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CASE STUDY

CASE STUDY

M.M. is a 56-year-old man who was referred to rehabilitation by his physician after several falls and increasing balance problems as per his wife’s observation. The patient has a history of schizophrenia that has been well controlled with medication. Recent imaging and clinical diagnostic tests have ruled out any neurological or structural central nervous system (CNS) pathology. M.M. is currently taking pantoprazole (a proton pump inhibitor) and quetiapine. During the patient interview, M.M. reported that his prescribing practitioner increased his dose of quetiapine after a psychotic episode 2 months ago. Hesitantly, M.M. also reported several recent episodes of lightheadedness. M.M. states that he has begun to feel extremely stiff at times and has had a hard time moving. During the physical therapy examination, M.M. appeared to be in no acute physical distress. When moving from sitting to standing, M.M. stated that he became slightly lightheaded with the edges of his vision blurring. The therapist confirmed orthostatic hypotension during a sit-to-stand transfer with a fall in systolic and diastolic blood pressure of 24 and 18 mm Hg, respectively. Although M.M. had normal range of motion and strength in all extremities, he displayed some postural rigidity evident by resistance to passive stretch that was more severe in the lower extremities. The patient did not demonstrate a resting tremor. M.M.’s performance on the Mini-BESTest revealed moderate impairments in dynamic balance.

REHABILITATION FOCUS

Over the last 50 years, antipsychotic drugs have had a major impact on psychiatric treatment—enabling many individuals to move from inpatient mental institutions to the community. For many, this shift has provided a better quality of life as a result of improved behavior and reality perception. Physical therapists may encounter individuals taking antipsychotic medications in several settings. Many psychiatric facilities employ physical and occupational therapists to provide direct care to their patients. More commonly, therapists treat individuals within the community taking antipsychotic medications who have been referred for rehabilitation for a diagnosis unrelated to their psychosis. Prescribers always weigh the risk of adverse effects with the benefits of antipsychotic drugs. Adverse effects such as sedation, dry mouth, and constipation are usually tolerated. However, the extrapyramidal effects—bradykinesia, tremor, and rigidity—of many antipsychotic drugs can impair activities of daily living and increase the potential for falls and injury. Therapists noting increasing impairments in balance, posture, or involuntary movements should report these to the prescribing healthcare professional. Finally, patients may be referred to physical therapy for the development of physical activity programs, as several of the newer drugs have the potential for weight gain. Figure 18-1 outlines the drugs discussed in this chapter that are used to treat both psychosis and bipolar disorders.

FIGURE 18-1

Common drugs used to treat psychoses and bipolar disorder. Antipsychotic drugs are broadly divided into two groups. The first-generation classic drugs have stronger affinity for the dopamine D2 receptor than the newer second-generation drugs, which have stronger affinity ...

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