Hey there crew,
This past week I had the opportunity to work with a sub-acute stroke patient on my placement. The patient was admitted to hospital after a fall and suffered a right MCA infarct the following day. After almost a month of rest in bed and no time spent sitting out bed, the patient slowly improved and was moved to the ward. I had the privilege of being there the first day this patient was transferred to the wheelchair and taken to the physiotherapy gym.
Initial assessment findings revealed Gowland Postural Control stage 1/7, Arm stage 1/7 and Leg stage 1/7 in addition to perceptual deficits leading to the patient having left unilateral neglect. As the stages of recovery suggest, the patient has flaccid paralysis of both the upper and lower limb as well as decreased tone of the trunk and pelvic muscles. The patient has left side diminished light touch and intact JMS but mod-severe left side sensory inattention. Our initial goals are to improve static sitting endurance, bed mobility and transfer ability. However, my knowledge of how to progress recovery of voluntary control from stage 1 is rather limited. Our teachings have been mostly around re-training balance, whether in sitting or standing, and activating muscles through active assisted exercises.
My clinic tutor was able to provide a few ideas that I think would be helpful to share with the crew. The theories of adding proprioceptive and vestibular stimuli become handy in this situation. Such as having the patient in crooklying and then the therapist oscillating weight through the patient’s knees so that approximation of the hip joints occur as well as stirring up the vestibular system. Then doing active assisted lower limbs movements after adding that stimuli.
Additionally due to the left sided neglect, time spent during the session having the patient attend to sensory stimuli along the trunk, left upper and lower limb is effective. Providing stimuli such as heavier pressure than light touch and having the patient attend visually to the limb prior to facilitating movement in the limbs will be an intervention that will be used this week.
If any of the crew have further ideas to help make my treatment sessions effective I would really appreciate some feedback.
Thanks
Gareth
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Hey Gareth
Some other things we have been shown is using active assisted PNF patterns of movement, with specific verbal cues (eg PUSH your hand down then touch your chin, etch)to facilitate movement, and having specific goals, such as the patients chin, another staff memebers hand, the bed, etc for the patient to aim towards. This works for the upper and lower limbs.
Working on the arm, another good exercise is active assisted protraction/retraction of the scapula with the shoulder flexed to 90, to enable to patient to gain some proximal stability.
Also just some weight bearing exercises for the arm and leg will provide proprioceptive and sensory input as well as firing up the muscles. So standing as soon as you can for the legs, and just putting weight through the hand with the arm extended and positioned slightly posterior to the trunk for the arm.
For sitting balance, what we did was just begin by providing as much support as the patient needed with one perosn in front and one behind, and then slowly taking away our support to see how much the patient could do on their own, which was often much more than I had expected.
Hope that stuff works.
Bini
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