Scleroderma Case Study: Difference between revisions
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*'''Physical Performance Measures [[Image: | *'''Physical Performance Measures [[Image:Oral aperture.jpg|right|3x3px|Measurement of oral aperture (9)]]''' | ||
Grip strength (R)<sup>6</sup>: 20.7 kg | Grip strength (R)<sup>6</sup>: 20.7 kg | ||
Grip strength (L)<sup>6</sup>: 19.18 kg | Grip strength (L)<sup>6</sup>: 19.18 kg | ||
Pinch strength (R)<sup>6</sup>: 4.27 kg | Pinch strength (R)<sup>6</sup>: 4.27 kg | ||
Pinch strength (L)<sup>6</sup>: 3.98 kg | Pinch strength (L)<sup>6</sup>: 3.98 kg | ||
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Oral aperture<sup>7</sup>: 28 mm <!--[if !supportLists]--> | Oral aperture<sup>7</sup>: 28 mm <!--[if !supportLists]--> | ||
'''[[Image: | '''[[Image:Oral aperture.jpg|196x178px|Measurement of oral aperture (9)]]''' | ||
Measurement of Oral Aperture<sup>9</sup> | |||
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*'''Objective''' | *'''Objective''' |
Revision as of 20:54, 28 March 2015
Author/s[edit | edit source]
Catelin Infante, Jessica Frederick, Kristin Casagrand, Jarrod Smith from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.
Patient Characteristics[edit | edit source]
- Demographic Information: (occupation/vocation, gender, age, etc.)
Native American
Female
Born and raised in Oklahoma
Works in a factory
Thirty-five years old
Family history of rheumatoid arthritis on mother's side
- Medical diagnosis if applicable
Scleroderma
- Co-morbidities
Hypertension, Type II Diabetes
- Previous care or treatment
Previous physical therapy for low back pain
Examination[edit | edit source]
- Subjective
Ms. Smith comes into the clinic complaining of joint pain and muscle weakness, especially in her hands, hips and shoulders1. She explains that she has been having trouble making it through a full day of work because her body feels limited and she just cannot reach as well for boxes at her job because "her arms won't go up that far". She also has noticed that she gets out of breath and sometimes has chest pain when she lifts a lot too quickly2. Mrs. Smith indicates that her fingers often feel very swollen and stiff and sometimes feel "stuck" in a bent position1. She reports that for several months she has been getting a really cold, numb feeling in her fingers throughout the day, especially when she is sitting in the air conditioning at her office3. Overall, she has just not felt well for the past few months either. When she eats, she has trouble fully opening her mouth to put food in2. Then, when she lies down at night after dinner, she gets a feeling of heartburn and sometimes feels she has to vomit1. However, she says she has been eating poorly lately, so it's probably her fault she hasn't felt well. Additionally, Mrs. Smith reports losing 20 pounds in the past month without any lifestyle changes. Her goals for therapy are to decrease her joint pain and to get her muscles stronger so she doesn't struggle at work any longer. Her focus is on getting her hands and arms "back to normal" because they are what she uses most in her job.
- Self-Report Outcome Measures
Health Assessment Questionnaire Disability Index (HAQ-DI)4: 1.1
Disabilities of Arm, Shoulder, and Hand Questionnaire (DASH)5: 34
Verbal Pain Intensity Scale: "Severe pain"
- Physical Performance Measures
Grip strength (R)6: 20.7 kg
Grip strength (L)6: 19.18 kg
Pinch strength (R)6: 4.27 kg
Pinch strength (L)6: 3.98 kg
Oral aperture7: 28 mm
Measurement of Oral Aperture9
- Objective
MMT: WNL except for the following
4/5 finger and thumb abduction, adduction, flexion, extension
4/5 wrist flexion and extension
3+/5 shoulder flexion and abduction
3+/5 hip flexion and abduction
ROM: WNL except for the following
Decreased flexion and extension in all finger MCP and IP joints
Decreased wrist flexion and extension
Decreased hip extension and abduction
Reflexes: WNL
Sensation: Decreased facial sensation
- ICF Findings
Impairments1,2,8
Patient has stiffening around fingers and what appears to be finger flexion contractures developing
Patient has noticeable hard deposits palpated around UE joints
Patient has slurred speech due to difficulty fully opening mouth. The skin around the face is thickened and has begun to cause puckering
Pt has dyspnea and chest pain upon exertion
Activity Limitations1,2,8
Patient is unable to complete activities in supine secondary to reflux symptoms
Patient is unable to complete overhead activities due to decreased shoulder ROM
Patient is unable to complete more than 30 minutes of repetitive movements due to fatigue, muscle weakness and joint pain
Environmental Factors8
Patient is employed as a packer at a plastics company
Patient is a smoker of 20 years
Clinical Impression[edit | edit source]
- After Ms. Smith's assessment, we have determined that she has decreased range of motion in her fingers and wrists, decreased cardiovascular endurance, decreased muscle mobility, as well as increased muscle weakness and fatigue. All of these impairments have impacted her functional ability to do activities at home and in the work place. Physical therapy could benefit Ms. Smith by improving her impairments that were found and by providing patient education on management of her condition. The interventions during PT would include active joint range of motion, strengthening exercises and aerobic exercises to improve endurance, as well as education on a home exercise program and management of the symptoms of her condition. With the help of physical therapy, Ms. Smith would likely be able to reach her goals for improving her strength and endurance and decreasing her joint pain so that she can particpate in more activities at home, work and in the community.
Summarization of Examination Findings[edit | edit source]
Working Diagnosis and Targeted Interventions
Intervention[edit | edit source]
- Phases of Interventions
Edematous Stage:
Patient Education (About the disease; treatment of Raynaud's disease - dress in layers, monitor temperature changes, avoid air conditioning if possible, avoid things that cause vasoconstriction like smoking, cold temperatures and emotional stress)
Orthotic and adaptive equipment needs
Light range of motion exercises
Joint protection strategies (light weight splints)
Sclerotic Stage:
Paraffin/heat modalities for hands and fingers
Passive range of motion exercises progressing to active-assisted range of motion, then to active range of motion, can add a sustained stretch for five seconds at end range (finger flexion/extension and abduction/adduction, wrist flexion/extension - can use hand clasp with wrist extension stretch)
Soft tissue mobilizations
Joint manipulations (Traction)
Kabat's method to improve mouth opening (activation of orbicularis oris, zygomaticus, levator labii, nasalis, frontalis and corrugator muscles by exaggerated facial movements) - progress from active-assisted ROM to active ROM
Soft tissue massage
Aquatic therapy (Upper and lower extremity range of motion and strengthening exercises, walking, squatting, marching, etc)
Atrophic Stage:
- Dosage and Parameters
SMART framework - combines physical therapy sessions with self-management of care through a home exercise program. The PT session focuses on designing an individualized program for each patient in order to treat their specific impairments and goals. The sessions are planned less frequently during the week, but spaced out over a longer period of time. This is to help shift the focus of the care to self-managed that way the patient can manage their condition for the long-term. The HEP uses exercises, self-stretches and paraffin to help the patient manage their condition at home. The patient is given 4-5 exercises that are performed 1-2 times per day, for 5 days per week.
- Rationale for Progression
- Co-interventions if applicable
Occupational Therapy
Joint preservation principles
Devices for independent living
Medications
Disease modifying drugs (Penicillamine) - treatment of disease processes
ACE inhibitors - treatment of acute hypertension/pulmonary hypertension and renal complications
Nonsteroidal anti-inflammatory drugs (NSAIDs) - treatment of joint inflammation
Antibiotics/Oral Tetracyclines (Minocycline, doxycycline) - treatment for disease by reduction of pain, severity of condition and quality of life
Analgesics - treatment of pain
Calcium channel blockers - treatment of Raynaud's
Immunosuppressants - treatment during the acute phase of the disease
Outcomes[edit | edit source]
Findings Over time
Discussion[edit | edit source]
Summary Statement which should include related findings in the literature, potential impact on clinical practices
Related Pages[edit | edit source]
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References[edit | edit source]
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