1 Clinical Therapy GuidePo… · · 2017-08-21• All required actions and performance skills present MOTOR SKILL DEFICITS • Weakness ... Personal factors contributing to patient’s

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Clinical

Therapy Guide

Not for external distribution - Reference tool only

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NURSING PROCESS

Risk Factors for Geriatric Syndromes 1

TESTS AND MEASURES

Short Physical Performance BatteryGait Speed5X Sit to StandBerg Balance ScaleDGIUnilateral Stance (Eyes Open)360° TurnFunctional ReachBarthel IndexTUG Mean Arterial Pressure

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OBSERVATIONAL ANALYSIS

Sit-to-Stand AnalysisStand-to-Sit AnalysisStanding Postural Control AnalysisGait AnalysisComplex Gait AnalysisActivity Analysis

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TABLE OF CONTENTS

OT/PT ASSESSMENT

OT Assessment – Medical Necessity andHomebound StatusOT Assessment – Impairments and PrognosisOT Assessment – Activity Limitations and Contextual Factors PT Assessment – Medical Necessity andHomebound StatusPT Assessment – Impairments and PrognosisPT Assessment – Activity Limitations and Contextual FactorsImprovements in Task PerformanceOngoing Deficits in Task Performance

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OT/PT INTERVENTION

Older Adult Strength Training RecommendationsGait TrainingCue TrainingmCIMTTraining Amplitude in Voice and MovementTraining Posture Vertical (A/P) Changes Related to Foot OrthosesOT Treatment IdeasPT Treatment IdeasGo-to TasksOther Treatment Ideas

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SLP SPECIFIC

SLP Assessment – Impairments and PrognosisSLP Assessment – Activity Limitations and Contextual FactorsMotor with SwallowBolus ModificationSLP Language and Cognition Treatment IdeasSLP Swallow and Voice Treatment Ideas

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TABLE OF CONTENTS

Collaborative Construct TeamLisa Archibong, Project ManagerJennifer Ellis, PT, DPT, MSLaurie Otis, PT, MBA, MHAPatty Scheets, PT, DPT, NCSChris Stadler, Manager of Education

Thank you to each Subject MatterExpert for invaluable contributions

SELECTED REFERENCES

A – FF – MM – W

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CARDIOVASCULAR SCREENING AND GUIDELINES

Vital Sign Response GuidelinesDyspnea ScaleBorg Rating of Perceived Exertion (RPE)

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RISK FACTORS FOR GERIATRIC SYNDROMES FALLS FX DECLINE INCONTINENCE DELIRIUM DIZZINESS

• Older age• Two or more

falls in one year• Decreased

strength, balance, ambulation

• Psychotropic meds

• >4 total meds• Impaired depth

perception• Orthostasis• Foot problems• Depression

• Older age• H/o falls• Functional

impairment• Cognitive

impairment • Hospitalization• Stroke or MI• Depression• Vision

impairment• DM• Limited mobility

• Older age• High BMI• Constipation• UTI/urinary

retention• Antihistamines• Narcotic

analgesics• Diuretics• Impaired

mobility• Environmental

hazards• Cognitive

impairment• Restrictive

clothing

• Older age• Cognitive

impairment• Psychotropic

meds• Severe illness• Dehydration• Functional

impairment• Alcohol abuse• Infection• Metabolic

derangement• Sleep

deprivation• Visual

impairment• Hearing

impairment

• Depression• Cataracts• Impaired

balance or ambulation

• Orthostasis (20% decrease in MAP)

• DM• H/o MI• Three or

more meds

SYNDROME IDENTIFICATION

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SHORT PHYSICAL PERFORMANCE BATTERYCLASSIFICATION

MCID = 1 – 2 points≤ 10 = increased risk of mobility disability

0 – 3 Severe limitations 7 – 9 Mild limitations

4 – 6 Moderate limitations 10 – 12 Minimal limitations

GAIT SPEED

Gait Speed Normal 3.3 ft/s (range 2.5 – 3.3)

Risk for Fx Decline 2.3 – 3.3 ft/s

Risk for Hospitalization <2 ft/s

Categories Household <1.3 ft/s

Limited Community 1.3 – 2.6 ft/s

Full Community >2.6 ft/s

MCID Older Adults 0.33 ft/s

Stroke 0.48 ft/s (acute); 0.45 – 0.75 ft/s (sub-acute)

PD 0.57 ft/s

TESTS AND MEASURES

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5X SIT TO STANDAGE NORMS

Normal = 10 sFall risk = >14 – 15 sMCID for vestibular patients = 2.3 s

60 – 69 yr = ≤ 11.4 s70 – 79 yr = ≤ 12.6 s80 – 89 yr = ≤ 14.8 s

BERG BALANCE SCALE

MCID = 3.3 – 5.9 points in elderly patients7 – 8 points in stroke patients5 points in Parkinson’s patients

DGI

Fall risk = ≤ 19 MCID = 3 – 9 points (higher with lower baseline score)

UNILATERAL STANCE (EYES OPEN)AGE NORMS

60 – 69 yr = 27.0 s70 – 79 yr = 17.2 s80 – 89 yr = 8.5 s

360° TURN

Normal = Full circle without loss of balance in <3.8 s

TESTS AND MEASURES

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FUNCTIONAL REACHAGE NORMS

≤ 6 inches = limited balance10+ inches = adequate balanceUnwilling = fall risk 8x >normal<6” = fall risk 4x >normal6 – 10” = fall risk 2x >normal≥ 10” = low fall risk

41 – 69 yr: 15” men; 14” women70 – 87 yr: 13” men; 10.5” women

BARTHEL INDEX

MCID = 1.85 0 – 40 = associated with placement in long-term care or death> 6 0 = likely to be in homes and community, have more social

interaction and higher life satisfaction

TUG AGE NORMS

>14 s = high fall risk>30 s = predicts need for amb device

and assist with ADLs

60 – 69 yr = 8.1 s70 – 79 yr = 9.2 s80 – 89 yr = 11.3 s

MEAN ARTERIAL PRESSURE

MAP = 2(DP) + SP 3

20% drop in MAP indicates orthostatic hypotension

TESTS AND MEASURES

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SIT-TO-STAND ANALYSISOVERALL INITIATION EXECUTION TERMINATION

• Unable to assume normal starting posi-tion; stiffness

• Absent preparatory movements

• Unable to modify movement strategy with cues/practice

• Increased base of support

• Insufficient force production

• Decreased weight bearing• Shifts center of mass to

one side• Shifts COM to one side or

back; resists correction• Medial hip rotation/hip

adduction• Extends knees before hips

in first half• Insufficient anterior transla-

tion of tibia over foot• Pushes on thighs to extend

trunk• Valgus of knee• Varus of knee• Excessive pronation of foot• Supination of foot

• Posterior sway• Steps• Shifts COM to

one side• Shifts COM to one

side or back; resists correction

• Increased lumbar extension

• Inadequate hip extension

• Inadequate knee extension

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STAND-TO-SIT ANALYSIS

• Insufficient knee flexion on initiation and during execution

• Insufficient hip flexion during execution

• Inadequate control of descent into chair• Unable to modify movement

strategy with cues/practice

STANDING POSTURAL CONTROL ANALYSIS

• Structural alignment faults (scoliosis, kyphosis, etc.)

• Prefers wide base of support• Increased sway• Increased sway with eyes closed• Aversion to eyes closed condition• UE guarding or reaching• COM shifted left, right, or back • Shifts COM away from midline; resists correction • Hesitation when changing BOS or initiating

movement

• Multiple starts when changing BOS or initiating movement

• Insufficient hip/knee extension during WB• Insufficient hip flexion on swing limb for stair

touching • Loss of balance; steps to recover• Loss of balance; needs to be caught to prevent

a fall• Unable to modify movement strategy with

cues/practice


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GAIT ANALYSISOVERALL STANCE SWING

• Unable to modify movement strategy with cues/practice

• Poor pathfinding• Difficulty maintaining

precautions• Variable line of progression• Line of progression deviates to

left or right side

• Decreased base of support• Increased base of support• Decreased weight bearing• Lateral trunk flexion over limb• Decreased hip extension from

mid-stance to terminal stance• Hip drop• Hyperextension of knee• Sustained hip/knee flexion• Decreased plantarflexion • Increased pronation• Excessive supination

• Hip hiking• Circumduction• Vaulting• Inadequate hip flexion• Inadequate dorsiflexion• Decreased step length• Increased step length• Variable foot placement• Freezing


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COMPLEX GAIT ANALYSIS

• Deviation in line of progression with head turning• Hesitates or takes extra steps when changing

direction• Poor control of posterior momentum when stepping

backward• Hesitates before stepping over obstacles• Poor adjustment in step length to step

over obstacles

• Difficulty clearing second limb when stepping over obstacles

• Insufficient hip/knee extension when stepping over obstacles

• Guarded movement/fear avoidance behavior• Unable to modify movement strategy with

cues/practice


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ACTIVITY ANALYSIS

• All required actions and performance skills present

MOTOR SKILL DEFICITS

• Weakness• Abnormal movement synergy• Delayed initiation• Bradykinesia• Hypermetria• Tremor

• Stiffness• Poor balance• Apraxia• Impaired fine motor• Requires frequent rests

SENSORY – PERCEPTUAL SKILL DEFICITS

• Impaired body positioning for task• Impaired visual identification of objects/

environment

• Impaired tactile location of objects/environment• Impaired spatial orientation of objects

COGNITIVE SKILL DEFICITS

• Attention to task limited to ____________________• Impaired selection of objects appropriate for task• Impaired sequencing of task components• Impaired organization of task components given

allotted time• Seeks excessive assistance• Seeks insufficient assistance

• Task perseveration• Impaired prioritization of attention, increasing

risk of adverse events• Impaired adaptability to changing task or

environmental demands• Diminished performance with a secondary

cognitive task


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COMMUNICATION AND SOCIAL SKILL DEFICITS

• Delayed response• Impaired use of gestures

• Lack of response to visual cues

EMOTIONAL REGULATION SKILL DEFICITS

• Lack of persistence with task completion• Frustration with efforts

• Anxious• Anger with efforts


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OT ASSESSMENT – MEDICAL NECESSITY AND HOMEBOUND STATUSPatient requires skilled intervention due to new deficits related to recent events including:

• Hospitalization and related functional decline• Recent or progressive decline in mobility• Increased dependence on caregiver for ADLs

and mobility• Recent c/o dizziness, unsteadiness, and/or pain• Fall

• Change in mental status• S/p fracture • Exacerbation of chronic condition

affecting function• New problem in health condition

Patient requires care in the home because:

• Unable to transfer without assistance• Unable to walk community distances• Unable to negotiate stairs without assistance• Symptoms at rest _________________• Symptoms when away from home• Requires rest every ________ minutes• Excessive fatigue when away from home

• Unable to toilet self in community• Pain with extended sitting, standing or walking• Unable to maintain attention with distractions • Unable to problem solve in community situations• Unable to manage behaviors in

community situations

OT/PT ASSESSMENT

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OT ASSESSMENT – IMPAIRMENTS AND PROGNOSISPatient's primary impairments identified on clinical examination which contribute to decline in function:

SENSORY-PERCEPTUAL

• Impaired spatial/object organization• Perceptual deficits• Visual field loss• Other visual deficits• Disregard/neglect• Impaired tactile sensation

• Impaired two-point discrimination or proprioception• Pain• Impaired sensory selection, weighting, and

integration needed for balance• Decreased balance confidence

MOTOR

• Joint pain/stiffness• Impaired postural reactions• Weakness/muscle fatigue• Delayed postural responses• Hypertonicity/non-fractionated movement/

impaired tone

• Slowness of movement• Dyskinesia/dystonia• Hypermetria• Apraxia• Slow/imprecise object manipulation

FUNCTIONAL CAPACITY

• Impaired activity tolerance • Impaired respiratory capacity

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OT/PT ASSESSMENT

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OT ASSESSMENT – IMPAIRMENTS AND PROGNOSISCOGNITIVE

• Impaired sequencing • Impaired organization• Impaired judgment/safety• Impaired problem solving/adaptability

• Impaired attention to task• Instability with secondary tasks• Impaired memory• Delayed initiation

EMOTIONAL/BEHAVIORAL

• Lack of response to cues• Lack of interest/depression• Anxiety

• Anger• Frustration

Prognosis for improvement in impairments that contribute to decline in function:

• Good (75 – 100% improvement) • Fair (30 – 75% improvement) • Poor (0 – 30% improvement)

OT ASSESSMENT – ACTIVITY LIMITATIONS AND CONTEXTUAL FACTORSPatient’s impairments are believed to contribute to the following activity limitations and participation restrictions:

• Inability to perform tasks with sufficient consistency, flexibility, and/or efficiency

• Decreased independence with ADLs• Decreased independence with IADLs• Inability to tolerate continuous activity

• Inability to manipulate objects• Impaired safety awareness• Inability to plan for future events• Inability to manage medications

OT/PT ASSESSMENT

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Personal factors contributing to patient’s expected outcome (indicate facilitators and barriers):

• Understanding of condition• Acceptance of condition• Mood• Motivation to participate• Safety consciousness/judgment• Problem solving/adaptability• Attention to task

• Insight• Appropriateness of behaviors• Memory• Capacity to learn new information• Fluctuating health condition• Health-related habits

Environmental factors contributing to patient’s expected outcome (indicate facilitators and barriers):

• Accessibility in home• Access to community• Access to services• Appropriateness of living situation relative to

patient’s needs • Willingness of family/friends to provide assistance• Availability of family/friends to provide assistance

• Ability of family/friends to provide assistance• Support from family/friends• Support from personal care assistant• Attitudes of family• Attitudes of friends• Financial resources

Prognosis for improvement in activity limitations and participation restrictions using old or new strategies:


OT/PT ASSESSMENT

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PT ASSESSMENT – MEDICAL NECESSITY AND HOMEBOUND STATUSPatient requires skilled intervention due to new deficits related to recent events including:

• Hospitalization and related functional decline• Recent or progressive decline in mobility• Increased dependence on caregiver for ADLs

and mobility• Fall• Recent c/o dizziness, unsteadiness, and/or pain

• Change in mental status• S/p fracture • Exacerbation of chronic condition affecting

function• New problem in health condition

Patient requires care in the home because:

• Unable to transfer without assistance• Unable to walk community distances• Unable to negotiate stairs without assistance• Symptoms at rest _________________• Symptoms when away from home• Requires rest every ________ minutes• Excessive fatigue when away from home

• Unable to toilet self in community• Pain with extended sitting, standing, or walking• Unable to maintain attention with distractions • Unable to problem solve in community situations• Unable to manage behaviors in community

situations

OT/PT ASSESSMENT

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PT ASSESSMENT – IMPAIRMENTS AND PROGNOSISPatient’s primary movement system impairments identified on clinical examination which contribute to decline in function:

MUSCULOSKELETAL

• Skeletal muscle weakness/fatigue• Structural alignment faults• Joint pain/stiffness

• Neuropathic pain• Other pain

NEUROMUSCULAR

• Impaired postural responses and reactions• Impaired sensory selection, weighting, and

integration needed for balance• Decreased sensation• Impaired vertical orientation• Impaired vertical orientation with resistance

to correction• Decreased balance confidence/fear avoidance

strategies

• Dizziness• Hypertonicity/non-fractionated movement• Hypokinesia/Bradykinesia• Dyskinesia/dystonia• Hypermetria• Impaired motor planning• Instability with secondary tasks


OT/PT ASSESSMENT

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PT ASSESSMENT – IMPAIRMENTS AND PROGNOSISCARDIOPULMONARY

• Poor gas exchange at rest or with activity per O2 SAT monitoring

• Labored breathing at rest or with activity• Irregular heart rhythm with activity

• Cardiovascular inefficiency with extended recovery period after activity

• Pulmonary inefficiency with extended recovery period after activity

• Abnormal vital sign response with activity



PT ASSESSMENT – ACTIVITY LIMITATIONS AND CONTEXTUAL FACTORSPatient's impairments are believed to contribute to the following activity limitations/participation restrictions:

• Inability to perform tasks with sufficient consistency, flexibility and/or efficiency

• Decreased independence with mobility• Inability to tolerate continuous activity• Instability in sitting• Instability in standing

• Instability with walking• Impaired safety awareness• Pain during functional activity or at rest• Risk for falls• Risk for functional decline

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OT/PT ASSESSMENT

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Personal factors contributing to patient's expected outcome (indicate facilitators and barriers):

• Understanding of condition• Acceptance of condition• Mood• Motivation to participate• Safety consciousness/judgment• Problem solving/adaptability• Attention to task

• Insight• Appropriateness of behaviors• Memory• Capacity to learn new information• Fluctuating health condition• Health-related habits


• Accessibility in home• Access to community• Access to services• Appropriateness of living situation relative to

patient’s needs• Willingness of family/friends to provide

assistance• Availability of family/friends to provide

assistance




OT/PT ASSESSMENT

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IMPROVEMENTS IN TASK PERFORMANCECONSISTENCY because

• Larger/faster associated postural adjustments• Larger/faster corrective postural responses• Larger/faster protective postural responses• Patient is getting stronger

• Maintaining attention to primary task• Allowing more time for movement preparation

and planning• Able to report intrinsic feedback

FLEXIBILITY because

• Rapid access to best movement strategy• Able to change strategy relative to situational

demands

• Able to shift attention from one aspect of task performance to another

• Able to maintain primary task performance during performance of a secondary task

EFFICIENCY because

• Improved vital sign response during activity• Decreased energy expenditure associated with

fear or instability

• Decreased co-contraction in order to complete task or activity

• Improved speed of movement

OT/PT ASSESSMENT

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ONGOING DEFICITS IN TASK PERFORMANCECONSISTENCY because

• Fluctuating medical condition limits opportunity for repeated practice

• Lack of intrinsic feedback to guide movement performance

• Performance within a session improving but needs more practice for learning

• Deficits in movement timing which are changing but still insufficient for all tasks

• Deficits in movement timing which are not changing with practice

• Deficits in movement amplitude which are changing but still insufficient for all tasks

• Deficits in movement amplitude which are not changing

• Weakness which is improving but will require ongoing resistance training

• Weakness which is not changing• Deficits in placement of attentional resources• Agitation which limits opportunity for repeated

practice

FLEXIBILITY because

• Fluctuating medical condition limits opportunity for repeated practice

• Lack of intrinsic feedback to guide movement performance

• Inability to develop effective strategy without extrinsic feedback

• Fear or anxiety with new activities• Agitation which limits opportunity for practice

EFFICIENCY because

• Fluctuating medical condition limits opportunity for extended practice

• Primary medical condition limits opportunity for extended practice

• Poor prognosis for improvement in impairments

OT/PT ASSESSMENT

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OLDER ADULT STRENGTH TRAINING RECOMMENDATIONS

Stroke: likely to progress from 60 to 80% 1 – RM more slowly; 3 sessions/week; 12 weeksPD: generally follow guidelines for older adultsMS: 60% 1 – RM; 1 – 3 sets initially, then 3 – 4; 2 – 3 days/week; 10 – 12 weeks

• 60% 1 – RM• 15 reps @ RPE

of 12 – 13 (Borg)

• 80% 1 – RM• 10 reps @ RPE

of 15 – 17 (Borg)

• 1 – 3 sets• 2 – 3 days/week• 6 – 8 weeks

Minimal Intensity

Sets/RepsTarget Intensity

OT/PT INTERVENTION

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GAIT TRAININGCONTINUOUS STEPPING SPEED TRAINING

• Gait is a continuous task• More steps are better

• 10 sec bouts as fast as possible• Recover• Repeat• Increase baseline speed

CUE TRAINING

For speed • Visual cue: lines 20 – 24 inches apart; “Step on (or over) the lines.”• Auditory cue: 10% above baseline; “Match your movements to the beat.”

For amplitude • Visual cue: lines 20 – 24 inches apart• Auditory cue: 10% below baseline (especially for patients who freeze)

For freezing and turning

• Visual cue: lines 18 – 22 inches apart where likely to freeze; “Use the cue to remind you to take a bigger step to prevent freezing.”

• Auditory cue: baseline or 10% below; “Use the cue to maintain stepping movements.”• Stepping through strategy: keep stepping through the tricky spots, all directions• Approach doorway by aiming for the wall to the side of the door handle to allow

room for door to open

For dyskinesia • Visual cue: lines 20 – 24 inches apart; lines indicating step width for lateral deviations• Auditory cue: 10% above baseline

OT/PT INTERVENTION

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mCIMT

• Constrain unaffected arm five hours/day, five days/week; two weeks

• Structured therapy; 1/2 hour sessions; three times/week

TRAINING AMPLITUDE IN VOICE AND MOVEMENT

High Effort “On a scale of 1 – 10, with 10 being a lot and 1 nothing at all, how much effort was that? Try to get as high on the effort scale as you can each time.”

Sensory Calibration

“How do your limbs feel? Do you hear how loud you can be? What you are feeling produces sound (or movement) that is normal. Repeat that feeling each time.”

Shape Quality Manual and verbal cues to improve quality of movement and sound each time. “Do what I do.”

Homework Incorporate therapy activities into functional activity. Do every day.

OT/PT INTERVENTION

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TRAINING POSTURE VERTICAL (A/P)

Standing with the back against the wall

• Heels against wall; relax in position; use assistive device if needed• Increase amount of time standing without resisting• Produce active sway forward so that COM moves toward forward limits of stability• Practice walking and/or sit to stand after • Progress to wedge training with ankles in DF

Sit to Stand • Without UE support if possible, raise the surface height to accommodate for weakness during initiation

• If must use UE, do so only during initiation; then have the patient let go; push and let go• Provide a manual block to posterior translation of the tibia during execution• Provide assistance with anterior translation of the tibia relative to the foot • Provide encouragement and support related to fear of falling

Stand to Sit • Initiate by flexing the knees, keeping the COM over the BOS during the first half of execution

• Avoid teaching to initiate sitting down by reaching back for the chair • Avoid teaching to step back until the back of the knees touch the chair before sitting down• Use UE to compensate for weakness during the last half of execution

Ambulation with continuous stepping

• Emphasis on forward progression

Backward stepping

• Keep COM over BOS; don’t let COM get behind BOS

OT/PT INTERVENTION

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CHANGES RELATED TO FOOT ORTHOSES TYPE OF SUPPORT EFFECT ON FOOT EFFECT ON ANKLE EFFECT ON KNEE

Medial Rearfoot eversion Calcaneal eversion Inversion moment

Eversion Tibial medial rotation moment

Valgus angle

Lateral Plantar strain Subtalar valgus Supination

Lateral instability Varus moment

Posterior Soft tissue strain DF excursion Flexion

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OT/PT INTERVENTION

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OT TREATMENT IDEAS• Remediation or compensation?• Is treatment harder than self-selected (intensity)? • What is the dosage of each treatment?

Self-Care Training • In standing • Speed training

Cognitive Training • Task complexity • Sequencing

Balance Training • Foam• Surface transitions• Trunk displacement• Secondary manual or cognitive task

• Head rotation and tilt• Eye exercises• VOR and VOR cancellation

UE Task Training • Containers and lids• Reach overhead and at ground level• Object manipulation• Unilateral and bilateral item transport

• Alternating item transport• mCIMT• Auditory cueing

Risk Factor Reduction • Improve lighting• Add visual contrast• Reduce visual stimulation and

distraction

• Organization

OT/PT INTERVENTION

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PT TREATMENT IDEAS• Remediation or compensation?• Is treatment harder than self-selected (intensity)? • What is the dosage of each treatment?

Task Specific-training • Go-to tasks

Sit to/from Standing w/o UE Support

• Variable practice

Floor to/from Standing • With/without external support

UE Task Training • Reach, grasp, release • mCIMT

Stair Training • With/without railing• Step-to

• Step-through

Gait and Balance Training

• With/without device• Variable surface and surface

transitions• Foam, foam, foam, foam• Narrow BOS• Incline and verticality training• Secondary manual or cognitive task• Speed training – 10 sec bouts;

baseline speed

• Amplitude training• Cue training• Step up, over, and around• Backward stepping• Continuous stepping• Head turning and tilts• VOR and eye exercises

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OT/PT INTERVENTION

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GO-TO TASKS OTHER TREATMENT IDEAS

OT/PT INTERVENTION

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SLP ASSESSMENT – IMPAIRMENTS AND PROGNOSIS Patient’s primary impairments identified on clinical examination which contribute to decline in function:

SENSORIMOTORSPEECH/LANGUAGE PRODUCTION DYSPHAGIA COGNITION

• Structural anomalies• Decreased ROM• Muscle weakness/

fatigue• Impaired coordination• Impaired sensation• Neglect• Delayed response

time or reflexes• Decreased respiratory

support

• Aphasia– Broca’s– Global– Wernicke’s– Anomic– Conduction– Transcortical motor/

sensory/mixed• Oral apraxia• Spastic/flaccid/ataxic

dysarthria • Velopharyngeal

insufficiency

• Oral/pharyngeal/esophageal dysphagia

• Impaired pharyngeal closure/laryngeal vestibule closure

• UES dysfunction• Impaired esophageal

motility• Poor dentition/oral

hygiene• Weak/imprecise

mastication• Ineffective bolus for-

mation/propulsion

• Decreased sustained/selective/divided/alternating attention

• Decreased imme-diate/short-term/long-term memory

• Impaired insight/ judgment

• Impaired problem solving

• Delayed processing/sequencing

• Decreased organiza-tion/planning


SLP SPECIFIC

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SLP ASSESSMENT – IMPAIRMENTS AND PROGNOSIS Patient’s primary impairments identified on clinical examination which contribute to decline in function:

SENSORIMOTORSPEECH/LANGUAGE PRODUCTION DYSPHAGIA COGNITION

• Impaired intonation/pitch/rate of speech/volume

• Dysfluency• Impaired auditory/

reading comprehension• Impaired written

expression

• Impaired ant/post bolus transit

• Increased oral/ pharyngeal residue

• Impaired soft palate elevation and retraction

• Decreased executive function

• Agnosia• Impaired orientation



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SLP SPECIFIC

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SLP ASSESSMENT – ACTIVITY LIMITATIONS AND CONTEXTUAL FACTORSPatient’s new or worsened activity limitations and participation restrictions related to the impairments:

• Inability to perform tasks with sufficient consistency, flexibility and/or efficiency

• Safe swallowing/meals• Medication management• Calendar management• Financial management• Independent disease management• Respond in an emergency• Home safety• Express basic wants and needs• Verbalize plans/solutions• Understand spoken information• Comprehend basic information• Follow simple written instructions• Follow a map or directions

• Reading tasks (e.g., newspaper, medication labels)• Understand technical/complicated written material• Participate in simple conversation• Participate in complex conversation• Create routine lists/take simple messages• Compose reports/express complex ideas

in writing• Recall pertinent information• Perform routine tasks with/without reminders• Plan/execute new/unfamiliar tasks• Community activities• Understand and participate in abstract thinking• Divide or alternate attention between multiple

tasks


SLP SPECIFIC

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SLP ASSESSMENT – ACTIVITY LIMITATIONS AND CONTEXTUAL FACTORSPersonal factors contributing to patient’s expected outcome (indicate facilitators and barriers):

• Understanding of condition• Acceptance of condition• Mood• Motivation to participate• Baseline memory• Safety consciousness/judgment• Problem solving/adaptability

• Attention to task• Insight• Appropriateness of behaviors• Baseline cognitive status• Capacity to learn new information• Fluctuating health condition• Health-related habits


• Noise/distraction in the home• Organization in the home• Access to services• Appropriateness of living situation relative to

patient’s needs• Willingness of family/friends to provide assistance• Availability of family/friends to provide assistance




SLP SPECIFIC

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MOTOR WITH SWALLOW

Supraglottic Super- supraglottic Effortful Mendelsohn

ManeuverMasako

Maneuver

Closes vocal cords before and during swallow

Closes airway entrance before and during swallow

Increases BOT retraction and propulsive forces

Facilitates pharyngeal clearance

BOT function

Timing and extent of laryngeal closure

Bolus swallow

Bolus swallow

Facilitates UES opening

Hold ant. por-tion of tongue between teeth and swallow

Bolus swallow

Hold breath; bear down; swallow; cough

Squeeze hard with tongue during swallow

Bolus swallow

Hold breath; swallow; cough to clear

Swallow; hold larynx elevated 3 – 5 sec; release

10 times/day for 5 min

SLP SPECIFIC

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BOLUS MODIFICATION

CARBONATED• Carbonated water,

seltzer, soda water, ginger ale

BOLUS MODIFICATION

TEXTURE• Potato chips in puree• Crushed crackers in

mashed potatoes

EVERY 2 – 3 SWALLOWS• Rotate among different

bolus characteristics

SOUR• 1/2 lemon juice• 1/2 water

TEXTURE• Potato chips in puree• Crushed crackers in

mashed potatoes

CARBONATED• Carbonated water,

seltzer, soda water, ginger ale

EVERY 2-3 SWALLOWS• Rotate among different

bolus characteristics

BOLUS MODIFICATION

SLP SPECIFIC

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SLP SPECIFIC

SLP LANGUAGE AND COGNITION TREATMENT IDEAS

• Remediation or compensation? • Is treatment harder than self-selected (intensity)?• What is the dosage of each treatment?

LANGUAGE/APHASIA

• Phonemic and semantic cueing• Phrase completions• Object, divergent/convergent naming• Picture descriptions

• Conversational speech• Synonyms/antonyms• Constraint-induced treatment

WRITTEN EXPRESSION

• Signature• Grocery lists and personal letters/cards

• Applications• Medical information

PRAGMATICS

ACC

AUDITORY COMPREHENSION

• Answering questions• Following increasingly complex directions

• Increasingly complex levels


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SLP SPECIFIC

SLP LANGUAGE AND COGNITION TREATMENT IDEAS


READING COMPREHENSION

• Newspapers• Medication lists

• Medication schedules• Calendar

COGNITIVE SKILL DEVELOPMENT

• Daily journal/schedule• Calendar management• Digits forward/backward

• Recall tasks and strategies• Environmental adaptations

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SLP SWALLOW AND VOICE TREATMENT IDEAS


VOICE/DYSARTHRIA

• Overarticulation/articulation tasks• Speech pacing/rate of speech• Breath support• Sustained phonation tasks

• Voice amplitude training• Pitch training• Vocal quality training

ORAL MOTOR

• Jaw/buccal exercises• Labial exercises

• Lingual exercises

DYSPHAGIA

• Bolus modification• E-stim/VitalStim• Thermal-tactile stim• Oral hygiene

• Postural techniques• Motor with swallow• Diet modification/diet trials

SLP SPECIFIC

38

SELECTED REFERENCES

Selected ReferencesAvers D, Brown M. White paper: strength training for the older adult. Journal of Geriatric Physical Therapy. 2009;32(4):148-152.

Barbieri G, Gissot A-S, Perenonnou, D. Ageing of the postural vertical. Age. 2010;32:51-60.

Bastian AJ. Understanding sensorimotor adaptation and learning for rehabilitation. Current Opinion in Neurology. 2008;21:628–633.

Birkenmeier RL, Prager EM, Lang CE. Translating animal doses of task-specific training to people with chronic stroke in 1-hour therapy sessions: a proof-of-concept study. Neurorehabil Neural Repair. 2010;24(7):620-630.

Dean CM, Richards CL, Malouin F. Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Arch Phys Med Rehabil. 2000;81:409-17.

Dromerick AW , Lang CE, Birkenmeier RL, et al. Very early constraint-induced movement during stroke rehabilitation (VECTORS). Neurology®. 2009;73:195–201.

Ebersbach G, Ebersbach A, Edler D, et al. Comparing exercise in Parkinson’s disease - the Berlin LSVT BIG study. Movement Disorders. 2010;25(12):1902–1908.

Farley BG, Fox CM, Ramig LO, et al. Intensive amplitude-specific therapeutic approaches for Parkinson’s disease: toward a neuroplasticity-principled rehabilitation model. Topics in Geriatric Rehabilitation. 2008;24(2):99-114.

Farley BG, Koshland GF. Training BIG to move faster: the application of the speed–amplitude relation as a rehabilitation strategy for people with Parkinson’s disease. Exp Brain Res. 2005; 167(3):462-467.

39

SELECTED REFERENCES

Fried TR, Tinetti ME, Iannone L. Primary care clinicians’ experiences with treatment decision making for older persons with multiple conditions. Arch Intern Med. 2011;171(1):75-80.

Horn SD, DeJong G, Smout RJ, et al. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggres-sive therapy better? Arch Phys Med Rehabil. 2005;86(2):S101-14.

King LA, Horak FB. Delaying mobility disability in people with Parkinson disease using a sensorimotor agility exercise program. Phys Ther. 2009;89:384–393.

Kleim JA. III STEP: a basic scientist’s perspective. Physical Therapy. 2006;86(5):614-617.

Kleim JA, Jones TA, Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research. 2008;51:s225-s239.

Lang CE, MacDonald, JR, Gnip C. Counting repetitions: an observational study of outpatient therapy for people with hemiparesis post-stroke. JNPT. 2007;31:3-10.

Lang CE, MacDonald JR, Reisman DS, et al. Observation of amounts of movement practice provided during stroke rehabilitation. Arch Phys Med Rehabil. 2009;90:1692-8.

Manckoundia P, Mourey F, Perennou D, et al. Backward disequilibrium in elderly subjects. Clinical Interventions in Aging. 2008;3(4):667–672.

Matheron E, Dubost V, Mourey F, et al. Analysis of postural control in elderly subjects suffering from psychomotor disadaptation syndrome (PDS). Archives of Gerontology and Geriatrics. 2010;(51):e19–e23.

Morris ME. Locomotor training in people with Parkinson disease. Physical Therapy. 2006;86(10):1426-1435.

40

SELECTED REFERENCES

Morris ME, Martin CL, Schenkman ML. Striding out with Parkinson disease: evidence-based physical therapy for gait disorders. Physical Therapy. 2010;90(2):1-9.

Nieuwboer A. Cueing for freezing of gait in patients with Parkinson’s disease: a rehabilitation perspective. Movement Disorders. 2008;23(2):s475-s481.

Ozturk A, Simsek TT, Yumin ET, et al. The relationship between physical, functional capacity and quality of life (QoL) among elderly people with a chronic disease. Archives of Gerontology and Geriatrics. 2011;53:278–283.

Pak S, Patten C. Strengthening to promote functional recovery poststroke: an evidence-based review. Topics in Stroke Rehabilitation. 2008;15(3):177–199.

Sullivan KJ, Brown DA, Klassen T, et al. Effects of task-specific locomotor and strength training in adults who were ambulatory after stroke: results of the STEPS randomized clinical trial. Physical Therapy. 2007;87(12):1580-1602.

Thaut MH, Leins AK, Rice RR, et al. Rhythmic auditory stimulation improves gait more than NDT/Bobath training in near-ambulatory patients early poststroke: a single-blind, randomized trial. Neurorehabil Neural Repair. 2007;21:455-459.

Tilson JK, Settle SM, Sullivan KJ. Application of evidence-based practice strategies: current trends in walking recovery interventions poststroke. Topics in Stroke Rehabilitation. 2008;15(3):227–246.

Wolf SL, Winstein CJ, Miller JP, et al. Retention of upper limb function in stroke survivors who have received constraint-induced movement therapy: the EXCITE randomised trial. Lancet Neurol. 2008;7:33–40.

Wolf SL, Winstein CJ, Miller JP, et al. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke. JAMA. 2006;296:2095-2104.

41

VITAL SIGN RESPONSE GUIDELINES

RESTING NORMAL HIGH VERY HIGH EMERGENCY

SBP 70 – 160 160 – 190 190 – 220 >220

DBP <90 90 – 110 110 – 120 >120

Heart Rate 60 – 90 90 – 110 110 – 125 >125

Heart Rhythm

Regular rhythm New arrhythmia with ≤ 6 skipped beats or irregular beats/min

New or different arrhythmia with >6 skipped or irregular beats/min

New or different arrhythmia with rapid rate

Therapist Response

Safe to begin exercise

Ask if taken medica-tion; avoid vigorous exercise; encourage compliance with medication; check at rest again next visit: report to MD if persists

Call MD; do not exercise; ensure plan for medical follow-up

Call MD; arrange for office visit or ER visit immedi-ately; return to bed; continue to monitor until patient under someone else’s care

CARDIOVASCULAR SCREENING AND GUIDELINES

41

42

How

short of breath are you? 0

Nothing at all

1 Very slightly

2 Slightly

3 M

oderately 4

Somew

hat severely 5

Severely 6 7

Very severely 8 9

Very, very severely 10 M

aximally

dy

SP

ne

a S

ca

le

44

Syndrome identification


teStS and meaSureS

Short Physical Performance Battery 2Gait Speed 25X Sit To Stand 3Berg Balance Scale 3DGI 3Unilateral Stance (Eyes Open) 3360° Turn 3Functional Reach 4Barthel Index 4Tug 4Mean Arterial Pressure 4

obServational analySiS

Sit to Stand Analysis 5Stand to Sit Analysis 6Standing Postural Control Analysis 6Gait Analysis 7Complex Gait Analysis 8Activity Analysis 9

ot/Pt aSSeSSment

OT Assessment – Medical Necessity and Homebound Status 11OT Assessment – Impairments and Prognosis 12OT Assessment – Impairments and Prognosis 13PT Assessment – Medical Necessity and Homebound status 15PT Assessment – Impairments and Prognosis 16PT Assessment – Impairments and Prognosis 17Improvements in Task Performance 19Ongoing Deficits in Task Performance 20

ot/Pt intervention

Older Adult Strength Training Recommendations 21Gait Training 22Cue Training 22mCIMT 23Training Amplitude In Voice And Movement 23Training Posture Vertical (A/P) 24Changes Related to Foot Orthoses 25OT Treatment Ideas 26PT Treatment Ideas 27Go-To Tasks 28

table of contentS

b

How

short of breath are you? 0

Nothing at all

1 Very slightly

2 Slightly

3 M

oderately 4

Somew

hat severely 5

Severely 6 7

Very severely 8 9

Very, very severely 10 M

aximally

dy

SP

ne

a S

ca

le

44

Syndrome identification


teStS and meaSureS

Short Physical Performance Battery 2Gait Speed 25X Sit To Stand 3Berg Balance Scale 3DGI 3Unilateral Stance (Eyes Open) 3360° Turn 3Functional Reach 4Barthel Index 4Tug 4Mean Arterial Pressure 4

obServational analySiS

Sit to Stand Analysis 5Stand to Sit Analysis 6Standing Postural Control Analysis 6Gait Analysis 7Complex Gait Analysis 8Activity Analysis 9

ot/Pt aSSeSSment

OT Assessment – Medical Necessity and Homebound Status 11OT Assessment – Impairments and Prognosis 12OT Assessment – Impairments and Prognosis 13PT Assessment – Medical Necessity and Homebound status 15PT Assessment – Impairments and Prognosis 16PT Assessment – Impairments and Prognosis 17Improvements in Task Performance 19Ongoing Deficits in Task Performance 20

ot/Pt intervention

Older Adult Strength Training Recommendations 21Gait Training 22Cue Training 22mCIMT 23Training Amplitude In Voice And Movement 23Training Posture Vertical (A/P) 24Changes Related to Foot Orthoses 25OT Treatment Ideas 26PT Treatment Ideas 27Go-To Tasks 28

table of contentS

b

42

DY

SP

NE

A S

CA

LE

4343

BO

RG

SC

ALE

44

NOTES

45

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