Case Report

Long-Term Locomotor Training for Gait and Balance in a Patient With Mixed Progressive Supranuclear Palsy and Corticobasal Degeneration Teresa M Steffen, Bradley F Boeve, Louise A Mollinger-Riemann, Cheryl M Petersen TM Steffen, PT, PhD, is Professor, Program in Physical Therapy, Concordia University Wisconsin, Background and Purpose 12800 N Lake Shore Dr, Mequon, Progressive supranuclear palsy (PSP) iuic! corticobasal dcgencnition (CBO) arc slowly WI 53097 (USA). Address all progressive tauopathics characterized by impaired balance, disturbances in gait, and correspondence to Dr Steffen at: frequent falls, among otber features. Wbeelchair dependence is an inevitable out- [email protected]. come in people witb these disorders. Insufficient evidence exists regarding tbe BF Boeve, MD, Division of Be- effectiveness of exercise in the management of people with these disorders. Tbis case havioral Neurology, Department report describes a program of exercise and long-term kjcomotor training, using a of Neurology, and Alzheimer's treadmill (both with and without body-weigbt support), to reduce falls and improve Disease Research Center, Mayo the balance and walking ability of a patient with mixed PSP and CBD features. Clinic, Rochester, Minn.

LA Mollinger-Riemann, PT, MS, is Case Description Assistant Professor, Program in Six years after diagnosis with mixed PSP and CBD features, the client, a 72-year-old Physical Therapy, Concordia Uni- dentist, was seen for physical therapy for asymmetric limb apraxia, markedly im- versity Wisconsin. paired balance, and frequent falls during transitional movements. CM Petersen, PT, DPT, is Assistant Professor, Program in Physical Intervention Therapy, Concordia University Wisconsin. Over a 2.5-year period, intervention ineluded routine participation in an exercise group for people with Parkinson disease (mat exercise and treadmill training) and [Steffen TM, Boeve BF, Mollinger- intermittent participation in individual locomotor training on a treadmill, Ilie exer- Riemann LA, Petersen CM. Long- cise group met for 1 hour, twice weekly. The individual treadmill sessions lasted 1 term locomotor training for gait hour, once weekly, for two 14-week periods during the follow-up period. and balance in a patient with mixed progressive supranuclear palsy and corticobasal degenera- Outcomes tion. Phyi Ther. 2007;87: Over tbe 2.5-year period, fall frequeney decreased, and tests of fimctional balance 1078-1087.] sbowed improved limits of stability (fimctional reach tests) and maintained balance © 2007 American Physical Therapy function (Berg Balance Scale). Tests of walking peribrmance sbowed only slight Association declines. A 4-wheeled walker was introduced and accepted by the client early in tbe intervention period. The client, with supervision, remained ambulatory witb this wbeeled walker in the community. Discussion In this case report of a person witb mixed PSP and CBD features, a pbysical tbenipy intervention, whlcb included locomotor training using a treadmill and a long-term exercise program of stretching and strengthening, appears to bave improved some dimensions of balance, slowed the rate of gait decline, prevented progression to wheelchair dependence, and decreased falls. Contrary to the expected decline in function, this client maintained independent mobility over a 2.5-year period. An ongoing, intensive program of exercise and locomotor training may belp people with Post a Rapid Response or PSP and CBD maintain upright balance, decrease falls, and decrease tbe rate of find The Bottom Line: decline of ambuJation. www.ptjournal. org

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roj;ressive supranuclear palsy hibited prominent gait impairment tion in fimction within 8 months af- (PSP) and corticobasal degener- prior to death.» Gait impairment and ter discharge from therapy. A study Pation (C;BD) arc neurodegcncni- the associated falls, therefore, are a of 24 clients with Parkinson disease tive disorders. In one study,' the av- major source of morbidity and mor- (PD)" demonstrated that bped that alters the pathophysioiogy creases with age and is higher in of tau-associated neurodegeneration, Beyond these studies, there is a gap men.' Tliese neurodegenerative management is directed toward in the literature on the effectiveness disorders are characterized by tau- problem symptoms. The motor im- of rehabilitation programs for people positive inclusions in neurons and pairments of hoth disorders are par- with parkinsonian disorders such as glia.- Axial and limb rigidity, ticularly disabling. Phamiacotherapy PSP and C:BD. Because the preva- supranuclear gaze palsy, biilance and with carbidopa/levodopa and with lence of these disorders is low, case gait impairment, and frequent falls dopamine agonists typically is inef- studies allow researchers and clini- are the clinical hallmarks of PSP.^ ' fective in managing tlie disorders; if cians to present informative data to All of the "tauopathies" (ie, Pick dis- modest improvement oecurs, it is help others deal with these diseases. ease, corticobasal degeneration, PSP, never prolonged.^"' Nonpharmaco- argyrophilic grain disease, and fron- logic therapies such as physical ther- Encouraged by the outcomes in a totemporal dementia with parkin- apy and occupational therapy are po- case study hy Suteerawattananon et sonism due to a mutation in the tentially useful, with the principal at" of a person with PSP and the microtubule-associated protein tau) goals being tbe maintenance of func- availability of a physical therapist- involve abnormal accumulation of in- tional ambulation and the reduction supervised, community exercise tracellular tau protein that results in of falls and associated Injuries. class that included locomotor train- the development and accumulation ing on treadmills, the first author of inclusions in neurons or glia that There is very little published data (TMS) offered an exercise and gait render the cells dysfimctional and ul- regarding physical therapy ap- training intervention to a man with timately cause cell death. proaches for people with PSP or parkinsonian-Hke features who was (;BD. Only one case study could be eventually diagnosed as having Corticobasal degeneration typically found that studied the effect of loco- mixed PSP and CBD. The present is manifested by asymmetric limb ri- motor training on the fimction of case report describes the longitudi- gidity and apraxia (ie, the core fea- people with either disease. This case nal progression of several functional tures of "corticobasal syndrome") study" showed a decrease in falls outcomes during the course of a and other features such as dystonia, and improved balance for a person long-term therapy program of myoclonus, alien limb phenomenon, with PSP after 8 weeks of body- strengthening and stretching exer- ideomotor apraxia, corticosensory weight-support treadmill training. cises combined with locomotor loss, and tremor.**** Some clients Two other case reports of physical training for this client. The locomo- have features of hoth disorders. Pos- therapy intervention for people with tor training was done on a treadmill, tural instability ultimately occurs in PSP were found.'-'* These reports with and without body-weight sup- botb disorders, leading to frequent described programs of strengthening port, with the goals of improving falls, injuries, and sometimes death and range-of-motion exercises for balance and walking perfonnance, due to traumatic brain injury or the tnmk and limbs, coordination as well as reducing falls. The tread- intracranial hemorrhage.^** In one and balance activities, gait and trans- mill program was not designed to study of 24 cases of autopsy-proven fer training, and tine motor activities. induce cardiovascular adaptation. PSP,^ median survival time was 5.6 The patients improved in walking The therapy pn)grain was provided years (range=2-l6.6). Onset of falls ability and .safet>' over the course of in both a community setting (a phys- during the first year predicted a therapy, but this improvement was ical therapist-supervised exercise shorter survival time.^ Median sur- dependent on heavy-weight ambula- class for people with PD) and a vival time after onset of symptoms in tory devices or a structured environ- university-based physical therapy a series of 14 cases of autopsy- ment. However, 2 of the 3 patients in clinic setting. proven CBD was 7.9 years these case reports required ntirsing Crange=2.5-12.5), and all clients ex- home placement due to deteriora-

August 2007 Volume 87 Number 8 PhysicalTherapy • 1079 Locomotor Training for Progressive Supranuclear Palsy/Corticobasal Degeneration

Table 1. stretch that a muscle exhibits) also Chronology of Significant Events for the Client With Progressive Supranuclear Palsy was present in the lower extremi- (PSP) and Corticobasal Degeneration (CBD) ties, but axial tone was normal. Al- Date Significant Events ternating nn)tion rates of the limbs were decreased, more so on the left June- JS. 1933 DaK." of hinh side than on tbe right side. Deep 1959 Bcf-an clinical practice as a dtntisi tendon reflexes were brisk, but Bab- 19^)7 Bahmce and speech became noiiceably impaired inski and Hoffman signs were absent. April 1997 Diagnosis of CBD by neunjlogisl 1 be palmomcntal reHex was present bilaterally. His stance was wide- nccembcr 1997 Stopped driving automohile based, and his stride was sbort with 1998 <:arbid(>pa/levodopa prescribed to manage balance impairment decrea.sed arm swing, which was 1999 I'irsi tall greater on the left side. A Rombei^ sign was present, and the pull test 1999 Stopped working with patients due to spet-ch and communication problems was positive. There was no tremor, myoclonus, dystonia. alien limb phe- 1999 Carbidopa/levodopa distontiniied nomenon, or mirror movements. Jimt- 2(M)() r>mgn contirnifd ;tt the Mayo t;iinic J(«)l Falls became an increasing problem Ancillary Test Results 200'i Nt'iin)logist siifipected mixed FSP and CBD His initial assessment on neuro- psychological testing demonstrated set maintenance problems, impaired Case Description preserved by himself and his family, working memory, impaired divided Historical Features with no significant features of mem- and sustained attention, and pcrsc- The client had been a practicing den- ory, language, visuospatial. or exec- veration. (Complex reasoning in a tist for 40 years and, during that utive dysfunction. Also absent were novel setting also was mildly im- time, worked with several types of tremors, sialorrhea, dyskinesia, par- paired, but performance on all tests metallic compounds, including gold, esthesias. bladder and bowel in of language, visuospatial function- silver, amalgam, and mercury. He continence, muscle twitching, and ing, and delayed recall was normal. was right-handed and initially began cramps. His medical history was oth- Magnetic resonance imaging and experiencinj- ciianges in gait and erwise remarkably benign. He used no tluorodcoxyglucose positron emis- limb coordination around 60 years of prescription medications. Tliere was sion tomography showed abnormal- age. Tliis was paniculariy notahle no significjint history of tobacco or al- ities in the parietofrontal cortex, when he was playing curling, with cohol use. 'Iliere was no f;imily histor>' which were maximal on the right tinsteadlness on the ice and stnig- of any neurtxlegenerative dist)Rler. side. All laboratory tests for treatable gling to curl as he aimed with the causes of cognitive impairment and skips hroom. Over subsequent Neurologic Examination motor dysftinction were negative or years, he began falling, particularly Initial neurologic examination (age normal. in the forward direction. By age 6S 66 years) was notable, with a score years, he also noied changes in his of 32/38 on the Kokmen Short Test Assessment and speech, with difficulty manipulating of Mental Status'^ witb mild difficul- Longitudinal Course his tongue and lips. Others described ties in attention, calculation, con- Ihe constellation of features and his speech as "slurred." By age 68 struction, and recall. His extraociilar findings initially was considered years, he had fallen numerous times, movements (vertical and horiztmtal most eonsistent with (~lll). albeit sustaining many bniises and laceni- saccades and pursuits) were essen- atypical. Longitudinal evaluations at tions, and he reported occasionally tially normal. He had moderately yearly intervals over the subsequent choking on liquids. By age 70 years, severe apmxia and rigidity in the years have demonstrated mild prth his limb dyspnixia was increasing left upper extremity, less so on the gression in his asymmetrie rigidity such that he could no longer button right side than on the left side, and apraxia. spastic dysartbria. buttons, tie shoes, or perfonn other with corticosensory loss on the left apraxia of speech, and protnincnt activities requiring fine motor dex- side as well. He had modcnite con- gait impairment. At each evaluation, terity. At age 71 years, he began ex- structional dyspraxia in drawing the client and his family reported hibiting mild emotional lability and complex figures. Increased lone tbat he had frequent tails; on one apathy. His cognition was viewed as (velocity-dependent resistance to occasion, a fall resulted in a deep

1080 Physical Therapy Volume 87 Number 8 August 2007 Locomotor Traitiing for Progressive Supranuclear Palsy/Corticobasal Degeneration

week at the dental office perfwrniing bookkeeping anil paperwork. Tlie cli- ent also attended church and a stxial group once a week. A chronologic;il index of his disease progression is shown in Table 1.

On initial examination, the client's sensation and kinesthesia were in- tact bilaterally, and passive range of motion and muscle strength (force- generating eapaeity) for all 4 extrem- ities were within functional limits. Vestibular testing was not per- formed. Tlie client did not report diz- ziness. The elient walked without an assistive device and was unsteady, exhibiting a wide base of support and short steps. He was unable tt> perform a secondary cognitive task while walking. He could not negoti- ate stairs without using both of his hands on the rails, and he was inde- pendent but unsafe in transitional movements. Although his speeeh was dysarthric, he was able tt> com- municate verbally.

Functional tests of balance and walk- ing performance were administered every 2 months, beginning in IVbru- Figure 1. ary 2003, at the university clinie. In- Client walking forward on treadmill at the YMCA. formed consent was obtained from the client to be photographed and laceration on his elbow that exposed exereise program for people with videotaped when he came in for the olecranon, rt-qiiiring sutures. PD. At that time, the elient was for- his first session. Testing was done Cognition and behavior ehanged mally diagnosed with atypical CBD by a team of 3 physical therapists minimally. His axial musele tone and by a neurologist specializing in this who were experienced in adminis- extnioeular movements remained in- rare disease at the Mayo Clinic. At tering the tests. Tlie same therapist taet until age 72 years when mild the time of his initial visit for physi- collected the same outcome mea- saeeadic pursuits on vertieal extraoc- eal therapy intervention, he lived at surements. The order of the out- ular movement testing were evident home with his wife, who perfonned come measures was rotated every and his eye-blink frequency de- all household chores and helped the session and included: (>Muiute creased significantly. At age 72 years, client with basie aetivities of daily Walk Test (6-MWT),"' comfortable a diagnt)si.s of mixed <;;BD and PSP living and instrumental activities of and fast gait speeds,'•" Berg Balanee best characterized his symptoms and daily living. He relied on family mem- Scale (BBS),'**'" limed "lip & Cio" clinical findings. bers for eommunity transportation. Test (TUG),^'> forward functional He no longer participated in recre- reach (FFR).-' backward ftinctional Physical Therapist Examination ational aetivities such as golf due to reach (BFR)/' right functit)nal reach and Evaluation his impaired balanee and apraxia. He (RFR),2i left ftinctional reach (LFR).-^' and the Shaqx-ned Romlx-r>i Test Tliis client was referred in 2O()3 (at chose to discontinue working with (SRT).-^ Tliese tests were chosen Ix.-- 70 years of age) to a university phys- patients in his dental practice due to eause they are reliable ;ind valid mea- ical therapy program clinic after ini- impaired balanee and speeeh difficul- sures of balanee and gait function in tially being reeruited for a research ties but continued to woric 3 hours per

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Table 2. therapist always present during the Sequence of Physical Therapy Interventions for Client With Progressive Supranuclear sessions. The exercise session Palsy (PSP) and Corticobasai Degeneration (CBD) started with 20 minutes of lower- Date Key for Vertical Physical Therapy Interventions extremity and tnink stretching :md a Lines in Figures 3 few lower-extremity strengthening and 4 exercises on a lloor mat. followed hy January 2l>0.^ Jtiint-d physical thfiapist-direcifd 10 minutes of upright balance and exercise jyoup for [x-ople with strengthening exercises and tread- Parkinstin disease (1 hour per session, mill walking. On the Life Fitness 2X/wk. began functkinal testing) treadmill (95OOnR or 95Ti)^ used at IVbmary l^K^^ Participated in 14-wk rehabilitation the YMCA program, the client program at the university physical walked backward for 10 minutes at a therapy clinic speed of 1.6 km/h holding on to the April 2005 Started ii.se of 4-whcel walker side rails and walked forward for 10 M;iy ims University physical therapy elinic ended minutes at a speed of 2.25 km/h u.s- for 2(K).-^; client eontinucd 2X/wk with ing unilateral arm stipport (Fig. 1). exercise gn)up These speeds were as fust as the cli- IVbniary 2004 University physical therapy clinic ent could safely walk. The client resumed; client coniinued 2X/wk with started in the group in Febmary 2003 exercise grutip (at age 70 years) and continued March 2004 lief-an body weight-supported treadmill throughout the 2.5-year follow-up training at ihe univeoiity physical period. He rarely missed a group therapy clinic session. July 2004 University physical therapy clinic ended for 2004; client continued 2X/wk with exercise group University-based Individual Physical Therapy Intervention January 2()0S University physical therapy clinic resumed Table 2 outlines the sequence of in- July Zm'j University physical iherapy clinic ended dividual physical therapy interven- f(»r 2iH)S; client continued 2X/wk with tions at the university clinic concur- exercise group rent with the exercise group intervention. The individtial treat- ment sessions were added, as avail- able, througliout the 2.5-year period various populations of older adults. Us- lomite 4-wheeIed walker* for ambu- to increase the intensity of interven- ing :i cutoff sc(5re of 50, the Bas has a lation tests. He walked with the exam- tions addressing the client s postural sensitivity of 85% for predicting future iner, following to the side of and instability. Figure 2 shows the tread- falls.-^^ Tlie FFR test used in people hehind liini, to ensure salety on the mill and body-weight-support har- with FD h;Ls a low sensitivity of 3()^> ambulation tests. ness at the university clinic. The cli- in predicting fiitua- talls.^' It was clear ent's physical therapy intervention the client had numerous f:Uls; thus, Community-based Group sessions at the university clinic in tlie balance measures were used to Exercise Intervention 2003 consisted of balance training, measure responsiveness of the inter- Tliroughout the 2.5-year interven- strengthening and stretching exer- vention. High intnirater reliahility has tion period, the client participated in eises. transitional movement prac- been reix>rted tor most of these mea- a physical therapist-designed exer- tice, gait training, stair training, antl sures in ixrople with PI),''* The lateni! cise group for people with PD at a safety education. Tliese 14 sessions reach tests were added 1 year into YMCA. His program was not altered lasted 60 minutes each. the follow-up when asyminetrical from that of the other participants limb apnixia Ixrcame more apparent with the exception that he was Each 2004 physical therapy interven- on the left side. Tiie refiahility and closely supervised. This group met tion session at the clinic involvetl 40 validity of data obtained with these for 1 hour twice weekly, with a phys- minutes of treadmill training with meastires has been dcK'umented for ical therapist or an occupational people with PO.^^-^^ Tlie cUent did the body-weight-support system. not use a walker for the (irst 2 testing • Dolomite Home Care Pn>ducts Inc, SO sessions, but thereafter he used a Do- Shields Ct, Markham, Ontario, c:ana(Ia L3R ^ life Fitness, 5KK) River Rd, Sthilkr Park, IL 60176.

1082 Physical Therapy Volume 87 Number 8 August 2007 Locomotor Training for Progressive Supranuciear Palsy/Corticobasal Degeneration

The client's falls while upright in all 4 directions indicated he was not aware of his limits of stability. Bal- ance activities in 4 directions with- out the use of hand support pro- vided movement control training. Speeds were increased to challenge him.

The client trained hy walking in each of 4 directions on a Marquette Series 2000 treadmill* supported hy a Bit> dex Offset Unweighting System^ set to unweighl 10% of hody weight. The sequence of walking direction (forward, hackward, left, and right) was randomly determined at each session. To optimize the locomotion training, verhal or tactile feedhack was given for proper upright posture while walking. The treadmill had a support bar in front of and to b

August 2007 Volume 87 Number 8 Physical Therapy • 1083 Locomotor Training for Progressive Supranuctear Palsy/Corticobasal Degeneration

Forward Mean-21 SD=5 CV (%)=24 25- Range-12-29 y-0.82x-(- 14 Right Mean-17 20- SD=4 CV (%)=24 Range-9-24 y-0.18x + 15

Left Mean^l 1 SD-2 CV(%)-19 Range=10-16 17

0 Feb-03 May-03 Aug-03 Nov-03 Feb-04 May-04 Aug-04 Nov-04 Feb-05 May-05 Aug-05 Test Interval Figure 3. Longitudinal performance on the functional reach tests in 4 directions. A line of best fit and linear equation are shown for each data series. A mean score, standard deviation, coefficient of variation (CV), and score range are shown for each data series.

as tlic data for gait speed and the In this case report, we have shown proved balance function, coupled (vMWI. The client's mean TOG functional outcomes throughout a with the observed reduction in fall score was IS seconds CSD=4). Over 2.5-year physical therapy interven- frequency, certainly is a positive out- the follow-up period, TllCi scores tion period in an individual with come for this client. ranged from 21 seconds initially to CBD and PSP. Tlie degree of variabil- 27 seconds at the end. Tlie coeffi- ity in the outcome measurements The trend for declines in measure- cient of variation for the walking over time (coefficients of variation ments of walking perfoniianee (gait tests and the IIJG ranged from 10% ranging from 10% to 25%) make in- speed, 6-MWT, TUG) is not as en- to terpretation of the longitudinal data couraging, especially because a main challenging. Thus, we chose a line of foeiis of the intervention was task- Discussion best fit througli the data points to specific for walking. Tlie progressive Most of the client s symptoms were illustrate trends in test performance nature of the client's disorder and consistent with underlying (^BI), al- over time. In light of this client s the effects of normal aging on walk- though the early and prominent gait chronic progressive neurological dis- ing peribrmance are both likely fac- impaimient and frecjuent falls are far order, we believe that even graphic tors contributing to these declines. more suggestive of PSP, and thust)ur trends with a relatively flat line of However, these declines in perfor- classitication of tliis case as mixed best fit suggest treatment effective- mance on walking tests should not CBD and PSP. The client's duration ness. We have interpreted the stable overshadow the fact that the client of symptoms (9 years, as of 2006) or slightly positive trends for the BBS maintained independence with already exceeds the median survival and the fimetional reach tests as sup- household ambulation with a time reported hy people with CBD port for this client s maintenance of 4-wheeled walker and maintained and PSP. He not only remains alive, balanee function over a time period eommunity amhutation with supervi- hut is ambulatory with a reasonable when decline could be expected. sion and the walker. In addition, our quality of life. This maintenance or slightly im- client and his wife sought out the

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Mean-1.0 Fast SD=0.1 y=-0.02x+ 1.18 CV(%)=10 Range=0.83-1.16

Comfortable y—0.01 x-K 0.95 Mean=0.84 SD=0.08 CV(%)=10 Range=0.67^1.04

6-Mrnute Walk Test y=-5.7x + 301 Mean=247 SD=38 CV(%)=15 Range=l91-301

)-03 May-03 Aug-03 Nov-03 Feb-04 May-04 Aug-04 Nov-04 Feb-05 May-05 Aug-05 Test Interval Figure 4. Longitudinai performance on measures of comfortable and fast gait speed and 6-Minute Walk Test. A line of best fit and linear equation are shown for each test series, along with mean score, standard deviation, coefficient of variation (CV), and score range. exercise program, and his readiness ple with these diseases. Minimal clin- between the 2 cases. In the present to exercise was evident from the ical differences on these tests for this case, the question of whether the start. The client reported that he was population would belp clinicians in- addition of weekly body-weight-su|> an active exerciser before bis disease terpret the changes made with indi- port treadmill training in the univer- began, altliougb he was not actively vidual clients. In a case report by sity clinic enhanced the client's per- exercising when he entered the prtv Suteerawattananon et ai" of an formance beyt)nd the twice*weekly gram. We believe that the motivation 8-week intervention with body- exercise program cannot be sup- of our client and his wile to continue weight-support treadmill training, ported by the data. There were no treadmill training and exercise on a the client with PSI* sbowed improve- clear trends suggesting an associa- regular basis was an important factor ment in balance and gait and a de- tion between intermittent changes in maintaining bis functional ambu- crease in falls. The difference be- in intervention intensity and changes lation status. tween the present case report and in functional performance over the the outcomes reported by Suteera- follow-up period. No otber literature was found witb wattananon et al may be explained similar long-term data on the effects by the difference in diagnosis, indi- The decrease in this client s func- of rehabilitation intervention on the vidualized therapy versus group ther- tional reach to the left side, but not progression of the condition of peo- apy, or the length of the intervention the other directions, may be due to

August 2007 Volume 87 Number 8 Physical Therapy 1085 Locomotor Training for Progressive Supranuclear Palsy/Corticobasal Degeneration

the fact that his left extremities, es- ous level of ambulation in his home (functional reach tests, TIJG, gait pecially his left arm, demonstrated and the community with the speed) similar to those used in more apraxic movements than the 4-wheeled walker. His falls since the Suteeniwattananon and colleagues' right extremities. The lasi 2 measure- last measurement period averaged case study oi' a client with PSP" ment .sessions demonstrated that his one fall per month. Any declines in because of the lack of longitudinal reach to the left side had plateaued balance (as measured by falls, BBS, or outcomes with these diseases. The around U) cm compared with ap- functional reach tests in 4 directions) reach in 4 directions of the client in proximately 17 cm on the right side. also would support the need for in- the present case report demon- This overall asymmetry in his left and creasing intervention related to this strated the most positive change. right limits of stability is different problem. The TlJt;, 6-MWT, and gait speed from the left and rigbt limits of sta- measurements demonstrated similar bility of other people his age.-^'' Al- Physical therapy intervention, as de- declines in this client, suggesting though we were not able tt) quantify scribed here, appears to have con- that only one of these measures the seriousness t)f tbe client's falls, tributed to maintenance of balance might be necessary. Tbe case higli- most falls reported in 2003 and early ftmction and a stowed decline in lights the evolving physical therapy 2004 caused nosebleeds, injuries re- walking pertbrmance for this client rt)le in providing ongoing interven- quiring stitcbes. the simultaneous with mixed features of C:BD and PSP. tion for people with chr<.)nic, pro- fall of a nearby person, or damage to We suggest that physical therapists gressive disorders. nearby objects. Ills wife reported continue to support decision making that most of bis falls later in 2004 and regarding interventions witb tiinc- in 2005 involved reaching from a sit- tional outcome measures. Another Dr Steffen provided concept/idea/project design and data analysis. All authors pro- ting position for an object (eg, re- option to support maintenance of mote control) and usually did not vided writing and data collection. A special function would be referral to a per- thanks to Will Cates, Ben Maschke, Beth involve injury, llius, we believe that sonal trainer or other supervising ex- Geboy, and Antoinette Spector, who as- there was not only a decrease in fall ercise personnel, with intennittent sisted with data collection and treatment frequency over the intervention pe- physical therapy reassessments. It is while they were physical therapist students riod, but also a decrease in fall sever- worth noting that the community- at Concordia University Wisconsin, and to ity. In addition to treadmill training Una La Licata for clerical support and Paul based exercise group was led by a Wangerin for statistical support. and exercise, undocumented cueing physical therapist with the assis- regarding safety was done in physi- tance of an occupational therapist. This work was presented at the World Par- cal therapy intervention sessions and kinson Congress; February 22-26, 2006; The intangible effect of additional Washington, DC. by family members. How this feed- therapeutic information from the back affected the fall outcomes can- skilled professionals needs to be con- This article was submitted June ! 6, 2006, atid was accepted March 12, 2007. not be separated out from the effects sidered when exercise groups for of the exercise protocol. people with balance disorders are DOI: 10.2522/ptj.20060166 lead by non therapists. The client continued to participate References in the exereise group and treadmill Summary 1 Itowt-r .|H, Maraganore DM, Mct^onncU SK, Rocca WA. IncicU-ncf of progri-ssivt- tniining at the YMCA after the time C^urrent medical interventions for cli- supninufU'ar palsy and niiiliipk- system al- of our reported follow-up. Based on niphy in Olmsicil County. MinncsoUi, ents witb CUD and PSP have not 1976 to 1990. Neurolofyy. 1997;49: the gait speed decline observed in been able to slow the progression of 1284-1288. our data, especially tbe decreasing these diseases. This case demon- 2 Uickson 1)W. Nturopatholof-ic (JiJftTcnii- distinction between fast and com- strates how a physical therapist- ation oi" pr<>}>rtssivf siipnmuclfar palsy and conicobxsal dcgcntniiioii. / Neural. fortable speeds, a decision was made designed inter\'ention, including ex- 4 to increase the treadmill speed for ercise and locomotor training on a 3 IJtvaii I. Update on pn)grfssivf stipranii- forward and backward walking with- treadmill, may have contributed to clcar palsy. Curr Neurol Neurosci Rep. 446 t)ut adding variability in tbe incline. maintenance of balance fimction 4 Rampcllo I. Butia V. RalTiuk- R. tt al. l»ri>- As of January 2007, the client contin- and slowing of decline in walking grf.ssivf supramiclcar palsy: a sysitmaiit ued to show improvement in that he function for a highly motivated rcvkw. Meurofnol Dis. 2(»()5;2():'l7y-18(». was walking backward on the tread- client with CBD and PSP. Tlie case 5 Boeve B, Lang A, Litvan I. <:orticohasa] degeneration and ils relationship lo pro- mill at 1.6 km/h and forward on the also shows the value of functional gressive siipraiun.kar palsy aiui fnniio- treadmill at 3.20 km/li using only outcome measures to validate and temponil deniemia. Ann ?^eurol. one upper extremity for support. He progress treatment interventions. 4 6 ZadikoftC, l^njt A. Apnixia in movement also continued to maintain his previ- We chose to use outcome measures diMirdcrs. Brain iCKISJiS: I |S()-1 i97.

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7 Litvan I. Manyone <^A, McKcc A, ft al. Nat- 13 Kokmen E, Smith . Verny M. ei al. commimity-dwelling elderly people: Six- with Parkinson s diseiLse? Arch Phys Med Progression of falls in pftstmortem- Minute Walk Test, liei^ Balance Scale, Rehahil. 2(M)2:83:S38-542. eonlirmed parkinsonian disorders. Mov Timed "Up & (io" Test, and gait speeds, 25 Steffeii.1 M. Mollinger \A. Age- and gender- Disord. I 'J<)9; I i :947-9S(). Phys Ther. 2OO2;«2:l2a-l37. related lesi iH'rfomiance in conmuinity- 10 Muller j. Seppi K, Stefanova N, et al. Freez- 18 Berg KO, Maki BE, Williams jL et al. Clin- dwelling adulls: Multi-directional Reacb ing of gait in postniorteni-eonfimied atyp- ical and lalxn-aiory measures of postural Test. Berg Balance Scale, sharpened Rom- ical parkinsonism. Mor Disord. 2OO2;I7: balanee in an elderly populatiiHi, Arch berg tests. Activities-specific Balance <^on- lOil-lO-iS. Phys Med Rehahil. 1992:73:1073-11)80, fidenee Scale, and Physical I'crtbrniancc Test. J Neurol Phys IJjer. 2(K)5;2«X4): 11 Suteerawattananon M. MacNeill B, Proias 19 llerg KO, WcKjd-Dauphinee SL, Williams Jl, 181-188. EJ. Supported ircadmill training lor gait Maki BE. Measuring balance in the elderly: and balance in a patient with progressive validation of an instrument. Can / i'uhlic 26 ClanningCG, Ada L, Jobnson JJ, McWIiirter supranuciear palsy. Phys Ther. 2OO2;82: Heaith. S. Walking capacity in mild to moderate 485-495. parkinson"s disease. Arch Phys Med Reha- 20 Podsiadlo I). Richardson S. The Timed "Up hil. 2OO6;87:,^71-375. 12 Sosner J, Wall ('.. Sznajder J. Progressive and(io : :i test of basic funclional mobility supranuclear palsy: clinical presentation for frail elderly person,s.7.4m (ieriatrSoc. 27 Dibble L, Unge M. Predicting falls in indi- and rehabilitation of two patients. Arch 1991;39:142-148, viduals with Parkinson disease: a recon- Phys Med Rehahii. 1993;74:'J37-5.W. sidtrration of clinical balance me^isures. 21 Newton R. Balance screening of an inner J Neurol i'hys Wer. 2006;30(2):6O-67. 13 Izzo K. DilA)renz« P, Roth A. Rehabilita city older adult population. Arch Phys tion in projyessive supranuclear palsy: Med Rehtthil. I997;78:587-59I. 28 Portney L, Waikins M. /'oundaiions of case repon. Arch Phys Med Rehahil. Clinical Re.warch Applications lo Prac- 6446 tice, 2nd ed. r.nglewody weiglu-supported treadmill training in l^irkinson s diseiLse; a randonii/ed controlled triiil. Arch Phys Meet Rehahil.

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