week 3 neuro

S- Today I was to perform my first treatment of Mr B in the neurological inpatients gym after assessing him the day before. Mr B suffered a L pontine stroke on the 12/03/2010 and is now experiencing R sided hemiparesis and hemisensory loss. He also has moderate dysarthria and expressive dysphasia, and since the stroke he has noticed a decrease in motivation, increase tiredness and a general flat affect. Mr B is displaying great movement return, with his number one impairments being a decrease in postural tone and stability, decrease R sided voluntary control and decrease in static and dynamic sitting balance. He doesn't seem to have the abdominal strength to save himself once outside his base of support. Mr B's main goal for now is to be able to stand up and transfer without the use of a hoist.

T-My task was to perform an initial treatment of Mr B targeting his main impairments . As he is quite difficult to transfer (due not only to his lack of voluntary control but also the fact that he is over 6 foot tall and over 90kg) I had to structure the session so that it flowed well (none of my usual sit up, lie down sit up again). I also had to maintain Mr B's interest in order to keep him focussed and motivated.

A-I decided to treat Mr B in supine first and work on his abdominal strength. I thought it was important to get this firing before he was in sitting to prepare his abs for balance work. We worked on sit-ups with a wedge behind Mr B. This made the sit-up easier for him as he didn't need to start from a fully lengthened position. We also worked on posterior pelvic tilt in crook lying, progressing to a bridge. Once we completed these, we moved to sitting. Here we worked on reaching out of his base of support with the left and right hand. We emphasised lateral tilt of the pelvis and trunk righting. Rather than growing on the reaching side Mr B seems to slump or pull down. We practiced component work when reaching with the right working first at the shoulder and breaking the movement into parts. After this, we came into standing and practiced finding the centre (Mr B pushes to the R). To end the session, I gave Mr B a list of exercises for his hand that he can do on the ward. (Previously he was squeezing a stress ball which only works to reinforce the flexor pattern of the arm.)

R-Mr B was happy with the treatment session, particularly coming up to standing. This is his short-term goal and he was so proud to be making the first steps. I was happy that he could prove this to himself, as he was feeling like the situation was hopeless prior to treatment. I also felt that the exercises we did in sitting were very successful at firing up his trunkal tone, as I could see good extensor activity happening in his back after reaching.

E-All in all I think our first treatment session together worked well. I think that the flow of the exercises worked well from a transfer perspective as well as preparing him for each new and more challenging exercise. However, I feel the work we did in supine didn't achieve the desired effect. Mr B seems to take whatever support is given him, thus in supine, he completely switches off and does very little work, which isn't really achieving anything... aside from making me work more! I also found that Mr B led his sit-ups through global extension, particularly leading with his head, so I need to think of some strategies to improve this. In sitting, reaching was very effective at firing up postural tone and preparing him for standing. On the left I made this interesting by incorporating coits, but on the right, he cannot hold coits. As such, Mr B found this a bit boring and lost interest. He is quite hard to motivate, and I became slightly disheartened as he starting yawning a lot! I also felt that reaching to the R is particularly problematic because he hinges from his trunk rather than switching it on to provide a stable base for the scapula. I feel that it would thus be best to reach to the R in standing while his trunk has max input, but his being so tall may not make this possible with only 1 assist. I do however think that we made a great start and I developed a good rapport with Mr B. I really feel that the best thing to come out of the session was proving to Mr B that there is hope and a point in trying, and that with continued work he can only get better!

S-For our next session I have decided to eliminate supine all together. I think for now it is important for Mr B to be doing most of the work and reminding his brain that he can! I do think it is so important for him to work on his abdominal strength, but I will try this in reclined sitting. I will not let him fully rest or let go in the reclined position, forcing him to do the work for himself. I will also get him to do this ab work with his chin on chest, hopefully this prevents global extension and leading with the head. To make the reaching to the R more interesting and in order to involve Mr B more in his own treatment I'm going to try and relate it to something that interests him. He previously worked full time as a bus driver and loved this job, so maybe we can look at holding a steering wheel or flicking indicators. I can also use my voice here to fire him up. Lastly, I think I will give him generally less support. He is capable of working on his own, but takes whatever you give him. I need to make sure that I give him every opportunity to do this, within reason and staying safe. Plus, this will go towards helping him see that he is indeed capable and there is much hope of being functional again.