“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