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About this client and how they’ve presented it.

Mr X. is a 60-year-old male presenting a diagnosis of muscular dystrophy.

Subjective:

–          Aim to identify the history of presenting condition

o Progression of disease across a lifetime – stable or progressive?

o What activity limitations does this infer to gait, pADLs, dADLs, cADLs? Falls.

o Pain profile: 24h behaviour and aggs/eases

o Other: respiratory function

–          Current activity levels: walking, structured exercise etc.

–          Previous management: medications, exercises, gait aids etc. and what has been successful or not

–          Main goals: independent mobility, playing golf, independent ADLs

–          Other issues: SIJ pain, previous elbow, adductor and foot injuries

Objective:

–          Mobility: gait and use of gait aid and balance

–          ROM: possibility of contractures or limited by weakness

–          Global functional strength: STS, UL elevation, bridge, walk up/down 1 step

o Relevant to proximal muscles effected by MD eg. glutes, core, paraspinal muscles.

Any other relevant symptoms if present: neurological, vision etc.

 

What’s My Diagnosis of the condition?

Muscular Dystrophy

Pathophysiology background:

Genetic condition resulting in impairments to the dystrophin protein. Dystrophin is responsible for connecting muscle fibres to the basal lamina ie. when the muscle fibre contracts it contracts the connective tissue to create global tissue shortening = bodily movement. MD also impairs calcium signalling, leading to increased oxidative stress which in turn can cause cell death. Necrosis of muscle fibre cells leads to replacement with connective fibrous tissue, reducing the number of muscle fibres available for contraction – thus incurring functional deficits to strength, and may lead to contracture. MD typically develops in proximal muscles (trunk, hips, shoulders) and may later spread distally. 

Differential Diagnosis 

Idiopathic spinal cord injury

Pathophysiology background:

Presentations of muscular weakness may instead be of neurological cause such as a spinal cord lesion (birth abnormality, malignancy, infectious or inflammatory disease). They are also likely to present with further neurological symptoms such as sensory impairments. Further, weakness can be seen as both an upper and lower motor neuron sign, however MD is typically a peripheral disease. In the presence of spinal cord lesions, patients are likely to also demonstrate upper motor neuron signs such as hypertonia (spasticity) and hyperreflexia. 

 

Looking at Treatments

Mr X. presented with SIJ pain, global LL weakness and poor lumbopelvic control.

–          Treatment revolves around addressing weaknesses in global strength as well as LL and lumbopelvic muscular control.

o Glute strength: STS, banded abduction, bridging

o Core strength (golf focus): med ball rotations, cable twists up/down, bird/dog

o Other Ex’s: leaning out of BOS all directions

–          Pain relief for additional problems was also necessary

o Eg. Isometric exercises for pain relief – iso hip abd, iso add squeezes

o Eg. STM to glutes and low back for SIJ could be considered in future sessions.

Summary: because of the patient’s history of minimal exercise rehabilitation, isometric exercises were able to serve as both analgesic and strengthening exercises for Mr X. This was combined with functional movements related to Mr X’s goals and ADL functions eg. bridges and STS for functional strength and core exercises for golf.

 

The Plan

Due to MD, I expect this patient will have a slower hypertrophic and anabolic response to loading with resistance training. Therefore, he will likely require an ongoing 1-2/week exercise program as able (eg. via NDIS funding). The patient’s exercises will likely be progressed slowly to accommodate for a delay in adaptive responses as well as to avoid acute overload of tissues (given the patient has a history of various musculoskeletal injuries). Due to MD, we also expect a lower ‘ceiling’ for Mr X’s rehabilitation and in particular areas this is more likely to result in prolonging/maintaining function (eg. gait), whereas other areas will demonstrate capacity for genuine improvement (muscular control).

Goals:

–          Maintenance/improvement of independent mobility with gait aid (1x FAC)

–          Improve core strength, LL strength and lumbopelvic control

    Reduce SIJ pain