Will lower extremity strengthening be beneficial for ambulation in patients with Guillain-Barrà Syndrome?

Transcription

1 University of New Mexico UNM Digital Repository Doctor of Physical Therapy Capstones Health Sciences Center Student Scholarship Will lower extremity strengthening be beneficial for ambulation in patients with Guillain-Barrà Syndrome? Bernadette Frigerio University of New Mexico Follow this and additional works at: Recommended Citation Frigerio, Bernadette. "Will lower extremity strengthening be beneficial for ambulation in patients with Guillain-Barrà Syndrome?." (2014). This Capstone is brought to you for free and open access by the Health Sciences Center Student Scholarship at UNM Digital Repository. It has been accepted for inclusion in Doctor of Physical Therapy Capstones by an authorized administrator of UNM Digital Repository. For more information, please contact

2 Will lower extremity strengthening be beneficial for ambulation in patients with Guillain-Barré Syndrome? A Case Report and Evidence Based Analysis Berna Frigerio DPT 2013 PT 691: Capstone Project

3 ABSTRACT BACKGROUND & PURPOSE To determine if lower extremity strengthening would be beneficial for ambulation in patients with Guillain-Barre Syndrome. CASE DESCRIPTION R.C. is a 48 year old male referred to home health physical therapy status post Guillain-Barré Syndrome onset seven years ago. o He was diagnosed one year post military retirement and lives in Torreon with his two school-aged daughters as well as his fiancé, however, his fiancé only stays with him 1-2X/week due to working and going to school in Albuquerque. OUTCOMES At the end of my rotation, R.C. was not discharged from home health physical therapy because he still demonstrated a need for skilled care. However, at time for his reassessment, he had achieved all of his goals except for transferring with supervision utilizing an assistive device and increasing his Tinetti score to 19/28 or greater. He scored an 11/28 still classifying him as a high risk of falls, but a significant increase from his initial evaluation score of 0/28. R.C. s goals were adjusted to advance program and is still going to be seen for skilled home health physical therapy for continuation of gait, transfer and balance training. DISCUSSION When determining if the PICO question, Will lower extremity strengthening be beneficial for ambulation in patients with Guillain-Barré Syndrome? was answered sufficiently, an extensive amount of research was analyzed and examined to ultimately conclude that yes, implementing a lower extremity strengthening program in a home health setting is beneficial for ambulation in patients with Guillain-Barré Syndrome. 2

4 SECTION 1: BACKGROUND AND PURPOSE During the first few weeks of my second rotation at a home health agency in Albuquerque, New Mexico, a patient with Guillain-Barré Syndrome was on the caseload. When arriving at his house for his initial evaluation, his fiancée was present and R.C. explained that he had been diagnosed with Guillain-Barré Syndrome 7 years ago, but over that time, had still seen some positive changes in his function and strength. He was affected at a young age with this immune based illness; Guillain-Barré Syndrome is more common in older persons, but can occur at a relatively young age, years old 4. In the home health setting, it is rare to see a patient with this diagnosis, especially so long after the initial onset. Typically, recovery begins after the acute/subacute and plateau phase with gradual resolution of the paralysis lasting 1-2 years 5. However, the ongoing impact of Guiilain-Barré Syndrome on activities of daily living, work, social activities and health-related quality of life can be considerable 4. This patient was unique in nature and when asked to develop a bilateral LE strengthening program to assist in ambulation, I turned to research for assistance because this was my first encounter in clinic with this diagnosis. As I investigated further on how to progress this patient, I noted that increase in muscle strength usually occurs in the first 6 months of recovery, but continued, significant progress can be observed beyond 12 months 2. Therefore, I had a discussion with my clinical instructor to determine if this specific case would be an optimal choice for my capstone project and ultimately, she agreed. Thus, the PICO question, Will lower extremity strengthening be beneficial for ambulation in patients with Guillain-Barre Syndrome? and purpose of this project, was formulated. 3

5 SECTION 2: CASE DESCRIPTION INTRODUCTION R.C. was one year post retirement from the military when he first started to notice his symptoms. He describes working a full day on the ranch, unloading bales of hay, when he returned home that evening feeling, a little under the weather. R.C. states he drank a glass of water before lying down at 6:00 in the evening and when he woke up 4 hours later to use the restroom, was unable to get up. He also states he was paralyzed from the waist down and his family immediately took him to the hospital. When he arrived at the hospital, he states, I was starting to lose function in my arms and hands it was getting more difficult to breathe. R.C. was immediately intubated and stayed intubated for three months. He was later discharged to Kindred hospital where he was on a ventilator for ten months. R.C. was later discharged to HealthSouth Rehab Hospital and then seen at the SCI unit at the VA hospital. It was during his time at the VA hospital where he fell from his wheelchair and fractured his left fibula, setting his recovery back even more. REASON FOR REFERRAL R.C. is a 48 year old male referred to home health physical therapy status post Guillain-Barré Syndrome onset seven years ago. PATIENT HISTORY Medical History: R.C. was seen for physical therapy on 10/30/12 after having developed a severe case of Guillain-Barré Syndrome in 2005, one year post military retirement. Guillain- Barré is an immune-mediated response that triggers destruction of the myelin sheath covering the peripheral nerves. The demyelination occurs between the nodes of Ranvier, blocking the transmission of impulses from node to node. Typically, the axons are spared, but recovery occurs slowly as the remyelination takes place 2. R.C. also reports having a left ankle ORIF in 95 due to a fracture as well as a left fibular fracture during his recovery of Guillain-Barre Syndrome in 07 after falling from his wheelchair at the VA hospital. However, other than the Guillain-Barré onset, R.C. denies any other pertinent medical history, pre and post Guillain-Barré, relating to limitations in his functional mobility or ADLs. Social History: R.C. retired from the military in 2004 and lives in Torreon with his two schoolaged daughters as well as his fiancé, however, his fiancé only stays with him 1-2X/week due to working and going to school in Albuquerque. He lives in a one level home with ramps to get inside as well as a ramp to get to the hallway where the bathroom is located. R.C. has a few friends who live down the road from him in his guest house that will help him out around the house and on the ranch. Expectations and Goals of Treatment: R.C. states he has started to see increased movement and function and would like to maximize this functional movement to continually be able to provide for his family, especially his young daughters. 4

6 EXAMINATION Systems Review: o Cognition Patient is alert and oriented X3 (person, place, time/situation) o Cardiac HR: 73 BP: 116/78 o Respiratory RR: 16 o Pain Patient reports a pain of 2/10 and describes it as general achiness and can take some over the counter medication to relieve the pain o Integumentary Patient displays intact skin and is not at risk for breakdown and states his fiancée assists him in performing regular skin checks o Neurological Patient reports dull sensation of bilateral LEs and distal UEs o Musculoskeletal MMT o R/L: HF 2+/2+, AB/AD 3+/3+, KE 3-/3-, DF 0/0, PF 1/0 o Reports he can wiggle toes minimally on right foot AROM PROM WNLs Mobility Bed Mobility Lacking of bilateral terminal knee extension AROM Patient is modified independent with rolling and supine-to-sit Transfers Patient requires minimal assistance for sit-to-stand and a stand-pivot transfer Tests and Measures: o Tinetti: unable to perform at time of initial evaluation due to not having medical clearance of possible disuse osteoporosis Please see above for further explanation EVALUATION Diagnosis: R.C. s medical diagnosis is Guillain-Barré Syndrome with a physical therapy diagnosis of impaired motor function and sensory integrity associated with chronic polyneuropathies. 5

7 Narrative Assessment: R.C. is a 48 y/o male referred to home health physical therapy s/p Guillain-Barré Syndrome onset seven years ago. He demonstrates a significant decrease in strength of LEs bilaterally, however states he can wiggle his toes on his right foot. R.C. lacks of AROM terminal knee extension bilaterally, but PROM of bilateral LEs are WNLs. R.C. demonstrates altered sensation in bilateral LEs and distal bilateral UEs. He is modified independent with bed mobility including rolling and supine-to-sit, but requires minimal assistance for sit-to-stand and for a stand-pivot transfer. R.C. is unable to ambulate at time of initial evaluation due to possible disuse osteoporosis and required a bone density scan to gain medical clearance from his doctor. Therefore, he was unable to complete the Tinetti and scored a 0/28 classifying him as a high risk of falls. R.C. reports working on ambulation in the past, but has not been able to continue the past two years even though he has noticed improved strength/changes in his bilateral LEs. He would benefit from skilled physical therapy intervention and after clearance from his doctor, displays excellent potential to return to ambulation in a limited capacity to maximize his functional mobility, independence with ADLs and increased quality of life. Clinical Judgments & Problem List: o Activity-Functional Limitation Level Mobility Transfers o Impairment Level Education Strength ROM Potential for falls o R.C. has a great family support from his fiancée as well as his children. He also mentioned that he attends a support group for people experiencing the deficits caused by Guillain-Barré Syndrome. R.C. has a very positive outlook on life and is very optimistic about his physical therapy treatments. Prognosis (including goals): o Goals 8 weeks Activity-Functional Limitation Level Patient will ambulate household distances of 50 feet with minimal assistance utilizing the least restrictive device Patient will perform all functional transfers with or without and assistive device with supervision Impairment Level Patient will take the initiative of his own self care by developing a list of all ADLs that requires the help of his family Patient will increase lower extremity strength by +1 MMT or greater Patient will increase AROM in bilateral terminal KE with a HEP 6

8 o o o Patient will increase Tinetti Balance Assessment score to 19/28 or greater to reduce risk of falls Goals 1 year Activity-Functional Limitation Level Patient will ambulate household distances of 150 feet with supervision utilizing the least restrictive device Patient will perform all functional transfers with or without and assistive device independently Impairment Level Patient will be able to direct his fiancée and/or children for all care needs Patient will report the ability to stand in standing frame >15 minutes with minimal fatigue Patient will report no loss of gained of bilateral terminal KE to increase independence with ambulation Patient will report no falls requiring hospitalization 3 rd Party Payers R.C. has Medicare insurance and all 16 visits are approved and authorized with no co-pay. R.C. exhibits an excellent rehab potential from skilled physical therapy intervention, to maximize his functional mobility and independence with ADLs. He should expect to achieve most if not all goals in the two months of rehabilitation. INTERVENTIONS Person-Related Instruction: R.C. will be given information about available resources for patients with Guillain-Barré Syndrome including social groups, recreational and leisure activities and coping skills. R.C. will also be instructed on the proper techniques of transfers and equipment management as well as avoidance measures necessary to uphold healthy skin. Coordination/Communication with other health professionals: R.C. will be seen by his primary care physician as needed to discuss progress and/or questions that may have come up during treatment. R.C. will also be seen by OT to increase functional independence with ADLs as well as be seen by his neurologist biyearly as a regular check up for preventive maintenance. R.C. has also been instructed to obtain immediate medical assistance with any complications. Direct/Procedural Interventions: R.C. will receive PT for minutes 2X/week for 8 weeks or until safely functional and skilled care is no longer needed. His therapy will consist of but not limited to AROM, stretching, bilateral LE strengthening, gait, balance and transfer training. o Initially when attempting to implement the lower extremity strengthening program, it needed to be adjusted immediately because the patient displayed minimal difficulty with the simplicity of the program (sitting long arc quads, hip abduction, marching on one leg and a supine hip flexor stretch). These exercises got changed to supine heel drags, short arc quads, bridges, side-lying abduction and keeping the hip flexor stretch. 7

9 The exercises were prescribed X10, 1X/day. As the weeks went on, his strengthening program advanced to standing exercises consisting of hip abduction/extension, hamstring curls, mini squats and to stand in his standing frame for 1-2 minutes with minimal fatigue. The exercises were prescribed X10, 1-2X/day. o The patient received clearance from his doctor denying him having disuse osteoporosis and he began to work on ambulation. He required minimal assistance to stand as well as ambulate 15 feet X2. This distance progressively increased to 25 feet X2 and finally 50 feet X1. The amount of assistance needed also decreased to supervision at the end of my rotation. His AFOs were also adjusted to allow some movement of DF to keep him in a more upright posture and not ambulating on his heels. R.C. demonstrated some difficulty with the adjustment at first, but by the end of the rotation was ambulating with less difficulty. o R.C. was seen 2X/week for 8 weeks for a total of 16 visits that lasted minutes in duration. Outcomes: o At the end of my rotation, R.C. was not discharged from home health physical therapy because he still demonstrated a need for skilled care. However, at time for his reassessment, he had achieved all of his goals except for transferring with supervision utilizing an assistive device and increasing his Tinetti score to 19/28 or greater. He scored an 11/28 still classifying him as a high risk of falls, but a significant increase from his initial evaluation score of 0/28. R.C. s goals were adjusted to advance his program and he is still going to be seen for skilled home health physical therapy for continuation of gait, transfer and balance training. 8

10 SECTION 3: EVIDENCE BASED ANALYSIS METHODOLOGIES OF SEARCH Databases utilized o Pub Med Guillain-Barre Syndrome physical therapy o o 97 results added limits English and 10 years o 45 results 6 chosen on title 2 excluded on irrelevance of PICO "Guillain-Barre Syndrome/rehabilitation"[MAJR] 23 results with limits 10 years and English o 5 chosen based on title 3 excluded based on low level of evidence and irrelevance CINAHL (limits: 10 years, English) Guillain barre syndrome (in title), rehabilitation (in text) 65 results o 3 chosen based on title 2 excluded based on inaccessible and not closely related Web of Knowledge Guillain barre AND physical therapy 105 results o 3 chosen based on title 2 excluded based on date and duplicate (study under review) A total of eight articles from all three databases will be included for analysis and rated on their levels of evidence and will assist in answering the PICO question, Will lower extremity strengthening be beneficial for ambulation in patients with Guillain-Barré Syndrome? o Please see Figure 1 in the appendix for depiction o Please see Table 1 in the appendix for article summaries o Please see Attachments 1-16 for complete article analysis s and synopsis s DISCUSSION When attempting to research literature concerning Guillain-Barré Syndrome and physical therapy, not many articles were available, unless the treatment was regarding a medical intervention. Guillain-Barré Syndrome is similar to traumatic brain injuries in that not two cases are alike. Each person who has developed Guillain-Barré Syndrome is distinctive in their own way and may have different time frames of symptoms, recoveries and outcomes. Therefore, the research investigated pertaining to Guillain- Barré Syndrome and physical therapy consisted extensively of case studies. Very few randomized controlled trials or systematic reviews could be found on Guillain-Barré Syndrome, physical therapy or 9

11 lower extremity strengthening. Although the evidence was poor, it was beneficial for rehabilitation purposes for the patient of discussion. As with any intervention implemented for a patient, it was reassessed at every visit to determine if the program needed to be progressed or extracted appropriately. On the first day of implementing the lower extremity strengthening program, it needed to be adjusted immediately because the patient displayed minimal difficulty with the simplicity of the program. One key barrier in this patient s physical therapy regimen was that he lived one hour and 45 minutes away from Albuquerque and wasn t very accessible. If the patient had concerns during the week when we weren t there, they were addressed as best as possible over the phone. Guillain-Barré Syndrome is a multifaceted diagnosis and when this patient population is on the road to recovery, there is little evidence that provides a formal exercise program to follow that would improve their functional capacities. Further research needs to be conducted in all aspects of rehabilitation as well as different stages of Guillain-Barré Syndrome in order to gain a firmer grasp on how to ideally treat these patients with physical therapy interventions. There is one fact that researchers seem to agree upon, a referral for physical therapy needs to be made at the earliest stage of Guillain-Barré Syndrome to have the most effect in promoting functional ability. CONCLUSION/BOTTOM LINE When determining if the PICO question, Will lower extremity strengthening be beneficial for ambulation in patients with Guillain-Barré Syndrome? was answered sufficiently, an extensive amount of research was analyzed and examined to ultimately conclude that yes, implementing a lower extremity strengthening program in a home health setting is beneficial for ambulation in patients with Guillain- Barré Syndrome. For future patients with Guillain-Barré Syndrome, I would utilize a similar intervention individualizing and advancing their program according to their needs in any type of physical therapy setting. The only thing I would do differently would be to have the opportunity to spend more time with the patient because 6-8 weeks is not nearly enough time to truly see the gains made in this patient population. 10

12 REFERENCES 1. Bussmann, J. B., et al, (2007). Analyzing the favorable effects of physical exercise: Relationships between physical fitness, fatigue and functioning in guillain-barre syndrome and chronic inflammatory demyelinating polyneuropathy. Journal of Rehabilitation Medicine, 39, Davis, L., King, M., & Schultz, J. (2005). Fundamentals of neurologic disease. (1st ed., pp ). New York, NY: Demos Medical Publishing Inc. 3. Karavatas, S. G. (2005). The role of neurodevelopmental sequencing in the physical therapy management of a geriatric patient with guillain-barre syndrome. Topics in Geriatric Rehabilitation, 21(2), Khan, F., & et al., (2011). Outcomes of high and low intensity rehabilitation programme for persons in chronic phase after guillain-barre syndrome: A randomized controlled trial. Journal of Rehabilitation Medicine, 43, Khan, F., Amatya, B., Brand, C., & Turner-Stokes, L. (2011). Multidisciplinary care for guillainbarre syndrome. European Journal of Physical and Rehabilitation Medicine, 47, Khan, F., & Amatya, B. (2012). Rehabilitation interventions in patients with acute demyelinating inflammatory polyneuropathy: a systematic review. European Journal of Physical and Rehabilitation Medicine, 48(3), Mhandi, L., et. al., (2007). Muscle strength recovery in treated guillain-barre syndrome: a prospective study for the first 18 months after onset. American Journal of Physical Medicine Rehabilitation, 86(9), Pitetti, K. H., Barrett, P. J., & Abbas, D. (1993). Endurance exercise training in guillain-barre syndrome. Archives of Physical Medicine Rehabilitation, 74, Tuckey, J., & Greenwood, R. (2004). Rehabilitation after severe guillain-barre syndrome: the use of partial body weight support. Physiotherapy Research International, 9(2),

13 Figure 1: Articles Included and Excluded for Analysis APPENDIX PubMed 120 MeSH Database Two different keyword combinations & 2 limits 11 CINAHL 65 Keyword Search One keyword combination & 2 limits 3 Web of Knowledge 105 Keyword Search One keyword combination 3 Some Key Words: Guillain- Barre Syndrome/ rehabilitation [MAJR], Guillain-Barre Syndrome physical therapy Limits: 10 years, English Selected based on title 5 Excluded based on: Lowest level of evidence and irrelevant to PICO 2 Excluded based on: Inaccessible and irrelevant to PICO 2 Excluded based on: Date and duplicate article under review 8 Total Articles (Relevant to Topic) 12