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A 78-year-old male was referred to a neurologist due to complaints of difficulty with gait, feeling unsteady, and urinary urgency. His wife reported that over the last year he has had progressive difficulty with memory and has been unable to manage financial matters for the household. Prior medical history was unremarkable. Neurologic examination revealed impaired memory and visuospatial skills and difficulty with calculations. The rest of the neurologic examination was notable for diminished postural reflexes and magnetic gait with en block turning. Laboratory tests did not reveal any treatable cause of dementia (e.g., vitamin B12 deficiency or thyroid toxicity). Magnetic resonance imaging (MRI) demonstrated large ventricles and hypodensity of white matter. A spinal tap was performed with normal opening pressure and 35 cc of cerebrospinal fluid (CSF) was collected. The CSF analysis was normal. The patient's gait transiently improved after the spinal tap. A diagnosis of normal pressure hydrocephalus was made based on the MRI results and on the presence of the characteristic clinical triad: gait impairment, cognitive decline, and urinary urgency. The patient was admitted to the hospital and underwent ventriculoperitoneal (VP) shunting. The physical therapist is asked to evaluate and treat the patient to assist in determining the effect of the VP shunt on the patient's functional abilities.

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What are possible complications interfering with physical therapy?

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What are the most appropriate physical therapy outcome measures for gait and balance?

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What is his rehabilitation prognosis?

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What are the examination priorities?

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Based on his health condition, what do you anticipate will be the contributors to activity limitations?

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  • EN BLOCK TURNING: Lack of trunk rotation when walking and turning around, resulting in movements that are “in mass” or as a whole
  • MAGNETIC GAIT: Walking as if feet are attached to floor by a magnet; each step is initiated in a “wrestling” motion that carries the foot upward and forward
  • NORMAL PRESSURE HYDROCEPHALUS (NPH): Accumulation of cerebrospinal fluid that causes the ventricles in the brain to become enlarged, sometimes with little or no increase in intracranial pressure

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  1. Describe normal pressure hydrocephalus.

  2. Identify key questions to determine the history of the present illness, prior level of function, and presence of factors at home/work such as stairs, ramps, thresholds that may interfere with gaining access to these environments.

  3. Identify reliable and valid outcome tools to measure gait and functional mobility.

  4. Discuss appropriate components of the examination for the individual with NPH.

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PT considerations during management of the individual with gait instability, history of falls, general motor and balance difficulties, and decreased endurance due to normal pressure hydrocephalus:

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  • General physical therapy plan of care/goals: Assess gait and possible benefits of VP shunt placement; maximize functional independence and safety while minimizing secondary impairments
  • Physical therapy ...

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