Poster 59: Clinical Improvements in a Patient With Normal Pressure Hydrocephalus Status Post Lumbar Puncture and Ventriculoperitoneal Shunt Placement

Abstract

Objectives: To describe, in a patient with normal pressure hydrocephalus (NPH), the clinical response to a diagnostic lumbar puncture, and to report on the stability of this response over time, after permanent ventriculoperitoneal (VP) shunt placement. Design: Single-case study: within-subject, repeated measures at 3 time points: preintervention, postintervention, and long-term follow-up. Setting: Outpatient physical therapy (PT) and medical clinics at a spinal cord injury center. Participant: A 74-year-old white man, presented with bradykinesia and flat affect. He complained of balance impairments, gait disturbance, and memory loss, and was diagnosed with NPH. He had a VP shunt placed on April 11, 2005, then fell on April 13, 2005, while still an inpatient, and fractured his right femoral neck, requiring internal stabilization with hardware. He also developed a VP shunt infection, requiring its removal on August 23, 2005. During this period post-shunt removal, he received PT intervention 3 times a week at this clinic, from September 12, 2005 until December 13, 2005, to address endurance, functional skills (eg, bed mobility, transfers), and gait training. At this time, he was using a manual wheelchair, with caregiver assistance, for all functional mobility tasks. The subject had a permanent VP shunt placed in February 2006. His history was also remarkable for pneumonia, infections, congestive heart failure, myocardial infarction, history of pacemaker placement, and chronic atrial fibrillation. Intervention: Lumbar puncture (LP) with resulting reduction of cerebrospinal fluid volume on November 10, 2005. Main Outcome Measures: Gait analysis (temporospatial) using GAITRite system, Berg Balance Scale (BBS), video of ambulation, Mini-Mental State Examination (MMSE), and the Minnesota Test of Hand Function. These outcome measures were performed the day before the LP, and within hours after the procedure. For long-term follow-up, the measures were to be repeated 14 months after he underwent permanent VP shunt placement. Results: Comparing pre- and post-lumbar puncture measures, the subject’s cadence increased from 85.1 to 110.7 steps/min (30% increase) (age norm, 104 steps/min). Velocity increased from 21.2 to 41.9cm/s (a 98% increase) (age norm, 108.7cm/s). Step length of the left leg increased from 23.2 to 27.8cm (a 20% increase) and step length of the right leg increased from 7.4 to 18.6 (a 148% increase) (age norm, 60cm). Stride lengths of the right and left legs increased from 31.2 to 47.3cm (a 53% increase) and from 31.6 to 48.3cm (a 52% increase), respectively. Age norm for stride length is 119cm. BBS score increased from 18/56 (pre-LP) to 32/56 (post-LP) (age norm, 56/56). Interpretation of BBS: 0 to 20 is wheelchair bound; 21 to 40 is walking with assistance; and 41 to 56 is independent. These results of the study are ongoing; long-term follow-up data on gait analysis and balance will be discussed. The MMSE score increased from 22/30 (pre-LP) to 24/30 (post-LP) (age norm, 28/30). On the Minnesota Test of Hand Function, his time pre-LP was 2:20.87 and his post-LP was 1:42.69. Conclusions: Preliminary results show meaningful changes in gait, including velocity, cadence, step and stride lengths, as well as standard measures of balance and cognitive function. In this case, LP had an immediate impact on his function, and may be useful in predicting outcomes of permanent VP shunt placement.