Amy Belanger, BS, DPT Student, Kirsten Buchanan, PhD, PT

AWeightedVestRehabilitationProtocoltoImproveGaitinaPatientwithCerebellarDegeneration:ACaseReport.

AmyBelanger,BS,DPTStudent,KirstenBuchanan,PhD,PT,ATCUniversityofNewEngland,DoctorofPhysicalTherapyProgram,Portland,Maine

Background• Cerebellardegeneration(CD)isararebraindysfunctionthataffects

motorcontrol.• AtaxiaisacommonmanifestationofCD,definedasthediscoordinationofthelimbsortrunk.

• Interventionsthathaveseparatelybeenfoundtobeeffectivewhentreatingataxiaareposturaltraining,comprehensivephysicaltherapy(PT)andweightedvestprotocols.1,2,3,4

• Whileeachofthesetreatmentshaveindividuallybeenshowntodecreaseataxia,theyhavenotbeenusedincombination.

CaseDescription• Thepatientwasa34-year-oldfemalewhopresentedwithsevere

ataxiaandimpairedmobility.• Thepatientwaspreviouslyingoodhealthandworkedatthehospital.• ThepatientwasadmittedtotheinpatientrehabilitationunitforintensivePT,occupationaltherapy,andspeechtherapy.

• AcomprehensivePTprogramincludingstrengthening,enduranceandbalancetrainingwasutilized.

• Additionally,thepatientworeaweightedvestandusedaweightedwalkerwhenparticipatingintransfers,gaittraining,andfunctionaltasks.

• Over3weeks,shewasseenfor21visits.• Thepatient’spersonalrehabilitationgoalwastoreturnhometoherhusbandand3-year-oldson.

Discussion• Studieshaveinvestigatedtheuseofweightedvestprotocolsand

comprehensivePTprogramsseparatelybutnotincombination.• After3weeksofacombinedweightedvestprotocoland

comprehensivePTprogram,thepatientshowedgainsinallareasofstrength,balance,transfersandgait.

• Thecomplexityofhermedicalconditionlimitedherabilitytomeetherlong-termPTgoalsofcompleteindependence,however,shewasabletoreturnhometoherhusbandand3-year-oldsonatdischarge.

• Alimitationofthiscasereportwasthat6differentphysicaltherapiststreatedthispatientoverthecourseofherstay.

Conclusion• Thispatientappearedtomakeimprovementsinmobilityafter

participatinginstrength,enduranceandbalancetrainingandfollowingtheuseofaweightedvestduringfunctionaltasks.

• Theidiopathiccauseofherconditionmadeitdifficulttoanticipatetheexpectedprogressionofherdisease.

• FuturestudiesshouldinvestigatethepercentofbodymassaweightedvestshouldbetohavethemostbenefitforpatientswithCD.

PurposeThepurposeofthiscasereportwastoinvestigateacombinedweightedvestprotocolandcomprehensivePTprogramfora34-year-oldwithcerebellardegeneration.

AcknowledgementsTheauthoracknowledgesKirstenBuchanan,PhD,PT,ATC,forassistanceofcasereportconceptualization,theclinicalinstructor JenniferTweedie,MSPT,forsupervisiononthecase,andthepatientforthewillingnesstoparticipateinthedatacollectionforthiscasereport.

PlanofCareTimeline

References1. Sarva H,Shanker VL.Treatmentoptionsindegenerativecerebellarataxia:asystematicreview.Mov Disord Clin Pract.2014;1(4):291-

298.doi:10.1002/mdc3.120572. DuncanP,Studenski L,Gollub S,etal.Randomizedclinicaltrialoftherapeuticexerciseinsubacutestroke.JAmHeartAssoc.

2003;34:2173-2180.3. HuntCM,WidenerG,AllenDD.Variabilityinposturalcontrolwithandwithoutbalance-basedtorso-weightinginpeoplewithmultiple

sclerosisandhealthycontrols.Phys Ther.2014;94(10):1489-1498.doi:10.2522/ptj.201302884. NoahS,Gibson-HornC,VincenzoJL.Fourmonthsofwearingabalanceorthoticimprovesmeasuresofbalanceandmobilityamonga

cohortofcommunity-livingolderadults.JGeriatr Phys Ther.2018:1.doi:10.1519/jpt.00000000000001745. Weightvestpic:https://www.homedepot.com/p/Pure-Fitness-20-lb-Adjustable-Weighted-Vest-8635WV/204758221?cm_mmc

OutcomesTests&Measures InitialEvaluationResults DischargeResults

MMT +3/5 4/530secondsittingbalance

Unabletoperform Abletositfor8minutes

Attention Lethargic,difficultyattendingtotasksinbusyenvironment

Abletoattendtoproblemsolvingscenariofor20minutes

FIM 1Walking0Stairs1TransferToilet1Transferbed/chair/wheelchair3Cognition

1Walking1Stairs6TransferToilet6Transfertobed/chair/wheelchair6Cognition

ObservationGaitAnalysis

Unabletoassessuntilday3

Decreasedcadence,severeataxicmovementsandlargebaseofsupport

Decreasedcadence,mildataxicmovementsandnormalbaseofsupport

InterventionsWeekOne WeekTwo WeekThree

Bedmobility PerformedwithCGA,useofbedrails,andmultiplesequencingcues

Performed withsupervisionandnouseofbedrails

Distant supervision

Transfers Squat pivotw/minimalassistof2andsittostandin//barsw/moderateassistof2

Squatpivotw/CGAandpt selfcueing,sittostandwithFWWandstandstepw/minimal assistof2

Squatpivotw/ supervision,sittostandwithFWW,andstandstepw/CGAof1

TherapeuticExercise LEstrengtheningandsittingbalancewithbacksupport

LEstrengthening,dynamicsittingbalanceand staticstandingbalancein//barw/UEsupport

LEstrengthening,dynamicsittingbalance, andstandingbalancein//barw/osupport

Family Education Initialteammeeting anddischargeplanning HomeEvaluation Her husband providedguardingforsquatpivottransfersandtoilettransfers

Wheelchairmobility UE+LEusew/ minimal assistover150ft andw/inpt room

Supervisionover evenandunevensurfacesfor100ft x3

Independent w/evenandunevensurfacesw/unrestricteddistance

Gait Trainingwithweights* 30ft to60ft w/moderateassistof2w/FWW,w/cfollowandseatedrestbreaks

60ft to100ft w/minimalassistof2w/FWWandaw/cfollow

100ft x2w/CGAof1w/FWW

*WeightedVestProtocol Progressively increasedweightedvestfrom0to30#andweightonwalkerfrom0to15#

30#weightedvest+FFWw/7.5#ankleweightsonthesidesofthewalker+ 1.5ankleweightsaroundherankles

Slowly decreasedweightsto0#

Key:CGA=contactguardassist,w/ orW/=with,W/out= without, //bars= parallel bars,pt=patient,FWW=frontwheeledwalker,LE=lowerextremity,UE=upperextremity,ft=feet,#=pounds.

Figure1.30poundweightedvest

Figure2.Patientwearing1.5poundankleweightswithfrontwheeledwalkerwith7.5poundsoneachside

Acutecarefocusedonincreasing

arousalandtransfersfrombedto

chair

PresentedtoED3times

MedicalManagement PhysicalTherapyManagement

Extensivetestingwasinconclusive

Admittedwithpossibledxof

meningitis

Transferredtolargerhospitalfor

higherlevelofcare

4daysafter

admission

20days

later

Patientreturnstooriginalhospital’s

InpatientRehabilitationUnitwiththe

diagnosisofpancerebellar

degeneration

Thepatientwasfollowedbya

physiatrist,nursing,acaseworker,

occupationaltherapists,speech

therapistsandphysicaltherapists

wheninthehospital’sinpatient

rehabilitation

Rehabday

1

Acomprehensivephysicaltherapy

programincludedstrength,balance,

andenduranceexercises.Aweighted

vestandwalkerwereutilizedduring

transfers,gaittrainingandfunctional

tasks

Treatmentfocusedonbedmobility,

squatpivottransfers,ambulating

withweightedvest/walkerwith

moderateassistanceof2

Rehab

week2

Rehab

week1

Thepatient'shusbandparticipatedin

treatmentsessionsworkingonsafe

transfertechniquesandfinalpatient

educationwascompleted

Treatmentfocusedontransfers,

wheelchairmobility,andambulation

withweightsandwithminimal

assistance

Rehab

week3

Dischargehomewithreferralfor

HomeHealthPhysicalTherapy

Ambulatingwithoutweightsand

longerdistanceswasemphasized

Onsetof

illness

10days

afteronset

7weeks

post

onset