Delivering Safe
Restorative Care:
Shake a Leg…
And a Legrest!!!
Dennis W. Klima, PT, MS, PhD, DPT, GCS, NCS
Department of Physical Therapy
University of Maryland Eastern Shore
dwklima@umes.edu
 Purpose
of
Presentation
 Begin
with a case
 Discuss
restorative
care issues
 Laugh
5 times
Subject Description: Patient
Profile
S--- “Sol”
 70 years old
 Considered “frail”
 Mr.
– Why? Which scale?
» CHS vs. SOF
 Fell
- 7/14
Frailty-Causes of Falls
 Intrinsic
Causes
– E.g. DiabeticRelated
Complications
 Extrinsic
Causes
– Environmental
Frail Older MenConsiderations

Average unintentional home injury
death is higher for elderly males.

Men are less likely to report a fear
of falling.
Runyan CW, Casteel C, Perkis D, Black C, Marshall SW, Johnson RM, CoyneBeasley T, Waller AE, Viswanathan S. Unintentional injuries in the home in the
United States. American Journal of Preventative Medicine. 2005; 28:73-79.
Hospital Course
 Admitted
to acute care hospital
 Diagnosed with renal carcinoma
 Underwent resection 7/22
 Admitted to rehabilitation center 8/2
Examination
 History
– P.M.H. of Diabetes-Type II, Diverticulitis,
Depression, Mild HTN
– Meds: Glucophage (500mg. bid)
Effexor (75 mg.)
– Social:
» Going to senior center less frequently with wife
Review of Systems
 Cardiopulmonary
– Bibasilar rales
» Stable vitals
 Musculoskeletal
– Bone Scan and M.R.I.
– Revealed no metastatic spread
Lab Values
9,000
mm3
3.8
mEq/dl
105
Examination

Cognition: Alert and Oriented X 3

Balance Confidence: 70%

Sense of Humor- 2/5

Joint Integrity/ROM:
Upper Extremities-No limitations/Goni. form
Lower Extremities-Limitations
Hip Extension-R: 0 L: -5
Hamstring Length: R: 40 degrees L: 45 degrees
Ankle Dorsiflexion - R: 0 L: -2
Examination
 Sensation
– Intact to light touch and proprioception X 4
extremities. Protective Sensation intact: 5.07 g
 Coordination:
(-) Dysmetria,
(-) Dysdiadochokinesia
Skin Integrity: Sacral Pressure Ulcer
Stage II: 4 cm. X 3 cm.
Examination
 Muscle
Strength:
Grip Strength: 32 lbs. /Right
-Upper extremity: Deltoids: 4-/5
Biceps, Triceps: 4/5
Wrist/Hand: 5/5
-Lower extremity: Hip Flexors, Extensors: 3+/5
Abductors:3-/5
Quads: 4-/5, Hamstrings: 4/5
Anterior tibialis:5/5
Gastrocnemius:3/5
Evaluation, Diagnosis,
Prognosis
 Deconditioned,
pleasant older
gentleman
– Good rehab candidate
– Good family support
 Impaired
functional mobility secondary
to deconditioned status
 Prognosis-Good, though concerns
regarding fall risk; Candidate to return
home with DME and family training
Interventions
1
hour daily, 6 days/week
 Session
divided:
– gait and transfers/20 min.
– exercise/stretching-20 minutes
» Started at 50% 1 R.M. 10 repsX3
– functional training-sit to stand, bed
mobility, wheelchair propulsion-20 minutes
The Eyes and Ears…
How
the CNA’s
and CGA’s
helped……..
Outcomes

At discharge:
– Independent in bed
mobility and
transfers
– Ambulate household
distances with
straight cane with
supervision
– Negotiate stairs with
right rail with CG;
curbs and uneven
terrain-CG
Home Assessment/Follow-Up
1
Month
 Returned
to senior center
 Participating
1
Problem…
in Tai Chi and Dance
Mr. Pussycat was plotting…
I. Wheelchairs
 Seating
Considerations
– Minimally responsive patients
– Fractures
– Hemiplegia
Wheelchair Parts
 Legrests
 Footplates
 Heel
loops
 Seat
belt
 Brakes
– Push to lock
– Pull to lock
– Extensions
Wheelchair Parts
Management and Propulsion
 Parts
Managementbrakes, legrest
management, and
armrests
 Propulsion-level surface,
steering strategies, turns
 Upper extremity Nonweightbearing
precautions
Wheelchairs
 Safety
 Maintenance
– Locking of brakes?
– Brakes tight?
– Footrests in place?
– Clean?
– Anti-tips in place?
Specialty Chairs
 Recliner
Wheelchair
– Back Reclines from
vertical
– Special brake
location
– Importance of antitips
– Collapsing
mechanism
II. Range of Motion
 Frequency
 Types
 Precautions
– Excessive Flexion
III. Bed Mobility



Transfers
Sitting balance
Supine to sit:
–
–
–
–
–




4 Cardinal Instructions
Roll
Legs
Elbow
Push
Bridging---Don’t let
NWB extremity push!!!
Scooting
Rolling
Supine to sit
IV. Transfers
 Principles
– Body mechanics---Lift with….
– Side---Transfer to the strong
– Proximity---Close
 Types
 Use
of Mechanical Devices
V. Ambulation
– Guarding---On the weak
– Levels of Assistance
– Communication to other professionals
VI. Positioning
 Avoid
excessive flexion
 Check
key landmarks for excessive
pressure
 Check
ALL landmarks for excessive
pressure
Managing Patients of
Significant Size
 Safety
is imperative at all times
 Assess
gynoid vs. android build with respect
to mobility activiites
 Select
 Do
safest strategy for supine to sit
appropriate lead-up activites for transfers
and ambulation
Bariatric Equipment
 Wheelchairs
 Beds
 Lift
Systems
Important Tips

Consider psych-social implications of patient’s
diagnosis

Thoroughly assess bed position prior to mobility
activities

Use caution when using equipment NOT
designed for clients of significant size
QUESTIONS ???
THANK YOU!!!