1 Rehabilitation of a Complex Patient with Autoimmune Disease and ARDSKatherine Leuck, PT, DPT Cori Cohen, OTD, OTR/L Main Campus, Acute Care December 07, 2016

2 CASE DESCRIPTION HPI- Patient is a 41 y/o male presenting to CCF MICU on 8/19 with recent diagnosis of Adult-onset Still's disease and ARDS. History 5/9/16 presents to OSH with chest pain, outpatient workup negative Pt is followed as an outpatient by multiple specialists; continued to have multiple nonspecific symptoms as seen in ROS Outpatient workup included imaging demonstrating ground glass opacities and was recommended for admission to OSH for continued workup But he was admitted for worsening symptoms including muscle/joint pain, vomiting, cough, and diarrhea. Review of Symptoms Respiratory: non-productive cough Gastrointestinal: vomiting, diarrhea Musculoskeletal: arthralgia/myalgia Integumentary: non-specific, pruritic rash grossly on UE/LE

3 Case continued Imaging and testing Inpatient courseCT positive for enteritis & mesenteric lymphadenopathy, enlarged fatty liver WBC elevated, LFTs elevated, negative tests: RSV, strep, HIV, fungal serologies, EBV and CMV Bronchoscopy with BAL showed inflammatory changes, began antibiotics CT chest shows progressive ground glass infiltrates ANA negative, RF negative (autoimmune inflammatory markers) Inpatient course 8/6: Pt intubated 2/2 respiratory distress (AC 50%, PEEP 12) 8/10: Pt extubated 8/11: Rheumatology suspected adult onset Still's Disease and was started on Anakinra (pulse dose steroids) 8/16: Re-intubated for possible transfer, asynchronous and tachpyneic to 50s. Required proning (FiO2 100%; PEEP 15) 8/19: arrival to CCHS. Pt is paralyzed, sedated on propofol, fentanyl and paralyzed with atrocurium. Patient on dopamine and norepinephrine 8/20: spontaneous pneumothorax, chest tube placed 8/29: Physical and Occupational therapy are consulted This slide might be able to fit in elsewhere…..

4 Literature Review Adult Onset Still’s Disease (AOSD) is a constellation of symptoms and is a dx of exclusion. Presents as several non-specific symptoms and is often preceded by infection triggering immune response. Can have involvement with heart, lungs and kidneys. Acute Respiratory Distress Syndrome (ARDS): occurs quickly, within a few hours or up to a few days following the initial disease/trauma.  ARDS occurs when fluid builds up in the alveoli and results in hypoxemia. Patients present with respiratory distress, tachypnea, tachycardia and use of accessory muscles for respiration. This patient population requires high concentrations of supplemental oxygen, mechanical ventilation with low tidal volumes and high PEEP. Cardioinhibitory vasovagal response

5 Ventilator ManagementResearch shows that managing the vent with low tidal volumes and a higher than normal PEEP maximizes alveolar recruitment. These two factors together may decrease the risk of ventilator associated lung injury. This is referred to as open lung ventilation, which may help improve mortality and other clinical factors. Low tidal volumes are a protective mechanism for the lungs (avoiding alveolar overdistention).

6 ARDS vs Typical Vent SettingsTypical parameters which indicate proceeding with PT and OT FiO2 <60% PEEP <12 Respiratory Rate <30 When treating ARDS patients daily discussion must take place between PT, OT,RT and medical team A patient with ARDS will often have an increased RR secondary to a low tidal volume to ensure the patient is receiving the entire minute ventilation. Reasonable SpO2 saturation is 88-95%. The typical ARDS patient will desaturate at a moderate rate requiring extended rest breaks and increased supplemental O2 for therapy Relevance for therapy: ventilator settings for ARDS patients may contradict proposed guidelines for progression of therapy. See Treatments to compare vent settings to normal

7 EXAMINATION Subjective MeasuresPatient Goals Short Term: tolerate out of bed tasks Long Term: Go to rehab, Return home and regain baseline function Home Set Up Patient Lives With: Significant Other Assistance Available: PRN Number Of Stairs Into Home: 2 Number Of Stairs To Bed/Bath: 0 Equipment Owned:  None Prior Functional Level: Within Functional Limits - patient is a police officer, independent with ADL/IADL tasks. Wife and family at bedside throughout hospital stay, very involved family

8 EXAMINATION ObjectiveMMT/ROM Evaluation on 8/30/16 (limited exam, focus on function to EOB this session) R knee extension 2-/5 L knee extension 2/5 L ankle DF 1/5 R ankle DF 1/5 R and L shoulder <50% ROM; 2-/5 MMT BUE 2-/5, exam limited by sedation/weakness

9 THERAPY DIAGNOSIS & PROGNOSISAcute Care PT diagnosis included reduced mobility and generalized muscle weakness Acute Care OT diagnosis included decreased activities of daily living (ADL) and reduced mobility Problem list: Occupational Therapy Problem List: Impaired Self Care; Decreased Activity Tolerance; Functional Mobility Impairment; Balance Impaired Physical Therapy Problem List: Education Deficit; Impaired Self Care; Decreased Activity Tolerance; Decreased Range Of Motion; Decreased Strength; Functional Mobility Impairment; Balance Impaired Early physical and occupational therapy intervention look similar in the ICU working toward very different goals

10 Challenges and ComplicationsMedical complications Pneumothorax (2 instances) Hypoactive delirium High amounts of sedation Difficulty controlling BP/HR/SaO2 and volume status High anxiety requiring OT for relaxation training during physical function tasks per PT Vasovagal response (atypical) High oxygen requirements and difficulty weaning from ventilator Poor tolerance of transition from IV to PO steroids (respiratory distress, shock)

11 INTERVENTION Evaluation on 8/30/16 Physical TherapyOccupational Therapy Intervention Bed mobility supine <> sitting with max x2 Postural control exercises, posterior assist with cues for cervical extension, assist to maintain midline posture during EOB task per OT Positioned in chair mode at end of session to promote hemodynamic tolerance to upright 20 minutes at EOB Cognition Anxiety reduction Family interaction/support Education Assist w/ calming at EOB Education to family and pt for ROM and positioning Response Patient drowsy throughout session, followed 1 step commands. Rec LTAC with hopeful progression to AR. Oxygen Requirement Oral endotracheal intubation Settings at PSV 40% FIO2, PEEP 5 Pressure Support 8 Assessment/Notes Family arrived mid session, improved alertness, able to participate with patient at EOB Patient mildly agitated at end of session.

12 Therapy Goals Physical Therapy Goals Occupational Therapy GoalsTransfer supine to/from sit with contact guard Transfer sit to/from standing to be assessed when deemed safe Pt will improve seated balance to contact guard in preparation for transfers Pt will tolerate BLE/BUE exercise > 20 reps to facilitate strength Occupational Therapy Goals Feeding with: Set Up Grooming with: Set Up Upper Body Bathing with: Modified Independent Upper Body Dressing with: Modified Independent Lower Body Bathing with: Modified Independent Lower Body Dressing with: Modified Independent Chair Transfer with: Contact Guard Assistance Toilet Transfer with: Contact Guard Assistance Tolerate (minutes of functional activity): 30 Functional Activity with: Contact Guard Assistance Demonstrate Positive Coping Strategies with: Independent Demonstrate Competence With Education with: Independent 

13 Pt not seen again until 9/6 due to multiple reasons: illness requiring pressors, vent weaning, tracheostomy (9/2). Treatment 9/06/16 Physical Therapy Occupational Therapy Intervention Bed mobility supine <> sitting with max x2 Postural control exercises, assist for performance of anterior trunk lean during exercises per OT to improve midline/upright posture EOB x13 minutes Activity tolerance at EOB Posture for ADL tasks and promoting PT transfers Significant relaxation and anxiety management Single step breakdown of commands and tasks for cognition and anxiety Decreased attention Response Session limited by fatigue Oxygen Requirement Tracheostomy to vent Pressure support, 40% FIO2, PEEP 5, Pressure support 5 Assessment/Notes Patient required extensive time for rest breaks and relaxation training per OT to optimize breathing throughout functional tasks

14 Physical Therapy Occupational TherapyTreatment on 9/07/16 Physical Therapy Occupational Therapy Intervention Extended supine warm up Bed mobility supine <> sitting with max x2, rolling max x2 with assist for hip/knee flexion and reaching for upper trunk rotation Assist to maintain seated balance throughout cognitive/relaxation cues per OT EOB x10 minutes To cope with significant respiratory needs and promote optimal participation in functional EOB activity, pt was cued extensively for anxiety reduction and relaxation. He required tactile, visual and verbal assist. Response Session limited by desaturation; during seated task patient SaO % with slow recovery once in supine. RT present throughout for suctioning and hyperoxygenation. Oxygen Requirement Trach + passy muir valve, required RT at bedside to remove passy muir and allow patient to work only on trach collar (50% FIO2) Assessment/Notes Patient required extensive time for rest breaks and relaxation training per OT to optimize breathing throughout functional tasks

15 Patient tachypenic, tolerated supine exercise onlyTreatment on 9/09/16 Physical Therapy Occupational Therapy Intervention Supine AP x10 Chair mode LAQ x10 Review of HEP with patient and family for weekend performance Not seen this date by OT Response Patient tachypenic, tolerated supine exercise only Oxygen Requirement Trach collar, 50% FIO2 Assessment/Notes Patient eager and motivated, although unable to maintain safe respiratory rate for OOB activities.

16 Treatment on 9/12/16 Physical Therapy Occupational TherapyInterventions (Seen separately) Supine and seated EOB exercise, supported and unsupported VC/TC for posture, positioning and breathing control 10 x5 seconds trials of sitting static EOB with weight shifting anterior/posterior with min A to improve core strength and endurance EOB x11 minutes Goal of session to address physiologic tolerance of position changes to allow engagement in ADLs and reduce anxiety related both to respiratory status and responses to activity. Cued for breathing during movement to encourage rhythmic, regular breathing. Response Vitals stable throughout session Desaturation to 80s Bradycardia to 40’s Oxygen Requirement Trach collar 50% FiO2 Assessment Notes Patient tolerated EOB sitting after increasing elevation of HOB in multiple increments and performing exercises in each position prior to sitting Change of recommendation from LTAC to Acute Rehab Pt noted to desaturate and become bradycardic at EOB to 40s. RN aware. Upon immediate return to supine, SaO2 increased to 96% and HR to 106. Remainder of session completed w/ gradual increase in HOB angle.  Change of recommendation to AR from LTAC

17 Symptoms and physiological presentation resolved with return to supineTreatment on 9/13/16 Physical Therapy Occupational Therapy Intervention Supine to sitting with mod x2, 1 trial of static sitting with maxA, sitting to supine with max A x2 Supine and modified chair mode exercises for BLE AROM Bed mobility sequencing Education on self pacing Compensatory responses for vaso-vagal response Response Patient HR and SaO2 decreasing below normal limits with sitting EOB, pt mildly asymptomatic Pt continues to experience decreasing HR and desaturations during sitting position. MD present to witness occurrence x2. During episodes, pt is stable in supine or semi-fowlers. Upon sitting (whether pt is active in mobility to EOB or is passive) he drops his HR from 100s to 60s. Pt becomes diaphoretic and endorsed feeling faint. BP WNL. Upon return to supine, immediate return to baseline vitals. Lowest desaturation this date on 2 trials of sitting, 85%, spontaneous recovery upon return to supine. Oxygen Requirement Trach collar 50% FiO2, PMV Assessment/ Notes Symptoms and physiological presentation resolved with return to supine Recommendation change from Acute Rehab to SNF due to activity tolerance

18 Recommendation change from SNF to Acute RehabTreatment on 9/14/16 Physical Therapy Occupational Therapy Intervention Supine warm up – AP x10, heel slides 2x5, SAQ 2x5 – cues for breathing/rest breaks 3 trials of long sitting with min/mod x2 at bilateral UE support seconds each trial, TC for improved thoracic extension and scapular retraction Sit to/from supine with max A x2 TC for postural corrections while EOB to improve thoracic extension with CGA to mod A to maintain control – x7 minutes extensive guidance for breathing and pacing, pt was able to sit up at EOB and complete multiple long sits in bed w/ no deleterious vital response.  Response Patient with appropriate physiological response, improved anxiety with counting aloud 1,2,3 or A, B, C Oxygen Requirement Trach collar 40% FiO2, PMV Assessment/ Notes Patient eager and motivated, although unable to maintain safe respiratory rate for OOB activities. Recommendation change from SNF to Acute Rehab

19 Transfer out of ICU (yay!)Treatment on 9/15/16 Physical Therapy Occupational Therapy Intervention 3 trials of long sitting with mod x2 at bilateral UE support 30 seconds each trial Sit to/from supine with mod A x2 TC for postural corrections while EOB to improve thoracic extension with CGA to min A to maintain postural control – x2 minutes Significant education on sleep schedule, maintenance of cognitive health Engagement in leisure activities, visitation with family, use of iPad/tablet. Response Patient fatigued 2/2 session after modified barium swallow Oxygen Requirement Trach collar 40%; increased to 50% for therapy d/t desat. Use of PMV. Assessment/Notes Patient required increased O2 and suctioning during session

20 Improved vasovagal response to activityTreatment on 9/16/16 Physical Therapy Occupational Therapy Intervention Log roll with min A – 2 trials CGA to min A for balance and postural correction at EOB Cotreatment with PT AND SLP for speech and swallow posture in chair (lift to chair). Continues to have poor vital response to EOB/upright sitting including significantly dropped HR and saturations. Positioning in chair Response SaO % during session Oxygen Requirement Trach collar 35% FiO2, PMV Assessment/Notes Patient continues to improve strength and functional mobility with less assist, improved motivation Improved vasovagal response to activity

21 SaO2 low 80s during session, recovered well with rest breaksTreatment on 9/19/16 Physical Therapy Occupational Therapy Intervention Sit to/from standing with min to mod A x2 with PT on left and OT on right each providing cues to maintain balance, bed to chair stand pivot transfer Prolonged rest to maintain appropriate SaO2 Patient stood and transferred to chair. Significant assist by OT for talking for pacing during mobility and activity to prevent desaturation and bradycardia during transfer Response SaO2 low 80s during session, recovered well with rest breaks Oxygen Requirement Trach collar 35%; PMV Assessment/Notes Patient now performing transfers sit to/from standing, transferring bed to chair

22 Treatment on 9/20/16 Physical Therapy Occupational Therapy Intervention Log roll with min A, assist for trunk management Instructed in sit to stand with min A x2, stand to sit with min A x2 and assist for eccentric control – 2 trials each Bed to chair transfer with use of RW and min A x2, cues for step height to decrease shuffling Extensive discussion on discharge planning – goal of sitting in chair x6 hours in prep for travel plus transfers with 1 person (pt wanting to transport with wife, discussed with MD as recommendation unsafe) Cotreatment for portion of session. OT focused on continued self pacing and goal setting. Required extensive discussion on safety awareness and discussed logistics of transportation to AR. Response SaO2 from 81-93% during session, recovered well with rest breaks (approx 2 minutes) Oxygen Requirement Trach collar 30% FiO2, PMV Assessment/ Notes Patient progressing well toward therapy goals, transferring and performing short distance ambulation

23 No cotreat – assist per tech No OT session Intervention Treatment on 9/22/16 No cotreat – assist per tech No OT session Intervention Supine to sitting with min A Sit to/from standing with min A/HHA with cues for efficiency Transfer bed to chair with min A/HHA with cues for posture, stepping and breathing control Response SaO2 low 80s during session, recovered well with rest breaks Oxygen Requirement Trach collar 30% FIO2, PMV Assessment/Notes Patient transferring well but limited by chest pain intermittently – MD aware (CT scan negative)

24 Patient discharged to Acute Rehab on 9/26 via ambulanceTreatment on 9/25/16 Physical Therapy Occupational Therapy Intervention Supine to sit with CGA Transfer bed to chair with min A, use of RW Sit to stand from EOB with min A, 2 trials Instructed in 15 feet ambulation x2 trials, use of RW with cues for proper body position within walker, min A for balance ADLs including LE dressing and self pacing. Seen following PT session. Response Tolerating all tasks, including short distance ambulation No desaturation Tolerated all tasks well No bradycardia Oxygen Requirement Trach collar 30% FiO2, PMV Assessment/Notes No cotreat – assist per tech Patient now ambulating! Patient discharged to Acute Rehab on 9/26 via ambulance

25 OUTCOMES Treatment on 9/15/16 updated Treatment (last tx) on 9/25/15BLE 3/5 Treatment (last tx) on 9/25/15 >/= 4/5 measured through function, ambulating with RW BUEs at least 4/5 noted by ADL UE/LE dressing performance Oxygen requirement at 30% FIO2 via trach collar Discharged home from acute hospital following pleurodesis on 10/22 Patient ambulating with walker (MIN assist) Patient performing ADLs w/ MIN assist

26 CONCLUSION Complex case combining autoimmune disease with ARDSCombination of cognitive management with physical progression Skilled cotreatment required to maintain hemodynamic monitoring during slightest mobility and exercise Skilled cotreatments can significantly benefit complex patients while addressing separate goals

27 Where he is now… Patient discharged to Acute Rehab in Louisville, KY.Patient re-admitted to Jewish hospital with pneumothorax (3rd) requiring chest tube re-insertion, VATS, and pleurodesis. Patient required PEG tube 2/2 decreased swallow reflex, poor esophageal sphincter contractility, now resolved and patient tolerating PO, full diet! Patient ambulating without adaptive equipment, assisting with coaching daughter's basketball team Physical therapy outpatient 3x/wk Discharged from home OT

28 REFERENCES 1)Pearmain L , and Herridge MS . Outcomes after ARDS: a distinct group in the spectrum of disability after complex and protracted critical illness. Minerva Anestiologica; :   2)Putman, M.S. and Du, A.B. Adult Onset Still's Disease Complicated by the Acute Respiratory Distress Syndrome. Lupus: Open Access. 1/2016; 1:111. 3) Siegel, M. D., MD, & Hyzy, R. C., MD. (2016, June 16). Mechanical Venitlation of adults in acute respiratory distress syndrome. Retrieved November 29, 2016, from  Patient provided HIPAA release for photos and privacy information.

29 Spinal Manipulation & Sport-Specific Strengthening in a Collegiate Baseball Player with Thoracolumbar Junction Syndrome Alli Burfield, SPT & Eric Jankov, PT, DPT, C-OMPT, CSCS University Hospitals St. John Medical Center Outpatient Rehabilitation

30 Thoracolumbar Junction Syndrome Case ReportPurpose Outline the patient/client management of thoracolumbar junction syndrome (TLJS) using an evidence-based, manual therapy and therapeutic exercise approach. Explain the clinical signs and symptoms of TLJS. Provide treatment strategies to effectively manage TLJS. Provide rationale for clinical decision making process in the treatment of TLJS.

31 Thoracolumbar Junction Syndrome Case ReportPatient History 19 y/o M with complaints of left-sided low back pain with radicular symptoms, groin pain, and lateral hip pain following batting practice. Medical Diagnosis: Acute Lumbar Disc Herniation Pain: 4/10 at rest, 8/10 during baseball Aggravated by batting, throwing, forward bending, & prolonged sitting. Relief with prone press ups & stretching before and after practice. Radiological Impression: Unremarkable, except hypoplastic ribs at T12. -The patient was performing repetitive right-handed baseball swings and reported a sudden onset of low back pain that progressively increased in intensity with subsequent swings. -The patient had not experienced any low back pain prior to this episode, but reported that he had started to increase his number of swings per practice to 100 or more before the injury. - Diagnosed by excellent diagnostician/physician.

32 Thoracolumbar Junction Syndrome Case ReportExamination Posture: Excessive lumbar lordosis + anterior pelvic tilt in standing Palpation: Hypertonicity and tenderness of the L lumbar paraspinals & hypersensitivity to the L greater trochanter and the inguinal region. Spinal Palpation: Painful at L4-L5 and at TLJ with PA pressure. M/L glides to SP at TLJ reproduced symptoms in lateral hip & groin. Lumbar ROM: Grossly WNL with LBP pain in all directions, extension being the worst.

33 Thoracolumbar Junction Syndrome Case ReportExamination Repeated Movements: Prone lumbar extension centralized LBP, but no effect on lateral hip or groin pain. Hip ROM: Limited hip extension bilaterally, otherwise WNL. Hip & Core MMT: WFL except gluteus medius & maximus 2/5. Unable to sustain testing position without compensating with lumbar extension.

34 Thoracolumbar Junction Syndrome Case ReportMaigne R. Low Back Pain of Thoracolumbar Origin. Arch Phys Med Rehabil. 1980; 61 (9): 389 – 95. TLJS is caused by compression or entrapment of the dorsal rami at T11-L1 and/or the thoracolumbar fascia. Diagnosed by clinical symptoms or by periapophyseal joint injection. Referral Areas: 1. Inguinal/Groin Area 2. Posterior Iliac Crest 3. Greater Trochanter Thoracolumbar junction syndrome (TLJS) was first acknowledged and considered a creditable source of low back pain by a French physician, Robert Maigne, in the 1980s. TLJS is defined by pain in any one region local to the posterior pelvis near the iliac crest, the lateral hip, or the inguinal region. As a result, TLJS can easily mimic sacroiliac pain, hip pain, or groin and pubic pain.5,6 This triad pattern of pain can be directly correlated to the spinal nerve roots at the thoracolumbar junction (TLJ). The posterior ramus of T11-L1 variably innervates the subcutaneous tissue of the upper buttocks, the anterior ramus innervates the lower abdomen and groin, and the lateral cutaneous branch innervates the lateral hip. Anterior Ramus Posterior Ramus Lateral Cutaneous branch

35 Thoracolumbar Junction Syndrome Case ReportClinical Presentation Symptoms reproduced by: PA or lateral pressure at the TLJ Contralateral Sidebending Ipsilateral Rotation Skin rolling test Deep palpation along posterior iliac crest Commonly seen in individuals who perform repetitive/overuse activities with rotational components. The T11-L1 vertebrae act as transitional segments of the thoracolumbar spine, as the orientation of the zygapophyseal joints transitions from the frontal plane to the sagittal plane in this region. Due to limited rotational movements throughout the thoracic and lumbar spine, the thoracolumbar junction undergoes increased rotational distress and is more susceptible to dysfunction.

36 Thoracolumbar Junction Syndrome Case ReportClinical Impression TLJS Lumbar Paraspinal Strain Acute Lumbar Disc Herniation The patient presented with signs and symptoms consistent with the diagnosis including pain upon palpation of the thoracolumbar junction, hypersensitivity near three referral areas, and tenderness to palpation near the iliac crest.7 The patient also presented with symptoms consistent with an acute lumbar disc herniation at the levels of L4-L5, as his low back pain local to those levels centralized with repeated prone lumbar extension. The patient also likely had a strain of the left lumbar paraspinals secondary to a protective mechanism to the injured spinal levels previously stated The patient presented with left-sided low back, buttock, lateral hip, and groin pain, which was likely due to TLJS, acute lumbar disc herniation, and a strain of the lumbar paraspinals. Secondary causation included repetitive overuse, poor neuromotor control, abnormal length-tension relationships, and altered spinal mechanics.

37 Thoracolumbar Junction Syndrome Case ReportInterventions Spinal Manipulation to TLJ

38 Thoracolumbar Junction Syndrome Case ReportTLJ Rotation & Self Mobilization

39 Thoracolumbar Junction Syndrome Case ReportResisted Baseball Swings & Core Stabilization

40 Thoracolumbar Junction Syndrome Case ReportOutcomes Plan of Care: 2x/week for 3 weeks, then 1x/week for next 3 weeks At discharge and at a 3 month follow up, patient was pain-free with full athletic participation. Rated +6 (a great deal better) on the 15-point Global Rating of Change Scale Oswestry Disability Index 0% disability at discharge, from 26% at initial evaluation.

41 Thoracolumbar Junction Syndrome Case ReportAnatomy https://upload.wikimedia.org/wikipedia/commons/thumb/a/a3/Sobo_1909_35.png/201px-Sobo_1909_35.png

42 Thoracolumbar Junction Syndrome Case ReportAnatomy

43 Thoracolumbar Junction Syndrome Case ReportSinger KP, Breidahl PD, Day RE. Variations in Zygapophyseal Joint Orientation and Level of Transition at the Thoracolumbar Junction. Surg Radiol Anat ; 10: 291 – Level of Evidence: 2b CT scans through superior endplates of T11, T12, L1, and L2 (N = 214) Joint angles calculated using computer aided digitiser Coronally oriented superior & sagittally oriented inferior joint processes Articular tropism (> 20°) most frequent at T11-12 (21%), then T12-L1 (9%)

44 Thoracolumbar Junction Syndrome Case ReportAnatomy

45 Thoracolumbar Junction Syndrome Case ReportMaigne JY, Maigne R. Trigger point of the posterior iliac crest: painful iliolumbar ligament insertion or cutaneous dorsal ramus pain? An anatomic study. Arch Phys Med Rehabil. 1991; 72 (10): Level of Evidence: 2b

46 Thoracolumbar Junction Syndrome Case ReportBiomechanics

47 Thoracolumbar Junction Syndrome Case ReportHansen L, de Zee M, Rasmussen J, Anderson TB, Wong C, Simonsen EB. Anatomy and Biomechanics of the Back Muscles in the Lumbar Spine with Reference to Biomechanical Modeling. Spine. 2006; 31 (17): Level of Evidence: 2a

48 Thoracolumbar Junction Syndrome Case ReportBiomechanics Normal (neutral) mechanics TLJ = higher degree of rotation available compared to lumbar spine Orientation of the facet joints Floating ribs https://www.researchgate.net/figure/ _fig3_Figure-3-Movements-of-the-lumbar-spine-A-side-lateral-flexion-B

49 Thoracolumbar Junction Syndrome Case ReportBiomechanics Abnormal (non-neutral) mechanics Excessive lumbar lordosis + ant. pelvic tilt further limits lumbar rotation, thus increasing stress to TLJ Also increases risk of extension overload at TLJ https://s-media-cache-ak0.pinimg.com/236x/f3/03/93/f30393c4b07ce64bb0d2c9a204a67ee1.jpg

50 Thoracolumbar Junction Syndrome Case ReportFortin JD. Thoracolumbar Syndrome in Athletes. Pain Physician ; 6: 373 – Level of Evidence: 4. Sports with repetitive spinal loading with hip flexion & cervical extension concentrate forces at TLJ (i.e. equestrian, hockey, football, golfing, baseball, etc.) Limited cervical extension when head is already tilted upwards Limited thoracic extension available due to biomechanical limitations (i.e. ribs) No extension available at LSJ due to hip flexion TLJ becomes pivotal region for further extension loading

51 Thoracolumbar Junction Syndrome Case ReportBiomechanics https://torquehitting.files.wordpress.com/2013/12/griffey.jpg

52 Thoracolumbar Junction Syndrome Case ReportConclusion / Review: TLJS has 3 primary referral sites (other than local tenderness) 1) Posterior iliac crest 2) Inguinal / groin region 3) Greater trochanter https://www.hfe.co.uk/blog/wp-content/uploads/2015/09/Maignes-2.jpg

53 Thoracolumbar Junction Syndrome Case ReportConclusion / Review: Concordant radicular symptoms reproduced with: P/A or lateral pressure at spinous process or zygapophyseal joint of involved spinal level Skin rolling test / palpatory tenderness 7 – 8 cm lateral to midline along posterior iliac crest Contralateral side-bending / Ipsilateral rotation Imaging typically non-contributory Most commonly insidious onset with h/o repetitive overuse activities

54 References Maigne R. Low Back Pain of Thoracolumbar Origin. Arch Phys Med Rehabil. 1980; 61 (9): 389 – 95. Singer KP, Breidahl PD, Day RE. Variations in Zygapophyseal Joint Orientation and Level of Transition at the Thoracolumbar Junction. Surg Radiol Anat ; 10: 291 – 295. Maigne JY, Maigne R. Trigger point of the posterior iliac crest: painful iliolumbar ligament insertion or cutaneous dorsal ramus pain? An anatomic study. Arch Phys Med Rehabil. 1991; 72 (10): Hansen L, de Zee M, Rasmussen J, Anderson TB, Wong C, Simonsen EB. Anatomy and Biomechanics of the Back Muscles in the Lumbar Spine with Reference to Biomechanical Modeling. Spine. 2006; 31 (17): Fortin JD. Thoracolumbar Syndrome in Athletes. Pain Physician ; 6: 373 – 375.

55 “Dancing To Reduce Dystonia” Benefits of Salient Treatment to minimize symptoms from Dopa-Responsive Dystonia Courtney Petrone, PT, DPT Cleveland Clinic Main Campus Neurologic Physical Therapy Resident

56 Case Description 35 year old female with complaint of lower abdominal pain, hematuria, and worsening dystonia Past Medical History: Genetic torsion dystonia Spasmodic torticollis Spina bifida Past Surgical History: Multiple spine surgeries Spine surgeries in 97, 99, 2002 x 2

57 **Diagnosed with “Dopa-Responsive Dystonia”Case Description Dystonia History Childhood: R foot would turn in when ill, “poor posture” Diagnosed with spondylolisthesis  multiple spinal surgeries 20’s: increased posturing of neck, R hand, and R foot 2005: diagnosed with generalized dystonia Intensive outpatient PT, Botox injections Early 30’s: exacerbation of symptoms secondary to UTI, sinus infection Intensive inpatient rehab discharged with TLSO + HKAFO 4 months later: trial of carbidopa/levodopa with notable improvement **Diagnosed with “Dopa-Responsive Dystonia” Ballet teacher told her she didn’t have perfect posture – did an arabesque, felt shooting pain down leg, diagnosed with spondylolisthesis Until early 30’s, had been symptom free for 2 years Tried carbidopa in college, but was not really taking meds regularly bc made her nauseous

58 Case Description Psychiatric history: Hospital Admission:2015: Increased job demand  self increase in Sinemet  mood changes 2016: further development of mood changes, started on Abilify Hospital Admission: Infection + Abilify = Dystonia Admission to inpatient rehabilitation for 2 weeks Admitted to inpatient psych after increasing sinemet dose to up to 600mg a day; meds changed to CR 100mg 3x/day Mood changes usually a result of high demand job Positive response to therapy in the past, therefore wanted to go back Discontinued abilify and began aggressively treating the UTI

59 Literature Review …. Not a lot of research on Dystonia“The basics”: stretching, strengthening Control antagonists of the dystonic muscles Improve endurance of trunk/scapula muscles for postural improvement PD Approach? Presents with trunk rigidity + bradykinesia Mind Set? Control and activate antidystonic muscles Mind set: seems to have a bit of a psychogenic component, so if we could reinforce good behavior and add in components of goal-oriented treatment, could we make a difference? Voos, Mariana Callil, Tatiana De Paula Oliveira, Maria Elisa Pimentel Piemonte, and Egberto Reis Barbosa. "Case Report: Physical Therapy Management of Axial Dystonia." Physiotherapy Theory and Practice 30.1 (2013):

60 EXAMINATION: Subjective Measures“Walk across campus” “Care for my daughter” “Walk in heels” “Return to ballet class” Goals

61 EXAMINATION: Objective MeasuresAssessment Admission Strength BLE grossly >4/5 with exception of: R hip flexion: 3-/5 R knee extension: 3+/5 R hip abduction: 3+/5 Spasticity Right LE Left LE Knee flexors 3 1+ Knee extensors Plantarflexors Hip adductors 2 Flexibility Ankle DF 5 degrees 20 degrees Hip abduction 45 degrees 55 degrees Knee extension - 15 degrees - 5 degrees Posturing of the feet

62 EXAMINATION: ObjectiveOutcome Measure Admission FIM: Transfers 2 -Max Assist FIM: Walking 1 - Total Assist 25ft with EVA walker, R KAFO FIM: Stairs 0 - Unable TUG 60 seconds with EVA walker, CGA

63 Interventions: InpatientStanding frame: 5-7 days/week for minutes Gait Training Overground: RW  B Lofstrands Timed trials: seconds to walk 10 feet Use of agility ladder to promote hip flexion/reciprocal gait pattern Treadmill: emphasis on increasing speed Postural Training Quadruped, Tall Kneeling, Half Kneeling Emphasis on core activation + trunk rotation Standing frame over lunch – had “lunch buddies”; typically had PT either directly before or after; prone positioning Initially seconds to walk 10 feet

64 Interventions: SalienceSalience: “very important or noticeable” Classical conditioning stimuli: demonstrated that there must be a system in place to weigh the importance of a given experience Animals trained to recognize a specific tone to receive a reward  1 tone more salient than others Increased representation of the salient tone within the auditory cortex Classical conditioning stimuli: use of auditory tones has showed that plasticity within the auditory cortex is dependent upon the salience of the experience Recognize a specific tone  1 tone becomes more salient than the others; see increased representation of the salient tone within the auditory cortex Kleim, Jeffrey A., and Theresa A. Jones. "Principles of Experience-Dependent Neural Plasticity: Implications for Rehabilitation After Brain Damage." J Speech Lang Hear Res Journal of Speech Language and Hearing Research 51.1 (2008):

65 Interventions: SalienceAcetylcholine: promote cue processing in various ways Brainstem: manage circuits in thalamus to control attention Motivation + attention = essential for engagement to task Septum: promotes memory storage In combination with emotional reactivity processed in amygdala Emotions modulate the strength of memory consolidation Little research on the direct effects of saliency on recovery of function and associated plasticity, but wealth of knowledge showing that acetylcholine is involved  may be due to its contribution of salient experiences Acetylcholine released from variable places in the brain “I’ve done ballet for so long it’s like my body just knows what to do”

66 Outcomes Outcome Measure Admission Discharge FIM: Transfers2 (Max Assist) 6 (Modified Independent) FIM: Walking 1 (Total Assist) - 25ft with EVA walker, R KAFO 6 (Modified Independent) - 200ft with B Lofstrands, no AFO FIM: Stairs 0 (Unable) - 12 steps, uni rail + uni Lofstrand TUG 60 seconds with EVA walker, CGA 11.84 seconds with B Lofstrands 8.72 seconds without AD

67 Interventions: OutpatientKinesiotape R obliques + B erector spinae: inhibitory + muscle facilitation to promote improved postural awareness Quadriceps: inhibitory to reduce clonus Treadmill Training Speed progression: 1.5mph – 2.6mph Dual tasks Multi directional walking + turns Dual tasks: cognitive – stroop, listing off items; manual- catching ball, passing ball in between cones Multi directional walking: multi purposeful -1) improve glut strength, 2) improve balance 3) dual task challenge – different sides would have different numbers, would have to turn towards specific side on PT command

68 Interventions: OutpatientCore Stability TRX straps Multi directional stepping onto compliant/uneven surfaces Lunges with trunk rotation Planks Forward: “threading the needle”, knee to contralateral elbow Side: “threading the needle”, dips Ballet Progression Jumps and run sequences Core stability – followed up at home with her tall kneeling/quadruped exercises “threading the needle,

69 Outcomes Outcome Measure Evaluation Progress Note 25ft Walk Test10.57 seconds with B lofstrands 13.28 seconds without AD 8.68 seconds without AD TUG 12.58 seconds with B lofstrands 15.41 seconds without AD 8.8 seconds without AD 5X STS Norms: 8.2 seconds 17.53 seconds 17.6 seconds

70 “Driving short distances”Subjective Outcomes “Driving short distances” “Walking across campus with 1 lofstrand” “Doing ballet at home with my daughter” “I think I’ll be back to where I was soon”

71 Salience Involve patients in goal settingEstablish a home exercise program that the patient will do Include patient hobbies into therapy

72 References Dressler, Dirk, Eckart Altenmueller, Roongroj Bhidayasiri, Saeed Bohlega, Pedro Chana, Tae Mo Chung, Steven Frucht, Pedro J. Garcia-Ruiz, Alain Kaelin, Ryuji Kaji, Petr Kanovsky, Rainer Laskawi, Federico Micheli, Olga Orlova, Maja Relja, Raymond Rosales, Jaroslaw Slawek, Sofia Timerbaeva, Thomas T. Warner, and Fereshte Adib Saberi. "Strategies for Treatment of Dystonia." Journal of Neural Transmission J Neural Transm (2015): Kleim, Jeffrey A., and Theresa A. Jones. "Principles of Experience-Dependent Neural Plasticity: Implications for Rehabilitation After Brain Damage." J Speech Lang Hear Res Journal of Speech Language and Hearing Research 51.1 (2008): Rebour, Remi, Ludovic Delporte, Patrice Revol, Lisette Arsenault, Katsuhiro Mizuno, Emmanuel Broussolle, Jacques Luaute, and Yves Rossetti. "Dopa-Responsive Dystonia and Gait Analysis: A Case Study of Levodopa Therapeutic Effects." Brain and Development 37.6 (2015): Voos, Mariana Callil, Tatiana De Paula Oliveira, Maria Elisa Pimentel Piemonte, and Egberto Reis Barbosa. "Case Report: Physical Therapy Management of Axial Dystonia." Physiotherapy Theory and Practice 30.1 (2013):

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