PTH 745-Patient Care III Part 1 & 2 -Practical 2, Haines-2018

Jocelyn Braun- Case 1

PTP 745 Lab Practical 2 Worksheet-35 points
After reviewing the case history assigned to you, identify and list key (no more than 3) additional history questions
that you would ask the patient/family and provide your rationale for asking those questions. (3 points)
History Question Rationale
1.What types of jobs, hobbies, and interests Knowing the interests of the patient and things he needs to be able
has the patient had in the past and/or most to do in his life, his treatment plan can be tailored to fit these tasks
recently? that he needs to be able to do in his daily life. Also, knowing these
things it can help to create saliency in his treatment program so that
he gets more out of the treatment and finds the value in
participating in the different exercises.
2. What kinds of perceptions does the patient Patient’s medical history reports that he lacks insight into his
have about his impairments versus what kinds problems with mobility. If the patient thinks that there are things he
of impairments are actually present? can do, but he really has deficits in certain tasks then he could be
putting himself at risk for falls and decreasing his safety.
3. What are the motivating factors for the This will help to decide how well therapy might work for the patient
patient to participate in rehabilitation and and how he feels about therapy. His attitude towards therapy may
complete rehabilitation? be indicative of the progress that he makes and how he feels that he
will be able to improve upon his impairments.
1. What specific outcome measures would you anticipate completing with this patient? What is your rationale for
selecting these tests and measure? What do you expect to find? (9 points)
Test and Measure (.5) Rationale (.5) Expected findings (.5)
1.Berg Balance Scale Measure of different functional and balance This patient would be expected to
tasks that the patient needs to be able to do. score in the middle category of 21-40
This test is appropriate for this patient because (walking with assistance). He has
it will measure different tasks that he is having some difficulty with maintenance of
trouble with at this time and give an objective balance, but he should be able to
measure of the different aspects of the tasks earn full points for most of the
that he can do, and the areas of deficits that we functional tasks.
can work on in his rehabilitation.
2.Barthel Index The Barthel Index gives a measure of the For this patient, it would be
patient’s functional independence in their suspected based on the given
mobility and personal care. This test could give information that he would most likely
a good measure of how much assistance the score between the marked and
patient is needing for these types of tasks and severe dependence categories. While
this can be used for treatment in designing he can do a lot of the personal care
different activities and knowing how we can activities somewhat independently
increase the level of the patient’s he still needs assistance for some of
independence. them as well as some assistance in
his mobility.
3.Mini-BESTest The Mini BESTest looks at a lot of different For this patient, it would be expected
components of functionality including reactive that he would score lower indicating
balance, anticipatory balance, functional skills, that he has difficulty performing the
sensory integration, and gait. For this patient tasks that are measured in this test.
this test can be used to look at these different He would score lower because of the
areas to see where his deficits are and what mentioned problems with balance,
things he is able to do independently to come mobility, and gait in his history.
up with treatment options that will address his
areas that need improvement, because the
PTH 745-Patient Care III Part 1 & 2 -Practical 2, Haines-2018

patient has some difficulties with balance, gait,

4.Mini Mental State
Examination
5.Postural Assessment
Scale for Stroke Patients
6.Activities Specific Balance
Confidence Scale
and some functional skills.
This test will be used to test the mental
impairment level of the patient. It looks at
short term recall, following directions,
orientation, and recognition of objects. With
the patient’s injury it will be useful to test these
areas to see where he may have impairments
to be aware of these types of things when
designing treatment options.
The PASS would be appropriate for this patient
to get a measure of his postural ability in static
postures as well as when he is changing
postures. Based on his medical history of
having difficulty with maintaining and changing
postures this would be appropriate to measure
how independent he is in these activities.
The ABC scale gives a subjective measure of
how confident the patient is in their own
balance abilities in different tasks. This would
be appropriate for this patient because it could
give the PT an estimate of how the patient is
feeling about their own balance versus what
the PT sees in their evaluation. If this patient is
having impaired judgement of his abilities in
mobility this could be a way of measuring that.
It would be expected that this patient
would score in the severe
impairment category. With his
Ranchos Los Amigos stage, he will
still be confused and have some
memory deficits of the past and
present along with not being able to
follow more than two step
commands.
This patient would be expected to
have a score in the middle indicating
that he is improving in his functional
mobility. He should be able to do
some of the sitting balance tasks
independently as well as the
changing posture tasks with little
assistance. He may score lower in the
standing balance tasks and those that
involve changing postures in
standing.
Based on the patient information,
this patient would likely score himself
as having higher confidence in the
range of 60-80% in his balance
abilities for different tasks based on
his impaired insights about his
mobility impairments.

2. Discuss your POC for this patient utilizing the appropriate Intervention framework for your specific case. Be specific
enough in your individual activity descriptions so that your POC can be reproduced easily by another PT. (23 points)
CVA/TBI/GB FRAMEWORK-document specific Rationale
interventions (15)
Task-specific training: Circuit Training (One 4
station circuit)
All circuit activities performed for 1-minute
with a 1-minute rest between each activity.
Activities can be repeated 3 times.
1. Pt. will stand in front of a set of stairs and 1. Patient is having difficulty with clearing his foot when climbing
will hold onto the rails that are on both sides stairs. With facilitation pt. will learn how to clear his foot and gain
of the stairs. PT facilitates at the posterior more confidence in his ability to climb stairs on his own. He needs
thigh just distal to the knee and the to be able to climb steps independently to live at his mother’s
contralateral hip for stabilization switching home.
between the R and L sides to help pt. clear Regression: Slow down metronome to 40 bpm
foot. Metronome will be set to 50 bpm. Pt will Progression: Increase time of metronome to 60 bpm, climb
step onto stair with one foot and then the successive stairs
other, and then step back down with both feet.
PTH 745-Patient Care III Part 1 & 2 -Practical 2, Haines-2018
2. Pt. will stand at the sink and wash dishes at
a rate of 70 bpm, “washing” each dish 5 times.
When done washing the dish he will set them
on a high shelf. PT will facilitate at the pelvis
for stabilization and weight shifting when
reaching up to the cupboard. PT can put dishes
back into the sink as pt. washes them if he runs
out of them before time is up.
3. Pt. will be standing with a broom and will
sweep in diagonal directions following a piece
of tape that has been placed on the ground.
There will be 4 different pieces of tape and
they will come to a center location, where
after the pt. has “swept” up each piece of tape
he will then have to sweep all the dirt into a
pile and pick it up with the dustpan to place it
in the trashcan. PT will facilitate at the
ipsilateral gluteus medius and contralateral
pelvis switching sides as needed to assist pt.
during stance phase for stabilization of ataxic
gait and weight shifting.
4. Pt will be in a high sitting position with a
laundry basket of clothes in front of him on the
floor. Pt will reach and grab a piece of clothing
and then fold it, and once it has been folded he
will place it on a shelf to either the right or left
of him as specified by the PT. PT will guard and
facilitate at the pelvis for stabilization as
needed to maintain balance.
Task-specific training: Treadmill
Training/Overground (3 act):
1. Pt. will walk down a long hallway. Obstacles
will be set up for pt. to maneuver around
including opened doors, people (a PTA, an
aide, or pt.’s mother) walking towards him,
and “rocks” in the middle of the walkway. PT
will facilitate at pt.’s gluteus medius during
stance phase for stabilization on both sides as
needed. Pt. will use walking sticks in both
hands to help with stability for ambulation. A
metronome will be set at 60 bpm for the pt. to
keep pace to. Walk down the hallway 3 times.
2. Two lines of tape will be placed at the
normal BOS for the pt. for their gait in a long
hallway (~150ft). PT will facilitate at the
gluteus medius for stabilization during stance
phase and with hand held assist for
maintenance of balance. Pt. can use a walking
stick in the hand not being used for assist given
by the PT to help with further maintenance of
2.This task mimics an ADL that the pt. needs to be able to do on his
return to his mother’s home and may possibly help him in getting a
job in a restaurant setting. It will work on weight shifting and
standing balance that the pt. is having trouble with.
Regression: Lower shelves that the pt. is reaching towards.
Progression: Specify different shelves for different types of dishes
(plates, cups, silverware, etc.), higher shelves, standing on foam
3.Sweeping is a common ADL that the pt. will need to be able to
complete if he is going to return home and may also be a possible
task at a future job for him. This task will work on his balance along
with ataxic gait by having him following the tape on the ground. The
tape may also help with his distractibility and getting him to focus
on the task at hand.
Regression: sweeping in a straight line
Progression: standing on a balance beam and sweeping
4.This activity will help to improve the pt.’s sitting balance and
weight shifting to different directions. It mimics a common ADL he
should be able to complete and works on areas of his deficits.
Regression: Put clothing on shelf only on one side, the shelf can be
moved closer to him
Progression: Pt. can be responsible for alternating putting clothing
on opposite shelves without cuing, shelf can be placed at a farther
distance, moving the clothes basket so that the patient must reach
across his body to grab an item of clothing.
1. This task will focus on helping improve the patient’s anticipatory
and reactive balance in a real-life situation that he may encounter
when walking down the sidewalk. It will cause him to have to focus
and maintain attention so that he does not run into the different
obstacles.
Regression: Metronome set to 50 bpm, obstacles placed farther
apart
Progression: Metronome set to 70 bpm, obstacles placed closer
together, person walks closer towards him
2.For this task, pt. will be forced to work on his ataxic gait by
keeping his BOS within a set width and distance. This will force the
pt. to concentrate on his gait pattern and controlling his LEs. This
should help for the pt. to better be able to control his balance and
work on his endurance by walking further distances as he
progresses.
Regression: Metronome set to 50 bpm, tape placed further apart for
greater room for error
PTH 745-Patient Care III Part 1 & 2 -Practical 2, Haines-2018
balance. Pt. will have to keep within the lines
of tape to help with their ataxic gait.
Metronome will be set at 60 bpm.
3. Pt. will walk around the mat table switching
the stepping pattern each time that he makes
a turn. Stepping patterns will include forward,
backward, and side stepping, and stepping
with one foot in front of the other. PT will
facilitate at gluteus medius during stance
phase for stability and with hand held assist.
Pt. can use a walking stick in his hand not being
used for assist given by the PT to help with
further stabilization during ambulation.
Perform 5 laps around the table.
Therapeutic Exercise: Strength/resistance
Training (3 act)
1. Pt will complete sit to stands for 30 seconds
keeping pace to a 45-bpm metronome. PT will
facilitate at the pelvis for standing upright and
have one hand on the pt.’s chest to keep them
from falling forward. Repeat 3 times.
2. Pt. will perform a glute bridge with a friction
reducer underneath their feet. When they lift
their buttocks off the ground they will move
their feet in and out reciprocally. This will be
done for 30 seconds and with a metronome
set to 50 bpm for the pt. to keep pace to. PT
can tap at the glutes to keep the buttocks
lifted. Repeat 3 times.
3. Pt. will be in a 4-point position with 5-pound
weights in each hand. He will perform the PWR
Twist move with the weight in his hand. He will
alternate arms back and forth, performing it 10
times on each side. PT can facilitate at the
trunk to increase the twisting motion and at
the scapula to increase the range to which he
can lift the weight. Perform 3 sets.
Therapeutic Exercise: Balance Training (3 act)
1. Patient will sit on a physioball in a corner
while throwing a football back and forth to a
PTA, an aide, or his mother (may have to use
the trampoline if neither of these are
available). PT will facilitate at the pelvis of the
pt. for weight shifting in catching the ball.
Exercise will be performed for 1 minute, with a
1-minute rest for 3 sets.
Progression: metronome set to 70 bpm, tape place closer together
to work more on balance with narrower BOS
3.This activity will work on changing body position and the
executive function of planning for the patient as he will have to
think of how to change his body position and remembering each
change as he goes around the table. It will work on turns and
maintenance of balance while changing body position.
Regression: include less types of variable stepping
Progression: set metronome to 60 bpm for pt. to keep pace to, give
commands for pt. to switch steps before making a turn
1.This activity will help to strengthen LE muscles and is very
functional for the patient. It will help to improve his transfer from
sitting to standing.
Regression: decrease time of exercise to 15 seconds, set
metronome to 55 bpm
Progression: increase time of exercise to 1 minute, set metronome
to 35 bpm
2.Glute bridges will help to strengthen the hip extensors which are
important for gait and may help the pt. to become more stable in
ambulation and decrease his ataxic gait. It can also help to
strengthen core muscles which are important for upright posture.
Regression: decrease length of time, take out friction reducer, have
pt. perform 3 sets of 10 repetitions of glute bridges
Progression: increase length of time, increase pace of metronome
to 60 bpm
3.With this exercise the patient will be strengthening his arm and
scapular muscles along with some of his core muscles. This can help
in being able to gain more strength needed for ADLs and a future
job that he may have. It will also work on trunk rotation that is also
needed for good mobility and functionality.
Regression: decrease the weight size and number of repetitions
Progression: set exercise pace to a metronome, increase weight
size, increase number of repetitions
1. This exercise may be salient for the patient because of his interest
in sports. It will work on his reactive sitting balance because he is
still having problems in this area.
Regression: pt. could sit on a stationary table, shorter distances for
him to throw
Progression: bringing the physio ball away from the corner,
progressing the pt. to standing
PTH 745-Patient Care III Part 1 & 2 -Practical 2, Haines-2018
2. Pt. will stand on a foam pad and will throw a
tennis ball to targets on a wall. The targets will
be different colors and the PT will specify
which color the pt. should be hitting. Pt. will
have to catch the ball after it comes back from
hitting the wall. PT will facilitate and stabilize
at the pelvis for balance control. Task will be
performed for 2 sets of 15 repetitions.
3.Pt will be standing with a 6-inch step in front
of him and will take a step onto the stair with
one foot and then bring the foot back to the
ground. He will then repeat the task with the
opposite foot. When taking a step, he will also
punch a punching bag (or boxing paddle held
by a person) that is in front of him. PT will
facilitate at the pelvis for stability and at the
contralateral posterior thigh just distal to the
knee to help the pt.’s foot clear the step.
Therapeutic Exercise: Cardiovascular/Aerobic
Training (3 act)
1. Pt. will have on boxing gloves and will be
standing facing a PTA, a aide or his mother
who is wearing the boxing paddles. PT will give
commands for him to jab, cross, or do
uppercuts alternately with his R and L hands.
PT will help to stabilize at the pelvis for
maintenance of balance and weight shifting.
Pt. will do this activity for 10 minutes at a time.
HR will be measured for pt. so that it is kept at
a range from 70-80% of his HR max (approx.
120-140 bpm for this pt.).
2. Pt. will be in the 4-point position with a
friction reducer underneath his arms. He will
move his arms back and forth in midline to a
metronome set to 100 bpm. This will be done
for 10 minutes. PT will facilitate at the arms as
needed for increasing ROM and will guard the
pt. in case he loses balance.
3. Pt will be in a high seated position and will
have a physioball in front of him that is sitting
in a bucket. Pt. will have boomwhackers in his
hands and will tap the ball in rhythm with a
song of his choosing (hoping to have a fast-
paced song to increase pt.’s HR). PT will
supervise pt. in this position for loss of
balance.
UE Recovery: (Discuss 3 specific UE
interventions/activities so they are
reproducible) (6)
2.This activity will help work on dynamic reactive standing balance.
It increases saliency for the patient by using a ball for his love of
sports.
Regression: pt. can stand on solid surface, take away targets on wall
Progression: set metronome for pt. to throw and catch to, move
farther away from the wall, create a pattern for the targets that pt.
must recall
3.This activity will work on single leg stance balance and weight
shifting for climbing stairs both of which are impairments for this
patient currently. It will also work on helping him to clear his foot
when climbing stairs and maintaining balance with dual tasking
which is important for daily activities.
Regression: take away boxing element, decrease height of stair
Progression: pt. can punch to the side or across body, increase step
height of stair, use consecutive stairs
1.This activity can help the patient to get some of the aggression out
that he may be experiencing and be salient for him because of his
interest in sports. It can be very intensive and raise his HR to the
needed range to be beneficial. It can also work on balance and gait
stability.
Regression: decrease number of tasks for patient, high sitting
position
Progression: increase length of time of activity, add commands for
pt. for R and L hands
2.This activity will increase the aerobic capacity of the patient and
will also help to strengthen the arm muscles. It is a challenging
activity that will increase his HR and help to increase his endurance.
Regression: decrease metronome to 80 bpm, decrease length of
time of task
Progression: reach in directions away from midline and across
midline, increase bpm to 120
3.This task will be salient for the patient because of his interest in
rock music. It will also be beneficial for him in increasing his aerobic
capacity to be able to walk further distances and in completing
ADLs.
Regression: pick slower paced songs or use a metronome set to a
slower beat, pt. could be in a sitting position
Progression: pt. can stand, use a metronome to use a higher bpm,
create patterns for pt. to follow
Rationale: Provide rationale for each of your three specific
interventions.
PTH 745-Patient Care III Part 1 & 2 -Practical 2, Haines-2018

1.Pt. will stand in front of a mirror and will This task will help the pt. to improve his ability for grooming tasks
reach for hygiene items (comb, toothbrush and that he is having difficulty with and it is salient for him because of
paste, deodorant, etc.) that are on different his need to do these types of tasks. By timing him it will simulate
height shelves. Once he has each item he will getting ready in a set amount of time.
use them for their respective uses to take care Regression: use lower shelves, increase time allowed for activity
of his daily hygiene needs. PT will facilitate at Progression: stand on foam pad, decrease time needed to complete
the scapula for the reaching tasks and then at activity, decrease height of shelves
the pelvis for stability when using each item.
Pt. will be given 5 minutes to try and complete
this activity (using all of the items).
2.Pt. will be in a high sitting position with a For this patient, this activity will be purposeful because of his
clothesbasket of his clothes in front of him (will difficulty with dressing himself which is a very important ADL that
include shirts, pants, socks, shoes). He will he needs to be independent in. It will involve weight shifting and
reach into the basket for an article of clothing maintaining balance in a sitting position.
and then will put that item on. Once he has the Regression: move clothesbasket closer to pt., pt. can put on fewer
clothing on he will undress himself and fold the articles of clothing (just shirt and pants for instance)
clothes and put them back into the basket. PT Progression: pt. in standing position, put on multiple layers of
will supervise pt. for loss of balance and weight clothing (coat, sweatshirts, clothes with buttons)
shifting. Physical facilitation will be used on the
pelvis as needed. Time for pt. to do this activity
will be timed and compared to future attempts
at this activity.
3.Pt. will start in a sitting position and then This activity is useful for the pt. because it mimics an ADL that he
perform a modified sit to stand stopping in the will need to do after he is discharged and may also be useful for a
midway position and will hold this position. In future job. It is working on balance and can be progressed to work
this position he will “clear off the table” on gait as well with dual tasking. Additionally, it can work on
(plates, bowls, cups, silverware, etc.) that is in strengthening the muscles of the LEs.
front of him from his meal and stack the dishes Regression: perform less repetitions, move table closer to pt.
into different piles. After stacking the dishes, Progression: move table farther away so pt. has to perform full sit to
he will return to the sitting position. Then he stand and walk back and forth to clear and set the table, move table
will come back to the modified standing away from midline
position where he will unstack the dishes to
set the table, and then return to the sitting
position. Task will be repeated 10 times (5
setting the table and 5 clearing the table). PT
will be at the side of the pt. facilitating at the
pelvis for weight shifting and pelvis control.
Resources. Provide at least 4 resources for your client and family to assist them in the recovery process. Give a web
link and brief description of why you are recommending this resource. (2)
1.This site is a guide for patients after sustaining a TBI. It has good information regarding what people can expect their
impairments to be after a TBI and ways to help manage some of the symptoms that they may be experiencing. For
this patient, I would give him parts of the resource in intervals so that he doesn’t get overwhelmed because it is a long
document and may be too much for him at one time. For instance, I would give him the information about headaches
first because this seems to be his greatest complaint at this time. Some of this information may also be helpful for his
mother in knowing what to expect of her son with his TBI and some of the things she may be able to do to help as
well. https://www.mentalhealth.va.gov/docs/tbi.pdf

2.This resource gives information for support groups for alcohol and drug abuse in Michigan. A big component in this
patient’s recovery process is going to be whether he can stay clean or not. If he is not able to do this, his mother isn’t
going to let him live with her and his success in rehab is going to decline. Furthermore, this can give him social support
PTH 745-Patient Care III Part 1 & 2 -Practical 2, Haines-2018

that he does not seem to have a lot of based on his history and a way to become clean in a supportive environment.
https://www.psychologytoday.com/us/groups/addiction/michigan?sid=1540041742.4299_14312&spec=248

3.This resource is specifically designed for caregivers and families of patients with a TBI. This would be appropriate for
the patient’s mother in knowing what to expect of her son and things that she can do to help him. It may also help her
realize the challenges that her son will face, and that he is going to need her help and support in the recovery process.
There is information in the resource that includes ways to help the patient, things that the caregiver can do in
different phases of the rehab proves, and sources for help in paying medical bills and getting other types of assistance
for recovery. It also includes housing options that may be available for patients with a TBI.
https://www.biausa.org/downloads/brain-injury/Guide%20for%20Families%20and%20Caregivers.pdf

4.This resource gives a list of support groups for people with a TBI in Michigan. This is a good resource for this patient
because it can help him to build a group of people around him who are experiencing the same types of things as him
and give him a positive outlook on his situation. From his history, he doesn’t have a lot of social support other than his
mother, so this could be a way for him to make new friends and find support from other people who have been
through this same experience. https://www.biami.org/support-group-list/

“I ATTEST THAT I HAVE COMPLETED THIS WORKSHEET (PART 1) ON MY OWN AND HAVE NOT
SHARED MY WORK WITH ANOTHER CLASSMATE OR USED ANOTHER CLASSMATE’S WORK
FOR THIS WORKSHEET.”

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