Rehabilitation of an elderly man with undiagnosed balance and speech issues: a case study Target pathology: Neurologica

1. Rehabilitation of an elderly man with undiagnosed balance and speech issues: a case study Target pathology: Neurological Student name: Daniel O’Sullivan Case Description The patient is 62 years of age, has a BMI of 25.64 and looks reasonably fit for his age. On initially meeting him he had slurred speech, an altered gait whereby he shuffled and took very small steps and always hung onto the wall as he moved. His balance problems started about a year ago, at which time he had suffered a couple of falls. An MRI showed no evidence of any neurological disease including MS and PD. His specialist has indicated that he has not developed PD or MS but indicated he may have had a stroke. Normally stroke patients are affected on the left hand side of their body, however the patient has no problems with his upper body strength or movement at all, rather he has slurred speech and severe balance issues. His specialist has also indicated that his condition is a result of changes within the cerebellum. Loss of function in the cerebellum can result in the total lack of coordination of activities such as speaking, walking and typing on a computer. • Patient Assessment • The following assessment indicators were recorded in the initial meeting: • BMI 25.64 Berg Balance Score 15 • Chest Strength 26kg Tinetti Gait 5 • Back Strength 31kg Tinetti Balance 4 • Left Grip strength 41kg SARA (Ataxia) 18/40 • Right Grip Strength 45kg • Blood Pressure 110/65 • Resting HR 71bpm • The assessment results indicate he has relatively good upper body strength with normal blood pressure and resting pulse. His Berg Balance Score indicates that he has a very high fall risk, coupled with this the Tinetti Assessment Tool¹ also indicates he has a high risk of falls through his gait and balance score. The Berg Balance Scale is identified as the most commonly used assessment tool across the continuum of stroke rehabilitation. His SARA² score is 18/40, however, his speech disturbance and gait make up most of those points. • Exercise Therapy • The exercise intervention for the patient included a range of balance exercises with strength and cardiovascular exercise. The patient would only exercise in his home or garage. He had some free weights, resistance bands and a treadmill. The following exercises were supervised once a week with the patient undertaking a session on his own in that same week. The following exercises were prescribed with an small increase in intensity and frequency³ each fortnight: • Patient Outcome During the 24 week intervention the patient increased all his upper body strength indicators. The most significant strength increase was his chest strength (15kg). The patient decreased his body weight slightly and his BP and RHR remained stable mainly due to medication. His fall risk is still high and remained unchanged. His SARA or scaling for ataxia did improve, however, this was due to an improvement in the dexterity in his upper body. • Reflection Overall the patient increased his upper body strength with the greatest increase reported in his chest strength. On reflection, a recumbent or arm crank cardiovascular test at the beginning of the program would be of benefit to observe changes within his aerobic function. Positive changes were recorded in the ataxia assessment however this was due to some improvement in his upper body dexterity. Unfortunately the patient’s balance and gait is slowly declining affecting his functional ability. • References • Tinetti, M. E. (1986). Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc, 34(2), 119-126. • Schmitz-Hubsch, T., du Montcel, S. T., Baliko, L., Berciano, J., Boesch, S., Depondt, C., et al. (2006). Scale for the assessment and rating of ataxia: development of a new clinical scale. Neurology, 66(11), 1717-1720. • Bird, S.P. & Cannon, J. (2006).The role of resistance exercise in chronic disease: Prescription guidelines and application in clinical practice. Critical Reviews in Physical and Rehabilitation Medicine, 18(4): p. 317-342.