meningitis weakness/motor control issue

[Jerram]

I've been working with an outpatient that came to me about 3 months ago after a mystery aseptic meningitis. While the cultures all came back negative, the neurologist continues to consider the possibility of an infectious agent. In any case, she presented with bilat LE weakness, LEFT>RIGHT. She has made great progress progressing from use of RW to no AD except SC for long distances or difficult community settings. The primary impairment that continues to limit her is poor knee control at terminal stance/toe off. This results in early heel rise/knee flexion. While she can generate very good force in the quads, she has limited ability to maintain a consistent contraction and switching from extension to flexion is especially challenging. Even with open chain knee flex/ext, there can be some cocontraction that occurs at rapid speeds. There is some residual gastroc weakness too. We have focused a ton on terminal knee extension type activities from wall squats to tBand TKEs to lateral step ups to lunges. I generally try to do these at multiple speeds. The situation worsens with fatigue. She is starting to plateau and getting very frustrated. We've also done BWSTT with FES on trigger to quads at the appropriate portion of gait cycle. I think its a timing issue as much as power generation.

Any other suggestions?

Medically, one thing I suggested is that she discuss EMG/NCV studies with the neurologist (I could suggest it too, of course!). Perhaps there is some peripheral problem here.

Appreciate any insight!
Thanks,

Jeremy

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[Fyzzio]

Hi,
firstly, I do not understand you abbreviations.
LE presumed 'lower extremity' ? What do the others mean?
Secondly, since it seems like a co-ordination problem, have you assessed balance? What are the outcomes there?
How is she on stairs?
Cheers, Fyzzio

[Jerram]

Fyzzio, thanks for your reply. Sorry for all the abbreviations. They might be a little different here in the States! LE= Lower extremity SC=straight cane RW= Rolling walker AD= Assistive device
BWSTT= body weight support treadmill training; FES=Functional Estim; TKE= terminal knee extension

Balance: Is very good from a sensory standpoint - in other words, when doing balance testing such as Berg Balance test, she is only limited in activities that require good strength. For Example, she can't do the Single Leg Stance item well because she can't maintain a consistent quad contraction, but she's fine with feet together stand. There is a bit unsteadiness with the item requiring 1/2 step up to a stair because she has to stand on her left leg to put the right up on the stair. The overall score is 54/56.

Likewise, on stairs she struggles most with taller steps that require strong concentric contraction ascending and especially a smooth eccentric contraction descending (has a "ratchety" appearence to it). So she is indep if using a rail but supervision without it.

Maybe I'm making this more complicated than it is and she just needs to continue strengthening, but I just expected a better outcome by now. When therapy started her quad strength with Manual muscle testing was 4/5, but best at midrange. Her endrange strength has improved but still can't withstand full body weight well for any length of time, it just tremors and wants to buckle.

In terms of overall coordination, she doesn't show signs of ataxia/pass pointing etc. It seems more a problem with grading/maintaining force and at times, coordinating agonist/antagonist alternation.

I hope that is clearer.

Jeremy

[Fyzzio]

Cheers, thanks.
Indeed, the abbreviations differ so much even between English speaking countries.

Sounds very interesting. Berg Balance has a massive problem with ceiling effect, so I don't think it's appropriate for your patient any longer, but it certainly shows the problem areas.
I (with my magic intercontinental X-Ray vision like diagnostics ) would also do a combination of strength training and functional tasks. So, weight resisted machine based exercises for quads, hamstrings and gastroc to purely strengthen; sit st sit, resisted walking (TheraBand), single leg activities, stairs etc for functional (have you ever tried to get her climb upstairs backwards?). Also, a lot of co-ordination/ balance type exercises on uneven ground (e.g. on balance pad, outside. mini tramp).

As you mentioned fatigue. Has she received fatigue management education? Been assessed by an Occupational Therapist? And had advise on the activity - rest balance, etc.?
Am wondering whether she does too much. How often does she practise - I presume that she has got a home exercise programme.

I don't like the word 'plateau". I think hat sometimes the brain just takes time off to store memory and fine tune skills, just like defragmentation of the computer. And that looks like you make no progress, when in fact you create space for more learning. it's hard to get through this. Maybe she might need a e.g. 6 week break from therapy and then come back for more.

???

Cheers, Fyzzio

[toddchaney]

Are you able to figure out the reason for aseptic meningitis as in many cases treatment options completely depend upon the cause of the condition.

[Fyzzio]

Hi Todd,
now that's an interesting comment - could you explain this further, please?
Cheers, Fyzzio