Rehab strategies for patients with chronic conditions A complete, - - PowerPoint PPT Presentation

Rehab strategies for patients with chronic conditions

A complete, patient-centered approach to effectively treat challenging patients

Andy McCormick

• Clinical faculty for APTA Geriatric Residency Program 2014
• tDPT Regis University 2009
• MSPT University Alabama at Birmingham 1996
• MEd Auburn University (Exercise Physiology, minor Biomechanics)
• Board Certified Geriatric Physical Therapy 2013
• Board Certified Orthopedic Physical Therapy 2001
• Certified Strength and Conditioning Specialist 1996
• Advanced Credentialed Clinical Instructor APTA 2014
• Tennessee Physical Therapy Association Clinical Instructor of the Year 2018

Andy McCormick

• Developed and implemented Phase 4 Cardiac Rehabilitation

Program featuring interval circuit training which lead to significant improvement in functional abilities and decreased fear of activity

• Developed and implemented advanced Cardiopulmonary

Rehabilitation program for SNF which lead to a system-wide reduction in re-hospitalization of 30%

• Significant improvements in breathing capacity, endurance,

gait speed and tolerance and SOB index

• Successfully integrated manual therapy techniques into acute

and subacute settings leading to significant functional improvements for patients

Learning Objectives

• 1. Classify patients with chronic conditions, prevalence, pharmacological considerations

and the therapists role in improving functional status

• 2. Select the appropriate outcome measures to codetermine baseline function and show

improvement, including appropriate documentation of performance and expectations

• 3. Recognize common breathing substitution patterns and effectively improve these

patterns to increase functional endurance

• 4. Utilize alternative treatments for common pathologies associated with the medically

complex patient to improve balance and mobility

• 5. Implement effective soft-tissue and joint mobilization techniques with confidence

across a wide spectrum of patients and complaints

• 6. Incorporate appropriate corrective exercise to maintain improved airflow changes

gained through manual therapy

My goals

• 1. Reduce or resolve your fears in working with the chronically ill
• 2. Encourage you to “raise the bar” on yourself and your patient; use

your skills and don’t let YOUR mind limit YOUR outcome

• 3. Create consistency in your thoughts, attitudes, beliefs and

approaches with your patients

• 4. Educate regarding the impact of the mental state on performance

and outcomes in the medically complex patient

• 5. Improve your confidence in applying manual therapy techniques in

the complex medical patient

• Hypertension
• Hyperlipidemia
• Diabetes
• Back pain
• Anxiety
• Obesity
• Respiratory

problems

• Hypothyroid
• Visual refractive

errors

• Osteoarthritis
• Fibromyalgia
• Malaise/fatigue
• Joint pain
• Major depressive

disorder

• Bronchitis
• Asthma
• Depressive

disorder

• Coronary

atherosclerosis

• UTI
• Cancer
• Parkinsons
• Alzheimers
• Dementia
• CVA

• Heart disease affects ~ 47% of US
• 647,000 die (1 in 4 deaths)
• Diabetes affects ~ 9.4% os US; 0.55% to 8.6% (type 1 and 2

respectively) and 25.2% of geriatrics

• 79,535 die (7th leading cause) and 252,806 die as secondary cause
• Anxiety affects ~ 18.1% of US
• <40% seek treatment
• Parkinson’s affects ~1.2% of US
• Cancer risk for the lifetime is ~ 42.05% men and 37.58% women
• COPD affects ~ 14.5% of US
• Leading cause of death of women in US

Classification

“the action or process of classifying something according to shared qualities or characteristics”

What should we classify?

Things that DIRECTLY impact treatment decisions Cognitive Sensory Motor

Evaluation and Assessment

Evaluation and accurate assessment is the ESSENTIAL INGREDIENT in providing correct care for all patients “What else can it be?”

Demonstration

Sit<>stand (Strength)

Evaluation

Accurate classification for treatment

• Pertinent history
• MI, cancer, COPD, pneumonia, CHF
• Surgery (CABG, stent, filters, pacers)
• Rehabilitation (Cardiac, pulmonary)
• Specific leading questions OUTCOME MEASURES & TREATMENT GOALS directly impacting

movement

• Exacerbation
• Fatigue
• Anxiety
• Fear avoidance
• Shortness of breath

• How many exacerbations of your COPD have you had this year? On

average how intense were they (1-10 scale)? How many times did you to go to the hospital?

• Do you feel tired most of the time? What things make you tired?

How long does it take to recover?

• Are you anxious when you do …..? If so how much? What do you

do to decrease your anxiety?

• Are you afraid to fall? Are you afraid to walk outside? Are you afraid

to become short of breath?

• How short of breath do you become when you do …..? How often

are you short of breath? How long does it take to recover?

• Exacerbations of Chronic Pulmonary Disease Tool (EXACT-Pro)
• Beck Anxiety Inventory (BAI)
• Fear Avoidance Beliefs Questionnaire (FABQ)
• Fear of Falling Avoidance Beliefs Questionnaire (FFABQ)
• Fall Efficacy Scale International (FES-I)
• Activities-Specific Balance Confidence Scale (ABC Scale)
• Modified Medical Research Council (MMRC) Dyspnoea Scale
• Shortness of Breath with Daily Activities Questionnaire (SOBDA)
• Dyspnea Management Questionnaire (DMQ)
• Modified Borg
• Patient Specific Functional Scale

Exacerbation

COPD patients with severe exacerbation are at greater risk for cardiovascular disease … probably due to the high prevalence of arterial hypertension and diabetes mellitus Quality of life (CAT Test) and glucose control are predictors for increased CVD risk

Mekov et al. Cardiovascular risk assessment in COPD patients with severe

• exacerbation. European Respiratory Journal 2016;48: PA1134

Fatigue

• “Do you feel tired most of the time?” (Yes increases 10 yr mortality 55%)

Hardy et al. J Am Geriatric Soc 2008

• Vital Exhaustion Questionnaire (> 9 increases relative risk 2.57 for IHD)

Prescott et al. Epidemiology 2003

• Walking Impairment Questionnaire - PAD (Stair climbing < 8 all cause mortality)

Jain et al. J Vasc Surg 2012

Lab Values

• Hemoglobin < 7 gm/dl
• Hematocrit < 15-20%
• PaO2 < 60 mmHg
• Potassium < 3 or > 6 mEq/L

Academy of Acute Care Physical Therapy Laboratory Values Interpretation Resource 2017 Update

Anxiety

A general term for several disorders that cause nervousness, fear, apprehension and worrying. These disorders affect how we feel and behave and can cause physical symptoms

Anxiety

CBT reduced anxiety and fatigue, improved social functioning and better health-related quality of life

Freedland et al. Cognitive behavior therapy for depression and self-care in heart failure patients: A randomized controlled trial. JAMA Intern Med 2015;175(11):1773-1782.

CBT demonstrated “a significant 17% reduction” in perception of dyspnea in patients with COPD

Livermore et al. Cognitive behavior therapy reduces dyspnea ratings in patients with chronic

• bstructive pulmonary disease (COPD). Respir Physiol Neurobiol 2015;216:35-42.

CBT, exercise and anxiolytic use was associated with changes in depression and anxiety

Tully et al. A dynamic view of comorbid depression and generalized anxiety disorder symptom change in chronic heart failure: the discreet effects of cognitive behavioral therapy, exercise and psychotropic medication. Disability and Rehabilitation 2015

Cognitive Behavioral Therapy

• Depression - O’Hea 2009 CHF
• Anxiety & depression - Cully 2010 CHF

, COPD

• Emotion/anxiety - Karbasdehi 2018 CHF
• Chronic fatigue, self-efficacy - Tack 2018 Type 1 DM
• Psychological distress - Ires 2019 MS & Parkinson’s
• Mood, anxiety, sleep, negative feelings - Dobkin 2019 Parkinson’s

Cognitive Behavioral Therapy

Psychological problems are based in part on:

• Faulty or unhelpful ways of thinking
• Learned patterns of unhelpful behavior

Patients can learn better ways to cope, relieve their own symptoms and become more effective in their lives

Cognitive Behavioral Therapy

• Can learn to recognize distortions in thinking that create problems
• Can learn to reevaluate thoughts in a different light
• Gain a better understanding of behavior and motivation of others
• Use problem solving skills to cope with difficult situations
• Increase confidence in oneself

Cognitive Behavioral Therapy

Modifies dysfunctional emotions, behaviors and thoughts

• Focus on solutions
• Encourage the patient to challenge cognition
• Change destructive patterns of behavior
• Face fears
• Learn to relax and calm the body
• Prepare for challenges

Cognitive Behavioral Therapy

• Not motivational, educational or negotiation
• Ask “loaded” questions that you know the answers
• Use analogies and examples that are generally known

and understood

Lab

Battery vs generator

• “Why do you think you need to rest?”

We need to establish “baseline thinking” so we can change it

• “How long have you been resting?”

They will say only a short time, but we know it has been progressively longer and longer so make them acknowledge this

• “Is it fair to say you are doing less than… ?”

Establish history of progressive weakness to help them recognize rest hasn’t helped

• “Is rest really helping you feel stronger?”

This helps them begin to understand that rest isn’t helping as much as they think

• Did you ever know someone who decided to begin exercising? How did it feel at

first? Did it get better over time? How much could they do at first? Over time?

Most people know someone who decided one day to begin exercising and they also know how the typically improve with effort “Is it fair to say they “Rested” before they began? Did it help?

• Did you ever play a sport? Or an instrument? Did you have a hobby? Could you

do it now? If you practiced a little could you do it better?

Most people have played a sport or some kind of musical instrument or participated in hobbies and understand practice is crucial in performance

“Is it fair to say you have “Rested” from the activity? Has it help?

• Did you read about the marathoner who broke the world record? How was he

able to run so fast?

Many people are aware of current events and this particular event was a “big thing” and can be used to demonstrate the importance or regular training and the benefits

“Is it fair to say he “Rested” before he began? Did it help?

• Focus on solutions

What do you think you can do? What will you do?

• Encourage them to face their fears

“OK let’s go…”

• Increase their confidence

How was that? How do you feel?

Fear Avoidance

A psychiatric model that describes how patients develop musculoskeletal pain in the absence of pathology as a result of avoidant behavior Avoidance of symptoms; ie SOB, fatigue, pain

Fear Avoidance

Fear avoidance is directly related to physical disability and

perception of quality of life

Stenzel et al. The impact of illness perception and fear avoidance on disability in

• COPD. European Respiratory Journal 2014;44(58):p3674

Dyspnea-related fear may be more closely related to critical processes involved in pulmonary rehab and may have predictive value for COPD outcome

Janssens et al. Dyspnea perception in COPD: Association between anxiety, dyspnea- related fear and dyspnea in pulmonary rehabilitation. Chest 2011;140(3):618-625.

Lab

Fear of SOB

• “How long have you had shortness of breath?”

We need to establish “onset related to disease” in order to challenge

• “Never before your disease?”

They will say “NO” but we will show them they have always had episodes of SOB and that it is completely normal

• “Is rest helping you feel stronger?”

See previous

Mindfulness

• MBCT significantly reduced psychological distress in

COPD patients

• Psychological distress negatively impacts physical health
• Sensory and subjective
• Psychological and emotional process
• MBCT demonstrated a durable effect on psychological

distress

Mind-body connection

Thoughts, feelings, beliefs and attitudes can positively or negatively affect our biological and physiological function

Lab

• Music (effects subcortical areas, modulates limbic system,

distracts from negative feelings, inhibits release of stress hormones)

• Familiar
• Humor
• Sounds
• Visualization vs Guided imagery
• Meditation/Relaxation/Deep Breathing

Mindfulness

• www.tamethebeast.org
• www.gradedmotorimagery.com
• thiswayup.org.au
• bodymind.org
• www.painrevolution.org
• www.niogroup.com/product/recogniseapp

Evaluation and Assessment Breathing

“The process of taking air into and expelling it from the lungs”

Breathing vs Respiration

The mechanical act of moving air (Breathing) Energy production from the utilization of oxygen (Respiration)

Outcome Tools Physical Performance

FEV1, FEV1/FVC, FVC Reduction in lung function is a risk factor for all cause and cardiovascular mortality

Glabb et al. Outcome measures in chronic obstructive pulmonary disease (COPD): strengths and limitations. Respiratory Research 2010;11:79.

Lung Volume Measurement

• Interventions aimed at mitigating restrictions on operational chest

wall volumes are expected to enhance daily activity levels

Kortianou et al. Limitation in tidal volume (“normal breathing” about 0.5 l) expansion partially determines the intensity of physical activity in COPD. J Applied Physiol 2015;118:107-1134.

Capacity

Airflow limitation and hyperinflation

• Forced Expiratory Volume/1 second (FEV1)
• Forced Vital Capacity (FVC)
• Total Lung Capacity (TLC)
• Functional Residual Capacity (FRC)
• Residual Volume (RV)
• Inspiratory Capacity (IC)

Google = Pulmolife spirometers

Google = Baseline Windmill type Spirometer

Google = Peak Flow meter

Lab

• General posture
• Kyphosis, scoliosis, barrel chest, scapular positioning
• Static to dynamic - Morais
• General air movement
• Volume and rate normal (tidal volume ~ 0.5 liters) and maximum breathing
• Substitution patterns
• Ancillary movement

“Why do they substitute?” Lack of mobility OR Lack of control

Stiff vs Loose

Hypomobility - a decrease in the normal movement of a joint

• r body part; restricted joint movement that limits normal

range of motion Motor Control - "The process of initiating, directing, and grading purposeful voluntary movement”

Joint & soft-tissue mobility lab

Ribs - Bucket and Pump handle (Standing or sitting) Abdomen - Reverse diaphragmatic pattern Trapezius Anterior Neck Pectorals Intercostals and Scapulothoracic joint (Sidelying) Thoracic Spine, Diaphragm and Glenohumeral joint (Supine)

Shoulder Sweep

• Establish functional and impairment baselines
• Patient is sidelying, reaches as far as possible (note trunk rotation)

then attempts to move his/her arm through 180 deg without coming

• ut of plane (can use trunk and shoulder rotation)
• Reassess functional and impairment baselines

Treatment techniques

• Grades 1-5 mobilizations
• Inhibitive pressure
• Bending and longitudinal deformation (myofascial)
• Manual traction/unloading

Diaphragm

• Diaphragm stretching increased maximal respiratory

pressures, forced vital capacity and forced expiratory volume in the first second

Gonzales-Alvarez et al. Effects of a diaphragm stretching technique on pulmonary function in healthy participants: A randomized controlled trial. Int J Osteopathic Medicine 2015;18(1):5-12.

Manipulation

• Manipulation and diaphragmatic release

techniques improved functional exercise capacity with OR WITHOUT pulmonary rehabilitation

Jayde et al. The clinical effects of manipulative therapy in people with chronic obstructive pulmonary disease. J of Alternative and Complimentary Medicine 2018;24(7):677-683.

Manipulation

• Improved lung function and exercise tolerance

Wearing et al. The use of spinal manipulative therapy in there management of chronic obstructive pulmonary disease: A systematic

• review. The J of Alternative and Complimentary Medicine 2016:22(2):

108-114.

Manual Therapy

• Improved muscle function and inspiratory strength
• Improved SpO2
• Reduced dyspnea, fatigue, heart and respiratory rate

Yelver et al. Immediate effect of manual therapy on respiratory functions and inspiratory strength in patients with COPD. Int J Chron Obstruct Pulmon Dis 2016;11:1353-1357.

Manual therapy +

• Manual therapy + Exercise has always produced

improved function over either in isolation

• Neck; back; shoulder; hips; BREATHING

Lopez-de-Uralde-Villaneuva et al. The effectiveness of combining inspiratory muscle training with manual therapy and a therapeutic exercise program on maximum inspiratory pressure in adults with asthma: a randomized clinical trial. Clinical Rehabilitation 2018:32(6):752-765.

SNF Screen

Predictive of loss of FVC

• Decrease shoulder flexion
• Forward head posture
• Thoracic kyphosis

Morais et al. Posture and mobility of the upper body quadrant and pulmonary function in COPD: an exploratory study. Braz J Phys There 2016;20(4):345-354.

Corrective Breathing

• Airflow!!!
• Appropriate utilization of abdomen/diaphragm
• Movement of thoracic bony anatomy

Corrective Breathing Progressions

• Supine abdominal breathing
• Quad
• Sidelying
• Sitting
• Standing
• Walking
• Task

How do you add challenge between levels?

• Physical
• Static to dynamic
• Small to big movement
• Cognitive
• Dual task
• Sensory
• Change in balance or pain

Aerobic Capacity

Requires multiple workloads to assess cardiovascular response to various exercise stress levels Direct measure of oxygen consumption

Aerobic Capacity

• Bruce Treadmill Test
• Balke Treadmill Test
• Astrand-Rhyming Bicycle Test
• Harvard Step Test

Bruce Treadmill

• Bruce treadmill
• 1.9 mph, 10% grade (~ 6 deg), 3 minutes (5 METs, 18 ml/kg/min)
• 2.5 mph, 12% grade, 3 minutes
• 3.4 mph, 14% grade, 3 minutes
• 4.2 mph, 16% grade, 3 minutes
• 5.0 mph, 18% grade, 3 minutes
• Level walking
• 1 ft/sec (4 ml/kg/min; 14% harder than just sitting; 22% of level 1 Bruce)
• 3 ft/sec (5.5 ml/kg/min; 1.57 METs)

6MWT

Not aerobic assessment (But IS standard with pulmonary patients)

• No assessment of VO2Max
• No graded condition
• Distance walked is influenced by many factors

“Aerobic capacity has LOW correlation with walking speed and MODERATE correlation with walking distance” Outermans et al. Phys There 2015

Functional Assessment Gait Speed

Normal and fast conditions; Simple, reliable and repeatable measure; No equipment required; No special conditions Reference numbers

< 0.92 ft/sec increased postural synergy pattern (Isometric walking) < 1.96 ft/sec increased hospitalization risk < 2.13 ft/sec AND Grip strength < 25kg; strong predictor of 6 month mortality risk < 2.26 ft/sec recurrent STEMI (37%) with 17% increased mortality rate in women < 3.05 ft/sec recurrent STEMI (37%) with 17% increased mortality rate in men

Vital Signs Monitoring

Blood Pressure, Heart rate, Pulse oximetry, MET, RPE At Rest During exercise/activity Post exercise/activity

Example

86 yocm with COPD Resting BP 137/94; 88 BPM; 93% SpO2 on 2 liters via nasal canula; RPE 3/10 NuStep x 5 minutes at 3 MET’s with BP 155/101; 101 BPM (77% HRMax); 90% SpO2 on 2 liters via nasal canula; RPE 5/10 Ex+1 at rest (1 MET) with BP 148/99; 94 BPM; 89% SpO2 on 2 liters via nasal canula; RPE 4/10 Ex+3 at rest (1 MET) with BP 139/91; 90 BPM; 92% SpO2 on 2 liters via nasal canula; RPE 3/10

Targeted training

• Improved exercise tolerance and capacity with decreased dyspnea

Wada et al. Effects of aerobic training combined with respiratory muscle stretching

• n the functional exercise capacity and thoracoabdominal kinematics in patients

with COPD: a randomized and controlled trial. Int J Chron Obstruct Pulmon Dis 2016;11:2691-2700.

High Intensity Interval Training (HIIT)

• 80-85% HRpeak:50% HRpeak
• Progressing time and volume at 1:1 ratio (1-4 min)
• 90% HRpeak:60% HRpeak
• Progress volume of intervals at 1:1 ratio (1 set - 8 sets at 2 min)
• 80-100% Wpeak:Passive rest
• Progress volume (30 seconds on/off up to 45 minutes)

Wewege MA et al. High-Intensity Interval Training for Patients with cardiovascular disease - Is it safe? J Am Heart Assoc 2018;7:e009305. DOI 10.1161/JAHA.118.009305(21):

HIIT Program

PRE: BP 137/94; 88 BPM; 93% SpO2 on 2 liters via nasal canula; RPE 3/10 Week 1 - NuStep 30:30 sec 85% (4.1 METs):50% (2.2 METs) HRpeak; RPE 8/10, 8/10, 9/10 (3 cycles, 3x/wk); 7 minutes to return to baseline Week 2 - NuStep 30:30 sec 85% (4.1 METs):50% (2.2 METs) HRpeak; RPE 7/10, 8/10, 8/10, 9/10 (4 cycles, 3x/wk); 6 minutes to return to baseline Week 3 - NuStep 45:45 sec 85% (4.3 METs):50% (2.3 METs) HRpeak; RPE 8/10, 8/10, 9/10 (3 cycles, 3x/wk); 6 minutes to return to baseline Week 4 - NuStep 45:45 sec 85% (4.3 METs):50% (2.3 METs) HRpeak; RPE 7/10, 8/10, 8/10, 8/10 (4 cycles, 3x/wk); 7 minutes to return to baseline POST: BP 131/90; 84 BPM; 93% SpO2 on 2 liters via nasal canula; RPE 1/10

Guidelines for Termination of Exercise

• Is the patient “inside” or “outside” normative values at rest?
• HR 50-120 BPM
• BP 80/40 mmHg <>180/110 mmHG (160/90 mmHg most common “standard”)
• SpO2 90% (> 80%?)
• Yellow flags - how does the patient respond to load?
• Dizziness > 60 seconds
• > 30 BPM increase HR
• > 30 mmHg increase SYSTOLIC
• > 10 mmHg decrease in SYSTOLIC in the first 5 minutes with ST depression OR > 20 decrease mmHg
• Red Flags
• Blurred vision
• Dilated pupils
• Angina
• SOB

Example

86 yocm with COPD Quiet sitting x 5 minutes (1 MET) BP 137/94; 88 BPM; 93% SpO2 on 2 liters via nasal canula; RPE 3/10 Walking at 1 ft/sec (1.14 MET’s) with BP 187/122; 130 BPM (97% HRMax); 78% SpO2 on 2 liters via nasal canula; RPE 8/10; complaint of significant fatigue, SOB and dizziness

Example

86 yocm with COPD Quiet sitting x 5 minutes (1 MET) BP 137/94; 88 BPM; 93% SpO2 on 2 liters via nasal canula; RPE 3/10 NuStep x 5 minutes at 3 MET’s with BP 155/101; 101 BPM (77% HRMax); 90% SpO2 on 2 liters via nasal canula; RPE 5/10; no subjective complaints

Documentation

Pertinent medical histories and reason for treating Quantify the subjective (fear, anxiety, SOB) Establish baseline functional limitations and impairments Describe how the subjective directly impacts the physical Document “In session” change Objective/subjective goals

Pertinent Medical History 76 yocf with CRF , COPD, dependence on supplemental oxygen, long term (current) use of inhaled steroids, muscle weakness, repeated falls, Parkinson’s, localized edema, “other specific arthropathies right knee”, “other specified disorder of bone density and structure of right ankle and foot”, essential HTN, cervical DDD, chronic pain, opioid dependence, bipolar disorder, major depressive disorder, anxiety disorder, “unspecified psychosis”, restlessness and agitation, dizziness and giddiness, hypothyroidism, laceration without foreign body of right middle finger, GERD w/o esophagitis, unspecified dementia, generalized enlarged lymph nodes, nicotine dependence. Admitted following recent falls x 4 in 2 weeks (walking to bathroom).

Quantify the Subjective Fear of falling 9/10 when walking, anxiety when walking 7-8/10; confidence to NOT fall 0-1/10 when walking.

Baseline functional limitations and impairments Step and stride length severely limited (>90%), shuffling and unwillingness to pick up her feet; CGS = 0.12 ft/sec to walk 10 ft w/ RW, HR 99 BPM, PRE 8/10; stair climbing was reciprocal without hesitation at nearly normal speeds Retropulsion during arising; perception of falling forward (despite significant retropulsion) with high fear of falling backwards and grabbing tightly to her walker (which rises as she falls). Increased tone into PF despite 5 deg DF; ankle joint and soft-tissue hypomobility bilaterally; excellent strength, very poor visual clarity

Treatment Bilateral ankle joint and soft-tissue mobilization (5-10 min); standing

• n 3 deg incline (~ 5 min with 30:30 cycles WITHOUT hands in parallel

bars) with emphasis on perception of weight in the balls of the feet, head and trunk forward position with cognitive reinforcement “You are NOT falling forward”; FoF 8-9/10. Patient IS allowed to fall backwards when she shifts her weight posteriorly and is asked “Which way did you think you were falling?” (forward) and “Which way did you fall?” (backwards). Patient is shown an object standing upright and asked “Why isn’t this falling?” And patient states it is balanced. “Correct”! Then the object is tilted relatively posteriorly and it falls; the patient is asked “Which direction did it fall?” and the patients states “Backwards”. “Correct”! The patient is educated on gravity, CoM and relative BoS related to falling. Visual targets (yellow tape) in parallel bars for step and stride length 5x6 ft

~ 15-20 minute total

In-session Change FoF 8-9/10 > 7/10; confidence increased 3-4/10; reported improved sensation of weight distribution over balls of feet; anxiety walking 5/10; CGS = 0.65 ft/sec and PRE 5/10 walking 25 ft; continued shuffling particularly near lines in floor; some improvement in step and stride Learning Parkinson's was initially assumed to be limiting step and stride as well as continued difficulty stepping over lines in the floor until glaucoma was eventually reported. It was treated and shown to have biggest influence on overall walking ability

Goals

• Patient will demonstrate > 25% reduction in SOB Index

during dressing to facilitate increased independence

• Patient will report > 50% reduction in fear-avoidance during
• utside walking to promote improved general health
• Patient will demonstrate > 25% improvement in FVC to

facilitate increased endurance on the 6MWT to return him to the community

Goals

• Patient will demonstrate > 10% reduction in resting vital

signs to facilitate decreased fatigue and improve participation in activities

• Patient will report reduced anxiety with aerobic activity to

promote improved cardiovascular endurance in order to increase walking tolerance to participate in fund raising

• Patient will tolerate > 10 minutes activity at 3.2 METs

intensity with 3 self-chosen activities to promote improved health

Questions?