Neuro-Physiotherapy Regimen to Enhance the Functional Performance of Meningitis with Ventriculitis and Hydrocephalus: Case Report

   

Theeb Naif S Alsalem^*

Received: January 27, 2024 | Published: March 06, 2024

Copyright^© 2024 by Alsalem TNS, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Prolonged immobility following acute meningitis often contributes to diminished strength, endurance, and balance as well as an increased risk of secondary problems such wounds, contractures, and respiratory infections. The purpose of this case report is to describe the progress from acute course toward a subacute and chronic phase of rehabilitation of a patient with a severe meningitis with ventriculitis and hydrocephalus plus emphasize the role of physical therapy in preparing the patient for the next level of care.

Keywords

Rehabilitation care; Physiatry; Physiotherapy; Rehabilitation; Meningitis

Introduction

The public health concern of traumatic brain injuries is consequentialabout153 people in the U.S. die each day from brain injuries (BI) that include meningitis, costing a calculated $76.5 billion each year [1]. In 2013, these injuries lead to 2.5 million emergency department visits and 282,000 hospitalizations [1]. The Glasgow Coma scale (GCS) authorized classification of brain injury as mild, moderate, or severe and is need as soon as possible after the injury, and at variable times thereafter. Scores 3-8 are segregated as severe BI, 9-12 as moderate BI, and 13-15 as mild BI [2]. Severe BI demands aggressive management and often results in cognitive and physical manifestations that force long-term disability. It is calculated that 5 million people in the United States are affected by long-term disability after BI [3]. Severe injury provokes not only long-lasting neurological deficits (20% of adults) but it has been exposed that 20%-40% of patients end up dying as a consequence of brain injury or secondary complications [4]. Other studies declared mortality rates as high as 76% to 89% [4]. Due to neuronal damage, concomitant injuries such as orthopedic fractures, integumentary wounds, and/or vascular damage, as well as secondary disorders that develop after the accident, brain traumas cause a wide range of clinical demonstrations. It is important for clinicians to be ready for deficiencies in the areas of arousal, attention, cognition, joint integrity, motor function, endurance, and cardio-respiratory function [5].

Due to neuronal damage, concomitant injuries such as orthopedic fractures, integumentary wounds, and/or vascular damage, as well as secondary disorders that develop after the accident, brain traumas cause a wide range of clinical demonstrations. It is important for clinicians to be ready for deficiencies in the areas of arousal, attention, cognition, joint integrity, motor function, endurance, and cardio-respiratory function [6].

In this case report, early functional mobility training was proposed based on well-documented evidence to aid its validity in improving patient outcomes. Physical Therapists who are specialist in the critical care unit work as well as in neurorehabilitation to progress the quality of life, physical function, peripheral and respiratory muscle strength, escalating ventilator-free days, and reducing hospital and ICU stay [7]. Level 2 evidence, according to the Evidence-Based Review of Acquired Brain Injury project, supports the idea that early rehabilitation leads to better outcomes, including longer hospital stays and fewer comas, higher Functional Independence Measure (FIM) scores, extremely high cognitive levels at discharge, and a higher chance of being discharged home [8]. Interventions are designed to reduce muscle shortening, joint stiffness, and sensory deprivation while improving movement quality and promoting balance [9]. Functional training directly improves sit-to-stand, transfers, upper extremity usage, and gait, according to [10]. Animal models demonstrate that an enhanced environment (other people's presence) and early training (having the flexibility to move about) enhance functional recovery. Training in motor abilities will increase brain plasticity or adaptive mechanisms akin to reestablishment, which may aid in function reconstruction or memory [11]. Following a brain injury, the victim's sensorimotor actions construct this neural remodeling by suggesting that physiotherapeutic interventions stimulate the brain's neuroplastic potential [12].

Early sitting instead of supine transition is encouraged in acute hospitalization, and this leads to gains in functional residual capacity as well as more consistent breathing and perfusion. Additionally, gravity helps the lungs' mucus to mobilize [13]. Significant improvements in arousal and/or awareness were observed when standing brain-injured individuals who were either vegetative or partially conscious changed their position. It has also been demonstrated that changing positions every two hours can help rule out hypovolemia, modify the length of resting muscles, load vertebrae, redistribute skin pressure, support the respiratory system, lessen the risk of osteoporosis, enhance circulation, and support renal function [14].

Despite an imperfect level of consciousness, the inception of physical therapy as soon as medically appropriate may drive to enhanced outcomes. Edlow et al. found that Magnetic Resonance Imaging (MRI) and Electroencephalogram (EEG) can identify covert consciousness and cortical feedback in patients who lack behavioral evidence of consciousness, giving evidence that patients may recover consciousness before behavioral hints are present. Lack of a reliable clinical tool to identify consciousness delays and limits approaches to rehabilitative care [15]. In this case, the early inception of physical therapy despite impaired cognition was important to maximize the patients' rehabilitation potential.

Clinicians can easily audit patients' functional status with a readily available tool when outcome measures, like the FIM scale, are widely used. It depends on the accurate assessment and evaluation of the degree of help necessary to finish a mobility activity, which is something that trained nurses and physical therapists, as well as the patient's family members, are qualified to perform. In order to prepare the patient for the next level of care and to prevent secondary complications that could result in immobility, this case report aims to describe the subacute rehabilitation course of a patient with a severe BI infection who has more weakness in his left side than his right. It also highlights the importance of physical therapy interventions, particularly functional mobility training. By preparing the patient for the next stage of care and averting issues linked to immobility, functional mobility training helps patients stay mobile.

This patient's case was chosen because of the unusual difficulties faced by those with serious brain infections and its associated comorbidities, such as cognitive impairments and processing difficulties, as well as the lack of comparable examples in the literature. In addition, the cultural context here highlights social issues that should be taken into account when managing a patient care plan.

Case History

The patient was a 15-year-old male who had a complain of ear pain and sore throat. He presented to a local clinic in Saudi Arabia diagnosed with otitis media which he was started on antibiotics. He was only taken it for two days then he felt better so he stopped it altogether. Four days later he developed fever reaching to 40 degrees along with severe headache and multiple episodes of vomiting. As per his family he became confused and hallucinated about where he was but did not seek any medical advice at the time. By 3ed of October 2022 admitted to an advanced hospital where he had a prolonged hospitalization complicated by bilateral arm tonic posturing with facial deviation and frothy salivation, he was brought by ambulance car.

Examination

The neurosurgery doctors mandated that the patient be kept in contact isolation owing to an infection, wear a right arm sling, and undergo right "Ankle-Foot Orthosis." Patient issues included his inability to walk, his need for assistance getting in and out of bed, his need for two assists when standing, and his inability to climb stairs. The right side's passive range of motion was restricted by dystonia in both the upper and lower limbs, but the therapist was unable to evaluate the right side's active range of motion or do Manual Muscle Testing (MMT). On the "Modified Ashworth Scale" (MAS), spasticity was observed in the right hip adductors, knee flexors, and plantar flexors in lower limbs 3/4. While there is considerable spasticity 4/4 on MAS in the upper limbs in the shoulder adductors, elbow flexors, and wrist flexors. The patient had sessions with a psychologist who explained that the patient could have input and output in verbal cue affected and manipulate, which is treated by psychosis medications. MMT was performed on the left side, which revealed a powerful left side with no weakness found. Therefore, what the physical therapist could not assess was patient impairment cognition and behaviour, which tends to be mild to moderate aggressive. Mobility out of bed was addressed for high-risk falls.

Plan of Care

The treatment plan consisted of functional training, gait training, monitored mobility, verticalization in tilting table, proprioceptive neuromuscular facilitation, weight shifting, and therapeutic exercise with physical therapy treatment sessions occurring daily. The period of the inpatient intensive rehabilitation program took 16 weeks.

Short term goals	Long term goals
Transfer skills = minimal assistance	transfer skills=complete independent
standing =supervision	mobility skills=hemi-walker, right dynamic AFO
sit > stand =Minimal assistance	assistive devices= hemi-walker, right dynamic AFO, Right arm sling, Right wrist support
Bed to chair = minimal assistance	ambulation =reach 400ft no supervision with walking aid