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 1078 • Physical Therapy Volume 87 Number 8 August 2007 Locomotor Training for Progressive Supranuclear Palsy/Corticobasal Degeneration 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 b<xly- erage annual incidence rate of PSP tality in people with PSP and weight-support treadmill training (new cases per 100,000 person- CBD.'^'" improved gait speed after 12 ses- years) was 5.3 for people aged 50 to sions over a 1-month period, but this 99 years. Progressive supranuclear Because no pharmacologic or reha- outcome was not retained at the palsy is almost nonexistent before bilitation therapy has been devel- 4-month follow-up. age 50 years, atid its occurrence in- t>ped 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