Physiotherapy Management Programme - Case Study Example

Running Head: PHYSIOTHERAPY MANAGEMENT PROGRAMME FOR MRS. B Physiotherapy Management Programme For Mrs. B of Physiotherapy Management Programme For Mrs B Introduction Physiotherapy in the therapy of cerebrovascular accident patients is characterized by diverse techniques such as Brunnstrom, Bobath, Proprioceptive Neuromuscular Facilitation, and the Motor Relearning Programme. The aspiration of the current research was to compare and contrast the effects of two of these techniques in post-cerebrovascular treatment. The two approaches chosen were Bobath and Motor Relearning Programme. The Bobath model represents a theoretical framework in a reflex-hierarchical theory, while Motor Relearning Programme is based in system theory, and is basically task oriented. The patients in this study received strictly one of these two physiotherapy methods during early rehabilitation, while all other aspects of the treatment programmeme were kept alike for all patients. The researcher sought to find out whether variations in motor function, behaviors of daily living and subjective evaluation of life eminence are different under the two treatments. Researchers Langhammer and Stanghelle (2000) randomized the patients into two clusters. They stratified these two groups on the basis of gender and hemisphere site. The man age of the patients was nearly 78 years with approximately similar marital status. Langhammer and Stanghelle that patients treated with physiotherapy according to motor relearning programme had stayed for a short period in hospital and got better in motor technique than patients treated with the technique of Bobath. Further, females treated with motor relearning programme got better in activities of daily living in comparison to females treated with Bobath. The patients either males or females treated with Bobath were a little more reliant at entrance, a result that could clarify an inferior outcome. A substitute proposition could be that the motor relearning programme is not more successful, but basically that it is helpful more quickly, than the Bobath. The treatment rule would not affect the ultimate status of the patient, but may vary the period of improvement. (Langhammer and Stanghelle, 2000) Functional rehabilitation exercises are chosen over the non-functional rehabilitation ones. In case of comparing isometric muscle strengthening in comparison to the functional rehabilitation exercises like wearing a shirt, pressing a ball or combing one’s hairs one will prefer functional rehabilitation. It is noticed rehabilitation using functional exercises is more advantageous than pure muscle strengthening alone like evaluation between combing hairs and an isolated bicep curl. Since combing hairs involve more muscles during exercise at a moment in comparison to isolated bicep curl. The physiotherapy management program for Mrs. B who is 29 years old woman and is suffering from cerebro-vascular accident is being classified into 2 subdivisions, which are: Acute rehabilitation Post acute rehabilitation Physical Therapy Assessment It is very important for the physiotherapist to assess first of all Mrs. B’s mental status, her level of consciousness, memory level and her ability to follow instructions. The physiotherapist should also investigate her emotional and behavioral responses. As Mrs. B is also suffering from aphasia so physiotherapist must evaluate her status about aphasia and collaborate it with speech pathologist. The therapist should carefully examine the functional deficits of dysarthria and dysphagia. A sensory examination should include superficial proprioceptives and combined sensations. (Nathan, 2004) The physiotherapist should evaluate her sensory and perceptual deficits of right side of her body with the left side of the body. Significant information on sensory and perceptual deficits will be provided by close collaboration of occupational therapist. The physiotherapist will also assess her range of motion, joint play and soft tissue compliance. The therapist should also assess her motor control of right upper and right lower extremity. Mrs.’s right side of the body is in flaccid stage so therapist will also assess her daily life activities which include feeding, hygiene, dressing, bed mobility, movement transitions, transfers, gait pattern and stairs. Acute Rehabilitation Plan Rehabilitation during the acute stage can begin as soon as Mrs. B is medically stabilized, most probably within 72 hours. Goals of physical therapy during the early rehabilitation might include: Maintain range of motion of her right side of the body and prevent deformity. Promote awareness, active movement and proper use of her right side of the body. Improve trunk control, symmetry and balance. Improve functional mobility. Initiate self-care activities. Improve respiratory and oromotor function. Monitor changes with recovery. Regulation of blood pressure. (Janet, 2002) Positioning Of Mrs. B Positioning of Mrs. B is one of the first considerations during early rehabilitation. The room should be arranged to maximize her awareness of the hemiplegic side, which is the right one. A bed positioned with the hemiplegic side towards the main part of the room, door and source of the interaction with the nurse, family members, TV, physiotherapist will stimulate her to turn toward and engage her right side of the body. Mrs. B should be placed on a positioning schedule with turning every two to three hours. The supine position should be balanced with other positions since there is a high risk of pressure sores development in the sacral area, heel and lateral malleolus if the leg is externally rotated. It also maximizes reflex effects. (Harvey, 1999) Thus extensor tone associated with the tonic labyrinthine reflex and tonal responses associated with head positions of the tonic neck reflexes e.g. ATNR and STNR may be promoted. A footboard should be avoided since abnormal extensor responses of the foot and leg may be stimulated with a contact stimulus to the ball of the foot that is positive support reaction. (Baker, 1991) Similarly, objects should not be placed in her hand since the grasp reflex may be stimulated, increasing flexor spasticity. Common positions that should be promoted include; Lying in the supine position. The head and trunk of Mrs. B should be positioned in midline or flexed slightly towards her sound side, which is the left one to elongate muscles on the hemiplegic side that is the right one. A small pillow or towel under the scapula will assist in scapula protraction. The arm can rest on a supporting pillow, extended and in abduction with wrist and finger extension. Her pelvis should also protract on a small pillow or towel with the leg in a neutral position relative to rotation. Her right knee should position with a small towel to prevent hyperextension. Lying on her unaffected side. When Mrs. B is lying on her left side, her trunk should be straight, a small pillow under the rib cage can be used to elongate her hemiplegic side. The right shoulder is protracted with the arm well forward on a supporting pillow, with the elbow extended and the forearm in neutral position or supinated. The pelvis is protracted and the right leg flexed at the knee with the hip extended in neutral rotation and supported by a pillow. Lying on her affected side. When Mrs. B is lying on her right side her trunk should be straight. Her right shoulder underneath is positioned well forward with the elbow extended and forearm supinated. Her right leg is positioned in hip extension with knee flexion. When Mrs. B is in sitting position (in bed or wheel chair). She should sit upright with trunk and head in midline alignment. Symmetrical weight bearing on both buttocks should be encouraged. Her legs should be in neutral position with respect to rotation. (Wang, 1998) Exercises For Mrs. B As Mrs. B has also the difficulty in speaking so the therapist should tell her about exercises that are very useful in aphasia e.g. vowels speaking, chewing, blow air in balloons, whistling and tongue movements in all directions. Icing on her tongue will stimulate the gag reflex as well as initiate tongue movements. The physiotherapist’s instructions must be in commanding tone and Mrs. B should perform all these exercises in front of the mirror. Range of motion exercises during early recovery will serve to maintain her normal range in flaccid of right side of her body and to maintain the mobility of joint capsule. In the upper extremity correct range of motion techniques should include careful attention to external rotation of the arm with scapular mobilization and upward rotation during shoulder activities. If the physiotherapist does not perform these motions passively then Mrs.B may experience shoulder impingement, rotator cuff injury and pain. Full range of motion should be performed in all shoulder motions. Inadequate ranging can lead to the adhesive capsulitis. Tightness and swelling of the wrist and finger flexors may develop. Daily range of motion, elevation, massage, icing or compression wrapping may improve the status of her right hand. Splinting in a functional position can also be used. Either volar or dorsal resting pan splints that incorporate her arm, forearm and hand can be used. Weight bearing on her right arm with joint approximation will improve the stabilizing responses of her shoulder muscles. Too much assistance on the part of the therapist can foster dependency and impede motor learning. Rolling, sitting up, bridging, sitting, standing, and transfer activities should be start as soon as possible. Initial treatment strategies should focus on using both sides of the body rather than just the sound side (a compensatory training approach). Guided and active assisted movements provide a good early base for learning. Mrs. B should be given only as much assistance by the therapist as needed and she should be encouraged to actively participate in movement as soon and as much as possible. Rolling and sitting up should be encouraged in both directions, on to the sound side to promote early independence and on to the affected side to encourage functional reintegration of the hemiplegic side. (Appel, 1992) Bridging activities develop control in important functional tasks, including the use of a bedpan and initial bed mobility. They also develop pelvic control, advanced limb control and early lower extremity weight bearing. Bridging activities should include assisted and independent assumption of the posture, holding in the posture and moving in the posture. If she is not able to hold her right lower extremity in a hook lying position then the therapist will need to assist by stabilizing her foot during the bridge activity. Strengthening exercises of her left side of the body should also be regularly done with the help of physiotherapist. During standing and walking, the physiotherapist should stand on her right side. For walking purpose, knee immobilizer can also be applied on her right knee to keep it straight and prevent it from late osteaoarthritis. Walker or quad cane of adjustable size can also be used for ambulatory purpose. She can also go downstairs and upstairs with the help of physiotherapist. She might be depressed because of her illness so to overcome her depression the physiotherapist can play a vital role by encouraging her all the time. This can be achieved with close collaboration of the psychologist and psychiatrist. (Knutsson, 1997) Postacute Rehabilitation Many goals and treatment activities, which were begun during early recovery, will be continued throughout the course of Mrs. B rehabilitation. Some will be modified to appropriately challenge her and propel her to optimal recovery. During the middle late stages of her recovery, she will be out of bed and will be involve in a variety of activities and therapies. (Hall, 1996) It is important to monitor her cardiovascular endurance carefully and avoid overtiring. Physical therapy goals during this period will include, 1. Prevent or minimize secondary complications. 2. Compensate for sensory and perceptual loss. 3. Promote selective movement control and normalization of postural tone. 4. Improve postural tone and balance. 5. Develop her independent ACTIVITIES OF DAILY LIVINGs. 6. Develop her independent functional mobility skills. 7. Develop her functional cardio respiratory endurance. 8. Encourage her to be socializing and motivate her. (Ray-Yau, 2000) Further Exercises For Mrs. B Physical therapy training for Mrs. B in post acute period should be focusing on improving her motor control by stressing selective (out of synergy) movement patterns. Movement combinations that allows success in functional tasks e.g. feeding, dressing, gait should be emphasized. Weak muscles should be activated first in unidirectional patterns and then challenged by activities that stress slow reciprocal movements. This emphasis on balanced interaction of both agonists and antagonists is crucial for normal co ordination and effective function. If she demonstrates the strong spasticity typically seen during the middle phases of recovery may benefit from a number of techniques designed to modify to reduce tone. These include positioning out of reflex dependent postures, reflex inhibiting patterns that encourage movement of weak and hypotonic antagonists. Postures of sidelying, sitting or hooklying should be used frequently. (Cassidy, 1998) Proprioceptive neuromuscular facilitation extremity or trunk patterns (chopping or lifting) that emphasize diagonal and rotational movements combined with techniques designed to reduce tone e.g. rhythmic initiation may also be helpful. Local facilitation techniques (muscle tapping, vibration) may prove success. Activities begun during early training that focus on upright static control and balance should be continued and extended. Sit to stand transitions should be practiced with an emphasis on symmetrical weight bearing and controlled responses on her hemiplegic’s side. Making her stand up and shift her pelvis to one side or the other before sitting down can increase trunk rotation. By using a platform mat for this activity, she can move all the way around the mat first in one direction, then in the other. (Devins, 1996) Her arms should be clasped and held straight ahead during this activity. Modified plantigrade is an ideal posture to focus on symmetrical standing. Progression can then occur to support standing in the parallel bars and to free standing. Initial mobility of her right upper extremity can be achieved by focusing first on her scapular motions. This should be performed in sidelying position where her arm is supported in shoulder elevation with elbow extension. Her arm should mobilize forward and then she should ask to hold that position. If holding is successful then eccentric and reciprocal movements should also be attempted by using techniques of hold after positioning, push pull, modified hold relax active movement or slow reversals. Once initial control is achieved, then her posture can be altered to a more challenging one e.g. sitting and more active control of shoulder and elbow. She should be taught to mobilize her right arm using hands clasped together, which is prayer position. Training of her hand function should emphasize on forearm, wrist, and finger movements independent of shoulder and elbow motions. (Karen, 2000) The therapist needs to observe these movements carefully and to assist her in eliminating those aspects of performance that interfere with effective control. Training of her lower extremity essentially prepares her for ambulation. Pregait mat activities should concentrate on working muscles in the proper combinations needed for gait. Hip and knee extensors should be activated with abductors and dosrsiflexors for early stance. Strong synergy patterns should be broken. She should be encouraged to stand upright with correct posture. During standing and walking the therapist should stand on her affected side, which is the right one, and provide support to her. Before walking ankle foot orthosis and knee immobilizer can also be applied for support and prevention of foot drop and late osteoarthritis of knee respectively. (Edwards, 1999) Balance training in supported standing can also be achieved by using a large gymnastic ball. One therapist will stimulate her mediolateral balance reactions while the other supports and assist her. Walking should be done in parallel bars first. Walking should be done in forward direction then in backward direction and finally sideways. After achieving this walking can also be done without parallel bars and a quad cane or walker can be used for this purpose. She should go upstairs and downstairs with the help of therapist initially. Councelling Proper counseling of Mrs. B and her family by the physiotherapist throughout the rehabilitation program will play a very vital role for her recovery. She may feel depressed, isolated, irritable and demanding. The physiotherapist should motivate and educate her. The physiotherapist should provide actual facts and proper information of her disease to her as well as to her family (Fells, 2000) The physiotherapist should be supportive, sensitive and he has to maintain a hopeful attitude. References Appel, P. (1992). Performance enhancement in physical medicine and rehabilitation. American Journal of Clinical Hypnosis, 35, 11-19. Baker L. (1991), Clinical uses of neuromuscular electrical stimulation, In: Nelson RM, Currier DP, editors. Clinical electrotherapy. Norwalk, CT: Appleton & Lange p. 143-70. Cassidy, T. P., Lewis, S. & Gray, C. S. (1998). Recovery from visuospatial neglect in stroke patients. Journal of Neurology, Neurosurgery and Psychiatry, 64, 555-557. Devins, G. M. & Binik, Y. M. (1996). Facilitating coping with chronic physical illness. In M. Zeidner & N. S. Endler (Eds.), Handbook of coping: Theory, research and applications (pp. 640–696). New York: Wiley. Edwards, M. G. & Humphreys, G. W. (1999). Pointing and grasping in unilateral visual neglect: Effect of on-line visual feedback in grasping. Neuropsychologia, 37, 959-973. Fells, N. T. (2000). Mental imagery and mental practice for an individual with multiple sclerosis and balance dysfunction. Physical Therapy Case Reports, 3, 3-9. Hall, K. M. & Johnston, M. V. (1994). Outcomes evaluation in traumatic brain injury rehabilitation. Part II: Measurement tools for a nationwide data system. Archives of Physical Medicine and Rehabilitation, 75, 10-18. Harvey, M. & Milner, A. D. (1999). Residual perceptual distortion in “recovered” hemispatial neglect. Neuropsychologia, 37, 745-750. Janet P. Niemeier, (November 2002), Visual Imagery Training for Patients With Visual Perceptual Deficits Following Right Hemisphere Cerebrovascular Accidents: A Case Study Presenting the Lighthouse Strategy, Rehabilitation Psychology. Vol. 47(4), pp. 426-437. Karen L. Perell, Gregor J.Robert, Scremin, A.M. Erika. (May 2000), Bicycle Pedal Kinetics Following Force Symmetry Feedback Training in Subjects with Unilateral Cerebrovascular Accident, Journal of Applied Biomechanics, Vol. 16 Issue 2. Knutsson E, Martensson A, Gransberg L. (1997), Influences of muscle stretch reflexes on voluntary, velocity-controlled movements in spastic paraparesis. Brain; 120:1621-33. Langhammer, B., Stanghelle, J. K., (Aug2000), Bobath Or Motor Relearning Programme? A Comparison Of Two Different Approaches Of Physiotherapy In Stroke Rehabilitation: A Randomized Controlled Study, Clinical Rehabilitation, Vol. 14, Issue 4. Nathan Herrman, Muhammad Mamdani; Linctot L. 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