The Efficacy of a Physical Therapy Plan of Care for a patient with Inclusion Body Myositis:

A Case Report

Adam Miller, SPT

Cleveland State University

Abstract

Background and Purpose: Inclusion Body Myositis (IBM) is an inflammatory myopathy with no effective pharmacological treatment. Exercise, originally thought to be detrimental to the disease progression, has been shown to be safe and beneficial in recent years. Exercise recommendations, as well as other physical therapy (PT) intervention methods, have not been thoroughly explored. This case report provides a description of an episode of care for a patient with IBM and examines the effectiveness of both an exercise program and interventions targeting function.

Case Description: The patient is a 68-year-old male diagnosed with IBM 8 years ago. He was referred to PT from a recent hospitalization and acute rehab stay following a car accident. The patient presented with significant strength deficits and functional limitations characteristic of IBM. A progressive exercise program, gait training, and sit to stand training were utilized to specifically target function. The patient was seen over a period of 8 weeks for a total of 13 visits.

Outcomes: Improvements were seen in lower extremity (LE) strength, predominantly in the lesser affected muscles. The patient also showed improved scores on the Timed up and go (TUG), the 5 times sit to stand (5xSTS), the 10 meter walk test (10mWT), and the balance portion of the Tinetti Performance Oriented Mobility Assessment (Tinetti POMA).

Discussion: Despite continued LE weakness, the patient reported significant improvement in function. This adds to the evidence that an individualized exercise program is a safe and integral component of the management of patients with IBM. It also demonstrates the value of moving beyond impairments to incorporate functional level treatment. Continued research is needed to establish PT treatment guidelines for this population.

Word count: 4777

Background and Purpose

Inclusion Body Myositis (IBM) is an idiopathic inflammatory myopathy with progressive muscle weakness. Histological evidence confirms the disease when inflammation, degeneration, and specific protein accumulation are found within affected myocytes.1 The condition is classified as a neurological disease, yet the pathogenesis remains unclear, and debate continues regarding the cause and relationship of the inflammatory and degenerative processes.1,2 Regardless, these damaging processes occur in specific muscle patterns that characterize the clinical presentation of a patient with IBM. An initial pattern of asymmetric weakness is typically seen affecting the proximal LE and distal upper extremity (UE) musculature, most often the quadriceps and the wrist and forearm finger flexors.3 These muscles progressively weaken and others, such as ankle dorsiflexors and swallowing muscles, become affected as the disease progresses. The initial severity, number of affected muscles, and rate of progression are variable. Although it is the most common acquired myopathy affecting those over the age of 50 years, the reports of incidence and prevalence vary.4 A recent review reported the incidence ranging from 0.9 and 3.2 per million per year and the prevalence from 0.3 and 13.9 per 100,000, with variability depending on geographic location.5

Not only is the pathogenesis of IBM unknown, but much uncertainty remains in regards to treatment. Research continues to seek an effective pharmacological intervention as all efforts so far to stop or even slow down the disease have proven fruitless.5,6 There has been, however, some success in the area of physical activity as treatment. Initially, activity as intervention was discouraged due to fear of exacerbating the inflammatory response and accelerating the disease, but the results of multiple studies have shown that these fears are misplaced.2,3,7,8 Multiple studies demonstrate that appropriately graded resistance training can potentially provide an avenue for moderately improving strength and possibly function.4 Resistance training regimens ranging from 12-16 weeks and even a study utilizing blood flow restriction training were shown to be safe and in many cases beneficial.2,7,9 Despite their success, or possibly in light of it, there exists a need for more information on the functional impact and specifics of implementing an exercise program for this population. Physical therapy guidelines facilitating the most effective exercise protocols are not yet established.8 Furthermore, there is a lack of evidence regarding the effectiveness of a comprehensive physical therapy plan of care addressing more than impairment level limitations. Thus far, the literature has focused mainly on strength training as a treatment. Little information exists regarding the impact of activity and function based treatments, such as gait training and sit-to-stand training. Only one study attentively considered functional intervention, but included it only as repeated sit-to-stands as part of their exercise protocol.9 There is a lack of evidence and precedence for the overall management of this patient type in the outpatient rehabilitation setting. Identifying precedents for comprehensive physical therapy care can help direct patient management and ultimately benefit the patient. The purpose of this case report is to demonstrate the execution of a plan of care and examine its effectiveness for a patient with IBM. Using the ICF model to help differentiate impairment and function and to guide treatment, this report will detail an episode of care of a patient with IBM.

Case Description: Patient History and Systems Review

The patient is a 68-year-old male diagnosed with IBM 8 years prior, although he reports the actual initial onset was likely several years earlier than the formal diagnosis. He was referred to physical therapy for multiple rib fractures from a motor vehicle accident (MVA) occurring 1 month ago. Before the MVA, the patient was experiencing progressive difficulty walking with increasing muscle weakness and atrophy, but could still function in his role as a professor. He was able to ambulate using a cane and a left knee brace, but could not transfer without a raised seat height and UE assist, nor stand for any extended period of time. Following the MVA, a resultant hospital stay, and despite a 3-week stay in acute rehab, the patient and his wife noted his condition had worsened with increased difficulty ambulating, getting up from bed, and getting up from a chair. At the time of the initial evaluation, the patient lived at home with his wife and utilized a wheeled walker to ambulate. He also used a raised bed, a raised chair, and a tub bench to ease transfers. The patient’s goals for therapy included improving his ability to ambulate and transfer, and achieve sufficient mobility and endurance to return to teaching and gardening. His wife also disclosed they desired a method to manage the various seat heights at restaurants in order to meet up with friends for coffee. However, the patient was not very hopeful for achieving these goals, and was hesitant to engage in exercise. He had been informed about the risk of exacerbating IBM by triggering inflammation through exercise. Based on what he learned during his initial diagnosis, he believed little to no gain in muscle strength or recovery of function was possible with IBM. Apart from IBM, the MVA, and rib fractures, the patient’s medical history included lumbar radiculopathy and degenerative disc disease of the lumbar and cervical spine.

Clinical Impression #1

Using the ICF model to guide decision making, the patient’s primary problem was identified as progressive muscular weakness, as is typical in patients with IBM.1,4 This impairment was secondary to a diagnosis of IBM and resulted in impaired mobility that affected his participation in social interactions as well as his role as a professor, husband, and gardener. Relevant environmental and personal factors worthy of consideration were the patient’s negative health beliefs about his condition and the involvement of his supportive and patient wife. Additional information was requested to identify the degree to which the MVA and hospitalization contributed to his weakness. The patient reported his chief complaints were present before the accident, and that he had been experiencing notable decline and requiring increased assistance at work and at home. He had not sought out physical therapy before the accident due to his beliefs about his condition and a lack of awareness of physical therapy. Therefore, it was determined the patient’s primary impairment of weakness and resultant decreased mobility and function were the result of his inflammatory myopathy and would be the focus of the examination. This patient’s case allowed for the opportunity to demonstrate an episode of care for a patient with IBM in the outpatient setting, considering individual variability and showing a comprehensive treatment approach, highlighting not only the patient’s impairments, but also their limitations in activity, function, and participation with the intention of assisting future clinicians in determining appropriate and effective management of patients with IBM. As these individuals typically experience trouble with walking and increased fall frequency, outcome measures were used to assess these areas.8,23 The examination plan consisted of assessing strength, range of motion (ROM), sensation, and proprioception, along with analysis of posture, bed mobility, transfers, balance, and gait, in order to generate a comprehensive clinical picture. The 10 meter walk test (10mWT), the 5 times sit to stand test (5xSST), the timed up and go (TUG), and the Tinetti Performance Oriented Mobility Assessment (POMA) were utilized to assess function and measure outcomes.

Figure 1: An integrated framework of the patient’s condition via the ICF model28

Examination

Strength was assessed using the standard Kendall manual muscle test grading (MMT) scale and positioning.10 The patient was instructed to move through the ROM in a gravity resisted position. Depending on the ability to complete the motion, he either completed the motion again with graded resistance or switched to a gravity eliminated position. The motions tested were hip flexion, extension, and abduction, knee flexion and extension, and ankle plantarflexion and dorsiflexion. The proximal segment was stabilized for all movements and ramping forces were used to determine the patient’s strength against the examiner’s resistance when the patient was able to move through the entire ROM against gravity. Resistance was graded based on the MMT scale (Figure 2).

Figure 2: MMT Grading Scale

ROM was assessed with the use of a goniometer by placing the patient supine. Hip flexion was measured using the midline of the thorax as the stationary arm, the greater trochanter as the axis, and the lateral midline of the femur as the moving arm. Knee flexion was measured using the midline of the lateral femur toward the greater trochanter as the stationary arm, the lateral femoral epicondyle as the axis, and the midline of the fibula toward the lateral malleolus as the moving arm. Ankle plantarflexion and dorsiflexion were measured using the midline of the fibula toward the fibular head as the stationary arm, the lateral malleolus as the axis, and the fifth metatarsal as the moving arm.

Sensation Testing was assessed by determining a response to stimuli. The patient closed his eyes and reported when he felt the examiner lightly and quickly stroke his skin using a fingertip, moving distally in a dermatomal pattern on the LE. Proprioception of the hallux, ankle, and knee were completed bilaterally. The patient closed his eyes while the proximal segment was stabilized and the distal segment was moved through its range multiple times. The patient reported on the position when motion stopped. The methods were in accordance with those described in Berryman Reece.21

Postural assessment was completed with the patient standing. His posture was examined in the sagittal plane, inspecting if the line of gravity fell near the mastoid process, anterior to the second sacral vertebra, just posterior to the hip, and anterior to the knee and ankle. The curvature of the back and neck were assessed. The same observations were completed in sitting.

To analyze bed mobility, the patient demonstrated a transition from edge of bed sitting to supine lying, and then from supine lying to sitting edge of bed. Level of assist was graded according to the following: Max Assist—the patient performs 25% or less of the transfer, Moderate Assist—the patient performs 50% or less of the transfer, Minimal Assistance—the patient performs at least 75% of the transfer.

To analyze transfer ability the patient demonstrated a sit to stand transfer from varying seat heights, starting with the patient’s reported bed height at home of 24 inches. The height was increased to 25 inches and then 26 inches due to the patient’s fatigue and unsafe movement. Observation of the patient’s foot width, use of upper extremities, sequencing, mechanics, effort, and time to complete the sit-to-stand were noted.

To analyze gait the patient ambulated using his assistive device 15 meters x 2, while the therapist observed both the sagittal and coronal plane. Observation of stance and swing phase deviations were noted for LE joints. Trunk and head positioning and control were also noted.

The 5xSST was completed from a 26-inch height chair following the standard test administration instructions on the StrokEDGE Taskforce compendium of instructions.11 The patient completed the 10 meter walk test. He was instructed to walk 10 meters, pre-marked on the ground, while time was recorded, and adequate additional space for the patient to accelerate and decelerate were allotted. The TUG was completed from a 26-inch height chair following the standard test administration instructions on the StrokEDGE Taskforce compendium of instructions.11 The Tinetti POMA was completed using the 28-point version with a total possible score of 16 on the balance section and 12 points on the gait section. The measurement was completed following the standard test administration instructions on the StrokEDGE Taskforce compendium of instructions.11 The results of each examination measure along with details of the rationale behind their selection, and information on their reliability and validity are found in Table 1.

Table 1: Examination Procedures

Assessment

Results

Reliability

Validity

Rationale

5 x Sit to Standa

35.4 seconds

0.89012

Not established but highly correlates with other measures of balance and gait, clearly tests an individual’s ability to sit to stand and is reflective of balance, sensorimotor function, and lower extremity strength13

Used to determine a baseline level of sit to stand function and reflects on lower extremity strength

10 mWTa

0.41 m/s

0.9914

Excellent correlation with IADLs14

Used as a reliable assessment of gait speed which reflects function

TUGa

30.9 seconds

0.9715

The TUG is able to predict fall risks and is highly correlated with various outcome measures16

Used to assess and establish a baseline for mobility, balance, and fall risk

Tinetti POMAa

Balance: 11/16

Gait: 8/12

Total: 19/28

0.8417

Content validity not established, but highly correlated with gait speed and other outcome measures17

Used to identify specific and overall gait and balance levels and to help direct treatment

Goniometer ROM

0.77-0.8318

High correlation with radiographic measurements for the lower extremity .97-.9819

Used as a reliable and accurate tool to determine range of motion and identify joint mobility restrictions contributing to movement deficits

Hip flexion

AROM:

L-55° R-30°

PROM:

B- 90°

Knee Flexion

AROM:

L-104° R-64°

PROM:

L-110° R 105°

Ankle Dorsiflexion

Supine: -5° from neutral

Standing: Neutral

Strength

Manual Muscle Test

0.65 to 0.93 for muscle groups rather than individual muscles20

Good validity for patients with neuromuscular dysfunction, correlates well with hand held dynamometry (0.768)20

Critical area of assessment for a patient with IBM, MMT is a reliable and valid tool for assessing strength

--Hip

Flexion

B: 2+/5

Extension

B: 2-/5

Abduction

B: 2-/5

--Knee

Flexion

B: 2/5

Extension

R: 2+/5 L: 2-/5

--Ankle

Plantarflexion

B: 4/5

Dorsiflexion

R: 3-/5 L: 2+/5

Sensation

Light touch

Proximal right quad numbness

Decreased sensation to light touch in right medial gastrocnemius

Validated and recommended method of assessment21

The patient has a neurological disease; the role of sensation in gait and mobility should not be overlooked

Proprioception

Reduced proprioception of right and left hallux

Qualitative Assessments

Posture

Forward head posture with flexed upper trunk in seated and standing position

Necessary to examine due to its impact on mobility mechanics and function

Bed Mobility

Supine to sit: moderate assist

Sit to supine: minimal assist, mainly with moving the lower extremity

Necessary assessment of function

Transfers

Sit to stand: From a 26-inch height seat, using B upper extremity assist, B knee hyperextension, forward flexed posture, poor quality of movement, increased time and effort to complete transition

Gait

Ambulated using a wheeled walker, demonstrating a forward flexed posture, B reduced step length, B knee hyperextension worse on Left

aAll ambulation performed with a wheeled walker, all sit to stands performed from an elevated seat height of 26-inches

AROM-Active Range of Motion, PROM-Passive Range of Motion, B-bilaterally, MMT-Manual Muscle Test

The patient’s results on the 5xSTS assessment were much slower than age matched norms and indicated a fall risk.12 They were also representative of LE weakness and the difficulty of transitioning from sit to stand, even from a raised height. The results of the 10mWT, Tinetti gait component, and gait analysis revealed marked gait deviations. These included increased step width, decreased step length bilaterally, bilateral knee hyperextension during stance phase, forward trunk lean, and a gait speed that was much slower than that of age matched norms.14 The TUG score was much higher than aged matched norms and indicative of high fall risk and decreased function.15 The Tinetti score was indicative of a moderate fall risk. Bed mobility and sit to stand transfers were challenging for the patient to complete, largely due to difficulty controlling the LE. Limitations were found in PROM and AROM hip flexion, knee flexion, and ankle dorsiflexion. Strength testing revealed significant weakness in the hip flexors, abductors, extensors, knee flexors and extensors, and ankle dorsiflexors. The left side was worse than the right. Good trunk control was demonstrated during all transfers and testing. Marked, asymmetric muscle atrophy was observed among the finger and wrist flexors, with sparing of the thenar and hypothenar eminences. These findings along with asymmetrical quadriceps, hips, and dorsiflexor weakness were typical of the clinical presentation of IBM.4

Clinical Impression #2

The initial impression of the patient’s decreased function resulting primarily from weakness due to IBM and exacerbated further by a MVA was confirmed. The examination revealed the classic clinical presentation of IBM, significant and asymmetrical quadriceps weakness along with wrist and finger flexor atrophy.4 The significant hip and dorsiflexor weakness were indicative of the progression of the disease and possible deconditioning from decreased mobility before the accident which intensified after the accident. Hip extension and abduction weakness were more profound than expected. The patient also displayed poor gait mechanics and significant limitations in transfers and maintenance of upright balance. The outcome measures all indicated an increased fall risk and decreased mobility, with markedly reduced gait speed and sit to stand ability. The examination results demonstrated significant impairments and activity and functional limitations in a patient with IBM that guided the areas of focus for intervention. This allowed for the opportunity to determine the effectiveness of a comprehensive treatment plan for a patient with IBM in an outpatient setting. The patient’s fear of falling, hesitancy to engage in exercise, and frustration with his limitations during movements were apparent. The patient would require a discussion, education, and positive reinforcement. An exercise program would be initiated to facilitate improved strength and prevent additional strength loss. Strength gains in the more proximal musculature of the LE, improvements in posture and trunk control, and improved motor control for gait and sit-to-stand were expected based on presentation and prior studies.2,3,9 The patient was also referred to occupational therapy to assist with UE function. The patient was scheduled to be seen 1-2 times per week for 8 weeks, with a reassessment to occur on the tenth visit. The areas identified for intervention included an exercise plan addressing the strength and ROM deficits, along with gait training, bed mobility training, sit-to-stand training, and education on IBM and maintenance of an appropriate exercise plan.

Intervention

The interventions are divided into three categories: an exercise program, gait training, and sit-to-stand training. The purpose of each was to improve LE strength and function. The exercise program targeted the patient’s most significant impairments and incorporated exercises to maintain and improve functional mobility. The exercises and progressions are shown in Table 2.

The research of Johnson et al formed the basis of a rudimentary exercise program, which was then adapted and augmented to fit this individual patient.9 In this patient population, it is difficult to discern which muscle groups can be strengthened and to what degree due to IBM’s variability.9 Therefore, exercises were designed to improve overall LE strength, with the intent of improving strength of unaffected musculature, preserving strength of affected musculature, and ameliorating impairments that negatively impact function. The patient was educated on the safety and efficacy of an exercise program in the presence of IBM, with a discussion on determining intensity and monitoring soreness and fatigue. Quality of motion with a focus on increased muscle fiber recruitment was emphasized initially. Hip flexion, extension, and abduction along with knee flexion were completed in gravity eliminated positions for the first two weeks and then progressed to standing to increase challenge and translation to gait and overall function. The patient’s spouse was educated in facilitating gravity eliminated movements at home.

As previously stated, quadriceps weakness is a major cause of function loss, severely impacting sit to stand transfers, gait, and balance.23 Therefore, preservation and improvement of available knee extensor strength and motor control were targeted through quad sets, gravity eliminated knee extension, resisted total knee extension in standing, and functional whole body movements. A standing gastrocsoleus stretch was completed to improve dorsiflexion ROM to allow increased knee flexion during the stance phase of gait. Active dorsiflexion was addressed through seated toe raises and progressed to standing toe raises with the back supported against a wall to prevent a loss of balance posteriorly. Improved plantar flexion strength in patients with IBM can help stabilize the knee during gait and prevent hyperextension, even in the presence of significant quadriceps weakness.23 Therefore, plantar flexor strengthening was included through seated heel raises and progressed to standing heel raises. Mini squats and sit-to-stand training were included as whole body exercises to improve overall LE strength and function. Resisted scapular rows were included to facilitate upright posture and reduce thoracic flexion. The patient began occupational therapy on visit 6 to address hand function and preserve UE strength. The patient was progressed via increased repetitions, increased sets, or adjusted positioning when he demonstrated control with the exercise with decreased fatigue with mild to no soreness afterward. Each session began with a 5-minute warm up on a SciFit exercise bike with progressive resistance. The patient’s home exercise program (HEP) was adjusted throughout the plan of care per his progressions.

Table 2: Exercise Program

Muscle Group Targeted

Exercise Description & Progression

Whole Body

Mini Squats for 2 x 10 (Visit 1 - 4)

Mini Squats with lateral step 2 x 10 (Visit 5 – 6)

Mini Squats for 3 x 10 (Visit 7 – 13)

Whole Body

Sit to stand from mat height of 28 inches

2 x 8 (Visit 1 – 4)

2 x 10 (Visit 5 – 13)

Hip Flexors

Hip flexion in sidelying 2 x 10 (Visit 1 - 2)

Hip flexion in standing 2 x 10 (Visit 4 – 5)

Hip flexion in standing 2 x 12 (Visit 6 – 13)

Hip Extensors

Glute sets supine 10 second hold x 10 (Visit 1)

Sidelying Hip Extension 2 x 10 (Visit 2)

Standing Hip Extension 2 x 12 (Visit 3 – 13)

Hip Abductors

Hip Abduction supine x 10 (Visit 1 – 3)

Hip Abduction Standing x 15 (Visit 4 – 13)

Knee Flexors

Supine Heel Slides x 10 (Visit 1)

Sidelying Knee Flexion x 10 (Visit 2)

Standing Knee flexion 2 x 10 (Visit 3 – 13 as able)

Knee Extensors

Quad Set supine x 10 (Visit 1 - 2)

Sidelying Knee Extension x 10 (Visit 3 -13)

Total Knee Extension standing

Yellow resistance band x 30 (Visit 2)

Yellow resistance band 2 x 25 (Visit 3 – 4)

Red resistance band 2 x 20 (Visit 5 – 13)

Plantar Flexors

Seated Heel Raises x 20 (Visit 2 -3)

Standing Heel Raises x 25 (Visit 4- 5)

Standing Heel Raises 3 x 15 (Visit 6 – 13)

Dorsiflexors

Seated Toe Raises x 20 (Visit 2 – 5)

Standing Toe Raises with back against wall 3 x 10 (Visit 6 – 13)

Gastrocsoleus Stretch

Standing on incline board at 30 degrees

1 min (Visit 7 – 8)

3 x 2 minutes (Visit 9 – 13)

Scapular Rows

Yellow resistance band 2 x 12 (Visit 3 – 5)

Studies of the gait parameters of patients with IBM demonstrate the possibility of normalized gait patterns even in the presence of quadriceps weakness.23 Little attention has been given to the application of motor learning in patients with IBM, despite the established effectiveness of motor learning strategies on other neurological and musculoskeletal conditions.24 Gait training was completed every session starting the second week, but prioritized and with motor learning emphasized after the patient demonstrated proficiency with his exercise program, near visit 6. In the parallel bars, the patient was progressed through forward, retro, and lateral ambulation with bilateral UE assist, unilateral UE assist, and ultimately no UE assist with the intent of improving standing dynamic balance, LE and trunk control, and gait mechanics. The patient’s lack of knee control and compensatory hyperextension were identified as the most limiting factors in gait. Quadriceps strength and control were addressed in part through the knee extensor exercises explained earlier. Manual and verbal cues to maintain a minimal degree of knee flexion were given throughout all gait training. A red resistance band placed inferior to the patella was used to provide an anterior to posterior (AP) extension force to the knee while the patient was standing. The patient was then required to achieve a controlled, graded quadriceps contraction to maintain a minimal degree of knee flexion against the resistance band to avoid hyperextension. This technique proved effective in reducing hyperextension and facilitating quadriceps activation. With this method, the patient was taken through a progression of lateral weight shifts, staggered stance anterior-posterior weight shifts, stepping forward and backward (with resistance band on the stance leg), and stepping on and off a 1-inch board. The patient was taken through the same progression without the resistance band once he could maintain a consistent level of knee flexion for weight shifts and consistently avoid hyperextension with stepping. The hip and knee flexion exercises, plus repeated combined hip and knee flexion in standing to mimic stepping, were used to improve stepping mechanics. A mirror was used to provide visual feedback and upright posture and improved heel strike during all gait training were emphasized. Overground walking was completed each session, with cues to implement all components of training practiced within the parallel bars. The patient was progressed from a walker to a cane once he demonstrated controlled ambulation within the parallel bars using unilateral UE assist. Improved pelvic stability and upper trunk mobility were targeted last. The patient was instructed to stand independently within the parallel bars, rotate the pelvis, and incorporate contralateral arm sway. The patient was then instructed to maintain a staggered stance and reach across the body with the UE, with cues for pelvic stabilization and decreasing upper trap activity. The patient then ambulated within the parallel bars with exaggerated arm swing.

Sit-to-stand training was completed throughout the entire plan of care, but prioritized during the last two sessions through neuromuscular reeducation. A baseline seat height was established using the lowest height from which the patient could sit to stand independently using bilateral UE assist off the mat. The task was broken down into two parts for part practice: 1) from the seated position the patient practiced tilting the pelvis anteriorly, leaning the trunk forward, and briefly lifting the ischial tuberosities off the mat and 2) the patient practiced transitioning from a standing position of trunk flexion, hip flexion, and slight knee flexion to an upright position by bringing the upper trunk erect and extending the hips. Whole part practice was completed with repeated sit to stands progressing from bilateral UE assist to unilateral UE assist to no UE assist. Seat height and base of support were progressively decreased as able. Manual and verbal cues for foot placement (maintain toes below knees with equal foot distance from center of gravity), forward weight shift with UE reaching, and proper sequencing were given. Eccentric, controlled stand to sit practice was also employed. The part practice components were included in the patient’s HEP. The patient’s wife was also instructed in providing moderate assist using a gait belt for sit to stand transfers.

Outcome

After treatment sessions, the patient experienced mild soreness and fatigue which would resolve within 1 day. The patient steadily overcame his fear and apprehension regarding exercise as he gained confidence in his ability to increase his activity level and monitor fatigue. By the fourth visit, he noticed his balance was improving. By the sixth visit, the patient could go into his work office for 5 hours and perform sitting work related activities. On the tenth visit, the patient self-reported he was at 80% of his total function with significant improvements, especially in regards to gait, although he wasn’t yet satisfied with his ability to transfer from sit to stand positions. By visit 12 the patient was able to work in his greenhouse for 3 hours and walk around campus using a cane without any issue. By visit 13, the patient reported completing more work around his greenhouse and planned on returning to work full time until the end of the semester. Table 3 shows the results of the tests and measures taken at visit 10 for all quantitative measures and visit 13 for all qualitative measures alongside the initial examination results. In addition to observation and patient report, functional gains were evident by the improvements in outcome measures. The patient continues to be at risk for falls based on the 5xSST, but demonstrates improvement in sit to stand ability nonetheless within the minimal clinically important difference (MCID)12. The 10mWT showed walking speed improved by 0.12 m/s, which is well above the level of small meaningful change and just below the level of substantial meaningful change in the geriatric population.26 The TUG improved by 7.9 seconds with a final score that is still indicative of fall risk, but demonstrates improvement in transfers and mobility. Finally, the Tinetti POMA improved by 2 points in the balance section, resulting in an overall improved score that is still within the moderate fall risk category. The results of these measures can be seen in Figure 3. No strength loss occurred, and the specific improvements in muscle strength can be seen in Table 3, along with a description of changes seen in the qualitative assessment.

Table 3: Results from Tests and Measures at Examination and Reassessment

Tests and Measures

Initial Results on Examination

Final Results on Reassessment

Goniometer ROM

Hip flexion

AROM:

L-55° R-30°

PROM:

B- 90°

AROM:

Not Tested

PROM:

L-92° R-90°

Knee Flexion

AROM:

L-104° R-64°

PROM:

L-110° R 105°

AROM:

L-100° R-98°

PROM:

L-108° R-112°

Strength

Manual Muscle Test

--Hip

Flexion

B: 2+/5

B: 2+/5

Extension

R: 2-/5 L: 2-/5

R: 3-/5 L: 2-/5

Abduction

B: 2-/5

B: 4/5

--Knee

Flexion

R: 2/5 L: 2/5

R: 2+/5 L: 2/5

Extension

R: 2+/5 L: 2-/5

R: 3-/5 L:2-/5

--Ankle

Plantarflexion

B: 4/5

B: 4/5

Dorsiflexion

R: 3-/5 L: 2+/5

R: 3-/5 L: 3-/5

Qualitative Assessments

Posture

Forward head posture with flexed upper trunk in seated and standing position

Decreased forward head posture, improved upright upper trunk in standing; continued forward head posture in sitting

Bed Mobility

Supine to sit: moderate assist

Sit to supine: minimal assist, mainly with moving the lower extremity

Supine to sit: modified independent

Sit to supine: independent

Transfers

Sit to stand: From a 26-inch height seat, using B upper extremity assist, B knee hyperextension, forward flexed posture, poor quality of movement, increased time and effort to complete transition

Sit to stand: From a 26-inch height seat, able to perform without B UE assist, with decreased base of support, improved foot placement, and improved quality of movement with adequate trunk flexion to extension transition

Gait

Ambulated using a wheeled walker, demonstrating a forward flexed posture, B reduced step length, B knee hyperextension worse on left

Ambulating using a single point cane, demonstrating significantly improved upright posture with appropriate pelvic and upper trunk movement, moderately improved step length bilaterally and reduced knee hyperextension

Figure 3: Results of the 5xSTS, TUG, 10mWT, and Tinetti POMA29,30

Discussion

This case report has shown how an individually tailored, comprehensive physical therapy plan of care incorporating an exercise program with functional training was used to address impairments and functional deficits in a 68-year-old male with IBM. There were no adverse outcomes as a result of engaging in the interventions. Functional improvements were demonstrated through tests, outcome measures, observations, and patient report. LE strength improvements were seen in various muscle groups, most notably in bilateral hip abduction and right hip extension.

The exercise program used in this case report impacted strength in a manner largely consistent with the literature.7,9 The ability of appropriately graded resistance training to improve LE strength in musculature unaffected by IBM without worsening affected muscles has been established.1 Ventral muscle groups are involved far more than dorsal, so hip abductors and extensors are typically unaffected by IBM, yet their profound weakness in this patient’s initial visit was apparent.8,23 This was most likely a result of a prolonged avoidance of movement secondary to a fear of falling, a fear of condition exacerbation, and poor mechanics. Similar deconditioning effects may be seen in other patients with IBM, indicating an area for potential intervention as hip abduction and extension are integral to gait and function, and were successfully strengthened in this patient. The strength improvement of right knee extensors and left ankle dorsiflexors were fortuitous outcomes. As the quadriceps are the primary muscles of the LE affected by IBM, with dorsiflexors subsequently following, significant strength gains in these areas are atypical.1,4 These results indicate the value of attempting exercise training not only for the hope of preserving function in these damaged muscles but also for the potential to strengthen any remaining unaffected muscle fibers. In contrast, the strength of the more severely affected left quadriceps remained unchanged. However, improved quadriceps voluntary contraction and improved motor control of knee motion during gait were evident. This indicates the merit of incorporating motor learning and neuromuscular reeducation into the plan of care of patients with IBM. Perhaps in addition to strength training, enabling a patient to regain control and better use the muscle strength they already have available can be emphasized. On the other hand, multiple case reports have remarkably improved maximal voluntary isometric knee extensor contraction in the more affected limb without overloading or exacerbating inflammation by utilizing vascular occlusion resistance training.2,27 This method may indicate an efficient and safe way of maximizing contractile potential of remaining muscle fibers within an affected muscle group, but more evidence is needed, especially when considering the variability of IBM. Based on this patient’s results and the literature, treatment targeting LE strength gains and maximal utilization of current strength with functional consideration may be the best overall approach.1,2,7,8,9,27

Gait training as an intervention was shown to positively impact the patient’s function. Facilitating knee extension with a resistance band as a part of pre-gait training was especially effective for eliciting graded quadriceps contractions and reducing knee hyperextension during stance phase. Additionally, improved hip strength, improved right knee flexion strength, and better overall muscular timing and recruitment, especially improved plantar flexor firing and trunk positioning, may have contributed to improved knee control. Addressing other common deviations in gait mechanics helped facilitate a more efficient gait, progression from a walker to a cane, and increased patient confidence in ambulatory ability. Although gait speed remained well below normal, the change was clinically significant and any improvement in function is worth pursuing, especially in populations with progressive diseases.26 The same results and reasoning apply to the patient’s improvements in the 5xSST and the TUG.12,13,15,16 The patient demonstrated improved mechanics and consistency of movement with sit-to-stand transfers following functional training. It is unlikely he will ever achieve independent sit-to-stand transfers from average chair heights (≤ 20 inches). Functional training can only take him as far as strength limitations allow, but nonetheless proved beneficial in improving sit-to-stand transfers from decreased heights with a more appropriate base of support and increased efficiency.

This case report adds to the evidence that an individualized exercise program is a safe and key component of the management of patients with IBM. It also demonstrates the value of moving beyond impairments to incorporate functional level treatment. Finally, it shows the importance of education on exercise for patients with IBM. Further research should focus on the specifics of exercise programs and the utilization of motor learning, gait training, neuromuscular facilitation, and other physical therapy treatment techniques in this patient population. Future studies need to provide insight into the clinical effectiveness of each intervention including those focused on function, and various strengthening protocols, such as vascular occlusion training. Ultimately, the growing research should lead to the establishment of clinical recommendations and practice guidelines that assist the physical therapist in providing the best care for patients with IBM.

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