Evaluation and Treatment of the Geriatric Patient with Neurological Impairments in the

Acute Rehab Setting

Erin Boyle, PT, DPT

Board-Certified Geriatric Clinical Specialist

ObjectivesTo list the signs/symptoms of Miller-Fisher Syndrome (MFS)

To verbalize the importance of evidence-based practice and perform a thorough literature search.

To provide examples of various high-level interventions that may be performed on a geriatric patient.

To demonstrate the use of standardized tests in the clinic.

To elicit clinical decision making in regards to the use of assistive devices.

Patient M: 72 yo male transferred to UPMC Mercy on 3/18/15 with variant of Guillain-Barre Syndrome (GBS).

Chief Complaint: double vision in R eye, unsteady gait, LE weakness

Of note: pt reports a bad cold which resolved 3 days prior to onset of symptoms

Physical Therapy Evaluation (3/29/15):HPI:◦Miller Fisher Variant of GBS

PMH:◦Astroglioma x 2 s/p resection (1990s)◦CAD s/p stent◦HTN◦HLD◦BPH

Physical Therapy EvaluationChief Complaint:◦“Double/Foggy Vision”

Cognition:◦Impaired safety awareness◦Impulsive

Pain:◦8/10 R Forearm “Burning”

Physical Appearance:◦Well-nourished male◦Wide eyes◦R eye ptosis◦Forward head posture◦Thoracic kyphosis

Physical Therapy Evaluation

Home Set-Up:◦2 story (split level) house with his wife

PLOF:◦Completely independent

Denies recent falls

R handed

Employment:◦Retired investor

Leisure Activities:◦Watching TV◦Reading

Physical Therapy Evaluation

ROM:◦WNL B UE / LE

Strength:◦Grossly 4/5 B UE / LE

Sensation:◦Intact bilaterally UEs and LEs

Balance:◦Seated balance: S EOB sit unsupported◦Standing balance: ModA for static stance x 30 seconds

◦Berg Balance 15/56 (3/31/15)

Physical Therapy Evaluation:

Oculomotor Exam:◦Impaired convergence, divergence◦Impaired ROM / weakness (R>L)◦Saccadic movement impaired B◦Smooth pursuit impaired B

Coordination:◦Fine Motor - Finger to thumb; finger to nose – WNL◦Gross coordination – heel to shin – impaired bilaterally

Physical Therapy Evaluation:Transfers:◦Sup<>Sit = Supervision◦Sit<>Stand = MinA

Ambulation:◦25’ without AD ModAx1 HHA and w/c follow

Stair Negotiation:◦Deferred on eval 2’ safety concerns

Vital Signs:◦HR: 62◦BP: 156/70 mmHg◦Pulse Ox 99% on room air

Physical Therapy Evaluation: Short Term Goals:

◦Sup<>Sit Mod I

◦Sit<>Stand with S

◦Ambulate on Level Surfaces 100’ with LRD MinA for safe household ambulation

◦Negotiate 4 stairs with B HR MinA

Physical Therapy Evaluation

Long Term Goals:◦Sup<>Sit I◦Sit<>Stand Mod I◦Ambulate on Level Surfaces >150’ with LRD Mod I for safety in the home and the community◦Negotiate 12 stairs with 1 HR Mod I for safe entry into the home and community navigation◦Negotiate curb step with LRD Mod I for safe community navigation◦Perform car transfer Mod I for safe discharge and transportation

What is Miller Fisher Syndrome?

Miller Fisher Syndrome (MFS) is a variant of Guillain-Barre syndrome (GBS) that is characterized by ophthalmoplegia, ataxia, and areflexia.

POC Based on Evidence3 studies support the following: ● Continued PT is beneficial in GBS.● High-intensity rehab programs reduce disability in

GBS.● Functional outcomes and Quality of life were

improved by PT in those with GBS.

(Davidson, I et al. 2009) (Mhandi, et al. 2007) (Khan, et al. 2011) (Garssen, MP 2004)

POC Based on Evidence

Don’t treat the disease

Treat the patient!

ICF ModelHealth Condition

Miller Fisher Syndrome

Body Function & Structures Activity Participation

Environmental Factors Personal Factors

Driving, Reading, Watching TVBed Mobility, Ambulation, StairsDizziness, Double Vision, Weakness, Fatigue, Balance

Wife, Children, 2 Story Home, Wheeled Walker

Coping skills, Compliant with HEP, Motivated to return to Independence

April 2nd 2015 (4 Days Later):

Double vision:◦Still present at objects of > 1 ft. distances

Transfers:◦Sit<>Stand MinA

Ambulation:◦150’x2 MinA, HHA without w/c follow◦Carpet 25’x4 MinA, HHA without LOB

Stair Negotiation: ◦4 with B HR MinA step-to gait pattern◦Curb step ModA with HHA

Interventions:

Ther Ex:◦NuStep◦Sit<>stand without use of UEs◦Mini Squats

Balance:◦Static stance◦Ball rotations laterally◦Standing ball toss◦4” step taps◦Side-stepping◦Ambulation with head turns◦Obstacle course

Evidence to Support Balance Interventions:“Exercise programs significantly improve balance and mobility in patients with balance problems, independent of strategy.” (Steadman, et al)

“Our intervention can improve functional performance and protect against falls and fall-related injuries.” (Means, et al)

“Progressive resistance training and progressive functional training are safe and effective methods of increasing strength and functional performance.” (Hauer, et al)

Interventions:Non-Supported Gait Training:◦80’x1 S->ModA able to self-correct LOB ~25% of the time

Vestibular:◦Horizontal and Vertical Saccades◦Horizontal and Vertical Smooth Pursuit◦Until Fatigue with frequent rest breaks

Non-Supported Gait Training: What is it?◦“Nonsupported gait training uses error-driven learning, high challenge, and high-repetition task practice to train walking skills without the use of equipment.”

(Perry, et al. 2014)

Non-Supported Gait Training:

How do you implement NSGT?◦The patient takes 1 or 2 steps without external support◦EXTREMELY close supervision◦Allow loss of balance◦Only take a few steps at a time◦Continue with reciprocal gait pattern as able◦Minimal verbal instruction (Perry, et al. 2014)

Literature to Support NSGT: ● Task-specific practice

● Increased time spent in therapy

● Limiting variability through physical constraints of

robotic assistive devices for walking may reduce

error signals to the nervous system(Perry, et al. 2014)

Week 2 (4/6/15)Transfers:◦Sup<>sit and sit<>stand with supervision

Ambulation:◦100’x2; 150’x1 MinA for steadying

Week 2 (4/6/15)Stair Negotiation:◦16 stairs with B HR supervision using reciprocal gait pattern◦8 stairs with 1 HR supervision using reciprocal gait pattern◦Curb Step MinA, HHA

Obstacle Course

Foam

Week 2 (4/6/15)Berg Balance Scale:◦Increased to 29/56 (from 15/56 on 3/31/15)◦Remains fall risk (<45) but minimal detectable change met (4.6)

Oculomotor HEP:◦VOR 1&2◦Smooth Pursuit◦Saccades

Implementation of Assistive Devices4/8/15:◦Initiated ambulation with standard cane ◦MinA and VCs for sequencing required.◦175’ MinA with std cane

4/9/15:◦Initiated amb with WW◦Max education for safety/sequencing/hand placement◦175’ close S with WW

Implementation of Assistive DevicesTherapist- “How do you feel about using this walker at home because it allows you to be independent until you get more return of function?”

Patient- “There’s no way in #*! I’m going to use that!”

Gait without WW

What Do You Do???

VS.

Assistive Devices: Things to consider:◦Device use compliance◦Allowing for increased SAFE mobility

Do they CAUSE falls?◦“The incidence of falls and recurrent falls was not associated with the use of multiple devices or any particular type of mobility device” (Gell, 2015. JAGS)

The Next Day (4/10/15)...After the first walk of the morning without a device-◦(PT trying to be more hands off and allow patient to lose balance)

“Maybe I should try that walker thing.”

Week 3 (4/13/15) Improved saccadic eye movements, smooth pursuit, and VORx1

Ambulation:◦150’ without AD, MinA when turning◦200’x2 Supervision with WW

Stair Negotiation:◦12 stairs using R HR ascend and L HR descend with Supervision

Gait With Walker

Obstacle Course

Day of Discharge (4/14/15)Evaluation (3/31/15) Discharge (4/14/15)

Transfers Min Assist Modified Independent

Ambulation 25’ without an AD, Mod Assist 150’ with WW, Supervision

Stair Negotiation

Deferred 12 with 1 HR, Supervision

Berg Balance Scale

15/56 34/56

Day of Discharge (4/14/15)HEP:◦Standing TE Program◦Oculomotor Exercises

D/C Instructions:◦HANDS with transfers◦Use WW when alone◦Do not negotiate stairs alone

Conclusion:Challenge your older patients

Utilize evidence based practice as much as possible

Use your clinical judgement when prescribing assistive devices

QUESTIONS??????

References Perry, et al. Supporting clinical practice behavior change among neurologic physical therapists: A case study in knowledge translation. NJPT. 38: (134-143). April 2014. Carey JR, Kimberley TJ, Lewis SM, et al. Analysis of fMRI and finger tracking training in subjects with chronic stroke. Brain. 2002;125(pt 4): 773-788. Nudo RJ, Milliken GW, Jenkins WM, Merzenich MM. Use-dependent alterations of movement representations in primary motor cortex of adult squirrel monkeys. J Neurosci. 1996;16:785-807. Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? Arch Phys Med Rehabil. 2005;86(12) (suppl): 101-114. Hornby TG, Campbell DD, Kahn JH, Demott T, Moore JL, Roth HR. Enhanced gait-related improvements after therapist- versus robotic-assisted locomotor training in subjects with chronic stroke : a randomized controlled study. Stroke. 2008;39:1786-1792. Hidler J, Nichols D, Pelliccio M, et al. Multicenter randomized clinical trial evaluating the effectiveness of the lokomat in subacute stroke. Neurorehabil Neural Repair. 2009;23:5-13. Mhandi LE, Calmels P, Camdessanché JP, Gautheron V, Féasson L. Muscle Strength Recovery in Treated Guillain-Barré Syndrome. American Journal of Physical Medicine & Rehabilitation. 2007; 86 (9): 716-724 Khan F, Pallant JF, Amatya B, Ng L, Gorelik A, Brand C. Outcomes of high- and low-intensity rehabilitation programme for persons in chronic phase after Guillain-Barré syndrome: a randomized controlled trial. Journal of Rehabilitation Medicine 2011 Jun; 43(7):638-646Brown, et al. Physical Therapy for Central Vestibular Dysfunction. Archives of PM&R Volume 87, Issue 1. January 2006: 76-81.

Lammers, et al. Defining Dizziness: An Acute Approach to Vestibular Dysfunction in the Hospital Setting. CSM 2017.

ReferencesGarssen MP, Bussmann JB, Schmitz PI, Zandbergen A, Welter TG, Merkies IS, et al. Physical training and fatigue, fitness, and quality of life in Guillain-Barre syndrome and CIDP. Neurology 2004; 63: 2393–2395. Khan F, Ng L, Amatya B, Brand C, Turner-Stokes L. Multidisciplinary care for Guillain-Barré syndrome. Cochrane Database of Systematic Reviews 2010, Issue 10 Hughes, R, Cornblath, D. Guillain Barre Syndrome. Lancet 2005; 366: 1653-66. Mullings, K, et al. Rehabilitation of Guillain-Barre Syndrome. DM 2010. 288-292. Davidson I, Wilson C, Walton T, Brissenden S. Physiotherapy and Guillain–Barré syndrome: results of a national survey. Physiotherapy 2009; 95:157–163.

Gell, et al. Mobility device use in older adults and incidence of falls and worry about falling: Findings from the 2011-2012 national health and aging trends study. JAGS. 63:853–859, 2015

Aranyi, et al. Miller Fisher syndrome: brief overview and update with a focus on electrophysiological findings. European Journal of Neurology, 19: 15–20. 2012.

Steadman, Et Al. A Randomized Controlled Trial of an Enhanced Balance Training Program to Improve Mobility and Reduce Falls in Elderly Patients. J Am Geriatr Soc 51:847–852, 2003Means, et al. Balance, Mobility, and Falls Among Community-Dwelling Elderly Persons Effects of a Rehabilitation Exercise Program. Am. J. Phys. Med. Rehabil. Vol. 84, No. 4 Huer, et al. Exercise Training for Rehabilitation and Secondary Prevention of Falls in Geriatric Patients with a History of Injurious Falls. J Am Geriatr Soc 49:10–20, 2001.Brown, et al. Physical Therapy for Central Vestibular Dysfunction. Archives of PM&R Volume 87, Issue 1. January 2006: 76-81.

Thank You!