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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
• 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¤tPage=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