Rehabilitation in progressive supranuclear palsy: case report

Progressive supranuclear palsy (PSP) is a distinct clinicopathologic entity characterized by supranuclear ophthalmoplegia, pseudobulbar palsy, axial dystonia in extension, and subcortical dementia. Although relatively rare, PSP is disabling, thus rehabilitation techniques and management are indicated in nearly every case. This report describes the neurologic presentation, rehabilitation management, and outcome of treatment of a patient with PSP during a 12-month period. The patient required thorough neuromuscular, neuropsychological, speech, swallowing, vision, and social service evaluations prior to the implementation of a rehabilitation program. Therapeutic rehabilitation techniques focused on limb coordination activities, tilt board balancing, ambulation activities, and activities to improve route finding and visual scanning ability. Prism lenses were introduced to compensate for deficits in vertical eye movements. Treatment improved the patient's functional status. Later, as the patient's neurologic status deteriorated, it became necessary to educate the family and caretakers in the ongoing rehabilitation management of the patient.     

Characteristics and symptom management of progressive supranuclear palsy: a multidisciplinary approach.

Progressive supranuclear palsy (PSP), a neurodegenerative disorder that may be mistaken for Parkinson's disease early in its course, is the most common type of atypical parkinsonism. PSP is fatal; it transforms a normal person into an invalid within 5-7 years of the onset of symptoms. PSP requires a multidisciplinary approach to symptom management and treatment. The neuroscience nurse who is knowledgeable about PSP and the complex way in which it overlaps with numerous other devastating neurological diagnoses can help in achieving the correct diagnosis and treatment. The nurse must understand the disease pathophysiology and the plan of care required and is instrumental in recognizing the needs of the patient and the family.     

Supported treadmill training for gait and balance in a patient with progressive supranuclear palsy

BACKGROUND AND PURPOSE: Impaired balance, gait disturbances, and frequent falls are common problems in people with progressive supranuclear palsy (PSP). This case report describes the use of a modified body weight support treadmill training program to reduce falls and improve the balance and gait of a patient with PSP. CASE DESCRIPTION: The patient was a 62-year-old man diagnosed with PSP. His major problems were impaired balance and frequent, abrupt falls. METHODS: Physical therapy included walk training, balance perturbation, and step training using body weight support with a treadmill. Training sessions lasted 11/2 hours and occurred 3 days a week for 8 weeks. Fall incidence, balance, and gait were assessed before, during, and after the program. OUTCOMES: The patient reported fewer falls during and after training. Balance and gait improved after training. DISCUSSION: This case report is the first to report fall reduction, improved gait, and improved balance following physical therapy for a person with PSP.     

Lower-extremity kinematics and postural stability during stair negotiation: Effects of two cognitive tasks

Background

Concurrent cognitive tasks were found to affect gait characteristics during level walking, such as decreasing speed, cadence, step length, etc. Given that many accidents occur during stair negotiation and people often perform cognitive tasks concurrently with stair negotiation in daily life, there is a need to study how cognitive tasks affect gait characteristics and postural stability during stair negotiation. This study aimed to determine cognitive task effects on lower-extremity kinematics and postural stability during stair negotiation. We also examined the difference in cognitive demands between ascent and descent.

Methods

Two cognitive tasks, i.e. ‘backward digit recall’ and ‘counting backward in threes’, were examined. There were three testing conditions corresponding to a baseline and the two cognitive tasks, respectively. In the baseline, no cognitive task was performed. In the cognitive task conditions, the cognitive task was performed continuously throughout the stair negotiation trial. Each participant performed six ascent trials and six descent trials under each testing condition. We measured the cognitive task performance. Lower-extremity kinematics and postural stability were calculated using the data collected from a complete stair gait cycle that was obtained for the dominant leg.

Findings

In general, concurrent cognitive tasks had adverse effects on lower-extremity kinematics and postural stability during both ascent and decent. No differences in dependent measures were found between cognitive tasks. Additionally, ascent and descent appeared to be equally cognitively demanding.

Interpretation

The findings from this study can help better understand inadequate postural reactions due to cognitive load that may cause stair accidents.     

Trunk and lower limb biomechanics during stair climbing in people with and without symptomatic femoroacetabular impingement

BackgroundFemoroacetabular impingement is a pathomechanical hip condition leading to pain and impaired physical function. It has been shown that those with femoroacetabular impingement exhibit altered gait characteristics during level walking and stair climbing, and decreased muscle force production during isometric muscle contractions. However, no studies to-date have looked at trunk kinematics or muscle activation during dynamic movements such as stair climbing in this patient population. The purpose of this study was to compare biomechanical outcomes (trunk and lower limb kinematics as well as lower limb kinetics and muscle activation) during stair climbing in those with and without symptomatic femoroacetabular impingement.MethodsTrunk, hip, knee and ankle kinematics, as well as hip, knee and ankle kinetics and muscle activity of nine lower limb muscles were collected during stair climbing for 20 people with clinical and radiographic femoroacetabular impingement and compared to 20 age- and sex-matched pain-free individuals.FindingsThose with femoroacetabular impingement ascended the stairs slower (effect size = 0.82), had significantly increased peak trunk forward flexion angles (effect size = 0.99) and external hip flexion moments (effect size = 0.94) and had decreased peak external knee flexion moments (effect size = 0.90) compared to the control group.InterpretationFindings from this study indicate that while those with and without femoroacetabular impingement exhibit many biomechanical similarities when ascending stairs, differences in trunk forward flexion and joint kinetics indicate some important differences. Further longitudinal research is required to elucidate the cause of these differences as well as the clinical relevance.     

Effect of balance training on postural balance control and risk of fall in children with diplegic cerebral palsy

Abstract

Purpose: The purpose of this study was to evaluate the effects of balance training on postural control and fall risk in children with diplegic cerebral palsy. Methods: Thirty spastic diplegic cerebral palsied children (10–12 years) were included in this study. Children were randomly assigned into two equal-sized groups: control and study groups. Participants in both groups received a traditional physical therapy exercise program. The study group additionally received balance training on the Biodex balance system. Treatment was provided 30?min/d, 3?d/week for 3 successive months. To evaluate the limit of stability and fall risk, participated children received baseline and post-treatment assessments using the Biodex balance system. Overall directional control, total time to complete the test, overall stability index of the fall risk test and total score of the pediatric balance scale were measured. Results: Children in both groups showed significant improvements in the mean values of all measured variables post-treatment (p?<?0.05). The results also showed significantly better improvement in the measured parameters for the study group, as compared to the control group (p?<?0.05). Conclusion: Balance training on Biodex system is a useful tool that can be used in improving postural balance control in children with diplegic cerebral palsy.

• Implications for Rehabilitation

• Postural problems play a central role in the motor dysfunction of children with diplegic cerebral palsy.

• Balance control is important in the competence in the performance of most functional skills.

• The Biodex Balance System is an important balance assessment and training tool.

• Balance training in children with cerebral palsy can improve performance in postural control.

     

Long-term locomotor training for gait and balance in a patient with mixed progressive supranuclear palsy and corticobasal degeneration

BACKGROUND AND PURPOSE: Progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD) are slowly progressive tauopathies characterized by impaired balance, disturbances in gait, and frequent falls, among other features. Wheelchair dependence is an inevitable outcome in people with these disorders. Insufficient evidence exists regarding the effectiveness of exercise in the management of people with these disorders. This case report describes a program of exercise and long-term locomotor training, using a treadmill (both with and without body-weight support), to reduce falls and improve the balance and walking ability of a patient with mixed PSP and CBD features. CASE DESCRIPTION: Six years after diagnosis with mixed PSP and CBD features, the client, a 72-year-old dentist, was seen for physical therapy for asymmetric limb apraxia, markedly impaired balance, and frequent falls during transitional movements. INTERVENTION: Over a 2.5-year period, intervention included routine participation in an exercise group for people with Parkinson disease (mat exercise and treadmill training) and intermittent participation in individual locomotor training on a treadmill. The exercise group met for 1 hour, twice weekly. The individual treadmill sessions lasted 1 hour, once weekly, for two 14-week periods during the follow-up period. OUTCOMES: Over the 2.5-year period, fall frequency decreased, and tests of functional balance showed improved limits of stability (functional reach tests) and maintained balance function (Berg Balance Scale). Tests of walking performance showed only slight declines. A 4-wheeled walker was introduced and accepted by the client early in the intervention period. The client, with supervision, remained ambulatory with this wheeled walker in the community. DISCUSSION: In this case report of a person with mixed PSP and CBD features, a physical therapy intervention, which included locomotor training using a treadmill and a long-term exercise program of stretching and strengthening, appears to have improved some dimensions of balance, slowed the rate of gait decline, prevented progression to wheelchair dependence, and decreased falls. Contrary to the expected decline in function, this client maintained independent mobility over a 2.5-year period. An ongoing, intensive program of exercise and locomotor training may help people with PSP and CBD maintain upright balance, decrease falls, and decrease the rate of decline of ambulation.     

Hip, knee, ankle kinematics and kinetics during stair ascent and descent in healthy young individuals

BACKGROUND: Few studies have reported the biomechanical aspects of stair climbing for this ergonomically demanding task. The purpose of this ethically approved study was to identify normal functional parameters of the lower limb during stair climbing and to compare the actions of stair ascent and descent in young healthy individuals. METHODS: Thirty-three young healthy subjects, (16 M, 17 F, range 18-39 years) participated in the study. The laboratory staircase consisted of four steps (rise height 18 cm, tread length 28.5 cm). Kinematic data were recorded using 3D motion analysis system. Temporal gait cycle data and ground reaction forces were recorded using a force platform. Kinetic data were standardized to body mass and height. FINDINGS: Paired-samples t tests showed significantly greater hip and knee angles (mean difference standard deviation (SD): hip 28.10 degrees (SD 4.08), knee 3.39 degrees (SD 7.20)) and hip and knee moments (hip 0.25 Nm/kg (SD 0.18), knee 0.17 Nm/kg (SD 0.15)) during stair ascent compared to descent. Significantly greater ankle dorsiflexion angles (9.90 degrees (SD 3.80)) and plantarflexion angles (8.78 degrees (SD 4.80)) were found during stair descent compared to ascent. Coefficient of variation (mean (SD)) in percentage between repeated tests varied for joint angles and moments, respectively (2.35% (SD 1.83)-17.53% (SD 13.62)) and (4.65% (SD 2.99)-40.73% (SD 24.77)). INTERPRETATION: Stair ascent was shown to be the more demanding biomechanical task when compared to stair descent for healthy young subjects. The findings from the current study provide baseline measures for pathological studies, theoretical joint modelling, and for mechanical joint simulators.     

Hip moments during level walking, stair climbing, and exercise in individuals aged 55 years or older

BACKGROUND AND PURPOSE: Low bone mass of the proximal femur is a risk factor for hip fractures. Exercise has been shown to reduce bone loss in older individuals; however, the exercises most likely to influence bone mass of the proximal femur have not been identified. Net moments of force at the hip provide an indication of the mechanical load on the proximal femur. The purpose of this study was to examine various exercises to determine which exercises result in the greatest magnitude and rate of change in moments of force at the hip in older individuals. SUBJECTS AND METHODS: Walking and exercise patterns were analyzed for 30 subjects (17 men, 13 women) who were 55 years of age or older (X = 65.4, SD = 6.02, range = 55-75) and who had no identified musculoskeletal or neurological impairment. Kinematic and kinetic data were obtained with an optoelectronic system and a force platform. Results. Of the exercises investigated, only ascending stairs generated peak moments higher than those obtained during level walking and only in the transverse plane. Most of the exercises generated moments and rate of change in moments with magnitudes similar to or lower than those obtained during gait. CONCLUSION AND DISCUSSION: Level walking and exercises that generated moments with magnitudes comparable to or higher than those obtained during gait could be combined in an exercise program designed to maintain or increase bone mass at the hip.     

Shoulder and elbow kinematics during the Mallet score in obstetrical brachial plexus palsy

BackgroundThe physical signs of obstetrical brachial plexus palsy range from temporary upper-limb dysfunction to a lifelong impairment and deformity in one arm. The aim of this study was to analyze the kinematics of the upper limb and to evaluate the contribution of glenohumeral and scapulothoracic joints of obstetrical brachial plexus palsy children.MethodsSix children participated in this study: 2 males and 4 females with a mean age of 11.7 years. Three patients had a C5, C6 lesion and 3 had a C5, C6, C7 lesion. They were asked to perform five tasks based on the Mallet scale and the kinematic data were collected using the Fastrak electromagnetic tracking device.FindingsThe scapulothoracic protraction and posterior tilt were significantly increased in the involved limb during the hand to mouth task (p = 0.006 and p = 0.015 respectively). The scapulothoracic Protraction/glenohumeral Elevation ratio was significantly increased in the involved limb during the hand to neck task (p = 0.041) and the elevation task (p = 0.015). The ratios of scapulothoracic Tilt on the three glenohumeral excursion angles were significantly increased during the hand to mouth task (p ≤ 0.041). The scapulothoracic Mediolateral/glenohumeral Elevation ratio was significantly increased in the involved limb during the elevation task (p = 0.038). The glenohumeral elevation excursion was significantly decreased in the involved limb during the hand to neck task (p < 0.001) and the elevation task (p = 0.0003).InterpretationThis study gives us information about the greater contribution of the scapulothoracic joint to shoulder motion for affected arm of obstetrical brachial plexus palsy patients compared to their unaffected arm. Kinematic analysis could be useful in shoulder motion evaluation during the Mallet score and to evaluate outcomes after surgery.     

Delayed onset of quadriceps activity and altered knee joint kinematics during stair stepping in individuals with knee osteoarthritis

OBJECTIVE: To determine if the electromyographic onset of vastus lateralis and kinematic knee joint motion in individuals with knee osteoarthritis (OA) differs from that of asymptomatic persons, during the task of stair stepping. DESIGN: Cross-sectional. SETTING: University laboratory in Australia. PARTICIPANTS: Twenty-five participants with symptomatic knee OA and 33 asymptomatic controls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Surface electromyography to determine the onset of vastus lateralis activity. Two-dimensional kinematic analysis of sagittal plane knee motion during stance phase of stair ascent and descent. RESULTS: Participants with knee OA showed delayed onset of vastus lateralis activity during stair descent (P<.05) but not ascent. Both groups displayed a similar total range of knee motion. However, during stair descent, participants with OA had less knee flexion during early stance (P<.05) than controls. CONCLUSION: Individuals with knee OA display altered quadriceps function and knee joint kinematics during stair descent. These impairments may have implications for force attenuation across the knee joint and warrant future investigation.     

Vibration perception threshold in relation to postural control and fall risk assessment in elderly

Abstract

Purpose: This study investigates (i) the potential discriminative role of a clinical measure of peripheral neuropathy (PN) in assessing postural performance and fall risk and (ii) whether the integration of a simple screening vibration perception threshold (VPT) for PN in any physical (fall risk) assessment among elderly should be recommended, even if they do not suffer from DM. Method: One hundred and ninety-five elderly were entered in a four-group model: DM with PN (D+; n?=?75), DM without PN (D?; n?=?28), non-diabetic elderly with idiopathic PN (C+; n?=?31) and non-diabetic elderly without PN (C?; n?=?61). Posturographic sway parameters were captured during different static balance conditions (AMTI AccuGait, Watertown, MA). VPT, fall data, Mini-Mental State Examination and Clock Drawing Test were registered. Two-factor repeated-measures ANOVA was used to compare between groups and across balance conditions. Results: The groups with PN demonstrated a strikingly comparable, though bigger sway, and a higher prospective fall incidence than their peers without PN. Conclusions: The indication of PN, irrespective of its cause, interferes with postural control and fall incidence. The integration of a simple screening for PN (like bio-thesiometry) in any fall risk assessment among elderly is highly recommended.

• Implications for Rehabilitation

• The indication of peripheral neuropathy (PN), irrespective of its cause, interferes with postural control and fall incidence.

• Therefore, the integration of a simple screening for PN (like bio-thesiometry) in any fall risk assessment among elderly is highly recommended.

• It might be useful to integrate somatosensory stimulation in rehabilitation programs designed for fall prevention.

     

步态运动学特征及MRI总负荷与脑小血管病步态障碍患者跌倒风险的相关性研究

目的：采用Logistic回归分析和ROC曲线评估步态运动学特征联合MRI总负荷对脑小血管病（cerebral small vessel disease,CSVD）步态障碍患者跌倒风险的预测价值。方法：选取2019年3月1日—2020年3月30日就诊于甘肃省人民医院中法神经康复科诊断为CSVD且以步态障碍为主要症状的43例患者为研究对象,统计临床数据,根据TUG测试时间将所有患者分为高跌倒风险（high risk of falling,HRF;TUG时间≥15s）组和低跌倒风险（low risk of falling,LRF;TUG时间<15s）组,采用Logistic回归分析和ROC曲线评估步态运动学特征联合MRI总负荷对CSVD步态障碍患者跌倒风险的预测价值。结果：研究共纳入43例患者,平均年龄（71.07±8.17）岁。其中女性26例（60.4%）,高血压患者30例（69.8%）,Logistic回归分析显示,在校正年龄和TUG后,步长（OR 0.821,95%CI 0.702—0.959,P=0.013）为CSVD步态障碍患者跌倒风险的独立保护因素,MRI总负荷（OR 4...     

Kinesiophobia,catastrophizing and anticipated symptoms before stair climbing in chronic fatigue syndrome: an experimental study

Purpose: Kinesiophobia and catastrophizing are frequent among people with chronic fatigue syndrome (CFS). This study was aimed at examining (1) whether kinesiophobia, anticipated symptoms and fatigue catastrophizing are related to stair climbing performance in people with CFS; and (2) whether kinesiophobia and fatigue catastrophizing are related to daily physical activity in CFS. Method: Patients with CFS filled in a set of questionnaires, performed a physical demanding task (two floors stair of climbing and descending) with pre-test and post-test heart rate monitoring and immediate post-stair climbing symptom assessment. Real-time activity monitoring was used between the baseline and second assessment day (7 days later). Results: Kinesiophobia and fatigue catastrophizing were strongly related (ρ?=?0.62 and 0.67, respectively) to poorer stair climbing performance (i.e. more time required to complete the threatening activity). Kinesiophobia and fatigue catastrophizing were unrelated to the amount of physical activity on the first day following stair climbing or during the seven subsequent days. Conclusion: These findings underscore the importance of kinesiophobia and fatigue catastrophizing for performing physical demanding tasks in everyday life of people with CFS, but refute a cardinal role for kinesiophobia and fatigue catastrophizing in determining daily physical activity level in these patients.

Implications for Rehabilitation

• People with chronic fatigue syndrome (CFS) can easily perform stair climbing, a daily physical activity perceived by themselves as threatening, without triggering symptom flares. This is important as it can be used clinically to convince people with CFS of undertaking such a threatening task during treatment programs such as graded activity or graded exposure.

• The finding that kinesiophobia and fatigue catastrophizing are strongly related to stair climbing performance in CFS underscores the importance of restructuring the beliefs of these patients about the relationship between activity and symptoms. This should be a key component of the early stages of rehabilitation for people with CFS.

• In rehabilitation practice, diminishing kinesiophobia and fatigue catastrophizing in patients with CFS appears only relevant for targeting physical activities that are perceived as threatening (e.g. stair climbing), and not for increasing work-related or social (physical) activities.

• Clinicians can use the Tampa Scale Kinesiophobia version CFS for assessing the fear of patients with CFS to exacerbate their symptoms (including pain, fatigue and brain fog) due to physical activities.

• Clinicians can use the Tampa Scale fatigue for assessing the fear of patients with CFS to exacerbate their fatigue level due to physical activities.

     

Test–retest reliability of the IDEEA system in the quantification of step parameters during walking and stair climbing

The aim of this investigation was to evaluate the inter‐ and intra‐session reliability of spatio‐temporal gait variables collected during walking and stair climbing with the Intelligent Device for Energy Expenditure and physical Activity (IDEEA) accelerometer‐based system. Eighteen healthy subjects (10 men, 8 women) completed a standardized indoor circuit comprised of walking and stair climbing. Intra‐and inter‐session reliability was investigated for several pertinent spatio‐temporal gait variables using intraclass correlations [ICC (3,1)]. Intra‐session reliability during walking showed a high reliability of the IDEEA with ICCs ranging between 0·84 (number of steps) and 0·97 (single limb support/double limb support). The ICCs for stair climbing were slightly lower than those during walking with values ranging between 0·74 (step duration) and 0·92 (number of steps). Inter‐session reliability during walking showed a high reliability of the IDEEA between all trials, with values ranging between 0·87 (speed) to 0·98 (step duration). The ICCs of stair climbing were again lower than those during walking with values ranging from 0·64 (swing duration) to 0·79 (number of steps). The IDEEA accelerometer‐based system provided a highly reliable measurement of spatio‐temporal variables, in healthy subjects, during walking with moderately reduced correlations during stair climbing.     

Factors associated with stair climbing ability in patients with knee osteoarthritis and knee arthroplasty: a systematic review

Abstract

Purpose: People with knee osteoarthritis (OA) report ongoing limitations in climbing stairs, even after total knee arthroplasty (TKA). The aim of this systematic review was to synthesise the available evidence of factors affecting stair climbing ability in patients with knee OA before and after TKA. Method: A systematic search was conducted of common electronic databases. All English language abstracts where stair-climbing was assessed in patients with either knee OA or at least 6 months after TKA, and a relationship to any physical, psychological or demographic factors was reported. Results: Thirteen studies were included in the final review, nine investigated a knee OA population, and four investigated a TKA population. For patients with knee OA there was consistent and convincing evidence that greater stair-climbing ability was related to stronger lower limb muscles and less knee pain. For patients with TKA there was much less research, and no conclusions could be reached. Conclusions: For people with knee OA there is evidence that some physical, demographic and psychosocial factors are related to stair-climbing ability. However, the evidence for similar relationships in the TKA population is scarce and needs more extensive research.

• Implications for Rehabilitation

• People with knee osteoarthritis experience difficulty when climbing stairs, and this remains challenging even after knee replacement.

• For people with knee osteoarthritis, a range of physical, demographic and psychosocial factors contribute to stair-climbing ability, however, evidence for similar relationships in the TKA population is scarce.

• Rehabilitation that is multi-faceted may be the best approach to improve stair-climbing in people with knee osteoarthritis.