“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 for 40 years 59 y.o. male History of Falls (5x last 3 mo) Depression

3 Body Structure & Function CognitionOriented x3; able to follow multi-step directions SensationAbsent (5.07 g) on plantar surface of B feet except for R lateral mid- foot (diminished). MMTB LE & UE: Proximal < Distal AROMB shoulder abd ~50° / flex ~85° L shoulder ER < Abd < Flex BERG21/56 (High Fall Risk) LATChair Stand: 2 Arm Curl: 8 (non-dominant) TUG (8 ft.): 17.6 sec (0.14 m/s) TransfersSupine  Sit Mod A, Sit  Supine Independent, Sit  Stand SBA OGA0.80 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 4 th 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. ExcellentGoodFairPoor  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 I1234D 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 1-3 Treatment Session HEP Week 1Week 2Week 3: JPM Solo! No Falls!! Initial Evaluation Transfer Training Supine  Sit with caregiver assist Berg Balance Test Gait Training Amb 120 ft. with 4WW & CG 2x 180° turns, stopping, head turns Tried walking sticks Gait Training Amb 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 4-6 Treatment Session HEP Week 4Week 5Week 6 Multiple LOB!! Diarrhea, L Shoulder No Falls!! Broke his Glasses! One LOB!! Balance Training Lateral WS with SL lift Step-up/down 4” step Monofilament Tests MI about walker Balance Training Clocks Gait Training Amb 750 ft. with SBA with 2 breaks  15 stairs, head turns Discharge Plan Continue HEP HHPT for shoulder, balance, gait Assess 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 Arm Curl BERG Chair Stand Foot Up & Go (sec) Initial Discharge

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 ADLS IADLS PACE SRAHPS Outcomes Expectations Initial Discharge