Physical therapist examination, evaluation, and intervention for a patient with West Nile virus paralysis: this case report describes a detailed course of rehabilitation for a patient with deficits incurred after infection with West Nile neuroinvasive disease.

West Nile virus (WNV) disease is a recently described emerging infectious disease in the United States, joining other emerging diseases including acquired immunodeficiency syndrome (AIDS), ehrlichiosis, Lyme disease, Ebola virus disease, dengue fever, and hantavirus pulmonary syndrome described during the last 30 years. West Nile virus has become a major public health concern in the Western Hemisphere. The 2003 WNV activity reported in the United States as of May 21, 2004, to the Centers for Disease Control and Prevention (CDC) included 9,862 human cases with 2,866 cases (29%) of neuroinvasive disease and 264 deaths in 45 states. (1) For several states, WNV has become the most common of the 6 reportable viral encephalitides. (1)

West Nile virus is an "arbovirus" (arthropod-borne virus). (2) Arboviruses are transmitted to humans by blood-feeding arthropods, including mosquitoes, sand flies, "no-see-ums," and ticks. (2) West Nile virus is in the family Flaviviridae, genus Flavivirus, which also includes and is antigenically related to Japanese encephalitis virus and St Louis encephalitis virus. (2) West Nile virus is transmitted primarily through the bite of mosquitoes that acquire the virus after taking a blood meal from infected birds. (2)

A majority of people who acquire WNV are asymptomatic (80%). (3) Common estimates are that 1 in 5 people who are infected (20%) develop a mild, nonspecific febrile illness (West Nile fever) and 1 in 150 (<1%) develop neuroinvasive disease. (3) The most characteristic presentation of West Nile neuroinvasive disease (WNND) is encephalitis with weakness; other neurologic manifestations include meningoencephalitis, acute flaccid paralysis (AFP), a poliomyelitis-like syndrome, optic neuritis, and seizures. (4-7) West Nile virus is of interest to physical therapists because WNND can cause injury to the anterior horn cell of the spinal cord, creating the need for physical therapy interventions for impairments of force generation (strength), functional deficits, and disability.

West Nile virus was first isolated from the blood of a febrile woman in the West Nile province of Uganda in 1937. (8) The first documented cases of human encephalitis due to WNV occurred in New York City in 1952, after patients with advanced cancer were inoculated with an Egyptian isolate with the hope that the virus might have an oncolytic effect. (9) Few cases of encephalitis were thereafter reported until epidemics of WNV encephalitis in Romania in 1996, in Russia in 1999, and in Israel in 2000. (10-12) The first US cases of WNV infection occurred in New York City in 1999. (13) Currently, the disease has been identified

in almost all parts of the United States.

Birds are the main hosts and reservoirs of WNV. (14) More than 200 species in the United States have been found to be infected, including American crows, hawks, bluejays, mourning doves, gulls, house sparrows, and American robins. (14) Several species of mosquitoes can acquire the virus after biting a bird with high-level viremia, and they then transmit their virus-laden saliva into warm-blooded hosts during subsequent feedings. The virus can over-winter in infected mosquitoes that enter a hibernating state in colder months and can be transmitted transovarially from an infected mosquito to its offspring. Mosquitoes of the genus Culex have been implicated most frequently as important vectors. (14) Several species of vertebrates can be infected by these mosquitoes, including horses, cats, dogs, and humans. Humans are considered to be a dead end for the virus because humans have low-grade, transient viremia, although with the 2002-2003 US epidemics, descriptions of transmission of WNV through blood and organ transplantation, in utero transmission, and probable breast milk transmission have been reported. (15-18) The viremias in both humans and horses are generally thought to be of insufficient magnitude and duration to infect feeding mosquitoes. (19) Other mammals that can be infected with WNV and can develop disease are not currently believed to be important amplifying hosts.

The incubation period of WNV infection is 3 to 14 days, with the frequency and severity of infection increasing with age. People older than 50 years of age have a higher risk for developing WNND. (13) With the estimates that 80% of people who are infected are asymptomatic, it can be reasonably estimated that hundreds of thousands of unreported cases of WNV occurred in the United States in 2003. The frequency of severe neurologic disease in the current epidemic suggests a more neurovirulent strain of the virus than the one classically associated with West Nile fever. The weakness and flaccid paralysis in some cases of West Nile menigoencephalitis were initially thought to represent an axonal variant of Guillain-Barre syndrome. (20) Clinical findings of acute asymmetric paralysis or weakness without paresthesias or sensory loss developing during an acute infectious process, with diminished or absent deep tendon reflexes in the affected limbs; findings of electromyography (EMG) and nerve conduction velocity (NCV) studies and postmortem studies; and pathology data support the localization of the injury to the anterior horn cells. (21) An acute poliomyelitis-like syndrome * appears to be a major central nervous system finding.

Culture of the WNV is rarely detected in humans because the level of viremia in humans is low and of short duration. Diagnosis of WNV infection in humans is usually made by the presence of WNV-reactive immunoglobulin-M (WNV-IgM) antibody enzyme-linked immunoassay in serum or cerebrospinal fluid (CSF). (2) The CSF findings may include mild pleocytosis with lymphocytic predominance, elevated protein, and normal glucose. (23) Central nervous system inflammation is identified via magnetic resonance imaging of the brain in 30% of patients with WNND with leptomenigeal or periventricular enhancement. (13) Patients with WNV receive supportive care because no specific treatment for WNV infection has been established as effective. Treatment drugs with in vitro efficacy are being investigated. Prevention of WNV infection is via avoiding exposure to infected mosquitoes. Currently, a WNV vaccine for humans is being developed.

At the time of onset of symptoms in the patient described in this case report, several authors (4,24) had described the outcomes of patients with WNV. In a community-based prospective case series of 16 patients, Sejvar et al (4) described 3 patients with AFP. These authors reported "no improvement in limb weakness" (4(p514)) for the 3 patients after 8 months, and the patients required "use of a wheelchair for ambulation." (4(p514)) The follow-up EMG data for these patients "suggested permanent motor neuron loss, indicating that significant recovery in weakness is unlikely." (4(p515)) No physical therapy or occupational therapy interventions were documented in this report.

Ohry et al (24) reported on a single patient with WNV and AFP. A 33-year-old woman was described as having areflexic tetraparesis, which "subsided into incomplete flaccid upper limb paresis" (24(p663)) at approximately 5 months after onset of symptoms. The patient was able to return to work as a secretary. The report included some information from the occupational therapist and physical therapist examinations of the patient, but details of the occupational therapy and physical therapy interventions were not provided.

The primary purpose of this report is to describe the physical therapist management for a patient with WNV and WNND and the patient's outcomes up to I year after onset of symptoms. A secondary purpose is to describe the physical therapist's approach to evidence-based care when faced with a relative absence of research literature addressing physical therapy for patients with WNND.

Case Description

History

A 55-year-old female in her usual state of excellent health became severely ill while bicycle touring in France 6 days after leaving her home in Colorado. Initial symptoms included acute severe bilateral anterior thigh pain with fever and chills, followed within hours by bilateral lower-extremity weakness. She was immediately hospitalized in Paris, and, on day 5 of her illness, she experienced sleepiness with some cognitive impairment and hallucinations, which were thought to be secondary to encephalitis. A lumbar spinal tap confirmed aseptic meningitis. Her past medical history included an L4-S1 microdiskectomy 5 years previously with full functional recovery. Prior to this illness, the patient worked as a physician assistant and was extremely active, regularly participating in hiking, biking, skiing, and triathlon events. The patient's desired outcomes at this time were to recover full motor function to allow her to return to her baseline level of physical activity and social roles, including returning to work.

Examination

The initial physical examination by the neurologist in Paris documented "significant proximal weakness of the left lower limb and moderate weakness in the distal muscles ... on the right side the proximal weakness was mild. The patellar and Achillean reflexes were absent, reflexes were present in the upper limbs." No additional details of the motor examination were recorded. Results of sensory testing were normal, and there were no bowel or bladder abnormalities.

The medical evaluation in Paris showed normal brain and lumbar computerized tomography (CT) scans, a negative Lyme serology, and a positive serum WNV-IgM. Clinical EMG and NCV testing demonstrated no evidence of demyelination and normal sensory amplitudes but did indicate motor axonal loss. An electroencephalographic analysis showed moderate diffuse slowing, and CSF analysis revealed 59 leukocytes with 91% lymphocytes, and no growth. The Pasteur Institute laboratory in France was unable to test for CSF-IgM for WNV or provide a sample of CSF to the CDC in the United States, but the encephalitis was presumed to be due to WNV.

The patient became more alert while receiving supportive care in Paris. Physical therapy in Paris was limited to the patient's spouse receiving instructions to facilitate mobility (eg, assisted transfers to a wheelchair) for the return flights to Colorado. On day 14 of her illness, the patient was transferred to an acute care hospital in Colorado, where her diagnosis of WNV (WNND with AFP) was confirmed. On day 17 of her illness, she was transferred to an inpatient rehabilitation hospital, where she was treated for approximately 3 weeks. The primary inpatient physical therapist did not make a formal diagnosis at that time, but using the diagnostic classifications described by Sheets et al (25) for patients with neuromuscular conditions, the patient's features were consistent with a force production deficit, type I (improvement expected). The patient also had functional limitations of gait and mobility and disability associated with being unable to work or participate in recreational activities such as hiking, skiing, and cycling. Sheets et al (25) included both general muscle strength in the range of 2+/5 to 3+/5, and difficulty with mobility as 2 of the key examination results for this diagnosis. This patient had both findings at the time of the initial inpatient rehabilitation examination.

Manual muscle testing (MMT) was used to assess the force production deficit (or impairment of strength). Manual muscle tests were administered by the inpatient and outpatient therapists using the principles and scoring system described by Kendall et al. (26) Kendall et al contend that MMTs are a "necessary part of diagnostic procedures in the field of neuromuscular disorders," (26(p39)) noting that MMTs were developed out of the care of patients with poliovirus. The use of MMT also is supported by Sheets et al, (25) who listed MMT as the single examination tool for impairments of strength. Hall and Brody described MMT as "the most fundamental of all strength tests" in their text on therapeutic exercise. (27(p72)) Manual muscle testing also has been described as the "method of choice for assessing the strength of patients whose muscle test grades fall below fair," (28(p5)) as was true for this patient.

The intrarater reliability of MMT scores for individual muscles has been reported to range from .71 to .93 using a Cohen weighted kappa, with the reliability of MMT scores for the proximal muscles higher than the reliability of MMT scores for the distal muscles. (29) Reese (28) and Clarkson (30) have both recently summarized the literature on the reliability of MMT scores. Clarkson (30) concluded, in part, that interrater reliability is lower than intrarater reliability. Reese found there to be "good intrarater reliability for MMT" (28(p10)) and observed that higher values have been reported for interrater reliability when the study designs included standardized methods of testing. We did not estimate the reliability of our measurements.

Once the patient returned to the United States, MMT was used as a component of her clinical examination by several members of the health care team, including an internist, a neurologist, a physiatrist, and physical therapists. Tables 1 and 2 display the results of the various MMTs documented during her inpatient community hospital stay, her inpatient rehabilitation stay, and her outpatient rehabilitation. The early MMT results were generally consistent with the findings of the initial neurologist in France, with primary deficits in the lower limbs and with the left side weaker than the right side. A comprehensive upper-extremity MMT conducted by an occupational therapist during the patient's inpatient rehabilitation stay revealed that MMT scores for all tested muscles were in the 4/5 to 5/5 range bilaterally. The interventions used by the occupational therapist are not included in this report.

The primary inpatient physical therapist also completed a functional assessment that focused initially on wheel chair mobility but within a week shifted to assessment of the patient's standing balance and ambulatory status. No formal outcome measures (eg, for balance, endurance, or quality of life) were used.

Interventions

This section primarily focuses on the interventions used during the outpatient rehabilitation care provided during week 8 after onset of the patient's illness and thereafter. This section includes a description of the rationale for the interventions, followed by the intervention details. The interventions used during the 3-week inpatient stay have been documented to the extent available in the medical record. The rationales for these interventions were not available.

Intervention rationale. The physical therapy interventions were developed by the primary outpatient physical therapist following the principles of evidence-based practice (EBP). A literature review was conducted using both medical and allied health reference databases such as PubMed and CINAHL. Key words used in the search included "West Nile virus," "West Nile neuroinvasive disease," "rehabilitation," "physical therapy," and "case report." The literature available at that time describing physical therapy interventions and functional outcomes of patients with WNND was scant. In the 2 reports described earlier, (4,24) the authors described the outcomes of patients with WNV and AFP. The patients described in these articles had recovery that ranged from 1 patient being able to return to work (24) to another who died and others who had no improvements in strength and remained nonambulatory. (4) The physical therapy and occupational therapy interventions for these patients were not detailed in either of these reports, but there was a suggestion that physical therapists and occupational therapists were involved in the care of the single patient with more substantial functional recovery (24) and that physical therapy and occupational therapy were not provided to the patients with poorer functional recovery. (4)

The primary outpatient physical therapist also elicited the input of physicians and physical therapists who were expert in the care of patients with neurologic disorders. Several of these experts noted the similarity in anterior horn cell pathology between WNV and acute poliovirus and recommended using interventions that had been used with patients with poliomyelitis from the poliovirus. Because the therapist was not personally experienced in the care of patients with acute poliovirus, she also conducted a review of this literature. The therapist had conducted an extensive search of the WNV literature, but did not feel that it was essential to complete as comprehensive a search of the large volume of poliovirus and post-polio syndrome (PPS) literature. This was primarily because she was not certain how relevant the information on poliovirus would be to this patient's care. To maximize efficiency, the therapist focused on secondary sources such as chapters from textbooks that summarized poliovirus and PPS and the rehabilitation of patients with these diagnoses. Based on this review, the therapist considered the 3 stages of poliovirus: acute (febrile), period of recovery or convalescence (from the time of resolution of the patient's fever to up to 2 years after onset of symptoms), and stable or chronic disability. (31,32) The therapist elected to try treatment approaches that had been used for patients in the poliovirus "period of recovery," reasoning that her patient might improve based on a combination of neuronal (terminal axonal) sprouting and muscle hypertrophy similar to that reported for patients with polioviris. (31) The interventions selected by the therapist included therapeutic exercises that varied in intensity, based on the strength of the muscles involved.

A very low-load, low-repetition approach was used to exercise the muscles with a MMT grade below 3/5. (27(p68)) In addition, the therapist attempted to reduce the functional demands of the muscles with grades less than 3/5 by use of assistive devices (eg, wheelchair, walker, cane), thereby providing support and protection of these muscles to avoid possible overuse injuries. The therapist also considered the need for substituting for these weak muscles by use of orthoses (eg, ankle-foot orthosis [AFO]) as needed. Muscles at the 3+/5 grade were exercised with caution. Specifically, the therapist determined a weight that the patient could complete through a full joint range of motion for 3 sets of 10 repetitions each. If, during an exercise session, the patient was not able to complete the full complement of 30 repetitions, either a lighter weight was used or the number of sets was reduced to 2. Muscles in the grades of 4/5 to 5/5 were exercised more aggressively by using a progressive resistive approach with a 10-repetition maximum as the training load. (33) In general, the therapist's approach was to provide as intensive an exercise program as the muscles could tolerate, without creating substantial post-exercise symptoms such as delayed-onset muscle soreness or overuse injuries, and to maximize function through support, protection, or substitution only to the extent they were necessary.

In deciding to aggressively strengthen this patient's involved muscles, the therapist did consider that some patients with poliovirus who had participated in an aggressive strengthening protocol subsequently developed PPS. (32,34) Patients with PPS can experience new onset of symptoms decades after their acute episode of poliovirus. (32,34)

The therapist had not been able to identify any literature that confirmed that patients with WNV or WNND were at risk for eventually developing symptoms similar to those of PPS. The therapist, however, did discuss her concerns with the patient about the possibility of symptoms associated with a "post-West Nile virus syndrome" (PWMVS). (35) Post-West Nile virus syndrome has been hypothesized (35) as a possible long-term outcome of WNND, but had not been documented in patients at the time of the discussion. Based on her age (55 years) at the time of onset of the WNND and the information about the PPS literature, the patient and therapist concurred that the best choice was to pursue the aggressive strengthening protocol to encourage a quicker and possibly more complete recovery. Specifically, they agreed that, given the patient's age, the anticipated benefits of improved strength and function for the next 20 to 30 years far outweighed the possible risk of diminished functioning in later life. This approach, they reasoned, represented the potential for improved quality of life for the patient in the intervening time period, and for this patient these benefits outweighed the concerns about the potential for future symptoms of PWNVS. The therapist also discussed with the patient the possibility of type II or secondary osteoporosis that might result from the patient's diminished strength. (33(p102))

In addition to the force production deficits, fatigue has been a symptom in some patients with acute poliovirus or PPS. As a consequence, the therapist was concerned about the potential effects of fatigue in this patient. The therapist reviewed Halstead's work on PPS, who acknowledged that "fatigue is an imprecise term with several meanings." (31(p17)) Fatigue in patients with PPS, according to Halstead, (31) can be of peripheral or central origin. Fatigue of peripheral origin would be evidenced by diminished force production with repeated contractions, (31) typically managed by lowering the resistance of the exercise, reducing the number of repetitions, or increasing the number or duration of rest breaks. (33(p64)) Central fatigue, in contrast, is "characterized by rapid onset of mild to extreme tiredness, generalized headache, difficulty in concentrating, and general malaise." (31(p17)) A therapist can evaluate for the presence of central fatigue by observing for signs and symptoms and by communicating with the patient. If present, central fatigue can be managed with increased number and duration of rest breaks, energy conservation techniques, and lifestyle modification. (34(pp33-35))

Other authors have used different terms but similar definitions in describing these 2 types of fatigue. For example, Paty and Ebers (36) described fatigue in patients with multiple sclerosis using the terms "fatigability" and "lassitude." Fatigability occurs when a "single muscle or group of muscles becomes weaker after repeated use," (36(p160)) a definition similar to Halstead's definition for peripheral fatigue. (31) Lassitude, in contrast, was defined as a "persistent sense of tiredness," (36(p160)) similar to Halstead's description of central fatigue. (31)

The therapist also was concerned at the beginning of the therapeutic exercise program about the possibility of fatigability (or peripheral fatigue) because of the patient's personality:

   A second concern was more specific to the patient's own
   personality. I felt she was motivated to the point she would
   over work innervated muscle groups and increase the
   chance of a setback due to overload or fatigue. I also
   discussed this with her, and we agreed to monitor her
   fatigue levels regularly.

In summary, the therapist blended the available literature and input from physical therapist experts, medical experts, and the patient with the therapist's own experience to develop the physical therapy interventions. Rehabilitation goals were focused on strengthening the weak muscles, thereby reducing or eliminating the functional limitations and disability, while monitoring the patient for symptoms of fatigue.

Intervention details. The course of care initially included aquatic therapy and advanced to progressive resistive exercises (PREs) on land. For the muscles of the left lower extremity below the strength of 3/5, patient positioning based on the Bobath neurodevelopmental treatment (NDT) (37) was initially used to improve muscle strength through co-contraction of the muscles around the joints of the lower limb (eg, quadruped and tall kneeling positioning, other kneeling activities). The therapist progressed the patient to gentle PREs, as tolerated. (27(p68))

Peripheral fatigue levels were frequently monitored by the patient's self report and by MMT of each of the exercised muscles to determine whether there was a transient loss of strength. Central fatigue was monitored through visual observation of and communication with the patient. Early in the outpatient rehabilitation, the patient was typically seen for physical therapy 2 to 3 times per week. Additional details of the interventions and functional activities are provided in Table 3.

As the treatments progressed, the therapist and patient became satisfied with the patient's functional gains (eg, progression in gait from wheeled walker to quad cane, eventually to single-point cane) and her reduction in disability (return to part-time work by week 22 after onset of symptoms). Based on these developments, and again in consultation with the patient, the interventions were modified. During week 24, the therapist provided a trial with a "knee cage" for the left lower limb to attempt to prevent genu recurvatum during the stance phase of gait. The use of this orthosis was rejected after a short trial because the weight of the orthosis actually diminished the quality of gait. When the patient wore the knee cage, the therapist observed that she was unable to initiate hip flexion at the beginning of the swing phase of gait, which the patient compensated for by hiking her hip on the swing side; she also demonstrated an increased posterior thrust of the trunk during the initiation of swing.

An AFO also was considered for the left lower extremity, but not actually tried. The use of the AFO was rejected based on the improving strength of the ankle dorsiflexor muscles. At week 22 after onset of symptoms, the patient began a Pilates-based strengthening class once a week and was swimming laps independently twice a week for 45 minutes per session. By week 34 after onset of symptoms, the individual outpatient physical therapy sessions occurred once a month, and the patient attended the Pilates-based strengthening class once a week. She was swimming 45 minutes 2 to 3 times per week, and hiking 1 to 2 times week with trek poles for 1 to 1.5 hours. The patient also attended an additional community outpatient physical therapy session 1 to 2 times per week. This session included 30 minutes of stretching followed by 30 minutes of conditioning and cardiac fitness work (eg, stationary bicycle, exercise "fitter," and stair-stepper) and PREs, most of which incorporated a weight-bearing component. At week 43 after onset of symptoms, the patient returned to work full-time, and as a consequence the time per week directly committed to her physical rehabilitation efforts decreased slightly. In addition, at about this time, she began a community-based rowing class in an 8-person shell in which the only adaptation was that she did not lift the shell in and out of the water. She also continued with a Pilates class in a private setting and an outpatient physical therapy exercise session, each 1 to 2 times per week.

Peripheral fatigue of individual muscles or muscle groups was not considered by the therapist or the patient to have been a limiting factor throughout her rehabilitation. Similarly, the patient did not demonstrate any signs or symptoms of central fatigue throughout the rehabilitation period described. Although no exercise or participation log was maintained during her rehabilitation, the patient was described by her therapist as adhering to all exercise and activity recommendations.

Outcomes

The functional gains achieved by the patient are incorporated into Table 3. At the beginning of her inpatient rehabilitation in Colorado, she was able to self-propel her wheelchair short distances independently, but was nonambulatory. She was able to begin gait with a front-wheeled walker within the first week of her inpatient rehabilitation stay (week 3 after onset of symptoms). Her early functional gains were focused on gait, with progression from a 4-wheeled walker to a wide-based quad cane at week 13 after onset of symptoms and to a single-point cane at week 18. Prior to the onset of WNND, the patient used an automobile with a manual (standard) transmission. After developing WNND, she was unable to operate the clutch with her left lower extremity. By week 13, she had changed to an automobile with an automatic transmission and was thereafter able to drive independently.

Overall, the patient achieved slow, steady functional gains. She was able to ambulate without any assistive device part-time at home by week 21, and she had begun some ambulation in the community with no assistive device by week 34. At the same time (week 34), she purchased a recumbent tricycle; by week 40 she was able to complete a 16-km road cycling trip using the tricycle. At week 43, the patient returned to full-time work as a physician assistant. She discontinued her use of the cane during week 49 and the only assistive devices or adaptations at 1 year (week 52) were the use of trekking poles bilaterally for hiking, the recumbent tricycle for biking, and use of the automobile with the automatic transmission.

Discussion

This patient achieved a high level of return during the year after onset of symptoms. As documented by MMT, the primary deficits of force production (strength) were reduced in the left lower limb, and eliminated in the right lower limb. Her impairments of mobility and gait were resolved, and the patient needed few adaptations in her daily living. She was able to return to work full-time at week 43 after onset of symptoms, and was able to resume recreational activities, including hiking, skiing, and cycling, which all were important goals of the patient. The patient had a substantially higher level of recovery compared with the 3 patients with WNV and AFP described in the report by Sevjar et al. (4) Her recovery appears similar to that experienced by the patient described by Ohry et al, (24) in which the patient had residual upper-limb weakness but was able to return to work. This patient's good recovery may have been due, in part, to her relatively young age and her high level of fitness prior to the onset of WNND. She also was extremely motivated and adherent to her rehabilitation program.

The observation of AFP in this patient combined with the absence of any substantial symptoms of fatigue is consistent with the patients with WNV described in a case series by Leis and colleagues. (38) Out of a group of 13 patients, 4 were reported to have AFP with meningoencephalitis, and 2 other patients had meningoencephalitis with primary symptoms of "disabling fatigue" with generalized weakness but "no objective muscle weakness." (38(p306)) The term "disabling fatigue" was not further defined by these authors. Muscle weakness was assessed by MMT using Medical Research Council grades. (38) None of the patients in this series had symptoms of both AFP and disabling fatigue. In the patient with WNND and AFP described by Ohry et al, (24) there was no specific mention of fatigue as a symptom. Additional reports are needed to determine whether this pattern of either substantial fatigue or AFP (but not both) is common in patients with WNND.

Finding, appraising, and applying the best available evidence is the basis of both evidence-based medicine and EBP and entail the integration of the best scientific research evidence along with clinical expertise and patient values. (39,40) This case illustrates the challenges of developing an evidence-based physical therapy plan of care for deficits incurred as the result of an emerging disease.

How does one proceed when application of EBP techniques yields just case reports and case series? The focused clinical question pertinent to the physical therapy intervention in this case was developed after reviewing the basic pathophysiology of WNV, poliovirus, and PPS and the literature on physical therapy for patients these conditions: "In adults with WNND with lower-extremity paresis (thought to be due to anterior horn cell injury), will treatment with a 'period of recovery' poliovirus approach result in maximum improvement in strength and function?" This question could not be definitively answered by review of the available research literature. The decision of how to manage the patient demanded the review and integration of the available literature with clinical reasoning and input from experts, the physical therapist, and the patient. Communications with the patient's local physician and neurologist also were combined with input from physical therapist experts familiar with poliovirus and PPS and the WNV neuroepidemiologist at the CDC. The experts consistently recommended strengthening the involved muscles, but there was not agreement about how intensive the strengthening approach should be. The therapist and patient jointly agreed to pursue a more aggressive approach after weighing what was known (and not known) about the possible risks and benefits. The use of such networking with experts may contribute to the decisions used to select the best possible interventions for a patient, especially when the patient has an emerging disease and the available research literature is quite limited.

We believe it is important to note that the therapist did not explicitly identify a physical therapist diagnosis at the time of care. The therapist, however, did recognize that the patient had muscle weakness, or force production deficits, and that they appeared to be reversible. Her review of the literature allowed her to generate a plan of care consistent with the interventions described by Sheets et al (25) for type I force production deficits. Therefore, in this case, although a diagnosis did not directly guide the interventions, the therapist did use interventions that are consistent with the classification identified later.

This case report has several important limitations, including the assessment of muscle strength and the selection of outcome measures. Motor function was assessed in this patient by use of MMT, which we selected because the patient's primary impairment was lower-limb strength deficits. Use of MMT may facilitate communication among different members of the health care team (eg, physicians, physical therapists, occupational therapists) because it is in common use across disciplines. Unfortunately, the reports of the patient's motor function were a challenge to follow, especially early in her care. The initial examiner, the neurologist in France, used a general description of the pattern of weakness, using terms such as "proximal," "distal," "significant," "moderate," and "mild." The overall picture of more weakness in the left lower extremity than in the right lower extremity emerges from this record, which is a consistent pattern across examiners and over time. Upon the patient's return to the United States, several physicians also completed components of lower-limb MMTs, and the results of their testing are represented in Tables 1 and 2. The US-based neurologist used a traditional approach to MMT, using numbered grades. A physiatrist 2 days later used a qualitative description of motor function. The same pattern of left-sided weakness greater than right-sided weakness emerged, but use of terms such as "particular weakness" and motor function that was "functional" and "diminished" rendered this assessment much less helpful in following the progress of recovery of strength and function.

In the early testing by several examiners, there appeared to be inconsistencies among examiners (eg, MMT grades for the left lower extremity obtained on the same day by the first physician and the physical therapist). Although these inconsistencies may have been due to actual variability in the patient's responses, we suspect they were more likely due to differences in MMT techniques or imprecision by 1 or more of the examiners. The variability of MMT grades in this patient across examiners also might be explained by the observation that interrater reliability of MMT scores is generally lower than intrarater reliability. (30) More consistent use of MMT principles such as those advocated by Kendall et al (26) may have added to the understanding of this patient's progress.

The assessment of the patient's force production deficits could have been documented in other ways, such as by use of isokinetic testing, handheld dynamometry (HHD), or some other force measurement system. For example, Gross and Schuch (41) elected to use isokinetic testing in a case report of a patient with PPS. Handheld dynamometry also has been used to document force production. (42) Handheld dynamometry has been reported to be more sensitive to change than MMT in patients with spinal cord injury. (42) Force measurements also can be documented with an electronic strain gauge system. Brussock et al used such a system to assess strength in children with and without Duchenne muscular dystrophy and concluded that their system was a "valid and reliable method of measuring isometric force in children with and without [Duchenne muscular dystrophy]." (43(p112))

We believe the description of the patient's recovery would have been enhanced by use of 1 or more functional outcome measures. (44) For this patient, the measures might have included the Berg Balance Scale to measure balance impairment, (44(p93)) the 6-Minute Walk Test to assess exercise tolerance, (44(p248)) the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) to assess perceived health status, (44(p210) or measurement of gait speed (44(p152)) or some other component of gait analysis (45) to better document the observed changes in gait. We do not know whether the use of 1 or more of these outcome measures would have substantially altered the pattern or extent of the patient's recovery. We do believe that they would have provided a more sensitive assessment of the ongoing changes in the patient's status and thereby provided a more comprehensive description of her progress. Another limitation is that, as a case report, this work cannot demonstrate causality or provide any evidence of treatment effectiveness or efficacy. The report also is limited by the relatively short-term follow-up of the patient. We therefore can provide no conclusions about the long-term consequences of the condition. Long-term follow-up of patients with WNND will be helpful in determining whether such patients develop symptoms of PWNVS similar to those found in people with PPS.

Many questions remain about the physical therapist examination and care of patients with WNND. Future research is needed to better document the outcomes of patients with WNND, including information about possible effects of patient's age and premorbid health status. Future reports also should provide additional details about the course of recovery, and should attempt to identify the essential features of optimal physical therapy interventions. This might include linking patients with WNND to 1 or more of the preferred physical therapist practice patterns as described in the American Physical Therapy Association's Guide to Physical Therapist Practice, (46) which may help frame and organize future physical therapist management of patients with WNND.

Conclusions

This case report appears to be the first to describe a detailed course of rehabilitation for a patient with deficits incurred as a result of WNND. The report also includes an approach for determining a physical therapy plan of care for a patient with an emerging disease. Over a 12-month period, this patient's progress included a steady, but incomplete, improvement in lower-limb strength. She had substantial functional gains, including achieving independent gait with a single-point cane, independent driving, and returning to full-time work. This is 1 of only a few published reports in which a patient with WNND achieved a high level of functional recovery.

This article was received June 2, 2005, and was accepted December 19, 2005.

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* Poliomyelitis is a clinical syndrome defined by the presence of fever, meninigitis, and flaccid paralysis. (22) In the past, this syndrome was associated with infection by poliovirus, although this syndrome can be caused by many viruses, including enteroviruses, echoviruses, Coxsackie viruses, and other flaviviruses. (22) Pathologic confirmation of poliomyelitis in people with WNV has been obtained, and when describing the pathology, inflammation (iris) of the spinal cord (myelos) gray matter (polios) is termed "poliomyelitis." Differentiation among the varying etiologies of poliomyelitis must be made on the basis of serology or virus isolation via culture. (22) Use of the term "poliomyelitis" continues to be confusing in the lay and medical literature because the term is commonly assumed to infer infection by the poliovirus rather than the pathological description of inflammation of the spinal cord gray matter. West Nile neuroinvasive disease, by this pathologic definition, can be accurately termed "WNV poliomyelitis" or "WNV poliomyeliris-like syndrome." (22)

Nancy H Miller, David J Miller, Joanna L Goldberg

NH Miller, MD, is Assistant Professor of Pediatrics, Department of Pediatrics, Baystate Medical Center, Springfield, Mass. Address all correspondence to Dr Miller at Baystate Children's Hospital, General Pediatrics and Adolescent Medicine, 3300 Main St, 4th Floor, Springfield, MA 01199 (USA) ([e-mail]).

DJ Miller, PT, PhD, is Professor and Chair, Department of Physical Therapy, Springfield College, Springfield, Mass.

JL Goldberg, PT, BS, is Physical Therapist, Neurologic and Orthopedic Rehabilitation Center at Mapleton, Boulder Community Hospital, Boulder, Colo.

All authors provided concept/idea/project design, writing, data collection and analysis, and consultation (including review of manuscript before submission). Dr NH Miller and Dr DJ Miller provided project management and clerical support. Ms Goldberg provided the patient, facilities/equipment, and institutional liaisons.

This work was presented as a poster presentation at the Combined Sections Meeting of the American Physical Therapy Association; February 23-27, 2005; New Orleans, La.

Table 1.
Manual Muscle Testing (MMT) of Left Lower Extremity After Patient
Returned to the United States

                           Initial (a)     Progression (Note
                                           Irregular Intervals)

Week post-onset            3       3       5         6       8

Setting (b)                CH      CH      IR      IR      OR
Examiner (c)               MD      PT1     PT2     PT3     PT4

Muscle Group
Hip
  Flexors                  2       2       2+      3-      2-
  Extensors                2       M       2-      M       M
  Abductors                M       3-      2-      M       2+
  Adductors                M       3-      2-      M       M

Knee
  Flexors                  2       3-      M       3       2+/3-
  Extensors                2       3-      2-      3-      2

Ankle
  Dorsiflexors/inverters   4-      3+      3       3       1+/2-
  Plantar flexors          4+      3+      3+      M       2+
  Evertors                 M       M       M       M       M

                           Progression (Note
                           Irregular Intervals)

Week post-onset             12      18      25      29

Setting (b)                OR      OR      OR      OR
Examiner (c)               PTA     PTA     PTA     PTA

Muscle Group
Hip
  Flexors                  2-      2+      2+/3-   3-/3
  Extensors                2       2+/3-   3+      2+/3-
  Abductors                2-      3-      3-      3-
  Adductors                M       M       M       3+

Knee
  Flexors                  2       2+      M       3/3+
  Extensors                2+      2+/3-   3+      3+/4-

Ankle
  Dorsiflexors/inverters   2+      2+      M       3+/4-
  Plantar flexors          2-      2       3-      3-
  Evertors                 2+      M       M       4+

                           Progression (Note
                           Irregular Intervals)

Week post-onset             34      38      43      49

Setting (b)                OR      OR      OR      OR
Examiner (c)               PTA     PTA     PTA     PTA

Muscle Group
Hip
  Flexors                  3+/4-   4-      5-      5
  Extensors                3+      3+      3+      3+/4-
  Abductors                4       4       4-      4
  Adductors                M       2+/3-   3-      3

Knee
  Flexors                  4       4       4       4
  Extensors                3+      4-/4    4       4+

Ankle
  Dorsiflexors/inverters   4       4       4       5
  Plantar flexors          2+/3-   2+/3-   3-      3
  Evertors                 4+      4+      5-      5-

(a) A second physician assessed motor function the same week but did
not use MMT grades, rather strength was described as: lower-extremity
weakness, left greater than right; proximal weakness in quadriceps
femoris muscle, left and right; particular weakness in hip and knee
flexors, left greater than right; foot dorsiflexion and plantar
flexion are functional and diminished in left foot.

(b) CH = community hospital, IR = inpatient rehabilitation hospital,
OR = outpatient rehabilitation.

(c) MD = physician; PT1, PT2, PT3, and PT4 = the 4 physical therapists
who completed the described MMTs; M = missing value.

Table 2.
Manual Muscle Testing (MMT) of Right Lower Extremity After Patient
Returned to the United States

                           Initial    Progression (Note Irregular
                           (a)        Intervals)

Week post-onset             3     3    5     6     8     12     18

Setting (b)                CH    CH    IR    IR    OR    OR      OR
Examiner (c)               MD    PT1   PT2   PT3   PT4   PT4     PT4

Muscle Group
Hip
  Flexors                  4     3     3+    3+    3+    3+      5
  Extensors                M     M     M     M     M     3-      5-
  Abductors                M     4-    3     M     3     3-      5-
  Adductors                M     4-    3     M     M     M       M

Knee
  Flexors                  4     4     M     3+    3+    3+/4-   5
  Extensors                M     3+    3     3+    3     4+      5-

Ankle
  Dorsiflexors/inverters   M     3+    3+    3+    3-    4+      5
  Plantar flexors          M     4     4     3+    3+    3+      3+
  Evertors                 M     M     M     M     M     5       M

                           Progression (Note Irregular Intervals)

Week post-onset            25    29     34    38    43     49

Setting (b)                OR    OR     OR    OR    OR    OR
Examiner (c)               PT4   PT4    PT4   PT4   PT4   PT4

Muscle Group
Hip
  Flexors                  M     5      5     5     5     5
  Extensors                M     5      5     5     5     5
  Abductors                M     5      5     5     5     5
  Adductors                M     5      M     5     5     5

Knee
  Flexors                  M     5      5     5     5     5
  Extensors                M     5      5     5     5     5

Ankle
  Dorsiflexors/inverters   M     5      5     5     5     5
  Plantar flexors          M     5      5     5     5     5
  Evertors                 M     5      5     5     5     5

(a) A second physician assessed motor function the same week but did
not use MMT grades, rather strength was described as: lower-extremity
weakness, left greater than right; proximal weakness in quadriceps
femoris muscle, left and right; particular weakness in hip and knee
flexors, left greater than right; foot dorsiflexion and plantar
flexion are functional and diminished in left foot.

(b) CH = community hospital, IR = inpatient rehabilitation hospital,
OR = outpatient rehabilitation.

(c) MD = physician; PT1, PT2, PT3, and PT4 = the 4 physical
therapists who completed the described MMTs; M = missing value.

Table 3.
Details of Interventions and Functional Activities (a)

Week(s) Post-onset
and Setting              Interventions and Activities

Week 3                   IR, admitted mid-week, initially was
  (IR second half)         nonambulatory but able to independently
                           propel wheelchair short distances.
                         Note: For IR during weeks 3-6, physical
                           therapy was typically completed twice a day
                           on weekdays and once a day on the weekend
                           days. All sessions were scheduled for 30
                           minutes.
                         Began initial gait training with FWW on level
                           surfaces up to 91.4 m with supervision,
                           initiated recumbent stationary bicycle for
                           10 min at level 16 (low resistance), gait
                           training on stairs with bilateral railings
                           ascending and descending leading with right
                           lower limb (10.2- and 15.2cm steps), and
                           transfer training (car transfers and toilet
                           transfers to and from wheelchair).

Week 4 (IR)              Gait training with FWW on level surfaces up
                           to 152.4 m with supervision; mat exercises
                           for right lower extremity, including
                           short-arc quadriceps femoris muscle
                           extension (active knee extension from
                           30[degrees] of flexion to full extension);
                           hip flexion and abduction in supine
                           position with assistance as needed; trunk
                           stability exercises (repetitions not
                           documented in physical therapy record);
                           continue recumbent stationary bicycle (10
                           min at level 1) and gait training on stairs
                           with bilateral railings ascending and
                           descending and leading with right lower
                           limb (10.2- and 15.2-cm steps) with contact
                           guarding. Added side-stepping and braiding
                           (gait with steps crossing over midline)
                           activities; sit-to-stand practice using
                           surfaces 40.6 cm high; and gait training
                           with FWW on uneven terrain, including
                           7.6-cm curbs and 15.2-cm stairs with
                           contact guarding.

Week 5 (IR)              Gait training with FWW 91.4 m-152.4 m,
                           independent on level surfaces, gait on
                           stairs with railing with standby assist,
                           gait in community and on uneven surfaces
                           with FWW with supervision. Community
                           outings with FWW, including ramp and curb
                           negotiation, and initiated gait training
                           with bilateral axillary crutches. Increased
                           duration of exercise on recumbent
                           stationary bicycle to 15 min, remaining at
                           level 1. Strengthening activities for lower
                           extremities, including gluteal muscle sets
                           (isometric contractions of bilateral
                           gluteus maximus muscles while positioned
                           prone), heel slides (in supine position,
                           with knee flexion and extension while
                           maintaining heel in contact with mat
                           table), and standing squats. The
                           repetitions and rest breaks for these
                           strengthening activities were not
                           documented in physical therapy record.
                           Aquatic therapy initiated, 45-60 min
                           walking and bilateral lower-extremity
                           exercises in pool.

Week 6 (IR)              Discharged mid-week
                         Initiated gait training with 4WW, independent
                           on level surfaces and uneven terrain
                           (> 152.4 m). Standing squats, side stepping
                           with use of handrails, short-arc quadriceps
                           femoris muscle extensions, heel slides,
                           gluteal muscle sets (repetitions and rest
                           breaks not documented in physical therapy
                           record).

Week 7                   No physical therapy.

Weeks 8-12               Initial outpatient physical therapy;
                           land-based physical therapy 1 x per week
                           and aquatic physical therapy 1 x per week.

Indoor pool              Gait in chest-deep water for warm-up,
                           including forward, sideways, and backward
                           directions. In sitting position (pool
                           bench, chest deep), seated bicycle,
                           full-arc knee extension and marching (3 x
                           10 x 15). Sit-to-stand from pool bench (1 x
                           10) using a 3-s count for both raising and
                           lowering. Standing in chest-deep water:
                           squats, open-chain active hip flexion,
                           extension, and abduction on right,
                           bilateral heel-toe raises, standing knee
                           flexion, 15.2cm step-ups (2 x 10 x 15).
                           Standing in chest-deep water in aquatic
                           parallel bars: reverse trunk curl-ups,
                           lower trunk rotation (2 x 10 x 15 each),
                           single-leg balance, and grapevine
                           (crossover side stepping). Forward crawl
                           with floatation waist belt (10 min).

Strength                 Active co-contraction of bilateral knee
                           extension/flexion and hip extension/flexion
                           on gravity-reduced equipment (Total Gym
                           (c)) with 0[degrees]-60[degrees] of hip
                           range of motion for squats and bilateral
                           heel raises (2 x 10 x 15). All Total Gym
                           exercises were completed with the inclined
                           slide set to a slope of 18.2%. Seated
                           full-arc knee extension on the right
                           (open-chain active knee extension from
                           maximal flexion to full extension in a
                           sitting position) (2 x 10 x 15), prone knee
                           flexion, right (2 x 10 x 15), side-lying
                           clamshell exercise right (starting in
                           side-lying position with hip flexion to
                           60[degrees] and knee flexion to
                           90[degrees], then moving into active hip
                           lateral [external] rotation while keeping
                           the feet together) (2 x 10 x 15), seated on
                           55-cm exercise ball, pelvic circles and
                           pelvic tilts (1 x 20 each), and seated
                           balance on exercise ball without
                           upper-extremity support.

Cardiovascular/warm-up   Recumbent stationary bicycle (5 min,
                           level 1).

Proprioception           Single-leg balance activities on the right in
                           parallel bars with bilateral upper-
                           extremity assistance as needed on flat
                           surface.

Functional training/     Sit-to-stand with an emphasis on control from
  activities               heights between 45.7 and 61.0 cm, with 3-s
                           count each direction (2 x 10), 8.9-cm steps
                           with right lower extremity leading while
                           ascending and descending, with upper-
                           extremity assistance, pre-gait activities
                           in parallel bars in preparation for gait
                           with WBQC, with progression to gait
                           training with WBQC on level surfaces and
                           stairs (contact guarding).

Weeks 13-15              Outpatient physical therapy, land based 2x
                           per week; independent pool exercises and
                           activities 2-3x per week.

Indoor pool              10- to 20-min forward crawl with floatation
                           waist belt, single-leg balance activities
                           in waist-deep water, 3-way leg lifts,
                           squats, heel raises, marching, standing
                           knee flexion, toe raises, and sit-to-stand
                           (3 x 10 x 10 each).

Strength                 Seated leg press, 13.6 kg (3 x 10 x 15).
                           Quadriceps femoris muscle extension on the
                           right starting in 110[degrees] of knee
                           flexion, extending with resistance to
                           90[degrees] of knee flexion, 6.8 kg (1 x
                           10 x 15), seated hamstring muscle curl with
                           6.8 kg (2 x 10 x 15), developmental
                           positions of quadruped, kneeling, and tall
                           kneeling with manual perturbations from
                           therapist at shoulder and pelvic girdles to
                           elicit and reinforce co-contraction of
                           postural muscles. Exercise ball activities:
                           pelvic circles, neutral spine position with
                           lower-extremity marching and knee
                           extension, roll-outs (posterior pelvic tilt
                           and posterior lean of the trunk, attempting
                           to engage rectus abdominis muscle with
                           return to neutral sitting, with no use of
                           hands while retaining balance) and bridging
                           (3 x 10 x 15).

Cardiovascular/warm-up   Recumbent stationary bicycle (5 min, level
                           3), stair-stepper with 10.2cm step for 5
                           min.

Proprioception           Dynamic balance activities on 20.3-cm foam in
                           parallel bars and mini-trampoline (ball
                           toss, marching), single- leg balance on
                           right in parallel bars.

Functional training/     Transfer training to automobile and back from
  activities               4WW and with WBQC, independent by week 14.
                           Gait training with WBQC on right side,
                           independent with level surfaces indoors
                           > 152.4 m, progressing to WBQC outdoors,
                           including 5% grade, curbs, and stairs with
                           contact guarding. Initiated driving with
                           change from manual/standard transmission to
                           automobile with automatic transmission.

Weeks 16-21              Outpatient physical therapy, land based 2x
                           per week; independent pool exercises and
                           activities 2-3x per week.

Indoor pool              Gait in waist-deep water (4 laps of 11 m
                           each, for each of the following directions:
                           forward, side stepping, and backward),
                           squats, leg raises, toe raises, heel
                           raises, marching, step-ups (3 x 10 x 15).
                           Sit-to-stand practice (2 x 10) and
                           single-leg balance activities.
                           Forward-crawl lap swimming with floatation
                           waist belt 10-15 min.

Strength                 Seated leg press, bilaterally using 18.1 kg
                           (3 x 10 x 15), right using 13.6 kg (3 x
                           10 x 15), left using 4.5 kg (3 x 10 x 15);
                           seated hamstring muscle curl (6.8 kg, 3 x
                           10 x 15), multi-hip machine; hip extension,
                           left 4.5 kg, (1 x 10), right 9.1 kg (2 x
                           10 x 15); hip abduction, left 6.8 kg (2 x
                           10 x 15), right 9.1 kg (2 x 10 x 15); hip
                           flexion, left 4.5 kg (2 x 10 x 15), right
                           9.1 kg (3 x 10 x 15); activities on a
                           55-cm-diameter exercise ball, including
                           pelvic circles, roll-outs, bridging, and
                           neutral spine in sitting position with
                           marching (3 x 10 x 15 each).

Cardiovascular/warm-up   Recumbent stationary bicycle (level 3, 5
                           min), stair-stepper (15.2 cm step, 5 min).

Proprioception           Dynamic balance activities on 20.3-cm foam
                           (marching and ball toss), single-leg
                           balance activities in parallel bars,
                           marching on mini-trampoline.

Functional training/     Gait training, independent with single-point
  activities               cane on level surfaces and 15.2-cm stairs
                           with railings indoors; able to ambulate
                           short distances with no assistive device
                           indoors. Began downhill skiing with chair
                           ski and double poles.

Weeks 22-26              Outpatient physical therapy 1 x per week for
                           assessment of muscle strength and
                           modification of home program as needed;
                           independent pool exercises and activities
                           2-3x per week, community-based exercise
                           class 2x per week; Pilates-based
                           rehabilitation on Reformerd with Pilates
                           instructor 1 x per week.

Indoor pool              Independent lap swimming 2-3x per week
                           (approximately 30 min/session).

Strength                 Community-based exercise class (1 h) with
                           physical therapist, class ratio 8:1, 1/2-h
                           stretching, mat-based core strengthening,
                           and 1/2 h of weight room machines (leg
                           press, multi-hip, hamstring muscle curl),
                           and cardiovascular equipment (stair-
                           stepper, recumbent stationary bicycle).
                           Also began Pilates-based rehabilitation on
                           Reformer 1:1 with Pilates instructor
                           (45-min sessions).

Propriception            Heel-to-toe gait, braiding and lunge walking
                           with contact guarding by therapist or
                           spouse.

Functional training/     Gait training using reciprocal or step-over
  activities               step method on 20.3-cm stairs with narrow-
                           based quad cane. Gait training outdoors
                           with bilateral single-point canes on level
                           surfaces, 5% grade, and 15.2cm (6-in)
                           curbs. Gait training indoors on level
                           surfaces without assistive device. Returned
                           to work part-time.

Orthotic assessment      Assessed gait with use of ankle-foot orthosis
                           vs knee cage on left lower limb and
                           narrow-based quad cane. Both orthoses
                           rejected for use.

Weeks 27-30              Outpatient physical therapy once every 2-3 wk
                           for assessment of muscle strength and
                           modification of home program as needed;
                           independent pool exercises and activities
                           4-5x per week, community-based exercise
                           class 2x per week; Pilates-based
                           rehabilitation on Reformer with Pilates
                           instructor 1 x per week.

Indoor pool              Gait in waist-deep water forward, sideways,
                           backward 4-6 repetitions each, 3-way leg
                           raises, squats, heel raises, toe raises,
                           marching, knee flexion in standing (3 x
                           10 x 15), 45-min forward crawl with use of
                           waist-belt floatation device. Also
                           continued independent lap swimming 4-5x per
                           week (approximately 45 min/session).

Strength                 Pilates-based rehabilitation on Reformer
                           (45 min) and continued other strengthening
                           activities as in weeks 22- 26. Added a hip
                           abduction against gravity with lateral
                           rotation (clamshell) exercise in side-lying
                           position (3 x 10 X 15); standing with
                           open-chain active hip flexion, extension,
                           and abduction (3 x 10 x 15); community-
                           based exercise class with weight machines
                           2x per week.

Proprioception           Grapevine (crossover side stepping),
                           braiding, and lunge walking without
                           assistance or assistive device, near wall
                           for balance as needed.

Functional training/     Ascend and descend 15.2- and 20.3-cm stairs
  activities               without assistive device independently.
                           Floor transfer training to and from various
                           level surfaces with contact guarding.
                           Independent hiking on level surfaces and
                           grades up to 10% with bilateral trek poles
                           (3.2 km).

Weeks 31-44              Outpatient physical therapy 1x per month for
                           assessment of muscle strength and
                           modification of home program as needed;
                           independent pool exercises and activities
                           4-5x per week, community-based exercise
                           class 1-2x per week; Pilates-based
                           rehabilitation on Reformer with Pilates
                           instructor 1-2X per week, independent
                           hiking, rowing class.

Indoor pool              Independent lap swimming 4-5x per week
                           (approximately 45 min/session).

Strength                 As in weeks 27-30. Pilates-based
                           rehabilitation on Reformer 45 min 1-2x per
                           week. Step downs (10.2 cm) and lateral dips
                           (10.2 cm) with a focus on eccentric control
                           of quadriceps femoris muscles bilaterally.

Cardiovascular           Hiking on level surfaces with bilateral trek
                           poles 1-2x per week for 1-1 .5 h; rowing in
                           8-person shell 3x per week (duration not
                           documented).

Proprioception           Braiding, heel-to-toe walking, and single-leg
                           balance activities on the right near a wall
                           for balance as needed.

Functional training/     Gait training without assistive device on
  activities               level surfaces and stairs with railings,
                           indoors and outdoors. Continued to use
                           single-point cane for work and community
                           outings. Purchased and began to use
                           recumbent tricycle. Returned to work
                           full-time in week 43.

Weeks 45-52              Outpatient physical therapy once every 6 wk
                           for assessment of muscle strength and
                           modification of home program as needed;
                           independent pool exercises and activities
                           4-5x per week, community-recreation center
                           exercise class 4-5x per week; Pilates-based
                           rehabilitation on Reformer with Pilates
                           instructor 1-2x per week, independent
                           hiking, rowing class.

Indoor pool              Independent lap swimming 4-5X per week
                           (approximately 45 min/session).

Strength                 As in weeks 31-44. Patient stopped
                           community-based class at outpatient
                           physical therapy facility and transitioned
                           to independent gym program for her
                           swimming, cardiovascular exercises, and
                           weight machine regimen (details not
                           available). Pilates training was
                           transitioned to a private facility for
                           continued use of Reformer 1x  per week.

Cardiovascular           Hiking 1-2 h 1-2x per week on rolling terrain
                           with bilateral trek poles, including 8-km
                           hike with 304.8-m elevation. Rowing in
                           8-person shell 3X per week (duration not
                           documented); see also independent gym
                           program under strength.

Functional training/     Completed >25.7-km ride on tricycle;
  activities               independent with floor transfers;
                           independent with gait with no assistive
                           device in home and community and at work.

(a) The term independent" is used as defined in: Pierson FM, Fairchild
SL. Principles and Techniques of Patient Care. 3rd ed. Philadelphia,
Pa: Saunders; 2002:128. IR = inpatient rehabilitation, FWW =
front-wheeled walker, 4WW = 4-wheeled walker, WBQC = wide-based quad
cane. Numbers in parentheses refer to sets and repetitions (eg, 2 x 10
would indicate 2 sets of 10 repetitions). A third number, if present,
indicates duration of rest (in seconds) between sets (eg, 2 X 10 X 15
would indicate 2 sets, 10 repetitions in each set, With 15-second rest
between sets).

(b) Resistance for the recumbent bicycle is as follows: levels 1-3 =
low resistance, levels 4-6 = moderate resistance, and levels 7-8 =
high resistance. No other quantification of resistance was available.

(c) Engineering Fitness International Inc, 7755 Arions Dr, San Diego,
CA 92126.

(d) Balanced Bode, 8220 Ferguson Ave, Sacramento, CA 95828.