1. Daniel Woodward
East Tennessee State University, Year II
Mount Pleasant Manor

2. 
1. Pelvis Anatomy:
 Sacrum
 Coccyx
 Ilium
 Ischium
 Pubis
2. Pelvis Functions:
 Provides link between spine & lower extremities
 Provide stability for trunk & legs
 Transmits body weight downward
 Absorbs forces when standing & walking
 Serves as bony site for muscle attachment
 Protects internal organs in lower abdominal region
Introduction
[10] [14]
SPR
IPR

3. 
1. Classification:
 High Impact Injury vs. Low Impact Injury
 Stable vs. Unstable
2. Pelvic Fractures associated with:
 Increased mortality rates in the elderly
 Decreased mobility & independence
 Increased hospital stay
 Substantial health care cost
Pelvic Ring Fractures
[2,4,11]
High Impact
Low Impact

4. 
Right Superior and Inferior Pubic Rami Fracture
1. Date of Injury: 1/08/13
2. Mechanism of Injury:
 Patient fell at home when walking to bathroom; legs gave way as she
fell on her bottom
3. X-Rays confirmed stable pubic rami fractures
4. Received Acute PT/OT for pain management in hospital
5. Discharged 1/15/13 from hospital to sub-acute rehab facility (Mount
Pleasant Manor)
Patient Injury

5. 
Medical Diagnosis
Right Superior & Inferior Pubic
Rami Fractures [13]
Muscles Attaching
around the Pubic Rami
[12]

6. 1. Injury Classification:
 Low Impact
 Stable
2. MOI:
 Trauma usually due to a simple fall (fall less than 3 feet)
3. Occurrence:
 Commonly occurs in the elderly (60+ years old)
4. Females > Males
5. Symptoms:
 Bruising, swelling, or crepitus in pubis region
 Pain in groin, lateral hip, or the buttock area when WB
 Decreased ROM/strength due to pain
 Decreased ability to perform SLR on affected side
 Antalgic gait for those who can ambulate
Epidemiology
[11]

7. 
1. Current Treatment Strategies:
 Pain management, rest, maintain ROM & strength, & gait
training with protected weight bearing.
2. Prognosis:
 Varies depending on patient age, mental status, & overall
health
 Injury usually heals quickly due to large amount of soft
tissue in this area.
 Most healthy patients require protected weight bearing for
about 6 weeks until the pain has diminished
Epidemiology
[6, 8, 11 ]

8. 
1. To examine deficits of a patient who
has suffered a right superior & inferior
pubic rami fracture
2. To create an effective treatment plan
utilizing evidence based practice to
address deficits associated with injury
Purpose Statements

9. 
1. Tinetti’s Gait & Balance Assessment Score
2. Level of Assistance Required for Functional Tasks
3. Ambulatory Distance
4. Pain Rating
Outcome Measures

10. 
1. Medical History:
 75 year old female
 Severe osteoporosis with multiple fractures
 Right TSR, Left RCT repair
 Right THA, Left THA with 2 revisions (15 years ago)
 Apparent & True Leg length discrepancy
 April 2012 – Fracture of Left femur/patella due to fall
 Most Recent: (R) superior & inferior pubic rami
fracture (stable) & 4th finger fracture due to fall
The Patient

11. 
2. Medial History Continued:
 Depression
 History of Hypertension
 Multiple Bowel Resections; residual spastic colon
 Peptic Ulcer Disease
 Chronic diarrhea
 Inguinal hernia repair
 Bilateral Cataract Surgeries
 FALL RISK!
The Patient

12. 
3. Family History:
 (+) for cancer in her brother
 Sister has peripheral artery disease
 Father had diabetes
 Mother had congestive heart failure
4. Social History:
 Smoked ~ 1 pack per day for more than 50 years
 Does not drink alcohol or abuse any drugs
 Manages well on her own with her ADL’s
The Patient

13. 
5. Medications and POSSIBLE side effects
 Imodium: Dizziness and drowsiness
 Temazepam: Day time drowsiness, muscle weakness, lack
of balance or coordination.
 Vilazodone: Dizziness, fatigue, feeling jittery
 Losartan: Dizziness, drowsiness, confusion
 Omeprazole: Dizziness, confusion, feeling jittery, weakness
 KCl: Confusion, anxiety, muscle weakness
 OxyContin: Drowsiness, dizziness
 Lortab: Anxiety, dizziness, drowsiness, blurred vision.
The Patient

14. 
6. Occupation:
 Retired
7. Living Situation:
 Lives with sister; 9 steps to enter home
8. Prior level of function:
 Ambulated at home without assistive device
9. Precautions:
 WBAT on Right Lower Extremity
 Full Code
The Patient

15. 
Patient Information Measurement
Height 5'4''
Weight 88 lbs
Blood Pressure 135/78 mmHg
Heart Rate 60 bpm
Awareness Alert and oriented x 3
Neurological WNL
The Examination

16. 
1. UE ROM: Non-functional use of (R) shoulder; See OT Eval.
2. LE ROM:
The Examination
Joint Motion Left Extremity Right Extremity Normal Values
Hip Flexion 104° 95° 121°
Hip Extension NOT TESTED NOT TESTED 19°
Hip IR 29° 33° 32°
Hip ER 25° 23° 32°
Hip Abduction 35° 30° 42°
Hip Adduction 15° 17° 20°
Knee Flexion 126° 109° 132°
Knee Extension 0° 0° 10°-0°
Ankle Dorsiflexion 12° 14° 11°
Ankle Plantarflexion 48° 42° 64°
[9]

17. 
1. UE Strength: See O.T. evaluation
2. LE Strength:
The Examination
Muscle Group Left Extremity Right Extremity
Hamstrings 4 (GOOD) 4 (GOOD)
Quadriceps 4 (GOOD) 4 (GOOD)
Adductors 3 (FAIR) 4 (FAIR)
Abductors 4 (GOOD) 4 (GOOD)
Hip Flexors 2+ (POOR) 2+ (POOR)
Hip Extensors NOT TESTED NOT TESTED
Dorsiflexors 4 (GOOD) 4 (GOOD)
Plantarflexors 5(NORMAL) 5 (NORMAL)

18. 
1. Leg Length Discrepancy
 Patient has custom 1 inch (2.54 cm) lift for Left shoe
which she does NOT where.
The Examination
Leg Length Testing Left Lower
Extremity (cm)
Right Lower
Extremity (cm)
Difference
(cm)
True Leg Length 86.5 90 3.5
Apparent Leg Length 90 92.5 2.5

19. 
The Examination
Balance Tests Grade Description
Static Sitting GOOD Patient able to maintain balance without handhold support,
limited postural sway
Dynamic Sitting GOOD Patient accepts a moderate challenge; able to maintain balance
while picking object off floor
Static Standing GOOD Patient able to maintain balance without handhold support,
limited postural sway
Dynamic Standing FAIR Patient accepts minimal challenge; able to maintain balance while
turning head and trunk

20. 
Functional
Tests
Required
Assistance
Description
Bed Mobility Modified
Independence
*Unable to complete rolling to side-lying on either side secondary to pain.
*Required MI to initiate and complete roll half way towards both sides.
Transfers Stand By
Assistance
*Required verbal cueing for safety.
*Required SBA for supine<>sit and sit<>stand/SPT with RW.
Ambulation Contact Guard
Assistance
*Required verbal cueing for proper sequencing of gait to accommodate for
pain and WBAT status for Right LE.
*Ambulated 30 feet with RW.
The Examination

21. 
1. Tinetti’s Balance Assessment Tool:
 Measures patient’s gait & balance
 Scoring: Ordinal scale ranging from 0 – 2
 0 = most impairment
 2 = independence of the patient
 Three measures: Gait assessment score, overall balance assessment
score, and gait & balance score
 Total Balance Score = 16
 Total Gait Score = 12
 Total Test Score = 28
2. Interpretation:
 25 – 28 = Low Fall Risk
 19 – 24 = Medium Fall Risk
 < 19 = High Fall Risk
The Examination

22. 

23. 
1. Tinetti’s Score = 14
 Patient is a HIGH FALL RISK!
2. Pain = 7 / 10
 Pain Description:
 Pain in legs, lower back, pubic region. Pain increased
with SLR, when turned onto side, or in WB; especially
painful on (R) LE in hip & pubic region.
The Examination

24. 
1. Achieves ¾ side-lying to either side using bed rails & without
pain
2. Modified Independent Transfers
 Supine <> Sit
 Sit <> Stand/SPT with a RW
3. Modified Independent > SBA for ambulating with a RW up to
60’
4. GOOD dynamic standing balance
5. Tinetti’s score of 16
Short Term Goals
These goals changed from week to week as patient progressed

25. 
1. Independent Bed Mobility
2. Independent to modified independent Transfers
 Supine <> Sit <> Stand/SPT with RW
3. Modified Independent Ambulation up to 150’ with RW
4. Able to Ascend/Descend 9 steps
5. Final Tinetti’s minimal score of 19
Long Term Goals

26. 
1. Physical Therapy: 5x/week x 4 weeks
 Safety & Moderate Independence with all of the following:
 Demonstrate Functional LE ROM
 Demonstrate Functional LE Strength
 Demonstrate Functional Bed Mobility
 Demonstrate Functional Transfers
 Demonstrate Functional Gait
 Be able to ascend and descend 9 steps
2. Discharge Plan
 Mount Pleasant Manor  Home
Plan of Care

27. 
1. Cryotherapy5
 Research confirms that cryotherapy results in:
 Decreased inflammation
 Decreased blood flow
 Reduced swelling
 Reduced pain
2. Nustep7
 Research supporting this exercise suggests that it:
 Decreases blood pressure
 Increases strength
 Increases walking speed
Evidence Based Practice

28. 
3. Prophylactic Measures11
 Range of Motion
 Strength
 Prevent Immobility
4. Standing Activities/Ambulation1
 Research suggests that weight bearing activities are
effective in preserving or even increasing bone mass.
 Ambulation should be encouraged!
Evidence Based Practice

29. 1. Warm Up
 Nustep 15 minutes at Level 1
2. LE ROM
 Heel slides for hip flexion, hip abduction, & hip adduction; 3 sets of 10
3. LE Strengthening
 Knee extension (quads), bridging (gluts), knee raises (hip flexors); 3 sets of
10
4. Bed Mobility
 Worked on rolling from side to side using modified independence
5. Transfer Training
 Practiced sit<>stand/SPT & sit<>supine using modified independence
6. Cryotherapy
 Ice pack x 15 minutes to control pain
Initial Treatment Plan

30. 
1. Modified 3-point Gait Pattern while using
walker.
2. Importance of using assistive device during
gait/transfers at all times
3. Importance of wearing proper shoes with custom
lift for left shoe
4. Pain Rating Scale
Patient Education

31. 
Pain Scale Interpretation
1. Initial Rating = 7 (Very Intense):
 Pain completely dominates your senses, causing you to
think unclearly about half the time. At this point you are
effectively disabled and frequently cannot live alone.
Comparable to an average migraine headache
2. After Education = 4 (Distressing):
 Strong, deep pain, like an average toothache, the initial
pain from a bee sting, or minor trauma to part of the
body, such as stubbing your toe real hard. So strong you
notice the pain all the time and cannot completely adapt.

32. 1. Warm Up:
 Nustep 20 minutes at Level 1
2. LE Strengthening and ROM Exercises:
 Heel slides for hip flexion, abduction, adduction
 Knee extension (quads), bridging (gluts); 3 sets of 10
3. Gait Training:
 CGA ambulation 30’ x 2 with a rolling walker, breaks, & a more continuous
and symmetrical gait
 Knee raises over small hurdles while ambulating in parallel bars (hip
flexors)
4. Step Exercise:
 CGA stepping exercise on to 2 ½ inch step while in parallel bars ; 3 sets of 10
 Leading with both LE’s
Treatment Progression 1
Step Exercise

33. 
1. Warm Up:
 Nustep 20 minutes at Level 1
2. LE Strengthening Exercises:
 Knee extension (quads); 3 sets of 10
3. Gait Training
 SBA Ambulation 75’ x 2
4. Dynamic Standing Balance Activities
 Tic-Tac-Toe Toss in standing
 Balloon Volleyball in standing
5. Step Exercise:
 CGA stepping exercise on to 4 inch step while in parallel bars ; 3 sets of 10
 Leading with both LE’s
Treatment Progression 2
Tic-Tac-Toe Toss Balloon Volleyball

34. 
1. After three weeks, patient demonstrated sufficient
safety, endurance, and strength with all transfers
and ambulation
2. In order to continue the progression towards further
independence, the W/C was discharged
3. Patient was educated on current status & was asked
to use supervision when ambulating away from her
hall
W/C Discharge

35. 
1. Warm Up:
 Nustep 20 minutes at Level 1
2. Gait Training:
 MI ambulation 150’ x 2 with a rolling walker
3. Standing Balance Activities
 Balloon Volleyball in standing
 Kicking ball activity with Right LE
4. Step Exercise:
 CGA stepping exercise on to 6 inch step on therapy stair set ; 3 sets of 10
 Leading with both LE’s
Treatment Progression 3
Single Leg Stance Activity

36. 
1. Warm Up:
 Nustep 20 minutes at Level 1
2. Gait Training:
 MI ambulation 150’ x 2 with a rolling walker
3. Standing Balance Activities
 Balloon Volleyball in standing
 Kicking ball activity with Right LE
4. Step Exercise:
 CGA ascending with the Left LE and descending leading with the Right LE 4
steps 3x
 Also worked on ascending/descending steps sideways to simulate home
environment.
Final Treatment
Therapy Steps

37. 
Outcome Measures
Outcome Measure Initial Assessment Final Assessment
Tinetti’s Score 14 24
Required Assistance for
Functional Tasks
MI Bed Mobility
SBA Transfers
CGA Ambulation
Independent Bed Mobility
MI Transfers
MI Ambulation
Ambulatory Distance 30 feet 150 feet x 2
Pain Rating 7/10 3/10

38. 
1. Wii Therapy (Balance/Decreased Fall Risk)3
 Research shows that six 1 hour sessions of Wii
bowling simulation significantly improved Berg
Balance, DGI, and TUG scores for an 89 year old
female
Alternative Treatment

39. 1. Aisenbrey, Jeannie A. "Exercise in the Prevention and Management of Osteoporosis." Journal of the American Physical
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<http://www.physther.org/content/67/7/1100.full.pdf+html>.
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People, New South Wales, Australia." Injury 36.11 (2005): 1323-329. PubMed. Web. 12 Mar. 2013.
<http://www.sciencedirect.com.ezproxy.etsu.edu:2048/science/article/pii/S0020138305000495>.
3. Clark, Robert, and Theresa Kraema. "Clinical Use of Nintendo Wii(TM) Bowling Simulation to Decrease Fall Risk in an Elderly
Resident of a Nursing Home: A Case Report." Journal of Geriatric Physical Therapy 32.4 (2009): 174-80. Ebscohost. Web. 10
Apr. 2013. <http://search.proquest.com.ezproxy.etsu.edu:2048/docview/736484473?accountid=10771>.
4. Dodge, Greg, and Rob Brison. "Low-impact Pelvic Fractures in the Emergency Department." Canadian Journal of Emergency
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<http://www.joponline.org/doi/pdf/10.1902/jop.2007.060319>.
6. Hill, R., C. M. Robinson, and J. F. Keating. "Fractures of the Pubic Rami: Epidemiology and Five-year Survival." The Journal of
Bone and Joint Surgery 83-B.8 (2013): 1141-144. Google Scholar. Web. 12 Mar. 2013.
<http://www.bjj.boneandjoint.org.uk/content/83-B/8/1141.full.pdf+html>.
7. Johnson, Timothy, Scott McPhee, and Mary Dietrich. "Effects of Recumbent Stepper Exercise on Blood Pressure, Strength and
Mobility in Residents of Assisted Living Communities: A Pilot Study." Physical & Occupational Therapy In Geriatrics 21.2
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References

40. 
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References