Neurology Rehabilitation ILP 2006

Neurology Rehabilitation Independent Learning Package TABLE OF CONTENTS Rehabilitation Unit Information Page • Introductory comments .......................................................................................................................................3 • Objectives..............................................................................................................................................................3 • Case allocation and load.....................................................................................................................................7 • How to use this independent learning package...............................................................................................9 • The Student Pathway Tool...............................................................................................................................10 • The Clinical Reasoning Form..........................................................................................................................14 Independent Learning Activities • Pre commencement of unit Review of Neurological Conditions...............................................................................................19 Neurological Assessment .................................................................................................................20 Outcome Measurement.....................................................................................................................31 Physiotherapy Principles and Practice of Intervention in the Aged..........................................33 Safe Practice .......................................................................................................................................34 Practice Questions for Start-up Exam ............................................................................................42 • Week one Prediction of Outcome/Goal Setting...............................................................................................45 Treatment Planning ...........................................................................................................................51 Written Records .................................................................................................................................56 • Week two Modes of Physiotherapy Service Delivery ....................................................................................62 Group Therapy ...................................................................................................................................62 Facilitating Independent Practice / Self Management.................................................................68 Gait .......................................................................................................................................................72 • Week three Technical Applications.....................................................................................................................75 Walking Aids and Orthoses .............................................................................................................76 Wheelchair Prescription....................................................................................................................83 • Week four Home Visits ........................................................................................................................................85 Discharge Planning............................................................................................................................87 Further Independent Learning Activities related to specific diagnosed conditions CVA .....................................................................................................................................................88 Cerebellar Dysfunction / In-coordination......................................................................................92 Traumatic Brain Injury .....................................................................................................................92 Amputee ..............................................................................................................................................93 Parkinson’s Disease...........................................................................................................................96 Shoulder Hand Syndrome ................................................................................................................97 Appendix One: Guidelines for Physiotherapy Assessment of the Adult with Acquired Brain Injury ..............100 Appendix Two: Outcome Measures Guidelines.........................................................................................................118 Appendix Three: Strategies to Assist Learning..........................................................................................................142 ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 2

REHABILITATION UNIT INFORMATION Introductory Comments A rehabilitation placement is a core clinical experience which you will all undertake. You will be placed in either a hospital or community-based setting and may be allocated a second placement as an elective unit. The rehabilitation placement provides you with an opportunity to work with a wide variety of clients/clients and staff, as well as the experience of working as part of a multi-professional team. The placement will assist with your development of analytical and clinical reasoning skills for a variety of clients who seek and participate in rehabilitation programs. The goal of your rehabilitation experience is to facilitate competencies and confidence in your ability to communicate, assess, problem solve, plan, implement and review appropriate interventions which you can modify and progress with your patients , and/or develop self-management programs with clients who seek physiotherapy services which may need to be reviewed and progressed to effectively maintain clients in the community. The selection and application of appropriate outcome measures will be an integral part of the management of your patients/clients. You may work with a variety of neurological and ortho-geriatric clients who access rehabilitation services at different stages along the continuum of care. At all times the patient/client is to be encouraged to actively participate in their management with self-management strategies fostered to sustain the benefits of the rehabilitation process. The emphasis on self-management will vary across the continuum of care but attention to this aspect is critical for effective carry-over to the ward and home setting and the sustainability of clients living in the community. The rehabilitation placement also aims to expose you to multi-professional team-work and foster a desire to learn and encourage an open attitude to feedback and learning. In addition to your rehabilitation placement, you are provided with an independent learning package to systematically work through as an essential part of the placement. To maximise your experience in your placement and to provide your clients with optimal management, you need to complete the recommended revision and the tasks set-down in this package. During your rehabilitation placement, you need to remember that you are an adult learner and take responsibility for your own learning. You need to revise and prepare for your placement, be pro-active, and stay open to learning opportunities. Clinical educators and other staff will give feedback and make suggestions to assist with your learning. You need to be open to these suggestions and realise that while you are not expected to know everything as a student, you are expected to allow someone to direct you to information that will assist you to learn as well as be a direct source for your learning related to their experience. You will need to take advantage of the exp erience of your clinical educator and their enthusiasm and to benefit from their knowledge, experience and skills. The clinical placements which you visit may have students for most of the year. You need to remember this in your interactions with staff. The staff will usually have the responsibility for a clinical load in addition to teaching and working with you. You need to show the due respect to the staff who make this extra effort and spend time to teach you. As you will be allocated patients/clients from a staff load, you MUST talk to the staff every day and discuss the patient’s/clients’ plans, progress, or any change in their condition or your planned program with the staff member. If you cannot speak directly with a staff member, you may leave a note with an appropriate staff member. Good communication is imperative for the appropriate management of your patient/client. You also need to be very aware that the patients/clients that you are allocated may be seen by several students, indeed every four weeks they may have a new student! Generally in week one you are not giving your optimal performance but it is critical that you attempt to provide the highest quality of program from your first interaction with any patient/client. You need to consider the patient/client at all times and to value the willingness of patients/clients to assist with your learning. Those patients/clients who give their time repeatedly to help with student learning need to be particularly acknowledged. You need to show them the utmost respect, and think how you would like to be treated in the same circumstances. Thus your very best effort is required at all times with the quality of your preparation, your communication and attitude to patients and staff , your willingness to learn and take advice as well as the quality of the programs that you implement, review, progress and document perceived as critical aspects of your professional development. Objectives The objectives for the student in the rehabilitation placement (teaching/learning environment) are to: 1) Demonstrate the ability to build on established knowledge and skills from pre-clinical education and develop applied knowledge, skills and attitudes required for the professional delivery of physiotherapy services in the rehabilitation setting (hospital or community). ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 3

2) Implement the appropriate model of care for each patient / client by considering the setting/stage of rehabilitation at which the client is accessing physiotherapy services ie Consider the continuum of care in relation to your rehabilitation placement and the role of physiotherapy services • Primary intervention with the aim of preventing disease processes leading to neurological disorders. The focus of physiotherapy services will be education and health promotion within a multi-professional team • Early diagnosis of neurological disorders may involve - hospitalisation and early intervention from a multi-professional team (eg stroke/TBI). Patients may be discharged home or be transferred to formal rehabilitation units for ongoing rehabilitation prior to return home or placement in a residential care facility - referral to services within private practice, OP hospital facilities or community-based rehabilitation services (eg PD/MS). • Ongoing rehabilitation in designated rehabilitation units (eg GARU at RBH or PAH) to prepare for return to home; hostel or residential care facility - multi-professional teams are employed in most facilities • Community based rehabilitation services aim to integrate the patient/client within the community and empower the client to self manage. Physiotherapy may be one of many service providers accessed by patients/clients living in community and your role may involve: - Reviewing the presenting movement disorder - Establishing or upgrading a home program - Fostering self-management attitudes and skills to sustain the benefits of rehabilitation - Maximis ing the ability of the patient/client to return to work or volunteer activities - Developing recreational activities - Fostering fitness to assist patients/clients to age well with a disability 3) Acquire competence in the ability to independently assess, problem-solve, plan and implement targeted physiotherapy management programs through selection and application of effective techniques , review of programs and measure the outcomes achieved for each patient/client. This involves the integrated development of clinical decision making skills along with your communication, professional and ethical responsibilities which places the patient/client needs and goals as the focus of the intervention. Outcomes for you include: • Application of your theoretical knowledge as a basis for your clinical practice with sound clinical decisions demonstrated. • Demonstrated use of a clinical reasoning process to assess and manage neurological or ortho- geriatric patients/clients. This requires your knowledge and use of the steps involved in the clinical reasoning process - Assessment (review of relevant information through chart or with patient/client; interview patient/client/; review relevant functional movements; identify the impairments contributing to movement dysfunction; measure impairments and functional limitations using appropriate outcome measures) - Assimilation of findings using a problem-solving process to link impairments with presenting movement dysfunction - Planning and implementing holistic physiotherapy management programs to address short term goals including the establishment of carry -over programs that are executed in the ward or at home with or without the support of family or carers - Selection and application of techniques that are evidence based and effectively manage impairments interfering with movement – this may include the prescription and training of patients/clients in the use of mobility aids such as walking aids, orthotics or prostheses or selection and use of a wheelchair for ambulation - Review of outcomes achieved to amend or progress programs towards long-term goals . ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 4

• Clear and accurate documentation of informed consent and the - findings from the § qualitative assessment process that links the primary impairments with the movement disorder (eg problems with balance, mobility or UL function) and § outcome measures selected to record impairments and functional ability/limitations - treatment plan with appropriate long and short term goals established with patients/clients - comprehensive and varied treatment program for each patient/client that includes the § progressive program implemented with effective use of techniques § ward/home program that is to be carried out independently or with the help of family/carers § the aids/orthoses required by each patient/client - re-assessments undertaken with outcomes achieved or modifications to program required - liaison with / referral to other health professionals - transfer / discharge requirements for each patient/client and the services recommended/organised. • Fostering holistic care and of self-management principles for all patients/clients across the continuum of care 4) Effectively using the learning environment, working with the clinical educator to enable optimal management of patients/clients and to review their outcomes from the program(s) implemented. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 5

In order to achieve these aims, there are a number of essential and desirable experiences which the placement may be able to offer and in which you need to actively participate. ESSENTIAL DESIRABLE A mix of clients with neurological and/ or ortho-geriatric Responsibility for the management for 3-4 allocated disorders in either a hospital or a community setting cases Implements an optimal physiotherapy service for the Actively participates in all steps in the rehabilitation allocated clients appropriate to their stage of rehabilitation. process for each client. Executes an assessment appropriate for a neurological or an Practices using a wide variety of handling techniques ortho-geriatric client to demonstrate ability to review and not required for allocated cases but are in use with other interpret client records if available; execute an interview/ patients / clients subjective which identifies the problems/goals that the client Eg lifts and transfers, methods for ambulating patients priorities; use observations to direct questions, handling or palpation; review functional level safely and with Practices using equipment available within the appropriate analytical skill, administer appropriate tests to rehabilitation setting eg. Treadmill, Biofeedback units, define problems. Tilt Table, hoist, FES, taping, bandaging, walking aids Practices using a tilt table, ergometer, treadmill as Identifies / interprets problems using a clinical reasoning available process that gives due emphasis to the perceived problems identified by the client. Plans a treatment with the client that identifies immediate and long-term goals for holistic care. Gain consent to implement the program with the client. Implements appropriate strategies to manage the identified Takes a class which is offered in a traditional or problems; evaluate / modify the program and the preferably a work-station mode effectiveness of techniques applied Fosters the principle of self management by introducing Becomes familiar with a range of service delivery ward / home programs eg practice books and empowers the modes, understanding the specific emphasis of the client to self manage independently or with a carer to sustain placement the benefits of the program Uses outcome measures to evaluate progress focussing on Practices using objective tests and outcome measures those used in the specific setting that are not in place in your unit.(eg functional reach, step test, Get up & go test, timed 10m walk, CTSIB test, Eg Functional balance measures or a scale that monitors sternal /thoracic push and application of the Pastor- functional motor ability – MAS, EMS Marsden Scale, DGI Predicts the long-term outcomes for each patient/client Participates in case discussions to develop an (under the guidance of the therapist) understanding of the factors used to predict outcomes for other cases Documents findings and records statistics as required by the Assists with hydrotherapy sessions if available unit eg written assessments, treatment plans, progress notes, medical chart entries, discharge summaries and hand-over letters, home visit reports where attended Liaises with physiotherapy staff and other staff as Attends home visits/ ACAT visits/ community visits appropriate Attends client education classes Attends relevant clinics (eg. Amputee or CVA program) Organises client bookings for the next day / next appointment Attends / Reports at case conference as appropriate Plans for discharge to home, hostel or residential care Attends staff /unit in-service facility Understands the role of other disciplines involved in the Understands the role of all other disciplines involved in management of each client and works collaboratively rehabilitation settings ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 6

Case Allocation and Load A load of 3-4 cases each day should be allocated for you to manage with additional opportunities to work with staff members to expand the type of experiences / cases managed to fit in with the clinical placement. This could include: - at least one, and preferably 2 neurological cases from the following disorders: • Cerebro-vascular lesion from any site e.g. R and L MCA; ACA; PCA; PICA. • Traumatic Brain Injury • Cerebellar Dysfunction • Parkinson’s Disease • Multiple Sclerosis • Guillain-Barre Syndrome • Late Effects of Poliomyelitis • Peripheral Nerve Lesions e.g. Facial Palsy - Any other client seeking rehabilitation e.g.: • Ortho-Geriatric cases (Faller, #NOF, elderly requiring upgrade mobility) • Amputees • Clients ageing with a disability (e.g. Cerebral Palsy) • Clients referred for Hydrotherapy Every attempt will be made to give you a varied and a wide experience of different conditions and their relevant management. The management of clients should address their specific needs, be task- oriented and develop your handling skills. Your caseload could include clients who are at a higher level of mobility and independence and require minimal/no direct handling but require knowledge of when to be nearby in a position of anticipation should the client over-balance while executing a challenging task. In contrast, experiences may include clients who are at a lower level of independence, who may have more obvious problems but are heavy to handle and require more skill and decision making in this area. You may be allocated to work as a pair with a client who requires heavy handling. You are encouraged to assist other students and staff with their clients to expand your handling experiences. This rehabilitation experience could be based in a: • community setting (e.g. DAART or NAB Clinic, UQ) • public hospital setting (e.g. PCH, RBH, PAH, QEII, Townsville, Rockhampton, Toowoomba) • Private Hospital (e.g. St Andrews) or private practice such as mobile rehab • Specialised unit (e.g. BIRU or Spinal Injury Unit, PAH) You may be allocated a case load from the client pool seeking the rehabilitation service at these facilities. Alternatively, you may not be allocated a specific case load but be introduced to different service modes such as case management. In these cases, you will work with the physiotherapist in carrying out their duties / roles associated with this type of service. In community based rehabilitation the client ‘consults’ the physiotherapists and although targeted interventions are delivered, a greater emphasis is placed on self management and strategies for assisting the client to remain independent in the community. This is dependent on the facility. Some of the particular experiences that you seek may not occur. For example, it may not be possible to allocate a client who has had a CVA to you or there may be no clients in your unit who have had a CVA. In this case you will not have the opportunity to manage a client who has had a CVA. You will just have to accept this, as staff cannot make a client to order. You can however, apply the process of assessment, problem solving, treatment planning and execution, review and measurement of outcomes to each client for whom you are responsible. This is the critical experience required for rehabilitation not the specific management of particular disorders even though some specific cases are desirable to experience given their prevalence within the community. In such cases where you can not be allocated specific desirable experiences, other strategies can be put in place such as working with ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 7

another student who does have a client who has had a CVA, or offering to treat the staff member’s client when you are allocated to work with specific staff. Some of these activities require you to have initiative and for you to take advantage of the learning environment – such initiative is noted by your clinical educators. If at any time you feel you would like a different experience, or more practice of some particular facet of the setting, you will need to take the initiative and discuss this with your clinical educator. There is no point in thinking at the end of a unit that you would have preferred more opportunities to see a particular problem or practice a technique etc. Your clinical educator cannot know this unless you tell them! ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 8

HOW TO USE THIS INDEPENDENT LEARNING PACKAGE This Independent Learning Package (ILP) contains a number of Independent Learning Activities. The Independent Learning Activities are arranged in groups according to the optimal time for you to complete them – either pre-commencement of the Reha bilitation Clinical Placement or in a specific week of the placement The Student Pathway form (see the next section) will guide you when to complete the various Independent Learning Activities. In order to gain the most from this ILP and to be effective in the management of your clients, this ILP should be worked through in a specific order. Of course this does not mean that you can’t do more of the independent learning activities earlier, but you will need to do at least the ones set out for the week you are in. You are required to do some preparation for this unit before you commence it. This is a reasonable expectation at a university level of education. This is so that you will be able to be more effective in the initial period of the placement and to successfully treat your clients and gain the most from the unit. It is not acceptable to see clients without some preparation, as they deserve your best effort. Think how you would like to be treated in a similar situation. When using this ILP you will be directed by the following icons : When you see this icon you need to review the Blackboard Website. You will still have access to the relevant courses on the Blackboard website for the year after you completed them. When you see this icon, you need to read a set of notes provided on a specific topic or access a relevant reading. When you see this icon you need to view a video. When you see this icon you need to undertake a written task. This icon indicates feedback on a written task you have undertaken. When you see this icon you need to practice an activity or technique. When you see this icon, you need to participate in a discussion. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 9

THE STUDENT PATHWAY TOOL Aim: The student pathway tool has been developed to assist you in managing your independent learning throughout the Rehabilitation Clinical Placement. The student pathway is designed to be an interactive learning tool to facilitate communication between the student and the clinical educator. The Student Pathway has been designed to facilitate the achievement of the competencies assessed on the Student Profile. How it works: The student must print out a copy of the student pathway and bring it to the clinical placement. The Student Pathway outlines specific performance criteria to be achieved by the student and specific responsibilities to be provided by the clinical educator. There is one section of the Student Pathway that should be completed by the student pre- commencement of the Rehabilitation Clinical Placement. The Student Pathway should then be completed by the student and the educator together weekly. It should form the basis of feedback sessions, with differences from expected performance criteria documented with a plan of action developed to address these issues. It also contains suggested activities for the student (e.g.: attending other allied health disciplines) but some items may not be applicable to the clinic (e.g.: attendance at ward rounds). At the end of the Rehabilitation Clinical Placement, the signed and completed Student Clinical Pathway should be sent to the Division of Physiotherapy, The University of Queensland along with the student’s completed Student Profile . What happens to the returned forms? The Student Pathway forms will be used to make modifications to the Neurology /Rehabilitation Independent Learning Package and the Student Pathway for the following year with the aim of providing a better interactive learning tool. It is important to stress that the completed Student Pathway forms will not play any role or carry any weighting in your assessment for the Rehabilitation Unit. THE CLINICAL REASONING FORM The Clinical Reasoning Form has been designed to assist you in implementing the clinical reasoning process with each of your clients. Your clinical educator will expect you to utilise such processes when engaging in discussion about your clients. You are expected to print out the clinical reasoning forms and bring them to your clinical placement (you will probably need at least four copies). The Student Pathway tool will guide you when to fill in the form for each of your clients and when to discuss the form with your clinical educator. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 10

Rehabilitation Unit Student Pathway Pre- Performance Criteria Achieved Commencement Complete the following Independent Learning Activities: q • Review of neurological conditions q • Neurological assessment q • Outcome measurement q • Physiotherapy Principles and Practice of Intervention in the Aged q • Safe practice q Familiarise yourself with the Clinical Reasoning Form Week 1 Performance Criteria Achieved q Assessment Ability Observe clinical educator performing a subjective and objective assessment Extract information from medical records for at least 2 patients/clients q q Perform at least 2 subjective and objective assessments. q Practice observing / analysing the posture and performance of functional tasks for at q least 2 patients/clients. Use video if available to practice movement analysis Interpretation Reflect on and discuss key findings of the observed assessment with peer/s or clinical q educator Complete the Clinical Reasoning Form as you conduct each new client assessment q Reflect on the principles of clinical reasoning in the context of the assessments and q problem lists you have developed. Develop a basic functional problem list identifying key impairments (primary and q secondary) for at least 2 clients. q q Seek guidance from your clinical educator on the problem lists developed q q Treatment Planning Complete the Independent Learning Activity on Prediction of Outcome and Goal q / Application Setting Complete the Independent Learning Activity on Treatment Planning Discuss and confirm treatment goals with your supervisor Practice and seek guidance on handling techniques for assisting clients with functional tasks. Professional Establish the documentation requirements for the placement, including entry of q Practice / Safety statistics. q Complete the Independent Learning Activity on Written Records q q Demonstrate awareness of safety issues in all aspects of practice. q Seek feedback from clinical educators on safety during performance of assessment procedures, transfers and mobility (All first time transfers/ walks to be supervised). Attend Case Conference / team meeting (if applicable) ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 11

Week 2 Performance Criteria Achieved q Assessment Ability Apply each assessment item/tool on a client/peer as per Neurological Assessment q Guidelines q Familiarise self with uses, strengths and limitations of outcome measures q Interpretation Complete Clinical Reasoning Forms for your current clients q • Develop basic problem list, identifying those able to be managed by q physiotherapy intervention q • Identify impairments contributing to the problem (primary or secondary) • Seek feedback from your eductor on development of your problem list Consider objective assessment findings (of your clients) in light of normative values (found in ILP) Treatment Planning Discuss the implications of these findings with your peers / clinical educator / Application Identify 3 key functional goals for your clients (short term goals) Deliver comprehensive treatment programs targeting the identified goals. Consider the following aspects of treatment application: § Set-up § Environment § Equipment § Instruction § Accuracy § Feedback § Handling and facilitation § Positioning § Education Professional Complete the Independent Learning Activity on Modes of Physiotherapy Service q Practice / Safety Delivery q q § Group therapy q § Facilitating independent practice q Complete the Independent Learning Activity on Gait q q Documentation accurately records assessment processes and adequately reflects current client management focus Identify other team members and their role in client management Participate in Case Conference / team meeting (if applicable) Mid-unit Feedback Week 3 Performance Criteria Achieved q Assessment Ability Complete full assessment without assistance for each functional task q Complete the Independent Learning Activities related to specific diagnoses: q CVA q Cerebellar dysfunction/incoordination q Traumatic brain injury q Amputee q Parkinson’s disease Shoulder hand syndrome q Interpretation Develop prioritised problem list with minimal prompting q Identify non-physiotherapy problems which may be addressed via consultation with other team members ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 12

Treatment Planning Complete the following Independent Learning Activities: q / Application § Technical applications q § Walking aids and orthoses q q § Wheelchair prescription q Establish short term goals with realistic time frames q q Choose appropriate treatment options for identified key problems with minimal guidance q Establish long term goals with attempted time frames q q Consider alternative and novel treatment ideas for same key problems with guidance q from supervisor q q Produce comp rehensive treatment plans with guidance (incorporating appropriate Achieved Independent practice activities) q Professional Complete required documentation independently q Practice / Safety Initiate appropriate interdisciplinary liaison with guidance q Manage timetable with minimal prompt q Able to overlapping two clients with guidance q q Design and run a group therapy session with assistance q q Week 4 Performance Criteria q Assessment Ability Perform assessments accurately and effectively implement an initial treatment in a q q reasonable time frame (1.5 hours) q Select appropriate assessment items, rationalise assessment priorities and adapt to individual c lients independently Interpretation Develop understanding and insight into psychological and social issues which may impact on total client management Develop understanding of rehabilitation principles in context of continuum of care Treatment Planning Complete the Independent Learning Activity on Home Visits / Application Complete the Independent Learning Activity on Discharge Planning Initiate and implement effective treatment program with minimal guidance Can usually progress & modify Rx based on reassessment findings but may require occasional prompts Professional Complete required documentation independently Practice / Safety Manage at least 4 clients per day/ or as required Initiate communication with other team members to effectively plan for discharge/ follow-up care independently Prepare a written discharge report (including referral for ongoing therapy or appropriate services) for at least one client ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 13

NEUROLOGY CLINICAL REASONING FORM Student Name:............................................ Date:..................................................... Tutor’s Initials:.....................……………… Client’s Initials: ..................................... Part 1. After reading the medical records or community reports 1. What are the relevant findings from these sources and the implications for your Physiotherapy Assessment? Are there any special questions to include in the subjective interview or specific points to check in the physical examination? Main Findings Implications for Subjective Implications for Physical Interview Examination 2. Following the subjective interview, review the implications you have proposed in the above table and reflect on their value prior to commencement of the physical examination. Are there any additional elements to consider? 3. If the client has presented in a wheelchair, specify the method of transfer / handling you will use to move the client from the wheelchair to the plinth. Will you need any assistance? Describe this assistance and consider the instructions you will give to your client and to other assisting staff. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 14

Part 2. After completion of subjective/objective assessment 1. What are the key functional assessment findings? Identify (make a list of) the impairments which would be contributing to these findings (include both primary and secondary impairments). Functional Assessment Findings List of Impairments ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 15

2. What is the prioritised problem list for this client? 3. List your short term goals for this client (includin g timeframes). 4. Are there any additional functional tasks or impairments that you still need to assess in the next session? 5. What outcome measures will you use to reassess your client? 6. What will be your treatment plan for the next treatment? Briefly outline the rationale for each technique selected. Specify the time you will spend on each activity. Treatment Plan Rationale for technique ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 16

7. Are there any safety considerations to be addressed prior to implementation of your treatment program? Part 3. Predicting Outcome 1. List the positive and negative factors influencing the client’s prognosis that will be considered when planning long term goals. Positive Negative 2. List your long term goals for this client (include functional mobility goals, upper limb functional goals and discharge destination). Attempt to estimate time frames. Consider whether these goals are in accordance with the rest of the team/client. Part 4. Progressive Planning Date: 1. Has your client’s level of function and mobility progressed as measured by an objective score? If not, why do you think no improvement has occurred? ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 17

2. Have your short term or long term goals or discharge plans changed? Ensure any changes are recorded appropriately (i.e. in medical chart and/or physiotherapy notes) 3. State any other areas of your client’s management that you have been or should be responsible for organising (e.g. wheelchair/aids/equipment – permanent or temporary) 3. What follow-up services need to be organised? How do you intend to organise these and who should you liaise with? ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 18

INDEPENDENT LEARNING ACTIVITIES PRE COMMENCEMENT REVIEW OF NEUROLOGICAL CONDITIONS In preparation for your rehabilitation clinical placement it is essential to revisit the information covered pre-clinically related to the various conditions that clients undergoing rehabilitation may be experiencing. Notes are located on the Blackboard Website. Relevant information was presented as follows: PHTY3140 / 7814 Vascular Lesions Block 1 ILP 1 Neuroanatomical Localisation of Cerebral and Brain Stem Lesions Cerebrovascular Disease / Stroke Block 2 L1. Physiotherapy management of movement disorders following stroke Block 2 L2/3 Preventing secondary changes following brain injury Block 2 L4 Maximising upper limb recovery after stroke Block 2 L5 Management of perceptual disorders and dyspraxia after stroke Block 2 L6/7 Traumatic Brain Injury Block 2 L8 Medical Management of Traumatic Brain Injury & Neurosurgical Management for Brain Injuries Block 2 L9 Physiotherapy Management of the neurosurgical client Block 2 L10 Physiotherapy Management of the client following Traumatic Brain Injury Parkinson’s Disease Block 4 L1 Parkinson’s Disease and other Basal Ganglia Disorders Block 4 L2 Physiotherapy Management of Parkinson's Disease Block 4 Pr 1-2 Parkinson's Disease - Techniques/ Problem solving Lower Motor Neurone Disorders Block 4 L3-4 Lower Motor Neurone Disorders: Polyneuropathies (including + ILP4 Guillain Barre Syndrome) and Late Effects of Poliomyelitis Block 4 L5 Peripheral Nerve Lesions: Model Facial Nerve Palsy Block 4 Pr 3-4 Problem solving/ techniques – Lower Motor Neurone Lesions Vestibular Disorders Block 4 L6 Peripheral Vestibular Disorders Block 4 Pr 5-6 Management of BPPV (PCC); management of motion sensitivity and gaze instability Spinal Injuries Block 4 L7-8 Assessment / management of the client with spinal injuries Block 4 Pr 7-8 Spinal Injuries Block 4 Pr 9- Spinal Unit Video-Case Studies 10 Multiple Sclerosis Block 4 L9 ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 19

Note: Assessment and management of amputees was covered in the Lower Limb course PHTY2110/7810 When reviewing this material you should ensure you have an understanding of: - pathophysiology of the condition - clinical features - efficacy of interventions - expected outcomes To focus your review of the information presented pre-clinically, several independent learning activities have been developed (see page 86). The activities relate to the following conditions: - CVA - Cerebellar dysfunction / incoordination - Traumatic Brain Injury - Parkinson’s Disease - Amputee - Reflex Sympathetic Dystrophy ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 20

NEUROLOGICAL ASSESSMENT Pre-clinically you were presented with a clinical reasoning framework that can be applied during physiotherapy assessment of clients with a variety of neurological disorders or problems related to ageing. Review the lecture “A Framework for Neurological Rehabilitation” located on the Blackboard Website for PHTY3140/7814. Prior to this clinical placement it is essential that you review the Guidelines for Physiotherapy Assessment of the Adult with Acquired Brain Injury. A copy of these guidelines has been included in this ILP as Appendix 1. Additional preparation: Review the video entitled “Assessment of Stroke” held in the Biological Sciences library. Catalogue number: RC388.5 .A77 2004 . This video demonstrates the complete Neurological Assessment process being applied with a client who has had stroke. It includes the application of relevant outcome measures. Problem Solving Neurological Assessment 1. In what order would you undertake an initial assessment of a hemiplegic client who presents in a wheelchair? 2. What specific questions would you need to include when assessing a client with Parkinson’s disease? 3. What are you trying to achieve from your neurological assessment? Functional movement analysis 1. What are the components of sit to stand? 2. What may be the cause of poor/lack of anterior translation of the knee? 3. What are the implications for management and specifically for your positioning & handling? 4. Which muscles are being used concentrically in sit to stand? Which muscles are being used eccentrically in stand to sit? 5. What are the essential components of rolling? 6. What are the essential components of lie to sit? 7. What are the essential components of sitting alignment? 8. What are the essential components of standing alignment and balanced standing? Page 21 ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006

Balance 1. What will you include in assessment of standing balance? 2. Your client can sit with good trunk control, can reach outside his base of support slowly but looks precarious. He is impulsive. How would you describe his sitting balance? 3. Your client is an 18 year old male, with a closed head injury. He presents in a wheelchair, with a lap restraint on. What will you have to do when testing his sitting balance? 4. Your client walks into the gym. Where will you start your balance assessment? What objective measures would you need to do day one? 5. You notice when your client is performing sit to stand that they do not load their left side very well. What do you do? How would you progress your balance assessment? How will you decide whether you can test external perturbations? 6. The nurse in the ward comes to see you and is concerned that Mr A. keeps getting up and falling over at night. He is slightly weak on one side. The nurse is not sure why this is happening because Mr A is quite safe during the day. What do you do? (What subjective assessment, objective assessment and outcome measures will you undertake?) 7. What will you have to monitor when testing a functional reach? What type of clients would this test be suitable for? 8. You have the following three clients: Mr X who has had a CVA 2 months ago, Mrs Y who has had Parkinson’s disease for the past 10 years, and Miss Z who has had a traumatic brain injury and is centrally ataxic. Consider the contributing factors to balance problems, and the possible presenting balance problems for each client, and how the different causes will impact on retraining. Gait 1. What are the common deficits in gait following stroke? Break this up into stance and swing phase. Lower limb analysis 1. What ranges of motion are vital to check day one and why? 2. Can you grade (i.e. test muscle power) in a client with non-isolated (non-selective) movement? Upper limb analysis 1. What muscle activity will you search for day one in a hemiplegic client with no obvious upper limb return of movement? 2. What will you observe that leads you to believe the client has little return of movement? 3. What will this mean for your management of the client? 4. During your assessment, the client tells you he has been given a ball to squeeze, but you have found he has only abnormal patterning of finger flexion and no finger extension. What do you do? ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 22

Sensory Testing 1. Your client is a 56 year old male, who presents following a stroke. During the transfer you notice that despite having fully isolated movement (on testing in the wheelchair), his movements are very jerky. Identify how you would test sensation in this client and what position you would place the client in for testing. 2. Where would you need to be positioned to test visual fields if you were on your own? What changes would you have to make if the client was unreliable? What would you do if the client couldn’t understand or cooperate? 3. What are the implications for your management of a client who has a homonymous hemianopia? Coordination 1. What must a client have before you can test coordination? 2. What do you need to ascertain before you test coordination? 3. What are you looking for when testing coordination? 4. Your client has a cerebellar lesion, you suspect he might have coordination problems, but you have not seen anything on finger-nose testing. What do you do now? High Level Tests 1. Your client walks into the gym. What would you have to assess and in what order? Consider the client’s age in your answer. Cranial Nerves 1. Your client is a 33 year old lady who has had an aneurysm. It is two weeks post bleed. She is drowsy, but follows commands. Which cranial nerves must you test day one and why? 2. Miss Z has had a traumatic brain injury. She complains that she has difficulty looking down to read the paper and on descending stairs. What cranial nerve/s are affected? How will you test this? 3. Mr Y has also had a traumatic brain injury. He is on thickened fluids and a soft diet. He now has a chest infection. You discover that his family are feeding him ice-cream on the weekends when he goes home. Is there a connection? How would you find out? Apraxia 1. Describe ideomotor and ideational dyspraxia. How would you assess these impairments? Perceptual 1. List the impairments that may be associated with the “pusher” syndrome? 2. Your client, who has a L) hemiplegia, is leaning backward and to the L) when you stand them. They resist your attempts to bring them to the midline. What is happening? What would you do in the assessment? Wheelchair Skills 1. What are two basic wheelchair skills you need to ask your client about, or record from your client on day one? ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 23

Vestibular Assessment 1. What questions would you need to ask to decide whether there was a vestibular component to a client’s dizziness? 2. How would you monitor dizziness caused by a vestibular problem? 3. What are three major areas to assess in vestibular assessment? 4. How would you assess gaze stability? 5. What 4 different balance tests might you use to determine a vestibular component to balance and why? Feedback on Neurological Assessment Neurological Assessment 1. You would usually assess a client who was in a wheelchair in the following order: • Sitting in chair: subjective, quick active movements to decide on the best method of transfer. • Transfer onto plinth • Sitting – alignment àbalance • Sit à stand • Standing à alignment à balance • Gait à stairs if applicable • Back on plinth à bed mobility, rolling • Directed objective examination à isolated movement (power if appropriate), ROM, tone and proprioception, sensation (just light touch/and then double simultaneous if appropriate), vision, other impairment assessments as appropriate. 2. Specific questions to include with a client with Parkinson’s disease are: • History of falls • How long they have been diagnosed with the disease • If they freeze, frequency of freezing, where they freeze (e.g. confined spaces, doorways, turning) and if they do, have they any strategies to unfreeze • Difficulty with bed mobility, particularly rolling • Drug regime, timing and effect on movement, length of time on medication • Swallowing/coughing • Problems with manipulation (e.g. buttons etc) • Problems with ADL, especially showering, and rising from a chair • Tremor/dyskinesias and effect on movement 3. In an assessment you are trying to ascertain what the client’s activity limitations are and what is contributing to those limitations. From an assessment you are trying to define a problem list including functional difficulties and impairments (both primary and secondary) which are contributing factors to their functional limitations, so that you can set appropriate goals and implement an effective intervention. Functional Movement analysis Page 24 1. The components of sit to stand are: In the pre-extension phase- • Forward inclination of the trunk • Anterior pelvic tilt • Anterior translation of the knees In the extension phase – • Extension of the hips and knees • Posterior pelvic tilt ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006

2. Possible causes are tight calf (the most likely) due to shortening of muscle length (especially soleus), sometimes due to the effect of spasticity. Other factors to consider are the positioning of the client on the bed….are they close enough to the edge of the bed? If the client is not leaning far enough forward, they will be unlikely to do the correct sequence of movement and may push into the back of the bed to lever off it. 3. You must address the cause of the problem. Tonal changes must be addressed (prolonged stretch, prolonged ice, serial casting). Range of motion must be addressed (prolonged stretch, manual stretching, ward program for client, serial casting). The correct instructions and guidance must be given. Make sure you move with the client so as not to crowd them when they are leaning forward to get up. The height of the bed may need to come up to allow the client the possibility of doing the movement correctly. 4. Sit to stand: concentric activity of quads, hip extensors. Stand to sit: eccentric contraction of quads, hip extensors. 5. The essential components of rolling are: • Rotation and flexion of the neck • Hip and knee flexion • Flexion of shoulder and protraction of shoulder girdle • Rotation within the trunk • Some people roll their lower body by pushing their foot into the bed and extending their hip and knee 6. The essential components of lie to sit are: • Lateral flexion of neck • Lateral flexion of trunk (abduction of the lower arm occurs as these two components are performed) • Legs lifted and lowered over the side of the bed 7. The essential components of sitting alignment are: • Feet and knees close together • Weight evenly distributed • Flexion of hips with extension of trunk (i.e. shoulders over hips) • Head balanced on level shoulders 8. The essential components of standing alignment and balanced standing are: • Feet a few inches apart • Hips in front of ankles • Shoulders over hips • Head balanced on level shoulders • Erect trunk • Preparatory postural adjustments • Ongoing postural adjustments Balance Assessment 1. Assess essential components of standing alignment, ability of client to stand quietly (make postural adjustments in quiet standing), reach out of BOS, load a limb and then the other limb in preparation for taking a step, ability to take a step, ability to react to external perturbations (hip, ankle strategies and step to save themselves from falling). Objective measures as appropriate. 2. Safe to sit unsupported with close supervision as reactions are slow and he cannot save himself from falling in sitting. Requires supervision even in supported sitting as he is impulsive. Safe to be left supported in sitting only with restraint. Client can reach out of his base of support with supervision. 3. This client is retrained in sitting therefore he must be impulsive or have significant memory problems or lack of insight, and must not be safe in standing alone. When testing his sitting balance you will not be able to leave this person alone in sitting AT ALL. You will always have to be close enough to stabilise this client if he becomes unsteady. You cannot turn your back on him. People fall extremely quickly and it should not happen with recognition of such overt indications (such as restraints) that someone is impulsive. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 25

4. You will need to start in standing. There is no point testing sitting balance, as this will have to be good in order to walk independently. You need to assess the clients ability to step to save themselves from falling, narrow base (eyes open, eyes closed), single leg stance, gait, stairs jump, hop, run, skip, higher level balance tests, such as walking on a beam, and high level balance and coordination tests. Objective measures day one: • Timed narrow base (eyes open, eyes closed, left and right foot forward). • Timed single leg stance. • Functional reach (depending on age). • Lateral reach • Step test • 10 metre walk. 5. When assessing sit to stand, and your client is coming into standing asymmetrically, you need to correct this, even in the assessment. This is because you are trying to allow your client to achieve their very best effort. You are also assessing the client’s ability to respond to your instruction and handling. Asymmetrical loading in standing is indicating a deficit in a number of muscle groups. You need to find out just what activity the client can achieve. To do this, you have to aim for optimal symmetry in assessment and treatment. To progress from symmetrical standing, you would ask your client to reach out of their base of support (BOS). Each time they have reached outside their base of support (i.e. each time they have moved in one direction) you should facilitate realignment (so that they are symmetrical again). This is important, so that each new internal perturbation is starting from an optimally stable position, so that you get an accurate idea of how far they can really reach. Firstly reach forward, then laterally/quadrants and then towards the floor. If they can do this safely, then progress to step or step and reach. If your client can load each side and step with the other, you will be able to try external perturbations. 6. If he is alright during the daytime, but falls at night, he is possibly overly reliant on his visual system for balance. You need to ask him if he has had a history of falls when lighting conditions are poor. You will need to undertake a full neurological assessment to determine the extent of his motor deficit on the left, as well as determining any sensory loss (particularly proprioception). Objectively, you need to determine involvement of the vestibular system. Appropriate tests would be stance (eyes open/closed), narrow base and stride stance (eyes open/closed), CTSIB, functional reach, step test. 7. You will have to monitor that the client does not lean on the wall, that they reach forward and don’t rotate, that both feet stay on the floor. This test is suitable for elderly fallers, clients who are mobile, clients who are able to maintain standing alignment on their own and this can be used as a measure of improvement. 8. Contributing factors to balance CVA • Hemiplegia (lack of activation) àdecreased trunk stability, poor medio-lateral hip control, inability to ant/post pelvic tilt (poor abdominal control), lack of arm movement to assist in balance reactions, lack of dorsiflexion for ankle strategies, lack of hip flexion for hip strategies • Tightness à lateral flexors of the trunk, hip flexors, plantarflexors, • Decreased equilibrium reactions, • Increased tone plantar flexors • In retraining, need to activate muscles required, by stretch, stimulation, balance reactions etc. Try to carry out balance activities e.g. weight shift, stepping etc bringing in appropriate muscles/movements. Consider impact of decreased sensation, vision or perceptual impairments etc. Parkinson’s disease • Difficulty in initiation of movement (akinesia) • Rigidity • Lack of rotation • Hypokinesia (slowing of equilibrium reactions) • Lack of ROM from rigidity • Presence of dyskinesias • Implications for treatment are: • Rigid trunk: could be flexed, kyphotic à need to improve alignment, decrease contractures and maintain trunk extension. • Need to teach balance reactions: use cues to encourage ‘quick’ stepping in each direction. Client prepares cognitively before external perturbations. Progress to external perturbations without warning. • Consider the implications of balance in stopping, starting and turning. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 26

TBI • Central ataxia • Hypotonia • Shortening of antigravity muscles, particularly gastrocs, and of trunk muscles. • Decreased equilibriumreactions • Implications for treatment are: • Lacks trunkal/central stability àbuild up normal extensor tone in variety of weight bearing positions +/- sensory input (depending on severity). Increase holding (use rhythmic stabilisations, but TAKE CARE with using this technique à clients need a lot of control and adequate cognitive ability to execute this accurately). • Clients often have trunkal ataxia in combination with limb ataxia à treat accordingly. Implications for management of all clients: You need to address the underlying cause of the problem. This means an accurate assessment to define the cause, setting of relevant functional goals, and repeated task practice. This is progressed towards the conditions of home/work environment. Review goal setting and treatment planning ILPs. Gait Major gait deficits following stroke in stance phase: • Trendelenberg (decreased selective activation of hip abductors) • Lack of hip extension (decreased selective activation of hip extensors, tight calf) • Trunk flexion (to compensate for lack of hip extension, due to tight calf, decreased selective activation hip extensors, tight hip flexors) • Lateral trunk flexion over affected side (decreased selective activation hip abductors à brings weight over limb, thus less work required from abductors) • Lateral trunk flexion away from affected side (decreased selective activation hip abductors à afraid of loading affected side, do not bring weight over limb) • Asymmetrical loading (poor return of movement/lack of proprioception à not confidently able to load a side which may not support them/unable to feel where weight should be) • Hyperextension of the knee (tight calf) • Buckling of knee (poor quads control) • Inversion of foot and loading of lateral border of foot (decreased selective activation of evertors) • Weight on ball of foot (tight calf, increased tone in calf) • Toe curling (increased tone in long flexors, calf) Major gait problems in swing phase: • Inability to bring hip through to flexion (lack of adequate hip extension in pre-swing phase à do not get the pendular swing through after the initial activity of hip flexors. Decreased selective activation in hip flexors) • Lack of ability to shorten limb (decreased selective activation of dorsiflexion, hip/knee flexion) • Lateral flexion of trunk away from affected side (to shorten limb) • Hip hitching (to shorten limb) • Inadequate dorsiflexion (decreased selective activation of dorsiflexors, evertors) Lower Limb analysis 1. Ankle dorsiflexion, hip extension, knee extension. These ranges will allow a person to stand upright. If the plantar flexors are tight, the client will not be able to put their heel down, they will have to compensate with hyperextension of the knee, and hip flexion to stand. If the knee flexors are tight the client will not be able to get their heel down, and will be unable to weight bear evenly. If the hip is lacking extension and cannot attain neutral, the client will often compensate with trunk flexion to get their centre of gravity over their base of support. 2. NO! Upper Limb analysis 1. Scapular protraction, shoulder horizontal adduction, shoulder flexion/extension with arm at 90 degrees of flexion, elbow extension elbow flexion, pronation/supination, wrist flexion/extension, finger and thumb flexion/extension/abduction. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 27

2. Position of arm, attendance to arm, presence of hemiplegic sling and/or wrist splint, swelling, colour, spontaneous use of arm. 3. Immediate education of client and family regarding positions of support i.e. on a pillow in the chair or in a gutter arm support. Education of family, client and nurses regarding positions to maintain length. Early active and assisted active exercises to encourage activity. Need to be vigilant to prevent trauma. Need to educate staff in appropriate handling. Education of staff not to pull on client’s arm for sit to stand. Monitor any pain vigilantly: address immediately and actively. 4. You need to explain very carefully and thoroughly that at this stage it is important to encourage extension of the fingers and that continued squeezing of the ball alone may lead to tightness of the finger flexors and contractures. A hand that is contracted will become painful, and make ADL activities difficult. The return of selective finger extension may also be limited. You need to show how to stretch the hand (weight bearing etc) and provide a ward program to ensure the wrist flexors maintain length, while encouraging active extensor activity. You need to monitor the return of movement and overactivity very carefully. Sensory Testing 1. Test light touch while client is sitting (if found to be safe to reach outside base of support). This allows the client to reach to his lower limbs. Otherwise test in supine. Test proprioception in supine. You cannot test proprioception in sitting as the client will attempt to assist holding the limb you are placing, and therefore will be feeding that information forward – you will not be assessing what information the client is receiving. 2. You must sit in front of the client. You will not be able to see if they area cheating otherwise. If the client is unreliable, you would need to use a second person to bring the stimuli in from behind the client, while you remain in front. If the client is unable to understand, or is uncooperative, you will need to use your observation skills to ascertain if there is a hemianopia: they do not attend to the affected side; they leave the affected arm fall over the edge of the wheelchair; they run into things on that side, or if in a wheelchair hit the wall on that side, they leave ½ their food on the plate etc. 3. You will need to rearrange the bed position so that all stimuli come from the affected side. Nursing staff will have no problem with this if the value of this is explained carefully. You will need to educate staff, family and friends to always approach and sit on the affected side. The only chance the client has of accommodating to a visual loss and becoming safe is if he learns to compensate for this loss. This will only happen with a consistent and continual effort on behalf of all those involved with the client. Coordination Testing 1. Fully isolated movement, enough strength and ROM. 2. Hand dominance, sensation loss. 3. Speed, smoothness of movement, dysmetria (accuracy), timing/rhythm, ability to follow a sequence. 4. Assess the following - Break the movement down into indiv idual components: shoulder F/E, rotation, Abd/add; elbow F/E, supination/pronation; wrist F/E, finger strumming, individual opposition. - More complicated sequence of movements, for example clapping games. - Increase the speed. - Close eyes. High Level Tests 1. In a young client you would assess stepping reactions, narrow base stance (eyes open/closed), single leg stance (eyes open/closed), up on toes, jump, hop, skip/run, high-level jumping sequences. However, if your client is older, they may not have run for quite a while, and may not be up to this, but it may still be appropriate to test standing on toes/heels and one leg stance. If your client is elderly, then you will limit your assessment to much more age appropriate assessments, such as narrow base (eyes open and then possibly closed) and if able, one leg stance. Cranial Nerves 1. X, XI (vagus; glossopharyngeal: cough/gag, swallow). She is at high risk of aspiration, and you and the speech pathologist must decide early if she can protect her own airway. 2. IV (trochlear [obliques superior] – responsible for looking down and in). Often the only indication that clients have a IVth nerve lesion is complaints of double vision on stairs or when reading. When you test IV you need to test III and VI as well…there is not much point in testing them individually. Simply test all eye follow. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 28

3. Ice-cream is classified as a thin fluid. This is because it melts, and an efficient and effective swallow is needed to be able to eat ice-cream. Anyone who is on thickened fluids is at risk of silently aspirating if they are eating ice-cream. You need to explain all this to the family. If you are not sure of what food/fluids are appropriate, you need to ask the speech pathologist. You must not give a client anything to eat or drink unless you are sure of this. Apraxia Assessment 1. Ideomotor - Client fully understands the concept of a task but cannot perform it on command. e.g. bend arm; stand up; let go the ball. Ideational - Client cannot carry out a task either automatically or on command as he doesn't understand concept. He can perform individual movements but cannot develop sequence of action e.g. get off mat (from lying); light a match (give box of matches); clean teeth; roll over. Test - A formal test performed by Occupational Therapists or Psychologists is the Goodglass Test for Apraxia. {In Zoltan et al (1996)} The test consists of a series of tasks that the therapist asks the client to do. If the client fails on command, the therapist asks the client to imitate her doing the tasks. If the client still fails, and where applicable, the therapist asks the client to do the task with real objects. This is believed to be in the descending order of difficulty for apraxia clients. Examples of tests in this battery are: - brush teeth, use hammer, wave goodbye. Perceptual Assessment 1. Neglect; inattention (visual and tactile); other visuospatial perceptual impairments e.g. distance, depth, verticality; hemianopia; decreased light touch sensation or proprioception; apraxia 2. This client is demonstrating ipsilateral pushing. In the assessment, you are trying to find out the best ability the client has. When assessing sitting balance, you must not pull the client, as this will make them push back harder. You may need to do some active preparatory active/active assisted reaching to the unaffected side (you may need to use a table to achieve this) in order to obtain the best sitting ability the client has. Likewise to assess sit to stand, and standing balance you would bring a table in on the unaffected side, so that the client can lean on it if they need to. You need to get an idea if their posture is correctable. This may take a number of attempts, but you need to persevere. It is always best to give some sensory input while assessing (auditory tactile, visual – decide which combination of sensory input works best in improving the client’s alignment). You are also trying to decide which impairments (e.g. hemianopia, visuospatial neglect, altered body image) are contributing to the “pushing” problem. Wheelchair Skills 1. Ability to transfer from/to wheelchair from/to bed, toilet, plinth. Transfer status (ie. Independent, supervised, assisted and with how much assistance). Ability to push own wheelchair (level of independence, distance, accuracy). Vestibular Assessment 1. Questioning whether movement is associated with dizziness. Activities such as rolling, lying to sitting, bending forward, turning all stimulate the vestibular system. If there is dizziness on lying to sitting, or sitting to standing, postural hypotension may be a cause. With vestibular dysfunction, the dizziness usually settles once the movement ceases. With post hypotension, the changing position may increase the light- headedness, and the client may exhibit pallor, sweating and stress associated with the movement. If the client is hypotensive, sit them down if they are standing, lye them down if they are sitting. 2. Vestibular tests – detecting for dizziness during the performance of functional tasks such as rolling, sitting up, leaning forward, sit to stand, Hall Pike Dix manoeuvre. Use of dizziness inventory. 3. History of dizziness, balance, gaze stability. 4. Initially you will have to test eye follow, in order to see that they have the ability to move their eyes in the first place. Check for smooth pursuit of an object. To test gaze stability you start with the easiest stabilising exercises first, and progress from there. The target needs to be something the person can see easily, and needs to be within their focal length. When assessing gaze stability you are looking for the ability to keep the object in focus with head/eye movements. From easiest to harder: • slow ⇐ fast self initiated movement/stationary object in horizontal and vertical planes • slow ⇐ fast, self initiated movement/moving object (eyes in-phase with head) in both planes • slow ⇐ fast, self initiated movement/moving object (eyes out-of-phase with head) in both planes ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 29

This can be progressed to client moving, and turning their head to stabilize on sights on the wall. It can be made more difficult by increasing the density and frequency of objects, and ultimately to high level activities such as moving while catching/bouncing a ball. Again, begin slowly and progress to increased speeds. 5. There are a number of very important tests which will help decide if there is a vestibular component to balance. • Narrow base of support/tandem position – this tests the central stability of the trunk/pelvis which is reliant on vestibular signals. • CSTIB – a test of the integrity of the three sensory systems, determines over reliance on one system (conditions 5 and 6 challenge the vestibular system). • Fukuda – as eyes are closed, vestibular involvement is recruited, and will indicate deficits in this system. • Higher level skills (walking on a beam, heel-toe walking, braiding, 360 degree turns etc) - an efficient vestibular system is required to perform high level balance. • CSTIB – a test of the integrity of the three sensory systems, determines over reliance on one system. • Gaze stability – tests vestibular- ocular reflex. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 30

OUTCOME MEASUREMENT Review the following lectures located on the Blackboard Website. PHTY3140/7814 Block 2 Lecture 6: Physiotherapy Outcome Measures for Neurological and Geriatric Rehabilitation PT3130/7813 Balance Module/L1-3, P1-4 Balance throughout the Lifespan Prior to this clinical placement it is essential that you review the Guidelines for Physiotherapy Outcome Measures for Neurological and Geriatric Rehabilitation. A copy of these guidelines has been included in this ILP as Appendix 2. Testing procedures, normative data and references are provided for the following commonly used outcome measures: 1. Standing Balance Tests - Timed Static Standing Tests - Clinical Test of Sensory Interaction of Balance - Functional Reach - Lateral Reach - Step Test - Pastor, Day and Marsden Test 2. Functional Performance Tests - Timed Up and Go - Timed 10 metre walk – calculation of gait parameters (velocity, stride length and cadence) 3. Community ambulation measure - Dynamic Gait Index 4. Composite Measurement Scales for Measurement of Motor Tasks - The Modified Elderly Mobility Scale - Motor Assessment Scale - The Clinical Outcome Variables scale (COVS) - Berg Balance scale 5. Tools Used By Rehabilitation Team to Monitor General Outcomes from Rehabilitation - Functional Independence Measure (FIM) - Disability Rating Scale (DRS) - Glasgow Outcome Scale For an overview of measurement in neurological and geriatric rehabilitation please refer to the following texts: 1. Carr J & Shepherd R (1998) Neurological Rehabilitation- Optimising Motor Performance. Heinneman: London (Chapter 3). 2. Wade DT (1998) Measurement in neurological rehabilitation. Oxford Medical Publications. 3. Hill K, Denisenko S, Miller K, Clements T and Batchelor F (2005) Clinical Outcome Measurement in Adult Neurological Physiotherapy (3rd Edition) National Neurology Group, Australian Physiotherapy Association: Victoria. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 31

Problem Solving 1. What are the major advantages for using outcome measures? 2. You are working predominately with ortho-geriatric clients. Which outcome measure would be most appropriate and why? 3. You are now working in a brain injury rehabilitation unit. The unit is introducing outcome measures to evaluate effectiveness of intervention. Yo u and the other staff have input. The physiotherapists may use their own scale, but they need one for the unit as well. Which scale would be most applicable to measure physiotherapy outcome and why? Which outcome measure would be most useful as a unit outcome measure and why? 4. Compare the MAS and the COVS. What items are in common? What additional items have been included on each scale? Why would Brain Injury/Spinal Injury Units choose the COVS as an outcome measure? 5. What type of balance tests are built into the Berg Balance Scale? Feedback 1. Measurement of functional ability/impairments, provide evidence of progress, evaluate effectiveness of intervention. 2. The Elderly Mobility Scale, designed particularly to monitor progress in elderly mobility clients. 3. Physiotherapy Outcome: COVS: designed as a physiotherapy outcome measure for mobility and upper limb function, thus measuring physical improvement and outcome. Unit outcome: FIM as it measures cognition, social, ADL and physical outcome. 4. Common to MAS and COVS: rolling, lie ? sit, sitting and standing balance, gait, upper limb function. Additional items on MAS are more specific hand function and fine motor control of the hand. The COVS includes wheelchair mobility, transfers, getting off the floor, and a more detailed level of ambulation - velocity endurance, assistance aid. A brain injury or spinal injury unit would choose the COVS because of its detailed assessment of transfers with wheelchairs, wheelchair mobility, and assessment of floor to plinth transfers. 5. The Berg balance scale measures static, then dynamic and then functional tasks. It is a detailed assessment of ability to hold in narrow base and also with eyes closed, ensuring all contributing factors to balance are assessed. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 32

PHYSIOTHERAPY PRINCIPLES AND PRACTICE OF INTERVENTION IN THE AGED Review the module on Physiotherapy Principles & Practice of Intervention in the Aged on the Blackboard Website for PHTY3130/PHTY7813 (Block 4). Problem Solving 1. Your elderly BKA client is very keen to do another set of stairs. What would you observe and have to monitor in order to allow him to do this? 2. Your elderly client, who has some dementia, has a sore back. She says heat helps. She has frail skin. Can you give her heat pack? 3. What must you remove before handling any client, but particularly elderly clients? 4. Your elderly client, who has IHD and COAD, has tight hip flexors. How will you stretch them? 5. Mrs Y is deaf and slightly confused. You want her to do an exercise for you. How will you modify your instructions and handling in order to achieve this? 6. What emergency procedures must you be aware of at all times, particularly when working with clients with heart problems? Feedback 1. Monitor heart rate, breathing rate, general pallor. Clients are often keen to do more than they are capable of: you are in charge and need to make them sit down and have a short rest if they need it. 2. NO! She is not reliable because of her dementia. As well, she has fragile skin. You absolutely cannot give her a hot pack. 3. Always remove all rings and watches. They have the potential to tear skin. It is surprising how fragile skin can be, and a little tear often becomes a major problem in elderly clients. 4. You will not be able to stretch this client in prone. You can do it in side lying if your client can tolerate lying flat long enough. If not, you will have to stretch them in standing. 5. You will need to speak slowly, have simple instructions, and may have to use a lot of demonstration. 6. You have to be up to date with CPR. This is a requirement for working in hospitals, and you are expected to know how to do CPR. You must also familiarise yourself with the emergency procedures of the unit you are working in. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 33

SAFE PRACTICE Guidelines for Safe Practice The student is required to consider safety factors in all assessment and treatment encounters with every client over the 4 week rehabilitation unit. You must understand the contraindications and precautions necessary when assessing and treating client with various conditions. When giving warnings, the warnings must be clear to the client, and be given in a language and manner the client can understand. You must ensure the client has understood the warning or instruction that has been given to them. This concern for client safety must be demonstrated in ALL practice. The student should consider the following safety issues in addition to those listed in the overall Clinical Behavioural Objectives. The student must not attempt the following without prior approval from a University or appropriate Hospital Staff member: DO NOT: • transfer out of a wheelchair or walk a client (especially a new client) • take a client on the stairs • put a client into the prone lying position • put a client on a balance board • get a client down onto or up from the floor • take a client onto uneven surfaces or outside (You will ALWAYS have to have a registered staff member with you to go outside) • leave a client unsupervised in the gym for any length of time for whatever reason (NEVER!). A registered physiotherapist MUST be in the gym any time a client is. DO: • apply brakes and remove footplates before transferring clients out of wheelchair • put breaks on ANYTIME the wheelchair is stopped • remove clients’ socks/ stockings if trans ferring without shoes (NEVER TRANSFER A CLIENT IN STOCKINGS OR SOCKS) • obtain university or hospital staff approval before proceeding with any electrotherapeutic application and get application checked EVERY TIME by appropriate staff • take care when ha ndling elderly clients as they may have fragile skin. • seek help from tutor or staff when in any doubt about any aspect of treatment. • remove all jewellery to ensure protection of client’s skin. • report any incident/ accident to self or the client to the appropriate supervisor immediately (no matter how minor), as an incident report may have to be filled out. The supervisor will assist the student in doing this. Problem Solving 1. What should you never do when responsible for clients in a rehabilitation setting? 2. What should you always have checked before proceeding with your client? 3. What should you always put on when a wheelchair is stopped? ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 34

Feedback 1. Never transfer a client in socks/stockings. Never leave a client unsupervised in the gym. You may ask someone to supervise your client if you have to leave, but at all times there must be a registered physiotherapist in the gym. 2. Always have staff check all electrotherapy, transfers and walking tasks – you may be allowed to proceed with the mobility tasks when you have demonstrated competence but you MUST NOT TURN ON Electrotherapy equipment without an educator present. 3. Always put the breaks on as soon as the wheelchair stops, even if it is for a short time. Transferring the Neurological Client The method of transfer chosen for the neurological client will depend on a number of factors. When deciding on the best method of transfer for a particular client, the physiotherapist must consider the following: - Thorough investigation of chart entry - Client/ family report - Functional (anti-gravity) assessment of UL, LL and trunk control whilst client remains sitting in wheelchair (or bed). You should check the following: • Hip flexion: observing the quality of selective movement in the lower limb and considering whether the client will be able to take a step • Knee extension: observing quadriceps control, especially inner range; also look for the presence of any abnormal patterns of movement in the lower limb e.g. inversion of the ankle, which may need to be controlled during the transfer • Brief assessment of antigravity control in the upper limbs to establish whether you will encourage any use of the upper limbs during the transfer • Look at how the client moves themselves forward in the chair and prepares for standing - Knowledge of clinical presentations associated with various neurological conditions (e.g. SCI, stroke etc) - Knowledge of expected outcomes associated with various neurolo gical conditions - Knowledge of the NO-LIFT Manual Handling Policy - Consideration of the client’s height and weight Transfer Methods Following consideration of the above factors, you must choose the optimal method of transfer for your client at his/her current stage of rehabilitation. The following types of transfer will be considered here: 1. Standing transfer - stand and step - stand and pivot 2. Hoist Transfer 3. Standing Hoist transfer 4. Slide board transfer 5. Pat slide transfer 6. Floor transfer ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 35

Standing Transfer Following consideration of the above factors, ask the question: Is your client safe to perform a standing transfer with assistance? What level of assistance are you expecting to provide? • May require one or two people to assist • Light, moderate or maximal assistance? • What instructions will you need to provide to the second person assisting? What instructions will you need to provide to the client? How will you modify these instructions if the client: • Has reduced hearing • Has a fear of falling • Has perceptual deficits (e.g. reduced awareness of the midline) Where will you need to facilitate control? i.e. where will you put your hands? • At the pelvis to facilitate lateral weight shift • At the front of the knee to prevent buckling of the knee? • At the back of the pelvis to facilitate hip extension? • All of the above? (then may require 2 people) Use of a walk-belt is indicated: • When transferring the client for the first time • When deemed from the medical chart that the client requires assistance for the transfer • If it is the required standard of practice in your facility • The physiotherapist should be the staff member indicating when the requirement for using a walk-belt should be changed ****You must ALWAYS remove client’s socks/stockings if transferring without shoes Describing the client’s independence level If the client does not require physical assistance to perform the standing transfer, but does require stand-by assist (eg verbal prompts, feedback) in order to perform the transfer safely, you would describe the client’s transfer status as: “Transfers with SUPERVISION”. If the client is able to safely perform the standing transfer without physical assistance or stand-by assist, this client performs the transfer INDEPENDENTLY. Remember that a client may require a gait aid to perform a transfer safely, but may require no physical assistance or supervision. In this case in your assessment you would record the clients transfer status as: “independent transfer with a 4 wheeled walker” Types of Standing Transfer The standing transfer may be facilitated using a stand-step process or a stand-pivot method, depending on the client’s ability. It is optimal to encourage the client to stand upright and step around when transferring from chair to bed. A standing transfer must be performed by stepping or pivoting to the non-affected side. Therefore, it is important to consider the implications for environmental set-up when transferring into and out of a wheelchair. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 36

Usually the chair will be placed: - close to the bed or chair the client is moving to - angled towards the bed or chair - with the client’s less affected side nearest to the surface you are transferring to 1. Stand and Step Transfer - Assist from beside When using a stand-step transfer, assistance may be provided from beside the client. This method of transferring is suitable for the higher functioning stroke client or the de-conditioned elderly client. If the client is transferring to an adjacent bed or chair, this is best achieved through supervised use of the client’s mobility aid. 2. Stand and Step Transfer: Assist from in front For the hemiplegic client who requires more physical assistance, the stand-step transfer should be performed from in front of the client. In this way, it is possible to address medio-lateral pelvic control as well as antero-posterior control of the hip whilst facilitating the transfer. In addition to this, extension of the affected lower limb may be controlled using this method of transfer. When transferring the client, give the necessary assistance for a safe controlled transfer. While doing so note: – Posture – Balance – Weight shift – Movement onto the affected side – Amount of assistance required (from stand-by to maximal) – Effect of effort on movement ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 37

Problem Solving In the photo above, the therapist is facilitating a one-person stand-step transfer. Once the client obtains the upright position: 1. Where will the therapist best place her hands to achieve optimal stability? 2. How else might the therapist consider optimising the safety and efficiency of the transfer? Feedback 1. Once coming into the upright standing position the therapist would alter her hand placement so that the pelvis (postero-laterally) is supported. In this position, hand placement is positioned optimally to provide stimulus for gluteal activation, increasing the client’s participation to the hip extension phase of standing up. 2. The therapist may consider asking a second person to assist the transfer. She would need to instruct the second person: - How much assistance is required (light, moderate, heavy) - Where the assistance is needed (L knee and foot control) - Best position for second person to assist In addition to this, clear instructions must be provided to the client. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 38

Hoist Transfer For use when your client is considered unsafe to perform a standing transfer with assistance. Use of a hoist (electric or manual) is indicated when clients are unable to dynamically weight bear through the lower limbs and lack trunk control, and are therefore considered unsafe to attempt a standing transfer with one or two people. Such clients may include complete SCI (high level quadriplegia), severe Traumatic Brain injury, or frail elderly who have lost their ability to mobilise. Hoists are employed within Health Care Facilities as part of a NO-LIFT Manual Handling policy. Manual Handling Policy dictates that use of a hoist requires involvement of 2 operators at all times Standing Hoist Transfer A standing hoist may be used where the client is unsafe to transfer with one or two people, but has some control of the lower limbs and trunk. This transfer method is unsatisfactory for the acute hemiplegic client who has a flaccid upper limb which is unable to participate in this hoist transfer. Benefits of using the standing hoist include all physiological (and psychological) benefits associated standing upright and weight bearing. Slide Board Transfer This type of transfer requires the presence of some upper limb control and sitting balance. While the feet are in contact with the ground, the transfer is performed by shifting the COG (upper trunk) within a wide base of support (the hands).The arms and the trunk largely provide the propulsion for this activity. Clients with paraplegia (and low quadriplegics) and lower limb amputations may transfer using this method. Use of a slideboard to transfer a client may require one or two people or SUPERVISION only, depending on the physical/cognitive/emotional presentation of the client Pat Slide Transfer A large board (body length) called a Pat Slide may be used to transfer a totally dependent client from one flat surface (eg supine on bed) to another flat surface (eg supine on a shower trolley. Slide sheets are often used in conjunction with a Pat Slide. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 39

A minimum of two people are required to transfer a client using this method. An example of this transfer method would be when moving a severe traumatic brain injured client from bed onto the tilt-table in preparation for standing. Floor transfer This refers to the movement of an individual between resting on the floor to upright standing. A client may: • Require assistance of one or two people • Require supervision • Be independent Some clients may need to demonstrate their ability to perform floor-wheelchair transfers, if wheelchair is their mode of mobility. Mobility Status of the Rehabilitation Client Mobility status describes the manner in which the client mobilises from one point to another. There are a number of factors which must be stated when describing mobility status: 1. Mode of mobility • Walking (client is ambulant) • Use of a Wheelchair (client is non-ambulant) - Manual - Self-propelling - Attendant propelled - Electric 2. Amount of assistance required • Independent = client is able to mobilise independently, and does not require a therapist, nurse or family member to be present • Supervision = client must mobilise in the presence of a therapist, nurse or trained family member. ‘Supervision’ may require - Prompting - Encouragement - Verbal Feedback - Stand-by assist - Contact guard (to prevent a fall) • Assist X 1 = one person to provide hands-on assistance with mobility • Assist X 2 = two people to provide hands-on assistance with mobility 3. Degree of assistance required • Light assistance • Moderate assistance • Heavy assistance 4. Type of mobility aid • SPS = single point stick ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 40

• 4PS = 4 pronged stick • Hopper or Pick-up Frame • 2WW = 2 wheeled walker - With stoppers - With skis • 4WW = 4 wheele d walking frame - Push down brakes - Hand brakes • Rollater = 4 wheeled walking frame with elbow supports • Wheelchairs are varied in their type and function. Chairs that are suitable for short-term use (eg at beginning of rehabilitation while in hospital), have very different features than those that are used long-term in the community by the more dependent client. 5. Distance mobilised When documenting mobility status, it is very important to document the distance over which the individual is capable of mobilisin g. This may be on a hospital ward: - Client mobilising independently with 4WW 50 m - Client mobilising to and from toilet with nursing staff assistance X 1, nil gait aid (note that “to and from toilet” is a standard distance when referring to a particular client in a particular bed) Or in the community: - Client mobilising to shops (approx 400m) independently with SPS 6. Type of environment This is of particular relevance for the client who is being prepared for discharge, or when gaining information regarding pre-admission mobility status. Indoors: client mobilises independently with SPS (approx 25 m) Outdoors: client mobilises independently with 4WW to letter box and back (approx 40m) If applicable, also document the individual’s ability to mobilise over grass, slopes, pebbled surfaces, beach, etc. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 41

Practice Questions for Start-up Exam a) Which symptom is associated with vestibular dysfunction? 1. Hypokinesia 2. Gaze instability 3. Resting tremor 4. Rigidity b) Which of the follow ing impairments is least likely to directly contribute to hyperextension of the knee? 1. Weak quadriceps 2. Weak hip abductors 3. Shortened gastrocnemius 4. Increased tone in calf muscles 5. Increased tone in quadriceps c) Your client can walk with 1 assistant but has not been trained with a walking aid and is unable to step safely without support. Which outcome measure is not appropriate at this stage of your assessment. 1. Measures of timed standing balance 2. Use of the Timed Up and Go Test 3. Use of the Motor Assessment Scale 4. Use of the Clinical Outcomes Variable Scale 5. Measures of Functional Reach d) Which of the following symptoms is not related to cerebellar dysfunction? 1. Dysmetria 2. Dysdiadokokinesia 3. Hypokinesia 4. Intention Tremor e) If a complete lesion at the le vel of T5 /T6 has occurred which of the following muscles will be innervated? 1. Latissimis dorsi 2. Rectus abdominus 3. Transversus Abdominus 4. External Oblique 5. Internal Oblique f) Answer true or false – circle the correct response (correct answer highlighted) TF TF 1. Forward inclination of the trunk is a pre-extension component of sit to stand TF 2. Rolling over is only achieved by pushing through the foot TF 3. The dorsiflexors work concentrically to lower the foot to the floor TF 4. Reaching, supporting and manipulation are important upper limb activities 5. Reaching down to the floor requires eccentric control of the erector spinae ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 42

g) Which component of gait is not associated with the stance phase? 1. Heel strike 2. Mid stance 3. Heel rise 4. Foot flat 5. Terminal Swing h) Recovery of function after brain injury could be associated with 1. Stage of rehabilitation 2. Plasticity of the nervous system 3. Organisation of services 4. Quality of motor task training 5. All of the above i) Symptoms of Parkinson’s Disease may include 1. Difficulty initiating movement (akinesia) 2. Rigidity 3. Hypokinesia 4. Dyskinesias 5. All of the above j) The usual order for a qualitative assessment of a client who presents in a wheelchair but has been walking with 1 assistant is: (Present in random order to student who has to insert correct number) 1. Subjective and assessment of active movements while seated in the wheelchair. 2. Deciding on the method of transfer and executing the transfer with supervision 3. Analysis of motor tasks / use of relevant outcome measures 4. Execution of the directed objective examination to confirm the likely impairments k) There are a number of tests which will help you to decide if there is a vestibular component to the presenting balance problem. Circle true or false to the following: 1. A narrow base of support uses vestibular signals for optimal control T F 2. Standing on a foam (eyes open) only requires vestibular signals TF 3. The Fukuda stepping test indicates a peripheral vestibular deficit TF 4. Passive head movements challenge gaze stability TF l) Indicate if the statements are true or false True False A client may mobilise with TED stockings if he/she does not have X any shoes in hospital X Brakes must be applied and footplates removed before transferring a X client out of a wheelchair. X A client must never be left unsupervised in a physiotherapy gym for any length of time When progressing and challenging a client’s balance through prescription of a new exercise, a physiotherapist must be present to supervise and provide stand-by assistance ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 43

m) Read the following scenario and indicate which of the actions by a physiotherapist are acceptable practices. NB: More than one response letter can be circled. Two of the three highlighted correct responses would be accepted as a correct answer. You are helping your total hip replacement client to the toilet, but on arrival you find there is no raised toilet seat in the cubicle. Do you: 1. Sit the client on the toilet anyway and tell them it will be OK just this once. 2. Leave the client holding onto the doorway while you go and search in the next room for a raised toilet seat. 3. Take them back to their chair and tell them to call a nurse. 4. Press the nurse call button and stay with the client until the nurse arrives, and then ask them to bring you a raised toilet seat. 5. Take the client back to their chair and go and find a raised toilet seat before going back to the client and helping them to the toilet. n) Match the client presentation with the most appropriate method of transfer Note - answers are correct here, and would be randomised on the actual exam. One person light assist stand transfer 4WW 80 yo lady # L NOF (from beside the client) 78 yo lady dense (L) hemiplegia Two person assisted stand- pivot Independent standing transfer 62 yo mild lacunar infarct Slide Board transfer with supervision 27 yo lady C6/7 complete quadriplegic Hoist transfer 95 yo nursing home resident- bedridden PAT slide 22 yo man Severe TBI, decreased conciousness o) Your elderly client, who has some dementia, complains of longstanding LBP, exacerbated by today’s treatment session. She says heat helps. She has frail skin. Do you: 1. Find a hot pack and apply it directly, positioning the client supine on top of the hot pack? 2. Investigate the nature and behaviour of the back pain further, corroborating with information gained from the medical chart and any relevant x-rays 3. Discuss any contraindications for use of hot pack for your client with your clinical educator. Suggest any alternative management strategies. 4. Perform a sensory assessment (hot/cold) on the client’s lumbar region. When satisfied that Pain/Temperature sensation is intact, apply the hot pack when the client returns to their bed, telling her to remove it in about 15 minutes. 5. Tell the client that she should ask the nursing staff for a hot pack ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 44

WEEK ONE This week your focus should be on developing the fundamental skills of a physiotherapist working in rehabilitation. You should be performing neurological assessments based on clinical reasoning principles and implementing basic treatment programs. This week’s Independent Learning Activities are on: • Prediction of outcome and goal setting • Treatment planning • Written records PREDICTION OF OUTCOME AND GOAL SETTING It is important to be able to predict outcome based on one's early assessment of a client. This will be vital to the process of setting long term goals and deciding the type and amount of physiotherapy services that will be committed to the client. Consider the following steps to facilitate this process: • Determine and record problem list • Predict outcome for the individual clients with respect to: - upper limb - mobility - discharge destination/type of residence • Set long term and short term goals • Plan follow-up and community services, e.g. physiotherapy outpatie nts. Meals on Wheels, Blue Nurses, etc. Problem List • concise but thorough summary of problems • attempt to prioritise problems • include functional problems and primary and secondary impairments Example Problem List Decreased Functional independence: - Mobility: wheelchair dependent (unable to self propel) - Standing: requires maximal assist x 2 people - Sitting balance: 2 minutes static balance; requires supervision to reach outside base of support - Sit to stand: requires moderate assist of 2 people - Bed mobility: moderate assist of 1 person Right hemiparesis: - nil voluntary movement UL - able to initiate partial range antigravity at hip and knee (poorly isolated) - nil voluntary movement at ankle or foot Decreased Se nsation right side - Light touch: severely reduced UL(worse distally); Mildly reduced LL - Deep pressure: moderately reduced UL; Normal LL Right homonymous hemianopia Decreased passive ROM (R) glenohumeral joint Expressive Aphasia (moderate); Receptive aphasia (mild) Incontinence ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 45

Defining Long Term Goals/Outcome Together you and the client discuss and determine the goals the client wants to achieve. This needs to be a joint effort, as there is no point trying to make someone achieve something they have no desire to achieve. Remember, it is their life, and you are there to help them. You will predict outcome and set long term goals for individual clients with respect to: - discharge destination/type of residence - mobility - upper limb Discharge status/type of residence Options include: • home alone with no community services • home alone with community supports • home with others + community supports • hostel • nursing home Upper Limb Goals These might be: • fully functionalor • stabilising/assisting or • non-functional but painfree, (full range of motion no contractures to enable ease of dressing and bathing). Mobility Goals You should describe mobility goals in appropriate detail and should include: • level of independence (amount of supervision or assistance) • aid used, including wheelchair • type of surfaces client can negotiate • distance How to determine long term goals and outcome Prediction of outcome will depend on a combination of factors. Important factors to consider in general: • time since onset • change which has occurred in that time • pathology – size of lesion, type of lesion, site of lesion (e.g. is pathology progressive, degenerative, multiple or is CVA haemorrhagic, embolic, lacunar, etc.) • motivation/attitude • concomitant conditions/pre-existing pathology • presence of sensory and visual impairments • presence of speech/cognitive/behavioural/perceptual impairments • use of established/documented early predictors, e.g. attainment of early sitting balance • social and financial support ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 46

A useful task to aid you in predicting outcome is to consider all of the above factors in terms of whether they will have a positive or negative impact on the prognosis for the individual client. You will notice that you are guided to do this when you are filing out the Clinical Reasoning Form for each of your clients. Example: Negative Positive perceptual impairment (unilateral neglect) early movement return absent sensation (L) UL and LL hemianopia early attainment of sitting balance â concentration Older age good family support, wife well large embolic CVA in non-dominant, nil other pathologies parietal lobe 4 weeks since onset 14 stairs into house previously mobile no aids Setting short term goals Have a discussion with your clinical educator and other students about how to set appropriate short term goals. Triggers for discussion: • These may be the factors that will help to achieve long term goals (eg, á calf length, á quads control, â pain) • These may be intermediate steps to aim for in progression to ultimate long term goal - eg week 1 sit to stand pushing up from high chair - week 5 sit to stand, no arms, low chair • Should be established for - acute primary care phase - early rehabilitation phase - in preparation for discharge • Should be set, revised, modified or upgraded regularly in order to keep client achieving and progressing and optimally, should be measurable. Planning/organisation of follow-up community services Have a discussion with your clinical educator and other students about how to plan for and organises follow-up community services. In your unit, you need to talk to your clinical educator and/or the social worker and occupational therapist to find out what services are most commonly used by that unit. Many services are means tested, and not necessarily available to everyone. You need to know how you would go about organising an aid or service for a client. In the course of the four weeks, ask if you can do this yourself. This is up to you. It will mean that you know how to do it when you graduate. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 47

You should discuss how and why you would organise the following services and aids: Follow up physiotherapy • consider type (e.g. outpatient, monthly review, home program etc) • consider frequency – how often, how long till review • how to organise • protocol to follow – e.g. discharge summaries, letters and verbal contact Community Services • Meals on Wheels, Blue Nurses, Domiciliary Physiotherapy, Commonwealth Rehabilitation Services, Sporting Wheelies, associations like SASSY, PDA, Headway, etc. Organization of Aids • MAS (medical aids scheme: means tested supply of aids from Queensland Health); • DVA (Department of Veteran Affairs) • Red Cross • Queensland Cancer Fund. Problem Solving Try to predict the outcome for the following clients. You need to predict for 1) upper limb outcome; 2) mobility status outcome; 3) discharge status. Include 3 short term goals (i.e. what you want your client to achieve at the end of one week of treatment). 1. An 89 year old lady who has had a large benign frontal lobe tumour removed. She shows very little initiative. She lives alone, but has family who visit once a week. She requires one person to assist with sit to stand, and light assistance of 2 people to walk, because of unsteadiness and difficulty re-initiating walking when she stops. It is 6 weeks post operation. Mrs A has shown some improvement, but it has been slow. 2. A 17 year old male with a severe traumatic brain injury. It is 3 months post injury. Mr B has brainstem involvement, a dense L) hemiplegia, R) ataxia. He is still in PTA (post-traumatic amnesia), is very distractible, asking what the time is every 5 minutes. He can be kept on task for short periods. Presently he can sit unsupported for short periods with 1 person close supervision and requires 2 person assistance to stand. 3. A 45 year old man who has had a large R) CVA 2months ago. He has an L) homonymous hemianopia, a dense L) hemiplegia with little isolated return, a left neglect, limited insight, and is impulsive. He has a very supportive family, who want to take him home. Mr C has improved functionally since admission, and has gone from having no sitting balance, to having good trunk control (still needs supervision because of impulsivity and poor insight), and requiring 2 person assist to stand and walk. 4. A 79 year old lady with a similar presentation to Mr C, but her children, although supportive, all work full time. Until this event, Mrs D had been in excellent health. She lived alone, still did all her own cooking, cleaning and gardening. 5. A 50 year old man with a R) hemiparesis from a bleed 6 weeks age. On admission he had no sitting balance, was severely dysphasic and has a dense hemiplegia. Mr E has improved physically; he is now walks with one person assistance, but remains severely dysphasic. 6. A 40 year old lady who had a R) CVA 8 weeks ago and presented as a severe pusher. Mrs F remains a pusher, but is now more consistently correctable, and is starting to show carry over between treatments. She also now has isolated hip and knee flexion, and extension, but no ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 48

dorsiflexion/eversion. There has been no return of movement in her upper limb, and in fact the arm remains painful, has limited range and is showing some swelling. Mrs F arrived in the rehabilitation unit last week. 7. Mrs G is a 66 year old lady who has had a L) middle cerebral artery stroke 6 weeks ago. Her main problems are: - Severe expressive dysphasia; understands one stage commands. - Dense R) hemiplegia with no isolated upper limb return. Has a 2cm subluxation, but no pain. - Has grade 2 isolated hip abduction, a small amount of activity in hip extensors, patterned knee extension, no dorsiflexion or eversion, small amount of hip flexion against gravity, but also patterned. Feedback on Prediction of Outcome and Goal Setting 1. 89 year old lady with frontal tumour As Mrs A has a frontal tumour, she is unlikely to have any focal neurological deficit, such as a hemiplegia. Her prediction of outcome is going to be based on her cognition and lack of initiative, as well as the fact that she is 89, and therefore has less potential to improve/compensate neurologically. Thus, despite the ability to have fully functional upper limbs, Mrs A may not achieve this, as she will be dependent on supervision and verbal cueing to use her limbs functionally (e.g. to eat, assist with ADL etc). This also holds true for gait. It is likely that she will continue to be dependent on assistance, particularly to prompt and cue for safety, in gait. It would be reasonable to expect her to achieve gait with one person assist, perhaps with an aid such as a wheeled walker. At this age, and level of dependence post operatively, you are aiming for functional mobility: a supportive aid is not going to limit her potential, and in fact may be the only way of achieving some level of independence. Mrs A will need to go to some supported accommodation, such as a hostel, or home with family who would need to be there constantly. STG: Sit to stand with verbal cueing. Stand unsupported 1 minute, close supervision. Walk 10 metres with 2 people, one light assist, and 2nd person stand by in case of difficulty. 2. 17 year old TBI You would be aiming for a very high outcome for this young man, although it will depend on actual return of selective movement. He is very young, and will continue to improve for years. L) upper limb: functional, may not be optimal. R) upper limb: fully functional. Gait: independently mobile, all surfaces, all distances, no aides (may need an interim AFO); may go on to running and higher level activities, dependent on movement return. Discharge: home, may return to school dependent on cognition. Dependent on cognition, may go on to working. STG: Two person stand, client to maintain own knee extension for 30 seconds alone. Client not to ask for time for 6 minutes. Sit unsupported and reach ½ arms length to right without falling over. 3. 45 year old man, R) CVA 2months ago Because of his rapid change in a relatively short period of time, you would anticipate continued improvement. The negative factors are his lack of insight, impulsivity, neglect and hemianopia. These are however very significant negative factors. On the positive side his family support and their willingness to take him home are equally significant. Upper limb return: functional to stabilising. Gait: mobile with supervision, no walking aids (may need AFO), most surfaces, all distances (he may need supervision in gait if his hemiplegia/neglect/hemianopia do not improve, but should become physically able to walk without support or walking stick). Discharge: home to family, would not go back to work. May need to be supervised, if hemianopia, neglect and insight do not improve. STG: Maintain/gain ROM in upper limb. 2 person stand, client holds own knee in extension 10 seconds. Stand unsupported 5 seconds in parallel bars, with supervision/cueing. 4. 79 year old lady, R) CVA 2 months ago Mrs D may not have as positive an outcome as Mr C. This is because of her age (thus not as much possibility for neurological improvement), and the fact that her family are unable to take her home. Upper limb: probably stabilizing – maybe some function. Gait: may need an aid, and most likely ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 49

supervision. If improvement plateaus she will be wheelchair dependent for most of her mobility, and walk short distances only. She will not be able to return home alone. Unless her family can look after her, she will need to go to a hostel, or some supervised accommodation, and may need a level of assistance to perform ADLs. STG: Maintain/gain ROM in upper limb. Stand supported 10 seconds with less support from 2nd person. Teach family/nursing staff to attend to client from affected side. 5. 50 year old man, L CVA 6 weeks ago Given the rapidity of Mr E’s improvement physically, you would anticipate continued physical improvement. Thus he will achieve independent (i.e. no supervision or assistance) mobility, all surfaces, all distances, no aid. Upper limb: may achieve functional use, but at least stabilising. Discharge to home if family. Will not be able to go home alone, unless his dysphasia improves to a level that he can communicate should he have difficulties. STG: Walk with less assistance, same distance. Standing balance à improve time of unsupported stand, with correct alignment. Upper limb maintain/gain ROM (if there is a decrease in ROM, need to set a specific amount of degrees to improve by). 6. 40 year old lady, pusher, R) CVA 8 weeks ago This lady is still young. However she is still a severe pusher, which does not have such a good prognosis. She is improving, which is positive, however she is improving slowly, and is still at a very dependent level 8 weeks post stroke. This lady may achieve mobility, perhaps with supervision and over a longer period of time (i.e. she may need an extended period of rehabilitation). Her upper limb is of some concern. You need to be very assertive in your management of this limb (see shoulder hand syndrome Independent Learning Activity). Mrs F may continue to gain some recovery as she is young and it is only 8 weeks post stroke. Thus, she may achieve some functional or stabilising use of this arm. This early in the rehabilitation process you would aim a little higher, but take care what you say to the client. Later, you would aim for, at the very minimum, a pain-free arm with good ROM. Discharge: may be able to go home, if she has family, but this may take some time. If she has no family, and her spatial problems don’t improve, Mrs F may have to go to supported accommodation. STG: Stand with hip against table, but not leaning on it, for 10 seconds. Upper limb: Gain 5 – 10 degrees each limited ROM. Decrease swelling by measurable amount à maintain with glove or pressure bandaging. 7. 66 year old lady, L) MCA bleed 6 weeks ago As this lady has made very little improvement in the time since onset, her prognosis is not as positive. Upper limb: stabilising/pain free. Gait: mobility +/- supervision/aid, moderate/short distances, flat surfaces. Discharge: could go home if family at home (because of dysphasia, would not be able to call for help in the event of an emergency – need a means of communication). STG: Prevent/minimize subluxation – sling/education re positioning; encourage activation of muscles around scapula and glenohumeral joint etc. Stand minimal support 10 seconds. 2 person walk 5 metres. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 50