(Kiosk 2) Veteran Referred by Primary Care Doctor to a Pain Clinic with Worsening Gait: The Value of a Physiatric Exam, a Case Report

Case Diagnosis: Normal Pressure Hydrocephalus

Case Description or Program Description: A 79 year old male without formal neurological diagnosis presented to Physical Medicine and Rehabilitation (PM&R) musculoskeletal clinic referred by his primary care physician for evaluation of chronic shoulder pain. He also reported chronic urinary incontinence and frequent falls. On exam patient noted to have cogwheel rigidity in upper extremities, micrographia, and shuffling gait. The patient was recommended to start PT for fall prevention and referral to neurology.

Setting: Urban Veteran’s Affairs PM&R Musculoskeletal Clinic

Assessment/Results: After evaluation in PM&R clinic, patient reportedly had a ground level fall and presented to the emergency department, where workup revealed ventriculomegaly. Neurology was consulted and patient diagnosed with likely normal pressure hydrocephalus (NPH). Patient now to follow up with neurology for further workup. He continued his course of physical therapy to improve balance and reduce risk of falls.

Discussion (relevance): Patients can commonly present to PM&R clinic for pain when in actuality there is underlying systemic pathology. In this case, careful physical exam revealed parkinsonian features including gait disturbance which most likely led to the patient’s frequent falls, prompting further investigation. There is overlap in motor findings of Parkinson’s disease and normal pressure hydrocephalus, including bradykinesia and shuffling gait. Identifying patients who require additional workup is crucial for proper treatment. Treatment of symptomatic NPH typically involves shunt placement, which can improve gait and urinary incontinence, as well as a comprehensive physical therapy program to reduce fall risk. On the other hand, Parkinson’s disease requires medications to modulate dopamine levels.

Conclusions: PM&R musculoskeletal clinic can provide a valuable service with full investigation of not only musculoskeletal pain. The skills of a physiatrist are invaluable to diagnose red herrings beyond obvious pathologies for pain.