Week 1 STARES - Fremantle Hospital MS

Situation
I was presented with a patient who had been referred for physiotherapy assessment following a fall 5/52 ago and subsequent admission to Fremantle Hospital for head trauma and minor soft tissue injuries to his left arm. No issues were found upon assessment at hospital. The patient had fallen in his kitchen when attempting to reach an object at height and had fallen over due to “loss of balance”. The individual had fallen 2 weeks prior to this incident when he tripped over an object on the ground. No injuries occurred on this occasion. The patient lives at home alone but receives assistance for all DADLs every day and is independent with most PADLs. He has a daughter and friend close by who also assist and transport him as required. There are 3 x single steps in his house with rails next to all. He attends weekly exercise classes at the local recreation centre and is able to walk approximately 80m before becoming fatigued and requiring a rest. The main focus of the referral is to treat for decreasing functionality & impaired balance as required. The patient’s physiotherapy focused goal is to improve his balance and confidence with walking/activity.

Task
It was my task to determine exactly what his issues were from a functional point of view and treat as required. This would involve a thorough geriatric assessment and then creation of a treatment program to address the patient’s limitations.

Action
My examination began by clearly explaining to the patient the purpose of the session and how it would progress. Knowing the recent history of the patient I was able to prioritize the tests so that if he fatigued the most important tests would have been conducted. In a seated position I performed as many manual muscle tests for both UL and LL and also full ROM for the UL and the ankle. I then had the patient perform sit to stand with minimal hand use and from there I carried out static and dynamic balance testing. This alone would give me qualitative measures but also forms part of the Berg Balance Scale measure. The remainder of the BBS was completed as well as a 10mspwt and Timed Up & Go test. The patient was slow with most movements so I decided to gain quantitative timed measures of functional movements such as sit to stand, rolling, supine to stand etc. This would also allow me to assess his techniques with certain movements and suggest more efficient methods to achieve the same result. In the supine position I also conducted further strength tests. The individual was not able to perform the Step Test which was to be expected due his very poor single leg stance ability. To determine the patient’s response to external perturbations I performed the Pastor-Marsden test which resulted in a score of 2, meaning he required at least 2 steps back to prevent himself from falling. Through out all proceedings an informal gait analysis was performed.
I then prescribed exercises to be continued at home to target the impairments indicated. This was to be carried out twice a day and in addition increase his walking distance when under supervision and when he feels confident to do so.


Result
The test results showed that the individual had poor dynamic balance and diminished lower limb strength. His ability to respond to sudden disturbances to balance was impaired and he scored a BBS of 36/56 with scores less than 45 indicating a potential falls risk. The exercises prescribed were able to be performed well by the patient but there are questions about his ability to comply and continue them with effective techniques.

Evaluation
The Geriatric assessment is relatively standard but there is no need to complete the full assessment with each patient and I think I was able to guide the session in the most appropriate way based on findings that presented as the session progressed. The individual did not have severely impaired cognition but as I have found with most geriatric patients they do seem to misunderstand what appear to be simple instructions. The session did take longer due to decreased efficiency of movement between the different tests due to miscommunication. My understanding of the BBS is not sufficient to complete without being guided by the test details and I had to refer to it with most tasks. I felt I complete the manual muscle testing, TUG and 10mspwt well with the patient understanding my instructions clearly. When shifting from the assessment to the intervention I had to take time to decide what interventions I was going to use which for the sake of efficiency of a session will have to be sped up future.

Strategies
During the time I have a patient I will simplify instructions so as to not confuse the patient and also explain the progress of the session step by step instead of confusing them with too much information. I will need to take the time to learn the exact details of the BBS and how to most efficiently carry out the test with fast transitions between tasks. As I learn the basic exercises and interventions possible I will learn to pick and choose the most appropriate activities based on the patient presentation. I anticipate this will become easier as I am exposed to more patients but developing a list of standard interventions will put me in a position to more easily add more exercises to my repertoire.