dr. brown – pt 8390 what evaluation tools to use? patient mary p. 88 year old women with history...
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Dr. Brown – PT 8390What evaluation tools to use?
Patient Mary P. 88 year old women with history of hypertension, c/o of periodic dizziness
Other problems: arthritis of spine with marked height loss of 6 inches
Very limited household ambulator
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What evaluation tools to use?
Patient: Almost 80 year old man who wants to celebrate his 80th birthday by hiking up to Mt. Everest base camp and then climbing to Camp I which is at ~21000 ft.
His goal: to be in the best shape possible. Your goal: to put him in the best shape
possible
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What evaluative tools to use?
Your patient is 77 years old. Male widower Dx: osteoporosis, CHF, PVD, Stage I kidney
failure. Living along in a 2-story house. Bedroom
upstairs, does laundry in basement Stooped posture, shuffling gait, slow
movements…. Goal: remain independent in the home
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What evaluative tools to use?
Patient: 92 year old spry female who is incredibly thin, stooped
Dx: osteoporosis, a “touch” of “heart trouble” Goal: less fatigue during volunteer jobs, more
stable (fear of falling)
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Summary
Pick evaluative tools that will provide objective data
Pick assessments that help with functional goal setting
Choose evaluation tools that are consistent with the problems or complains the patient has
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Treatment approaches- Strength
Isokinetic– Advantages– Disadvantages
Isometric Concentric
– Advantages– disadvantages
Eccentric– Advantages– Disadvantages
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Strength training cont’d
Open chain– Advantages– Disadvantages
Closed chain– Advantages– Disadvantages
Functional training– Advantages– Disadvantages
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Strengthening
Velocity training Power training 40% 1-RM vs 80% 1-RM
– Reps
Hypertrophy vs. hyperplasia
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0102030
405060
708090
100
1 2 3 4 5
Neural
Hypertrophy
Weeks of Training
Per
cent
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0
5
10
15
20
25
30
1 2 3 4 8 12 16
Strength gain
Weeks of Rx
Per
cent
gai
n in
str
engt
h
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What IS strength gain?
Hypertrophy– Increase in individual fiber size through addition of
satellite cells, sarcomeres– Increase in contractile proteins: actin and myosin
Concomitant increase in connective tissue
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Fiatarone et al
Strength trained 9 men and women that averaged 90 years of age.
Knee extension with free weights for 8 weeks 270% increase in strength!!!!!!!!!
How??? What does this mean?
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Treatment approaches- Gait
Important components– Stability (isometric mostly)– Flexibility (adequate ROM)– Speed of movement– Coordination (a component of balance)– Direction changes– Modulating fast and slow speeds
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Exercises for Stability
Manual Resisted gait, resisted standing Weighted gait belt, backpack, ankle weights Resisted getting up from a chair, sitting down Resisted turning at the head, trunk, pelvis Reduced base of support, with resistance Strength machines have some carry-over
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Exercises for gait flexibility
“Mother may I”……. Specific ROM exercises for deficits at hip,
knee and ankle Obstacle course…high objects to step over,
large “streams” to step over etc. Practicing larger than normal and smaller
than normal steps in sagittal and frontal planes
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Exercises for gait speed
Walking fast and slow- alternate quickly Practice crossing the street Use a treadmill and increase speed incrementally,
but with time to adapt Put a 50 ft walkway in the middle of the gym: time
the participant repeatedly. Encourage to walk as quickly as possible (please use gait belt!)
Additional benefit: cardiovascular
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Exercises for gait coordination
Side stepping Crossing one foot over the other in sagittal plane “Braiding” “Put your left foot in, and put your left foot out….” Dance steps “lion hunt” Nu-step device
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Exercises for direction/speed
While walking have person “stop”! Repeat stop and start multiple times
Walk forwards and backwards, sideways, alternating speeds
For extra challenge and for balance, close eyes periodically
Others?
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Treatment approaches- Balance
Start with what your evaluation says is deficient………– One leg stand– Romberg postures– Turning whole body– Turning head and trunk– Reaching to floor
Others?
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Balance exercises
Rocking side to side, forward and back Balancing on unstable object Stepping over objects Stepping up to objects distractions- conversation, counting Obstacle courses Eyes open and closed
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Balance exercises
“Mine field” Walk on toes and heels Dance steps- waltz, tango, fox trot Conga line Avoid “cracks” in floor while walking Look up instead of at floor Others?
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Treatment approaches- Cardiovascular endurance
Most effective: increase time of any exercise, particularly walking
Increase speed of any activity- TM, gait, cycle rpm Fahrtlik approach- 10s on, 10s off…. Increase difficulty of any exercise that is
repetitive….walking with weighted vest or resistance, increase wattage on bike, increase uphill angle of treadmill
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Cardiovascular endurance
Work on getting from point A to point B as quickly as possible
Teach people how to take their own heart rate……set target heart rate for each activity
Set up an inside or outside endurance program– In the mall…..Sears to Penny’s for example– PedNet, MKT….with markers.
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Treatment approaches- ROM
Stretching exercises must be held at least 10s to be effective……….and repeated at least 4x! Continue to get additional benefit up to 7 stretches held for 10s.
Optimal stretch- hold 1 minute. Functional approach
– Bending, stooping, reaching…….
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Treatment approaches- speed, coordination
Increasing the speed of any activity– Hand to nose– Foot to line– Walking– Throwing– Kicking– Turning – Fine motor tasks