Topic 2 - Intervention

SITUATION

A 53 yr old man was admitted to SCGH with a large cerebellar bleed. This has left the man extremely confused and disorientated to time and place. He showed positive cerebellar signs in his objective assement (DDK, dysmetria and dysynergia, poor dexterity, + rebound phenomenon), along with truncal and limb ataxia, severe nausea, poor standing balance and was 2x mod-max A with ambulation. He is SBA with supine - SOEB and STS. His gait was poor, because of his bad wt t/f to the right, not allowing him to have a successful swing on the left which left him shuffling his feet. He also had a decreased stance phase on the left due to quads fatigue which started to fatigue as soon as he was standing. He had increased tone in his R gastroc which left it tight and caused him to hyperextend his R knee. His posture in sitting was highly kyphosed and it was very hard to move him out of posterior pelvic tilt, and he tended to wt bear on his R side. This man owns a chaffeur business and was worried about the running of it. Due to his confusion, he thought he was able to go home over nights, leaving him distressed when he was not able to leave (therefore him not fully grasping the extent of his injuries) which lead him to try to oget up during the night and walk, causing him to have falls and a posey jacket to be placed on for when he was in the bed, and a restraining tray when he was sitting in the chair. The plan for him, was to be referred to SPH and await placement

TASK

After a thorough assessment, an appropriate intervention was needed. As the man was previously independent, the aim was to try to get him to that functional level as best as we could before he was accepted into SPH. The areas chosen to treat were his truncal ataxia, poor standing balance, R calf length, wt t/f and ambulation.

ACTION

We took the patient to the gym and got him onto the plinth. There we explained that this treatment would help with his trunk instability. In bridging, we did rhythmic stabilisation. After >5 minutes we got him SOEB and then standing up with a bolster infront of him for him to lean on and a wedge under his right foot so that it was giving his right gastroc a stretch. While stretching his R gastroc, I was using facilitation to try to activate his L quads to stop them from fatiguing so easily. After 5 mins we stop to allow him to rest. We then got him up standing again without the wedge and asked him to slowly lower one arm, and to maintain static standing for as long as possible. We did this a few times with rests in between. He improved as he did it more. We then went onto standing with reaching, which would help with balance and also wt t/f. Lastly, we tried 2mod-max ambulation.

RESULT

The treatment session ran smoothly which was good. The facilitation to the L gastroc wasnt successful and it continued to shake throughout the whole treatment. When practicing standing balance, the patient tended to lean back onto his heels and then lose his balance backwards. He managed to maintain static standing for 5 secs but then with practice managed ~15secs. Reaching worked well to get him to shift his wt from side to side and he was surprisingly from his poor static standing, sometimes able to bring himself back into midline. He was able to reach further to the L but not the R and i think this was due to his truncal instability. His ambulation was still poor, as he still didnt effectively wt t/f to the R to clear his L foot, and he still shuffled after verbal prompting for big steps. He was able to ambulate ~10 m before his quads fatigue made his gait inefficient.

EVALUATION

When Rx his truncal ataxia, i found the choice of words i used was important to getting the right reaction out of the patient. I initially started saying for my rhythmic stabilization instructions "push against me" and i found that the patient didn't really understand what i meant, but i found much better results with "Don't let me move you." I think when Rxing his L quads fatigue next I'll continue the tapping, but it maybe that it just requires to build up its endurance, or instigate the facilitation earlier (before/during STS). During standing balance exercise, I found it challenging to try to convey the need for him to center his wt in the middle of his feet, and even with verbal prompting he still continued to lean back on his heels. Next time I think I'll work on his posture in standing as i think that may be the reason why he tended to lean backwards. Such prompts as "tuck your bottom in", "turn on your tummy muscles", "grow tall and look forward" and "bring your weight into the center of your feet" might be useful to achieve good standing posture and then allow him to have maintain his balance and not fall backwards. To help with his ambulation, I think i need to continue with wt t/f exercises but also maybe adding in wt t/f then facilitate bending his L knee and DF of his L foot to help with the swing phase to stop him shuffling.

STRATEGIES
I think my main setback during the Rx session was my word finding ability. I think i need to work on giving clearer instructions, especially when working in a neuro facility. I also need to work out where best to place my hands during facilitation to be able to get the best result out of the treatment. I think this will come with experience in what works best for me, yet still getting the best result.