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A Weighted Vest Rehabilitation Protocol to Improve Gait in a Patient with Cerebellar Degeneration: A Case Report. Amy Belanger, BS, DPT Student, Kirsten Buchanan, PhD, PT, ATC University of New England, Doctor of Physical Therapy Program, Portland, Maine Background • Cerebellar degeneration (CD) is a rare brain dysfunction that affects motor control. • Ataxia is a common manifestation of CD, defined as the discoordination of the limbs or trunk. • Interventions that have separately been found to be effective when treating ataxia are postural training, comprehensive physical therapy (PT) and weighted vest protocols. 1,2,3,4 • While each of these treatments have individually been shown to decrease ataxia, they have not been used in combination. Case Description • The patient was a 34-year-old female who presented with severe ataxia and impaired mobility. • The patient was previously in good health and worked at the hospital. • The patient was admitted to the inpatient rehabilitation unit for intensive PT, occupational therapy, and speech therapy. • A comprehensive PT program including strengthening, endurance and balance training was utilized. • Additionally, the patient wore a weighted vest and used a weighted walker when participating in transfers, gait training, and functional tasks. • Over 3 weeks, she was seen for 21 visits. • The patient’s personal rehabilitation goal was to return home to her husband and 3-year-old son. Discussion • Studies have investigated the use of weighted vest protocols and comprehensive PT programs separately but not in combination. • After 3 weeks of a combined weighted vest protocol and comprehensive PT program, the patient showed gains in all areas of strength, balance, transfers and gait. • The complexity of her medical condition limited her ability to meet her long-term PT goals of complete independence, however, she was able to return home to her husband and 3-year-old son at discharge. • A limitation of this case report was that 6 different physical therapists treated this patient over the course of her stay. Conclusion • This patient appeared to make improvements in mobility after participating in strength, endurance and balance training and following the use of a weighted vest during functional tasks. • The idiopathic cause of her condition made it difficult to anticipate the expected progression of her disease. • Future studies should investigate the percent of body mass a weighted vest should be to have the most benefit for patients with CD. Purpose The purpose of this case report was to investigate a combined weighted vest protocol and comprehensive PT program for a 34-year-old with cerebellar degeneration. Acknowledgements The author acknowledges Kirsten Buchanan, PhD, PT, ATC, for assistance of case report conceptualization, the clinical instructor Jennifer Tweedie, MSPT, for supervision on the case, and the patient for the willingness to participate in the data collection for this case report. Plan of Care Timeline References 1. Sarva H, Shanker VL. Treatment options in degenerative cerebellar ataxia: a systematic review. Mov Disord Clin Pract. 2014;1(4):291- 298. doi:10.1002/mdc3.12057 2. Duncan P, Studenski L, Gollub S, et al. Randomized clinical trial of therapeutic exercise in subacute stroke. J Am Heart Assoc. 2003;34:2173-2180. 3. Hunt CM, Widener G, Allen DD. Variability in postural control with and without balance-based torso-weighting in people with multiple sclerosis and healthy controls. Phys Ther. 2014;94(10):1489-1498. doi:10.2522/ptj.20130288 4. Noah S, Gibson-Horn C, Vincenzo JL. Four months of wearing a balance orthotic improves measures of balance and mobility among a cohort of community-living older adults. J Geriatr Phys Ther. 2018:1. doi:10.1519/jpt.0000000000000174 5. Weight vest pic: https://www.homedepot.com/p/Pure-Fitness-20-lb-Adjustable-Weighted-Vest-8635WV/204758221?cm_mmc Outcomes Tests & Measures Initial Evaluation Results Discharge Results MMT +3/5 4/5 30 second sitting balance Unable to perform Able to sit for 8 minutes Attention Lethargic, difficulty attending to tasks in busy environment Able to attend to problem solving scenario for 20 minutes FIM 1 Walking 0 Stairs 1 Transfer Toilet 1 Transfer bed/chair/wheelchair 3 Cognition 1 Walking 1 Stairs 6 Transfer Toilet 6 Transfer to bed/chair/wheelchair 6 Cognition Observation Gait Analysis Unable to assess until day 3 Decreased cadence, severe ataxic movements and large base of support Decreased cadence, mild ataxic movements and normal base of support Interventions Week One Week Two Week Three Bed mobility Performed with CGA, use of bed rails, and multiple sequencing cues Performed with supervision and no use of bed rails Distant supervision Transfers Squat pivot w/ minimal assist of 2 and sit to stand in // bars w/ moderate assist of 2 Squat pivot w/ CGA and pt self cueing, sit to stand with FWW and stand step w/ minimal assist of 2 Squat pivot w/ supervision, sit to stand with FWW, and stand step w/ CGA of 1 Therapeutic Exercise LE strengthening and sitting balance with back support LE strengthening, dynamic sitting balance and static standing balance in // bar w/ UE support LE strengthening, dynamic sitting balance, and standing balance in // bar w/o support Family Education Initial team meeting and discharge planning Home Evaluation Her husband provided guarding for squat pivot transfers and toilet transfers Wheelchair mobility UE+LE use w/ minimal assist over 150 ft and w/in pt room Supervision over even and uneven surfaces for 100 ft x3 Independent w/ even and uneven surfaces w/ unrestricted distance Gait Training with weights* 30 ft to 60 ft w/ moderate assist of 2 w/ FWW, w/c follow and seated rest breaks 60 ft to 100 ft w/ minimal assist of 2 w/ FWW and a w/c follow 100 ft x2 w/ CGA of 1 w/ FWW *Weighted Vest Protocol Progressively increased weighted vest from 0 to 30# and weight on walker from 0 to 15# 30# weighted vest + FFW w/ 7.5# ankle weights on the sides of the walker + 1.5 ankle weights around her ankles Slowly decreased weights to 0# Key: CGA= contact guard assist, w/ or W/=with, W/out= without, // bars= parallel bars, pt= patient, FWW= front wheeled walker, LE=lower extremity, UE= upper extremity, ft= feet, #= pounds. Figure 1. 30 pound weighted vest Figure 2. Patient wearing 1.5 pound ankle weights with front wheeled walker with 7.5 pounds on each side Acute care focused on increasing arousal and transfers from bed to chair Presented to ED 3 times Medical Management Physical Therapy Management Extensive testing was inconclusive Admitted with possible dx of meningitis Transferred to larger hospital for higher level of care 4 days after admission 20 days later Patient returns to original hospital’s Inpatient Rehabilitation Unit with the diagnosis of pan cerebellar degeneration The patient was followed by a physiatrist, nursing, a case worker, occupational therapists, speech therapists and physical therapists when in the hospital’s inpatient rehabilitation Rehab day 1 A comprehensive physical therapy program included strength, balance, and endurance exercises. A weighted vest and walker were utilized during transfers, gait training and functional tasks Treatment focused on bed mobility, squat pivot transfers, ambulating with weighted vest/ walker with moderate assistance of 2 Rehab week 2 Rehab week 1 The patient's husband participated in treatment sessions working on safe transfer techniques and final patient education was completed Treatment focused on transfers, wheelchair mobility, and ambulation with weights and with minimal assistance Rehab week 3 Discharge home with referral for Home Health Physical Therapy Ambulating without weights and longer distances was emphasized Onset of illness 10 days after onset 7 weeks post onset

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

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Page 1: 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

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