What is the approach to managing a patient with mobility problems?

Managing Mobility Problems: A Comprehensive Approach

The most effective approach to managing a patient with mobility problems involves standardized assessment using validated tools like the Timed Up and Go (TUG) test and 4-Stage Balance Test, followed by implementation of a multicomponent exercise program that includes balance training, strength training, gait training, and aerobic exercise. 1, 2

Assessment and Screening

Initial Mobility Evaluation

• Use validated screening tools:
  • Timed Up and Go (TUG) test: Patient rises from chair, walks 3 meters, turns, returns to chair, and sits down. Time >12 seconds indicates increased fall risk 1
  • 4-Stage Balance Test: Patient stands in 4 increasingly challenging positions for 10 seconds each (feet side by side, semitandem stand, tandem stand, single-foot stand). Inability to hold tandem stand for 10 seconds suggests increased fall risk 1
  • Three key screening questions: 1) Have you fallen in the past year? 2) Do you feel unsteady when standing/walking? 3) Are you worried about falling? 1, 2

Identify Contributing Factors (P-SCHEME)

• Pain (axial or lower extremity)
• Shoes (suboptimal footwear)
• Cognitive impairment
• Hypotension (orthostatic or iatrogenic)
• Eyesight (vision impairment)
• Medications (centrally acting)
• Environmental factors 1

Intervention Strategies

Exercise Interventions

1. Balance training: Tai chi, standing exercises with progressively reduced base of support
2. Strength training: Focus on lower extremity muscles with 3 sets of 8-10 repetitions at 50-70% of 1 repetition maximum 2
3. Gait training: Walking with proper technique, navigating obstacles
4. Aerobic exercise: Walking, stationary cycling

Medication Review

• Evaluate medications that may contribute to mobility problems, particularly centrally acting medications 1, 3
• Be cautious with medications like baclofen that may cause sedation and affect balance 3
• Consider polypharmacy (≥5 medications) as a risk factor for mobility problems 1

Assistive Devices

• Provide appropriate mobility aids based on assessment:
  • Canes for mild balance impairment
  • Walkers for moderate balance/strength issues
  • Wheelchairs for severe mobility limitations 2
• Ensure proper fitting and training in the use of assistive devices

Environmental Modifications

• Home safety assessment and modifications:
  • Remove tripping hazards
  • Install grab bars in bathrooms
  • Improve lighting
  • Consider ramps or stair lifts if needed 2

Special Considerations

Functional Neurological Disorders

For patients with functional movement disorders:

• Encourage optimal postural alignment at rest and during activities
• Promote even weight distribution in sitting, transfers, standing, and walking
• Grade activities to increase use of affected limbs with normal movement patterns
• Avoid prolonged positioning of joints at end range 1

Cognitive Impairment

For patients with cognitive impairment affecting mobility:

• Simplify instructions and environment
• Establish predictable routines
• Consider underlying factors like pain, sensory changes, and caregiver communication style 1

Monitoring and Follow-up

• Schedule regular follow-up visits to assess progress
• Reassess balance and gait using standardized tests
• Adjust interventions based on progress and emerging issues 2

Common Pitfalls to Avoid

1. Overlooking pain as a contributor: Always assess and manage pain that may limit mobility
2. Focusing only on assistive devices: While helpful, they should complement rather than replace exercise interventions
3. Neglecting psychological factors: Fear of falling can significantly limit mobility even when physical capacity exists
4. Inappropriate splinting: May prevent restoration of normal movement and potentially worsen symptoms in some conditions 1
5. Ignoring medication side effects: Some medications can cause sedation, orthostatic hypotension, or other effects that impair mobility 3

By systematically addressing mobility problems through comprehensive assessment and targeted interventions, clinicians can help patients maintain or improve their mobility, independence, and quality of life.