standards.
I couldn't agree with you more that we as a profession must continue to advance our level of knowledge in all related areas as it pertains to the most effective methods of examination, treatment, and referral of our patients in the most appropriate manner.
We may just have to agree to disagree on this one John.
Tim
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RE: Disturbing case - May 1, 2008 7:06:18 AM
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SJBird55
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From: Michigan
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Do you know what the hardest part of our job is when it comes to referring on?
Communicating in such a way that 1) the physician being referred to isn't pissed off 2) communicating in such a way that our findings are taken seriously. All we have are our eyes, hands and ears. Research doesn't seem to support intertester reliability with what we do have. That means that it is highly unlikely that physicians will be able to reliably reproduce our findings. Also, the physicians may not even know the particular assessment tests we performed to even attempt to replicate our findings.
At the same time, there are plenty of times that I know something isn't right, but I have no idea what or why. I can't even offer a suggestion.
At the same time, Tim, it really is helpful to have some idea of what is medically occurring and being blunt about it, yet also being humble and unsure at the same time. Just by questioning if X has been ruled out by the physician opens the doors. By being able to communicate the possibility of a particular medical condition gets the physician thinking along the same lines OR on potentially different lines, but a "connect" has been made and then the physician can take our minor findings and our concerns and run with them. We are in such a weak position when it comes to diagnosis - yet I like to think we are in a unique position to sometimes be the first to know something isn't right.
Then, again... in my little community, I have 3 PCPs that expect me to be blunt and to tell them what I think is going on. I don't have to walk on eggshells and worry about hurting anyone's egos or stepping on toes. The only reason though is because I do and did work at having a personal relationship with them. I don't have that luxury with other physicians though.
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RE: Disturbing case - May 1, 2008 1:04:25 PM
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TMondale
Posts: 131
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From: Newton-Wellelsley Hospital
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SJ,
I,in no way meant to suggest that we don't have a strong foundation in medicine, and should know a good bit about what system might be malfunctioning when we refer back, or on to another specialist. I just disagree that it in anyway is necessary for us to know the latest updated information on all disease. Disease follows patterns, mostly by it's not passing the common sense test. Take John's example earlier; May limp; If the child is limping when there hasn't been an injury that right there is a problem; if there has been an injury it should be resolving within 1-2 weeks. If it isn't anyone needs to know it doesn't make sense. That doesn't mean something sinister is going on, but it damn well needs to be pondered further by medicine. Swelling and Jt. effusion, same thing, pallor and listlesness; are you kidding me; gone on for more than a couple of days? A lay person would know that isn't right. Does it make us better at obs to know that there is some probability that this might be pediatric lukemia? This is PT 101. And the rest is medicine. I'm totally comfortable leaving the medicine to the MD's, and referring it back.
To your point SJ I will absolutely refer with explanation. Some MD's that I know who may want my differential, I give it to them. Usually I describe my finding specifics and make some global statement toward R/O whatever I might be concerned about.
The problem I have with perceptions like what John has suggested is that, we as a profession are not ready, or well enough prepared for that task. I know we are, and years of direct access has supported that. And even if our entire professional body isn't as dedicated as I like to think I am, or John, or you or Alex,or any of us reading this. We should be very competant within the confines of our entry level preperation, having the confidence to be assertive with the MD's can be another matter. For those students and younger therapists that I ocassionally council in matters like this, some of it has to do with the "I would feel foolish if I'm wrong" thing. I've said here before nowhone is perfect when it comes to this differentiation
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