Catatonia case :St Andrew's Healthcareshares Rose's inspiringrecovery journey

How physiotherapy in ABI Multi-Disciplinary Team enabled Rose's recovery from catatonia

With a longstanding history of schizoaffective disorders, Rose arrived at St Andrew’s Healthcare with catatonia, which resulted in profound physical effects.

^{Jyothi Kraleti is a Specialist Physiotherapist working across St Andrew’s Brain Injury Unit. To find out more about Jyothi and what she loves about her job,}^{watch her video here}

By using a multi-disciplinary approach, led by the physiotherapy team, Rose was supported in her recovery in a case so unique that the specialist physiotherapist, Jyothi Kraleti, involved in her care has now written a paper as a reference point for other clinical teams. NR Times learns more.
Having arrived at St Andrew’s Healthcare with schizoaffective catatonia - which resulted in an inability to use her arms or legs, or to speak - Rose left the hospital having regained the ability to walk and communicate after intensive therapy from the multi-disciplinary team.
While schizoaffective catatonia is very rare, each manifestation is different - meaning Rose’s case was unique and unlike anything the St Andrew’s multi-disciplinary team had seen before.
Physiotherapy proved particularly important in Rose’s rehabilitation, with a bespoke regime to initially free her from her catatonic stupor, gaining in momentum as she regained her ability to move.
Working alongside psychologists and supported by a combination of medication and treatment - which was continually adjusted until it could best support Rose’s recovery - the physiotherapy team were able to lead Rose’s rehabilitation during her time with St Andrew’s.
Having secured such a successful outcome for Rose and her family during the five-month programme, specialist physiotherapist Jyothi Kraleti has produced a case study paper to help guide and inform other therapeutic teams about the unique circumstances of this patient, the interventions and engagement from the St Andrew’s team and lessons learned along the way.
While the majority of previous studies have primarily used drug therapy, this case involved a multidisciplinary approach, with physiotherapy playing a key role in Rose’s recovery.
“Rose’s diagnosis was very complex, and in these cases each particular patient comes with a different presentation.
We referred to Journals but the approaches identified were deemed unsuitable for our patient, even though it was the same diagnosis,” says Jyothi.
“However, drawing the skills from across our specialist multi-disciplinary team meant that we were able to help Rose secure a very positive outcome. Her family were incredibly happy. I think the combination of the right interventions with the right frequency was very important here, and without our MDT working, I’m not sure we’d have got that.
“This is a very unique situation and that is why we wanted to produce a paper.
“I wanted to shine some light on this case so that other physiotherapy teams and psychiatrists can think ‘Oh, I have this patient, is there any reference to a similar case that can help us to define a clinical approach?’”

Supporting Rose in her recovery
Rose had a long history of schizoaffective disorders, with her first mental health problems presenting when she was 16.
In 1994, she experienced her first psychotic episode. Over the years, she had some catatonic episodes, but its manifestation in late 2017
was profound.
When she was admitted to the specialist unit at St Andrew’s in Northampton, she was bed-bound, mute, immobile and unable to feed. Assessment using the Barthel Index scale scored zero, indicating minimal functional capacity.
“There was no movement and no response from her. She couldn’t talk to us and was only able to make the same expression for everything, which was very difficult to understand - there would be the same expression for fear, for pain and for anything positive. It was very difficult to reassure her and provide the right care,” recalls Jyothi.
Whilst in her previous catatonic episodes she had displayed what her family described as ‘manic-like behaviour’, there were no physical symptoms - which this time were the dominant feature of her presentation.
However, following the intervention of the St Andrew’s specialist team, a short time later she regained her ability to speak.
The fact that Rose was mute when she came to us and then after a short period of clinical intervention she was able to speak again was
very interesting. It felt like something you’d see in a movie, but gave us confidence that the prognosis was good.”

^{Elgar ward in Kemsley is our female brain injury ward for women who have an acquired/traumatic brain injury requiring specialist programmes of care that enhance recovery and community reintegration. To find out more visit:}^{stah.org/Elgar}

The role of physiotherapy
Beginning with three sessions a week, Rose’s physical rehabilitation got underway very shortly into her stay with St Andrew’s.
“Initially the patient had no movement, so we were facilitating movements for her. She was presenting with a lot of rigidity, but over time you could see the rigidity loosening and see the muscles working in both the agonist and antagonist groups,” says Jyothi.
“We were using proprioceptive neuromuscular facilitation (PNF), where we are basically training the body functions to correlate with the brain. Through verbally counting and explaining the movements, and the use of mirror therapy for the patient to see and recognise the movements, we were able to make good progress.
“Initially Rose was laying flat on the bed restricting the range of movement we could perform with her, but through employing PNF techniques with a particular rhythm and frequency to get it working, we began to see positive movement.”
With Rose being brought out of her catatonic state, Jyothi and her team were then able to focus on the next phase of her physical
recovery, including sitting, balance, upper limb PNF and mobility.
“We incorporated more sensory-related techniques, like Tai Chi and ball activities.
Initially we would throw a ball across a room to another patient, and she would sit and watch.
As she progressed, we would throw the ball to her, but she would not catch it at first. Eventually, she would start kicking it,” says Jyothi.
“The sensory integration techniques we incorporated alongside the physiotherapy were very important, and we know she enjoyed the Tai Chi movement with its calming music.
That was a great addition to the physiotherapy and she would make active attempts to move her limbs.”
Over the course of several months, Rose regained the ability to walk, and went home with just a walking frame to support her.
“It was so nice to see her walking, and she actually improved to a stage where she didn’t always need the walker, but we had to come
up with a plan which could support her movement for the long term, and again that was a team approach.”

The importance of the MDT approach
While physiotherapy played a key role in ensuring Rose could regain her physical independence, the role of psychologists as part of the MDT, as well as the introduction of medication and treatment, was key to the outcome.
“It’s very much a team approach. So if you look at me doing my movements, and facilitating this regularly, that would not have had as much value without a much wider team approach,” says Jyothi.
“Without the input from the doctors I would not have the insight I needed to adapt my approach to Rose’s physiotherapy. Or if myself and my team are doing movements and report she is very stiff today, then the doctors can see that this medication maybe didn’t suit
her so well.
“I think without these lines of communication in place, we would have struggled a lot more.”
After Rose regained mobility and made strong progress in her recovery, the team decided to slowly reduce the intensity and frequency of her physiotherapy sessions following five months of intensive rehabilitation, reducing the medical interventions.
However, Rose experienced a relapse in both physical and psychological terms, meaning the team needed to scale up their support again. Again led by the physiotherapy team, the increased frequency and intensity of the sessions thankfully yielded positive results within a week.
“When she had a dip, we persistently provided physio input, because the team recognised that this was needed and thankfully the intervention was able to turn things around,” says Jyothi.
“We reintroduced the intensive physiotherapy and deployed the whole team to restart the treatment approach with full force like we
did before. Rose’s recovery was quite quick and she was able to continue progressing.”
St Andrew’s commitment to on-site, full time multi-disciplinary teams was crucial in achieving a positive outcome for Rose.
“I think that without the interventions that were used and put into place, she would probably still be here at St Andrew’s, she may well still be bed bound,” says Jyothi.
“We firmly believe that if we are persistent in the input of our interventions, then even patients with long term conditions can see some improvement and can get better.”
Rose received her treatment on one of St Andrew’s specialist brain injury wards because although her presentation was catatonic she required the same neuro rehabilitation techniques to regain movement and function as those people who are admitted with an acquired or a traumatic brain injury.
As a Specialist Physiotherapist Jyothi Kraleti has had extensive experience of working with patients with complex neuro and neuro muscular conditions.

If you are interested in finding out more about Jyothi’s research case study and the approaches she used you can contact her directly on jvkraleti@stah.org

To find out more about Brain Injury care at St Andrew’s
download a brochure here
or visit the brain injury area of the website.