View source for An Inpatient Rehabilitation Perspective on Neuromyelitis Optica: Case Report

== Intervention ==
Treatment consisted of a multidisciplinary approach involving PT and OT. Based on his clinical presentation, treatment resembled that of a stroke patient. The patient did not require speech therapy services.

<u>Wheelchair Mobility Training <sup>13</sup></u>

Wheelchair propulsion was trained as a primary means of mobility. Due to L UE and LE weakness, wheelchair propulsion was performed with the R UE and LE. The L LE rested on a standard leg rest during mobility and the L UE rested on a standard arm tray. Initial cuing was required for path finding and sequencing. Wheelchair management including leg and arm rest management was performed with the R UE bilaterally.  

<u>Functional Mobility Training</u>

Functional mobility began with training bilateral bed mobility and squat pivot transfers with handheld assistance. Maximum cuing was required for sequencing and safety initially. Out of bed mobility progressed as tolerance to upright positioning improved. Sit to stands and standing tolerance were initially trained in parallel bars. Sit to stands were progressed to a standard front wheeled rolling walker with L UE platform. The patient required cuing and facilitation for L scapular retraction and depression, L knee and hip extension for upright standing. 

<u>Activities of Daily Living Training <sup>14</sup></u>

The patient presented to IRF with a basic understanding of hemiplegic upper and lower extremity dressing techniques from his previous rehabilitation. The patient initially utilized a reacher and dressing stick for UE and LE dressing. Dressing was progressed without the reacher and dressing stick as the patient improved. A standard sock aid was used for footwear initially but progressed and discontinued as well. Patient began shower training using a standard shower chair for most of the task. A long-handled sponge was used for general washing. As the patient increased standing tolerance, he began using grab bars to maintain standing balance for more of the task. As standing balance improved patient progressed toileting and toilet hygiene as well. He initially attempted to use a general bathroom buddy however eventually discontinued use. 

<u>Gait Training <sup>15-17</sup></u>

Gait training began once the patient demonstrated safe upright standing and comfort with the rolling walker. Training initially began in parallel bars using an overhead body weight supporting harness with L UE and LE assistance and a step-to gait pattern. Gait was progressed to the standard front wheeled rolling walker with L UE platform used during standing. The patient initially presented with L knee buckling, L drop foot, R hip drop during L LE stance and decreased stride length bilaterally. The patient required max cuing and muscle facilitation initially. The patient eventually progressed to the addition of stair training using B rails, stepping up with the R LE and down with the L LE on each step. 

<u>Therapeutic Exercise <sup>18-20</sup></u>

General strength and cardiovascular endurance training were incorporated throughout the patients stay. Strength training primarily focused on Triceps Surae, Anterior Tibialis, Quadriceps, Gluteus Medius, Gluteus Maximus, general abdominals, rotator cuff and scapular stabilizers, elbow, and forearm musculature. Strength training was progressed from active assisted range of motion to resisted range of motion using ankle weights, hand-held weights, and TheraBand. Cardiovascular endurance training was primarily trained using progressive reciprocal B UE and LE cycling. The patient was given a home training regimen and encouraged to continue addressing strength and endurance deficits outside of therapy. 

<u>Trigger Point Dry Needling (TPDN)</u>

Throughout his stay, the patient presented with L upper back and UE musculoskeletal pain and palpable trigger points in his L upper, middle, and lower trapezius, latissimus dorsi, supraspinatus and infraspinatus. TPDN was performed on numerous occasions to the listed muscles. Limited evidence suggests TPDN may be effective in reducing pain in patients with myofascial trigger points.<sup>21</sup> Visual twitch responses were observed, and the patient reported immediate pain relief. Despite evidence regarding TPDN efficacy lacking, this patient responded positively in the short-term.<sup>22</sup> 

<u>Kinesiotaping</u> 

Kinesiotaping was used to facilitate L UE and LE musculature. Kinesiotaping to affected musculature has been shown to result in improved gait mechanics and balance in stroke patients.<sup>23</sup> Kinesiotape was consistently applied to the L anterior tibialis and L vastus medialis oblique using a facilitatory technique. The patient reported subjective improvement in muscle activation and motor control. Improvements in L knee extension and L ankle dorsiflexion were observed during gait. Taping was used in conjunction with orthotics for the above deficits. Additionally, tape was applied to the L shoulder. Kinesiotaping has been shown to decrease pain and improve glenohumeral joint subluxation in stroke patients.<sup>24</sup> This patient demonstrated increased joint space between the humeral head and acromion as well as visual and palpable anterior humeral head translation. The patient reported an overall improvement in shoulder pain and function with consistent taping. 

<u>Orthoses</u> 

An over-the-counter generic ankle foot orthosis (AFO) was applied to the L ankle during all upright functional mobility to address dorsiflexion deficits and knee hyperextension.<sup>25,26</sup> Notable improvements in L footdrop were observed during transitional mobility and gait. Once the patient demonstrated improved anterior tibialis muscle strength, a SaeboStep (Saebo, NC, USA) was utilized over the generic AFO. A DonJoy SE-4 (DJO Global, TX, USA) knee brace was applied to the L knee during all upright functional mobility to prevent knee buckling and hyperextension.<sup>25</sup> Improvements in L knee motor control and safety were observed. The patient reported increased confidence and perceived mechanics using orthotics with mobility. A SaeboStretch (Saebo, NC, USA) splint was applied to the L wrist and hand on a schedule to maintain adequate soft tissue mobility and prevent contractures. The L digits and wrist were splinted in neutral. 

<u>Neuromuscular Re-Education</u> 

Neuromuscular electrical stimulation (NMES) was utilized throughout the patients stay during therapeutic exercise and pre-gait training. Rectangular electrodes were applied to the L anterior tibialis and L quadriceps to address L foot drop and promote L knee extension and stability during L LE stance. Manual neuromuscular facilitation techniques and proprioceptive neuromuscular facilitation were used during functional mobility and gait to the necessary musculature. Techniques included stroking, tapping and deep pressure. These techniques have been shown to decrease muscle tone and increase overall function and motor control in stroke patients.<sup>27,28</sup> L talocrural joint posterior mobilizations and manual stretching to the Gastrocnemius and Soleus and hamstrings were used in conjunction with therapeutic exercise. These techniques have been shown to improve range of motion and spatiotemporal gait parameters in stroke patients.<sup>29</sup>