Leisure

• Instruction in balance safety related to yardwork

(Reaching, carrying items, stooping, etc.)

• Instruction in, balance safety strategies on golf course and use of

cart for golf Clubs

• Balance safety when climbing in and out Of his boat

ANTICIPATED GOALS AND EXPECTED

OUTCOMES

Impact on impairments

• Patient accurately demonstrates awareness of good postural alignment

and body mechanics and OF methods of self-correcting for incorporation
during borne and work activities.

• Patient correctly demonstrates self-cueing strategies performed during

ambulation on flat and uneven terrain.

• Patient demonstrates home exercise program correctly.

• Patient exhibits full cervical/trunk ROM in all planes.

Patient tolerates S hours of work activities with reported decrease in

episodes of neck and trunk stiffness during workday

Impact on functional limitations

• Patient demonstrates improved ease in bed mobility and rolling through

use of attentional strategies and adaptation of bed linens and nightwear.

Impact on disabilities

Patient continues to tolerate regular performance levels of self-care,

home chores, work schedule, yard work, golfing, boating, and community
service and

volunteer activities.

Risk reduction/prevention

Patient accurately identifies challenging balance risks and uses safety

strategies to reduce falls risk.

• Patient accurately verbalizes understanding of PD

Impact on mobility, along with strategies for risk reduction/prevention

of potential mobility changes through regular exercise and activity.

Impact on health, wellness, and fitness

Patient identifies appropriate behaviors chat foster healthy habits,
wellness, and prevention.

• Patient incorporates relaxation strategies into daily routine.

Impact on societal resources

• Decision making is enhanced regarding patient health and the use of

health care resources by patience, family significant others, and
caregivers.

Documentation occults throughout patient management and follows APTA's

Guidelines for physical

Therapy Documentarzon.7B

Patient/client satisfaction

• Access, availability, and services provided are acceptable to patient.

• Care is coordinated with patient, family, and other health care

professionals.

• Patient and family knowledge and awareness of the diagnosis, prognosis,

interventions, and anticipated goals and expected outcomes are increased.

Referrals arc made other professionals or resources whenever necessary

and appropriate.

REEXAMINATION

Reexamination is conformed throughout the episode OF care. lt is

anticipated chat patients placed in this pattern Will require multiple
episodes of care over the lifetime. Periodic reexamination and initiation
of new episodes of care should occur as the patient’s functional
limitations disability changes.

DISCHARGE

Mr. Barris is discharged from this episode of care after a total of Six
physical therapy visits over 4 weeks and attainment of his goals. As Mr.
Barris has a condition that may require multiple episodes Of care
throughout his life span, Mr. Barris and his wife received education
regarding factors that may trigger a call to his physical therapist for a
reexamination and new episode of physical therapy intervention.

'Case Study #1B.

Stage 3 Parkinson’s disease Mr. Barns is now a 67-year-old male who has
been referred to home physical therapy for a new episode of care due to
generalized Weakness and low endurance post hospitalization for bowel
obstruction Surgery 5 days ago.

PHYSICAL THERAPIST EXAMINATION

Note: Only changes from his first episode are included in this case.
HISTORY

General demographics: Mr. Barris is now a 67-year-old male.

Employment/work: He retired from Full-time employment as a bank manager 1

year ago.

Pag 2

General health status

General health perception: Mr. Barris recognizes the physical changes

that have since his hospitalization.

• Physical function: He also notes weakness and gait/ balance changes

since the recent surgery… He has noticed occasional difficulty initiating
motion when starting to walk and is concerned with episodic dizziness
during transitional movements.

• Psychological function: Mr. Barris is motivated co return to pre

surgery level OF function.

• Social function: He is currently sedentary due to low endurance post

hospitalization.

Medical/surgical history. His PD diagnosed 4 years ago. Mr. Barris had a

bowel obstruction requiring surgery 5 days ago. He was discharged from
hospital 2 days ago to his home.

Current complaint(s): He has generalized weakness and low endurance post

hospitalization and reports Fatigue and shortness OF breath with mild
exertion since the hospitalization. He was discharged to home with
support from his wife and home health services. Mr. Barris previously
received physical therapy services for assessment and management of PD
and for periodic updating of his homo program. He has been participating
in a Parkinson’s clinic program.

Functional status and activity level: He has not participated in

community ambulation or leisure activities since his surgery. Normally he
plays golf one or two times a week in warm weather months, and he had one
Fall on the golf course 3 months ago without injury. He also attends
movies, concerts, or the theater one or two times a week and travels
frequently with his wife. He stopped playing tennis 1 year ago after
experiencing difficulty with his serve and problems performing quick
stops and starts on the tennis court. Typically, he had been performing
his home exercise program of stretching, strengthening, and conditioning
exercises three to four times per week, but he stopped approximately 1
month prior to his hospitalization. The patient has also begun to
experience the onset of motor fluctuations with decreased motor ability
occurring as he nears the end of each carbidopa/levodopa dose.
Systems Review

Cardiovascular/pulmonary
 BP
 Sitting 122/64 mmHg
Standing: 100/52 mmHg

Integumentary

• Presence of scar formation: Healing abdominal surgical incision from

bowel surgery

• Skin color: Good, mild redness around incision

• Skin integrity

Seborrhea noted on nose, nails, and at hairline

Small healing abrasion on left elbow

Musculoskeletal

• Gross range of motion

• Decreased neck and spinal flexibility

• Hamstring and heel cord tightness noted bilaterally

• Gross strength: Generalized weakness

• Gross symmetry: When standing reduced lumbar lordosis and hip/knee

flexion

• Weight: 173 lbs. (78.47 kg)

Neuromuscular

• Balance imprecision noted when ambulating to bathroom or kitchen since

hospitalization

• Has noted several episodes of start hesitation, reporting one fall

since arriving home from hospital (lost balance when turning in bathroom
resulting in a small healing abrasion on left elbow and no other injury)

Reports lightheadedness upon rising from bed, toilet, and chair

Locomotion, transfers, and transition

He still ambulates without assistive devices, but he tends to reach out

for objects in walking path for added stability

Hypokinesia is more prominent with reduction noted bilaterally in stride

length and arm swing
Occasional start hesitation is evident

He requires armrest support upon rising from the chair and notes
difficulty with reduced step size as he approaches the chair to sit clown
that affects proper body alignment from standing to sitting

Communication, affect, cognition, language, and learning style

Communication, affect, and cognition: His voice volume is decreased with

mild facial masking

• Learning style: He is motivated, asks many questions, and has been

using his home written program with diagrams from previous episode of
care

TESTS AND MEASURES

Aerobic capacity/endurance

PAG 3

6MWl• measures the distance that a patient can walk on a flat, hard
surface in a period of 6 minutes

Mean scores for males age 60 to 69 for this test was found to be 497.7
meters96•95

Result: 282 meters

He currently notes shortness of breath after household ambulation of

greater than 2 minutes

Assistive and adaptive devices

Trial use of a single-end cane produced increased stability when walking

Needs side rail on bed to assist with coming to sitting

Circulation

OH observed

Sitting BP: 122/64 mmHg

Standing BP: 100/52 mm Hg

Patient describes "lightheadedness" upon -rising, but denies visual

disturbance or "blackout"

Patient reports lightheadedness is worst upon rising in the morning and

after meals

Ergonomics and body mechanics

• Body mechanics

Exhibits difficulty when approaching chair to sit down

Has significant reduction in step size as he approaches the target,

reaching too far forward for armrest, and beginning to turn and sit
before achieving good body alignment that results in uncontrolled descent
as he moves from standing to sitting.

Mrs. Barris (who is 6 inches 5horter than her husband) is unsure how to
assist with transfers, does not position herself to allow good body
mechanics when providing transfer assistance, tends to speak too rapidly,
and offers frequent verbal input and commands as patient attempts to
move.

Gait, locomotion, and balance

Timed Up and Go Test: 14 seconds65-71

• Observation of gait revealed

• Reduced stride length and Foot clearance secondary to hypokinesia

Start hesitation

Turns using multiple short, shuffling steps with balance instability

noted

• 48/56

Sitting to standing: 3-able to stand independently using hands

Standing unsupported: 4 =able to stand safely for 2 minutes

Sitting unsupported: four—able to sit safely and securely 2 minutes

Standing to sitting, 2-uses back of legs against chair to control descent

Transfers: 3 able to transfer safely with definite use Of hands

Standing unsupported with eyes closed: 4-able to stand 10 seconds safely

Standing unsupported with feet together: 4—able to place feet together

independently and stand 1 minute safely

Reaching forward with outstretched arm: 4 - can reach forward confidently

25 cm (IO in)

Pick up object from floor: 4-able lip slipper safely and easily

Turn to look behind/over left and right shoulders: 4 looks behind from
both sides and weight shifts well

• Turn 360 degrees: 4—able to turn 360 degrees safely in 4 seconds or

less
Alternating on stool: four—able to stand independently and complete eight
steps in 20 seconds

Standing unsupported, one Foot in front: 2-ablc to small Step

independently and hold 30 seconds

Stand on one leg: 22able to lift leg independently and hold more than 3
seconds

• Percent probability of falling based on BBS and fall history: 69%

Motor function

• UPDRS21 motor section scores

Speech: Grade 2 slurred but understandable, moderately impaired

Facial expression: Grade 24-slighr but definitely abnormal diminution of

facial expression

Tremor at rest

RUE: Grade 1 and infrequently present

RLE: Grade O—absent

LUE: Grade 2—mild in amplitude and persistent or moderate in amplitude

but only intermittently present

LLE: Grade 2zmild in amplitude and persistent or moderate in amplitude

but only intermittently present

Action or postural tremor of hands: Grade 0 absent

• Rigidity

RUE: Grade 2—mild to moderate

RLE: Grade 2-mild to moderate

WE: Grade 2—mild co moderate

LLE: Grade 2—mild to moderate

• Finger 2-moderatcly impaired with definite and early fatiguing and may
have occasional arrests of movement (7 To 10/5 sec)

• Hand movements: Grade 2—moderately impaired with definite and early

fatiguing and may have n0casional arrests of movement (7.to 10/5 sec)