Margaret Schenkman, PT, PhD, FAPTA University of Colorado, Denver Colorado

Margaret Schenkman, PT, PhD, FAPTA University of Colorado, Denver Colorado

Present a framework for clinical reasoning with emphasis on Patient centered care Application of enablement and disablement frameworks Clinical reasoning for evaluation Application of both reasoning and evidence to make decisions Illustrate with an individual who has PD

Physical therapy focuses on enhancing the patient s ability to function and participate within society The physical therapist Is attentive to the patient s needs, concerns and lifestyle Addresses those concerns and needs within the plan of care

Participation: involvement in a life situation Participation takes place In the home: Example: take care of the household On the job: Example: work in a coffee bar In leisure activities Example: vacation at the beach

Requires ability to carry out related functional activities Activity: execution of a task or action by an individual Some functional activities related to vacationing at the beach Carrying luggage Climbing steps onto train Walking on moving train, side walks, sand

Purpose To indentify relationships between difficulties that individuals have in their lives and disease processes Types of approaches Disablement Begins with the disease Identifies the resulting problems Relates them to function Enablement Begins with the person s life and participation Identifies the reasons for abilities and difficulties (including but not limited to disease processes)

Modified from Schenkman, Deutsch, Gill Body Phys Ther, 2006

Individual with Early Stage PD Mr. C 88 years old Still involved as president of a heating company Went to office every day Reported reduced energy, slowing down, didn t feel stable when walking Described painful knees (long standing osteoarthritis)

From enablement perspective Learn about the patient s participation and roles, desired functional activities, and skills & resources From disablement perspective Analyze impact of the patient s disease/ pathology on functional activities Make reasoned decisions regarding what can improve with physical intervention and what cannot

Patient centered perspective Why seeking treatment Needs for participation and function Context (living environment, job, leisure activities) Family issues Disease related perspective Medical history Likely contributing impairments from primary disorder and other conditions

Administer tests and measures that will Describe movement problem for important functional activities Guide evaluation Serve as outcome measures Meaningful to patient Relevant environmental context Takes into account Activities, participation, quality of life (enablement) Resources (enablement) Impairments (disablement)

Person Stationary Moving Stationary Moving Environment Stationary Stationary Moving Moving Adapted from Gentile In Shumway-Cook and Wollacott

Tremor Rigidity Minimal (controlled with medication) Bradykinesia Minimal in left hand (controlled with medication) Overall slowness of movement Postural instability Loss of balance with posterior pull

Based on postural instability, test for sensory impairments: Diminished vibratory sense ankle, foot Rhomberg test demonstrates instability Clinical Test for Sensory Interaction in Balance (CTSIB) demonstrates visual dependence

Identify Hypothesize Improve, compensate or prevent Consider prognosis How impairments, task and environment contribute to functional difficulties For function and impairments, consider whether to Resources and limitations For each contributing condition Determine realistic goals and plan of care

Enablement: resources Highly motivated Stable family Financial resources Physiological Cardiovascular Integument Disablement: limitations Identified by patient Painful knees Slowness Instability Identified by P.T. Bradykinesia from PD Lack of axial range of motion/flexibility Diminished vibratory sense with visual dependence

Functional limitations instability, slowness and pain Postural instability Primary problem of PD, ROM, postural alignment, vibratory sense, sensory/motor interaction Slowness for all functions Bradykinesia, pain, ROM, postural instability Pain Osteoarthritis

IMPROV E FUNCTION

PREVENT COMPENSAT E IMPAIRMENTS IMPROVE

PREVEN T PATHOLOGY

Disorder Parkinson s disease Tremor predominant versus Postural Instability Gait Disorder (PIGD) Age, dementia Comorbid conditions Osteoarthritis Age and PD surgical risk Post et al, 2007

PD Specific impairments Sequelae Bradykinesia, tremor, rigidity, postural instability Flexibility Balance/stability Co-morbid conditions Painful knees Sensory processing/stability Schenkman et al, 2000; Schenkman et al, 2006 Shumway-Cook, Wollacott, 2001

Prognosis for change with exercise Prognosis for this patient (evidence and clinical experience) Bed mobility Sit to stand Mobility Walking Electric scooter Fatigue Goodwin et al, 2008

Improve Compensate for Task performance (e.g., sit to stand, gait) Stability & endurance Painful knees (e.g., higher chair seat) Bradykinesia (e.g.; rhythmic auditory stimulation) Prevent Further loss of range of motion Falls and fractures, Pneumonia

Overall exercise program: similar program of Ellis et al., 2005 To maintain range of motion To improve stability Flexibility exercise Balance training within function; specific training on different surfaces To compensate for Bradykinesia Rhythmic auditory stimulation

The Plan of Care should lead to improvements of function and participation Both enablement and disablement perspectives guide decisions Evidence is used, combined with reasoning based on the patient s actual situation Prognosis is taken into account for both the primary and co-morbid conditions Evidence for possible intervention choices next presentation!

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