In this episode, I explore a condition that is completely new to me, and you get to come along for the ride. A long-time client shows signs of some complicated neurological problems. Is it Parkinson’s? Is it hydrocephalus? Why not both?
National Institute of Neurological Disorders and Stroke. “Normal Pressure Hydrocephalus Information Page. Accessed January 2021. www.ninds.nih.gov/disorders/all-disorders/normal-pressure-hydrocephalus-information-page.
Schneck, Michael J., “How is Parkinson’s Disease Differentiated from Normal Pressure Hydrocephalus (NPH)?” Last modified October 19, 2018. Accessed January 2021. www.medscape.com/answers/1150924-77103/how-is-parkinsons-disease-differentiated-from-normal-pressure-hydrocephalus-nph.
Williams, Michael A. and Malm, Jan. “Diagnosis and Treatment of Idiopathic Normal Pressure Hydrocephalus.” Continuum 22, no. 2 (2016): 579–99. https://doi.org/10.1212/CON.0000000000000305.
Diagram of a brain shunt. Cancer Research UK / Wikimedia Commons
This episode sponsored by Books of Discovery.
0:00:00.0 Speaker 1: Ruth Werner's best-selling book, A Massage Therapist's Guide to Pathology is a highly regarded comprehensive resource that sets the standard for pathology education. Written for massage therapy students and practitioners, this groundbreaking resource serves up a comprehensive review of the pathophysiology, signs, symptoms, and treatment of more than 500 diseases and disorders. Learn more at booksofdiscovery.com.
0:00:39.7 Ruth Werner: Hi, and welcome to I have a client who pathology conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I am Werner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients, but we need to figure out a way to do that safely, effectively, and within our scope of practice. And sometimes, as we have all learned, that is harder than it looks.
0:01:26.5 RW: Today's story comes from a massage therapist in Virginia who gives us this: I've been working with my client for around 20 years. She was a regular. She was very active and walked through nearby woods or she biked. About six years ago, she fell off her bike and broke her right shoulder. It's possible she might also have hit her head. Sadly, when she went to the ER, the doctor didn't see the fracture in the x-ray and he dismissed her with painkillers. Weeks went by before she returned to the doctor because the pain in her shoulder was becoming unbearable, it was then they discovered the break in her scapula, and at that point, nothing else could be done. Since that time, understandably, she has not been very well. She used to paint and now she couldn't do that anymore. She had to hold up her right arm with her left arm and she fatigued easily. A while later, she was diagnosed with Parkinson's disease, and she's been getting weaker and weaker.
0:02:27.9 RW: It was harder and harder for her to manage receiving a massage because of table height, turning, and undressing and so on, all of which I tried to work around, but it just turned into an exhausting event for her. Then I moved away and I have not seen her until very recently. Her husband had been talking to a friend who had received a Parkinson's diagnosis as well, but this person asked for a second opinion, which determined that he had hydrocephalus, not Parkinson's disease. So, my client also went to be re-evaluated by a doctor who found that she had hydrocephalus. A shunt was put in her brain and she improved markedly in her gate, motor skills, and speech. I had a chance to work with her one more time, she had extreme forward posture and trouble getting around, and I worked with all the frontline shortened muscles I could think of, so as anterior cervicals, diaphragms, sternocleidomastoids, and so on. The work seemed to help her stand more upright and increase the range of motion in her neck, but I haven't heard from her since then, and I don't know how she's doing now.
0:03:37.8 RW: So, there's no real question in this story, but there is a fascinating observation about Parkinson's disease and hydrocephalus, and the ongoing silent battle between flexors and extensors, and flexors almost always win. I love talking about Parkinson's disease, and I wanna do a deeper dive on it, but not in this episode, because we've got something else here to look at. So, if you have a client who has Parkinson's disease or any other pathologic condition that makes you curious, send it to me at firstname.lastname@example.org. That's ihaveaclientwho, all one word, all lowercase @abmp.com.
0:04:24.9 RW: For now, let's just start with this. Parkinson's disease describes a situation in which some dopamine-producing cells deep in the brain die off, and the cells that need the dopamine then can't do their job, and the result is a combination of many problems, including some changes in cognition, although that is often related to the meds as much as the disease itself, but also changes in motor control and muscle tone. Because of the part of the brain that's affected with this disease, it's the flexor side of the body that tends to become tight and rigid, and this is what causes the stooped posture and the tight facial muscles that we often see with Parkinson's disease. Problems in regulating the tone between flexors and extensors can also cause tremor that's often unilateral in Parkinson's. And there's a lot of other things to say about this condition, but I really wanna hold on to that for another episode when we can look at Parkinson's as the main issue.
0:05:26.8 RW: I know much less about hydrocephalus, except from the word that it means water in the head. I don't know if he picked it up, I didn't until I had more communication with our contributor today. That there is a possibility that when this client had her first fall from her bike that broke her shoulder, she may also have sustained a head injury that contributed to her problems. This was the first time I've ever really heard of the overlap between Parkinson's and hydrocephalus, so, I wanted to pursue this a little further, and I found this tidbit at Medscape which offers a specific comparison. In this quote, NPH stands for normal pressure hydrocephalus. That's a specific condition, and not Neil Patrick Harris, which was my first thought.
0:06:18.2 RW: So here is the quote from Medscape, multiple other illnesses may present similarly to NPH that should be considered in the differential diagnosis. In particular, Parkinson's Disease and NPH may present in a similar, but distinct manner. Start hesitation and freezing episodes, we'll talk about that in a minute, can occur in NPH often mimicking the gate in Parkinson's disease. In contrast to Parkinson's, rigidity and unilateral resting tremor are less commonly observed. Furthermore, a robust response to L-DOPA is not typically seen in NPH in contrast to Parkinson's disease. Okay. So now we have this condition that we need to get more information about, this thing called normal pressure hydrocephalus, and I went right over to the wonderful information page at NINDS, that's the National Institute of Neurological Disorders and Stroke, and here's what I found.
0:07:19.9 RW: Normal pressure hydrocephalus is an abnormal buildup of cerebrospinal fluid in the brain's ventricles. And it happens if the normal flow of CSF through the brain and spinal cord is blocked in some way, this causes the ventricles to enlarge, putting pressure on the brain. Normal pressure hydrocephalus can occur in people of any age, but it is most common in the elderly. And by the way, this client is in her mid-70s. It may result from a subarachnoid hemorrhage, a head trauma, infection, tumor or complications of surgery. Symptoms of NPH include progressive mental impairment and dementia, that sounds like part of Parkinson's, problems with walking, also sounds like Parkinson's and impaired bladder control. The person may have a general slowing of movements or may complain that his feet feels stuck, that sounds a lot like the start hesitation and freezing episodes that we heard about in the Medscape piece.
0:08:27.0 RW: Now, if you have learned much about disorders that affect older people, you will hear in this description elements of Alzheimer's disease or other dementias, and of course, Parkinson's Disease. Parkinson's is especially marked by a symptom called Bradykinesia. Technically, this word means slow movement, but it is often used to describe what happens when it's really difficult to initiate movement, so a person feels stuck to the floor, for instance. So, this is a symptom that the two conditions have in common. The NINDS document makes the point that many cases of NPH, Normal Pressure Hydrocephalus, go undiagnosed because they look so much like other problems that are also common in elders. It's usually diagnosed using CAT scans or MRIs, or a spinal tap or a lumbar catheter, and some neuropsychological tests and some other possibilities.
0:09:22.4 RW: The primary treatment, the main treatment for NPH is the surgical placement of a shunt in the brain that drains the excess cerebral spinal fluid into the thorax or the abdomen where it's absorbed as part of our normal processes. This is of course, risky and invasive surgery, so some protocols have been created to try to identify who's most likely to benefit from it. This shunt involves a tube that travels down the neck, and if we have a client who has such a device, we have to be careful about positioning them on the table. But otherwise, what I have learned is that it doesn't seem to be a super disruptive piece of surgical hardware. I will include a drawing of a brain shunt that I found on Wikimedia along with our show notes for today, if you're curious.
0:10:14.6 RW: So for this client, placing the shunt led to some significant improvements for her, which suggests that at some point she developed normal pressure hydrocephalus, and it's possible that it could have been part of her bicycle accident when she broke her shoulder. In what I just shared with you, there are two main distinctions between Parkinson's and NPH, people with Parkinson's tend to have rigidity and unilateral tremor, and they respond well to standard Parkinson's treatment, that's that L-DOPA. None of those things are true for NPH. However, it's worth noting that there's no reason a person can't have Parkinson's and normal pressure hydrocephalus at the same time. So for this client, her stooped posture and difficulty with movement could have been related to both of these conditions. What are the repercussions for massage therapy in this situation?
0:11:09.6 RW: To tell you the truth, very little. If our client complains that they feel their medical treatment is insufficient or inadequate, we can encourage them to go back to their doctors or to seek another opinion, but beyond that, this is definitely not our call. In the meantime, we do what we can to maximize the benefits of our work for both Parkinson's and NPH, this could include reduced rigidity and better ease of movement and range of motion and orientation and relief from fatigue and stress. And we encourage our clients to pursue medical care for their best possible outcomes. The research about massage and Parkinson's is sparse, but positive. And if you send me a Parkinson's story, I'll go into that in some more detail.
0:11:56.8 RW: There are some massage therapists and body work practitioners who suggest that craniosacral therapy might be helpful for normal pressure hydrocephalus, but I haven't seen any research on this, and I don't know enough about craniosacral therapy to have any opinions about safety or effectiveness. Are you a craniosacral therapy practitioner with experience with clients who have NPH, I'd love to hear from you. Send me your story and I will highlight it here.
0:12:23.6 RW: Hey, everybody, thanks for listening to I have a client who, pathology conversations with Ruth Werner. Remember, you can send me your I have a client whose stories to email@example.com. That's ihaveaclientwho all one word, all lowercase @abmp.com. I can't wait to see what you send me and I'll see you next time.