Case Study: Older Adult Age-Related Decline in Ability, Reduced Mobility, Falls Risk
A Physiotherapy and Rehabilitation Treatment Plan to Return Home and Stay Home
Client: J.P. Senior 96 years, now 97
Date of Admission to High Care Senior Facility: April 25, 2023
Admissions Diagnoses:
Right Hip Fracture and Total Hip Replacement after a Bad Fall, unable to Return Home
History Bladder/Prostate Cancer
Chronic Kidney Disease
Mild Cognitive Impairment
Hypertension
Osteoporosis
PRESENTATION BEFORE REHABILITATION
- Weakness, deconditioned due to injury and hospital stay
- Weight loss, muscle wasting, reduced overall strength
- Reduced range of motion and weakness in right hip joint, pain reported
- Tight hamstrings and calves
- Independent bed mobility – supervision only
- Transfers, standing minor verbal/physical assistance with 1 person
- Ambulation 2 wheeled walker 1 person assist
- Sitting balance: Static: good, Dynamic: poor
- Standing balance: Static: fair, Dynamic: poor
- Posture: right hip externally rotated, bilateral hips anteriorly and pelvis posteriorly tilted, knees flexed, head forward, mild thoracic spine kyphosis
J.P’s Rehabilitation Goal: Gain strength/balance to return home by the end of August 2023
REHABILITATION PROGRAM:
2x/wk 45 minute sessions with Physio Rehabilitation Assistant 4 months (April to August 2023) in facility
2x/wk 30 minute sessions In-Home Rehab ongoing support for maintenance (September 2023 to present (9 months and counting)
POSTURE AND ALIGNMENT:
- Range of motion for right hip using Total Hip Replacement guidelines
- Hams, calves and abdominal stretches in supine position
- Range of motion exercises for neck and shoulders to pull head in line with pelvis
- Reaching arms up the wall stretch with pelvic tilts
- Knee extension exercises in seated position
- Deep breathing with chest openers – rib cage expansion
BALANCE:
- Dynamic Standing Balance exercise holding onto a bar or counter
- Hip abduction/adduction
- Hip extension
- March in place
- Heel raises
- Squats
- Side-to-side stepping
- One-legged stance holds
- Lunges forwards, backwards and to the sides returning to centre with good posture
- Backwards, lateral and tandem walking
- 360 turns right and left
STRENGTHENING:
- Range of motion exercises for upper and lower body using 1lb weights, progressing to 2-3lbs. Increased from manually resisted exercises
- Increasing strength in gluteus maximus and minimus for stable walking
- Ambulation in hallways with 4 wheeled walker and cane
- Ambulation without walking aide and stand-by assist from RA to rebuild endurance, confidence and balance.
- Ambulation indoors progressing from 70 metres to 420 metres.
- Ambulation progressing to outside for 15 minutes with 4 wheeled walker
COGNITIVE/SOCIAL/EMOTIONAL:
- Challenging memory while ambulating
- Building confidence to enjoy walks with friends and family
- Positive reinforcement for realized goals
- Setting new goals day to day
REHABILITATION OUTCOME:
- Increased overall strength
- Weight gain (increased muscle mass)
- Independent dressing, tying shoes, increased grip strength
- Good sitting, standing and dynamic balance
- Improved balance for independent ambulation
- Improved posture: flexion at knees and external rotation of hips reduced, straightened thoracic spine with head over pelvis correction, head forward posture reduced
- Patient is able to self-correct posture with verbal cues
- Reduced pain in neck and back with massage and stretching
- Increased endurance and cardiovascular health
- Improved short term memory leading to greater independence
- Positive and more motivated outlook
- Renewed feeling of having some control over own life
- Able to return home to live in apartment independently
Timeline for Recovery, return home and on-going support from Physio for Seniors:
April/23 – bed exs., seated and standing balance exs., ambulation, massage and stretching
May/23 – same as above, increasing sets and repetitions, distance and duration
- adding standing lunges, bridging in supine, focus on correcting alignment of right hip
- Able to walk outside using 4 wheeled walker
June/23 – increase dynamic standing balance challenges: zig zag walking around obstacles, 360 turns, walking without aid to increase confidence, stepping up and down low rise step, stepping over bean bags
- More upright posture observed, hip less externally rotated, wider base of support/space between feet established for better balance (feet parallel instead of heels together
July/23 – Patient begins to feel more confident and thinks he will reach his goal to go home, but hip pain persists. Hip extension is still limited and Patient leans slightly to the right side
- RA increases focus on hip mobility and alignment through massage and stretching
August 1/23 – Patient goes home for a couple of days to see how he manages
- Patient is happy he was able to handle a few days at home alone – friends and family visit but Patient feels he needs more time to gain more strength and balance
- Rehab continues with practice going up and down ramps and a few stairs up/down
- Increasing outdoor walking with 4 wheeled walker
- Outdoor walking with cane (Patient does not feel confident, walker preferred)
- Patient sees doctor about pain management for right hip
- Timed Up and Go Test (TUG) is 11.29 seconds which is good. < 20 needed to be considered independent
- Occupational Therapist visits home with Patient to assess his functional ability in living space
Goal to return home by the end of August is reached.
Sept/23 to the present – In-home visits with Rehabilitation Assistant begin at 2x/wk for 30 minutes
Due to the Patient’s age, regular visits are highly recommended to maintain strength, flexibility and safe mobility. Stretching for leg muscles and spine, massage for the same as well as dynamic standing balance exercise continues. J.P. agrees that these visits are helping him to remain at home and be as independent as possible. Regular home visits allow us to check in on the Patient’s overall well-being and assess how he is coping with independent living. The Patient’s condition improves and declines from week to week, but he continues to enjoy outdoor walks with his friends and family and appreciates being able to remain in his home for as long as it is possible.