HM Medical Clinic

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OUTPATIENT REHABILITATION FOR A PATIENT WITH A CHRONIC LEFT A Doctoral Project A Comprehensive Case Analysis Presented to the faculty of the Department of Physical Therapy California State University, Sacramento Submitted in partial satisfaction of the requirements for the degree of DOCTOR OF PHYSICAL THERAPY ALL RIGHTS RESERVED OUTPATIENT REHABILITATION FOR A PATIENT WITH A CHRONIC LEFT A Doctoral Project Approved by: _, Committee Chair Edward Barakatt, PT, PhD _, First Reader Michael McKeough, PT, EdD _, Second Reader Katrin Mattern-Baxter, PT, DPT, PCS Date Student: David Gonzales I certify that this student has met the requirements for format contained in the University format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the project. , Department Chair Michael McKeough, PT, EdD Department of Physical Therapy OUTPATIENT REHABILITATION FOR A PATIENT WITH A CHRONIC LEFT A patient with a left middle cerebral artery stroke was seen for physical therapy treatment for 8 sessions from 4/17/15 to 5/15/15 at the Department of Physical Therapy at California State University, Sacramento. Treatment was provided by a student physical therapist under the supervision of a licensed physical therapist. The patient was evaluated at the initial encounter with the Five Times Sit to Stand to assess lower extremity muscular strength, the Six Minute Walk Test to assess cardiovascular endurance, the 10 Meter Walk Test to measure ambulatory status and gait speed, the Timed Up and Go test to measure fall risk, and the Falls Efficacy Scale- International to measure fall risk, and a plan of care was established. Main goals for the patient were to improve lower extremity strength, neuromuscular control, cardiovascular endurance, gait speed, and decrease risk for falls. Main interventions used were repetition, task-specific training, over-ground gait training, and neuromuscular control The patient improved lower extremity strength, cardiovascular endurance, gait speed, and reduced her risk for falls. The patient was discharged to remain living at home with a home exercise program. _, Committee Chair Edward Barakatt, PT, PhD _ Date ACKNOWLEDGEMENTS I acknowledge the Doctor of Physical Therapy Program at California State University Sacramento for allowing me to utilize its facilities to treat a patient for my case study. TABLE OF CONTENTS Acknowledgements . vii List of Tables . ix 1. GENERAL BACKGROUND . 1 2. CASE BACKGROUND . 4 3. EXAMINATION – TESTS AND MEASURES . 7 4. EVALUATION. 11 5. PLAN OF CARE – GOALS AND INTERVENTIONS. 13 7. DISCUSSION . 21 Evaluation and Plan of Care………………………………………………… 13 General Background
Stroke is a cerebral vascular accident (CVA) leading to a sudden loss of neurological function caused by an occlusion in cerebral blood flow.1 Deficits following stroke depend on type, location, and the size of the occlusion in the brain. The middle cerebral artery (MCA) is a main branch off of the internal carotid artery that supplies blood to subcortical structures and the lateral aspect of the cerebral hemisphere. The MCA is the most common artery occluded in stroke.1 Symptoms often present unilaterally and can affect the upper extremity, lower extremity or both. Common deficits may include paralysis, paresis, sensory and neuropathic pain, aphasia, impaired language comprehension and memory, and difficulty controlling emotion.2 Stroke occurs in roughly 795,000 people in the United States each year, of which, approximately 610,000 are first-time occurances.3 There are two types of stroke; the most common is an ischemic stroke affecting roughly 80% of the population with stroke. Ischemic stroke usually results from a thrombus or embolism that occludes cerebral blood flow disrupting oxygen supply to part of the brain. This ischemia causes death to neuronal tissue. The mortality rate of individuals suffering an ischemic stroke is 12% within the first month. Hemorrhagic strokes are caused by the rupture of cerebral vessels and accounts for roughly 20% of all strokes. The hemorrhage, which can be spontaneous or caused by a traumatic event, causes an increase in intracranial pressure. Increased intracranial pressure will occlude blood flow distal to the site of injury causing death to cortical tissues. Individuals who suffer a hemorrhagic stroke have a mortality rate of 38% in the first month.1 A MCA infarction may affect each individual differently. Acute signs may begin with sudden weakness or numbness of the face, arm, or leg. Sudden blurriness or loss of vision, particularly in one eye is common. Acute signs can be unsteadiness, sudden falls, sudden severe headaches, or difficulty speaking. Symptoms may be as severe as hemiplegia, hemianesthesia, or global aphasia.4 Prognosis of recovery following a MCA stroke is variable based on several factors including the severity of the impairments. However, research shows rehabilitation following stroke is usually a lifelong undertaking for the survivors due to their impaired mobility and disability.5 Patients with stroke should receive a long-term interdisciplinary team approach to optimize motor recovery and maximize functional capabilities.4 Stroke risk factors are classified as modifiable and non-modifiable. Modifiable risk factors include diabetes, atrial fibrillation, hyperlipidemia, smoking, obesity, carotid artery disease, and hypertension. Hypertension (HTN) is the most common risk factor for stroke. The prevalence of HTN is approximately 30% in the United States.6 Non- modifiable risk factors include age, gender, and race. Beginning at age 55 years, stroke risk doubles every decade a person is alive. Gender plays an important role as women are more susceptible to stroke than men, primarily because they outlive men. Race and ethnicity also influence risk of stroke: African Americans are twice as likely as Caucasians to have a stroke, and Hispanics and Asian/Pacific Islanders have higher incidences of stroke than Caucasians.7 Other contributing factors that increase risk of stroke include positive family history, history of a previous stroke, fibromuscular dysplasia, patent foramen ovale, and a history of transient ischemic attacks.7 Case Background
Examination – History
The patient was a 78-year-old female who experienced two ischemic CVAs in her left hemisphere; one in 2008 and one in 2009. The main complaints of the patient were her impaired mobility, stability, and gait patterns. She reported three falls in 2014 and one in 2015 but with no serious injury. She had a history of HTN, had been using a urinary catheter for the past 7 years for incontinence, and was currently seeing a physical therapist for pelvic floor exercises. In 2004 she had a brain tumor removed, and she had a laminectomy of the first and second cervical spinal segments in 2006. Neither procedure resulted in any lasting residual neurological impairments. The patient had a Botox injection 3 months prior to her physical therapy evaluation to reduce the spasms of her bladder, which were caused by her strokes. The patient lived with her 56-year-old daughter and their dog. She was retired and her daughter was on disability. They took care of each other and preferred to be at home. When not fatigued, the patient occasionally attended church with her daughter, and the patient was part of a Stroke Survivor support group. Her primary assistive device inside and outside of the house was her four-wheel walker (FWW). In the house she used a quad cane when ambulating in her bedroom. She was able to use her quad cane with the aid of handrails placed throughout her room. The patient's goals were to walk further, increase overall strength, be more active, increase mental status, improve balance, and decrease falls. Systems Review
The patient reported her two CVA's affected the following systems: Urogenital, gastrointestinal, cardiovascular/pulmonary, musculoskeletal, and neuromuscular. The patient's urogenital system was impaired as seen by the use of urinary catheter as a result of incontinence. The gastrointestinal system was impaired as seen by the use of over the counter medications for gastric reflux. The patient's cardiovascular/pulmonary systems were impaired and controlled by medications for HTN. The patient's musculoskeletal and neuromuscular systems were impaired as seen from the results of the objective tests (Table 2). Her integumentary system was impaired due to her surgical scars from the removal of the brain tumor and laminectomy. Examination - Medications
Patient used baclofen Drowsiness, dizziness, weakness, (mg),1 tablet (tab) to decrease spasticity confusion, upset stomach, which allowed for difficulty breathing, or seizures greater ease and fluidity of movement 25 mg, 1 by mouth Parkinson's Disease Dizziness, loss of appetite, (p.o.) three times diarrhea, dry mouth, mouth and throat pain, constipation, or headache 100 mg tab, 2.5 tab tid. 1 hour before meals 6.25 mg tab, 1 tab Hyperglycemia, lightheadedness, p.o. two times per dizziness, headache, nausea, vomiting, or blurred vision 75 mg tab, once a Prevents blood clotting Diarrhea, itching, nausea, skin  Transient ischemic rash, or stomach pain attack and heart attack 10 mg/5 mg oral, Constipation, dizziness, 2.5 milliliter (mL) headache, confusion, or anxiety p.o. qid 30 min before meals and bedtime Nausea, vomiting, dizziness, (cap), 3 cap p.o. qd headache, confusion, or fever 0.5 mg tab, 1-2 p.o. Drowsiness, dizziness, diarrhea, nausea, or constipation 10 mg tab, qd in Fever, headache, dizziness, or 100 mg cap, 2 p.o. Epilepsy and seizures Blurred vision, loss of vision, double vision, or confusion Reflux esophagitis, Headache, nausea, vomiting, coated tab, 1 p.o. abdominal pain, ulcers constipation, or dizziness qd in the evening 10 mg tab, 1 p.o. Hypercholesterolemia Constipation, nausea, headache, qd in the evening or fever or chills 800 mg tab, 1 tab Drowsiness, dizziness, vomiting, headache, or nervousness Confusion, nausea, loss of appetite, lack of energy, fainting, or vomiting blood Examination – Tests and Measures
The patient was examined, evaluated, and a plan of care was developed based on the International Classification of Functioning, Disability and Health (ICF) framework and the patient management model.9 At the body function and structure level, the Five Times Sit to Stand Test (FTSST) was used to assess lower extremity muscular strength, and the Six Minute Walk Test (6MWT) was used to assess cardiovascular endurance. At the activity level, the 10 Meter Walk Test (10MWT) was used to measure ambulatory status and the Timed Up and Go (TUG) was used to measure fall risk. At the participation level, the Falls Efficacy Scale – International (FES-I) was used to measure The FTSST is an IFC body structure and function measure that assesses functional lower extremity muscular strength in patients with stroke. The FTSST requires the patient to rise from a seated position and descend back to the seated position without the support of their arms as fast and safely as possible. The total time taken for completion of five repetitions is measured. The FTSST has an established cut-off score of 12.2 seconds (s) that distinguishes individuals post-stroke who has impaired LE strength from those who do not.10 If the patient with chronic stroke were to score greater than 12.2 s on the FTSST that score would indicate that patient has impaired lower extremity muscular strength. The minimal detectable change (MDC) at a 95% confidence level (MDC95) for patients with chronic stroke is 5 s.11 The minimal clinically important difference (MCID) for the FTSST has not been established. A change in a score greater than 5 s allows for a clinician to conclude with 95% confidence that a real change in performance has occurred. The 6MWT is an IFC body structure and function measure used as a sub-maximal test that assesses aerobic capacity and cardiovascular endurance in patients with stroke. The 6MWT has a standard error of measure (SEM) of 11.9 meters (m) and the normative data shows a mean of 413 m, with a range from 129-664 m for patients with chronic stroke.12 The 6MWT has an MDC95 of 36.6 m or a 13% change to indicate a real change for patients with chronic stroke.13 There is no established MCID for the 6MWT for patients with chronic stroke. According to the most current research, the MCID for patients with sub-acute stroke ranges from 20 to 50 m. A change in 20 m indicates a small meaningful change and a 50 m change indicates a substantial meaningful change.14 The 10MWT is an ICF activity level measure that assesses gait speed in patients with stroke. The 10MWT has cut-off scores that can be used to classifying a patient's ambulatory status. If the patient were to score less than 0.4 meters per second (m/s), the patient would be categorized as more likely to be a household ambulator. Score of 0.4 – 0.8 m/s indicates the patient would be a limited community ambulator and a score of more than 0.8 m/s they were listed as community ambulators.15 For patients with acute stroke, the SEM is 0.04 m/s.14 The MDC95 for patients with chronic stroke is 0.13 m/s.16 The MCID ranges from 0.06 m/s for a small meaningful change to 0.14 m/s for a substantial meaningful change.14 This MCID is based on research on patients with acute stroke, and is the closest supporting research available for those with chronic stroke. The TUG is an activity level measure that assesses mobility, balance, walking ability, and fall risk in older adults with chronic stroke. The TUG has an SEM of 1.14 s in patients with chronic stroke.13 The TUG has an MDC95 of 2 s. The MCID has not been The FES-I is a participation level measure that assesses self-concern about falling during easy and difficult activities, both physical and social.18,19 This measure is a self- report questionnaire compiled of 16 questions. Each question is scored 1 to 4, making a total of 64 total points possible. A score of 16 to 19 is considered a low concern for falling, a score of 20 to 27 represents a moderate concern for falling, and a score of 28 to 64 represents a high concern for falling. The FES-I has an SEM of 2.41 and an MDC95 of 6.69 for patients with chronic stroke.18,19 The TUG test was developed for older adults and can be used as a prognostic measure to assess fall risk in patients with stroke. Elderly patients who have had a stroke that take longer than 14 s to complete the TUG are at higher risk for falls.16 The TUG cut-off score for assessing fall risk has a positive predictive value of 59% and a negative predictive value of 72%. Likelihood ratios (LR) used to determine the post-test probability for fall risk in the TUG prognostic measure are as follows: LR+ = 2.3, LR- = 0.64.20 The LR+ of 2.3 means if the patient were identified as being at risk for falls, according to their TUG score, there is a small increase in the likelihood of the patient actually falling. The LR- of 0.64 means if the patient were not identified as being at risk for falls according to his/her TUG score, there is a minimal decrease in the likelihood of the patient actually falling. Examination Data BODY FUNCTION OR STRUCTURE IMPAIRMENTS Measurement Category Test/Measure Used Test/Measure Results Five Times Sit to Total Score: 81 seconds (s) extremity muscular strength (bilateral) Decreased 6 Minute Walk Test Total Score: 228 meters (Patient used four- ACTIVITY LIMITATIONS Measurement Category Test/Measure Used Test/Measure Results Limited gait speed 10 Meter Walk Test Comfortable walking speed: Average speed = (Patient used four- 0.68 meters per second (m/s) Maximal walking speed: Average speed = 0.80 m/s Increased fall risk Total Score: 30 s (Patient used four-wheel walker) PARTICIPATION RESTRICTIONS Measurement Category Test/Measure Used Test/Measure Results Diminished community Church attendance limited to one time per month ambulation for social due to fatigue. Patient reported needing to walk a outings (i.e. church) total of 30 minutes in order to get to and from church. Increased concern for Falls Efficacy Scale The patient was found to have generalized weakness in lower extremity muscle groups as seen by an impaired FTSST, symmetrical gross motor symmetry, no hypertonia of the upper and lower extremity flexors and extensors, and range of motion limitations in her dorsiflexors and plantarflexors. These observations were not reassessed as outcome measures, except for the FTSST. Evaluation
Evaluation Summary
The patient was a 78-year-old female with impairments to the body structure or function, activity, and participation levels of the ICF model. Her impairments caused her to display decreased ability to perform sit-to-stand transfers, decreased endurance, limited gait speed, increased fall risk, and restricted community ambulation. Diagnostic Impression
The patient's two left hemisphere CVAs contributed to her body function and structure impairments, activity limitations, and participation restrictions. The body structure and function impairments were a contributing factor responsible for the activity limitations. The FTSST results showed impaired lower extremity strength and mobility. The 6MWT results showed that the patient had significantly lower walking endurance than patients with chronic stroke, and, as a result, restrictions in community ambulation.21 The results of the 10MWT indicated that the patient was limited in gait speed. The results of the TUG suggests an increase in fall risk. Her limitations to social outings were due to activity limitations. Prognostic Considerations
The patient's positive prognostic indicators included: non-smoker, non-drinker, an expected high-level of compliance to home exercise program (HEP), intact cognitive function, stable living environment, access to medical care, and positive family support. The patient's negative prognostic indicators included: the time since the stroke, having had two CVAs in the same hemisphere, history of HTN which puts her at risk for another CVA, 78 yeas of age, history of cancer, and carpal tunnel syndrome bilaterally which made ambulation for longer duration more challenging due to numbness in her hands while using the walker. Due to fall risk, the patient was not expected to regain the ability to ambulate without her FWW, to independently transfer, or to be independent with going up and down stairs. However, the patient was anticipated to reach the MDC95 for patients with chronic stroke during the FTSST by the completion of the treatment. The patient was anticipated to reach the MDC95 on the 10MWT for patients with stroke during both comfortable and fastest walking speed by the completion of treatment. The patient was anticipated to reach the MDC95 on the 6MWT for patients with chronic stroke. Discharge Plan
The patient was to be discharged to the care of her family, primarily her daughter. Continued assistance with a home exercise program was to be provided. • Current with modifier: G8978CK based on 6MWT • Goal with modifier: G8979CJ based in 6MWT Evaluation and Plan of Care Short Term Goals Planned Interventions (Anticipated Goals) (Expected Outcomes) Interventions are Direct or Procedural unless they (C) = Coordination of care intervention (E) = Educational intervention BODY FUNCTION OR STRUCTURE IMPAIRMENTS Improve Five Times Sit Improve FTSST from 81 Intervention will challenge neuromuscular control extremity functional to Stand (FTSST)from and lower extremity muscular strength during sit- 81 to 75 seconds (s) Minimal detectable change to-stand transfers. at 95% confidence level 2-3x/week for 4 weeks in the clinic Task-specific training of sit-to-stand and stand-to- sit transfers from a chair with repetitions until fatigue following educational protocol. Strength training was progressed by decreasing the height of the chair, placing a foam pad on the chair seat, and using a couch chair in place of the original Neuromuscular control training was utilized to teach the patient to prevent her knees from moving
medially, which was important to control during
swing phase of gait and transfers. Training was
implemented while patient ascended and
descended from the chair and reinforced during
gait training.
Visual feedback via a mirror and video recordings
were implemented during lower extremity strength
training.
(E) Lower extremity strength training (sit-to-
stands) were included in HEP for 10 repetitions for
2 sets 5 days per week following a standard
educational protocol on position and proper body
mechanics.
(E) Kitchen sink exercises were performed 10
times in each direction 3 days per week and were
progressed to 20 times each direction 5 times per
week.
1. All were done with hands on kitchen counter
2. Single leg kicks backward
3. Single leg kicks laterally to each side
(abduction)
4. Marching with high knees (progressed by
increasing height)
5. Heel raises up on to toes (same time)
Patient will demonstrate Patient will demonstrate Interventions will challenge the cardiovascular increased cardiovascular increased cardiovascular system during over ground gait training and during endurance with an endurance with an endurance training using the NuStep.22,23 improved walking improved walking distance 2-3x/week for 4 weeks in the clinic distance from 228 to 243 from 228 to 258 meters on meters on the 6 minute the 6MWT while not (E) Endurance training on the NuStep for 10 walk test (6MWT) while exceeding an RPE of 13 minutes at a progressively increasing workload not exceeding a rate of and MET level each week, based on RPE. RPE to perceived exertion be kept between 11 and 13. (E) Over ground gait training 4-8 laps of 20 meters in distance (per one lap) with 15-30 second breaks as needed based on RPE, patient instructed not to exceed an RPE of 13. Over ground gait training was progressively increased with increase in distance. ACTIVITY LIMITATIONS Limited gait speed Improve 10 minute Improve 10MWT normal Interventions for over ground gait training were to walk test (10MWT) walking speed from 0.68 challenge the lower extremity musculature comfortable walking m/s to 0.82 m/s to improve involved in gait. speed from 0.68 meters efficiency as a limited 2-3x/week for 4 weeks in the clinic per second (m/s) to 0.75 community ambulator Gait training on flat surface with FWW to up- efficiency as a limited Improve 10MWT maximal tempo music. 4-8 laps of 20 meters in distance (per community ambulator walking speed from 0.8 one lap) with 15-30 second breaks. Patient was m/s to 0.94 m/s to improve assessed with the RPE scale and instructed not to community ambulation exceed 13. She was instructed to walk as fast as maximal walking speed possible keeping her head up and looking forward. from 0.8 m/s to 0.87 m/s (MDC95 0.13 m/s) She was shown and educated how to properly heel to improve community strike and toe off during gait. Progressions of over ground training included increased repetitions, stepping over small obstacles while keeping a fast walking pace, and ambulating for a set time (2 minutes, 3 minutes, 5 minutes, etc.) instead of distance. Increased fall risk Patient will demonstrate Patient will demonstrate Combinations of FTSST intervention and over a decrease in fall risk by decrease in fall risk by ground training interventions were used to improving Timed Up improving TUG time from improve and reach the goals for the TUG. and Go (TUG) time PARTICIPATION RESTRICTIONS Diminished Increase the number of Increase the number of Evaluation of four-wheel walker height for community visits to church to every visits to church to every adequate body ergonomics and adjusted as needed. ambulation for social outings (i.e. Therapeutic exercise and over ground gait training Plan of Care - Interventions
Overall Approach
The patient demonstrated impaired lower extremity strength as measured by the FTSST. The musculature involved in sit-to-stand transfers is the same musculature activated during gait. Task-specific training, sit-to-stands and stand-to-sits until fatigue was implemented for the intervention addressing lower extremity strength. Neuromuscular control training was utilized to teach the patient to prevent her knees from moving medially, which was important to control during swing phase of gait and Task-specific training of over ground gait training was also used to increase gait efficiency. By gradually increasing gait speed, duration, and frequency over the treatment duration, the patient would demonstrate an improvement in her aerobic activity capabilities. Rhythmic auditory stimulus was applied during the over ground training portion of treatment to increase gait speed.24 The interventions implemented directly addressed the patient's goals to walk further, increase overall strength, improve stability, and be more active. High repetitions were used during treatment and augmented feedback via the use of mirrors and video recordings so the patient could see herself performing the correct movements. PICO question:
Will an elderly patient with chronic impairments following a stroke (P) show greater improvements in gait speed (O) when utilizing body-weight supported treadmill training (I) versus over ground training (C)? A randomized controlled trial pilot study compared the effects of body weight- supported treadmill training and over ground training. The study looked at the effect on measures of walking function, activity, and participation after stroke (level of evidence: 1b; Pedro score: 8/10).25 The study sample included 20 subjects that were in the chronic stage of stroke and were able to walk independently. Subjects underwent 30-minute walking interventions using body weight-support treadmill training or over ground training that were administered 5 times per week for 2 weeks. The authors concluded that over ground training showed increased benefit compared to body weight-support treadmill training at improving self-selected walking speed. The over ground training group showed significantly greater improvements in comfortable walking speed immediately and 3 months post training compared to body weight-support treadmill The patient of this case study demonstrated an impaired self-selected comfortable walking speed during her 10MWT. This study helped guided the treatment plan to utilize over ground training instead of body weight-support treadmill training. Knowing the patient was only going to receive approximately six treatment, a treatment plan was implemented that would help increase her comfortable walking speed. Not only does over ground training result in significantly increase comfortable walking speed, it was cost effective for the patient to continue to do over ground training post-treatment as part of Outcomes
BODY FUNCTION OR STRUCTURE IMPAIRMENTS Five Times Sit to Minimal detectable change at 95% confidence level (MDC95 5 s) (Patient used four- Minimal clinically important difference (MDC95 36.6 meters) ACTIVITY LIMITATIONS (Patient used four- (MDC95 0.13 m/s) (Patient used four- PARTICIPATION RESTRICTIONS Falls Efficacy Scale Discharge Statement:
The patient was seen for 8 sessions from 4/17/15 to 5/15/15. During the course of care the patient was provided with functional strengthening, over ground gait training, neuromuscular control training, task specific activity integration, and assistive device training with four-wheel walker. The patient was discharged from outpatient physical therapy to continue living at home. The patient and her daughter were educated, and expected to be independent in performing HEP exercises addressing the same interventions used during treatment. The patient was discharged from physical therapy after reaching all short-term and long-term goals. DC G-Code with modifier:

• Mobility: Walking & Moving Around Current: G8980 o Modifier: CJ 20-40% impaired o Patient walked 276 m with FWW in the 6MWT at last visit Discussion
All of the patient's goals were met at each IFC level. Improvements can be attributed to the patient's motivation and compliance with the POC and HEP to increase overall strength and become more stable, and to ultimately become a safer ambulator. The plan of care focused on improving the patient's impairments including strength, cardiovascular endurance, gait speed, ambulating efficiency, and an elevated fall risk. Therapeutic interventions consisted of repetitious task specific training, over ground gait training, and neuromuscular control training. Improvements in lower extremity muscular strength and distance ambulated were two of the most significant changes the patient experienced. These improvements are demonstrated by post-test measures that exceeded the MDC95 for the FTSST and the MDC95 for the 6MWT. Overall, this course of physical therapy was successful for this patient due to her improvements in her lower extremity strength, cardiovascular endurance, gait efficiency, and risk for falls. When treating similar patients in the future, I will apply similar interventions with the addition of ROM exercises. I will also apply gait training that emphasizes obstacles that mimic their home environments instead of focusing solely on community ambulation. I did a home evaluation, however, I did not emphasize gait training specifically within the context of her living environment. The patient had deficits with balance and coordination; in future examinations I will more thoroughly examine the vestibular system. Prior to treating my next patient who has experienced a stroke, I will evaluate the available evidence pertaining to the most clinically relevant interventions for improving balance. References
1. O'Sullivan S, Schmitz T, Fulk G. Physical Rehabilitation. United States: F.A. Davis Company; 2013. 2. Post-Stroke Rehabilitation Fact Sheet. 3. Mozaffarian, Benjamin E, Go A, et al. Heart Disease and Stroke Statistics--2015 Update: A Report From the American Heart Association. Circulation. 2014;131(4). doi:10.1161/cir.0000000000000152. 4. Goodman CC, Catherine C. Goodman, William G. Boissonnault Kenda S. Fuller. Pathology: Implications for the Physical Therapist. 2nd ed. Philadelphia: 5. Ferrarello F, Baccini M, Rinaldi LA, et al. Efficacy of physiotherapy interventions late after stroke: a meta-analysis. Journal of Neurology, Neurosurgery & Psychiatry. 2010;82(2):136-143. doi:10.1136/jnnp.2009.196428. 6. Romero J, Morris, Pikula. Review: Stroke prevention: modifying risk factors. Therapeutic Advances in Cardiovascular Disease. 2008;2(4):287-303. 7. Association NS. Uncontrolled Risk Factors Accessed February 7, 2015. Accessed July 11, 2015. 9. Atkinson H, Nixon-Cave. A Tool for Clinical Reasoning and Reflection Using the International Classification of Functioning, Disability and Health (ICF) Framework and Patient Management Model. Physical Therapy. 2011;91(3):416- 430. doi:10.2522/ptj.20090226. 10. Mong Y, Teo T, Ng S. 5-Repetition Sit-to-Stand Test in Subjects With Chronic Stroke: Reliability and Validity. Archives of Physical Medicine and 11. Pardo V, Knuth D, McDermott B, Powell J, Goldberg A. Validity, reliability and minimum detectable change of the maximum step length test in people with stroke. Journal of the Neurological Sciences. 2013;325(1-2):74-78. 12. Van de Port, I., Wevers, L. and Kwakkel, G. (2011) ‘Is outdoor use of the six- minute walk test with a global positioning system in stroke patients' own neighbourhoods reproducible and valid?', Journal of Rehabilitation Medicine, 43(11), pp. 1027–1031. doi: 10.2340/16501977-0881. 13. Lexell J, Flansbjer UB, Holmback AM, Downham D, Patten C. Reliability of Gait Performance Tests in Men and Women With Hemiparesis After Stroke. Journal of Rehabilitation Medicine. 2005;37(2):75-82. doi:10.1080/16501970410017215. 14. Perera S, Mody S, Woodman R, Studenski S. Meaningful Change and Responsiveness in Common Physical Performance Measures in Older Adults. Journal of the American Geriatrics Society. 2006;54(5):743-749. 15. Schmid, Duncan P, Studenski, et al. Improvements in Speed-Based Gait Classifications Are Meaningful. Stroke. 2007;38(7):2096-2100. 16. Hiengkaew V, Jitaree K, Chaiyawat P. Minimal detectable changes of the Berg balance scale, Fugl-Meyer assessment scale, timed ‘Up & Go' test, gait speeds, and 2-Minute walk test in individuals with chronic stroke with different degrees of ankle Plantarflexor tone. Archives of Physical Medicine and Rehabilitation. 17. Kim JS, Chu DY, Jeon HS. Reliability and validity of the L test in participants with chronic stroke. Physiotherapy. 2015;101(2):161-165. 18. Azad A, Mehraban A, Mehrpour M, and Mohammadi B. Clinical assessment of fear of falling after stroke: validity, reliability and responsiveness of the Persian version of the Fall Efficacy Scale-International. Med J Islam Repub Iran. 19. Yardley L. Development and initial validation of the Falls Efficacy Scale- International (FES-I). Age and Ageing. 2005;34(6):614-619. 20. Andersson Å, Kamwendo K, Seiger Å, Appelros P. How to Identify Potential Fallers in a Stroke Unit: Validity Indexes of 4 Test Methods. Journal of Rehabilitation Medicine. 2006;38(3):186-191. doi:10.1080/16501970500478023. 21. Van de Port I, Wevers L, Kwakkel. Is outdoor use of the six-minute walk test with a global positioning system in stroke patients' own neighborhoods reproducible and valid? Journal of Rehabilitation Medicine. 2011;43(11):1027-1031. 22. Billinger SA, Taylor JM, Quaney BM. Cardiopulmonary Response to Exercise Testing in People with Chronic Stroke: A Retrospective Study. Stroke Research and Treatment. 2012;2012:1-8. doi:10.1155/2012/987637. 23. Billinger SA, Mattlage AE, Ashenden AL, Lentz AA, Harter G, Rippee MA. Aerobic Exercise in Subacute Stroke Improves Cardiovascular Health and Physical Performance. Journal of Neurologic Physical Therapy. 2012;36(4):159- 165. doi:10.1097/npt.0b013e318274d082. 24. Suh JH, Han SJ, Jeon SY, Kim HJ, Lee JE, Yoon TS, Chong HJ. Effect of rhythmic auditory stimulation on gait and balance in hemiplegic stroke patients. NeuroRehabilitation 2014;34(1):193-199. doi: 10.3233/NRE-131008. 25. Combs-Miller S, Parameswaran K, Colburn, et al. Body weight-supported treadmill training vs. overground walking training for persons with chronic stroke: a pilot randomized controlled trial. Clinical Rehabilitation.

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Dermato 341-maquette6:dermato 332 maqbc

DERMATO 341-maquette6:Dermato 332 MAQbc 25/06/10 12:54 Page14 erèit Dépression et dermatologie, norF un problème fréquent : l'exemple du psoriasis DÉPRESSION PSORIASIS La comorbidité psychiatrique est fréquente en dermatologie pour diversesraisons. Parmi les troubles psychiatriques, la dépression est le plus fréquent.Parce qu'il s'agit d'une maladie fréquente, le psoriasis est un très bonexemple pour illustrer la problématique de cette comorbidité.

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Volume: 2, Issue: 1 April 2015 Twin Deficit Hypothesis: A Case of Pakistan Farrah Yasmin The Women University, Multan Pakistan Abstract: The prime motive of this study is to scrutinize the twin deficit for annual time series data over the period 1990-2010 for Pakistan. Twin deficit hypothesis expressed that an expansion in budget deficit will ground for rise in current account deficit. To diagnose affiliation amongst couple of variables, applied Unit root test (ADF-test), Johansen cointegration technique, Impulse response function and Granger causality test. The Granger causality demonstrate that the causality direction travel from current account deficit to budget deficit. When current account deficit occurs it leads to budget deficit. So the finding proves that there is a positive connection among both variables. Investigations are most reliable for Pakistan economy. Finally, this study confirms the rapport amid current account deficit and budget deficit. Keywords: Budget deficit, Current account deficit, Pakistan