Hi guys,
Currently I am doing my Neurological placement in the acquired brain injury ward. I am finding it a very rewarding experience both on a professional level and a personal level as one of the patient’s I am treating is a friend.
My patient ‘Tony’ is a 49 y.o. male who suffered right frontoparietal lesion after a traumatic accident and subsequent subdural and subarachnoid haemorrhage. At the scene Tony had a GCS of 3, with readings “below 6 or 7” (I think, Kate Smith ‘07) being associated with a high mortality rate. The accident occurred whilst at work on a rural property and the patient had to be transferred to Royal Perth Hospital by the Royal Flying Doctor Service. The following day a hemicraniectomy (partial removal of the skull) procedure was performed to relieve ICP. Over the next few weeks the patient remained in a serious but stable condition before having massive bilateral pulmonary emboli resulting in the patient being ventilated on CPAP at Fi 1.0 with SaO2 90%. Since then the patient has been transferred back to the ward and is currently undergoing extensive rehabilitation.
Currently 10/52 post injury the patient is independent for bed mobility, W/C mobility; standby supervision for transfers (WC←→bed) and moderate assistance of 1 for walking.
Tony can sit independently on the bed and can maintain his sitting balance both with internal and external displacement. Tony can stand independently for approximately 30 seconds and can shift his weight within his BOS but cannot stand on one leg. Tony also displays ataxia, dysmetria, dysdiadochokinesia and incoordination with his cerebellar testing. Tony’s impairments contributing to his loss of mobility and function include:
- decreased control of trunk, abdominals, back extensors and pelvic girdle
- decreased strength of the muscles of left side of the body
- diminished sensation of the left leg
- diplopia
- loss of ROM of the left shoulder, wrist and hand
Tony’s goal is to be able to walk again, return to work and home. Treatment so far has been aimed at improving strength of the upper and lower limb muscles, trunk strengthening exercises, sitting balance exercises and recently standing balance exercises have just commenced. Gait retraining has also been implemented with encouraging results thus far. Exercises which I have used include those learnt at uni in our neurological labs. It has been an immense experience implementing these with real patients in a clinical setting as the results gained so far have been very encouraging. When I firstly started treating Tony his limits of stability in sitting were severely reduced and he couldn’t stand independently. Initially he also needed the assistance of 2 to walk, and with assistance of my clinical tutor he can now walk with moderate assistance of 1 (myself). The improvement in Tony’s condition has been great to see from a professional experience and a personal one as well, as he really enjoys his treatments and works very hard in physio with me.
I was hoping if anyone can suggest treatments for Tony’s cerebellar signs and symptoms that can improve function? I know one treatment option is alternating isometrics but if anyone else can give further suggestions that would be fantastic.
Thanks
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Hey Mike,
My neuro placement last semester was at SCGH. I really enjoyed it as well it was very rewarding work. Quite a few of my patients had cerebellar signs all with varying levels. Due to this I became familiar with a variety of treatment strategies for both very high and low level cerebellar exercises. Where does your patient display these signs? Are they only in his limbs or does he have trunk ataxia? If so Bridging is very good for trunk ataxia. And holding a bridge while marching the feet can be very challenging on the trunk. I used the additional techniques such as alternating isometrics, rhythmic stabilization in a variety of positions. The positions were the most important I found adding variety and fun to the session 2pt, 4pt, bridging were common. I always just made sure they were on the edge of their balance. Those external displacement strategies ( AI’s RS) are good for lower level exercises. For the higher level I learned that it is important to have them externally displace themselves. For example on the trampoline or if you don’t have a trampoline then have your patient jump up and land. Their body learns to react to the displacement that they have caused on their own. I was so nervous at first and guarded like crazy however it was really neat watching their bodies react they progressed and adapted very rapidly. Start with little hops with the plinth up high so they can support themselves and gain confidence. Then of course you can alter variables such as one foot hops. Landing on different surfaces (foam) and taking off from different surfaces. Finally I know they have the outpatient running program at RPH that is high level and so they can continue with these high level activities which I referred my patient to. Hope those ideas help. Good luck enjoy.
DANI
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