Margaret Gosewisch, PT, DPT
Next Steps, Chicago, IL

History:  35 year old left handed male who sustained a traumatic brain injury secondary to a gunshot wound on January 12, 2010. Patient presents with spastic quadriplegia with greater involvement of his right side secondary to left sided brain injury that resulted in ventriculomegaly.  Co-morbidities include: heterotrophic ossification in his right elbow and right knee, history of deep vein thrombosis, kidney stones and urinary tract infections, blind in the right eye, and deaf in the right ear. He presents with expressive aphasia and inappropriate behavior.  He attended inpatient rehab at RIC from January to May 2010. Outpatient physical therapy initial evaluation at Next Steps Chicago in November of 2010, where he presented in a power wheel chair. His personal goals were to improve upper and lower extremity strength and to walk again.

Initial Presentation: Bilateral lower extremity tone average of ¾ per modified Ashworth scale. Patient presents with manual muscle test 0/5 globally on the right lower extremity, and 2/5 average for the left lower extremity. No lower extremity joint contractures were noted and all passive range of motion was within normal limits.

Treatment Progression: Patient was seen three times a week for aggressive physical therapy. Therapy focused on functional transitions on the mat table, increased weight bearing in the tilt table, tone reduction through whole body vibration and lower extremity stretching, and manual work on his right shoulder. Pt was introduced to the RT300 lower extremity cycle in April of 2011, five months after beginning intensive therapy. He began cycling consistently two to three times a week in August of 2011.  He has been using higher pulse widths (up to 400 usec in larger muscle groups). His endurance has increased as demonstrated through his ability to cycle for an hour where he could only tolerate 10 minutes when he first started. He is also able to tolerate higher amplitudes leading to a stronger muscle contraction so that he is able to cycle off motor support more frequently than in past sessions. Per patient report, the combination of whole body vibration with the Galileo and cycling with RT300 significantly decreases his lower extremity tone, improving his quality of life.

Final Lower extremity Assessment:  His right lower extremity tone now averages 2/4 per Modified Ashworth scale, with his left lower extremity averaging a 1+/4, which is significantly decreased from his initial evaluation.  He demonstrates an increase in right quadriceps strength to 1/5 per MMT, which has improved from 0/5, or no palpable contraction. All other muscle groups in the right lower extremity continued to measure a 0/5. His left hip flexors, quadriceps, and hamstrings have increased to a 3/5, all other muscle groups remained a 2/5. He demonstrates improvements in energy expenditure from 0.15-0.25 kcal in his first 30 sessions to an average of 0.45-0.55 kcal in recent sessions. Patient reports that his left lower extremity has improved functionally by 50% and that his right lower extremity has improved by 20%. He reports increased hamstring function, specifically. RT300 has also prevented muscular atrophy. He had lost a significant amount of weight following the injury and was able to increase his lower extremity muscle mass and return to a healthier weight.

Conclusion and Functional Assessment: The patient made strength gains in the left lower extremity and right quadriceps since starting RT300 FES leg cycling. He has made functional gains such as being able to independently adjust his hips in his wheel chair as well as performing sit to stand transfers with maximum assistance, compared to dependent assistance initially. He is able to stand upright with maximum assistance only at this time compared to dependent assist initially. He is able to initiate hip and knee extension though he requires Max A in order to perform an anterior weight shift. His quality of life has improved significantly through his tone reduction and he states that he is now motivated to get stronger as he is finally seeing gains in his lower extremity strength. Therapy will continue to focus on lower extremity cycling, whole body vibration, and standing in order to address his impairments and activity limitations. The strength gains and decreases in lower extremity spasticity have improved his bed mobility which has made it easier for his caregivers to perform tasks such as dressing and bathing. His caregivers also benefit from his increased independence with transfers.