Rotation 3 Fourth Year - Evidence Based Practice STARES

Situation
A 61 year old man was admitted to Hollywood Private Hospital rehabilitation ward for two weeks elective respite and rehabilitation. He presented with a 21 month history of severe Guillain Barre Syndrome, post-infection in July 2008.

He had spent 7 months in Sir Charles Gardener Hospital initially where he was intubated 6 days post the onset of his symptoms and remained so until January of 2009. He had lost complete use of his upper and lower limbs until September 2008 when he regained a minimal amount of strength. He was completely dependent for all activities of daily living and experienced a number of pulmonary complications during this time including pneumonia and a pulmonary embolism.

In February 2009 he was transferred to Shenton Park where he underwent extensive rehabilitation. It was during this time that he regained a large amount of strength and functional ability. When he was discharged in September 2009 he had independent bed mobility, x2 assist sit-to-stand and step-stand transfer and could operate an electric wheelchair independently. He had very little use of his upper limbs due to decreased strength in his arms and minimal use of his hands due to contractures at the fingers and weakness. He was however able to eat independently and use a modified computer set-up independently.

Currently he is receiving private physiotherapy twice a week (neurological and musculoskeletal) and attending Shenton Park outpatient department physiotherapy twice a week. He also receives private OT and help with showering and toileting twice daily from an outside carer. All other care is provided by his wife.

To give his wife a break he elected to spend 2 weeks at Hollywood Private Hospital where he felt he could also have intensive physiotherapy rehabilitation as well.

Task
My task was to assess and treat this patient accordingly.

Action
This patient had two main goals; to walk independently with an aid ~15m in his home and to regain the use of his upper limb to decrease his dependence on people with his activities of daily living. I therefore focused my treatment towards these goals. Whilst I did do some treatment to assist with his upper limb function, I decided to focus on his goal of ambulation, as he had recently begun to ambulate x2 maximum assistance at Shenton Park outpatient department.

Whilst ambulating the patient with 2 therapists we noticed how cumbersome and dangerous the task was. The patient weighed over 100kg and was very unpredictable in the way in which he moved his weight around. This was due mainly to his lack of core and hip stability. It was therefore important to find a task-specific treatment method for this patient that maintained the safety of the therapists involved. It was important that whilst safety was a high priority, the treatment of the patient was as specific as possible.

In my research I found the article:

Tuckey, J., Greenwood, R. (2004) ‘Rehabilitation after severe Guillain-Barré syndrome: the use of partial body weight support’. Physiotherapy Research International. 9 (2), 96-103.

It is a case report outlining the use of partial body weight support treadmill training in a man with severe chronic Guillain Barre Syndrome. It uses the evidence supporting partial body weight support (PBWS) treadmill training in other clinical populations such as stroke and spinal injury to justify its use in Guillain Barre and then follows the rehabilitation of this man to show its usefulness.

It outlines the fact that PBWS could allow task-specific gait training for patients in which purely therapist assisted ambulation is too cumbersome and poses a manual handling risk. This was especially poignant for our patient as he had decreased core stability which didn’t allow him to focus on the motor sequence of gait and the activation of his lower limb muscles. It also allowed the therapist to facilitate muscle activation instead of focusing on maintaining the patient upright and on balance.

It was then decided after a week of treatment focusing on his core and hip stability that the second week would include daily sessions on the PBWS treadmill system. It did take some trial and error, especially with the timing of the session as the patient was too fatigued for his treatment in the afternoon if he had been on the treadmill in the morning. Different facilitation methods were trialled but eventually it was found that one therapist was required at the trunk to facilitate trunk stability and weight transfer and one therapist was required at each leg to facilitate gluteal activation and knee extension.

Result
By the end of the two weeks, both on and off the treadmill, the patient was walking with improved core and hip stability, less trendelenburg signs in stance, less adduction of the leg in swing phase, larger stride length and a more rhythmical cadence. Whilst his dependence on the therapists during off-treadmill ambulation was still the same his gait pattern was greatly improved.

The patient also felt much more confident and a lot happier with his walking pattern and the psychological benefits of getting closer to his goal was definitely evident.

Evaluation
It is a hard balance to determine if low level evidence is reliable or not, especially in a clinical population as small as Guillain-Barre. However I think that it is important to extrapolate from evidence those benefits they may be useful for your patients and think outside the box. I believe that even if the case report did not exist I still would have chosen the PBWS treadmill training as a treatment due to strong evidence for task-specific training and the added benefits it gave in terms of safety of the patient and therapists and the ability to facilitate gait much more thoroughly than off the treadmill.

My one concern is that it was only one week of training and he may loose those benefits quite quickly. It has been shown that training such as this requires a program of at least six weeks for any long-term benefit, so the improvement may be short lived.

It may however open the door for Shenton Park or one of his private physiotherapists to offer the same treatment to him on a regular basis. I have sent a discharge letter to them to let them know what treatment the patient did receive here during his stay.

Strategies
I think the most important strategy here is to think outside the box and always remember that ‘a lack of evidence is not evidence of lack’ as people commonly say. If you can clinically reason a treatment choice that has been shown to help in another clinical population then there is no harm in trying as long as there is no risk to you or the patient. The evidence out there really did help to guide my treatment choice and made it an informed and reasoned one. It really does enforce the need to stay on top of the evidence once we have graduated and are out in the real world.