Journal of Exercise Medicine online

Size: px

Start display at page:

Download "Journal of Exercise Medicine online"

Charlotte Henderson
5 years ago
Views:

1 Journal of Exercise Medicine online February 2017 Volume 2 Number 1 Editor-in-Chief Official Research Tommy Journal Boone, of the American PhD, MBA Review Society Board of Exercise Todd Astorino,

1 1 Journal of Exercise Medicine online February 2017 Volume 2 Number 1 Editor-in-Chief Official Research Tommy Journal Boone, of the American PhD, MBA Review Society Board of Exercise Todd Astorino, Physiologists PhD Julien Baker, PhD Steve ISSN Brock, PhD Lance Dalleck, PhD Eric Goulet, PhD Robert Gotshall, PhD Alexander Hutchison, PhD M. Knight-Maloney, PhD Len Kravitz, PhD James Laskin, PhD Yit Aun Lim, PhD Lonnie Lowery, PhD Derek Marks, PhD Cristine Mermier, PhD Robert Robergs, PhD Chantal Vella, PhD Dale Wagner, PhD Frank Wyatt, PhD Ben Zhou, PhD Official Research Journal of the American Society of Exercise Physiologists ISSN JEMonline Effects of a Supervised Progressive Exercise and Balance Program on Functional Fitness Levels and Changes in the Chedoke Physical Inventory Scale in a Patient with Guillian-Barre Syndrome: A Case Report Eric Durak Medical Health and Fitness, 133 Campo Vista Drive, Santa Barbara, CA ABSTRACT Durak E. Effects of a Supervised Progressive Exercise and Balance Program on Functional Fitness Levels and Changes in the Chedoke Physical Inventory Scale in a Patient with Guillian-Barre Syndrome: A Case Report. JEMonline 2017;2(1):1-9. The purpose of this study was to test the effects of a chronic exercise and balance program on overall function and Chedoke stroke inventory ratings in a subject with Guillian-Barre Syndrome (GBS). The patient (age, 61 yrs; weight, 93.7 kg) was diagnosed with GBS in 2007 after being in a coma for 6 months and after suffering two strokes in the summer of The subject s training consisted of balance and coordination work, progressive resistance exercises using grip-free rubber tubing, stretching, and locomotor work 2 times wk -1 up to 20 min session -1 for 3½ yrs. We assessed the patient in the summer of 2013 using modifications of the Chedoke Scale for 19 components of the upper and lower body. The findings indicate an average improvement of 22% for upper body assessment tools, and a 41% improvement in standing and side braiding assessments. Upper body movements on the right side improved from 5.3 to 5.85 on Chedoke (P = 0.027), and for left side movements improved from 4.08 to 4.46 (P = 0.05). Overall fitness improved based on ability to perform increased sets, reps, and resistance from grip free technology, and number of stairs walked (ascended). The patient feels his quality of life is good based on his overall health and functional ability. Thus, a regular routine of basic functional exercises can improve function based on strength, and range of motion in a patient with Guillian-Barre Syndrome. Key Words: Guillian-Barre Syndrome, Stroke, Exercise Therapy

2 2 INTRODUCTION Seeing improvement in muscular spasticity post-stroke is rare. In most cases, depending on the severity and location of the stroke, keeping the musculature from deteriorating is important to the overall health of the patient. This preliminary case report presents the specific exercise program that was used with a patient who suffered two strokes in August of 2010, and who has been engaged in an individual exercise program since then to improve functional abilities. There are numerous assessment tools to assess stroke status (1,4,5,12). Much of the current literature discusses reliability (4,13), validity (14,20), and general effectiveness (3,5,6). Not all assessments tools are helpful. In fact, in the report by Ansari et al. (3), the Ashworth Scale, which is used to detect specific levels of post-stroke muscle spasticity, was deemed unreliable. However, the use of validated scoring assessments such as the Short Form 36 (SF-36) and Chedoke Scale have been shown to work with the majority of stroke survivors in order to make accurate assessments of their state of readiness to perform activities for daily living (ADLs). Both are also used to determine the patients ability to improve their overall condition by assigning them the proper functional and progressive programs that afford the maximum benefit with the smallest chance of an accident occurring during the performance of such tasks (4,13,17,19). Therefore, in order to promote improvement in the stroke patient, a modification of the Chedoke Impairment Inventory for Shoulder Pain and Postural Control was used to assess a chronic exercise program that consisted of basic range of motion exercises, progressive resistance exercises, and stair climbing to improve functional abilities (10,13,15). METHODS Subject In the spring of 2014, a primary care physician referred the patient for a chronic post-rehab program of which his functional abilities were initially assessed. Demographic data include: (age, 61 yrs; weight, 93.7 kg) who suffers initially from a 2007 flu vaccine-induced coma in which he spent over four months in that condition, and subsequent diagnosis of Guillian- Barre Syndrome. The patient was also hypertensive, and had adult-onset diabetes mellitus. After being discharged from a six-month physical therapy regime, he began training with our team for 15 to 20 min 2 times wk -1 performing post rehabilitative exercises. In August of 2012, he suffered a stroke at home and in the hospital. After a four-month period of recuperation, he again regained his 2 times wk -1 program. This consisted of walking up stairs (starting from ground floor, walking up 3 to 4 flights, and using the elevator to descend), basic balance work (one leg balance, turns, side bends, and side shuffles), and resistive strength training using standard rubber tubing equipment. Initial programs concentrated on standing balance work with assistance, locomotor drills (side to side walking, shuffle step, and turning 360 near a wall), upper and lower body stretches (self-paced and with the assistance of the therapist), and basic resistance activities using rubber tubing. The first set of rubber tubing included bands with handles (Power Systems, Knoxville, TN) that were difficult to grip, thus hampering the patient s effort to perform the full range of motion and increase resistance movements.

3 3 The following summer, the decision was made to switch to using grip-free technology rubber tubing resistance exercises. This technology (Flexolate Technologies, Missoula, MT) provided slip-on wrist handles that allow for attachment of different strengths of rubber tubing. Since the patient had limited to moderate use of the hand and fingers on the right side, and very little use of fingers and hand on the left side, the grip-free program allowed for pulling at different movement patterns in a progressive fashion through a full range without fear of the handles sliding off or losing a grip at any point during the pulling process. Velcro grips were also attached to the ankles for extension and flexion exercises using a pulley devise. A sample program included 1 to 2 lower body exercises and 3 to 4 upper body exercises (Table 1). Table 1. Exercise Program Components. Exercises Number of Sets Number of Repetitions Leg Extensions (sitting in chair) 2 to 3 sets 10 reps Quarter Squats (using padded bar attached to tubing) 2 sets 10 reps Leg Curls (sitting in chair assisted) 2 sets 10 reps Back Rows (one and two tubes) 2 set 10 reps, 8 reps Lat Pulls (using padded bar attached 2 sets 10 reps, 8 reps (two tubes) to tubing) Neutral Grip Bicep Curls 2 sets 10 reps, 8 reps (two tubes) Neutral Grip Tricep Extensions 2 sets 10 reps, 8 reps (two tubes) Chest Cross Pulls (adduction) 2 sets 10 reps Shoulder Lateral Flies (abduction) 2 sets 10 reps Standing Chest Press (using padded bar attached to tubing) 2 sets 10 reps, 8 reps (two tubes) On any given day the program featured two of the three levels of training format: (a) stair climbing and stretching; (b) progressive resistance and stretching (3 to 4 specific exercises); and (c) balance activities and resistance training (2 to 3 exercises each session). One area that was discontinued after 2 yrs was stair walking down flights because of weight and falling concerns. In addition, the subject continued to walk at home 3 to 4 d wk -1 up to 20 min at a slow pace using a walker devise. Analysis of Chedoke scale assessments were measured using Student s t-test.

4 4 RESULTS Change in Spasticity During the time frame of using resistance activities with handles, there was little change in levels of spasticity in both the left shoulder region (level and amount of twitches) and the left hand spasticity (involuntary movements of the hand). Change in Chedoke Ratings Chedoke ratings were applied to the upper body and the lower body movement assessments. Modifications were made to the Chedoke Arm and Hand Activity Inventory Assessment (4), and the Continuous Scale Physical Functional Performance Test 10 Item (16) to include the most applicable items related to the training and assessment of the patient. Results of each of the assessments are listed in Tables 2a, 2b, and 2c. Table 2a. Changes in Function and Chedoke Ratings. Assessment Component Pre Score Post Score / Change Chedoke Rating / %Change Shoulder Range of Motion % increase Standing 1 Leg (5 sec) 3 sec 5 sec 40% increase Side Braiding (2 M) 2.0 (10 pt scale) 3.5 (10 pt scale) 43% increase Standing Weak Leg (5 sec) 2.5 sec 5 sec 50% increase Resistance Shoulder Abduction Yes Yes Pre (R/L) 6/3 Post (R/L) 7/5 Touch Opposing Knees L/R Yes / Yes Yes / Yes Pre (R/L) 7/6 Post (R/L) 7/6 Shoulder Flexion > Pre (R/L) 7/4 Post (R/L) 7/4 Shoulder Pain in Abduction 3.5 (10 pt scale) 1.0 (10 pt scale) N/A The upper body assessments included shoulder range of motion, abduction, flexion above 90, and figure eight movements on average improved by 22% (green shaded areas of Table 2a and 2b). Standing exercises such as balance (weak vs. dominant leg) and side braiding assessment score improved on average of 41.5%. There was no visual improvement in high step, and little change in foot lift while sitting (Yellow shaded areas of Table 2b).

5 5 Table 2b. Changes in Function and Chedoke Ratings. Assessment Component Pre Score Post Score / Change Chedoke Rating Hand Knee to Forehead 5 sec 5.5 sec 4.5 sec 19% increase Shoulder Figure 8 Yes Yes Pre (R/L) 7/7 Post (R/L) 7/7 Arm 90 Full Supination Yes Yes Pre (R/L) 7/4 Post (R/L) 7/4 Overhead Clap 3X / 5 sec Yes Yes Pre (R/L ) 7/6 Post (R/L) 7/6 Shoulder Scissor 3X / 5 sec Slow Yes Pre (R/L) 7/5 Post (R/L) 7/6 Lift Foot (Sitting) 5X / 5 sec R L=slow Yes Pre (R/L ) 5/4 Post (R/L) 6/4 High Step (Standing) 10X / 10 sec No No Pre (R/L) 1/1 Post (R/L) 1/1 Table 2c. Changes in Function and Chedoke Ratings. Assessment Component Pre Score Post Score / Change Chedoke Rating Standing (1 min) <30 sec Yes Pre (R/L) 4/4 Post (R/L) 6/5 Walk Indoors (25 M) Yes Yes Pre R/L) 4/3 Post (R/L) 5/4 Walk Outdoors (900 M) Yes Yes Pre (R/L) 4/3 Post (R/L) 4/3 Age Walk 2 min 77 M 100 M + Pre (R/L) 4/3 Post (R/L) 5/3 Using the Chedoke Assessment Scale (see Appendix 1), the patient demonstrated the following improvements in hand and shoulder movements over the 2½ yrs of training.

6 6 Appendix 1. Chedoke Arm and Hand Inventory Scale. Chedoke Arm and Hand Activity Inventory Scale 7 Complete Independence Able to hold jar off the table and use the other hand to open the jar, without resting arms on table. [Able to perform movement to 100% of range with no assistance or cueing on the part of the therapist for multiple repetitions] 6 Modified Independence Requires use of assistive device (e.g., dycem) OR requires more than reasonable time OR there are safety considerations. (Able to perform the movement up to 90% of range with no assistance at least one repetition) 5 Supervision Requires supervision (e.g., standby, cueing or coaxing). 4 Minimal Assistance The weak upper limb requires light touch assistance to manipulate or stabilize during the task. Client performs 75% or more of the effort to complete the task. 3 Moderate Assistance Weak upper limb partially manipulates and stabilizes during task. Requires assistance (e.g., hand over hand technique OR uses table or body as support). Client performs 50 to 74% of the effort to complete the task. 2 Maximal Assistance Weak upper limb stabilizes during task. Requires assistance (e.g., hand over hand technique). Client performs 25 to 49% of the effort to complete the task. 1 Total Assistance Client performs less than 25% of an effort to complete the task Based on the basic movements (some which were not difficult to perform pre or post), there were significant improvements on both sides, with a slight favor on the right side of the body (the left side has significant impairment due to strokes) (Table 3). Table 3. Improvements on Both Sides of the Body. Body Part Pre to Post Measures ( ± SD) P Value Right Side Chedoke 5.38 ± 1.89 to 5.85 ± 1.77 P = Left Side Chedoke 4.08 ± 1.61 to 4.46 ± 1.61 P = 0.054

7 7 Change in Overall Fitness Over a 3-yr period there were improvements in basic levels of fitness. The first area observed was the ability to perform basic balance and coordination drills (side steps, body turns in both directions, and diagonal walking), basic aerobic conditioning (ability to walk flights of stairs timed), and specific strength movements. However, the patient s strength improvements were hindered by the inability to grip the handles of rubber tubing in order to perform full range of motion movements. Part of this problem was solved when a grip-free technology was used that allowed for wrist bands to be placed over the hands, thus allowing for movement using the major muscle groups as primary movers without the use of hand and forearm muscles as agonists. In fact, this technology allowed for an increase in the amount of reps, increase in tension (adding bands), and coordination of bi-lateral movements during the exercises. Change in Overall Quality of Life After spending four months in a coma, and out of work on disability for over a 2-yr period, the subject was given a prognosis by one physician of just 5 yrs post-diagnosis. As of this writing, he is going on 8 yrs and his other health issues (hypertension, weight gain, and diabetes) are all in better control. His believes that his quality of life is high (i.e., 7 out of a 10 rating). He has accepted the physical limitations, and he continues to teach ¾ time at his university position. As of this writing, he has just recently published a professional textbook in his area of expertise. DISCUSSION One of the issues in scoring strength training and movement items is that they were modified using a combination of the traditional Chedoke Scale and the Arm and Hand Activity Inventory, still using the 1 to 7 rating program score, but intermixing scores based on the specific type of activity we had the subject perform (7-9,11). The program undertaken by the subject over the years has proven to be a model of consistency (18). The subject still has a long way to go regarding some of the fundamental issues of his overall health program. Number one is his body weight. As a type II diabetic on insulin, he is still at 93 kg. This is roughly 12 kg higher than a normal body weight for his size. Given this expected weight loss, he would take less insulin and would likely have lower fasting blood glucose and a lower resting blood pressure. This is mainly a factor of diet. The second aspect is progression. It is difficult to add additional sets, and sometimes the subject would like to quit the sessions. This has been an on-going struggle. However, with over 240 sessions over the past 4 yrs, he understands the need for a regular program and, frankly, he has progressed as well as can be expected based on his overall health status. This program also underscores the results that can be achieved with a consistent supervised program that measures outcomes from both exercise and medicine (in this case, the Chedoke Scale) in a systematic method (2). CONCLUSIONS The use of regular exercise and movement therapy routines performed over a 3-yr period has helped the post stroke patient to improve functional movement and balance as indicated in significant changes in specific Chedoke ratings. This report underscores the importance of maintaining a regular exercise program despite the difficulties of performing specific types of

8 exercises based on functional movement. Without a doubt, the combination of specific tubing based resistance exercises, along with balance and basic locomotor movements contributed to the changes in the assessments for this stroke patient. 8 Address for correspondence: Eric Durak, MSc, Medical Health and Fitness, 133 Campo Vista Drive, Santa Barbara, CA 93111, durakfitness@gmail.com REFERENCES 1. Ahmed S, Mayo NE, Higgins J, Salbach NM, Finch L, Wood-Dauphinee SL. The stroke rehabilitation assessment of movement (STREAM): A comparison with other measures used to evaluate effects of stroke and rehabilitation. Phys Ther. 2003;83: Andresen EM. Criteria for assessing the tools of disability outcomes research. Arch Phys Med Rehabil. 2000;81:S15-S Ansari NN, Naghdi S, Moammeri H, Jalaie S. Ashworth Scales are unreliable for the assessment of muscle spasticity. Physiother Theory Pract. 2006;Jun;22(3): Barreca SSPMLLCGJMC. Validation of three shortened versions of the Chedoke Arm and Hand Activity Inventory. Physiother Can. 2006;58: Berg KO, Wood-Dauphinee S, Williams JL. The Balance Scale: Reliability assessment with elderly residents and patients with acute stroke. Scan J Rehab Med. 1995;27: Brock JA, Goldie PA, Greenwood KM. Evaluating the effectiveness of stroke rehabilitation: Choosing a discriminative measure. Arch Phys Med Rehabil. 2002;83: Carr JH, Shepherd RB, Nordholm L, Lynne D. Investigation of a new motor assessment scale for stroke patients. Phys Ther. 1985;65: Cole B, Finch E, Gowland C, Mayo N. Physical rehabilitation outcome measures. Toronto, Ontario: Canadian Physical Therapy Association, Chong DK. Measurement of instrumental activities of daily living in stroke. Stroke. 1995;26: Da Cunha, IT, Jr., Lim PA, Qureshy H, Henson H, Monga T, Protas EJ. Gait outcomes after acute stroke rehabilitation with supported treadmill ambulation training: A randomized controlled pilot study. Arch Phys Med Rehabil. 2002;83:

9 11. de Haan R, Aaronson N, Limburg M, Langton-Hewer R, et al. Measuring quality of life in stroke. Stroke. 1993;24: English CK, Hillier SL, Stiller K, Warden-Flood A. The sensitivity of three commonly used outcome measures to detect change amongst patients receiving inpatient rehabilitation following stroke. Clin Rehabil. 2006;20: Gowland C, Stratford PW, Ward M, et al. Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment. Stroke. 1993;24: Hsieh CH, Hsueh IP, Chiang FU, Lin PH. Inter-rater reliability and validity of the action Research Arm test in stroke patients. Ageing. 1998;27: Lyle RC. A performance test for assessment of upper limb function in physical rehabilitation treatment and research. Int J Rehabil Res. 1981;4: Manns, PJ, Tomczak, CR, Jelani, A, Cress, ME, Haennel, R. Use of continuous scale physical functional performance test in stroke survivors. Arch Phys Med Rehab ;90: Shinar D, Gross CR, Bronstein KS, et al. Reliability of the activities of daily living scale and its use in telephone interview. Arch Phys Med Rehabil. 1987;68: Sveen U, Bautz-Holter E, Sodring KM, Wyller TB, Laake K. Association between impairments, self-care ability and social activities 1 year after stroke. Disabil Rehabil. 1999; 21: Wade DT. Measuring arm impairment and disability after stroke. Int Disabil Stud. 1989;11: World Health Organization. International Classification of Functioning, Disability and Health: ICF. Geneva: World Health Organization, Disclaimer The opinions expressed in JEMonline are those of the authors and are not attributable to JEMonline, the editorial staff or the ASEP organization. Financial Disclosure The author has no financial interest with any of the companies listed in this report.

Journal of Exercise Physiologyonline

Journal of Exercise Physiologyonline 104 December 2015 Volume 18 Number 6 Editor-in-Chief Official Research Journal of Tommy the American Boone, PhD, Society MBA of Review Exercise Board Physiologists