“I’m beginning to
feel like a kid again!”
Six weeks with RB
Sarah Kruse & Jeffrey Miller
June 5, 2008
2
Health Condition
Vision
Corrected with
Glasses
R shoulder
pain
HTN managed
with meds
59 y.o. male
B Cochlear
Implants
Smoked for
40 years
L frozen
shoulder
MI x2 during
surgical stint
procedure
Amyotrophy
Depression
S/p DM II 19 yr.
History of Falls
(5x last 3 mo)
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 midfoot (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:
Arm Curl:
TUG (8 ft.):
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
2
8 (non-dominant)
17.6 sec (0.14 m/s)
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
Understands benefits of
exercise
Prior tx by HomeStretch
Support of caregiver
Motivated: “last shot”
Fair
Poor
- 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
Amb 500 ft with FWW and SBA
outside on level sidewalk
Report no falls in previous 7 days
Increase strength to 4/5 MMT
of B proximal LE muscles
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
Week 1
HEP
Treatment Session

Week 2
Week 3: JPM Solo!
No Falls!!
No Falls!!
Initial Evaluation
Transfer Training
 Supine  Sit with
caregiver assist
Berg Balance Test
Gait Training
Gait Training
 Amb 500 ft. outside
with 4WW & SBA
 Amb 120 ft. with
and 4 rest breaks
4WW & CG
 Part-to-Whole:
 2x 180° turns,
Knee flexion and
stopping, head
heel contact
turns
 Tried walking sticks  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
Week 4
HEP
Treatment Session

Week 5
Week 6
Multiple LOB!!
No Falls!!
Diarrhea, L Shoulder 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.
2.
3.
4.
5.
1. Supine knee flexion
2. Sit-to-stand head turns
3. Clocks  Waltz
4. Amb 20 min/day
5. Standing abd
Fatigue!!
1.
2.
3.
4.
5.
Sit-to-30-sec-Stand
Amb 250 ft outside
Lateral WS with lift
Seated Hip Abd
Shoulder ROM
Seated Hip Abd
Shoulder ROM
Amb 1500 ft outside
Clocks
Supine knee flexion
11
Initial
Discharge
Initial vs. Discharge
21
0
10
38
20
30
46
40
50
56
BERG
0
2
4
6
8
10
12
14
16
18
20
22
Arm Curl
0
2
4
6
8
10
12
14
16
18
20
Chair Stand
20
18
16
8 Foot Up & Go (sec)
14
12
10
8
6
4
2
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
Discharge
Initial vs. Discharge
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
ADLS
21
20
IADLS
1
2
3
4
5
6
7
8
9
10
2
3
4
5
6
7
8
9
10
PACE
1
Outcomes Expectations
14
10
SRAHPS
17
20
27