Normal Pressure Hydrocephalus

[gcoe]

Hi Jerram

Thanks for your case and your intelligent summary assessment of your patient. We had a couple of cases this year but I couldn’t find anything re: physiotherapy trials, let alone guidelines or reviews. Absolutely zilch actually!

Here are some comments:

• It sounds to me you have been treating him appropriately and rationally and I think taking a problem solving approach like you have done is the soundest way forward. Your emphasis on PD management techniques are probably the best as those are the symptoms he seems to have. Maybe has benefited from the combination of your care and neural recovery post op but is now hit a plateau – and that is just how it is.

• I couldn’t find anything on the strategy approach with normotensive hydrocephalus – could you? It seems reasonable to try it. However as you may have found with your PD patients responsiveness to strategies is variable anyway so it is more or less trial and error – if one strategy doesn’t work then try another. With the metronome was this a personal one he wears and operates himself. That is what was used in the RESCUE trial and was shown to be helpful. You can use it for both freezing and for improving step length. But it is another thing he has to operate himself. Just using an external metronome in PT sessions doesn’t seem to be much help. It is a matter of the patient having control and initiating the metronome as a strategy

•

“Also reduced arm swing unilaterally with ipsilateral pelvic protraction.”

- Sounds quite asymmetrically involved. Do you find this with his step length as well?

•

“and like many of my PD patients, cannot multitask very well”

– are you educating and providing strategies for reducing multitasking as much as he can? You probably are. But perhaps you could run through all the tasks he is having difficulty with and brainstorm strategies to reduce multitasking.

•

“This has cut down significantly his furniture walking and wall grabbing tendencies”

- Well done!

•

“he has to stop and start over after about 75'”

That sounds like typical Parkinsonian motor decay problem.

"Endurance seems limited and has definitely been a target area”

. – Yes I agree. Given that he has diabetes, and would therefore benefit from aerobic training, poor exercise tolerance and probable motor decay this may be the best thing you could do for him. The diabetes may end up being more of a problem than the residual hydrocephalus so anything to get him more active would be good. Have you put him on a treadmill?. The external demand to step sometimes helps with the decay towards small steps and helps in setting incremental goals. Maybe a circuit program that included some upper arm ergometry, overland walking and treadmill to give him breaks and changes for his walking.

• You say he has normal strength but is that based on MMT or on something more realistic, without ceiling effects? Introducing progressive resistance training might still be worthwhile for improving balance, force generation in gait, and could be good for reducing insulin resistance. And if you included some lower intensity higher reps this may help with his endurance. Weights can be great for building up confidence and improving mood as well.

•

“from what I understand from the research I have found, the two diseases appear similar, but probably impair motor planning in different ways”

– I would be interested to know what you have read. Here is one lab paper I found that I thought was interesting about Supplementary motor area improvement post surgery with normotensive hydrocephalus. It is worth reading because it may help give a perspective on your patient

Sorry not to have anything more evidentiary. I think you are right that there just isn’t anything out there. – Still maybe you might consider undertaking some research! It is obviously needed.

All the best with his further management
Additional Comment I forgot:
Here is that article on the SMA and normotensive hydrocephalus