Clinical Practice Guideline Clinical practice guidelines are - - PDF document

Application of a Clinical Practice Guideline for Persons with Multiple Sclerosis in a Multi‐Setting, Multi‐ Discipline Rehabilitation Facility

Morgan Eppes PT, DPT Kelli Doern PT, DPT, NCS, MSCS

Sheltering Arms Physical Rehabilitation Richmond VA

Clinical Practice Guideline

“Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” ‐Institute of Medicine, 1990

Why have a CPG?

• Reduce variability in evaluation and treatment

across levels of care and services

• Lifespan approach with consistent measurement
• The CPG was intended to provide the clinician in

each setting, guidance on a thorough assessment and evidence‐based plan of care, including an appropriate transition through the rehabilitation spectrum, into a long term fitness program.

Rehabilitation Algorithm

Body Structure & Function

Activity

Participation

Medical History Disease Course Systems Review ROM Spasticity Manual Muscle Testing

Cardiopulmonary Urinary Gastrointestinal Voice Vision Constitutional Integument Psychiatric Sexual function Vestibular

Outcome Measures

Berg Balance Scale Six Minute Walk Test 10 M Walk Test Box & Blocks 9‐hole Peg Test

Outcome Measures

Fatigue Scale for Motor & Cognitive functions MS IS‐29

ADL Assessment Functional Movement Analysis Gait Assessment Referral

Severity Modifier Vision Impairment Fatigue Cognitive Impairment Dominant Clinical Problem(s): 1.______________________ 2.______________________ 3.______________________ Services Screen

Do you currently have an active leisure lifestyle? Do you have a Community‐ Based Exercise Program? Outcome Measures

Trunk Impairment Scale Functional Reach/mFRT Box & Blocks 9‐hole Peg Test

Standing Tolerance greater than 60 seconds? No Yes

Have you unintentionally lost weight in the past 6 months

Interventions

8.1 Fatigue and the Impact of Heat Sensitivity on the MS Patient ……………. 38 8.2 Energy Conservation Education …………………………………………………………. 39 8.3 Activities of Daily Living (ADLs) and Transfers training………………………… 40 8.4 Spasticity …………………………………………………………………………………………… 41 Spasticity Algorithm – reprinted from Thompson et al, 2005 ……43 8.5 Endurance Training ………………………………………………………………………………45 8.6 Strength Training ………………………………………………………………………………….46 8.7 Gait Training …………………………………………………………………………………………48 Gait Intervention Algorithm ……………………………………………………….49 8.7 Balance ………………………………………………………………………………………………..55 Balance Intervention Table …………………………………………………………57 8.8 Dysphagia ………………………………………………………………………………………….. 60 8.9 Dysarthria ………………………………………………………………………………………….. 62 8.10 Aphasia ……………………………………………………………………………………………. 62 8.11 Cognition …………………………………………………………………………………………. 63

• Select the appropriate interventions based on

dominant clinical problem list

Interventions

• Evidence‐based recommendations
• Algorithms based on outcome measure

performance to aid the clinician in selecting the appropriate technology or tool to assist in maximizing the principles of motor learning, neuroplasticity and motor control.

Gait Intervention Algorithm

Transitions of Care

Transitions of care and community integration are also included in this model, with recommended service screens for RT, Fitness and Dietary services.

Services Screen

Do you currently have an active leisure lifestyle? Do you have a Community‐ Based Exercise Program? Have you unintentionally lost weight in the past 6 months

Participation

9.0 Participation …………………………………………………………………………………………65 9.1 Community, Social, and Civic Life …………………………………………………….... 66 9.2 Interpersonal Interactions and Relationships ………………………………….…. 66 9.3 Major Life Areas (Education, Work and Economic Life) ………………….….. 66 9.4 Leisure Life ………………………………………………………………………………………… 67 9.5 Leisure Education …………………………………………………………………………….... 68 9.6 Leisure Skills …………………………………………………………………………………….… 69 10.0 Disease Management …………………………………………………………………………69 10.1 Healthy Lifestyle Discharge Plan ………………………………………………………. 68 10.2 Chronic Disease Self‐Management Program ……………………………………. 69 11.0 Fitness & Therapeutic Recreation Services Screening Algorithms ………71 12.0 Transitions of Care ………………………………………………………………………………72 12.1 Skilled Therapy to Health and Wellness Services ……………………………… 72 12.2 Community Based Wellness & Exercise (not SA affiliated) ……………….. 73 12.3 Skilled Recreational Therapy to Community Based Services……………… 73 13.0 Environmental ……………………………………………………………………………………74 13.1 Products and Technology ………………………………………………………………… 74 13.2 Natural Environment and Human‐Made Changes to Environment…… 75 13.3 Support from Friends and Family …………………………………………………….. 75 13.4 Services, Systems, and Policies…………………………………………………………. 75 14.0 Nutrition …………………………………………………………………………………………….76 14.1 Diet ………………………………………………………………………………………………….. 76

Case A

• Diagnosed in 2005 at the age of 60
• Using a SPC until 2010 where she switched to

a rollator due to frequent falls and gradual worsening of L LE strength

• Presented to our system in OP PT summer

2015 due to weakness

• No personal history of fitness

Activity

Participation Outcome Measures

Berg Balance Scale Six Minute Walk Test 10 M Walk Test Box & Blocks 9‐hole Peg Test

Outcome Measures

Fatigue Scale for Motor & Cognitive functions MS IS‐29 MSWS‐12

ADL Assessment Functional Movement Analysis Gait Assessment

Severity Modifier Vision Impairment Fatigue Cognitive Impairment Dominant Clinical Problem(s):

1. Gait Abnormality a. Velocity b. Left Hemiparesis causing inconsistent foot clearance 2. Imbalance 3. Muscle Weakness and Impaired Endurance

Outcome Measures

Trunk Impairment Scale Functional Reach/mFRT Box & Blocks 9‐hole Peg Test

Standing Tolerance greater than 60 seconds? No Yes

Case A: Assessment Algorithm

Gait Intervention Algorithm

MMT LE's: Right Left

Hip Flexion 5/5 2+/5 Hip Abduction 3/5 2/5 Hip ER 4/5 3+/5 Hip Extension* 3/5 3/5 Knee Extension 5/5 5/5 Knee Flexion 4+/5 4/5 Ankle DF 5/5 4/5 Ankle PF 3+/5 <3/5

Case A: Plan of Care

• 2 x week x 8 weeks
• Treatments included:

– AFO prescription – Gait training – Balance training – CV and PRE fitness instruction

• Discharged to community based fitness within
• ur health system
• PT re‐assess at 3 months and 8 months

GaitRITE Initial D/C ‐ 8 weeks 3 month 8 month Conditions Rollator Rollator & Left AFO Rollator & Left AFO Rollator & Left AFO Velocity 0.46 0.75 0.74 0.71 Step Length L (cm) 48 57.8 60 61 Step Length R (cm) 48 60 56 56 Single Limb Support L (% GC) 24.2 30.5 31.1 30 Single Limb Support R (% GC) 28 33.5 33.3 34 Base of Support (cm) 9.5 8.6 6.3 5

Outcomes Outcomes

Initial D/C ‐ 8 weeks 3 month8 month Berg Balance Scale 35 44 41 42

Initial D/C ‐ 8 weeks 3 month 8 month MSWS ‐ 12 48% x 15% 56% MSIS ‐ 29 62 x 41 40 FSMC ‐ Motor 29 x 21 26 FSMC ‐ Cognitive 27 x 15 19

Case B

• 37 year old AA male diagnosed with MS at the

age of 31

• Progressive‐relapsing disease course, non‐

ambulatory within 3 years of diagnosis

• Multiple rounds of skilled therapy

– Kreger Institute – Home Health

• Stem Cell treatment in Mexico 2013, no

change in condition

Case B: Assessment Algorithm

Activity

Participation Outcome Measures

Berg Balance Scale Six Minute Walk Test 10 M Walk Test Box & Blocks 9‐hole Peg Test

Outcome Measures

Fatigue Scale for Motor & Cognitive functions MS IS‐29

ADL Assessment Functional Movement Analysis Gait Assessment

Severity Modifier Vision Impairment Fatigue Cognitive Impairment

Dominant Clinical Problem(s):

• 1. Poor trunk strength
• a. Impaired transfers
• b. Impaired ADL/IADL

independence

• 2. Low Activity/Fitness level

Outcome Measures

Trunk Impairment Scale Functional Reach/mFRT Box & Blocks 9‐hole Peg Test

Standing Tolerance greater than 60 seconds? No Yes

Case B

LE Strength 0/5 UE strength 3‐4/5 MFR = 1 inch Spasticity 2/4 ankles & quads

Case B: Plan of Care

• 2 x week x 8 weeks
• Treatments included:

– Standing Frame exercises

• Postural muscles
• Trunk muscles
• UE muscles

– UE PRE exercises from manual w/c – CV fitness (upper & lower ergometer) – Transfer training, including family training

• Discharged to community based fitness within
• ur health system

Case B: Outcomes

• Modified Functional Reach 1 inch 2 inches
• CV exercise tolerance 5 minutes  30 minutes
• UE PREs increased from 10‐15#  25‐30#

– Lat Pull Down – Seated Row – Seated Chest Press

2014

June Entry into SA system with OP therapy x 8 weeks  Fitness

2015

January MS Exacerbation IP Rehab x 3 weeks MFR = 0; Ataxia; UE <3/5  HHPT & OT August Restarted Fitness Program CV 10 min, Standing frame x 30 min OP Therapy October OP PT MFR = 0; TIS 0/23; MSIS 114; FSMC 53 4 weeks  Fitness

2016

February OP check‐in evaluation No change in outcome measures; Continue Fitness program

MS Clinical Practice Guideline

• Lifespan approach
• Promoting life long fitness at all mobility

levels, improving health and limiting development/worsening of comorbidities

• Picking up on relapses/regressions quicker

(not waiting for the next MD follow‐up)

• Consistency of care to track outcomes over

time throughout levels of care