Patient information
This case report describes the course of a 67-year-old male patient diagnosed with PD and MS who visited our rehabilitation hospital for intensive neurorehabilitation two times within the last year.
The patient lives with his wife in a flat. He worked as a consultant in a private company before his disease symptoms, especially fatigue and muscle weakness (tetra-paresis due to MS), forced him to retire 21 years ago (in 1999). The patient was a recreational musician, but stopped his activities due to the disease-related impairments, e.g. manual dexterity. Currently, he likes listening to audiobooks and he enjoys doing administrative work for his family and neighbours. He used to attend a support group for people with MS, but quit some years ago. The patient reports no other structured social activities except for close contact to his family, friends and neighbours.
The following diagnoses have been confirmed at hospital admission in October 2019 and in May 2020:
- Parkinson’s disease of the akinetic-rigid subtype and with left-sided predominance. Disease severity as rated with the Hoehn and Yahr scale was 4 out of 5 [16]. The first PD-specific medication was prescribed in 2015.
- Relapsing-remitting Multiple Sclerosis with a secondary progressive course. First MS specific medication in 1988, confirmed diagnosis in 1992. The last relapse took place in June 2016.
- Diabetes mellitus type 2.
- Arterial hypertension.
- Urinary retention and incomplete bladder emptying.
- State after right-sided L3 pain syndrome due to a foraminal/extraforaminal disc hernia at lumbar vertebrae 3/4. Microsurgical herniotomy L3 on the right side in September 2011.
The main symptoms of the patient were related to PD, MS and his low back pain syndrome. Clinical examination revealed bradykinesia of the limbs, while no significant rigidity or rest tremor were observed. The patient reported motor fluctuations including off-periods and dyskinesia. He featured a complex gait disorder with hypokinetic and spastic-ataxic elements. Besides he suffered from postural instability and freezing of gait episodes. The main physical MS-specific symptoms were tetra-paresis, fatigue and trouble with sensation and coordination. The main activity limitations were related to mobility (transferring, walking stability, walking endurance, stair climbing, balance).
The patient received a combination therapy consisting of levodopa/benserazide (Madopar® LIQ 62.5, Madopar® DR 250), levodopa/carbidopa/entacapone (Stalevo®) and pramipexole (Sifrol® ER) for treatment of PD. During the 1st reported stay in our hospital the daily dosage of levodopa was reduced by 150 mg. During the 2nd stay daily dosage of levodopa was increased by 150 mg and that of pramipexole by 0.75 mg. Motor fluctuations improved by the adjustments of the pharmacological therapy. The MS-specific medication consisted of 44 μg interferon beta-1a (Rebif®) three times per week and has been unchanged for several years.
Since the patient was diagnosed with PD in 2015, he had visited our clinic already several times for intensive inpatient rehabilitation, as prescribed by his general practitioner.
Timeline
The complete timeline of the patient is illustrated in Figure 1.
First inpatient rehabilitation (October 2019)
On 4 September 2019, the patient fell and fractured 3 ribs on the right side. The fractures were treated conservatively, but within the following weeks, the patient experienced significant deterioration in physical functioning, mobility and functional independence. Thus, he presented to his general practitioner who referred him for intensive inpatient rehabilitation to our neurological rehabilitation hospital. The patient visited the hospital for 4 weeks, starting 13 October 2019 until 9 November 2019. He was discharged home and referred to regular outpatient physiotherapy two times per week.
Outpatient rehabilitation and COVID-19 related interruption (November 2019 until May 2020)
From 10 November 2019 on, the patient lived in his home and participated in the prescribed regular outpatient rehabilitation. On 16 March 2020, a lockdown was federally directed in Switzerland due to the COVID-19 pandemic, including severe restrictions on outpatient rehabilitation services. Physiotherapy practices were only allowed to offer very limited outpatient services during the lockdown. Physiotherapy interventions for chronic neurological conditions were not considered ‘urgent’ and usually not allowed during the lockdown. Thus, the patient paused his outpatient rehabilitation for 6 weeks. Over this period of time, the patient experienced significant deteriorations in physical functioning and functional independence.
On 27 April 2020, outpatient physiotherapy services and practices were allowed to re-open and on 5 May 2020, the patient had his first physiotherapy session after the start of the lockdown. He had two physiotherapy sessions per week, but failed to regain his functional abilities that he lost during the COVID-19-related interruption of his rehabilitation process.
Second inpatient rehabilitation (May 2020)
The patient re-attended our hospital for intensive inpatient rehabilitation, starting 25 May 2020 and ending 19 June 2020 (4 weeks). After discharge, the patient received outpatient physiotherapy services two times a week. We did not follow-up the patient after discharge.
Diagnostic assessment
At hospital admission, the patient was assessed with a broad set of generic and disease-specific measures of physical functioning and mobility as part of the physiotherapy treatment. All assessments were performed during the on-state. The clinical outcome assessments are described in the following section.
Therapeutic intervention
First inpatient rehabilitation (October 2019)
The 1st inpatient rehabilitation stay (4 weeks) was prescribed to improve the patient’s mobility, walking distance and physical functioning; to reduce fall risk and fear of falling; to improve disease-related symptoms and activity limitations such as MS-related fatigue and PD-related start hesitations; to learn cuing strategies to deal with freezing of gait episodes; to increase quality of life; and to improve functional independence in the activities of daily living.
In the rehabilitation hospital, the patient received multimodal, interprofessional and intensive rehabilitation, according to clinical practice guidelines [4, 5] and accompanied by medical, social and nursing care. The rehabilitation modalities scheduled during this inpatient stay are listed in Table 1. Usually, a therapy session was scheduled for 30 to 45 minutes. On each weekday, the patient was scheduled for three to six interventions, either in single or group-based sessions. Most physical interventions, including physiotherapy, exercise training and resistance training, were prescribed to improve mobility, balance, ambulation, lower extremity muscle strength, physical functioning and functional independence. Occupational therapy was prescribed to improve functioning in daily life and dexterity of the upper limbs. Neuropsychological training aimed to improve cognitive abilities related to the patient’s functioning in daily life.
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Table 1 Overview of rehabilitation modalities received by the patient during his inpatient rehabilitation stays
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Rehabilitation modality
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First inpatient rehabilitation
(4 weeks)
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Second inpatient rehabilitation
(4 weeks)
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Physiotherapie (single)
|
14
|
16
|
|
Exercise and resistance training
|
10
|
1
|
|
Balance training (group-based)
|
10
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0
|
|
Gait training/supervised walking
|
7
|
6
|
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C-Mill †
|
7
|
5
|
|
Physical therapy modalities ‡
|
8
|
6
|
|
Sports and movement therapy (group-based)
|
5
|
4
|
|
Occupational therapy (single)
|
8
|
10
|
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Occupational therapy (group-based)
|
5
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0
|
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MS-Café §
|
2
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0
|
|
Neuropsychological training (single and group-based)
|
6
|
17
|
|
Podiatry
|
1
|
1
|
|
Nutritional therapy
|
0
|
2
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Orthoptics
|
0
|
23
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Speech and language therapy
|
0
|
1
|
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† Treadmill training combined with augmented and virtual reality; ‡ passive interventions such as massages or electric stimulations; § group-based social activities for people with MS
Abbreviations: MS = Multiple Sclerosis
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Outpatient rehabilitation
Regular outpatient physiotherapy was performed two times a week (30-minute session each) to maintain and improve physical functioning, mobility, balance, quality of life, and functional independence in the activities of daily life. The reduction of the patient’s low back pain was a further objective of the prescribed physiotherapy. The main treatment modalities were exercise and resistance training for the lower limbs and the trunk, balance training, massages, manual therapy interventions for the back and shoulders, and gait training, as reported by the outpatient physiotherapists. The selection of modalities was subject to the participant’s current needs and abilities. In addition, the patient performed regular gait training with his wife.
During the lockdown, the patient did not receive any professional rehabilitation interventions, but continued gait training with his wife frequently.
Second inpatient rehabilitation (May 2020)
The 2nd inpatient rehabilitation stay (4 weeks) was prescribed to improve the patient’s safe ambulation, mobility capacity, balance and functional independence, and to regain the functional level that he had prior to the COVID-19-related therapy break. Similar to the first hospital stay, the patient received multimodal, interprofessional and intensive rehabilitation, according to clinical practice guidelines [4, 5]. The extent of rehabilitation modalities scheduled during this inpatient stay is listed in Table 1. The interventions were prescribed to achieve the patient’s functional goals as described above (first inpatient rehabilitation stay). The medication was not changed during the time between the two inpatient rehabilitation visits.
Follow-up and outcomes
Within the regular hospital physiotherapy care, a set of functional outcome assessments was performed with the patient on admission and discharge. During the 2nd inpatient stay, some outcome assessments were repeated weekly to better describe the rehabilitation course. The physical outcome assessments and the patient’s assessment scores are listed in Table 2.
Mobility capacity was assessed with the de Morton Mobility Index (DEMMI; Figure 2) [17–20], the Hierarchical Assessment of Balance and Mobility (HABAM, Figure 3) [21, 22] and the mobility subscale of the Barthel Index (Figure 4) [23]. According to those three outcome assessments, the patient experienced improvements in mobility capacity during the first rehabilitation stay, which deteriorated or remained unchanged over the pandemic-related interruption of outpatient rehabilitation. However, mobility capacity improved over the second hospital stay by 17% (DEMMI), 50% (HABAM) and 20 points (Barthel Index mobility subscale). These improvements are beyond the measurement error of these assessments reported for older adults and can be considered clinically relevant [17, 20, 24].
Ambulation was assessed with the Functional Ambulation Categories (FAC; Table 2) [25]. At hospital admission after the COVID-19-related therapy break, the patient was mobile in a wheelchair for longer distances, but he could only walk for short distances with a rollator and intermittent support of one person to help with balance and coordination (FAC = 2). At discharge, he was able to walk independently with the rollator within the hospital for shorter distances (<300 m; FAC = 4). However, with two crutches (his preferred walking aid), the patient needed stand-by assistance by another person (FAC = 3).
Walking endurance was assessed with the 6-minute walk test [26]. As seen in Table 2, the patient improved his walking distance within 6 minutes by 102 m (improvement of 268 %) and by 98 m (109 %) over the 1st and 2nd rehabilitation stay, respectively. Figure 5 illustrates how the patient deteriorated in the 6-minute walk test after the therapy interruption but then regained his former walking endurance. This improvement can be considered clinically important [27].
Gait speed values (10-meter walking test) of the patient over time are illustrated in Figure 6. The patient improved by 77 % over the 1st inpatient rehabilitation stay, decreased back to his former ability (0.29 m/s) after the rehabilitation interruption and re-improved by 131 % to a gait speed of 0.67 m/s. This value is still very low compared to normative values of older people [28], but the amount of change can be considered clinically important [29].
In addition, we conducted some disease-specific assessments which were not part of standard clinical routine. To assess the level of fatigue, we conducted the Fatigue Severity Scale, a patient-reported outcome assessment [30]. However, no relevant changes were observed in the patient, who reported ‘substantial fatigue’ according to the scale score of 6.7 points [30]. MS-specific disability was assessed with the Expanded Disability Status Scale (EDSS). We did not observe any alterations in EDSS status of the patient, since he ‘required constant bilateral support to walk 20 meters without resting’ at all times (EDSS score of 6.5). Quality of life was assessed with the PD-specific Parkinson's Disease Questionnaire (PDQ-39) [31] and did not change substantially over time.
We do not have sufficient information or objective measures of the patient’s physical functioning or assessment scores prior to hospital admission in October 2019 or from the outpatient physiotherapy. We do not report any assessment scores from other rehabilitation disciplines, such as speech and language therapy or nutritional therapy.
Rehabilitation goals
At hospital discharge in November 2019, the patient was able to walk independently with a rollator within his domestic environment, and he was able to ambulate with 2 crutches when guided by his wife or another person. The maximum walking distance with two crutches was 605 m, which he was able to complete continually within 23 minutes.
The rehabilitation goals for the 2nd inpatient stay were directed by the patient, who aimed for independent ambulation within his house with a walking aid. In addition, the patient enjoys walking with crutches and he reported to aim at “a better gait stability and a long walking distance with crutches”. Since the patient explicitly wished to “regain his pre-pandemic functional abilities”, the mobility-related rehabilitation goals were subjected to the patient’s functional abilities prior to the pandemic and defined as:
- Intermediate goal: After 2 weeks of rehabilitation, the patient walks independently with a rollator in the hospital (FAC score of 4).
- Discharge goal 1: At hospital discharge, the patient walks independently with a rollator in the hospital (FAC score of 4) and the patient is able to walk with 2 crutches under standby-assistance (FAC score of 3).
- Discharge goal 2: At hospital discharge, the patient can walk up to 600 m continually with two crutches (no limitation of time defined).
The patient failed to reach the intermediate rehabilitation goal. Two weeks after hospital admission, he still needed stand-by assistance when he walked with a rollator within the hospital. Concerning discharge goal 1, the patient was able to walk for 200 m with 2 crutches and stand-by assistance or for 300 m with a rollator independently (goal achieved). He failed, however, to reach the discharge goal 2 since he did not reach the maximal walking distance of 600 m with 2 crutches.