Physical Therapy Following Tibial Plateau Fracture Complicated by

Stiff Person Syndrome

Julie Majcher, SPT

Cleveland State University

July, 2017

Abstract

Background and Purpose: Following a tibial plateau fracture, it is required that the

patient be non-weight bearing on the affected lower extremity for 6 weeks, and partial weight

bearing for 3 months following, which increases the amount of energy required to ambulate

safely.1,2 Stiff Person Syndrome (SPS) is a rare auto-immune disorder that is characterized by

changing muscular rigidity, muscle spasms, and increased environmental sensitivity, which

affects the physical therapy plan of care when dealing with a patient with both SPS and a tibial

plateau fracture.3 The purpose of this case report is to discuss the interventional modifications

when working with a patient with SPS and encourage increased multidisciplinary research in

non-pharmaceutical management SPS. Case Description: The patient was a 71-year-old female

who presented to a skilled nursing facility following hospital admission/discharge for a left tibial

plateau fracture complicated by a known diagnosis of SPS. She had difficulty with transfers, gait,

stairs, and had high anxiety, exacerbating symptoms of her SPS. Outcomes: The patient scored

an 80 on the Tinetti Falls Efficacy Scale prior to intervention and a 62 following the course of

treatment demonstrating improved outcomes with therapy, and a decreased fall risk. Discussion:

SPS affects more than the physical part of a person and care must be taken to address all aspects

of the disease.4 Most research on SPS has focused on pharmaceutical interventions while it has

been shown that not only physical therapy can help these individuals improve their quality of

life, but there is also psychological component to SPS. 5,6,7,8,9 Therefore non-pharmacological

management should be considered, and more research is should be done to better understand this

complex condition.

Body of Manuscript Word Count: 3,159 not including tables and references (2116 words in

tables and references)

A. Background and Purpose:

Following a tibial plateau fracture, a patient is usually required to be non-weight bearing

on the affected side. This non-weight bearing status is typically necessary for 6 weeks, however

full weight bearing is usually not recommended until 3 months following the fracture for proper

healing, which greatly affects the physical therapy plan of care.1 Forward progression of gait

with only one limb and an assistive device is much different and more difficult than normal

ambulation. Energy expenditure measured through oxygen consumption during gait with one

non-weight bearing extremity has been found to be 78% percent higher than normal non-

pathological gait.2 Because of this, it can be difficult to train an older adult to ambulate without

weight bearing on one side. Additional neuromuscular comorbidities can then further complicate

gait training and make it more difficult for the patient to ambulate safely.

The patient described in this case report required physical therapy following a tibial

plateau fracture, however rehabilitation was greatly affected by the patient’s comorbidity of Stiff

Person Syndrome. Stiff Person Syndrome (SPS) is an extremely rare auto-immune disorder that

has multiple types. It is characterized by changing muscular rigidity, muscle spasms of the trunk

and/or limbs, and increased sensitivity to the environment.3 SPS can be classified as classic stiff

person syndrome, stiff limb syndrome, jerking leg syndrome, and a progressive form:

progressive encephalitis with rigidity. Each form of stiff person syndrome has different effects,

and it is possible for one type of the syndrome to progress to another such as stiff limb syndrome

progressing to classical stiff person syndrome, or classical stiff person syndrome progressing to

progressive encephalomyelitis with rigidity.4

Stiff person syndrome not only affects a person’s body, but it also affects their mind.

Anxiety is often listed as a comorbidity to stiff person syndrome when in fact research shows

that the auto-antibody responsible for stiff-person syndrome induces nervous behavior in rats, so

it is very much a part of the disease process.5 Stiff person syndrome has so much of a

psychological component that it is often misdiagnosed as conversion disorder.6 Because SPS is

so rare, there is very little research available on the topic, especially concerning physical therapy

to treat the disorder. One case study found that physical therapy helped a patient in inpatient

rehab to improve lower extremity range of motion, increase gait speed, and improve quality of

life. In this case the authors emphasized that stretching needed to take place frequently, but

slowly and in a quiet place, and that stress exacerbated the patient’s spasms.7 Another case study

involved a woman with SPS presenting to an outpatient physical therapy clinic, who was able to

regain full lower extremity range of motion and improve gait pattern and stability. In this case

the authors shed light on the fact that the patient was dealing with severe anxiety, and during

treatment, standing for long periods of time increased stiffness in the patient. 8 These studies

were similar but also looked at very different types of physical therapy care.

Not only is there little research on treating this neuromuscular syndrome with physical

therapy, but there is no evidence of physical therapy’s role in treating a patient who has a

separate primary problem, with SPS as a comorbidity complicating treatment. Although rare,

more research on physical therapy’s role in treating patients with stiff person syndrome, both as a

primary diagnosis, as well as comorbidity, is necessary to determine what modifications need to

be made to enhance effectiveness of treatment and include a psychological component into the

plan of care.

B. Case Description: Patient History and Systems Review

This patient was a 71-year-old female who presented to a skilled nursing facility

following hospital admission/discharge for a left tibial plateau fracture. The fracture resulted

following a fall down her stairs earlier on the day of hospital admission. The physician at the

hospital ordered the patient to be non-weight bearing on the involved left lower extremity, and to

wear a knee immobilizer when out of bed. The patient also had acute hemarthrosis in the left

knee following the injury. The patient’s chronic comorbidities included stiff person syndrome

(SPS), type I diabetes mellitus, osteoarthritis, hypertension, garbled speech, anxiety and

depression. She also had a pertinent history of urinary tract infections as well as past fractures of

the wrist and ankle from a prior fall. She was on an insulin pump to manage her diabetes,

baclofen to manage SPS, and blood pressure medication chronically, as well as pain medication

acutely.

The patient was in the hospital for three days prior to coming to the skilled nursing

facility. At the hospital the patient was evaluated by a physical therapist and she was able to

perform bed mobility with moderate assistance, exhibiting difficulty due to the knee

immobilizer. Despite requiring moderate assistance for bed mobility, she was able to transfer

from sitting to standing with minimal assistance and a standard walker. The evaluating therapist

at the hospital did not examine gait with the patient.

Prior to admission to the hospital the patient was ambulating 50 feet at a modified

independent level with a rolling walker. She resided in a split level home with 5 steps to the

second floor where the bedroom is, as well as to the basement where the shower is located, with

hand rails on the right side. She was able to negotiate the stairs once per day with modified

independence using the hand rail. The patient had a walker on each floor of the home, as well as

a commode on the main level, to avoid needing to manage the stairs multiple times a day. She

also had a shower chair within her walk-in shower to aid in bathing.

The patient did not work, and resided with her husband who worked during the day and

managed grocery shopping, cooking, and cleaning for the patient, including cleaning her

commode. Her husband had a stroke years prior with lingering cognitive deficits and she needed

to cue him during some of the tasks he would help her with. Her son and granddaughter also

lived with her, however she stated that they were unable to assist due to mental health issues.

The patient was very fearful of ambulating following her most recent fall down the stairs and due

to her high level of anxiety. She did not have trust in many members of the healthcare team

within the skilled nursing setting, and was hesitant to work with physical and occupational

therapy because of her fear and distrust. The patient’s short term goal for physical therapy was to

be able to improve assisted transfers so that she would feel safe transferring with the nurses. Her

and her husband’s long term goal for therapy was for her to be able to return home safely, and

avoid having another fall.

C. Clinical Impression #1

Based on the medical chart review, the patient’s primary problem appears to be difficulty

with ambulation due to the non-weight bearing status of the left lower extremity following a

fracture. Potential physical therapy-related differential ICD-10 diagnoses for the patient could be

muscle weakness, difficulty walking or other abnormalities of gait and mobility. I used the

international classification of functioning, disability and health (ICF) to make my diagnosis. In

order to use this theoretical model to identify my patient’s pertinent problems, I needed to

acquire additional information through the examination. The most important additional

information I identified a need for were strength, balance, and pain assessments, along with

observational assessment of bed mobility, transfers, gait and stair negotiation. The plan for

examination of the patient included performing lower extremity sensation screening, manual

muscle testing of bilateral lower extremities, knee range of motion bilaterally, bed mobility

assessment, sitting balance observation, transfer performance assessment, standing balance

assessment, and gait observation. This particular patient is a good candidate for a case report

because of her rare comorbidity that vastly affected the treatment plan, outcomes, and opens

doors for further research into the rehabilitation of persons with stiff person syndrome.

D. Examination

Following questioning to obtain a thorough patient history, the exam began by assessing

the patient’s pain using the numeric pain rating scale.9 At rest her pain was a 0/10, with

movement her pain increased to a 6/10 generalized in the left lower extremity. Then a bilateral

lower extremity sensation screen was performed because of her history of diabetes. Tactile

localization and light touch sensation was assessed from L4 through S2, and all appeared

normal.10 Bilateral knee range of motion was then assessed both passively and actively while the

patient remained supine in bed.11 Right knee range of motion was within functional limits, from

0-110 degrees measured both actively and passively.12 Left knee range of motion however, was

limited at 5-85 degrees actively, and 5-95 degrees passively. All other upper and lower extremity

active range of motion was grossly screened, and appeared within functional limits, so no other

formalized goniometric measurements were done. Hip flexion strength was then tested bilaterally

in supine, followed by bilateral plantar flexion, dorsiflexion, and right knee extension strength in

sitting to assess feasibility of transferring.10 Left knee movement was too painful for the patient

to tolerate formal manual muscle testing, however movement against gravity through partial

range was observed. Shoulder flexion and abduction, along with elbow flexion and extension

strengths were then tested in sitting to assess the patient’s ability to use her arms to aid in

transfers and support herself on a walker during stance and ambulation.10 Manual muscle testing

results are listed in Table 1.

______________________________________________________________________________

Table 1.

Manual Muscle Testing Results10

(testing procedures adapted from Berryman Reese)

Right LeftHip flexion 4/5 3+/5Knee extension 4+/5 3-/5 Ankle dorsiflexion 4/5 4-/5Ankle plantarflexion 4+/5 4/5Shoulder abduction 4+/5 4+/5Shoulder flexion 4/5 4/5Elbow flexion 4+/5 4+/5Elbow extension 4/5 4/5

______________________________________________________________________________

Supine to sit transfer was observed upon giving the patient a verbal cue to “sit on the

edge of the bed,” where she required stand by assist to complete, due to some laborious

movement and difficulty with the task. This bed mobility was assessed with the head of the bed

flat and no use of the bed rail to mimic her home set up. Sit to stand ability was then assessed

using a front wheeled walker for support. Completion of the transfer required the bed to be raised

and minimal assistance to unweight hips from the bed surface, as well as to stabilize the walker

as the patient came to a standing position. The patient was able to maintain non-weight bearing

of the left lower extremity well, however was very retropulsive in stance which greatly impacted

balance and stability. Static standing balance and dynamic standing balance were assessed and

described using functional balance grades as described by O’Sullivan and Schmitz.13 The patient

had a Fair- static standing grade as she required a walker and contact guard to minimal assistance

for safety. She had a Poor+ dynamic standing grade when asked to reach across midline she was

unable to do so, only able to reach ipsilaterally with minimal assistance and a walker for

support.13 The patient was able to take two steps to transfer from bed to chair with moderate to

maximal assistance to control losses of balance and stabilize the walker. Due to safety concerns

and the patient’s fear of falling, no further gait assessment was performed this date. After

noting the patient’s fear of mobility, a fear based outcomes questionnaire was given to the

patient. The Activities Specific Balance Confidence Scale (ABC Scale) was considered, however

the task difficulty was unrealistic for this specific patient. Instead the Tinetti Falls Efficacy Scale,

also known as the balance efficacy scale was used to determine her fear of falling because it

assesses more realistic tasks for her. She scored an 80/100 which indicates a high fear of

falling.14 The examination data was used with the ICF model to determine what was most

impacting her and her rehabilitation prognosis.

Table 2.

ICF Health Condition: Tibial plateau fracture

Body functions and structure Decreased balance, decreased strength,

decreased left knee range of motion, increased

pain

Activity Limited in bed mobility, transfers, gait, and

stair negotiation

Participation Limited household ambulation, increased fall

risk

Environmental Factors Lives in a split level home with five steps up

to bedroom, and 5 steps down to shower from

main level, spouse is primary caregiver

Personal Factors Significant anxiety related to mobility and

fear of falling,

______________________________________________________________________________

E. Clinical Impression #2

Following the examination, the patient’s primary problem appears to be difficulty with

functional mobility, including transfers and gait, due to impaired balance and anxiety related to

movement, along with decreased strength. These problems are further exacerbated by her stiff

person syndrome. This confirms my initial impression that her gait would be the most limited

due to her non-weight bearing status on her left lower extremity, but adds in another component

that fear and anxiety are major limiting factors. At this point the plan is to proceed with

intervention. The patient continues to be appropriate for this case as she is willing to work with

therapy, and the symptoms her stiff person syndrome are affecting therapy in addition to the

tibial plateau fracture. The plan for intervention at this point was for physical therapy to work

with the patient five times per week for 30-60 minute sessions each week day, focusing on

increasing left knee range of motion, bilateral lower extremity strength, transfers, gait, and when

appropriate, stair negotiation. Progress would be reassessed on a weekly basis to gauge progress

with therapy.

F. Intervention:

Interventions for this patient focused predominantly on return to safe functional mobility.

Physical therapy sessions each day focused on a variety of different treatments, integrating

therapeutic exercise with functional activity. Therapeutic exercise activities included stretching,

straight leg raises, hip abduction strengthening, and standing mini squats. Functional activity

training included sit to stand transfer training, stand pivot transfer training, training on the use of

a transfer disc, gait training in parallel bars, gait training with a wheeled walker, and stair

negotiation training. In addition to physical intervention strategies, physical therapy also used

therapeutic listening to improve trust with the patient, thorough explanations of interventions to

ease anxiety prior to beginning interventions, and calming breathing techniques to ease anxiety

during interventions, to decrease the likelihood of stiff person syndrome symptom exacerbation.

Frequent breaks to refocus on the task, reassure the patient, and distract her from fearful thinking

was also used to help the patient to be more in control of her anxiety and not allow it to affect her

performance. Intervention specifics are listed in Table 3.

Table 3.

Intervention Type

Details Purpose

Stretching8,15 The patient was instructed in active assisted and independent left knee flexion stretches in the long sitting position. Active assist was used to begin the stretching regimen to manage pain, ease patient fears, and ensure that the patient was not self-limiting the range of motion. Independent stretching was then instructed with the use of mobilizing straps to allow the patient to slide her heel up for a passive knee flexion stretch. Independence with a stretching regimen was important to give the patient the ability to stretch multiple times per day as a home exercise program in order to get the best benefit. The patient was instructed to hold each stretch for 30 seconds, performing 3 repetitions, twice per day. There was increased emphasis on performing the stretches very slowly in order to avoid exacerbation of spasms from her stiff person syndrome.

To increase left knee flexion range of motion to within the functional range to improve ability to transfer safely and efficiently.

Straight Leg Raises15

The patient was instructed to perform 3 sets of 10 repetitions of straight leg raises with each leg once per day. This was performed in the supine position with one

To increase hip strength to ultimately

knee bent and foot planted on the mat or bed for increased stability. Initially this induced pain on the left leg so an active assisted method was used to complete the straight leg raise, with fewer repetitions per set.

improve forward progression ability during gait.

Hip Abduction Strengthening15

Hip abduction was performed using a sheet and a sliding board in supine due to difficulty isolating the gluteus medius muscle. The patient was instructed to perform 15 repetitions and 3 sets with each leg during a physical therapy mat table intervention session. To ensure proper performance there was emphasis on the patient keeping neutral hip rotation, vs. externally rotating the hip and using more hip flexors as a substitution. As the patient progressed, weights were added to increase difficulty of the task and to improve strength. The progression started with one pound weights on each ankle, progressing to 3 pound weights.

To increase hip strength, and stability in single stance to ultimately improve ambulation safety and efficiency.

Standing mini squat15

The patient was instructed during therapy sessions to stand with the support of her walker, and perform a mini-squat. Cues were given during performance to avoid overuse of upper extremity assistance, as well as to ensure an upright trunk, and midline knee bending for proper body mechanics during the exercise.

To improve dynamic balance during single leg stance with walker to ultimately improve transfer ability.

Sit to stand transfer training16

The patient was instructed to keep the left knee straight out in front of her in order to better maintain the non-weight bearing status of the left lower extremity. The patient was cued to lean her trunk forward to initiate sit to stand transfer, and this was emphasized throughout treatment as a way to dissociate the trunk as her stiff person syndrome often made this weight shift difficult. Her trunk stiffness was particularly severe when transferring from standing to sitting, so this forward trunk lean with hip flexion and knee flexion was particularly important to emphasize when having the patient sit down. Cues were also given to the patient for proper hand placement before the transfer (pushing up from the seated surface when standing, and reaching back for the surface before sitting), as well as where/when to shift hands to the walker for support.

To improve safety and independence with transfers, with weight bearing precaution compliance, to ultimately improve ability to return home safely.

Stand pivot transfer training16

The patient was instructed to stay in line with the walker while turning for increased stability and safety, and was given verbal and manual cues during the task to turn the walker as she had difficulty managing it during turning. She was instructed to push down through upper extremities to unweight the right lower extremity (RLE)

To improve safety and independence with transfers to a chair within room, to allow

in order to allow herself to pivot on her foot. She was also instructed to accept more weight into her RLE so that the walker would be easier to turn. Instruction on turning all the way, and getting in line with seated surface before reaching back was emphasized for safety to decrease fall risk.

the patient to sit up in a chair during the day, and eventually be able to return home safely.

Transfer disc training16

The transfer disc was introduced in order to ease patient fears when transferring with support staff, as she had increased anxiety while transferring with nursing aids, which then exacerbated stiff person syndrome symptoms. She was instructed to turn her foot on the disc while supporting herself with her upper extremities on the walker. Utilizing the transfer disc allowed the patient to turn her body more easily, easing fears, decreasing stiffness, and improving walker management.

To improve quality of transfers with support staff to ease patient fears when getting to a chair or commode.

Gait training utilizing parallel bars 4,

16

Gait training was first attempted using parallel bars for increased stability as she was very unstable and had difficulty managing the walker on evaluation and during stand pivot transfers. Patient fears were also a consideration using the parallel bars. Prior research has shown that those with stiff person syndrome have increased anxiety when walking in open spaces so the parallel bars were also used as a way to have a more closed off environment. The patient was instructed to push down with upper extremities when attempting to take a step in order to unweight the RLE. Due to her stiff person syndrome, when the patient would flex her hip for forward progression, her knee would not passively flex as we would expect, making gait very rigid. The patient would also become very retropulsive when attempting to take a step, attempting to gain momentum this way. In order to address this, gait training focused on trunk, hip, and knee dissociation. Pre-gait training in the parallel bars focused on hip flexion with a neutral trunk and passive knee flexion, avoiding trunk and knee extension.

To improve gait pattern and ease anxiety while learning non-weight bearing gait pattern.

Gait training with wheeled walker 4, 16

Gait training using the parallel bars was then progressed to gait training with a wheeled walker as it is more functional. However, to continue to ease patient anxiety, wheeled walker gait training was provided in the parallel bars to allow the patient to feel that she was in a more closed off environment. Emphasis was still placed on dissociating trunk, hip and knee during gait, with instruction on a non-weight bearing 3 point gait pattern with a wheeled walker. The focus of instruction was how to properly sequence gait. Gait training was then progressed to a tile surface next to a wall in a quiet

To improve safety and independence with gait, for eventual safe return home.

hallway so that it was more of an open space, but still had a structure next to her for improved feelings of safety. The patient had a noted increase in anxiety with this ambulation vs. ambulation in the parallel bars so instruction in pursed lip breathing was implemented to decrease anxiety. The patient was cued to take a small standing break and focus on pursed lip breathing every 5-7 steps, as she would get increasingly stiff with a poor gait pattern similar to that prior to treatment. The patient also needed to be cued for improved proximity to the walker. Next, gait training was progressed to being in the middle of a small quiet room to improve the patient’s ability to ambulate in open spaces focusing on the same gait training fundamentals as previously mentioned. Once the patient was able to weight bear as tolerated, gait training was done in an open quiet therapy gym, focusing on a step to-pattern with wheeled walker, and again on stress management techniques.

Stair training16 Stair training was first attempted once her weight bearing status was updated to allow weight bearing as tolerated. The patient was instructed to ascend with the right leg first and descend with the left leg first as a way to manage pain and improve stability on stairs. She was also instructed to use both hand rails as that was most like her set up at home. She was cued to maintain her center of mass over base of support as she became very retropulsive on the stairs from fear and anxiety associated with her stiff person syndrome. Finally, she was cued to take a break and assess her performance after each step, to avoid any loss of balance due to declined performance from anxiety.

To improve safety and independence with stair negotiation, to allow safe return home.

G: Outcomes

The patient was continuing to progress with therapy over the course of treatment,

however before she could reach her optimal potential and prior level of function through therapy,

she was cut by her insurance and unable to continue to stay at the skilled nursing facility. This

resulted in her not meeting all of her goals or returning to prior level of functioning, however she

was much more functionally mobile following treatment compared to the evaluation. Left knee

range of motion improved to 0-105 degrees both actively and passively, which is near the

functional range, and allowed her to transfer much more effectively toward the end of treatment.

Strength was not formally reassessed at discharge, however functional gains in strength were

noted based on improved performance of transfers, and stability during gait. Sit to stand

transfers improved from requiring minimal assistance to requiring only stand by assistance.

Standing dynamic balance improved from a Poor + grade, to a Fair- grade. Stand pivot transfers

progressed from requiring maximal assistance to requiring only stand by assistance with use of a

wheeled walker. Her ambulation quality and safety progressed from requiring moderate

assistance to ambulate 5 steps, to contact guard assistance requiring only contact guard assistance

to ambulate 40 feet with a wheeled walker. Her stair negotiation progressed from

ascending/descending 1 step with maximal assistance to ascending/descending 2 steps with

minimal assistance and bilateral handrails. As mentioned previously, the Tinetti Falls Efficacy

Scale was used as an outcome measure to determine confidence and fear associated with

mobility in this patient as those were severely limiting factors for her. This outcome measure has

an excellent correlation with balance, gait, and mobility in geriatric individuals.17 The patient has

an initial score of 80 indicating a high fear of falling, as it was about the threshold score of 70,

while her final score was 62, indicating decreased fear of falling from initial evaluation. Table 4

contains patient specific responses to the outcome measure.

Table 4.Tinetti Falls Efficacy Scale Score Evaluation vs. Discharge Comparison

Activity

Initial Score:

1 = very confident10 = not confident at all

Discharge Score:

1 = very confident10 = not confident at all

Take a bath or shower 8 7Reach into cabinets or closets 10 10

Walk around the house 10 10Prepare meals not requiring carrying heavy or hot objects 10 7

Get in and out of bed 2 2Answer the door or telephone 10 9Get in and out of a chair 9 5Getting dressed and undressed 7 3Personal grooming (i.e. washing your face) 4 3

Getting on and off of the toilet 10 6Total Score 80 62

H. Discussion

In this case, the patient’s most prominent problem of having a fractured left tibial plateau

was complicated by her unique co-morbidity of stiff person syndrome. Although stiff person

syndrome affects the neuro-muscular system, in which physical therapists are experts, there

remains little evidence on the role of physical therapy in treating those with stiff person

syndrome. Current available evidence recognizes the need for rehabilitation in those with stiff

person syndrome, to improve gait and mobility abnormalities, however few attempts have been

made to publish cases of stiff person syndrome where therapy was an integral part of treatment.18

Most stiff person syndrome research is primarily related to pharmacological treatments versus a

therapeutic whole person approach. Research has even shown that while functional disability

measured using the Rankin scale did decrease after the initiation of diazepam, the average patient

still had a slight disability following.4 This further acknowledges the need for therapy services in

those with stiff person syndrome to address difficulty with functional mobility through functional

retraining or education on compensatory techniques to improve safety, independence and quality

of life. In addition, stiff person syndrome is related to high anxiety and anxious behaviors, and

this has been proven to be a part of the disease process associated with the antibody responsible

for the syndrome.5,6 This demonstrates a need for more additional services to be included in the

management of stiff person syndrome as well, not only pharmacological or therapy related. Stiff

person syndrome affects multiple aspects of a person, and a multidisciplinary approach needs to

be taken. If psychology services are unavailable to the patient or he/she does not want to receive

these services, the physical therapist needs to be especially cognizant of the psychological

component and include anxiety relieving techniques along with typical physical therapy

interventions.

This patient in particular demonstrated that pharmacological interventions may not be

enough to manage stiff person syndrome. Her symptoms were exacerbated by anxiety and fear of

movement which was heightened due to her weight bearing precautions. Care was taken to

include stress management education and interventions such as deep pursed lip breathing, as well

as being cognizant of what would increase anxiety, to avoid any triggers that would exacerbate

her stiff person syndrome symptoms. Fear and anxiety were lessened by allowing the patient to

begin working in closed off environments, then progressing to more open environments as she

became more comfortable. Pursed lip breathing techniques along with frequent breaks to manage

stress and anxiety proved to be helpful in decreasing symptoms and improving patient

performance in this case. While these techniques helped to decrease exacerbation of stiff person

syndrome symptoms in this patient, all patients are different and more evidence is needed to

address what techniques work best for managing stiff person syndrome both as a comorbidity

and as a primary cause of treatment. Although rare, current evidence does not fully recognize the

potential that physical therapy has to improve the symptoms and quality of life in a person with

stiff person syndrome. In the few published case studies involving physical therapy as an

intervention for stiff person syndrome, it was shown to improve functional outcomes, both in the

outpatient and inpatient rehabilitation settings, and the patient featured in this case report had

improved outcomes when stiff person syndrome was managed as a comordbidity.7,8 As

movement experts, physical therapists need more evidence on what affects mobility in those with

stiff person syndrome in order to treat stiff person syndrome both as a comorbidity affecting

treatment and as the primary disease process.

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