The impact of a coronavirus disease 2019 pandemic-related interruption of regular physical rehabilitation on functional abilities in a patient with two chronic neurological diseases: a case report

This case report describes the course of a 67-year-old White Swiss male patient diagnosed with PD and MS who visited our rehabilitation hospital for intensive neurorehabilitation two times within 1 year.

The patient lives with his wife in a flat. He worked as a consultant in a private company before his disease symptoms, especially fatigue and muscle weakness (tetraparesis due to MS), forced him to retire 21 years ago (in 1999). The patient was a recreational musician, but stopped his activities because of the disease-related impairments, including manual dexterity. Currently, he likes listening to audiobooks and he enjoys doing administrative work for his family and neighbors. He used to attend a support group for people with MS, but quit some years ago. The patient reports no other structured social activities except for close contact to his family, friends, and neighbors.

The following diagnoses have been confirmed at hospital admission in October 2019 and in May 2020:

The main symptoms of the patient were related to PD, MS, and his low back pain syndrome. Clinical examination revealed bradykinesia of the limbs, while no significant rigidity or rest tremor were observed. The patient reported motor fluctuations including off-periods and dyskinesia. He featured a complex gait disorder with hypokinetic and spastic–ataxic elements. Besides, he suffered from postural instability and freezing of gait episodes. The main physical MS-specific symptoms were tetraparesis, fatigue, and trouble with sensation and coordination. The main activity limitations were related to mobility (transferring, walking stability, walking endurance, stair climbing, balance).

The patient received a combination therapy consisting of levodopa/benserazide (Madopar LIQ 62.5, Madopar DR 250), levodopa/carbidopa/entacapone (Stalevo) and pramipexole (Sifrol ER) for treatment of PD. During the first reported stay in our hospital, the daily dosage of levodopa was reduced by 150 mg. During the second stay, daily dosage of levodopa was increased by 150 mg and that of pramipexole by 0.75 mg. Motor fluctuations improved by the adjustments of the pharmacological therapy. The MS-specific medication consisted of 44 μg interferon beta-1a (Rebif) three times per week and has been unchanged for several years.

Since the patient was diagnosed with PD in 2015, he had visited our clinic already several times for intensive inpatient rehabilitation, as prescribed by his general practitioner.

The complete timeline of the patient is illustrated in Fig. 1.

At hospital admission, the patient was assessed with a broad set of generic and disease-specific measures of physical functioning and mobility as part of the physiotherapy treatment. All assessments were performed during the on-state. The clinical outcome assessments are described in the following section.

Within the regular hospital physiotherapy care, a set of functional outcome assessments was performed with the patient on admission and discharge. During the second inpatient stay, some outcome assessments were repeated weekly to better describe the rehabilitation course. The physical outcome assessments and the patient’s assessment scores are listed in Table 2.

Mobility capacity was assessed with the de Morton Mobility Index (DEMMI; Fig. 2) [17‐20], the Hierarchical Assessment of Balance and Mobility (HABAM, Fig. 3) [21, 22], and the mobility subscale of the Barthel Index (Fig. 4) [23]. According to those three outcome assessments, the patient experienced improvements in mobility capacity during the first rehabilitation stay, which deteriorated or remained unchanged over the pandemic-related interruption of outpatient rehabilitation. However, mobility capacity improved over the second hospital stay by 17% (DEMMI), 50% (HABAM), and 20 points (Barthel Index mobility subscale). These improvements are beyond the measurement error of these assessments reported for older adults and can be considered clinically relevant [17, 20, 24].

Ambulation was assessed with the functional ambulation categories (FAC; Table 2) [25]. At hospital admission after the COVID-19-related therapy break, the patient was mobile in a wheelchair for longer distances, but he could only walk for short distances with a rollator and intermittent support of one person to help with balance and coordination (FAC 2). At discharge, he was able to walk independently with the rollator within the hospital for shorter distances (< 300 m; FAC 4). However, with two crutches (his preferred walking aid) the patient needed stand-by assistance from another person (FAC 3).

Walking endurance was assessed with the 6-minute walk test [26]. As seen in Table 2, the patient improved his walking distance within 6 minutes by 102 m (improvement of 268%) and by 98 m (109%) over the first and second rehabilitation stay, respectively. Figure 5 illustrates how the patient deteriorated in the 6-minute walk test after the therapy interruption but then regained his former walking endurance. This improvement can be considered clinically important [27].

Gait speed values (10-meter walking test) of the patient over time are illustrated in Fig. 6. The patient improved by 77% over the first inpatient rehabilitation stay, decreased back to his former ability (0.29 m/second) after the rehabilitation interruption and re-improved by 131% to a gait speed of 0.67 m/second. This value is still very low compared with normative values of older people [28], but the amount of change can be considered clinically important [29].

In addition, we conducted some disease-specific assessments that were not part of standard clinical routine. To assess the level of fatigue, we conducted the Fatigue Severity Scale, a patient-reported outcome assessment [30]. However, no relevant changes were observed in the patient, who reported “substantial fatigue” according to the scale score of 6.7 points [30]. MS-specific disability was assessed with the Expanded Disability Status Scale (EDSS). We did not observe any alterations in EDSS status of the patient, since he required constant bilateral support to walk 20 m without resting at all times (EDSS score of 6.5). Quality of life was assessed with the PD-specific Parkinson's Disease Questionnaire (PDQ-39) [31] and did not change substantially over time.

We do not have sufficient information or objective measures of the patient’s physical functioning or assessment scores prior to hospital admission in October 2019 or from the outpatient physiotherapy. We do not report any assessment scores from other rehabilitation disciplines, such as speech and language therapy or nutritional therapy.

A strength of the management of this case is that the patient’s physical functioning was monitored with a broad set of valid and reliable clinical outcome assessments over a long period of time, covering an immediate interruption of his regular ambulatory rehabilitation process surrounded by two inpatient rehabilitation stays. We provide objective and patient-reported data on the functional course of the patient assessed at several time points, which allow a detailed analysis of his functional development during the different rehabilitation interventions. The patient received intensive, multimodal inpatient rehabilitation according to clinical guidelines [4, 5].

The patient’s functional abilities and rehabilitation needs differed for each inpatient rehabilitation stay. Since rehabilitation procedure were individually tailored, the prescribed multimodal therapies differed for each inpatient rehabilitation stay with respect to their kind, number, duration, and frequency. Medication was also altered during the first and the second inpatient rehabilitation.

One limitation of the management of this patient may be the lack of a home-based exercise program provided to the patient during the prepandemic inpatient or outpatient rehabilitation. If the patient had been provided with such an exercise program and strategies for adherence and motivation, he would have been able to perform physical exercises during the COVID-19-related lockdown to stop or slow down his functional decline. Several structured home-based exercise programs for people with PD or MS have been developed [32, 33]. The effectiveness of these different programs on physical functional and mobility related outcomes varies, but we are convinced that home-based exercise programs should be prescribed for people with chronic neurological conditions to support self-care and to improve functional abilities [34]. Although the current COVID-19 pandemic developed rapidly, and the lockdown came relatively unforeseen, the lack of a home-based exercise program for this patient can be considered a limitation of the management of this patient.

The patient has regularly visited ambulatory rehabilitation services, such as physiotherapy, for many years. He reported enjoying this service, but feeling that he would lose some of his functional abilities more quickly if he did not participate in this service and perform “his exercises.” Concerning the pandemic-related interruption of his regular ambulatory rehabilitation, the patient reported significant regret and disappointment when he was informed that he could not visit the ambulatory physiotherapy any longer. He tried to exercise with his wife but felt how he “got worse and worse,” and failed to stop the deteriorations in physical functioning (he especially considers “the ability to walk with two crutches” as “substantial for his well-being and satisfaction”). The worsening of physical abilities “developed strikingly fast,” and the patient was “very concerned” about his functional independence.

The patient reported high motivation for each hospital-based rehabilitation stay, and during the second inpatient rehabilitation, he experienced a subjective improvement in his gait stability, fall risk, and mobility capacity, with respect to hospital admission. However, he was also disappointed that he could not reach his goal of walking 600 m with two crutches. He confirms continuing walking exercises and regular ambulatory physiotherapy to regain his prepandemic functional abilities.