questionnaire will allow the therapist to gauge the impact the disease is having on Mr. Jones’s overall quality of life. His responses to the PDQ-8 indicate that PD is interfering with Case study 1: Part 2 Examination finds that Mr. Jones had a blood pressure reading of 120/80 in supine, which dropped to 90/55 when going sit-to- stand, indicating orthostatic hypotension. He has a short stride length with shuffling and a forward velocity of 0.9 m/s. The velocity indicates that his gait speed is slow and puts him at a higher risk of negative health outcomes such as hospitalization. His backward walk velocity is 0.4 m/s, which also indicates an increased risk of falling. His shuffling gait would make it difficult to walk on uneven surfaces and may be contributing to his loss of balance in those situations. To further assess fall risk, the Mini- BESTest was administered. Mr. Jones scores an 18/32 on the mini-BESTest and is found to be at increased risk of falling. Questions 1. What should be done to manage his orthostatic hypotension? 2. What interventions could be implemented to improve velocity and stride length? 3. Design a home exercise program for Mr. Jones to maintain function and prevent decline because of PD. Responses 1. Given the examination findings, the treatment plan would first include education to make slow position changes. Mr. Jones would be instructed to perform ankle pumps and lower extremity isometric movements before standing in order to increase lower extremity blood flow and alleviate the chance of a hypotensive episode. He would also be instructed to pause after standing to allow his blood pressure to adapt and, when possible, to have something solid near his chair or couch to grab on to if he becomes faint. 2. Based on the evidence, the most effective method for increasing velocity and stride length and decreasing variability would be a treadmill training program. The treadmill would initially be set at a comfortable pace for Mr. Jones and then slowly and incrementally increased with a goal of achieving a speed of 1.2 m/s or greater. Ideally, Mr. Jones would do 20 minutes of treadmill training 3 times per week for a minimum of 6 weeks. He would practice walking backward, around obstacles, and over uneven surfaces with unobstructed vision and also with vision diminished to mimic low-light situations such as sunset or entering a dark restaurant. Low-light situations can be mimicked by using dark wraparound sunglasses. 3. The home program is designed to maintain flexibility, balance, and functional strength and coordination. At a minimum, the home program should include the following stretches: Case study 2 Hannah Smith is an 82-year-old female who fell at home, fracturing her left wrist. She has a history of chronic obstructive pulmonary disease, hypertension, osteoarthritis, and PD. Mrs. Smith lives alone and uses home oxygen while sleeping. She takes carbidopa-levodopa and amantadine for her PD and is now on extra-strength acetaminophen for pain. She also takes a metoprolol for hypertension. The combination of metoprolol and carbidopa-levodopa can lead to additive effects in lowering blood pressure and in symptoms such as light-headedness, dizziness, and fainting. These interactions are more common when first initiating these medications. However, because Mrs. Smith has been on both of these medications for several years, there is less reason to be concerned about these effects beyond the normal elevated concern regarding hypotension in all individuals with PD. She underwent a pinning of the ulna and has a cast on her left wrist and hand. Before her fracture, she was supposed to ambulate with a wheeled walker; she has fallen 6 times in the last 6 months. When asked, she admits that
his functioning and contributing to feelings of depression and embarrassment.
○ Hamstrings : Seated hamstring stretches allow for a better stretch because there is no need for the person to also focus on maintaining balance. Mr. Jones should be instructed to look up and keep his back straight, while trying to bring the belly button to the thigh. When bringing the nose to the thigh, most people flex the thoracic spine rather than flex forward at the hips. By keeping the head up and bringing the belly button to the thigh, the stretch is isolated to the hip extensors. ○ Trunk flexors : Mr. Jones should spend 10 minutes per day lying prone on the elbows. This exercise may take place in two 5-minute sessions, if necessary. If he cannot tolerate this position, lying supine with a rolled towel along the spine also provides for a stretch into extension. ○ Trunk rotation : Because of balance issues, trunk rotations should be done from a seated position with the arms crossed over the chest. Mr. Jones should then turn side to side, trying to look as far on each side as possible. ○ Shoulder elevation and rotation : These exercises can be done by using diagonal patterns such as flexion and extension (arms move from a position of shoulder extension, adduction, and internal rotation to shoulder flexion, abduction, and external rotation, keeping the elbows extended at all times). The home program should include balance exercises such as single-limb stance while standing in front of a chair or counter. Mr. Jones should start with fingertip touch, try to increase to 60 seconds on each leg without touching, and then progress to maintaining a single-limb stance while moving the arms and finally adding some small head movements. He should practice walking backward and have a daily gait practice with long strides and a faster gait speed. If safety is a concern, he could do these exercises while using a wheeled walker or at a local center in which a long handrail is available. It is also possible to do walking in large stores or at malls. In most stores, Mr. Jones could use a shopping cart, which improves safety and allows him to work on increasing gait speed and stride length. Finally, Mr. Jones should begin a fitness program that he enjoys and would continue after therapy ends. Because he has expressed feelings of depression and embarrassment, an exercise group specifically for individuals with PD would be best for Mr. Jones. He would also benefit from social support and should be given information about attending local support groups. If his depression becomes a concern, he should be referred for psychological counseling. she frequently does not use her walker, and her falls occur when she is ambulating without the walker. On examination, she has rigidity in all four extremities and mild flexion contractures in her elbows, hips, and knees. She has significant thoracolumbar scoliosis and kyphosis. Based on the finding of bilateral involvement with postural instability, Mrs. Smith is in Hoehn & Yahr stage 3 or 4. To determine the exact Hoehn & Yahr stage, her ability to perform ADLs is assessed. She reports that it has become increasingly difficult for her to clean her home and that she no longer dusts lower shelves or moves chairs to vacuum. She also reports significant difficulty in the bathroom with toileting and bathing. Her most significant difficulty comes on in late morning and late afternoon. Several of her falls have happened after she awoke in the morning. Based on her loss of function before the wrist fracture, she is Hoehn & Yahr stage 4. The timing of Mrs. Smith’s difficulties indicates that she is probably experiencing on-off phenomena because of her system’s declining response
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