clinical problem solving mccaul benson november 5 trunk control as a prognostic factor for...
DESCRIPTION
Prior Level of Function Independent Works part time at family business Lives alone in private residenceTRANSCRIPT
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CLINICAL PROBLEM SOLVINGMCCAUL BENSON
NOVEMBER 5
Trunk Control as a prognostic factor for functional outcome of
CVA Patients
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Patient History: Patient “X”
63 year old female
Status post acute ischemic stroke, left MCA
R side hemiplegia
PMH: breast cancer with previous left mastectomy, HTN
Large family support
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Prior Level of Function
IndependentWorks part time at family businessLives alone in private residence
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Complications
Complex medical case
Current breast cancer diagnosis
Suspected stroke Saturday-found Monday
Suspected bone mets: Left clavicle and scapula
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Examination
Alert, no verbalizations
Decreased attention and concentration
Severe cognitive deficits
Able to follow simple commands
Responses not accurate
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Objective Measures
Strength: L UE/LE WFL; R UE/LE 0/5 except 1/5 R hip adduction Coordination: R UE/LE grossly decreased, non functional Tone: abnormal, flaccid R side except during R shoulder flexion PROM Sensation: unable to assess at this time ROM: Pt with + L gaze preference but able to turn head and eyes to R/past midline with cues. At one point, pt
observed to use L UE to lift R UE vs. another time when asked to touch her R hand, pt unable to use L UE to demonstrate knowledge of R UE
AROM: no AROM R side, L side WFL PROM: L UE/LE grossly decreased, non functional Bed mobility: Rolling-mod assistance, additional time, verbal cues to R vs. Max assistance to left , multiple trials for re-positioning Supine to sit: deferred due to pt fatigue and frustration
Note: minimal assistance: patient performs over 75% of work Moderate assistance: patient performs 50% Maximal assistance: patient performs 25% of work
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Prognosis
Fair Good family support + Severe hemiplegia - Severely impaired - Cancer dx - Young + Determination/interest +
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Question of interest
What we know: Trunk control=an important predecessor to other higher level motions, especially balance and gait, both important functions of ADLs and functional independence.
What we do not know…
The predictive value of core strength and the relationship to functional outcome
Treatment: bed mobility, transfer training, balance Core stability/trunk strengthening???
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Question of Interest
For my 63 year old female status post acute ischemic stroke, does the trunk control test predict functional outcome?
Importance of trunk control Importance of prognosis and discharge planning Implications for future treatment
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Trunk control test as an early predictor of stroke rehabilitation outcome.
Purpose: To investigate the construct and predictive validity of the Trunk Control Test (TCT)
Compared TCT scores at admission and discharge with the Functional Independence scores (FIM)
Subjects: 49 patients Inpatient rehabilitation Majority hemiparetic patients
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Trunk Control Test (TCT) and FIM
FIM: 13-item motor subscale and a 5-item cognitive subscale
TCT: examines four axial movements: rolling from supine position to weak side (T1), rolling to the strong side (T2), supine to sit (T3), sitting in balanced position on the edge of the bed with feet off the ground for 30 seconds (T4)
Scoring: 0=unable to perform without assistance 12=able to perform movement but in an abnormal manner 25=able to complete movement normally
total obtained on all 4 tests=100 total possible
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Results
Variables Admission DischargeGrooming .44 .57Dressing:upper body
.64 .60
Toileting .48 .71Transfer bed/chair/wheelchair
.87 .81
Toilet transfer .72 .85Walk, wheelchair
.65 .79
TCT at admission correlated with the total FIM and motor FIM Tct-adm correlation to total Fim: .707 (adm) and .79 (dis) (P<.0001)TCT correlated with the motFim: .819 (adm) and .856 (dis) (P<.0001)
AS well as various motor items specifically:
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Conclusion
Positive sensitivity to changeIntrinsic stability the authors conclude that the trunk mobility
test can actually predict motor FIM at discharge better than the motor FIM at admission alone
high correlations between the TCT and motor FIM and total FIM scores
concluding the construct validity of the TCT in severely impaired stroke patients
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TRUNK CONTROL TEST AS A FUNCTIONAL PREDICTOR IN STROKE PATIENTS
Purpose: to evaluate prospectively the trunk control test correlation at admission to rehab with length of stay, functional independence measure, gait velocity, walking distance and balance measured at discharge
Subjects: 28 patients hemiplegia secondary to CVA in the 4 weeks
preceding admission to inpatient rehab mean age=64.5 15 days was average time from onset of stroke
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Methods
Prospective designTCT and FIM administered < 72 hoursOutcome measures:
LOS FIM (motor, cognitive, efficiency) Gait velocity/distance Static and dynamic walking balance Berg balance
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Results
Variables R Length of stay r = -0.722 Discharge FIM r = 0.738 Discharge motor FIM r = 0.723 Gait velocity r = 0.654 Walking distance p = 0.003 COG symmetry r = 0.601Berg Balance r = 0.755
TCT was significantly correlated with the following…
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Conclusion
Trunk balance in the acute stage of stroke is a functional outcome prediction tool
TCT is a short and simple tool to predict functional outcome in stroke patients
TCT correlated well with some specific motor results such as walking speed, distance, and balance
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Limitations
Small sample sizesBias because patients were pre-selectedfurther research is needed particularly the
prediction tool of length of stay Differences between acute care timeframe
and inpatient rehab Correlation coefficients Minimal methodsNeed for future research
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Back to Patient X
The TCT was not appropriate for my patient in the acute care setting at initial evaluation due to severity of impairments
After multiple PT sessions, patient X would have theoretically scored 24/100 on the TCT, and as evidence would suggest, this indicates potential for poor functional outcomes
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Up Next
TCT=appropriate “predictive” toolQuick, easy, objective toolNot the only tool to use limitations with
TCT and researchDrawing assumptions to outcomes with my
patientIntervention-focus on trunk control, limit
dependent positions, challenging treatments, facilitate core muscles
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References
Duarte, E. (2002) Trunk control test as a functional predictor in stroke patients. Journal of Rehabilitation Medicine. Doi: 10.1080/165019702760390356
Franchignon, F.P. (1997) Trunk Control Test as an Early Predictor of Stroke Rehabilitation Outcome. Stroke Journal. Doi: 10.1161/01.STR.28.7.1382
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QUESTIONS???