“I’m beginning to feel like a kid again!”
Sarah Kruse & Jeffrey Miller
June 5, 2008
Six weeks with RB
2
Health Condition
MI x2 during surgical stint
procedure
S/p DM II 19 yr.
Amyotrophy
HTN managed with meds
R shoulder pain
L frozen shoulder
Vision Corrected with
Glasses
B Cochlear Implants
Smoked for40 years
59 y.o. male
History of Falls (5x last 3 mo)
Depression
3
Body Structure & Function
Cognition Oriented x3; able to follow multi-step directions
Sensation Absent (5.07 g) on plantar surface of B feet except for R lateral mid-foot (diminished).
MMT B LE & UE: Proximal < Distal
AROM B shoulder abd ~50° / flex ~85°
L shoulder ER < Abd < Flex
BERG 21/56 (High Fall Risk)
LAT Chair Stand: 2
Arm Curl: 8 (non-dominant)
TUG (8 ft.): 17.6 sec (0.14 m/s)
Transfers Supine Sit Mod A, Sit Supine Independent, Sit Stand SBA
OGA 0.80 m/s, Stride length, R path deviations, knee flexion (swing), flat foot IC, R lateral and forward flexed posture, Hip excursion
4
Functional Activities & Participation
Functional Limitations ambulation (velocity, safety, and
independence) transfer safety and independence BADLs and IADLs.
Participation shopping housework independence in the community
5
Environmental Factors
Lives alone on 4th floor of apartment Caregiver 5x/week for 4 hours Elevator and 5 stairs or ramp Neighborhood access: scooter Community access: car and manual w/c
6
Diagnosis & Prognosis
Increased risk of falls and ↓ mobility resulting in decreased independence at home and in the community.
Excellent Good Fair Poor
Understands benefits of exercise
Prior tx by HomeStretch Support of caregiver Motivated: “last shot”
- Complex health history
- Low exercise self-efficacy
- Recent decline in health
7
Goal Timeline
I 1 2 3 4 D
I supine sit from bed
Amb 200 ft with FWW in community room with 2
30-sec sitting breaks
I transfer floor standing
Report no falls in previous 7 days
Increase strength to 4/5 MMT of B proximal LE muscles
Amb 500 ft with FWW and SBA outside on level sidewalk
8
Plan of Care
1. Gait training with focus on increasing safety, distance, and improving biomechanics.
2. PRE program to increase strength of B hip muscles.
3. Transfer training targeting bed mobility & recovery from falls.
4. Education in preventing and recovering from falls.
5. Testing to assess and determine appropriate interventions to improve balance in varying conditions and environments.
9
Treatment Weeks 1-3T
reat
me
nt
Se
ssi
on
HE
P
Week 1 Week 2 Week 3: JPM Solo!
No Falls!! No Falls!!
Initial Evaluation
Transfer TrainingSupine Sit with
caregiver assist
Berg Balance Test
Gait TrainingAmb 120 ft. with
4WW & CG2x 180° turns,
stopping, head turns
Tried walking sticks
Gait TrainingAmb 500 ft. outside
with 4WW & SBA and 4 rest breaks
Part-to-Whole:Knee flexion and heel contact
Step-overs
1. Sit-to-Stand
2. Supine Knee Extension over towel
3. Seated Marching
1. Seated Marching
2. Sit-to-30-sec-Stand
3. Amb 160 ft in hallway
1. Sit-to-30-sec-Stand
2. Amb 250 ft outside
3. Lateral WS with leg lift & hold
10
Treatment Weeks 4-6T
reat
me
nt
Se
ssi
on
HE
P
Week 4 Week 5 Week 6
Multiple LOB!!Diarrhea, L Shoulder
No Falls!!Broke his Glasses!
One LOB!!
Balance TrainingLateral WS with SL
liftStep-up/down
4” step
Monofilament Tests
MI about walker
Balance TrainingClocks
Gait TrainingAmb 750 ft. with
SBA with 2 breaks 15 stairs, head
turns
Discharge PlanContinue HEPHHPT for shoulder,
balance, gaitAssess for AD
1. Sit-to-30-sec-Stand
2. Amb 250 ft outside
3. Lateral WS with lift
4. Seated Hip Abd
5. Shoulder ROM
1. Seated Hip Abd
2. Shoulder ROM
3. Amb 1500 ft outside
4. Clocks
5. Supine knee flexion
1. Supine knee flexion
2. Sit-to-stand head turns
3. Clocks Waltz
4. Amb 20 min/day
5. Standing abd
Fatigue!!
11
Initial vs. Discharge
2 4 6 8 10 12 14 16 18 20 22
Arm Curl
10 20 30 40 50 56
BERG
2 4 6 8 10 12 14 16 18 20
Chair Stand
20 18 16 14 12 10 8 6 4 2
8 Foot Up & Go (sec)
Initial
Discharge
21 38 46
0
0
0
0
12
Lessons Learned
Check-in is a MUST!! Have a good set of “behavioral” tools Punted on a few impairments we
discovered....appropriate??
13
?Any Biting Questions?
14
Initial vs. Discharge
21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1
ADLS
21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1
IADLS
1 2 3 4 5 6 7 8 9 10
PACE
10 20 27
SRAHPS
1 2 3 4 5 6 7 8 9 10
Outcomes Expectations14 17
Initial
Discharge
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