1. Clinical Problem Solving I
James Luker

2. Patient Demographics 48 years old African American female
College level medical education
Unemployed
Lives with family

3. Patient Diagnosis Complex migraine headaches Conversion disorder
Depression
Anxiety
GERD
Morbid Obesity

4. Patient History
Admitted to ER with c/o headache, LLE weakness, LLE numbness/tingling
Evaluated and d/c at another hospital one day PTA
No history of falls
Symptoms started one week PTA
Admitted/evaluated by neuro/psych for similar symptoms twice two years ago, dx of conversion disorder given at that time
Started treatment with home health PT and Topamax/Lexapro at this time
Topamax – Antiseizure/antimigraine
Lexapro - SSRI

5. PT Exam Findings Strength: 5/5 throughout with exception of LLE
LLE MMT
L hip flex 2+
L knee flex/ext 2-
L ankle DF/PF 2
Strength: 5/5 throughout with exception of LLE
ROM: PROM WFL throughout, AROM generally decreased in LLE
Neuro: A&Ox4, impaired LT sensation below L knee, coordination WFL
Mobility: Independent with all bed mobility, CGAx1 sit-to-stand/stand-to- sit
Ambulation: CGAx1 for ambulation 200ft total, L foot drop, widened BOS, decreased pace, decreased step clearance

6. PT Exam Findings Cont.
Stairs: CGAx1 for 15 steps up/down, step-through using rail on R, lead descent with RLE bearing full weight on LLE
Balance: Sitting balance intact, standing balance impaired – good static, fair dynamic
Tinetti test: Total score 19/28, (<19 = high fall risk, = medium fall risk, = low fall risk)
Pain: 6/10 headache pain
Activity tolerance: WNL

7. Patient Prognosis Rehab potential considered to be good
Initial deficits in gait/strength improved rapidly
Past care episodes for similar symptoms support conversion disorder dx and good prognosis for full recovery
Discharge to home recommended

8. PT Goals
Pt will transfer from bed to chair/chair to bed with modified independence using LRD within 7 days
Pt will perform sit to stand independently within 7 days
Pt will ambulate 400ft with modified independence using LRD within 7 days
Pt will ascend/descend 15 stairs with modified independence (single handrail) within 7 days

9. Patient Interventions
Education
Good prognosis for recovery/resolution of symptoms
Stress reduction/role of stress in symptom onset
Benefits of exercise
Gait training
Verbal cueing to correct deviations, promote self- awareness
Stair training

10. Treatment Outcomes Strength Gait LLE strength not re-tested
Sufficient for ambulation/stairs during treatment compared to baseline of 2- to 2+ throughout LLE during evaluation
Gait
Deviations during initial ambulation improved markedly over the course of one treatment session
Near complete resolution of gait deviations by end of first treatment session

11. Clinical Question
For my 48 year old female patient with conversion disorder, what are the most important prognostic factors for positive long-term outcomes?

12. Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms
n=73 patients
35 Female, 38 Male
Mean ages 35 (Female) and 38(Male)
Hospital discharge summaries reviewed for initial data
Follow-up conducted after 5-7 years
Semi-structured interview assessing evolution of symptoms, occurrence of other symptoms, utilization of medical services
Schedule for affective disorders and schizophrenia (SADS) completed
Chart review conducted
Physical re-assessment by neurologist

13. Prognostic Factors Outcome Odds ratio (95% CI) P-value
Symptoms present <1 year PTA +
.11 ( )
.018
Comorbid SADS disorder
7.34 ( )
.025
Change in marital status during follow-up period
33.66 (2.52 to )
.008
Received financial benefits at time of admission -
.15 ( )
.03
Pending litigation at time of admission
.09 ( )
.066
A low n may have contributed to some of these numbers.
Pending litigation has a CI including 1 and a p value >.05 indicating not significant.

14. Study Limitations 12% subjects lost to attrition
Specific study setting (neurological teaching hospital) limits generalizability
Severity of cases may be biased, less severe cases underrepresented

15. Psychogenic Tremor: Long-Term Outcome
n=127 patients with psychogenic tremor
92 Female, 35 Male
Mean age at initial evaluation 43.7 years
Verbal interview/chart review used to collect data
Follow-up conducted after mean of 3.4 years
McMaster Health Index Questionnaire for QOL
Patient-rated overall condition compared to baseline – “better vs. same/worse”
Follow-up data collection performed by 1 reviewer.

16. Prognostic factors Outcome Spearman’s Rho P-value
Perceived effective treatment by the physician +
.54
.0001
Presence of anxiety
.31
.007
Elimination of stressor(s)
.01
Complying with instructions to follow-up with other physicians/therapists
.29
Specific medication
.26
.03
Dissatisfaction with the physician -
.25
Weaker physical health
.24
.07
Longer duration of PMD symptoms
.22
.06
History of smoking
.21

17. Study Limitations Retrospective study design
Majority of patients lost before follow-up
Specific focus on psychogenic tremor

18. My Patient Positive prognostic factors Negative prognostic factors
Perceived treatment as effective
Comorbid SADS disorder/Presence of anxiety
Short duration of symptoms during current episode
Negative prognostic factors
Past history of conversion disorder symptoms

19. References https://www.ncbi.nlm.nih.gov/pmc/articles/PMC28460/
g-Term_Outcome