CPTE Oral Hip Fracture Case Scenario Practice

Mrs. T. presents with complex, multi-system impairments including post-operative left hip fracture, chronic COPD with ventilatory limitation, and Parkinson’s-related bradykinesia and balance deficits.

Her respiratory compromise increases risk of post-operative pulmonary complications, while Parkinson’s disease contributes to reduced motor control and impaired mobility recovery. The interaction between pain, deconditioning, ventilatory limitation, and neurological impairment significantly impacts her functional prognosis.

Given her reduced pre-admission mobility and chronic disease burden, realistic rehabilitation goals must focus on safe mobility, prevention of complications, caregiver education, and appropriate discharge planning, rather than full functional independence.

1.A – Key Factors Influencing Physiotherapy Management

1. Surgical Status

• Acute post-operative patient following hip fracture surgical fixation.
• Pain, inflammation, and weight-bearing status.
• Risk of post-operative complications including DVT, pneumonia, and delirium.

2. COPD

• Reduced respiratory reserve.
• Increased risk of post-operative pulmonary complications, hypoxia, and fatigue with exertion.
• Need for oxygen monitoring and pacing.

3. Parkinson’s Disease

• Bradykinesia and rigidity.
• Postural instability and high fall risk.
• Freezing episodes.
• Reduced automatic movement.
• Possible cognitive slowing.

4. Pre-admission Functional Status

• Significant baseline mobility limitations.
• Likely reduced endurance and ADL independence.

5. Environmental Barriers

• 4 steps to enter the home with no railing.
• Regular bed height.
• Standard toilet.

6. Psychosocial Factors

• Daughter’s expectations.
• Potential caregiver burden.
• Need for education and discharge planning.

1.B – Best Physiotherapy Approach in Acute Post-Operative Setting

1. Early Mobilization

• Bed mobility training.
• Sit-to-stand practice.
• Transfer training.
• Ambulation with appropriate aid, likely walker.

2. Respiratory Management for COPD

• Deep breathing exercises.
• Thoracic expansion exercises.
• Incentive spirometry, if indicated.
• Supported coughing and huffing.
• Early upright positioning.
• Monitor SpO₂, Borg RPE, and dyspnea scale.

3. Parkinson’s-Specific Strategies

• External cueing using visual or verbal cues.
• Rhythmic counting for movement initiation.
• Large-amplitude movement training.
• Allow extra time for transitions.

4. Functional Strengthening

• Sit-to-stand repetition.
• Lower limb strengthening within surgical precautions.
• Balance retraining as tolerated.

5. Education

• Energy conservation.
• Breathing control, including pursed-lip breathing.
• Fall prevention.
• Safe use of gait aid.

1.C – Precautions and Modifications for COPD and Parkinson’s Disease

COPD Precautions

• Avoid overexertion.
• Monitor oxygen saturation.
• Use pacing and rest breaks.
• Avoid supine positioning if dyspneic.
• Watch for cyanosis, excessive fatigue, and increased work of breathing.

Parkinson’s Modifications

• Avoid dual-tasking early.
• Reduce environmental clutter.
• Use simple, clear instructions.
• Anticipate freezing and use floor markers or cueing.
• Emphasize safety during turning.

Combined Considerations

• High fall risk.
• Reduced endurance.
• Slow motor responses.
• Increased fatigue.

2.A and 2.B – Key Multidisciplinary Team Members and Roles

Physiotherapist

• Mobility training.
• Gait aid prescription.
• Stair assessment for 4 steps with no railing.
• Balance and endurance training.
• Respiratory exercises.

Occupational Therapist

• Bed transfer assessment for regular-height bed.
• Toilet transfer assessment for standard toilet.
• Recommend raised toilet seat, grab bars, bed rail, and adaptive equipment.
• ADL retraining.
• Home safety assessment.

Nurse

• Monitor vitals and oxygen.
• Medication administration.
• Wound care.
• Reinforce breathing strategies.

Respiratory Therapist

• Optimize COPD management.
• Provide inhaler technique education.
• Support oxygen titration if required.

Physician / Geriatrician

• Determine medical stability.
• Adjust Parkinson’s and COPD medications.
• Manage comorbidities.

Pharmacist

• Review polypharmacy.
• Optimize levodopa timing.
• Review COPD inhaler optimization.
• Reduce fall-risk medications where appropriate.

Social Worker

• Arrange community supports.
• Coordinate home care.
• Address caregiver expectations.
• Support discharge planning.

2.C – Importance of Interprofessional Collaboration

• Ensures medical stability before discharge.
• Aligns functional goals with realistic outcomes.
• Prevents readmission.
• Reduces fall risk.
• Supports caregiver education.
• Ensures equipment is in place before discharge.

Effective communication prevents fragmented care and promotes safe, patient-centered discharge planning.

3.A – Ethical Principles Involved

• Autonomy: Respecting the patient’s wishes.
• Beneficence: Acting in the patient’s best interest.
• Non-maleficence: Avoiding harm, including unsafe discharge or unrealistic mobility demands.
• Justice: Fair resource allocation.
• Veracity: Honest communication.

3.B – Managing Unrealistic Expectations

Approach:

1. Acknowledge the daughter’s concern.
2. Provide clear clinical reasoning.
3. Use objective findings, including baseline mobility, COPD limitations, and Parkinson’s progression.
4. Use functional outcome measures where appropriate.
5. Emphasize safety over complete independence.

Example response:

“I understand you want your mother fully independent again. Based on her Parkinson’s and lung condition, our goal is to maximize her safety and independence within realistic limits.”

Maintain empathy while setting professional boundaries and explaining clinical reasoning clearly.

3.C – Establishing Realistic, Patient-Centered Goals

1. Involve the Patient

• Ask: “What is most important for you at home?”

2. Use SMART Goals

• Specific.
• Measurable.
• Achievable.
• Relevant.
• Time-bound.

Example Goals

• Ambulate 15–20 metres with walker and supervision.
• Independently transfer bed-to-chair.
• Climb 4 steps with assistance.
• Perform basic ADLs with adaptive equipment.

Focus on:

• Safety.
• Quality of life.
• Energy conservation.
• Functional independence within realistic limits.