CLINICAL PROBLEM SOLVING I Katie Blow DPT Class of /5/2014

Purpose  Present PT management for a patient post subarachnoid hemorrhage  Evaluate whether the Berg Balance Test predicts functional status at discharge from inpatient rehab

Patient History  60 yr old male admitted s/p fall vs. trauma 2 days prior to eval  Right frontal hemorrhage, bilateral temporo-parietal subarachnoid hemorrhage (SAH)  Other injuries: Maxillary fracture, R orbital fracture, R distal radius fracture  Additional Information:  Chest pain reported overnight, but EKG and two sets of cardiac enzymes negative  Vtach  Pertinent PMH:  DM, HTN, hyperlipidemia  Precaution:  Non-weight bearing on right upper extremity

Initial Evaluation  Pain: 8/10 in forearm and head  Mental Status: lethargic  increasingly alertness  Alert & Oriented x3  Single step commands  Motor: 3+/5 bilateral lower extremities  Mobility:  Supine  sit minA  Sit  stand CGA-minA MinA= minimal assistTherapist performs 25% of transfer CGA= contact guard assist Therapist contact maintained on pt but no physical support 3+/5 Full ROM against gravity, slight resistance Alert & Oriented x31.Person 2.Place 3.Time 4.Situation

Initial Evaluation  Gait:  Impulsive  Loss of balance to right, frequent lateral missteps, anterior lean, postural sway  Complaint of dizziness  Balance:  Short Berg Balance Test 16/28 (<23 considered increased risk for falling)  Assessment  Moderate deficits in balance, gait, strength, endurance, and cognition

Plan of Care  Treatment Goals:  Supine  sit with supervision (S)  Sit  stand with S  Ambulate 200 ft with S, no loss of balance  Ascend/descend 6 steps with handrails with S  Plan:  See patient 5x/week to improve balance, gait, strength, endurance, and cognition  Discharge: Inpatient rehab

Prognosis  Fair to good  Young  Healthy  Family support  Active prior to injury  Participatory in therapy

Clinical Question  In a 60 year old male with a subarachnoid hemorrhage, does the Berg Balance Test predict functional status at discharge from inpatient rehab?

Evidence #1 Admission Balance and Outcomes of Patients Admitted for Acute Inpatient Rehabilitation Juneja, 1998

 Objectives  Evaluate relationship between a measure of balance and a measure of functional independence  Determine if balance scores collected at rehabilitation admission were predictive of rehabilitation outcomes, including length of rehabilitative stay, gain in functional independence scores, and rehabilitation efficiency

 Prospective study  45 subjects  Stroke  Traumatic Brain Injury  Other diagnoses  Physical therapists administered Functional Independence Measure (FIM) and Berg Balance Scale (BBS) at admission and discharge from inpatient rehab  FIM gain= (FIM admission – FIM discharge)  FIM efficiency= (FIM gain/LOS) Admission Balance and Outcomes of Patients Admitted for Acute Inpatient Rehabilitation Juneja, 1998

 Found non-significant data between three groups; therefore, collapsed into one Admission Balance and Outcomes of Patients Admitted for Acute Inpatient Rehabilitation Juneja, 1998

 Balance was not predictive of gain in functional ability, but the total BBS at admission accounted for 22% of the variance in the FIM efficiency score  FIM efficiency= (FIM gain/LOS)  Reflects a likely relationship between balance and LOS Admission Balance and Outcomes of Patients Admitted for Acute Inpatient Rehabilitation Juneja, 1998 Results

Limitations  Small sample size  Older study  Definition of patient subgroups  Patient subgroups collapsed  Used full Berg Balance Test

Evidence #2 Berg Balance Scale and Outcome Measures in Acquired Brain Injury Feld, 2001

 Objective  To examine the relationship of the Berg Balance Scale (BBS) to the outcome measures such as Functional Independence Measure (FIM) and length of stay (LOS)

 40 subjects  24 experienced traumatic brain injury  16 experienced non-traumatic brain injury  BBS and FIM administered within 72 hours of admission and before discharge  Low BBS score group (<= 42)  High BBS score group (>= 43) Berg Balance Scale and Outcome Measures in Acquired Brain Injury Feld, 2001

Low BBS score group (<=42) High BBS score group (>=43) Traumatic Brain Injury159 Non-traumatic Brain Injury 124

Berg Balance Scale and Outcome Measures in Acquired Brain Injury Feld, 2001 Admission BBS v. Discharge FIM

Admission BBS v. LOS Berg Balance Scale and Outcome Measures in Acquired Brain Injury Feld, 2001

 Upon multiple regression analysis…  FIM at admission best predictor of FIM at discharge  Admission BBS not found to be independent predictor of FIM at discharge or LOS  ALTHOUGH, patients with balance deficits upon admission exhibited poorer functional outcomes and longer LOS Berg Balance Scale and Outcome Measures in Acquired Brain Injury Feld, 2001 Results

Limitations  Small sample size  Older study  No comparison in results between traumatic v. non-traumatic brain injury groups  Definition of groups  Used full Berg Balance Test

Significance for My Patient  Berg Balance score can be used to ENHANCE prediction of functional outcome status from inpatient rehab; but the score alone is not predictive  FIM at admission is best predictor of FIM at discharge

References  Juneja et al. "Admission Balance and Outcomes of Patients Admitted for Acute Inpatient Rehabilitation." American Journal of Physical Medicine & Rehabilitation 77.5 (1998): Williams & Wilkins.  Feld, Jody et al. "Berg Balance Scale and Outcome Measures in Acquired Brain Injury." Neurorehabilitation and Neural Repair (2001). Sage.

Questions?