Week Three Entry-Progessing my Intervention

Situation: I have been treating a 74 year old male who is 6 weeks post a left sided cerebral vascular accident (CVA) with daily gym sessions since starting my neurological placement on a stroke rehab ward. Currently his main problems include his decreased ability to weight shift to the left, lack of dexterity in his right hand, left trendelenburg gait pattern, requirement of 1 standby assist for mobility, right hemianopia and ideomotor dyspraxia. The thing that has made treating this patient even more complicated is that he suffers from expressive dysphasia. This means that he is unable to verbalise what he wants to say because of impairment in higher level function. This tends to be very frustrating for the patient and is difficult for the therapist as they can't get much feedback from the patient. Due to this dyspraxia most of my treatment has been based around functional tasks. To encourage weight shift to the left and use of his right hand I have been using a clothes line for reaching exercises, facilitated sit to stands has encouraged improvement in pelvic stability and gait retraining has helped normalise his gait pattern. I have also used obstacle courses that require the patient to look to his right to address his problem of a right hemianopia.

I felt that the patient was now at a level where I would need to progress his treatment to further enhance the strength in his left hip abductors and develop a more normalised gait pattern.

Task: To progress his treatment but use exercises that the patient can understand and perform correctly.

Action: I decided to try performing step ups with his right lower limb to facilitate weight shift to his left. Initially he had difficulty understanding the task and would often forget to take his foot off the step so would just rock forward and back on his planted right foot. Even when he did work out the purpose of the exercise and the correct technique it became evident he did not have the pelvic stability to control the weight shift to the left to put is whole foot up on the step. The gym in which we were working in has a clock set up on the floor with targets so I thought I'd try putting the patient in the middle and have him step with his right foot. Then I tried performing the step ups in the parallel bars.

Result: Stepping to the targets on the clock face turned out to be too much of a challenge due to his dyspraxia as he became confused and frustrated at not being able to perform the task correctly. The step ups in the parallel bars proved to be a better exercise which he was able to perform correctly. I was also able to progress the exercise by taking one of his hands off the bars without jeopardising his control and technique.

Evaluation: Although it took me a while to come up with an appropriate exercise I think I analysed the situation pretty well. I recognised the reasons as to why the patient was finding each different task too difficult and was able to come up with one that met his level in function physically and cognitively. Looking back I probably could have tried stepping towards a single target rather than having a lot of different targets to chose from. This would have also simplified the exercise so that he could understand the task and perform it correctly.

Strategies: The ability to evaluate an exercise and make adjustments to suit the patients ability but challenge them at the same time is a skill that physiotherapists always use. A strategy that I will utilise is to ask myself "why"? If I try an exercise and it doesn't work I will try to always ask myself "why isn't it working"? It will help me determine whether I need to change it to suit a patients impairments such as dyspraxia or strength or endurance or balance etc.