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1. The patient is a 68-year-old woman with a past medical history of type 2 DM complicated by peripheral neuropathy, HTN, CAD with resultant MI, and CABG, presenting to the clinic today with bilateral foot pain described as “burning” and three falls in the past 3 months. She ambulates without an assistive device but reports using furniture/shopping carts to stabilize herself as needed. The patient presents with ankle weakness, limited ankle dorsiflexion ROM, decreased sensation in BLE, and impaired balance. All of these contribute to impaired functional mobility and decreased safety. The patient would benefit from physical therapy to address her ROM, strength, endurance, balance, function, and safety. Will continue to follow.
2. Short-term goals:
Patient will improve her dynamic standing balance as evident by a score of 15 seconds on the TUG within 8 sessions to improve safety.
Patient will ambulate 250 feet with a least restrictive assistive device independently without loss of balance within 8 sessions to improve functional mobility and safety.
3. Long-term goals:
Patient will ambulate 540 meters with least restrictive assistive device on the 6MWT without loss of balance within 16 sessions to demonstrate improved endurance.
Patient will independently ascend/descend 13 steps with a single handrail, demonstrating reciprocal step pattern, within 16 sessions to improve safety at home.
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4. DM presents with various polyneuropathies, including autonomic nervous system neuropathies (vestibular and visual), diabetic peripheral neuropathy, affecting sensory and muscle strength. Diabetic peripheral neuropathy is the progressive loss of peripheral sensation in BUEs and BLEs, with a stocking glove presentation as the distal component most impaired. Individually or collectively, loss of peripheral sensation, limb proprioception, and/or vestibular and visual input can lead to gait deviations. Such gait deviations may include decreased speed, impaired swing phase with shorter step length, impaired terminal stance phase with decreased force production, and/or wide base of support.
5. Other health care providers that the patient should be referred to include, but not limited to, podiatrist, primary care physician, nutritionist, ophthalmologist, and/or diabetic educator. A podiatrist could address her pain and peripheral neuropathy via custom shoes and education, as well as provide proper nail care. Her primary care physician could address her uncontrolled HTN, her uncontrolled type 2 DM, and her undiagnosed decreased pulses, pain, and pale lower extremities. A nutritionist could address dietary intake for weight loss and improving her lab values (specifically fasting glucose, hemoglobin A1C, cholesterol, and triglycerides). An ophthalmologist screens annually for diabetic retinopathy. Diabetic educators are a great resource for overall education about the disease and appropriate self-care. |
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6. The patient has bilateral + 1 dorsalis pedis and posterior tibial pulses. + 1 is defined as a “thready” pulse or easily obliterated with slight pressure. Individuals with DM tend to have earlier onset atherosclerotic changes effecting peripheral arteries. Atherosclerosis leads to peripheral arterial disease (PAD), which presents with decreased distal pulses, lower extremity pain that worsens with lower extremity elevation, and pale skin of the affected distal extremities. Lower extremity hair loss, claudication, and arterial ulcerations can also be seen with PAD.
7.
The patient’s TUG score of 22.4 seconds is slower than the age-based norm of 15 seconds for community-dwelling adults with comorbidities, indicating impaired balance, positive fall risk, and impaired walking ability.
The patient’s Five Times Sit-to-Stand Test score of 12.2 seconds is slower than the age-based norm of 11.4 seconds for community-dwelling geriatric adults, indicating impaired strength, transfer function, and increased fall risk.
The patient’s 6MWT of 27 meters prior to loss of balance and termination of the test is well below age-based normative data for geriatric women, 538 feet.
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8. Since the patient is currently falling one time per month for the last 3 months, has balance deficits as identified on the TUG score and Five Times Sit-to-Stand Test, and ankle weakness, addressing lower extremity strength and balance should be prioritized. Two potential interventions are:
Standing heel raises while holding a stable object: This weight-bearing activity would focus on ankle strength and dynamic balance.
Single leg stance static balance: This would emphasize ankle muscle strengthening in weight-bearing position and assist in activation of ankle strategy for balance.
9. Since the patient is currently only ambulating household distances and endurance deficits as identified on the 6MWT, endurance interventions are indicated. Two potential interventions are:
Seated (recumbent or upright) bicycle 30 to 50% of peak work rates for 10 minutes with rest breaks as needed.
Upper body ergometer (UBE) 30 to 50% of peak work rates for 5 to 10 minutes with rest breaks as needed.
Both of these interventions have her in a seated position and therefore optimize safety until standing balance is improved.
10.
Due to physical therapy findings of fall risk TUG score and Five Times Sit-to-Stand Test score, physical therapy should educate on methods to decrease her risk of falls while she improves her balance via ongoing physical therapy: environmental modifications at home, benefits of a rollator for household ambulation to allow for seated rest breaks as needed, benefits of a commode to utilize at night next to the bed, and requesting family assistance with community-based ADL.
Due to past medical history of type 2 DM with hemoglobin A1C of 8.9%, the physical therapist should educate on methods to prevent skin breakdown on her feet: daily diabetic skin checks, diabetics socks, and appropriately fitted shoes.
Due to past medical history of CAD and MI with lab values of triglycerides 254 and LDL 128, and type 2 DM with correlating lab values, the physical therapist should educate on benefits of exercise to decrease cardiac risk factors (triglycerides, HDL, LDL, cholesterol, inactivity) and optimize her glucose metabolism, as well as timing exercise around meals and DM medication.
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11.
Metformin, sitagliptin, glipizide, dapagliflozin are all medications for control of glucose in the bloodstream. Glipizide promotes glucose-independent insulin release, which places the patient at high risk of developing hypoglycemia. The physical therapy implications are timing meals, medication administration, and exercise to prevent hypoglycemia.
Lisinopril and amlodipine can cause orthostatic hypotension.
Metoprolol causes a blunted heart rate response to exercise or any activation of the sympathetic nervous system. The physical therapist should utilize rate of perceived exertion (Borg rating of perceived exertion) for exercise intensity assessment, instead of heart rate.
Simvastatin is to decrease LDL level in the bloodstream, which causes statin-induced myopathy (muscle weakness, muscle pain, and muscle inflammation) in 5 to 10% of patients taking statins. Screening for statin-induced myopathy is an important part of physical therapy evaluation and physical therapy treatment sessions. Progression of statin-induced myopathy to rhabdomyolysis is another adverse effect of statins.
Aspirin inhibits platelet aggregation and is utilized post-MI to maintain coronary artery perfusion but can cause hemorrhaging.
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12. Metoprolol is a selective beta-blocker, and therefore can lower heart rate.
13. Type 1 DM is categorized by little to no endogenous insulin production requiring exogenous insulin to treat; onset is usually abrupt prior to 20 years of age and is most often associated with autoimmune destruction of pancreatic beta cells. Type 2 DM is categorized by varying insulin production linked to obesity-associated insulin resistance with a gradual onset. Incidence of type 2 DM increases with age. Type 2 DM can be treated with weight loss, lifestyle modifications, oral medications, and exogenous insulin. Type 2 DM is much more prevalent compared to type 1 DM.
14. The balance strategies utilized by the body to maintain the center of mass over the base of support are ankle, hip, and stepping strategies. Ankle strategy is movement occurring at the ankle joint with the gastrocnemius soleus and anterior tibialis muscles initially activated. The hip strategy is the movement occurring at the hip joint with abdominals, paraspinals, and hip musculature initially activated. Ankle strategy is typically utilized for low disturbances, then hip strategy is utilized for larger disturbances, and stepping strategy is utilized for fast and large disturbances. |
