Chronic inflammatory demyelinating polyradiculoneuropathy from a physical therapist's perspective: a case report.
Several medical interventions for CIDP are described in the literature, but no evidence-based approaches to rehabilitation specific to CIDP can be found. This case report reviews key background information on CIDP and describes an interdisciplinary approach between medical and physical therapy (PT) providers in an acute care setting. It illustrates the use of medical knowledge, clinical reasoning, and evidence in selecting outcome measures, formulating a plan of care, and assisting with clinical decisions.
The prevalence of CIDP ranges from 1.24 to 7.7 per 100,000 in many regions of the world including Australia, Japan, the United Kingdom, Norway, and Italy. (2-7) It affects people of all ages but is most prevalent in those between 40 to 60 year old regardless of gender. (8) In the US, incidence was reported to be l.6 per 100,000 per year to a high of 8.9 per 100,000. (9) As many as about 300,000 patients could have active CIDP at a given time (10) and CIDP could represent 10-30% of previously undiagnosed neuropathies. (8)
The pathogenesis of CIDP begins with an autoimmune response to an unknown trigger. The trigger leads to lymphokine-induced damage to myelin sheaths and axons of peripheral nerves. (11,12) Proposed triggers include influenza vaccination, tetanus toxoid immunization (13,14) and hepatocellular carcinoma. (15,16) Viral infection is more likely to trigger an autoimmune response in individuals who have immune-compromised conditions.
Clinical, laboratory, and electrodiagnostic features are used to diagnose CIDP. Based on these criteria, the diagnosis of CIDP may be categorized as possible, probable, or definite categories (See Table l). (17,18) Laboratory and electrodiagnostic criteria for a definitive diagnosis vary between institutions in level of sensitivity and specificity. (19) A successful treatment trial in the absence of clinical, laboratory, and electrodiagnostic features may also help confirm a diagnosis of demyelinating neuropathy. (10,17,20)
Since CIDP is an extremely heterogeneous condition, the exact clinical manifestations differ from person to person. Diagnosis depends on which structures are involved such as cranial nerves or central nervous system (21-25) and its clinical presentation such as distal versus proximal and symmetrical versus asymmetrical. (26,27)
Differential diagnosis may include polyneuropathy associated with monoclonal gammopathy of undetermined significance (MGUS), polyneuropathy-organomegaly-endocrinopathy M protein and skin changes (POEMS), and CharcotMarie-Tooth disease (CMT). Yet, age of onset, clinical course, electrophysiological presentation, and response to medical therapy of these diagnoses differ from CIDP. (28-30)
Patients with CIDP follow one of three clinical courses: monophasic, relapsing, or progressive. The monophasic course consists of one single episode of clinical deterioration followed by sustained improvement. The relapsing course involves at least two separate deteriorations with at least one improvement between relapses. The progressive course presents with unremitting gradual deterioration. Factors determining clinical course are unknown.
The clinical course of CIDP is heterogeneous with variable prognosis. Sixty-one per cent (61%) of patients with a relapsing or monophasic course experience minimal non-disabling symptoms. (31) In contrast, only 8% of patients with a progressive course have minor symptoms. Patients with CIDP often present with decreased functional balance, diminished quality of life, and increased fatigue. (32) In general, patients with a sub-acute onset, symmetrical symptoms, and distal nerve abnormalities in nerve conduction studies (NCS) have better prognostic outcomes compared with those with a chronic onset, asymmetrical presentation, and demyelination in the proximal nerve segments. (31,33)
Initiating intervention as early as possible until improvement reaches a plateau is the norm. (34) The most common medical therapies include prednisone, plasmapheresis, and intravenous immunoglobulin (IVIg), with similar short-term efficacy among the three. (35) First choice may depend on medical history and concurrent medical status, cost, side effects, and administration factors.
Prednisone dosage varies and treatment continues until strength returns to normal or the condition reaches a plateau over a three-to-six -month-timeframe. (8,18,34,36,37) As early as two weeks after the initiation of prednisone, patients often show improved strength and disability scores. (38) Treatment with IVIg has a high response rate and long-term efficacy. (39) Plasmapheresis is less commonly used due to its invasive nature, the need for special equipment, and high cost. (40) Physicians consider alternative therapies when patients do not respond readily to basic intervention or when they relapse. (36,41)
Very little evidence-based literature is available to assist therapists with the rehabilitation of patients with CIDP. One study examined the effects of a 12-week high-intensity bicycle exercise program on physical fitness, functional outcome, fatigue, and quality of life in patients with CIDP and Guillain-Barre Syndrome (GBS). (42)
Patients improved significantly in their cardiovascular fitness, muscle strength, and quality of life. Despite the high intensity training, patients also reported a twenty per cent (20%) reduction in fatigue severity and impact of fatigue from pre- to post-intervention. Although impairments, activity limitations, and participation restrictions resulting from CIDP fall under the physical therapist's scope of practice and the Guide to Physical Therapist Practice includes a practice pattern on GBS or CIDP (Pattern 5G:
Impaired motor function and sensory integrity associated with acute or chronic polyneuropathies), (43) evidence supporting PT as an integral part of the functional recovery of CIDP is anecdotal.
Based on available literature, the physical therapist's roles include:
1. Facilitating medical referral and need for further diagnostic tests when suspecting an unconfirmed case of CIDP. For example, patients with clinical presentations suggestive of CIDP but with an unknown etiology or diagnosis may trigger a referral to physicians and suggestions for a lumbar puncture or an NCS.
2. Using knowledge of atypical symptoms, clinical variants, differential diagnoses, and varying responses related to medical therapies to assist in differentiating the condition from others, and formulating a more accurate rehabilitation prognosis and plan of care. For example, the physical therapist needs to communicate with physicians if patients with preliminary diagnoses of CIDP do not show functional improvement with traditional medical therapies. Differential diagnoses or change in medical therapy may need to be considered. Rehabilitation prognosis and plan of care may need to be revised if a differential diagnosis results.
3. Applying knowledge of the side effects of prednisone therapy to the choice of exercise options. For example, in the presence of osteoporosis where high-impact exercise may increase the risk for falls and fractures, the physical therapist needs to adjust activity accordingly.
4. Observing the patient for possible side effects by closely monitoring vital signs and reporting these effects. For example, hypotension and cardiac arrhythmia may occur during IVIg and plasmapheresis therapies and mobility may be contraindicated.
5. Communicating observations in a timely and objective manner to other health care providers to facilitate better plan of care. For example, alert them to important signs and symptoms as well as key patient responses to functional activities and therapeutic interventions.
The patient was a 59-year-old man with a past medical history of non-Hodgkin's lymphoma, papillary thyroid cancer, hepatitis C, and liver cirrhosis. His surgical history included thyroidectomy, nonmyeloablative allogeneic stem cell transplant, and transjugularintrahepaticportosystemic shunt (TIPS) placement. His general health was otherwise noncontributory. The patient worked as a civil engineer during the six months prior to his hospital admission, is married and lives with his wife in a single-story home.
Approximately six months prior to this hospital admission, the patient had worsening liver function and underwent TIPS placement with subsequent improvement. Two months later, he again experienced worsening of liver disease, developed low back pain, and lower extremity weakness. Symptoms progressed to include headaches, fatigue, and bouts of pneumonia. The patient's functional ability decreased over a four-month period leading to wheelchair use for mobility. Multiple acute care hospital admissions followed and eventually he was admitted to a skilled nursing facility (SNF). Despite continued rehabilitation, his functional status continued to decline. This was initially attributed to end-stage liver disease, leading to discharge to home hospice care. Eventually, during an acute care admission for respiratory distress, further diagnostic tests revealed demyelinating features in the upper and lower extremities, most prominent in the distal regions, compatible with CIDP. A definitive diagnosis of CIDP was made one week after this hospital admission.
Systems Review & Examination
At the initial PT examination, the patient reported a 50-pound weight loss over the last several months. Table 2 shows the results of the cardiovascular/pulmonary, integumentary, neuromuscular, musculoskeletal, and internal organs systems review. Both the patient and his wife's goal was to obtain a definitive diagnosis of his condition with the ultimate hope that his condition was treatable. The patient also wanted to regain the ability to ambulate.
Physical examination included:
1. Pain: The patient reported 8-10/10 pain in the low back and bilateral hips on the numeric pain rating scale (NPRS), where zero = no pain and 10 = worst possible pain. NPRS is a responsive measure in patients with low back pain. (44) His pain increased with touch or any gentle lower limb movements, and eased with rest and intravenous (IV) morphine.
2. Passive range of motion (PROM): Bilateral upper extremity PROM was within functional limits (WFL). Therapists were unable to test PROM of the lower extremities secondary to pain. From observation during functional mobility, he showed bilateral passive hip and knee flexion to 90[degrees] in sitting, bilateral hips and knees reached full extension in supine, and ankle dorsiflexion to a neutral position.
3. Coordination: He demonstrated diminished finger-nose-finger coordination and rapid alternating movements (RAM) tests of his upper extremities. The tests did not reveal any gross dysmetria. Coordination and RAM of his lower extremities were not available due to severe weakness and pain.
4. Sensory systems: Proprioception, vibration, and pinprick sensation were decreased on both lower limbs and bilateral C3-4 dermatome sensation.
5. Tone: Muscle tone in the upper extremities was grade one (l) on the Modified Ashworth Scale but did not limit functional ROM. Pain on both lower extremities prevented the examination of muscle tone. Deep tendon reflexes (DTRs) were absent at the Achilles tendons and diminished (l+) at biceps, triceps, and patellar tendons bilaterally.
6. Muscle strength: Weakness was more severe in both lower extremities than the upper extremities and in distal versus proximal regions (Table 3).
7. Functional abilities: Based on the Functional Independence Measure (FIM), (45) bed mobility, feeding, grooming, and orientation required total assistance; problem solving and attention to task required moderate assistance (Table 4).
While the Guide to Physical Therapist Practice (43) also suggested other tests and measures, they were not included at the initial examination due to the patient's low functional level, pain, and activity tolerance.
Evaluation and Diagnosis
This patient was totally dependent for all activities of daily living (ADLs) and functional mobility with the inability to continue his previous role as an engineer. He presented with significant pain, impaired sensation, impaired DTR, significant weakness in all extremities, impaired sphincter control, and impaired social cognition. His impairments, activity limitations, and participation restrictions were consistent with Practice Pattern 5G:
Impaired Motor Function and Sensory Integrity Associated with Acute or Chronic Polyneuropathies. (43) The physical, occupational, and speech therapists recommended patient discharge to an inpatient rehabilitation setting after his acute care stay to optimize functional recovery. In addition, he would benefit from a social work or psychology consultation for emotional support during the process of rehabilitation.
For CIDP, prognosis depends on clinical course, clinical presentation, and initial response to medical therapy. (31,33) Long-term poor outcomes, including severe disability and inability to walk, occur in thirteen per cent (13%) of patients with CIDP even without comorbidities. (32,34) Since this patient's path to a confirmed CIDP diagnosis was lengthy, with severe existing co-morbidities, clinical presentation and initial response to medical therapy would determine his prognosis. Strong indicators included a somewhat symmetrical clinical presentation, demyelination in the distal nerve with abnormalities in NCS, and a fair response to initial steroid therapy. Due to a chronic onset of CIDP, expectations were for a slow and incomplete functional recovery with the patient requiring assistive devices and perhaps orthothes for future functional mobility. On a positive note, this patient was very motivated and had a supportive family.
Plan of Care and Interventions
Physical therapy short-term goals (one week) included:
1. Decreased pain level at low back and bilateral hips from 8-10/10 to 7/10 on NPRS to enable participation in bed mobility, transfer, and seated ADLs.
2. Improved static sitting balance from dependent assistance to maximal assistance to enable participation in seated ADLs and prevent adverse effects from prolonged bed rest.
3. Improved bed mobility from dependent assistance of two persons to maximal assistance of two persons to prevent pressure ulcer development. Bed mobility activities include rolling, scooting, bridging, and supine to and from sitting.
4. Increased bed to wheelchair transfer from unable (limited by pain) to dependent assistance of two persons. This would increase sitting tolerance for pneumonia prevention.
Physical therapy long-term goals (three weeks) included:
1. Decreased pain level at low back and bilateral hips to 5/10 on NPRS to enable participation in transfer, seated ADLs, and wheelchair mobility.
2. Improved overall muscle strength by one grade on MMT to facilitate use of extremities for functional mobility.
3. Improved static sitting balance with dependent assistance to dynamic sitting balance with stand-by assistance to facilitate independence in seated ADLs using upper extremities.
4. Improved bed mobility from dependent assistance of two persons to moderate assistance of one person to maintain skin integrity. Bed mobility activities include rolling, scooting, bridging, and supine to and from sitting.
5. Improved bed to wheelchair transfer from unable (limited by pain) to maximal assistance of one person squat pivot transfer with a sliding board. This would increase time out of bed for seated ADLs and exercises.
6. Improved wheelchair mobility from unable to able to propel wheelchair 150 feet with minimal assistance (required assistance less than 25% of time) to increase independence with locomotion.
Initial goals did not include ambulation secondary to significant lower extremities weakness on MMT, pain, limited activity tolerance, and risk of overstretch weakness. The physical therapist examined the patient's condition weekly and used examination results to determine whether the patient was ready to initiate gait training.
Intervention sessions: Each session consisted of approximately thirty minutes of therapeutic exercise and functional mobility training for an average of five times per week. The actual duration of each visit and frequency of treatment depended primarily on the patient's activity tolerance and fatigue level, as well as the operational nature in the acute care setting. The patient also performed ADLs (grooming, personal hygiene, and upper body dressing) to tolerance and strengthening exercises using exercise putty and elastic bands outside of PT sessions. In addition, nursing staff assisted the patient to get out of bed into a cardiac chair initially and a wheelchair using a mechanical lift as the patient progressed. Table 5 summarizes the interventions by week. The interventions were chosen based on the patient's interests, goals, and priorities in this setting. This was an attempt to minimize the adverse effects of bed rest, balancing overuse and fatigue with the patient's pain level, and perceived effort related to activities, and motivation.
About one week after the beginning of prednisone therapy, the patient made substantial progress in his strength and functional mobility. He stayed in the acute care hospital for one month and progressed steadily in his body function, strength, and functional mobility (Tables 3, 4, 6). Upon discharge from acute care, the patient required minimal assistance for bed mobility, supervision for wheelchair mobility on level ground, and maximal assistance of two persons for bed to wheelchair transfer. He was able to maintain good sitting balance without support while performing ADLs. Improvement in overall ADLs performance, social cognition, and continence bowel management supported his admission to an acute rehabilitation setting.
The positive relationship between team members was a key to optimal patient management in addition to a fluid and dynamic approach to the plan of care. While the literature reported daily multidisciplinary rounds in intensive care units were associated with decreased mortality rate, (46) no published frequency guidelines for medical unit rounds exists. In this case, the authors believed frequency and quality of interactions and communications served this patient well. These included:
1. Frequency: Daily reciprocal communication exchanges with occupational/speech therapists and nurses, and as needed with physicians. Weekly patient-care rounds with all other disciplines such as social workers and case managers.
2. Type: Reading progress notes of other team members, discussing changes in patient condition, and providing input during patient rounds.
3. Key areas: Alerts for medical concerns, issues, challenges, and obstacles that limit rehabilitation progress, patient frustration levels, and achievements towards functional goals, exercise tolerance, general motivation, and well-being.
4. Red flags: Communications for any neurologic changes, significant decline in muscle strength and/or functional abilities (signs and symptoms may indicate medication intolerance or adverse side-effects).
The strength of communication included focus on patient-centered goals and support for providers, patient, and family. A weak area for this particular case was that communications were not always totally clear and timely. Recommendations for future improvement include greater sharing of test results, medication changes, and possible side effects of and expected results from medications and rehabilitation.
The purpose of this case report was to describe the collaborative medical and PT management of a patient with CIDP who had multiple significant comorbidities and many complications over the course of his diagnostic and acute care period. The patient's course of improvement relied on coordination of care between the medical and rehabilitation teams for optimal recovery. In the first two weeks of his acute care admission, the patient showed little progress in bodily function and mobility. His initial pain level, low functional status, poor endurance, and anxiety about mobility greatly limited physical therapy interventions. The physical therapist's provision of supportive care, persistence, encouragement, and reinforcement of even small gains, likely slowed the onset of functional decline and immobility, and eventually laid the groundwork for a road to recovery. The physical therapist also used knowledge of specific factors about CIDP and evidence from the literature to remain vigilant for significant changes in the patient's condition, communicate regularly with the team, and implement a flexible plan of care. Medical interventions were key initially to reversing the inflammatory process, which allowed the patient to benefit from rehabilitation.
The patient in this case had slow functional gains despite improvement in strength and endurance. Complications related to his comorbidities, which included an incidental finding of kidney stones, a urinary tract infection with methicillin-resistant staphylococcus aureus, and TIPS malfunctioning during his acute care stay, might have contributed to the slow improvement.
While the role of exercise prior to the beginning of medical therapy is unclear, an appropriate level of training may minimize complications related to immobility. Whether an exercise program with dedicated frequency and schedule would have furthered this patient's functional gains in the acute stage is not known. Although the physical therapist managed the patient's fatigue level closely during interventions, no objective measures of fatigue or participation restriction were used. Since fatigue is a major impairment in patients with GBS and CIDP, (33,47) assessing how PT management affected this impairment, regardless of disease stages and settings would have been beneficial. The Fatigue Severity Score and Fatigue Impact Scale are two examples of potential outcome measures that could be used to indicate a change in self-reported fatigue with exercise trainings. (42) The development of standardized outcome measures and specific practice guidelines for CIDP could lead to best practice care for this condition. (48)
The authors thank Jeffrey Teraoka, MD, Lisa Ikuma, MSPT, Debby Bolding, MS, OTR/L, and Diane Allen, PT, PhD for their valuable comments during the preparation of the manuscript.
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Doris Y. Chong, PT, MSc, DScPT, NCS Neurologic Clinical Specialist, inpatient acute care at Stanford University Medical Center in California Adjunct Assistant Professor, Samuel Merritt University Assistant Clinical Professor, San Francisco State University firstname.lastname@example.org
Leslie B. Glickman, PT, PhD Assistant Professor and Director of Post-Professional Programs at the University of Maryland, School of Medicine, Department of Physical Therapy and Rehabilitation Science in Baltimore Maryland. LGlickman@som.umaryland.edu
Paz Susan Cabanero-Johnson, PT, DScPT Education Program Specialist, Department of Veteran Affairs in Maryland Assistant Clinical Professor, University of Maryland at Baltimore email@example.com
Table 1. Diagnostic Criteria for CIDP (17-19) Definite Clinical Presentation All clinical presentation * >2 months progressive onset of must be present symptoms * Majority of motor dysfunction * Symmetrical and proximal + distal weakness * Areflexia or hyporeflexia Laboratory Features All laboratory features must be present * CSF protein level of >45 mg/dL * Nerve biopsy = demyelination Electrodiagnostic Features (NCS) All NCS features must be present * Reduction in CV in >2 motor nerves * Abnormal CB/TD in >1 motor nerves * Prolonged DL in >2 motor nerves * Absent FW or prolonged minimum FW latencies in >2 motor nerves Probable Clinical Presentation All clinical presentation * >2 months progressive onset of must be present symptoms * Majority of motor dysfunction * Symmetrical and proximal + distal weakness * Areflexia or hyporeflexia Laboratory Features CSF result must be positive or 2 positive results * CSF protein level of >45 mg/dL out of 3 (CSF, biopsy, NCS) * Nerve biopsy = demyelination Electrodiagnostic Features (NCS) 2 positive results out of 3 * Reduction in CV in >2 motor (CSF, biopsy, nerves NCS) * Abnormal CB/TD in >1 motor nerves * Prolonged DL in >2 motor nerves * Absent FW or prolonged minimum FW latencies in >2 motor nerves Possible Clinical Presentation All clinical presentation * >2 months progressive onset of must be present symptoms * Majority of motor dysfunction * Symmetrical and proximal + distal weakness * Areflexia or hyporeflexia Laboratory Features 1 positive result out of 3 (CSF, biopsy, NCS) * CSF protein level of >45 mg/dL * Nerve biopsy = demyelination Electrodiagnostic Features (NCS) 1 positive result out of 3 (CSF, * Reduction in CV in >2 motor biopsy, NCS) nerves * Abnormal CB/TD in >1 motor nerves * Prolonged DL in >2 motor nerves * Absent FW or prolonged minimum FW latencies in >2 motor nerves Abbreviations: CSF, cerebrospinal fluid; NCS, nerve conduction study; CV, conduction velocity; CB/TD, conduction block/temporal dispersion; DL, distal latency; FW, F-wave. Table 2. System Reviews Systems Results Cardiovascular Temperature: 37.1[degrees]C /Pulmonary Blood pressure: 115/73 mmHg in supine Heart Rate: 95 beats per minute (bpm) Respiration: 18 bpm Oxygen saturation: 93% on two liters of oxygen Musculoskeletal Symmetrical weakness, lower extremities weaker than upper extremities Neuromuscular Alert & Oriented x 2 Mild dysarthria Limited bilateral upward gaze & impaired bilateral smooth pursuit Diplopia on the far right gaze Impaired proprioception/sensation Abnormal tone and deep tendon reflexes (DTR) Integumentary Skin rash at buttock area Internal Organ Negative liver and renal function tests Incontinent bowel and bladder Table 3. Manual Muscle Testing of Major Muscle Groups Muscle Groups Initial Discharge (Bilateral, Symmetrical) Examination Shoulder flexion 3/5 4/5 Shoulder abduction 2/5 4/5 Elbow flexion 3/5 5/5 Elbow extension 3/5 5/5 Wrist flexion 3-/5 4/5 Wrist extension 3-/5 4/5 Finger flexion 2/5 3/5 Finger extension 2/5 3/5 Hip flexion 1/5 2+/5 Hip extension 1/5 2-/5 Hip internal/external rotation 1/5 2-/5 Knee flexion 0/5 2/5 Knee extension 0/5 3/5 Ankle dorsiflexion 0/5 3-/5 Ankle plantarflexion 0/5 3/5 Table 4. Functional Independence Measure (FIM)44 FIM category Admission Discharge Self-care 1. Eating 1 5 2. Grooming 1 5 3. Bathing 1 1 4. Dressing--upper body 1 3 5. Dressing--lower body 1 3 Sphincter control 6. Bladder management 1 1 7. Bowel management 1 1 Transfers 8. Bed, chair, 0 1 wheelchair 9. Toilet 0 1 10. Tub, shower 0 1 Locomotion 11. Walk/wheelchair 0 5 (wheelchair) 12. Stairs 0 1 Communication 13. Comprehension 6 7 14. Expression 4 7 Social cognition 15. Social interaction 2 6 16. Problem solving 2 4 17. Memory 2 4 Total FIM Score 23 56 FIM Levels. 7 = Complete independence (timely, safe, no helper). 6 = Modified independence (device, no helper). 5 = Supervision (subject = 100%). 4 = Minimal assist (subject = 75%+). 3 = Moderate assist (subject = 50%+). 2 = Maximal assist (subject = 25%+). 1 = Total assist (subject = less than 25%). 0 = Unable to test. Table 5. Summary of Weekly Physical Therapy Intervention Week 1 Week 2 * PROM and AAROM * PROM and AAROM to upper and lower to upper and lower extremities, 5-10 extremities, 5-10 repetitions each repetitions each * Sitting balance and * Sitting balance functional activities and functional at edge of bed activities at edge of bed Week 3 Week 4 * AAROM and AROM * AAROM to lower to upper and lower extremities, 5-10 extremities, 5-10 repetitions each repetitions each * Hand strengthening * Sitting balance and using exercise putty functional activities * Sitting balance and * Standing Frame functional activities * Transfer training * Standing Frame or between bed and Body Weight Support wheelchair Therapy * Transfer training between bed and wheelchair * Wheelchair mobility Abbreviation: PROM, passive range of motion; AAROM, active-assisted range of motion; AROM, active range of motion. Table 6. Summary of Weekly Physical Therapy Progress in Functional Mobility & Pain Initial End of Week 1 Examination Pain * 8-10/10 on NPRS * 7-8/10 on NPRS at low back and at low back and bilateral hips bilateral legs Static Sitting * Dependent * Minimal assistance Balance assistance Dynamic Sitting * Unable * Maximal assistance Balance Bed Mobility * Total assistance * Maximal assistance of 2 persons of 2 persons Transfer * Unable * Unable Locomotion * Unable * Unable End of Week 2 End of Week 3 Pain * 9/10 on NPRS at * 5/10 on NPRS at low back and low back abdomen Static Sitting * Contact guard * Supervised Balance assistance Dynamic Sitting * Minimal assistance * Contact guard Balance assistance Bed Mobility * Moderate * Moderate assistance assistance of of 1 person 2 persons Transfer * Maximal * Maximal assistance assistance of of 2 persons bed 2 persons to to wheelchair cardiac chair Locomotion * Unable * Supervised wheelchair mobility on level ground 150 feet Discharge Pain * 4/10 on NPRS at low back Static Sitting * Supervised Balance Dynamic Sitting * Stand-by assistance Balance Bed Mobility * Minimal assistance of 1 person Transfer * Maximal assistance of 1-2 persons bed to wheelchair Locomotion * Independent wheelchair mobility on level ground 500 feet Abbreviation: NPRS, numeric pain rating scale.
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|Title Annotation:||CASE REPORT|
|Author:||Chong, Doris Y.; Glickman, Leslie B.; Cabanero-Johnson, Paz Susan|
|Publication:||Journal of Acute Care Physical Therapy|
|Date:||Sep 22, 2010|
|Next Article:||University of Rochester acute care evaluation: development of a new functional outcome measure for the acute care setting.|