Lecture 12Case Study

(Parkinson’s Disease and Femur Fracture)presented by Y. Ko,Y. Kim, H. Kim

Clinical Decision Making

Haneul Lee, DSc, PT

Parkinson’s diseaseand

Femur fracture

CONTENTS

02. BODY 03. CONCLUSION

What is the ‘PT’?

Patient introducing

Background Information

Past history review

Reevaluation

S.O.A.P

Exercise Treatment

Summary

Q&A

01. INTRODUCTION

01INTRODUCTION

01 What is the ‘PT’?

Physical therapy

Occupational therapy

PT aims to improve basic skill [BADL] OT aims to improve complex skill [IADL]

ADL

Body postural

Physical inactivity

balance

Grasping & reaching

transfer

gait

PT’s core area

02 Patient introducing

Background Information

Muhammad Ali Ronald Reagan

Joannes Paulus II Susan Hayward

4 major

symptoms

Resting tremor rigidity

Bradykinesia Unstable posture

Progressive chronic motor disorder, Midbrain, Substantia nigra, Zona compacta, Dopamine

[ Keywords ]

01 What “Parkinson’s disease”?

https://www.youtube.com/watch?v=zJ4H6ewXqCo

02 Parkinson’s pathophysiology

•No accurate cause

•By certain cause, substantia nigra impaired

•Dopamine which regulates basal ganglia lackage

•Encephalitis, trauma, syphilis, carbon monoxide

poisoning, shock, accident, drug intoxication

•Influenced by age, genetic, environmental, toxin etc

02 Parkinson’s pathophysiology

02

sinemetColace Hydrocodone

Medication

Sinemet

acetaminophen

상실된 도파민 대체 약물

도파민의 전구물질인 L-dopa가 뇌에 도달

뉴런이 L-dopa를 도파민으로 전환

Levodopa 부작용

메스꺼움(구토)오심저혈압이상운동인지기능장애

03 What is “Levodopa”?

뇌의 구조적인 이상 유무를확인하여 감별

정신행동 및 정서,일상생활활동, 운동기능검사,약물치료 부작용 등 검사

▶ UPDRS (The united parkinson’s disease

rating scale)

▶MRI (magnetic resonance imaging)

04 Diagnosis method(PD)

MRI(magnetic resonance imaging)

Non-motor experiences of daily living

정신검사 항목

Motor experiences of daily living

일상생활활동 검사 항목

Motor examination

운동기능검사 항목

Motor complication

운동기능과 관련된 합병증 검사항목

Part1

Part2 Part3

Part4

What is “UPDRS”?

01 Hoehn & Yahr scale

등급 질병 발생의 기간 설명

Ⅰ 증상이 진단 후 최소 5년간 전반적으로 안정적이다.

독립적으로 문제 없으며 약간의 치료가 필요하다.

Ⅱ 5년 후 약간 진행이 관찰된다. 대부분 독립적이며 적당한 약물치료가 필요하다.

Ⅲ 3~5년 후 현저한 진행이 관찰된다. 대부분 독립적으로 살 수 없으며 부분적인 운동장애가 있다.

Ⅳ 3~5년 후 심한 강직과 떨림으로 진행되며 8~10년 후에는 양측으로 진행한다.

보행은 가능하나, 심한 운동장애가 있다.

Ⅴ 몇 개월 내 심한 강직.떨림 운동장애가 오며, 1년 이내 급작스럽게 발병한다.

운동불능상태

05 Schwab classification

06 Modified Ashworth’s Scale(MAS)

07 Function of femur

WALKINGRUNNING

+

ESSENTIAL

Supporting the weight that passes through the pelvis and hip joint

고정기구를 피부 이하에 위치하도록 삽입하여 고정하는 방법으로 빠른 재활과 일상생활의 불

편을 감소시켜준다.

ORIF (open reduction internal fixation)이란?

01 What is “ORIF”

PRECAUTIONS

•Stress•Infection•Bone destiny ↓

01 Past history review

15.09.01넙다리뼈 골절(당일 ORIF)

15.09.05전문요양 방문

[입원]

15.12.06 외래방문

3년 전파킨슨병 발병

2BODY

02 Reevaluation/Reexamination

02 S.O.A.P note

• S(Subjective)① CC(chief complaint): Lt. hip pain & inconvenient gait pattern

② Discontinued from skilled nursing facility

③ Independent self-care, but limited endurance with pain

④ Rt. Shoulder and Hip pain (Rt. Hip pain ‘VAS’ 4/10, Rt. Shoulder minimum pain VAS’ 1/10)

⑤ Rt. Hip pain increased during running & excessive weight bearing

⑥ Independent gait

⑦ Motivated for rehabilitation using group & acuatic exercise

O(objective)

V/S- T: 36.7℃ , HR : 79 bpm/min, RR:18/min, BP:120/72

ROM

Lt. Hip flexion 90° /120 °

Rt. Hip flexion 110° /120 °

Lt. knee flexion 130° /135 °

Rt. Knee flexion 125° / 135°

MMT

Lt. shoulder abduction 4-

Lt. hip flexion 3-

Lt. hip adduction 3-

Lt. quadriceps 4

Rt. hip abduction 3

Gait – both gluteus medius severe rigidity(left)

왼쪽 다리에 대한 구두지시를 통해서 벌림근의 활성으로 인해 6 inche 계단을 3개 올라갈 수 있다. 계단을 내려가는 것은 불가능하다.

Berg-42/58

Measurement scale

-hoehn and Yahr scale

-Schwab classification

02 S.O.A.P note

02 S.O.A.P note

• A(Assessment)① Limited Strength and Balance

② Abnormal Gait pattern

③ Abnormal body posture(postural dysfunction)

④ Post-ORIF pain in Lt. Hip

Plan

*Principle of therapy*

1. 치료시 항상 치료사가 환자 곁에서 상태를 모니터링 한다.

2. 골절에 유의해서 실시한다.

3. 모든 치료는 최대 주3~4회 실시한다.

4. 모든 치료는 환자의 상태에 따라 유동적으로 수정될 수 있다.

02 Parkinson’ dz 보행시 나타나는 양상

짧은 걸음걸이

발을 질질 끌면서 걷는 양상

팔 움직임의 저하

(구축이 생겨서)앞으로 기울인 상태에서걷기

점점 빨라지는 보행(속도 증가)

낙상

02 Stage 1,2,3,4

Stage 1 Stage 2 Stage 3 Stage 4

Pain management

Simple isometric ex.

Flexibility exercise(Rom 위주로)

Aerobic exercise

Pain management

Simple isometric ex.

Flexibility exercise(Rom 위주로)

Aerobic exercise

Strength exercise

Gait training

Pain management

Flexibility exercise

Aerobic exercise

Strength exercise

Gait training

Pain management

Flexibility exercise

Aerobic exercise

Strength exercise

Gait training

02 Therapeutic exercise

Aerobic exercise –warm up

Strength exercise

Balance

Gait training

Flexibility exercise – cool down

02 Pain management

[ Ultrasound ]

+ Medicationacetaminophen hydrocodone

02 Aerobic exercise– warm up

3 times a week 15minute a day

02 Strength exercise

02 Balance training

[Tetrax] [Education of using cane]

02 Gait training

팔 다리 흔들기

parkinson’s exercise program

treadmill

02 Flexibility exercise – cool down

Exercises for Parkinson's: Flexibility Exercises

music start

그룹치료의 운동효과- 우울증 예방

02 Group exercise

• 식이섬유섭취, (콩,곡물,과일,야채)

• 물을 많이 섭취해야함 8잔이상

Diet02

정의 :인 후두의 기계적인 협착, 또는 입술, 혀, 구개, 인 후두에 관계하는 운동성 뇌신경핵(안면, 미주 · 설하신경)의 장애(가성구마비)에의해 연하가 곤란하게 되는 것.

What is “dysphagia”?02

호흡훈련흉식호흡 – 풍선 흡입구강호흡- 촛불끄기, 비눗방울 불기, 풍선불기

능동적인 자극법입술훈련- 입의 개폐 운동

“ 이” 발음하기볼훈련- 혀내밀기, 혀 들어올리기

3CONCLUSION

Summary

03 Refernece

1.http://m.blog.naver.com/PostView.nhn?blogId=kgony&logNo=50192376575&categoryNo=0&currentPage=1&sortType=recent&isFromSearch=true2. 질환별 물리치료 1,2 –민경옥,김순희 /도서출판대학서림3. 신경계 질환별 물리치료- 윤범철 외 8 / 현문사4. 신경계 질환별 물리치료- 박지환 외 공저/ 현문사5. “Allied health care interventions and comlementary therapies in Parkinson's disease”6. 물작메; 물리치료사의 작은 메모장7. “Hip fracture-Diagnosis, Treatment, and Secondary Prevention”8. Gachon univ. 'Clinical decision making' Lecture1, Lecture39. https://www.youtube.com/watch?v=DBvUCdwbO7k10.The effects of treatment with a TETRAX on balance and mobility in acute storke patients11. Music therapy interventions in Parkinson’s disease: the state-of-the-art .

ANY QUESTION?

감사합니다

https://englishatyourservice.files.wordpress.com/2013/02/lets-talk1.jpg

Critical ThinkingQuestions

1. How would you document your treatment in the SOAP orPatient Management format?

2. If the treatment goes as expected, what will you do for the next treatment?

3. How would you expect this patient to progress over time?

4. If the patient does not progress as expected, what might be some reasons for a lack of progress?

5. What signs or symptoms, if observed or reported by the patient, would cause you to hold treatment and check with the nursing staff, MD?

Critical ThinkingQuestions

After reviewing the continuum of care for this patient, consider the following:

1. How did the patient’s problems change over the months after hisfracture?

2. How did this affect the goals and the interventions that the PTincluded in the POC?

3. How were the same interventions modified over time toprogress the patient according to his changing needs?

Implications of Pathology for PT

1. What are the patient’s risk factors for falls and how might the PT incorporate fall reduction education and techniques throughout the interventions in the different settings?

2. How might the timing of Parkinson disease medications affect the physical therapy interventions?

3. How would cognitive impairment, as is common with later stages ofParkinson disease, affect your approach during the physical therapyinterventions?

1.

2.

3.

4. What should the PT be aware of when working with patients with thefollowing

Spinal fracture

Lower extremity fracture

Upper extremity fractures