Week 1

Situation:
patient A is a 65yr old who had a left anterior cerebral artery stroke one month ago. He has a right hemiplegia, very poor sensation in his Right upper and lower limb (particularly lower limb), he has short term memory loss, and is confused and disorientated. Patient A is leaning to the right in sitting, and pushes to the right when assisted to perform a sit to stand. Patient A also has a history of chronic lower back pain, which he has been complaining of over the last month. Today patient A is sitting in his recliner wheel chair, he has an arm support for his right arm. Patient A's wife has been visiting for approximately 5 hours every day and attending the physiotherapy sessions.

Task:
My task is to work on Patient A's sitting posture. I need to try and stop him from leaning to the right, increase his trunk extension and get him into more of an anteriorly pelvic tilted position, as he has been sitting very 'slumped'. My next task to practice a sit to stand. As patient A is 2 assist for all of his mobility, my supervisor will be assisting in the session. My final task is to practice standing posture and facilitate some weight transfer.

Actions:
I started off by asking Patient A if he could feel that his alignment was off center. I asked him to line his nose up with the middle of his knees. I then asked him to reach to the left for my hand, and kept him reaching until he brought his trunk back to the center of his body. As patient A was having difficulty with these tasks, i used a mirror to give him some visual feedback. I then progressed the treatment to a sit to stand with 2 assist. We blocked the right lower limb and facilitated hip extension, using a zimmer frame for support whilst we worked on standing posture.

Results:
Patient A was extremely distracted throughout today's session. He complained of back pain the whole time and seemed very confused and very distressed about something. When we questioned him as to what it was he was thinking about, patient A explained to us that he was confused about what had happened to him and why his body would not do as his brain wanted it to. He explained that he had lost all sense of time, and he was constantly paranoid that his wife was leaving him and not returning. Patient A stated he thought it had been a whole year since he had seen his wife, when really it had been one day. When i asked patient A if he could feel where his trunk was in space, or if he could feel how much pressure he had on each buttock and through his feet, he explained he couldn't feel anything and that he felt like he was sitting 'in the middle'. We had to stop the session early as patient A was experiencing very bad lower back pain and was very distressed and fatigued.

Evaluation:
It was apparent from patient A's behavior and response to the treatment today that Patient A has a lot of frontal lobe changes that are interfering with his physical progression. We are unaware as to whether the confusion is a result of his medications or whether it is a result of the stroke. Patient A 's lower back pain also seems to be exacerbated by his decreased mobility and poor sitting posture. We will need to liaise with the occupational therapist and the nursing staff to find some strategies to decrease patient A's level of distress. We will also need to give patient A's wife some strategies to manage his behavior.

Strategies:
1: Sensory bombardment; I am going to try and give patient A's right LL and UL lots of sensory input such as, pounding, approximation, weight bearing through the right lower limb and tapping of the muscles to see if i can awaken any of his sensory receptors, to give him more feed back about his posture and body position.
2: educate his wife and the nurses to constantly correct his sitting posture by asking him to reach out to the left.
3: Ask his wife to write down and date whenever she comes into the hospital or leaves, so that patient A is not distressed by her absence.
4: Start getting patient A to use a diary to write down his daily activities and thoughts. This may help to lessen the confusion and disorientation.
5: get some routine into patient A's daily activities. For example arrange physio so that it is at the same time every day. Twill enable patient A to have some consistency in his day to day life.
6: liaise with the nursing staff and doctors about giving patient A his pain medication before physio so that the lower back pain does not interfere with the session.
7: Liaise with the occupational therapy staff about a cushion for patient A's wheel chair (maybe one side more raised, to help correct the right lean.)