Weeks_case study final
-
Upload
allison-weeks -
Category
Documents
-
view
662 -
download
0
Transcript of Weeks_case study final
APPLICATION OF A COMBINED REHABILITATION APPROACH FOR A
CHRONIC STROKE PATIENT WITH GAIT IMPAIRMENTS: A CASE STUDY
Presented in Partial Fulfillment of the Requirements for the Degree of Doctor of Physical
Therapy in the
Graduate School of The Ohio State University
By
Allison N. Weeks
*****
The Ohio State University 2014
Doctoral Examination Committee: Approved by
Dr. Alexandra Borstad, PhD, PT, NCS
Dr. Deborah K. Kegelmeyer, DPT, MS, GCS
Dr. Marka Gehrig, PT, DPT
___________________________ Advisor School of Health and Rehabilitation Sciences
ABSTRACT Background and Purpose: Stroke is one of the leading causes of disability in the United
States, leaving the patient with residual deficits including: gait abnormalities,
hemiparesis, and impaired cognition.1, 2 Neuroplastic changes in the brain have been
found to occur most prominently in the first 3 months, and then progressively decline
through the 6 month time frame.3 Newer research has illustrated improvements in
functional outcomes occurring after the 6 month period when exposed to ideal
environment and interventions based on the motor learning theory.4 The purpose of this
case report is to describe a combined task-oriented and neurodevelopmental approach
implemented in an outpatient physical therapy setting for gait improvements in a patient
post stroke that did not receive acute or sub-acute rehabilitation services. Case
Description: The patient, J.O. was a 68 year old African American male presenting with
deficits from a stroke approximately 6 months prior. J.O. had generalized right-sided
weakness and impaired balance, which affected his ability to ambulate without an
assistive device, and negotiate stairs and obstacles without increased risk of falling;
therefore, preventing him to safely live alone or return to work as a professional cab
driver in New York. Intervention: The patient attended 11 45-minute sessions on the
course of 8 weeks. Physical therapy interventions included: a sequence of stepping
interventions, over-ground gait training, therapeutic exercises consisting of progressive
open and closed chain resistance exercises targeted for lower extremity strengthening and
flexibility, balance exercises, and cardiovascular endurance training. Outcomes: The
patient exhibited a minimal clinically important difference (MCID) on the Berg balance
scale (BBS), and a non-clinically important difference on the 6-minute walk test
(6MWT). The patient regressed by 0.2 m/s with the 10-meter walk test (10MWT), and
gait abnormalities persisted. Conclusion: This study describes there may be potential to
improve functional status of a chronic stroke patient, specifically balance and endurance,
with the combined therapy approach, but more research is required.
INTRODUCTION
Stroke is the fourth leading cause of death and one of the leading causes of disability
in the U.S. Ischemic stroke accounts for 87% of all strokes; the remaining 13% are
hemorrhagic.1 The American Heart Association has classified the risk factors of stroke in
two categories, uncontrollable, including age and race, and controllable. The risk of
stroke doubles with each decade after 55 years of age. African Americans have twice the
risk of mortality and twice the risk of first strokes compared to Caucasians. Controllable
risk factors include: hypertension, hyperlipidemia, atrial fibrillation, high cholesterol,
diabetes, atherosclerosis, tobacco and alcohol use, physical inactivity and obesity.2
There are many physical impairments resulting from stroke. According to the
Framingham Heart Study, the most common impairments at 6 months post stroke
included: hemiparesis, gait dysfunction requiring an assistive device, cognitive deficits,
depression, aphasia, and dependence with activities of daily living (ADLs).5 Duncan et al.
found that walking ability is impaired in more than 80% of post-stroke patients.6 Most
stroke survivors, 60-85%, learn to walk independently by 6 months post stroke; however,
gait abnormalities persist past this time, thus, one of the major goals of outpatient
rehabilitation is restoration of gait.8,9,10
A normalized gait pattern is comprised of dynamic interactions between the
cerebral cortex, brainstem, cerebellum, and the spinal cord. The spinal cord, comprised of
central pattern generators, allow for the basic locomotion stepping pattern, as well as
descending pathways that stop or trigger walking. The role of the cerebellum, brainstem,
and cortex are fine motor control and coordination that is involved in the gait cycle and
negotiation of the environment. In patients with a stroke, these areas of the brain can be
impaired, producing asymmetrical gait abnormalities and loss of the dynamic interactions
between gait and the environment.11 In addition to the gait asymmetry from the cerebral
cortex, there are secondary impairments contributing to the observed gait dysfunction,
including: muscle weakness, incoordination, pain, spasticity and decreased balance. Gait
training interventions, therefore, need to address motor control, muscle strength and
balance in order to improve locomotion.6, 11
Several prognostic factors have been shown to have significant correlation with
stroke recovery. A systematic review found that time of initiation of therapy, duration,
intensity, and location of rehabilitation are linked with functional outcomes and mortality
rates in patients post stroke. Rehabilitation initiated within 15 to 30 days in a
multidisciplinary acute rehabilitation setting was found to have better outcomes, and
shorter hospitalization stay regardless of severity of stroke.5, 12, 13 A study by Salter et al.
found that delayed rehabilitation, treatment initiated greater than 30 days after the stroke,
was associated with longer hospital stays and decreased adequate functional recovery due
to decreased cortical reorganization.46. In regards to duration, it was found that brain
plasticity and functional recovery can significantly change upwards of 6 months with
rehabilitation services. Higher intensity levels of rehabilitation were associated with
improved ADLs and lower degree of disability.14 A 1 year study by the Stroke Unit
Trialists’ Collaboration found that the patients who had shorter hospitalization and
increased independence were those who received inpatient rehabilitation in
multidisciplinary stroke specific rehabilitation centers compared to standard inpatient
rehabilitation.12 Thus, the rehabilitation received in the first several months is a significant
prognostic factor of functional recovery and neurologic recovery.
Most literature to date has found that spontaneous neurological recovery occurs
during the first 3 months after the stroke, and the rate of recovery decelerates in a
predictable phenomenon within 6 months; however new literature is showing that
recovery can occur after the 6 months although not as significant as the early stages.3, 18
Neurological recovery occurs early in affected areas of the brain with resolution of edema
and recirculation, lasting up to 4-6 weeks. Nudo et al. found that diaschesis, a state of
depressed neurological function from a sudden interruption in part of the brain, occurs
early after injury, and is a suppression of surrounding areas that are connected with the
affected area. The resolution of diaschesis is associated with the return of neuron function
if the connection to the injury is intact.16 Central nervous system (CNS) reorganization
that occurs later in the recovery stage includes: neurotransmitter alterations, unmasking
silent synapses, and synaptogenesis; all of which can occur months after the stroke.17
With the use of functional magnetic resonance imaging (fMRI), there is increased
opportunity to study the neuroplastic changes in the human brain.18 The evidence from
several fMRI studies illustrates the use of massed practice, involving high number of
repetitions in a session, create larger areas of activation. Thus, in rehabilitation, massed
practicing can yield a more complete neurological recovery.18
Another contributor to neurological recovery is motor learning.4, 12,1 5 Motor
learning focuses on repetitive practice with manipulation of specific variables in tasks
that require relearning in order to induce changes in the brain reorganization.19 Motor
learning can increase synaptic connections and promote synaptogenesis. Animal research
states that axonal sprouting and synaptogenesis appear to be associated with recovery,
and in order for reorganization to occur, there must be secondary cortical connections
with the damaged area.19
Several intervention approaches are commonly utilized in stroke rehabilitation.
One rehabilitation approach is task oriented training, which is based on active practice of
specific functional motor tasks with appropriate feedback that would promote motor
learning and recovery.4, 15 Task specific training involves functional repetitive tasks
performed in a skilled environment that are also meaningful to the patient.38 Studies have
shown that task specific practice must happen in order for motor learning to occur.4, 6, 15, 21
Another rehabilitation technique commonly utilized in stroke rehabilitation is the
neurodevelopmental method.15 This approach focuses on the patient receiving
proprioceptive neuromuscular facilitation, and on moving the patient through the desired
motions, with the patient being more of a passive recipient and the therapist being the
main active decision-maker. The latest Cochrane Review on stroke rehabilitation states
that there currently is no single approach to rehabilitation that is more effective than
another, and suggests a mixed approach to treatment.15 In a study by Belda-Lois et al., the
motor learning approach was primarily utilized with some aspects of the
neurodevelopmental approach, and found significant recovery in the patients compared to
the control.11
The purpose of this case study is to describe a combined rehabilitation approach
implemented in an outpatient physical therapy setting for gait in a patient post-stroke who
did not receive acute or sub-acute rehabilitation services and to describe his outcomes
from treatment.
CASE DESCRIPTION
This case study focuses on the physical therapy interventions for J.O. a 68 year
old African American male post left CVA, who gave consent to use his information.
Because J.O. had not received any rehabilitation during the first six months after his
stroke, when most spontaneous recovery occurs, the patient was a good candidate for a
case study to analyze the effects of a combined treatment approach in the chronic phase.
According to the Guide to Physical Therapist Practice, stroke corresponds with the
preferred practice pattern 5D: impaired motor function and sensory integrity associated
with nonprogressive disorders of the central nervous system- acquired in adolescence or
adulthood.20 The International Classification of Functioning, Disability and Health model
(ICF) was utilized in order to implement an individualized treatment, identify primary
function resulting in gait dysfunction, select appropriate outcome measures, and identify
personal and environmental factors that may influence treatment outcomes (Figure 1).20,21
Figure 1: The International Classification of Functioning, Disability and Health model of functioning and disability.20
Examination
History
Subjective: The evaluation was performed 5/13/14 at the outpatient clinic. The
patient was referred to the clinic after a fall he sustained the previous week at his son’s
apartment. He sought immediate treatment at the emergency room with primary
complaints of shoulder and elbow pain. The patient had a left ischemic cerebrovascular
accident (CVA) approximately six months prior to evaluation date while visiting his
hometown in Africa. Upon evaluation, he presented with reports of: increased confusion
and decreased memory, required use of standard cane for ambulation, limited standing
and walking endurance, and inability to return to work due to the weakness in his right
leg and arm. J.O. reported pain in the right shoulder only when reaching past 90°, none in
his elbow. J.O. also reported “stiff, achy” low back pain, rated a 6 out of 10 on a pain
rank scale, which worsened with prolonged sitting or standing, and had been occurring
prior to the stroke. He did not seek out therapy or any type of interventions for the
chronic low back pain or stroke. The patient’s son reported that J.O. might have had a
small stroke or transient ischemic attack (TIA) a few years ago resulting in a similar
presentation, but ultimately resolving. J.O.’s goal was to improve ambulation without an
assistive device and return to the level of independence before his initial stroke including
living alone in his home in New York independently, and returning to work.
The patient previously lived in New York City, working as a professional cab
driver and was independent with all ADLs. Past medical history included: TIA, benign
prostate hyperplasia, hypertension, past right clavicle fracture, and right femur fracture
with open reduction internal fixation. X-rays of the right shoulder were taken on 5/2/14
while in the hospital, showing no evidence of fracture, but fusion of the
acromioclavicular and coracoclavicular joints. Lumbar X-rays were also taken, showing
mild rotary scoliosis concavity to the right and mild disc space narrowing. CT scan
showed no acute process, however there was remote ischemic changes in left parietal
lobe and subcortical white matter with mild diffuse cerebral cortical atrophy. Current
medications included: Aspirin, Losartan, Labetalol, Nifedical, Simvastatin, Doxazosin
and Mesylate. The patient reported no allergies, and no falls since the initial fall that led
to his admission.
Objective: The patient was alert and oriented, able to follow 3-step commands. A
language barrier with comprehension of what the therapist said, and expression of his
feelings and goals was noted due to English being a secondary language. His
cardiovascular system was within acceptable levels, with pre-hypertensive blood pressure
of 130/76 mmHg, pulse 95 beats per minute, and oxygen saturation 99%. J.O.’s
integumentary system was intact, with no scars or discoloration observed upon
evaluation. The patient denied reports of numbness or tingling, and a touch screening was
intact in the lower extremities; therefore, a comprehensive sensory assessment was
forgone secondary to time constraints.
The neuromuscular system had noted impairments consisting of decreased inter-
limb and intra-limb coordination of the right side during coordination tests, including:
rapid supination to pronation, fine finger movements, and heel-to-shin tests. J.O. had
decreased ability to utilize specific movements out of synergy in order to perform
functional motor task, i.e isolating elbow flexion to take a drink of water. The modified
Ashworth scale has adequate intra-rater reliability for measuring tone in the lower
extremity for the stroke population; however, has poor inter-rater reliability, but is
currently the accepted primary means for assessing spastcity.22, 23 Tone was graded as 1+
on the modified Ashworth as resistance was noted with right knee flexion into extension,
indicating slight hypertonicity.
Manual muscle testing (MMT) is the most commonly utilized tool for
documenting strength impairments. A literature review performed by Cuthbert et al.
found overall there is adequate reliability and validity in MMT which improves with
more experienced clinicians.24 The musculoskeletal system was impaired on his right side
only, with most weakness in the hip and ankle (See Table 3 for MMT scores for right
lower extremity). The right upper extremity had adequate strength (3/5) for motions less
than 90° of shoulder flexion secondary to pain. In the lower extremity, he had decreased
pliability in bilateral hamstrings, measuring 50° on left and 60° on right with passive
knee extension.
Bed Mobility and Transfers: The patient was independent with rolling on a mat,
but this required significant effort. J.O. was able to perform sit to stand transfers
independently but demonstrated decreased weight shift on the right side, and increased
reliance for upper extremity support. Further functional analysis included: stooping to
retrieve objects from a lower cabinet in a kitchen and recovering to standing with the
object, which he performed with stand by assist due to imbalance; abnormal synergy
patterns with both flexion and extension of the right upper extremity was observed while
performing the task.
Stairs: The patient was able to reciprocally ascend and descend 4 standard 8”
steps with use of a handrail. When ascending and descending without the use of a
handrail, he demonstrated impaired balance and required close stand by assist. Weak
eccentric gastrocnemius and soleus, and quadriceps were noted during descent of the
stairs, along with excessive right lateral trunk flexion, resulting in an observed lack of
tibial control and decreased safety.
Posture: Seated posture revealed forward shift of head and shoulders, medial
winging of the right scapula with scapular elevation and downward rotation, and
decreased lumbar lordosis. Standing posture revealed similar abnormalities.
Gait analysis: The patient typically used the assistance of a standard cane to
ambulate, but upon evaluation, the therapist deemed it safe to perform gait analysis
without an assistive device. J.O. ambulated with stand by assist, demonstrating postural
dysfunction as observed in standing postural assessment, decreased right stance stability
with decreased left step length, and decreased right foot clearance. Initial contact was
made with the right lateral forefoot, foregoing the ankle rocker component in the loading
response. Right hip abductor weakness with left hip drop and lateral trunk lean to the
right were present during right midstance phase. During right terminal stance, the right
hip did not achieve adequate hip extension, and during the preswing phase, there was a
lack of concentric plantar flexion component to achieve an adequate push off.
Table 1: ICF model specific to J.O. ICF Category Patient description Health condition Left CVA Body functions and structures Decrease muscle strength (especially hip abductor,
extensor, plantarflexor, dorsiflexor, hamstring and
quadriceps), decrease control of voluntary
movement/synergistic flexion and extension pattern,
decrease cardiovascular fitness, mild spasticity, , adequate
PROM
Activities Decrease ambulatory speed and endurance, decrease
ability to ambulate on various terrain, decrease balance,
decrease ability to reach overhead, able to ambulate
with cane, ascending and descending stairs with assistive
device and handrail
Participation Unable to perform IADLS in order to live independently
without family support, unable to drive, unable to work
due to not driving, unable to ambulate safely without
AD in community
Personal Factors Decrease self efficacy, increased motivation, cultural
barrier, minimum income, previous CVAs
Environmental Home alone during day on second level home with son,
home in NY city with no family support.
Tests and Measures:
The patient’s gait speed was 1.1 m/sec without use of assistive device, which
places him in the “limited community ambulatory” category.29, 30 Self-paced gait speed is
the most common outcome measure for gait training strategies, and has been linked with
level of mobility.25 The 10 meter walk test (10 MWT) was used to assess gait speed, and
is highly recommended by the STROKEdge task force for patients with stroke due to the
evidence of high reliability and validity in several studies with post stroke population.25-27,
47 The 10 MWT has been considered a predictor for prognosis for ambulatory return.
Ambulating without an assistive device at a rate of less than 0.4 meters per second
(m/sec) is predictor of household walking, 0.4-0.8m/sec predicts limited community
walking, and >0.8 m/sec predicts unlimited community walking with self-selected pace.20
A study found that mean gait speed is 0.53 m/sec for chronic stroke patients compared to
1.3 m/sec in healthy adults.49
In the 6 MWT, the patient ambulated 312 meters with post vitals similar when
compared to pretest vitals. The 6 MWT is the second most commonly utilized test to
assess gait, and is also recommended by STROKEdge for outpatient and inpatient
rehabilitation to determine functional walking capacity.31, 32, 35, 47 This submaximal test has
excellent validity and reliability in the stroke population.32 Newman et al., found that the
ability and time to walk 400 meters was a valid predictor of mortality, cardiovascular
disease, and mobility disability for community dwelling adults.31 A study found that
subacute and chronic stroke patients ambulated on average 200 - 300 meters compared to
the average of 400 meters in healthy adults in the 6 MWT.33 Most standard tests utilize a
track with minimal turns; in the clinic we had to utilize a figure eight track for patient
safety thus potentially decreasing the validity of standardized measures, but maintaining
intra-rater reliability.
J.O. scored at a 35 on the BBS, placing him in the “moderate fall risk” category
(Table 5). The BBS is another outcome measure that is highly recommended by the
STROKEdge task force for chronic stroke and outpatient rehabilitation, and has shown to
have high reliability and validity in assessing fall risk in the stroke population.34, 47 A
systematic review performed by Blum et al., found that the BBS has excellent internal
consistency, interrater reliability, intrarater reliability, and test-retest reliability with the
stroke population.34 The total score attainable is 56; 41-56 is considered a low fall risk,
21-40 a medium fall risk, and 0-20 is high fall risk.34
The Dynamic Gait Index (DGI) was not performed during the initial evaluation
due to time constraints, however, was utilized later in the plan of care. The DGI is a
highly recommended by the STROKEdge as an outcome measure for dynamic balance,
and has high reliability with the stroke population.35, 47
Evaluation, PT diagnosis, Prognosis
The patient was modified independent for basic functional mobility skills, with
notable gait and balance impairments. Decreased scapular mobility prohibited appropriate
scapulohumeral rhythm and contributed to pain with overhead reaching. Gait was
impaired with decreased right stance stability, decreased right foot clearance and
decreased terminal knee extension with dorsiflexion, with impaired quality, speed and
balance. He was at increased risk of falls based on his BBS score. ICD-9 codes utilized
included: 438.21 Hemiplegia- Dominant Side, 781.2 Abnormality of gait.20
J.O. had good rehab potential to return to previous level of independence based on
not yet having the opportunity for neuroplastic changes that could be promoted in a
rehabilitation setting. The patient was also highly motivated to attend therapy because of
his desire to move back to New York and work again. He was living with his adult son,
who was able to offer some assistance to the patient. Unfortunately, the son worked
during the days and was unable to take his father to appointments, thus making
transportation a barrier. Recommended consults included speech therapy for impaired
cognition, and social work for financial and transportation problems. Occupational
therapy (OT) was already involved in the plan of care initiated by the physician. J.O. was
scheduled with PT, OT, and speech therapy 2 times a week for 8 weeks. The patient’s
goals were to return to premorbid level of independence. The therapy goals addressed
strength, balance, and gait, and comprised of the following:
Long-term goals (8 weeks):
1. Patient will ambulate independently in community (curb, stairs, terrains,
grades) with appropriate speed (1.2m/sec) without risk of falls (loss of balance),
as seen by negotiation in the outside grounds of the clinic.
2. Patient will demonstrate appropriate and adequate strategies to maintain and
regain balance while performing functional activities in standing, as measured
with a BBS score of 48/56 indicating a low fall risk.
3. Patient will demonstrate increased strength in the lower extremity as seen by
achieving adequate stance stability on right LE for normal step length 75% of
steps without assistive device as observed by a more symmetric gait.
4. Patient will reciprocally ascend/descend a flight of stairs without handrail with
supervision and minimal cueing.
5. Patient will achieve right hip extension in terminal stance in order adequately
set-up for the push-off and create a more efficient gait.
Short-term goals (5 weeks):
1. Patient will demonstrate an increase of 5° of active range of motion in right
gastrocnemius/soleus complex in order to achieve adequate tibial advancement in
gait.
2. Patient will demonstrate ability to complete 10 minutes of continuous
cardiovascular activity, on seated cardiovascular device with rate of perceived
exertion (RPE) <14 and stable vital signs.
3. Patient will demonstrate independent carryover of home exercise program for
strength and balance per patient report.
4. Patient will initiate use of affected UE for support and balance independently in
sitting and standing activities with minimal verbal cueing.
5. Patient will increase bilateral hamstring passive knee extension (PKE) by 10 ̊ in
order to improve functional ability.
INTERVENTION
The physical therapy sessions spanned along the course of 8 weeks. J.O. was only
able to participate in 11 of the 16 expected visits secondary to medical and transportation
reasons. A typical session with this patient included initial cardiovascular endurance
exercise on the Nu-Step, stretching and progressive resistive strengthening (PREs) for the
impaired muscle groups, task specific exercises at stairs or over ground gait training with
appropriate progression as needed (See Table 2 for summary of treatment). One to two
minute breaks from exercise were taken after 10-12 repetitions were performed, upon
patient request, when form began to decline significantly, or when warranted by
physiological responses to the intervention. Physiological measures that would cease
exercise were based on the American Heart Association guidelines, which included:
blood pressure that increased 20mmHg systolic, 10mmHg diastolic, heart rate above
100bpm, increased respiration rate with shortness of breath, or patient reports of
lightheadedness and/or dizziness.48 The tenth visit, the patient’s blood pressure was
irregularly high and in dangerous levels for stroke reoccurrence despite being
asymptomatic. Upon questioning by the physical therapist, J.O. reported he was not
taking his medication regularly due to not having the financial means of obtaining a refill
for the prescriptions. The session was discontinued until follow-up made with primary
physician, education was provided in the clinic regarding the importance of taking
medication as prescribed, and the EMT was called to take J.O. to receive immediate
treatment.
Functional task-oriented activities with NDT facilitation were the focus of the
sessions. An example of a task oriented intervention to improve right stance stability was
having the patient would perform a sequence of stepping at the stairs. Beginning simply,
the patient would step and tap the 1st step with his left foot. This was progressed by
stepping and pausing on the 1st step, requiring J.O. to sustain the stride position. This
further progressed by stepping to the 2nd and 3rd step, which increased the time spent in
single leg support. Also, decreasing the UE support increased the demand on the right
lower extremity for balance and strength. While performing these tasks, facilitation was
given at maximal to moderate intensity to the impaired right hip abductor and extensors
and abdominals. This facilitation in addition to verbal cues provided J.O. with the
necessary feedback to engage the muscles while performing the activity. As the patient
became increasingly independent in engaging the targeted muscles, the intensity and
frequency of the external feedback decreased in a faded manner. To allow for carryover
to gait, overground gait training was performed at the end of each session. The patient
was given similar verbal cueing and facilitation as the stance training, and similar
activities were performed, such as stepping over objects with his left during ambulation
in order to prolong stance time on the right.
Table 2: Summary of Treatments for J.O.
Findings Treatment Rationale Time (minutes)
Repetition/Threshold
Visit 2: Decrease cardiovascular endurance Decrease PROM in BL hamstring and gastrocnemius/soleus complex Right hip flexion, abduction weakness Decreased ground clearance on right swing phase during gait
NuStep Supine hamstring stretch with belt, standing gastrocnemius and soleus stretch against wall Clamshells, unable to perform sidelying abduction due to weakness. Straight leg raise Trial Swedish AFO Over ground gait training with AFO and patient education
Increase CV endurance Strengthening the hip abductors, hip flexor DF weakness and tightness in gastrocnemius- soleus complex contributed to decreased ground clearance and posed as fall risk. AFO addressed problem temporarily for therapist to focus on larger problems.
3 5 5 25
Time, vitals, RPE scale 2x30sec each stretch 2x10 or patient tolerance Patient tolerance
Visit 3: Decrease CV endurance Decreased stance time on right side with gait Decreased trunk stabilization during gait
NuStep Right stance progression at stairs. Progressions as appropriate (decreasing UE support, increasing step height, various directions) Gait training on level surface with upper extremity close chain, pressing an object against his right side.
Increase CV endurance Increase patient comfort with stance on right via performing task of stepping with left. Pressing the object activated core muscles (Quadratus lumborum, obliques, and paraspinals and transverse abdominus), and
5 15 15
RPE, vitals, time x15, or patient tolerance, and observation of compensation or fatigue Patient tolerance, observation of compensation or fatigue
assisted in preventing the trunk lean
Visit 4-5: Decrease CV endurance Decrease stance and terminal stance on right side Poor abdominal and gluteus medius activation during step training Gait with decreased midstance and terminal stance on right with right trunk lean and Trendelenberg.
Nustep Lunges, stepping forward with left to achieve terminal stance on right. Progressed by decreasing UE support. Right stance progression at stair, patient step to 2nd and 3rd step with left. Verbal cueing and tactile cueing given by therapist during above the interventions. Tactile cues on the abdominals with therapists’ left hand and right hip abductor and extensor with therapists’ left hand Gait training over ground with same verbal and tactile cues given with stance progression interventions. Stepping over object with left during gait. Patient push against hand of therapist at 60*
Increase CV endurance Lunge is exaggerated step, increased patient comfort and confidence with taking larger steps Stepping to 2nd and 3rd step required increased stance time on right, and required achieving terminal stance. Cueing to help provide feedback to patient to engage these muscles during the activity To apply the interventions directly to gait for carryover. Pushing at highest point without pain on right side engaged the core and decreased the trunk lean during ambulation
5 10 20 10-20
RPE, vitals, time Patient tolerance and observation of compensation or fatigue.
Visit 6-7: Weakness with hip flexion, extension, and abduction on right side Hip drop with stance exercises External rotation weakness with MMT
Multidirectional stepping BL with resistive band Stance exercise with side steps, progressed with increased heights and UE support. Added multidirectional pivoting movements with left foot on roller
Resistive band steps helped to functionally strengthen the targeted muscle groups Side steps focused on abduction and adduction strengthening and stability. Pivoting requires both abduction and external rotation.
5 15-20
X10 BL each direction. Patient tolerance or observation of compensating pattern.
Visit 8-9: Increased reports of back pain and poor transverse abdominal activation
Supine transverse abnominus (TA) activation progression.
Supine is easiest position to activate TA. Progress by adding UE and LE
10
2x10
Decrease core activation in standing Decrease core activation while ambulating
Wall squat with ball while performing pelvic tilts. 1# ball overhead reach and diagonals with TA activation Gait training overground while squeezing ball together, tactile cues at abdominals.
motion to increase difficulty while maintaining activation Standing is more functional and more carryover into gait. Tactile cueing along with squeezing the ball helped patient to activate and sustain the contraction.
15-20 15
Patient tolerance Patient tolerance
Bilateral (BL), Rate of Perceived Exertion (RPE), Ankle Foot Orthosis (AFO)
PATIENT EDUCATION:
The patient was issued a home exercise program (HEP) the second visit after
demonstrating the exercises in the clinic with supervision. J.O. and his son were both
educated on the HEP and issued a handout with standard pictures and descriptions of the
exercises. Additionally, the son took pictures of J.O. performing the stretches and
exercises on his iPad® to provide further clarity of the exercises.
The HEP was modified throughout the span of treatment sessions, exercises
included: gastrocnemius and soleus stretching, piriformis and hamstring stretching, 4 way
hip, squats, and balancing in stride, single leg and tandem stances. Interventions at the
stairs would have been an ideal addition to the home program in the later sessions;
however, the patient did not have any private stairs at his home.
The patient was also educated on the ankle foot orthosis (AFO) and its wearing
schedule. The first day, J.O. was educated to wear it only for a couple hours, then to take
it off and perform a skin check. He was educated to not wear the AFO if he noticed any
skin irritations or sore spots on his foot. The son was also present to receive this
information. The patient was also educated intensively on the signs and symptoms of a
stroke, and the importance of seeking medical help if he was experiencing any of those
indicators.
OUTCOMES
A progress note was performed on the 11th visit, for reassessment purposes. The
patient showed an increase in strength in the lower extremity as shown by the manual
muscle test (Table 3). The same outcome measures were administered as the initial date
in order to determine improvements in function through minimal detectable changes
(Table 4). J.O. had a minimal clinically important difference in the BBS, with
improvement from 35 to 45 (MCID >3.8 points), which places him at a lower risk of
falling compared to his initial score (Table 5).34 However, the patient was still at an
increased fall risk based on the DGI score of 12.35 An improvement in his 6 MWT for
cardiovascular endurance was observed, however it was not clinically significant (MDC
>36.6). His gait velocity declined from initial to reassessment date (Table 4). In
reassessing the short-term goals, the patient achieved increasing bilateral hamstring and
heel cord ROM, and was progressing towards using the affected UE for support and
balance. The patient did not meet the HEP carryover based on subjective report, and did
not consistently meet the 10 minutes of cardiovascular activity with stable vitals. Long-
term goals, the patient was progressing towards, however did not meet the set gait speed
of 1.2m/s (0.9 m/s at reassessment), the desired BBS score of 48 (45 at reassessment),
and still required close supervision when ascending and descending stairs. The patient
still required moderate to maximal external feedback in the form of tactile and verbal
cueing with the stair negotiation and the desired achieving stance stability on the right
side.
The gait assessment continued to show some excessive lateral trunk flexion to the
right during right midstance and decreased terminal stance, but improved compared to
initial assessment, especially with no observation of Trendelenburg sign, based on
therapist observation. Continued impairments in gait included: poor neuromuscular
activation of the core, lacking initial contact and therefore negating the forefoot rocker,
and decreased hip extension in terminal stance. The patient exhibited guarded positioning
with left upper extremity, and mild posturing of the right limb in flexion synergy. The
plan of care was to continue therapy to further progress interventions and work towards
meeting patient’s goals.
Table 3: Manual Muscle Test of Right Lower Extremity (_/5) Initial and 11th visit Initial Progress post 11th visit
Hip Flexion 3/5 5/5 Hip Extension 2/5 2+/5 Hip Abduction 2/5
Unable to isolate 3-/5
Knee Flexion 3/5 3+/5 Knee extension 4/5 5/5 Ankle Dorsiflexion 3/5 3+/5 Ankle Plantarflexion 2/5 4+/5
Ankle Evertors 2/5 2+/5
Ankle Invertor 2/5 3/5
Table 4: Neuro Outcome Measures for J.O. at initial evaluation and 11th visit Tests Initial 11th visit Berg 35 45* 10 MWT 1.1 m/s 0.9m/sec 6 MWT 312 meters 335 meters DGI Not assessed 12 *Indicates met the minimum clinically important difference for that measure
Table 5: Berg Balance Scale for Patient at evaluation date and re-evaluation BERG Initial 11th visit Sit to Stand 4 4 Arise 4 4
Sit Unsupported 4 4
Stand to sit 4 4
Transfer 4 4
Stand Unsupported Eyes Closed 3 4
Stand with feet together 3 3
Reach forward in standing 1 4
Picking up object from standing 3 3
Turning to look 1 4
Turning 360 Turn 1 2
Alternating foot on step 2 2
Stand unsupported one foot in front 0 2
Standing on one leg 1 1
DISCUSSION
There is evidence to support the use of a mixed rehabilitation approach in the
treatment of chronic stroke patients, despite not having an overall consensus in the
literature.9, 38 The studies that have evaluated the effectiveness of outpatient rehabilitation
and functional recovery for stroke patients illustrate that functional changes can be made
after the 6 month time frame with the use of a rehabilitation approach that involves
skilled, massed practice.13, 15, 19, 21, 43 The focus of this case study was to describe a
combined rehabilitation approach implemented in an outpatient physical therapy setting
for gait improvements in a patient who did not receive acute or sub-acute rehabilitation
services for his stroke deficits.
The benefit of providing a combined task oriented and NDT approach was that
the patient was able to have the repetition of a meaningful task, while receiving external
feedback through facilitation. In theory, task specific interventions were used to promote
motor learning and overcoming the learned compensatory strategies through skill
acquisition and massed practice.6, 41 Because the patient had poor body awareness, there
was the possible benefit from the facilitation and verbal cueing. With a verbal cue to slow
his gait speed and facilitation at the right hip abductor and extensor, J.O. had a more
symmetrical gait and was able to achieve adequate hip extension in terminal stance and
heel strike at initial contact. Additionally, there was a notable decrease in lateral trunk
flexion when J.O.’s right upper extremity was maintaining an isometric contraction, such
as pushing against the physical therapists’ hand, as this provided the necessary feedback
to activate the core stabilizers.
As discussed above, the patient was able to achieve a more efficient and
symmetric gait pattern during the sessions with the assistance of cueing from the physical
therapist, however this did not carryover during the gait re-assessment. Without the
facilitation, J.O.’s gait assessment at the 11th visit showed similar gait deficits as the
initial day. Due to one of the primary focuses being on functional hip strengthening, the
patient did exhibit more hip stability compared to the evaluation date, as shown by the
absent Trendelenburg sign. Lateral trunk flexion was still observed, with right upper limb
posturing, which could be due to not being addressed in the sessions as frequently as the
primary hip impairments.
Within the 8 weeks between the evaluation and reassessment, the patient showed
increased strength specifically with right hip musculature, although continued
demonstrated significant weakness in the right lower extremity. Many of the PREs that
were issued to strengthen the weak muscle groups were part of the home exercises, which
the patient reported he was not doing regularly, which would contribute to this observed
weaknesses. The patient exhibited minimal clinically important differences in balance as
shown by the BBS. Despite the significant improvements in this static balance score, the
patient was still at increased risk of falling with dynamic activities based on the DGI,
which more accurately describes his balance during gait. The 10 MWT regressed
compared to initial test. There are several potential explanations for this regression,
including that the test was performed later in the re-evaluation, so patient fatigue could
have been a factor, and the patient was tested without his AFO or assistive device, which
he had been accustomed to using on a regular basis outside of the clinic, which could
have decreased the patient’s confidence.
Several individual barriers were noted throughout this study. As discussed above,
the outcome measures and testing did not follow the same order from the evaluation
during the reassessment, thus possibly causing improvements on one test and declines in
the later tests when fatigue became a factor. It would have been ideal to use the Stroke
Impact Scale at evaluation and reassessment for subjective measure, however the trained
administers were not available to perform the test. Therefore, the only subjective
information was through informal discussions, in which the patient expressed concerns of
marginal progress being made with therapy, but wanted to continue working towards his
goals in therapy.
There were patient barriers that interfered with treatments throughout the course
of physical therapy. Firstly, with English being a secondary language, the patient
experienced difficulty with instruction comprehension, and required maximal tactile cues
and demonstration. Cognitive deficits from his stroke contributed to his difficulty of
understanding and following the interventions and sequencing, which was further
assessed with the speech therapists. The patient couldn’t afford a car and relied on the
public COTA bussing system as means of transportation, which often arrived late to
therapy sessions. Also, J.O.’s financial issues prohibited him from attaining refills for his
blood pressure prescriptions, which was discovered when his blood pressure was in
dangerous levels at the beginning of a session, and a non-emergent ambulance was
needed for patient to get appropriate treatment. Therapeutic progress was impeded in the
following therapy sessions secondary to attendance; J.O. was only able to attend 11 of the
45-minute treatment sessions scheduled on the course of 8 weeks, and a therapy session
that was ended early due to vitals exceeding appropriate limits. Additionally, minimal
home carryover in the HEP slowed the progress being made in therapy.
In hindsight, it may have been more beneficial for the patient to have more tasks
directly relating to gait, such as stepping over objects while ambulating and treadmill
training, and less focus on the stance progression at the stairs in order to maximize the
massed repetition of gait, which promotes neuroplasticity.6 Some task-oriented research
shows that there are minimal improvements in gait when the tasks performed are not
directly related to gait.40, 41 If it were available, a body weight supported treadmill may
have been beneficial as it is directly related to gait and involves maximal repetition.6 It
was expected that the patient would have been seen for 16 visits compared to the 11,
which may not have been long enough to promote the massed practice and repetition
required to evoke neuroplastic changes. Along the same idea, it would have been ideal to
have longer treatment sessions scheduled, as the patient often arrived late to his
appointments, several times having only 30 minutes of physical therapy. The patient
received physical therapy prior to occupational and speech therapy, thus when he arrived
late, it was not possible to extend time in therapy.
There is growing evidence that is showing improvements in functional tasks with
patients post stroke after the 6-month period; however, more research needs to be done as
to the interventions, timing, and amount of sessions in order to achieve these
improvements.50 Pleurala et al. recommend that an outpatient stroke patient be seen 3
times a week for 8 weeks in 45 minute treatment sessions in order to make gains past 6
months.42 Comparatively, this case study attempted to utilize 2 times a week for 8 weeks
with 45-minute treatment times; the patient only attended 1 time a week for 5 of the
weeks. It is unknown if there would be significant changes if the patient were to have
received therapy 3 times a week compared to the 1 to 2, or if there would have been any
additional changes if the patient were to have made all of his appointment sessions.
Although not possible, it would have been imperative that the patient received
early rehabilitation within the first three months of his stroke, were evidence shows most
neurologic recovery.31, 33, 41 In most of the evidence based rehabilitation studies agree there
is a significant benefit on functional outcomes and ADL status if the person receives
rehabilitation within the first 30 days.5, 43, 44, 46 Kelly-Hayes further describes functional
improvement if the patient receives at least 16 hours or more of physical therapy within
the first 6 months, with a minimum of 45 minutes per treatment session.5 Therefore, due
to this missed opportunity, the patient had developed many compensatory strategies and
habits over the 6 months, that proved difficult to overcome in rehab during this time
frame.
In the chronic stroke population, there is a lack of agreement on the best clinical
practice guidelines for stroke rehabilitation.5, 7, 21, 45, 49 This case study describes there may
be potential to increase significant changes with a combination of task-oriented and
neurodevelopmental approach in the functional status of a chronic stroke patient,
specifically balance and endurance, but more research is required in order to further
understand the potential for patients in this stage of recovery. Also, there is a strong need
to find optimal practice guidelines for stroke rehabilitation in regards to frequency,
intensity, time, and type of treatment in order for physical therapists to provide the best
treatment for their stroke patient population.
ANALYSIS OF FISCAL IMPACT
Medicare was the patient’s primary insurance. There were no previous therapy
visits in the year, thus the $1,880 cap was completely intact. The patient received
physical therapy, speech therapy, and occupational therapy. Medicare reimbursed the
physical therapy evaluation at a cost of $71.67; the re-evaluation was $39.67, and the
average treatment costing around $100 depending on the CPT code. The cost of a single
unit of therapeutic exercise was $29.62, a unit of neuromuscular re-education cost
$30.88, and therapeutic activity cost $32.44. The sessions were around 45 minutes, which
equates to three units, on the span of 8 weeks. The total amounted to approximately
$1,000 for total physical therapy visits, in which the patient was not responsible for any
of these therapy costs, as he did not exceed the hard cap on Medicare.
REFERENCES: 1. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al. Heart
disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014 ;128.
2. Sacco, R., Emilia, J., et.al. Risk Factors. Stroke 1997 28: 1507-1517. 3. Skillbbeck CE, Wade DT, Hewer RL, Wood VA. Recovery after stroke. J Neurol
Neurosurg Psychiatry. 1983; 46 (1): 5-8. 4. Eng JJ, Tang PF. Gait training strategies to optimize walking ability in people with
stroke: a synthesis of the evidence. Expert Rev Neurother. 2007; 7(10):1417-1436. 5. Kelly-Hayes M, Beiser A, Kase CS, et al. The influence of gender and age on
disability following ischemic stroke: the Framingham study. J Stroke Cerebrovasc Dis. 2003;12: 119-126.
6. Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD, et al. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke. 2005;36(9):e100–e143.
7. Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS. Recovery of walking function in stroke patients: the Copenhagen stroke study. Archives of Physical Medicine and Rehabilitation. 1995; 76: 27-32.
8. Andrews K, Brocklehurst JC, Richards B, Laycock PJ. The rate of recovery from stroke- and its measurement. Disability and Rehabilitation. 1981; 3(3): 155-161.
9. French, B., Thomas, L.H., Leathley, M.J., Sutton, C.J et.al. Repetitive task training for improving functional ability after stroke. Cochrane Corner. 2009; 40: 89-99.
10. Lindquist AR, Prado CL, Barros RM, Mattioli R, da Costa PH, Salvini TF. Gait training combining partial body-weight support, a treadmill, and functional electrical stimulation: effects on poststroke gait. Physical Therapy. 2007;87(9):1144–1154.
11. Belda-Lois J.M, Mena-del H.S., et al. Rehabilitation of gait after stroke: a review towards a top-down approach. Journal of Neuroengineering and Rehabilitation. 2011; 8: 1-19.
12. Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev. 2007; 4.
13. Teasell R.W., Foley N.C., Bhogal S.K., Speechely M.R An evidence-based review of stroke rehabilitation. Topics in Stroke Rehabilitation. 2003; 10(1): 29-58.
14. Boddice B, Brauer G, Gustafsson S, et al. Clinical Guidelines for Stroke Management 2010. National Stroke Foundation. 2010; 1-167.
15. Pollock A., Baer G., Campbell, B. et.al. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database Syst Review. 2014, 4.
16. Nudo RJ, Plautz EJ, Frost SB. Role of adaptive plasticity in recovery of function after damage to motor cortex. Muscle Nerve. 2001; 24 (8): 1000-1019.
17. Green JB. Brain reorganization after stroke. Topics in Stroke Rehabilitation. 2003; 10(3): 1-20.
18. Fisher B, Sullivan K. Activity-dependent factors affecting poststroke functional outcomes. Topics in Stroke Rehabilitation. 2007; 8(3): 31-44.
19. Teasell R, Bayona NA, Bitensky J. Plasticity and reorganization of the brain post stroke. Topics in stroke rehabilitation. 2005; 12 (3); 11.
20. American Physical Therapy Association. Guide to physical therapist practice. American Physical Therapy Association. 1999; 77.
21. Eng JJ, Tang PF. Gait training strategies to optimize walking ability in people with stroke: a synthesis of the evidence. Expert Rev Neurother. 2007; 7(10):1417-1436.
22. Blackburn M, van Vliet P, Mockett SP. Reliability of measurements obtained with the modified Ashworth scale in the lower extremities of people with stroke. Physical therapy. 2002; 82(1): 25-34.
23. Pandyan AD, Johnson GR, Price CI, Curless RH, Barnes MP, Rodgers H. A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity. Clin Rehabil. 1999; 13: 373–383.
24. Cuthbert SX, Goodheart GJ. On the reliability and validity of manual muscle testing: a literature review. Chiropractic & Manual Therapies. 2007; 15 (1): 4.
25. Collen F, Wade D et. al. Mobility after stroke: reliability of measures of impairment and disability. Disability & Rehabilitation. 1990; 12 (1): 6-9.
26. Flansbjer UB, Holmback AM et. al. The reliability of gait performance tests in men and women with hemiparesis after stroke. J Rehabil Med. 2005; 37 (2); 75-82.
27. Wolf SL, Caitlin PA, et al. Establishing the reliability and validity of measurements of walking time using the Emory Functional Ambulation Profile. Phys Ther. 1999; 79(12):1122-1133.
28. Perry J, Garrett M, et al. Classification of walking handicap in the stroke population. Stroke. 1995; 26(6):982.
29. Fritz S, Lusardi M. White paper: walking speed: the sixth vital sign. Journal of geriatric physical therapy. 2009; 32(2):2-5.
30. Dean CM, Richards CL, Malouin F. Walking speed over 10 metres overestimates locomotor capacity after stroke. Clin Rehabil. 2001; 15: 415–421.
31. Newman AB, Simonsick EM, Naydeck BL et al. Association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation and disability. JAMA, 2006, 295; 17: 2018-2026.
32. Harada ND, Chiu V, Stewart AL. Mobility-related function in older adults: assessment with a 6-minute walk test. Arch Phys Med Rehabil. 1999; 80: 837–84.
33. Eng JJ, Chu KS, Dawson AS, Kim M, Hepburn KE . Functional walk tests in individuals with stroke: relation to perceived exertion and myocardial exertion. Stroke. 2003; 33: 756-761.
34. Blum L, Korner-Bitensky N. Usefulness of the Berg Balance Scale in stroke rehabilitation: a systematic review. Physical therapy. 2008; 88(5): 559-566.
35. Lin JH, Hsu MJ, et al. The psychometric comparisons of 3 functional ambulation measures for patients with stroke. Stroke. 2010; 41(9): 2021-2025.
36. Danielsson A, Sunnerhagen KS. Energy expenditure in stroke subjects walking with a carbon composite ankle foot orthosis. Journal of Rehabilitation Medicine. 2004; 36(4): 165-168.
37. Kent RM, Gilbertson L, Geddes JM. Orthotic devices for abnormal limb posture after stroke or non-progressive cerebral causes of spasticity. The Cochrane Library. 2002: CD003694.
38. Bayona NA, Bitensky J, Salter K, Teassell R. The role of task-specific training in rehabilitation therapies. Topics in stroke rehabilitation. 2005; 12(3):58.
39. French B, Thomas LH, Leathley MJ, Sutton CJ, et al. Repetitive task training for improving functional ability after stroke. Cochrane Corner. 2009; 40: 98-99.
40. Barbeau H. Locomotor training in neurorehabilitation: emerging rehabilitation concepts. Neurorehabil Neural Repair. 2003; 17(3).
41. Kwakke G, Boudewjin JK, Wagenaar RC. Therapy impact on functional stroke rehabilitation. Physiotherapy. 1999; 85(7): 377-391.
42. Peurala S., Pitkanen K, Sivenius J. How much exercise does the enhanced gait-oriented physiotherapy provide for chronic stroke patients. Journal of Neurology. 2014, 4.
43. Pettersen R, Dahl T, Wyller T. Prediction of long-term functional outcome after stroke rehabilitation. Clinical Rehabilitation [serial online]. March 2002;16(2):149-159.
44. Musicco M, Emberti L, et. al. Early and long-term outcome of rehabilitation in stroke patients: the role of patient characteristics, time of initiation and duration of interventions. Arch. Phys. Med. Rehabil. 2003; 84(4): 551-8.
45. Paolucci, Stefano, et al. "Early versus delayed inpatient stroke rehabilitation: a matched comparison conducted in Italy." Archives of physical medicine and rehabilitation 81.6 (2000): 695-700.
46. Salter K, Campbell N, Richardson M, et al. Outcome measures in stroke rehabilitation. EBRSR. 2013:1-144.
47. Stroke-edge recommendations. NeuroPT.org Website. Accessed Oct 2014. <http://www.neuropt.org/docs/edge-documents/finalstroke-edge-recommendations-spread-sheet.pdf?sfvrsn=6.
48. American Heart Association. AHA/ACC Prevention Guidelines. Circulation. 2013; 129.
49. Dickstein, R. Rehabilitation of gait speed after stroke: a critical review of intervention approaches. Neurorehabil Neural Repair. 2009: 22; 649.
50. Novac, T.A, Satterfield, W.T., et. al. Stroke onset and rehabilitation: time lag as a factor in treatment. Arch Phys Med Rehabil. 1984; 65 (6): 316-9