1. Choose one of the functional outcome measures used in the client’s assessment (the Berg Balance Score, the Timed Up and Go or the six-minute walk test). Look up information on your chosen outcome measure. How do Mrs. Betic’s scores compare to normative data? What do these results suggest about Mrs. Betic’s current level of function? Include a reference.
Answer- The measures of the functional outcome of the Berg Balance Score for Mrs. Bectic was 41/56. Berg et al reported the cut-off scores for the aged people wherein a score of 56 indicates the functional balance. The score below 45 shows the person is at a higher risk of falls. The Berg Balance Scale assesses the efficiency of the patient on 14 tasks that are typical in everyday work (Berg et al., 1992). This test takes approximately 15 minutes to finish and is a responsive measure because it can differentiate between patients with a variety of mobility aids. A score of > 45 was deemed predictive of future falls. Muir et al reported that a score of 40 would predict multiple falls, as well as more likely to cause patient harm. Mrs. Bectic Berg Balance Score is 41 so she is in danger or at high risk of falls.
2. What aspects of the physiotherapy intervention listed in the case study are beyond the scope of practice of a PTA and should be carried out by the physiotherapist?
Answer- Being the PTA, I cannot change the plans of any patient even if I feel the need to change. I have to report to the physiotherapist about the progress as well as the shortcomings the patient is going through in achieving the target from the plan of care. In the outpatient setting is the duty of a physiotherapist to make the initial evaluation or the set up the plan of care, at this stage the PTA does not play any role. Like in Mrs. Bectic's case as a PTA I felt like she needs to be trained more for her leg pain. There is more exercise required to strengthen her leg muscles so that she can walk more confidently. Also, her training session can be more focused on cardio activities (Shumway-Cook et al., 1997).
3. What aspects of the physiotherapy intervention could be assigned to you?
Answer- In this whole process of physiotherapy, PTA plays a very important role in the progress of the patient in the rehabilitation centre. PTAs serve as member of a team delivering rehabilitation services under the physical therapist's guidance and supervision. PTAs incorporate various components of patient/client treatments (interventions), collect data about the treatments offered, and make adjustments to selected interventions to either progress the patient/client as instructed by the physical therapist or to improve patient/client health and wellbeing. The areas of engaging in program preparation and implementing the elements of the treatment plan as directed by the physiotherapist where a PTA should be allowed to participate (Physiopedia, 2020). In the multidisciplinary team the basic feedback and ideas from each team member including the PTA, helps in the well-being of the patient. As PTAs are the person who gets directly involved with the patients so they know the patient mental strength as well as physical strength accordingly they can work on the plan of care. PTAs help the physical therapist in treating people of all ages, from newborn babies to the very young, who have medical issues or other health-related disorders that hinder their capacity to travel and conduct functional tasks in their everyday lives. PTA 's function is to provide the allocated patient with clinical treatment as well as provide patient/family assistance and training to address physical, mental, and self-care requirements. The patients can be involved in conducting group activities/exercise programs to maintain the interests of the patients in activities (Cameron & Monroe, 2011).
4. What symptom is being treated with TENS? What type of TENS is being used? How long is the effect expected to last? What kind of electrode placement would you recommend?
Answer-Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological procedure which is widely used in pain relief recovery. Some of the conditions for which TENS have to be used for Mrs. Bectic include osteoarthritis, fibromyalgia, and diabetic neuropathy. Previous research has already shown that TENS can help to minimize pain, analgesic use, and side effects associated with medication (Johnson, 2007). These benefits are of major relevance to medical professionals with the elderly, a significant chunk of the community who often are strongly medicated and prone to side effects from pharmacology. TENS with a pulse duration of 60 µs, a frequency of 150 pulses per second (Hz), and an intensity that will produce a comfortable tingling sensation to be used at home as needed for Mrs. Bectic.
Acupuncture-like TENS involves a high frequency in the range of 90 - 130 Hz or pps which activates the large diameter of non-noxious afferent to elicit segmental analgesia. High frequency and low intensity at the site of pain produce a strong but comfortable sensation. The effect is expected to last for 30 min. Where the pain overlaps within a joint (e.g. elbow pain) the electrode pad must be positioned in horizontal and parallel direction on the muscle or the soft tissue just below and above the joint. If the pain stretches over a large region of the body (e.g. low back from just above the backside of the knee), then either the pads are placed on top of pain vertically and the other pad on the bottom of the pain vertically (Martimbianco et al., 2019). A-beta fiber selective activation is better accomplished using 10–200pps frequencies and 50–200μs durations.
5. What are three recommendations you would give this client to improve her safety at home?
Answer- The Ambulation showed that Mrs. Betic walks independently indoors with a slightly wide base of support. However, she has difficulty negotiating the obstacles safely. She requires close supervision to walk up a ramp and to ascend and descend two flights of stairs with no railing. Since the stairs of Mrs. Bectic house have railings, some need to be repaired. I'm going to ask Mrs. Bectic to get them to fix as soon as possible, because that's a danger to her. She may fall and may sustain some serious injuries. She can also change her arrangements in the house so she can work predominantly on the ground floor and avoid her climbing on stairs. She can also ask her daughter on weekends to take care of her father so she can go out with her friends, which will help her connect with people outside and remain optimistic.
6. Describe one balance exercise that would be appropriate for Mrs. Betic to practice with you, and one balance exercise you feel would be safe for her to practice at home.
Answer- The one balance exercise that would be appropriate for Mrs. Betic to practice with me is Clock reach. A chair will be needed for this exercise. Mrs. Betic will be made to imagine as if she is standing in the center of a clock. The number 12 is just above her and the number 6 is right behind her. She has to hold the chair with her left hand. She will then be asked to lift her right leg and broaden her right arm so that it points to number 12. First, she will be asked to point her arm to number three, and after that to point to number 6 behind her. The arm is taken back to number three, then to number 12. She still has to look straight ahead. This is to be replicated twice per side by her (Eldergym, 2014).
The other simple balance exercise will be given to her to perform at home is back leg raises. This type of strength training exercise for seniors like Mrs. Betic will make her bottom and lower back stronger. She should be asked to stand at the back of a chair. And then slowly, she can lift her right leg straight back without bending her knees. This position can be held for one second, and then gently she can bring her leg back to normal. This can be repeated ten to 15 times per leg (Lifeline, 2019).
7. Describe two strengthening exercises you would give Mrs. Betic including the muscle groups you are working and parameters. Provide a rationale for each exercise you chose.
Answer- The strengthening and muscle-building activities, along with cardio and aerobic exercises helps the seniors to be active and strong (Enright & Sherrill, 1998). Seeing the present condition of Mrs. Betic, I feel that there is a need for both rehab facility and home-based muscle strengthening exercises. She can be trained to increase her muscle strength with mild-to-moderate OA of the knee. The purpose of this exercise is to increase the muscle strengthening of the patients with osteoarthritis (OA) of the knee, and afterward, it will determine whether there are positive outcomes of the exercises on the muscles strength of Mrs. Betic, if any, it could be continued over the long period. The other part of the body which can be worked upon is low back pain which is due to lumbar (segmental) instability. Lumbar instability is one of the subgroups of non-specific low back pain (Tofthagen, Visovsky, & Berry, 2012).
Mrs. Bectic can be monitored for one-week knee extensor and flexor muscle strengthening exercises with a knee extender with 50 percent of the maximum peak torque (MPT) intensity measured at the baseline (20 times x 3 sets per week), together with routine home-based conditioning exercises (setting and straight leg raising) of the extender and flexor muscles (Czamara et al., 2011). The beneficial effects of the exercises on the MPT values of both the knee's extensor and flexor muscles, which started to be identified from 3 to 6 months after the beginning of the exercise regimen, regardless of gender, and age (Vincent, & Vincent, 2012).
8. Describe two safety precautions you would put in place when Mrs. Betic is working with you in the rehab center.
Answer- The two safety precautions that will be taken care of when Mrs. Betic is working in the rehab center is the use of the resistance bands and using the weight of the body for resistance (sit-ups, and push-ups).
9. Why do you think the physiotherapist decided to include cardiovascular (aerobic) exercise with this client? Use the FITT principle to describe an appropriate cardiovascular exercise prescription for this client.
Answer- Aerobic exercise decreases the likelihood of various conditions including obesity, metabolic syndrome, heart disease, type 2 diabetes, high blood pressure, stroke, and other cancers (Sigal et al., 2006) . Weight-bearing aerobic activities like walking aid in raising the risk of osteoporosis. Low-intensity exercises increase your heart and breathing rate only slightly, and are ideal for elderly people with a variety of health conditions which render exertion especially difficult or dangerous. Walking is the most common low-intensity aerobic exercise (Physiopedia, 2020). Walking at a slow pace during standard activities, like shopping, counts towards your goal every week. We can think of increasing the speed or duration of your walks if your health and stamina improve. Recreational swimming is also another cardio exercise of low intensity which reduces the joint strain. This can be done in a local facility such as a recreation center, we can also try low-impact water aerobics classes for Mrs. Betic. The FITT principle for Recreational swimming is as follows:
Frequency- For sedentary individuals like Mrs. Betic, we can start with 2-3 days/week of recreational swimming and build up to 5 days/week.
Intensity- Mrs. Betic should start at a low intensity as she will be new to the exercise, but later on the exercise intensity can be made moderate if her strength supports.
Type- It will be enjoyable, affordable, and achievable for her.
Time- 15 mins of swimming exercise can be accumulated throughout the day. This does not include the warm-up or cool down.
10. Mrs. Betic has decided she would like to buy a piece of cardiovascular equipment to use at home. What would you recommend? Why? Research affordable options for your client, and indicate the price of the equipment and a website or other contact information Mrs. Betic could use to purchase the equipment.
Answer- I would recommend a treadmill for Mrs. Betic which can be used at home. The treadmills are standard in most gyms and are great for walking or jogging and proved to be good for cardiovascular activities. They are not space consuming so they can be kept at home as well. They are ideal for seniors who may not have a safe route to walk nearby as well as those who just hate the gym or rehab centers. Some newer models can show health stats like heartbeat and calories burned during the walk on it. Mrs. Betic can be recommended to do 30 minutes of cardiovascular exercise per day, and for 5 days in a week on a treadmill. The Nordic Track C 990 Treadmill is a perfect treadmill which is available on online Amazon. It has high-technology features and gives a great run experience which makes it a good buy for less than $1,000. The Nordic Track C 990 Treadmill has a good motor, and decent-sized running belt. It has also got treadmill cushioning for comfort and reducing the chance of injury for the users. It's especially important for seniors because it helps compensate for the loss of our natural joint cushioning: cartilage.
11. Aside from the physiotherapist, the PTA and the physician, identify two other members of the health care team who could help Mrs. Betic, and describe what you feel their roles would be.
Answer- The rehabilitation staff is composed primarily of specialists, specially trained to provide rehabilitation services, but several other health workers, including non-health staff, also meet the needs of the population for physical rehabilitation. Examples include physicians, nurses, community health staff, athletic trainers, and even special educators. When addressing the needs of the client, all of these group members need to be considered within their specific competencies and practices (Physiopedia, 2020).
One person other than the physiotherapist, the PTA, and the physician, could be the certified athletic trainer. Occupational ATCs (certified athletic trainer) work alongside and share the same goals as other occupational health professionals. These objectives are prevention of injury through ergonomics, physical preparedness, health and fitness, and education. Occupational ATCs are involved in work-related injury evaluation and treatment, injury prevention, on-site rehabilitation programs, care coordination, and return-to-work programs. ATCs function under the supervision or, in some cases, through a doctor's prescription. ATCs will include on-site rehabilitation and worksite research with cost-effective outcomes. For these settings, ATCs will be combined with the recovery nurses, mental health nurses, and physical therapists. A community health worker (CHW) could be the second member of the group who can help Mrs. Betic with the purpose of providing basic health and medical services. The CHW can offer prevention, motivational, and recovery service to those members of the community.
12. Identify one community resource (outside of the health care system) that you feel could help Mrs. Betic improve her physical and/or psychosocial well-being. Provide a rationale for your answer and relevant contact information (i.e. website, phone number address).
Answer- The Local Senior Center helps seniors like Mrs. Bectic to handle all senior-related things, and it's a great starting point. Senior centers, along with the fellows, also offer a range of drop-in events for seniors to participate as well as group trips. Moreover, senior centers can frequently offer recommendations for vetted services ranging from housekeeping and handy work to home-based therapy. Website-https://www.mandurah.wa.gov.au/facilities/seniors-and-community-centre/activities-and-events
Phone number-(08) 9550 3799
Address- 41 Ormsby Terrace, Mandurah WA 6210
Another place could be the park district. Park district offers seminars on subjects ranging from medicare paperwork to immunization services, in addition to offering senior-specific programs, socialization opportunities, and events. Park Districts also often hold health fairs for seniors and their families in conjunction with community centers, where one can meet senior living and senior care practitioners. Website- https://www.mandurah.wa.gov.au/facilities/parks-and-reserves
Phone number-(08) 9550 3601
Address- 3 Peel St, Mandurah WA 6210.
Today when Mrs. Betic arrives she tells you that the pain in her feet is 4/10. She reports that she has been practicing the exercises you taught her every day at home. Her HR at rest is 80, strong and regular, and on the treadmill at peak intensity is 100, strong and regular. Her HR returns to 82 bpm with a 5-minute rest. You retest the Timed up and Go and her score is 14 seconds. You notice that her gait pattern has improved with a narrower base of support. Mrs. Betic walks for 10 minutes on the treadmill at 2.5 mph. After her session on the treadmill, you practice stairs with her and notice she still requires close supervision to ascend and descend 2 flights with no railing. You have no concerns and you plan to continue with treatment as assigned by the physiotherapist.
Document this session using SOAP format.
Answer- S: The patient reports that the pain in her feet is 4/10.
O: During the sessions of treadmill walk at peak intensity, her heart rate is 100, strong and regular and at rest it is measured to be 80, strong and regular. Once the patient took a rest of 5 minutes, her heart rate returns to 82 bpm. She was retested the Timed up and Go and her score is 14 seconds. Her gait pattern has improved with a narrower base of support was also noticed. Mrs. Betic walks for 10 minutes on the treadmill at 2.5 mph.
A: After her session on the treadmill, she was asked to practice stairs. And it was observed that still requires close supervision to ascend and descend 2 flights with no railing.
P: I have decided to continue current exercise plan.
14. Mrs. Betic tells you she never uses her rollator walker outside because it makes her feel old, and she feels she doesn't need it anyway. She says "That's just between you and me. Don't tell the physiotherapist. I don't want her to worry." What would you do in this situation? Describe what you would say to Mrs. Betic.
Answer- I will explain to Mrs. Betic and make her understand the fact that with the walker there will be an increase in independence. I will educate her on the advantages of using the walker as there will be no difficulty in getting up from the couch and walks to the kitchen or elsewhere in the house, as a walker or cane will give her balance and support. I will give her the authority to choose but at the same time, I will ask the physical therapist opinion or guidance on her case. I will also try to make her comfortable by showing the other clients who using it and the progress they have made so that she gets motivated to use it.
15. Several weeks have passed and Mrs. Betic is making good progress towards her treatment goals. Unfortunately, her husband had heart attack which affects both his physical and cognitive function. Mrs. Betic can not longer come to the rehabilitation center for treatment. The physiotherapist arranges for home care to continue treatment with her. Describe two potential advantages and two potential disadvantages of this change in treatment setting.
Answer- The therapy session at home has two major therapy advantages those are a great effect of the environment on actions and setting targets at home. Also, Mrs. Betic is aged she will be comfortable at home as it will reduce her travel to rehab and she can take care of her husband by staying at home. Assessment is the foundation of a physiotherapy appointment, and the basis for patient treatment. However, during a physiotherapy at home appointment, a professional can assess the home settings which can be avoided by the client to reduce the exertion. The defined drawbacks are the lack of infrastructure and floor space, and the home setting sometimes gives a demotivating impact to the session. One more disadvantage at home is the difficulty of determining control inside a therapy session.
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