Dr. Brown – PT 8390 What evaluation tools to use? Patient Mary P. 88 year old women with history...

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

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

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

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)

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

Treatment approaches- Strength

Isokinetic– Advantages– Disadvantages

Isometric Concentric

– Advantages– disadvantages

Eccentric– Advantages– Disadvantages

Strength training cont’d

Open chain– Advantages– Disadvantages

Closed chain– Advantages– Disadvantages

Functional training– Advantages– Disadvantages

Strengthening

Velocity training Power training 40% 1-RM vs 80% 1-RM

– Reps

Hypertrophy vs. hyperplasia

0102030

405060

708090

100

1 2 3 4 5

Neural

Hypertrophy

Weeks of Training

Per

cent

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

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

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?

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

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

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

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

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

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?

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?

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

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?

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

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.

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…….

Treatment approaches- speed, coordination

Increasing the speed of any activity– Hand to nose– Foot to line– Walking– Throwing– Kicking– Turning – Fine motor tasks