Clinical Correlates I Final Presentation

1. Right Superior and Inferior Pubic Rami Fracture Daniel Woodward East Tennessee State University, Year II Mount Pleasant Manor

2. Pelvis Anatomy: Sacrum Coccyx Ilium Ischium Pubis Pelvis Functions: Provides link between spine & lower extremities Provide stability for trunk & legs Transmits body weight downward Absorbs forces when standing & walking Serves as bony site for muscle attachment Protects internal organs in lower abdominal region Introduction [10] [14] SPR IPR

3. Classification: High Impact Injury vs. Low Impact Injury Stable vs. Unstable Pelvic Fractures associated with: I ncreased mortality rates in the elderly Decreased mobility & independence Increased hospital stay Substantial health care cost Pelvic Ring Fractures [2,4,11] High Impact Low Impact

4. Right Superior and Inferior Pubic Rami Fracture Date of Injury: 1/08/13 Mechanism of Injury: Patient fell at home when walking to bathroom; legs gave way as she fell on her bottom X-Rays confirmed stable pubic rami fractures Received Acute PT/OT for pain management in hospital Discharged 1/15/13 from hospital to sub-acute rehab facility (Mount Pleasant Manor) Patient Injury

5. Medical Diagnosis Right Superior & Inferior Pubic Rami Fractures [ 13] Muscles Attaching around the Pubic Rami [12]

6. Injury Classification: Low Impact Stable MOI: Trauma usually due to a simple fall (fall less than 3 feet) Occurrence: Commonly occurs in the elderly (60+ years old) Females > Males Symptoms: Bruising, swelling, or crepitus in pubis region Pain in groin, lateral hip, or the buttock area when WB D ecreased ROM/strength due to pain D ecreased ability to perform SLR on affected side Antalgic gait for those who can ambulate Epidemiology [11]

7. Current Treatment Strategies: Pain management, rest, maintain ROM & strength, & gait training with protected weight bearing. Prognosis: Varies depending on patient age, mental status, & overall health Injury usually heals quickly due to large amount of soft tissue in this area. Most healthy patients require protected weight bearing for about 6 weeks until the pain has diminished Epidemiology [6, 8 , 11 ]

8. T o examine deficits of a patient who has suffered a right superior & inferior pubic rami fracture T o create an effective treatment plan utilizing evidence based practice to address deficits associated with injury Purpose Statements

9. Tinetti’s Gait & Balance Assessment Score Level of Assistance R equired for Functional Tasks Ambulatory Distance Pain Rating Outcome Measures

10. Medical History: 75 year old female Severe osteoporosis with multiple fractures Right TSR, Left RCT repair Right THA, Left THA with 2 revisions (15 years ago) Apparent & True Leg length discrepancy April 2012 – Fracture of Left femur/patella due to fall Most Recent: (R) superior & inferior pubic rami fracture (stable) & 4 th finger fracture due to fall The Patient

11. Medial History Continued: Depression History of Hypertension Multiple Bowel Resections; residual spastic colon Peptic Ulcer Disease Chronic diarrhea Inguinal hernia repair Bilateral Cataract Surgeries FALL RISK! The Patient

12. Family History: (+) for cancer in her brother Sister has peripheral artery disease Father had diabetes Mother had congestive heart failure Social History: Smoked ~ 1 pack per day for more than 50 years Does not drink alcohol or abuse any drugs Manages well on her own with her ADL’s The Patient

13. Medications and POSSIBLE side effects Imodium : D izziness and drowsiness Temazepam : Day time drowsiness, muscle weakness, lack of balance or coordination. Vilazodone : Dizziness, fatigue, feeling jittery Losartan : Dizziness, drowsiness, confusion Omeprazole : Dizziness, confusion, feeling jittery, weakness KCl : Confusion, anxiety, muscle weakness OxyContin : Drowsiness, dizziness Lortab : Anxiety, dizziness, drowsiness, blurred vision. The Patient

14. Occupation: Retired Living Situation: Lives with sister; 9 steps to enter home Prior level of function: Ambulated at home without assistive device Precautions: WBAT on Right Lower Extremity Full Code The Patient

15. Patient Information Measurement Height 5'4'' Weight 88 lbs Blood Pressure 135/78 mmHg Heart Rate 60 bpm Awareness Alert and oriented x 3 Neurological WNL The Examination

16. UE ROM: Non-functional use of (R) shoulder; See OT Eval . LE ROM: The Examination Joint Motion Left Extremity Right Extremity Normal Values Hip Flexion 104 ° 95 ° 121° Hip Extension NOT TESTED NOT TESTED 19° Hip IR 29 ° 33° 32° Hip ER 25° 23° 32° Hip Abduction 35 ° 30 ° 42° Hip Adduction 15 ° 17 ° 20° Knee Flexion 126 ° 109 ° 132° Knee Extension 0° 0° 10 ° -0° Ankle Dorsiflexion 12 ° 14 ° 11° Ankle Plantarflexion 48° 42° 64° [9]

17. UE Strength: See O.T. evaluation LE Strength : The Examination Muscle Group Left Extremity Right Extremity Hamstrings 4 (GOOD) 4 (GOOD) Quadriceps 4 (GOOD) 4 (GOOD) Adductors 3 (FAIR) 4 (FAIR) Abductors 4 (GOOD) 4 (GOOD) Hip Flexors 2+ (POOR) 2+ (POOR) Hip Extensors NOT TESTED NOT TESTED Dorsiflexors 4 (GOOD) 4 (GOOD) Plantarflexors 5(NORMAL) 5 (NORMAL)

18. Leg Length Discrepancy Patient has custom 1 inch (2.54 cm) lift for Left shoe which she does NOT where. The Examination Leg Length Testing Left Lower Extremity (cm) Right Lower Extremity (cm) Difference (cm) True Leg Length 86.5 90 3.5 Apparent Leg Length 90 92.5 2.5

19. The Examination Balance Tests Grade Description Static Sitting GOOD Patient able to maintain balance without handhold support, limited postural sway Dynamic Sitting GOOD Patient accepts a moderate challenge; able to maintain balance while picking object off floor Static Standing GOOD Patient able to maintain balance without handhold support, limited postural sway Dynamic Standing FAIR Patient accepts minimal challenge; able to maintain balance while turning head and trunk

20. Functional Tests Required Assistance Description Bed Mobility Modified Independence *Unable to complete rolling to side-lying on either side secondary to pain. *Required MI to initiate and complete roll half way towards both sides. Transfers Stand By Assistance *Required verbal cueing for safety. *Required SBA for supine<>sit and sit<> stand/SPT with RW. Ambulation Contact Guard Assistance *Required verbal cueing for proper sequencing of gait to accommodate for pain and WBAT status for Right LE. *Ambulated 30 feet with RW. The Examination

21. Tinetti’s Balance Assessment Tool: Measures patient’s gait & balance Scoring: Ordinal scale ranging from 0 – 2 0 = most impairment 2 = independence of the patient Three measures: Gait assessment score, overall balance assessment score, and gait & balance score Total Balance Score = 16 Total Gait Score = 12 Total Test Score = 28 Interpretation: 25 – 28 = Low F all R isk 19 – 24 = Medium Fall Risk < 19 = High Fall Risk The Examination

22. Tinetti’s Score = 14 Patient is a HIGH FALL RISK! Pain = 7 / 10 Pain Description: Pain in legs, lower back, pubic region. Pain increased with SLR, when turned onto side, or in WB; especially painful on (R) LE in hip & pubic region. The Examination

23. Achieves ¾ side-lying to either side using bed rails & without pain Modified Independent Transfers Supine <> Sit Sit <> Stand/SPT with a RW Modified Independent > SBA for ambulating with a RW up to 60 ’ GOOD dynamic standing balance Tinetti’s score of 16 Short Term Goals These goals changed from week to week as patient progressed

24. Independent Bed Mobility Independent to m odified independent Transfers Supine <> Sit <> Stand/SPT with RW Modified Independent Ambulation up to 150’ with RW Able to Ascend/Descend 9 steps Final Tinetti’s minimal score of 19 Long Term Goals

25. Physical Therapy: 5x/week x 4 weeks Safety & Moderate Independence with all of the following: Demonstrate Functional LE ROM Demonstrate Functional LE Strength Demonstrate Functional Bed Mobility Demonstrate Functional Transfers Demonstrate Functional Gait Be able to ascend and descend 9 steps Discharge Plan Mount Pleasant Manor  Home Plan of Care

26. Cryotherapy 5 Research confirms that cryotherapy results in: Decreased inflammation Decreased blood flow Reduced swelling Reduced pain Nustep 7 Research supporting this exercise suggests that it: Decreases blood pressure Increases strength Increases walking speed Evidence Based Practice

27. Prophylactic Measures 11 Range of Motion Strength Prevent Immobility Standing Activities/Ambulation 1 Research suggests that weight bearing activities are effective in preserving or even increasing bone mass. Ambulation should be encouraged! Evidence Based Practice

28. Warm Up Nustep 15 minutes at Level 1 LE ROM Heel slides for hip flexion, hip abduction, & hip adduction; 3 sets of 10 LE Strengthening Knee extension (quads), bridging (gluts), knee raises (hip flexors); 3 sets of 10 Bed Mobility Worked on rolling from side to side using modified independence Transfer Training Practiced sit<>stand/SPT & sit<>supine using modified independence Cryotherapy Ice pack x 15 minutes to control pain Initial Treatment Plan

29. Modified 3-point Gait Pattern while using walker. Importance of using assistive device during gait/transfers at all times Importance of wearing proper shoes with custom lift for l eft shoe Pain Rating Scale Patient Education

30. Pain Scale Interpretation Initial Rating = 7 (Very Intense): Pain completely dominates your senses, causing you to think unclearly about half the time. At this point you are effectively disabled and frequently cannot live alone. Comparable to an average migraine headache After Education = 4 (Distressing): Strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma to part of the body, such as stubbing your toe real hard. So strong you notice the pain all the time and cannot completely adapt.

31. Warm Up: Nustep 20 minutes at Level 1 LE Strengthening and ROM Exercises: Heel slides for hip flexion, abduction, adduction Knee extension (quads), bridging (gluts ); 3 sets of 10 Gait Training: CGA ambulation 30’ x 2 with a rolling walker, breaks, & a more continuous and symmetrical gait Knee raises over small hurdles while ambulating in parallel bars (hip flexors) Step Exercise: CGA stepping exercise on to 2 ½ inch step while in parallel bars ; 3 sets of 10 Leading with both LE’s Treatment Progression 1 Step Exercise

32. Warm Up: Nustep 20 minutes at Level 1 LE Strengthening Exercises: Knee extension (quads ); 3 sets of 10 Gait Training SBA Ambulation 75’ x 2 Dynamic Standing Balance Activities Tic-Tac-Toe Toss in standing Balloon Volleyball in standing Step Exercise: CGA stepping exercise on to 4 inch step while in parallel bars ; 3 sets of 10 Leading with both LE’s Treatment Progression 2 Tic-Tac-Toe Toss Balloon Volleyball

33. After three weeks, patient demonstrated sufficient safety, endurance, and strength with all transfers and ambulation In order to continue the progression towards further independence, the W/C was discharged Patient was educated on current status & was asked to use supervision when ambulating away from her hall W/C Discharge

34. Warm Up: Nustep 20 minutes at Level 1 Gait Training: MI ambulation 150’ x 2 with a rolling walker Standing Balance Activities Balloon Volleyball in standing Kicking ball activity with Right LE Step Exercise: CGA stepping exercise on to 6 inch step on therapy stair set ; 3 sets of 10 Leading with both LE’s Treatment Progression 3 Single Leg Stance Activity

35. Warm Up: Nustep 20 minutes at Level 1 Gait Training: MI ambulation 150’ x 2 with a rolling walker Standing Balance Activities Balloon Volleyball in standing Kicking ball activity with Right LE Step Exercise: CGA ascending with the Left LE and descending leading with the Right LE 4 steps 3x Also worked on ascending/descending steps sideways to simulate home environment. Final Treatment Therapy Steps

36. Outcome Measures Outcome Measure Initial Assessment Final Assessment Tinetti’s Score 14 24 Required Assistance for Functional Tasks MI Bed Mobility SBA Transfers CGA Ambulation Independent Bed Mobility MI Transfers MI Ambulation Ambulatory Distance 30 feet 150 feet x 2 Pain Rating 7/10 3/10

37. Wii Therapy (Balance/Decreased Fall Risk) 3 Research shows that six 1 hour sessions of W ii bowling simulation significantly improved Berg Balance, DGI, and TUG scores for an 89 year old female Alternative Treatment

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