Neurology Rehabilitation ILP 2006

TREATMENT PLANNING During the pre-clinical Neurology Speciality Course a large number of treatment techniques, relevant for use with clients undergoing rehabilitation, were discussed and/or demonstrated. It is essential that you review this material now if you have not done so already. Review material presented in PHTY3140/7814 (Module 3) on Management strategies & technique selection for retraining function after acquired brain injury. Relevant information was presented as follows: Methods of eliciting movement recovery: L4/5 • Handling • Choice of training position • Structuring the training environment • Provision of specific sensory input and the use of augmented sensory feedback: - Visual - Tactile - Thermal - Proprioceptive - Vestibular - Auditory • Use of equipment - Electrical stimulation - Biofeedback - EMG - Positional Gait training for neurological disorders L7 A work-station model to retrain function: application to balance and mobility L8 training Retraining rolling and bed mobility tasks Pr 3-4 Retraining the tasks of sitting up and sitting balance Pr 5-6 Retraining sit to stand tasks Pr 7-8 Retraining the task of standing balance Pr 9-10 Gait Retraining Pr 11-12 Eliciting movement in the UL Pr 13-14 Retraining UL function using work-stations Pr 15-16 Management of Trunkal Ataxia, Higher Level Balance & In-coordination Pr 17-18 Retraining balance and mobility using workstations Pr 19-20 Review material presented in the module on Balance throughout the Lifespan in PHTY3130/PHTY7813 (Block 5: L1-3, P1-4) ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 51

Organisational Aspects of Treatment Planning Have a discussion with your clinical educator about the organisational aspects of treatment planning Discussion should include the following points. Planning of treatment session must consider: - Organization of treatment strategies into those that can be done independently and safely and those that require supervision or physiotherapy assistance. - Carry-over of program into the ward. - Use of practice books to promote consistency of practice and encourage client to take responsibility for rehabilitation. See independent learning activity on Facilitating Independent Practice. - Involvement of relatives as appropriate. - Time management. Remember to plan for each day, but also to plan for the entire week – Trigger questions could include: - Is enough being done? - Am I running out of time? - What is essential to achieve every day? - What could be addressed on alternate days? - What can be managed outside therapy time? - Are short term goals being achieved and revised? Strategies to help time management include: - Prioritisation of individual client’s main problems - Prioritisation of clients - Overlapping of clients - Involving relatives - Use of practice books - Combining 2-3 strategies at once e.g. positioning of upper limb whilst bridging lower limb etc. - Alternation of activities to minimise fatigue. Client should not always have to completely rest, perhaps just change the set of muscles being used. Problem Solving Now consider the following clients, for whom you have already predicted outcome and short term goals. Design an hour long program which addresses all the client’s problems in this time: 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 ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 52

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 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. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 53

Feedback on Treatment Planning (Suggestions of possible time allocations for optimal programming) 1. 89 year old lady with frontal tumour Bring family in for some treatments if possible. This is to treat your client holistically. The family will continue to visit this lady, and it is important for them to reinforce treatment strategies. This will ensure carry over into the supported environment, and allow the family to have active input into Mrs A’s life. Rx plan: 10 mins reaching forward on plinth to gain anterior pelvic tilt in preparation for sitàstand. To be done as a number of activities, such as bowls, quoits, throwing sandbags in an arc etc. 10 minutes standing balance: alignment, dynamic activities such as reaching for objects, building a tower to the left and right, transferring objects from low to high blocks incorporating trunk rotation. 10 minutes walking: 2 person taking less support as walk progresses. 5 minutes sit down: arm elevation with walking stick held in hands à to rotation of trunk touching a suspended balloon on each side. Ensure full ROM arm movements, and trunk extension. 10 minutes standing balance: step and reach, balloon tennis, uneven surface. 5 minute side walking: correcting for hip abduction , extension. 5 minutes rolling/getting out of bed. 5 minutes for transfers/to and from ward. 2. 17 year old TBI This young man will continue to improve for years; if at all possible he must be treated twice a day, and needs a lot of variation in his treatment plans. As he is so young, you are not limited to positions which you may be with a more elderly person. The programme below has not used 4pt, 2pt and ½ kneeling, all of which are highly appropriate positions when he has a little more trunk control. This is the sort of client you would sit on a theraball for trunk work and sitting balance. Your plans with a young brain injured client are only limited by your imagination. It is imperative that the programmes have variety and are interesting, so that you keep his attention and cooperation. Games incorporated into the programme make it rewarding for the client. Rx plan: 10 minutes sitting balance: unsupported to reaching out of base of support. Work on head and trunk alignment, and trunk movement to each side, and trunk rotation. 10 minutes standing with 2 people. Work for alignment and trunk extension. Try to decrease support. If possible do calves stretch in this position. 5 minutes prone standing, working on scapular stabilization on hemiplegic side, with reaching on R) side for ataxia. 5 minute sitting: R) UL incorporated in reaching forward (placing objects etc for ataxia) for anterior pelvic tilt (as per Mrs A), L)UL in position of weight bearing as able when coming back into correct sitting alignment. Add rotation when placing objects. 10 minutes stand/walk. 10 minutes supine: L)UL stretches, working for protraction/any activation. R)UL reaching for targets suspended from grill. Trunk stretches with shoulders still, flexed hips rotated to the opposite side. If time, placing of ataxic foot to markers on the wall. 5 minutes prone, weight bearing through L)UL, placing for R)UL. Rocking pelvis if have help. 5 minutes standing/transfer. 3. 45 year old man, R) CVA 2months ago Bring family into treatment initially, but not every treatment. You need to educate the family/staff/friends if there is to be any chance of Mr C compensating for his hemianopia. You need to try to incorporate attention to the affected side in all aspects of treatment. 5 minutes sitting balance: reaching forward with bilateral arm activities to increase attention to the L), aiming to increase anterior pelvic tilt for sit to stand. Have a target to reach for to increase attention, enjoyment and cooperation. Slowly move target to L). 5 minutes sità stand. Bed at height to allow optimal symmetrical loading (i.e. bed higher). 10 minutes standing: aim for symmetry, equal loading. Have interesting objects on left; get client turning head to left, if possible reaching to left. 10 minutes walk. 5 minutes supine: bed mobility, upper limb stretches, active upper limb activity as able. 10 minutes standing balance/components of gait –step and load/calf stretch/ arm loaded while stepping. 10 minute walk. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 54

5 minutes transfer/correct positioning of arm/ bright ribbon or balloon on left to stimulate attention to left side. 4. 79 year old lady, R) CVA 2 months ago Similar programme to above. Would need to concentrate more on transfers to make them consistent, and very easy for one person to do (should she not reach independent mobility). Mrs D may not cope with quite as much walking in one session, and you may have to give her more frequent rests. When resting, have interesting activities to the L), and load the L) arm/do activities with the L) arm. 5. 50 year ol d man, L CVA 6 weeks ago Your treatment will have to take into account Mr E’s dysphasia. Instructions need to be simple, use lots on non-verbal communication and positive reinforcement. Similar programme as to Mr C, Mrs D. 6. 40 year old lady, pusher, 8 weeks ago As Mrs F is a pusher, you will have to do a lot of preparatory work in sitting. As she is only just showing carry over now, you may need to repeat this work between stands in order to achieve the best stand. If her performance is fluctuating, then you may not necessarily achieve a walk in each session, but you need to aim for this. Also, presently Mrs F has a serious shoulder/arm problem and proportionally more of your treatment time will be spent on the arm. This emphasis will change as soon as her arm is non-painful, and you have arrested the progress of a potential shoulder-hand syndrome. 10 minutes sitting alignment, table on unaffected side, reaching to unaffected side, have targets to make treatment more interesting. 5 minutes sit à stand if able, with table. Try to take hand off table if able without loosing alignment. 10 minutes upper limb movement, working into flexion, use effleurage in elevated position, techniques for pain. 10 minutes sitting/standing. 15 minutes supine: upper limb ROM, effleurage, active ex, accessory movements to decrease pain, and to gain ROM. 10 minutes sitting à stand à walk with 2 people. 7. 66 year old lady, L) MCA bleed 6 weeks ago Treatment similar to Mr C, Mrs D, upper limb activities of Mrs F. you will need to focus somewhat on the upper limb, because of the subluxation and lack of movement return. It is imperative that you educate this lady, her family and the staff regarding positioning of the upper limb. It will need to be supported any and every time it is dependent. Thus every time this lady is sitting in her chair it will need to be supported on a pillow, or better yet, a gutter splint. Any standing activities require a sling to be used. If you cannot attain a hemiplegic sling, you may use a collar and cuff. Just remember that when using a collar and cuff, you are placing the upper limb in the positioning of shortening, and you will have to ensure this sling is not left on when it is not needed. Make sure you are vigilant regarding stretches/ROM. This lady may require more frequent rests than say Mr C. When resting this lady, you need to address the upper limb. You can do active protraction, depression, prolonged loading, etc. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 55

WRITTEN RECORDS Review the following guidelines on how to complete written records. NOTE: The following are general guidelines only. When completing written records it is essential that you follow the established protocols of the particular unit you are working in. Physiotherapists working in the field of rehabilitation may be required to produce the following types of written records: 1. Medical chart entries 2. Physiotherapy records - Write –up of the initial physiotherapy assessment - Progress notes - This often includes the recording of objective physiotherapy outcome measures (often on computerised data collection systems 3. Notes for case conference or team meeting 4. Physiotherapy discharge summaries 5. Letters to other physiotherapists or other health professionals Taking the time required to write high quality physiotherapy records will also ensure that you adequately reflect on all aspects of the clinical reasoning process. It will encourage you to consider the assessment process used and your assessment findings and how they relate to the goals you have set. It will also cause you to reflect on the effectiveness of your intervention. Medical chart entries This will include: - An initial chart entry - Progress notes Protocols for individual units should be followed at all times. In the absence of specific protocols, follow the guidelines provided here. A systematic and logical approach makes it easy to ensure all information is effectively relayed. Initial physiotherapy assessment - The record of your initial physiotherapy assessment must be clear, concise and easily understood. - A clear and simple method of writing up an initial assessment is shown in the example below. Look at this now. Progress Notes Frequency required: Individual units will have specific requirements which you will need to follow. Many inclient rehabilitation units require the physiotherapist to write weekly progress notes in the medical record. Other centres may require more frequent chart entries. Of course even if only weekly chart entries are required you will always write in the medical record immediately if some significant change has occurred e.g.: - You have changed the type of walking aid the client is using - The level of supervision of mobility has changed. - An incident has occurred e.g. a fall in the physiotherapy gym Progress notes should include: Page 56 - Subjective questioning re clients condition, progress. - Documentation of improvements, preferably objective and quantitative. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006

- Problems encountered including falls, accidents, failure to attend, organisational difficulties, incontinence, client attitude etc. - Brief outline of treatment including electrotherapy application. - Liaison conducted with other team members - Revision of short term goals. Conference Notes Most rehabilitation units have a regular team meeting or case conference to discuss clients’ progress. You will be required to attend and participate in these meetings. In preparation for these meetings you must write down what you are planning to say at the meeting. Conference notes should be checked by the clinical educator and by the relevant staff member prior to attending conference. Conference notes should be written for all clients regardless of whether the student is attending conference or not. If not attending, these must be given to the staff member attending. Conference notes should be kept with other written records and not discarded. When the client is first discussed at a case conference your report should include a thorough but concise problem list, accurately documenting the client’s mobility status, functional level, movement abnormality and specific problems on admission. Follow up reports should focus on improvements that have happened since last conference (with attempts made to be as objective and quantitative as possible), with particular reference to: - Current mobility status - Current functional level - Current balance status - Improved/new movement return or control. - Any problems that have hindered physiotherapy management and your clients potential to progress e.g. incontinence, pain, behaviour/attitude, cognition, timetabling of alternate appointments etc. - Any problems that warrant investigation by or referral to other professionals e.g. orthopaedic review, ophthalmology, podiatry, X-ray, etc. Although it is not required to be stated at every conference, you should think about updated long-term goals and discharge plans prior to attending the conference, as you may be required to discuss these with team members. Discharge Summary Should include: - The client’s personal details (demographics) - Diagnosis, date of onset, chronology of significant events since admission. - Relevant medical history. - Problems on admission. - Treatment/management strategies used during rehabilitation. - Current functional level, mobility status, balance status and level of movement recovery on discharge - Other residual problems on discharge, physiotherapy and non-physiotherapy. - Details of discharge - date, location, presence of others. - Follow up community services organised. - Follow up physiotherapy organised. State reasons for no follow up or long term aims if follow-up is to be organised. Could also include if home program given or review clinics organised. Letters Content will obviously depend on who the letter is for i.e. another physiotherapist or another health professional. When referring to another health professional you will often send a copy of your discharge summary (as discussed above) and add a cover letter. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 57

Read the following example of how to write up a neurological physiotherapy assessment. NEUROLOGICAL ASSESSMENT Client Sticker Here Hx: MVA à CHI à GCS 6/15. #L)Femur, #L)ribs 8,9,10, L)extradural, frontal haematoma. 1/1/2000 Admitted PAH: surgery : r/o extradural & frontal haematoma. Admitted PAH ICW: intubated and ventilated. 2/1/2000 ORIF L)femur. 10/1/2000 Tracheostomy 13/1/2000 Weaned. Transferred neurosurgical ward. 20/1/2000 Tracheostomy removed. On thickened fluid, soft diet. 30/1/2000 Two person stand, supervised sitting. Not following commands. 10/2/2000 Following some commands, PTA 1/12 20/2/2000 Transferred Brain Injuries Unit. Investigations: CT scan: L)extradural, frontal haematoma, diffuse axonal injury. 1/1/2000 Xray: #L) femur, ribs 8-10 on L). MRI: Injuries as per CT, as well small L) cerebella r bleed. 2/1/2000 Xray: Internal fixaton L) femur in place, alignment good. 3/1/2000 CT scan: Small recollection frontal haematoma. 12/2/2000 Medications: Baclofen (for spasicity) Tegretol (for epilepsy) Social Hx: 17 year old, about to start year 12. Doing well at school. Lives with parents & 2 younger brothers, older married sister lives in Melbourne. Loves soccer, tennis and horse riding. Parents say X was very sociable and outgoing prior to accident. R)handed. Was wanting to go to university to study mathematics. High set house on 2 acres between Brisbane and Gold Coast. • Friend killed in accident - client unaware. 1.Functional Movement Analysis: (You need to make a comment on each of the normal functional movement components) Rolling to L) • rotation of neck - present • hip and knee flexion – unable to flex hip/knee on affected side à needs assistance • flexion of shoulder and protraction of shoulder girdle à prompting to remember to brig R) arm. Assistance required with scapular protractionà tends to flex shoulder girdle. • rotation within the trunk à slight assistance for hip protraction. Rolling to R) not tested because of dense hemiplegia. Bed mobility • Able to bridge with assistance of one à needs R)leg placed and held in position, assistance to lift butto cks. • Requires assistance to bring shoulders across. • Assistance for rolling onto side as above. Slightly more assistance required because of softer mattress. Lie à Sit through left side (not tested through R) side) • lateral flexion of neck – pt rotates neck and flexes it forward instead of lateral flexion. • lateral flexion of trunk –pulls with L) hand instead of lateral flexion. • abduction of lower arm – pulls with L) hand, some abduction. • legs lifted and lowered over side of bed - has to hook L) leg under R) to get legs over bed. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 58

Sit <à Stand 2 person sit to stand. Assistance for feet placement, anterior translation of knees (tight calf), and hip and knee extension. Assistance for trunk inclination and anterior pelvic tilt. Requires assistance for trunk flexion to sit, and to allow knee flexion. 2.Balance: Sitting: Alignment- symmetrical loading, kyphotic and lacking lumbar lordosis. Protracted chin. Can achieve anterior pelvic tilt and hold, but needs constant verbal cueing. Can reach out of base of support to all quadrants, and can touch floor. Not safe to leave unsupported and unsupervised in sitting, as is still in PTA, and has unreliable reactions in standing. Standing: 2 person stand Alignment – asymmetrical loading àdecreased on R). Needs assistance to maintain knee extension and hip E/AB on R). Can maintain trunk extension, lordosis and head position, but trunk is laterally flexed to L). Unable to stand without support. 3.Gait: 2 person walk, 10 metres, flat surface. (If you were writing an assessment of a more mobile person, you would describe briefly the main gait faults seen in swing and stance phase, as well as their mobility status). 4.Movement Return Dense R hemiplegia with the following return:- UL Patterned shoulder flexion/abduction to 30o against gravity. Patterned elbow flexion ½ ROM against gravity No activity in triceps, wrist extensors, supinators Flicker of scapular protraction. LL Patterned hip flexion ½ ROM against gravity. Flicker of hip abduction and extension. Patterned knee extension from 90o F to –20o extension No activity in dorsiflexors/evertors L) side: Fully isolated movement, all groups, UL and LL. 5.Tone R)UL: Increased tone in shoulder internal rotators, adductors, latissimus dorsi. (Modified Ashworth scale 2). Elbow flexors (Modified Ashworth Scale 3), pronators and long finger flexors (Modified Ashworth Scale 3). R)LL: Increased tone in hip adductors and internal rotators knee extensors (Modified Ashworth Scale 1+), knee extensors (Modified Ashworth Scale 3), plantar flexors (Modified Ashworth Scale 3). L)side: appears normal, all groups, ?hypotonic in upper limb. Difficult to formally assess as client unable to relax fully. 6.Sensation Light touch: R)UL decreased localization whole arm. Out by 10 cm. Difficulty with formal assessment as client still in PTA. Will reassess again. Mr X c/o sensation decreased whole arm approx. ½ compared to L). R)LL localizes reasonably accurately. C/o L) =R) =N. L)side, accurate localization, c/o feels normal. Hot/cold: R)UL inaccurate hot/cold –unable to differentiate. R)LL – accurate hot/cold. L)side – accurate hot.cold. Sharp/blunt: R)UL inaccurate sharp/blunt–unable to differentiate. R)LL – accurate sharp/blunt. L)side – accurate sharp/blunt. Proprioception: Joint position sense: unable to get client to copy à unable to formally assess. Will repeat again at later date. Passive movement sense: X able to correctly identify direction of passive movement in R) side with large range of movement - ? some proprioceptive loss. Need to reassess in a week. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 59

7.ROM/Power (Power: REMEMBER you cannot grade power if the muscle return is not isolated.) Shoulder F Right Left POWER Elbow Ab Passive ROM POWER p/a ROM 3 ER 90° N/A 170° 3 Wrist F 45° 170° 3 E 15° 80° 4 Pron Full Full 4 Supn -20° Full 4 Full Full 4 E 45° Full 4 45° with elbow in full ext, Full fingers in full ext. Finger F full Full 4 Thumb E full Full 4 F full Full 4 Ab/Ad full Full 4 lumbricle full Full 4 Opp/F/E/Ab/Ad full Full Hip F Full Full 4 Knee E Full Full 4 IR/ER Full Full 4 AB 20° Full 3+ AD full Full 3+ F 120° (tight rectus fem) E -10° (contracture) 4 4 (with Ankle hamstring 45° quads lag of 10° , no lack) Toes DF Plantar grade 60° 4 EV/INV Full Full 4 PF full Full 4 F/E full Full 4 Full 4 8.Coordination: (Coordination: REMEMBER you cannot test coordination if the muscle return is not isolated.) R) side N/A L)UL: f/n/f – dysmetria, ataxic. Shoulder F/E very ataxic. Elbow F/E 10 rep. in 15 seconds: can be done smoothly. Wrist F/E 8 rep. in 15 seconds: can be done smoothly. Sup/pron 6 rep. in 15 seconds: can be done smoothly. L)LL: heel/shin - dysmetria, ataxic. Hip F in sitting - 8 rep. in 15 seconds: can be done smoothly. hip IR/ER in sitting (feet on floor)- 8 rep. in 15 seconds: can be done smoothly. Knee E/F in sitting- 12 rep. in 15 seconds: can be done smoothly. DF- 20 rep. in 15 seconds: can be done smoothly. Foot out to side (heel together, feet on the floor) - 20 rep. in 15 seconds: can be done smoothly. 9.Cranial Nerves II R) homonomous hemianopia III R) ptosis, R) fixed dilated pupil IV diplopia on downward gaze R) VI R) rectus lateralis palsy VII R) LMNL IX on thickened fluids, soft diet (please see Speech Pathology report) X slightly dysphonic, weak cough à can huff to effectively clear secretions ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 60

10.Cognition/dysphasia: Moderately receptively dyshasic, severe expressive dyshasia. Can follow 3 stage commands, cannot vocalize at all. Please see Speech Pathology report. OT report of 8/4/2000 (most recent report): PTA 7/12. Severe problem solving difficulties and route finding problems. Difficult to assess due to poor compliance, concentration and motivation. 11. ADL: Fully ADL dependent for showering/dressing. Assistance for feeding mainly due to poor concentration. 2 person stand transfer on ward for W/C ß à toilet, shower, bed. Doubly incontinent. Can push on chair around ward, but needs supervision, because of hemianopia and rout finding problems. LONG TERM GOALS Mobility : Fully independently mobile, all surfaces, all distances, no supervision, no aids. Upper limb: Functional. Discharge status: Home with family. ?Return to school in 2 years, dependent on cognitive return. STG (end of week) STG: Two person stand, client to maintain own knee extension for 30 seconds alone. .Sit unsupported maintaining correct alignment for 2 minutes, with no prompting. Gain 10 degrees all limited ROM in upper limb. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 61

WEEK 2 Your focus this week should be on progressive development of your management programs. You should be considering the various modes of delivery of physiotherapy services available and whether you are using an optimalcombination of these modes of service delivery. MODES OF PHYSIOTHERAPY SERVICE DELIVERY Carr and Shepherd (2003) suggest that three models of delivery of physiotherapy should be incorporated into every neurological rehabilitation program: • One to one client-therapist interaction • Group therapy • Independent practice / Self Management Up to this point you may have been focusing more on one to one client-therapist interactions. This week it essential that you develop your ability to use group therapy and drive independent practice and client self management. GROUP THERAPY Traditional Classes versus Workstation Model There is a shift towards a work-station model for delivering classes which enables an individualised and targeted approach to group interventions. a) WORK-STATION MODEL OF TRAINING BALANCE AND MOBILITY Review the Blackboard website for PHTY3140/7814 to consider the advantages of a work-station model and to help you address the subsequent questions. Relevant information was presented as follows: Lecture: Retraining Balance and Mobility using work-stations as a model for delivery (Block 3 – L8) Practical class: Retraining UL function using work-stations (Block 3 - Pr 15-16) Practical class: Retraining balance and mobility using workstations (Block 3 - Pr 19-20) ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 62

b) Traditional Approach to Running a Class Review the following notes related to the traditional approach to running a class. General Points to Consider: 1. Selection of Clients – class leader must know past medical history of all participants and any known contra-indications to participation in class. 2. Group Size – 14 maximum. 6 minimum for optimal interaction 3. Objectives - what is class for? • mobility • strengthening • socialisation • CV fitness • muscular endurance • coordination 4. Constraints: • who • where • when • how long • equipment needed • personnel – may need assistants Execution/Plan of Class – all classes should basically follow this format: Warm Up Core Material General Cool Down /---------------------/------------------------\\----------------------\\ 5-10 mins 20 mins 10 mins 5-10 mins Total Duration : 45-50 mins Core material must relate to objectives of class, e.g., if class is for group of Parkinson’s, must include a lot of mobilising exercises for trunk and pelvis in core section. Other Points to Consider– all people in class are not at same level, so leader must: (a) Recognise those who are either above or below average class standard and if necessary, instruct them in harder or easier tasks than the rest of the class (b) Monitor class and give rest breaks as necessary (c) Give adequate and constant individual correction and feedback - Music should be chosen to fit the objective of the class, i.e., either relaxing music, or may need stimulating or rhythmic music to motivate people. - ‘general’ section could include activities designed to increase socialisation, e.g. ball games, etc. Above all, classes must be fun and enjoyable. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 63

Example: AMPUTEE CLASS DESIGN REMEMBER: Some of these exercises will not be applicable to all age groups. You may have to adapt the exercises depending on the client’s overall health, age and mobility. A. WARM UP 5-10 mins Should include general mobility exercises for cervical spine, upper limbs and lower limbs. B. CORE 20 mins Prime aim is strengthening, especially for antigravity muscles. Should include a variety of the following: Supine Position - alternate hip/knee flexion, as appropriate cycling of legs bridging activities sit ups/abdominals alternate straight leg raises bottom walking in long sitting pelvic tilting bilateral hip abduction Side Lying - hip abduction hip extension hip adduction of lower leg combination of UL/LL flexion-extension Prone Lying - selected clients only alternate knee flexion-extension hip extension back extension – where appropriate; be careful not to aggravate back pain 4-Point Kneeling - selected clients only ‘bottom wiggling’ raising/lowering spine modified push ups hip extension with straight knee hip extension with bent knee full range flexion (hip and knee to chest), then straighten hip abduction to side balance activities, eg, lifting 1 arm and 1 leg together. Progress as appropriate. All of above interspersed with appropriate rests and deep breathing, and made harder or easier as applicable. B. GENERAL 10 mins Socialising, fun section. Also improves CV endurance. May need equipment, e.g., 3-4 balls, quoits, a ‘goalie’ basket, pass the walking sticks etc. D. COOL DOWN 5-10 mins As above (A), include gentle stretches where appropriate. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 64

Problem Solving 1. How is a work-station model different to a general exercise class? 2. What practical steps would you use for planning a work-station class that aims to improve balance and mobility 3. What components of balance and mobility could be addressed in a work-station model? 4. What are the advantages of a workstation model of intervention? 5. Design an exercise class using a work-station model to retrain high-level balance for one of the following client groups. The class should take one hour. - A community ambulant stroke or TBI group - A group with Parkinson’s Disease - A group or ortho-geriatric clients who have had a fall. 6. Design an upper limb circuit for clients who have recovering movement after stroke. The class could include a number of activities which integrate balance and incorporate standing with UL training. Feedback on Group Therapy 1. How is a work-station mo del different to a general exercise class? a) Current practice: Current practice focuses on classes that use a model of circuit training where 6-8 different aspects of balance are managed in by rotating through work-stations that target critical elements of balance and mobility. These could include functional strength training, medio-lateral stability, working at the limits of stability in sitting and standing, flexibility, sensory challenge through surface and visual conflict, speed and reaction times, balance strategy training for hip and ankle, endurance training, dual task demands during balance and mobility tasks. b) Traditional form 5 -10minutes: General warm up, all clients together. Include general mobility exercises for cervical spine lumbar spine, upper and lower limbs. 40 minutes: Series of high-level tasks to be done sequentially. Ideas include small blocks, balance beam, beam with throwing activities, uneven surfaces =/- throwing activities, hopscotch, trampoline, balance board (large and small). Need some time one on one supervision to do eyes closed activities on different surfaces somewhere in the circuit. 5 minutes combined ball activities with all clients together: narrow base/ one leg stand/ one leg on block or ball etc. 5 minutes warm down and stretches. 2. What practical steps would you use for planning a work-station class that aims to improve balance and mobility • Assess client group and determine aspects of balance that require emphasis • Set-up work stations ensuring that all elements of balance are included • Plan how you will make each station easier through to most difficult to cater for the individual client variations that will present in the group • Re-assess clients at the end of the program to determine improvement and further areas for intervention • Provide a program for the individual to continue with as a home based maintenance program 3. What components of balance and mobility could be addressed in a work-station model? ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 65

The following elements need to be considered in balance programs whether delivered as part of an individualised program or while using a work-station circuit training model for intervention. • Activation, integration and use of sensory information for balance during task execution and / or conditions involving vis ual /proprioceptive conflict • Decreasing reaction times / increasing speed of response • Enhancing postural reactions / regaining variable responses/strategies to displacement • Increasing limits of stability • Improving medio-lateral stability • Improving functional strength & flexibility • Improving musculo-skeletal/cardio -vascular endurance • Increasing ability to manage dual tasks Interventions need to • integrate all elements • deliver a targeted program addressing the problems of the individual • be cost effective (group intervention) Work stations through circuit training provide an effective option and need to • provide variable tasks • address the elements of balance under different environmental conditions • trunk and lower limb flexibility; • functional strength training using tasks involving the lower limbs (sit to stand; stepping activities and walking tasks); • internal perturbations through tasks that require weight shift • working at the limits of stability and developing medio-lateral stability • preparing for external perturbations by balance strategy training for ankle, hip, suspension and stepping responses; • processing sensory information as provided by walking on varying surfaces; interacting with objects in the environment such as different height blocks and chairs; and managing to interact with objects moving in the visual field (eg catch/throw a ball) ie balancing under different sensory demands (viual; tactile/proprioceptive and vestibular) • improving reaction times for internally and externally paced activities, and • dual task activities that increase the motor and cognitive demands. 4. What are the advantages of a workstation model of intervention? Interventions are targeted to address the specific problems of each client with the work-station made easier / harder to ensure positive outcomes. 5. Design an exercise class using a work-station model to retrain high-level balance for one of the following client groups • A community ambulant stroke or TBI group • A group with Parkinson’s Disease • A group or ortho-geriatric clients who have had a fall. The following work-stations could be used to address the specific problems of balance and mobility with which the above clients may present • Seated reach • Sit to stand • Reach in standing, including step and reach • Block work • Stepping out of the square • Ankle / hip strategy training • Stair work • Walking with narrower base / different surfaces • Obstacle course / find the cards in sequence • Ball work 6. Upper Limb Circuit a) Traditional model 5 – 10 minutes fine motor tasks such as picking up buttons, stringing beads on string etc. 10 minutes co-ordination tasks: timed drawing crosses in a square (must be done accurately, each person can keep their own score), stacking blocks, tracing around outlines etc. 10 minutes standing on beam (if able), combined with ball bouncing, throwing. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 66

10 minutes functional tasks: cutting putty, rolling putty, use of spoon, fork and knife. 10 minutes weight/strength training if applicable. 10 minutes ROM plus fine motor tasks: reaching/placing objects at different heights/distances etc. 5 minute warm down/stretches. b) Work-station model Workstations could target 6-8 elements of UL training and integrate with balance and functional tasks: client rotate through each station working at their level of ability Proximal stability Support and weight bearing Reach in sitting and standing close to; away from body; overhead Opening of the hand Manipulative skill Unilateral / bilateral tasks ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 67

FACILITATING INDEPENDENT PRACTICE / SELF MANAGEMENT Review the following notes on facilitating independent practice and compiling practice books. Practice is known to be a necessary prerequisite for acquiring skill in movement. It is only through repetition of accurate near-peak performance that movement control will develop. Most clients receive 1-2 hours of physiotherapy daily. However, there are another 10-12 hours in their waking day when independent practice or practise with a relative, friend or other staff could be achieved. One of the most significant ways of effecting carry over of practice outside of physiotherapy time is involvement of family, relatives, friends and staff and this involvement needs to start from day one. The client must learn to practice correctly and know what is incorrect or the practice is ineffective. One of the best ways of promoting independent correct practice is through issue of written (and preferably illustrated) instructions for independent practice in some form of practice book. Practice Books Advantages of using a practice book: - Encourages active participation of the client in the rehabilitation - Encourages consistency of practice outside formal therapy times. Ensures consistency between physiotherapist, other staff and client and relatives. Limitations on the use of practice books: - When issuing practice books you must consider the individual client carefully. - Clients must have the motivation and self-initiation to do practice independently; - Cognitive level, level of arousal and concentration span may also limit applicability of practice books. How to choose which activities to include in the independent practice program: - Practice must be goal orientated if possible and be seen as relevant. Visual cues and physical goals help direct and correct movement. - You will select which activities to include in the practice book after careful consideration of the client’s: • Short term and long term goals • Current impairments (e.g. muscle strength, sensory function, perceptual function, cognitive function, cardiorespiratory status etc.) • Current level of functional ability - You must observe the client performing each activity/exercise. See where he goes wrong. You absolutely cannot prescribe an exercise for independent practice if you have not seen them do it, and seen that they can do it correctly. - You must also decide whether relatives, family, friends or nursing staff will be required to supervise or assist the client in safely performing the activity/exercise and whether this assistance will realistically be available. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 68

Essential features of a practice book: - It must be portable so the client is able to bring it to appointments and store it easily (e.g. on their bedside table if they are an inpatient). - It must be durable. There is no point issuing the client with loose pieces of paper with exercises of other instructions on them. They will get folded and put away out of sight in a drawer or be thrown away. - It is ideal to bind the exercise/instruction sheets into a manila folder (possible cut into halves or thirds if you want a smaller book) - Text must be of appropria te size for the client’s level of vision. - It will be easier for the client to follow if there is not too much information or too many exercises per page. - It must be updated regularly as the client’s functional level and impairment levels change. Designing the practice book: - Each exercise needs a simple name. - Instructions must be clear and simple so that the client understands the correct movement to be performed. - Each activity needs to be fully described e.g. remember to include starting position - Include a checklist of errors that commonly occur during that activity. - Indicate the number of repetitions to be performed at each session and the number of sessions per day. - You must include some way to check compliance e.g. columns for the client to tick when the task has been completed. - Diagrams are very useful, if simple. - Many facilities now have computer software that you can use to create individualised practice programs. If using this type of software remember that you can usually type in your own instructions (i.e. modify the instructions to suit each individual client). ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 69

Now try to write up the following exercises as if in a practice book: 1. Wrist extension and radial deviation. (Do not allow elbow to bend. Keep forearm flat on table.) 2. Thumb abduction. (Do not allow wrist/fingers to flex or forearm to pronate. Do not let thumb slide up object, if practising abducting away from something.) 3. Knee flexion in prone. (Do not allow leg to fall in/out. Do not let hips come up off bed.) 4. Knee extension in sitting. (Do not allow foot and toes to point down and in.) 5. Cup to mouth. (Do not allow shoulder to elevate, forearm to pronate or arm to abduction. 6. Triceps in supine. (Do not allow forearm to pronate, elbow, wrist or fingers to flex or shoulder to internally rotate). Feedback Wrist extension 1. Arm on table, forearm flat Towel under wrist Lift wrist up (ONLY wrist must move) Hold 6 seconds Relax 6 seconds Repeat 10 x / 3 x day. Thumb exercise 2. Arm on table, forearm flat Bring thumb out to side Hold for 6 seconds/ relax 6 seconds Repeat 10 x/ 3 x day Don’t let fingers curl, or arm turn over Knee bends 3. Lie on stomach Bend knee up slowly Don’t let hips come up Hold for 6 seconds/ relax 6 seconds Repeat 10 x/ 3 x day Knee extension 4. Sit well supported Straighten knee slowly Don’t let toes point down (STOP if this happens) Hold for 6 seconds/ relax 6 seconds Repeat 10 x/ 3 x day ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 70

Cup to mouth 5. Pick up cup slowly Do not let shoulder come up or out Do not let arm turn over Hold for 6 seconds/ relax 6 seconds Repeat 10 x/ 3 x day 6. Elbow extension Lying on your back Elbow to ceiling Straighten arm slowly Make sure elbow stays vertical Do not let forearm roll in Do not let elbow/wrist or fingers bend Do not let shoulder roll in Hold for 6 seconds/ relax 6 seconds Repeat 10 x/ 3 x day Put a tick beside each exercise when you have done the correct number of repetitions each day Date: 1. Wrist extension 2. Thumb exercise 3. Knee bends 4. Knee extension 5. Cup to mouth 6. Elbow extension Problem Solving 1. Your new client has arrived in the ward and on examination you note she has a homonymous hemianopia. Who will you have to involve and how, in your holistic approach to management of this client? 2. Your client complains to you that she is bored in between treatment times and has nothing to do. She is also worried about going home. Whose help will you enlist and why? Feedback on Facilitating Independent Practice 1. You need to educate the family, relatives, friends and staff to attend to your client from the affected side, and the importance of doing so. Staff will rearrange furniture to ensure this, if there is a valid reason and it is clearly explained. It is only with a consistent approach that your client will learn to scan to the affected side to compensate for her visual field loss. 2. You obviously have not developed an adequate independent practice program for this client if she has time to be bored! Consider the client’s short term and long term goals and her current impairments and current level of functional ability. From this you should be able to select an appropriate range of tasks and exercises for her to practice in the ward. Enlist assistance of family, friends or nursing staff on the ward to provide supervision or assistance if required. Design a practice book including written instructions and illustrations for the exercises and activities you have selected. Make sure you check the client’s understanding of the practice program and her compliance with it. In the ward you would access the recreational officer (if available). He/she will be able to design interesting activities for your client to do, and include them in ward activities. The social worker needs to be involved, as this lady is worried about what will happen when she returns home. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 71

GAIT Many of your clients will have gait deficits. This activity has been developed to promote your ability to analyse gait in appropriate detail and to design and implement effective strategies that will improve gait deficits. You should already have reviewed the relevant material presented in PHTY3140/7814 (Module 3) on Management strategies & technique selection for retraining function after acquired brain injury. If you have not reviewed this material already, you should do so now. Relevant information was presented as follows: Gait Training for Neurological Disorders L7 Gait Retraining Pr 11-12 Problem Solving 1. What 4 things must you mention in defining mobility status? 2. What affects hip extension on the affected side? 3. What are common contributing factors to lack of dorsiflexion on the affected side? 4. What affects hip flexion on the affected side? 5. Your client, who has a dense hemiplegia and increased tone in his lower limb, requires two-person assistance to walk. After 20 metres, his gait has deteriorated, when it started off very well. The person assisting at the foot is having more difficulty placing it, the knee is hyper-extending and you are having more problems controlling hip extension. What is happening, and what do you do about it? 6. Mr A is only 3 weeks post stroke. He is young and showing improvement. At the moment he requires two- person assistance to walk in physiotherapy only. The nursing staff are pressuring you to give him a stick as it will be quicker for him and them on the ward. What would you do? 7. Mr A is now 6 weeks post stroke. He is allowed to walk short distances on the ward with no aid, but only with close supervision. He has had a fall, and the staff said they were supervising him, but distantly. What would need to be addressed? 8. Mr A is now independently mobile with no aid, but on flat surfaces only. He still has markedly increased tone in his lower limb, but this is manageable with constant stretching. He has no isolated dorsifexion. He still fatigues relatively quickly. He goes home for the weekend. His house is on a slope. He finds that his gait deteriorates over the weekend, particularly when going down and up the hill. What is happening, and what will you have to do. 9. A year post stroke, Mr A returns. Despite the fact that his movement return in his lower limb didn’t change, he was discharged fully independently mobile, no aids, no supervision, all surfaces, moderate distances. He had only had minimal return in his upper limb. He found that gradually he gave up doing the stretches you had given him to do, and his gait steadily became more awkward. Eventually a friend gave him a stick, which allowed him to go much faster, as he didn’t have to spend as much time on his affected leg. He has represented to physiotherapy with a worsening gait pattern and would like some help. What will you need to assess? What treatment plan will you implement? What are your short term goals? ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 72

Feedback on Gait 1. Mobility status: aid, level of supervision or assistance, surfaces, distances. Don’t forget that independent means independent. If someone needs supervision, even if they have no aid, then they are not independent (they cannot do it alone). Conversely if they are walking on a rollator, but don’t need anyone around to supervise, then they are independent with an aid. There is no such thing as independent with supervision. 2. Weak or poor return of hip extensors, tight hip flexors, tight calf à knee hyper extension à hip flexion to come over the limb. If there is inadequate hip extension, step length on the unaffected side is decreased. 3. Tight calf, increased tone in plantarflexors (often leading to shortening), lack of return of dorsiflexors/everters. 4. Lack of extension in the stance phase. Flexion is mostly pendular through the middle part of swing, with a little activity to initiate flexion: if there is not sufficient extension in the stance phase, flexion is compromised. Lack of return of hip flexors. 5. The client is stimulating the ball of his foot with each step, leading to increased plantarfle xor tone, and stimulating a build up of extensor tone in the lower limb. The plantar flexion thrusts the knee into hyper-extension, and to be able to come over the limb and remain upright, the client must flex at the hip. You need to stop and stretch the calf. This problem occurs frequently when walking clients with increased tone in their calf. There is no alternative but to stop and stretch to decrease the tone. You absolutely do not want to be walking someone when they are stimulating the ball of their foot and building up extensor tone: the pattern will continue to deteriorate. A simple stretch will allow you to continue with a more optimal pattern. In severe cases, inhibitory plastering is used, or sometimes an AFO to help keep the foot in dorsiflexion, and ensure heel contact (not stimulation of the ball of the foot). 6. This is a case for tact, while remaining very resolute in your convictions. If this man receives a stick early on, he may in fact walk faster initially, and be very happy about it. However, he will become dependent on it, and will have his potential for unaided walking compromised. Sticks make people asymmetrical. He will therefore have to use his affected side less, further limiting the demand on the affected side. He will be ultimately more unsafe because he is not using the activity he has on his affected side. At three weeks, when a client is improving, you would never introduce an aid. You limit someone’s potential giving them an aid too early. 7. Please see question one again. A client is either safe to walk independently or they require supervision. The point of supervision is that the supervisor can catch the client if they are unsafe: they must be close to the person to supervise them. If you are supervising someone from a distance, you will simply watch them fall! You, as the physiotherapist, must make the decision to allow someone to mobilise independently. This is based on your assessment of their balance reactions, insight, cognition and gait. 8. This problem is similar to that in question five. The same thing is happening: he is stimulating his plantarflexor spasticity by continually stimulating the ball of his foot. In this case you may need to give your client an AFO to maintain dorsiflexion in gait. He may also need to be taught a different way of getting up and down his slope, i.e. traverse it, or build some steps. He will definitely need a home programme of stretches, and to realise the importance of stretching when he starts to stimulate his tone. This means a thorough education and explanation regarding the means by which tone is stimulated and relaxed. 9. If Mr A has given up his stretches, he will continue to stimulate the ball of his foot, and so continue to increase the tone in his plantar flexors, as well as the extensors of his lower limb. This will make his gait pattern deteriorate. If he is given a stick, he will put less weight through his affected leg, and thus stimulate the ball of his foot more (he will be less likely to achieve a full ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 73

stretch to neutral if he is not putting his full weight on the limb), thus increasing the plantar flexor tone (and extensors of the lower limb), making it more difficult to achieve a neutral position and equal loading and so the cycle continues. You will need to reassess his dorsiflexion ROM, tone in his calf and extensors, balance, ability to load his affected side, gait. Your treatment plan will need to start foremost with education (regarding the above factors and their importance)!! You will have to find if he is willing to cooperate with treatment in and out of physiotherapy time; otherwise if he is non-compliant, your treatment is wasted. Until Mr A understands this, and learns to manage his increased tone/gait, this problem will continue to recur. Your treatment will have to focus on balance, loading the affected side, calf lengthening, gait. Your short term goals would be: To gain neutral dorsiflexion within a few weeks if your client has lost ROM (a highly likely scenario). In order to do this, you may need to use serial plastering. Mr A may then need an AFO, and this perhaps may need to be something as supportive as a Denver T to control the increased tone. To alter his gait pattern, and achieve independent mobility without the stick. This may take a few weeks if Mr A has become psychologically dependent on the stick. To be confident Mr A has understood the education you have provided, and the importance of his taking effective control of his own treatment. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 74

WEEK THREE This week your focus should be on enhancement of skill and quality of delivery of management programs. There should be an emphasis on expanding your experience with technical applications and improving your ability to appropriately prescribe aids, orthoses and wheelchairs. TECHNICAL APPLICATIONS It is desirable that you become familiar with a range of equipment used by physiotherapists working in the field of rehabilitation. This includes: • Functional Electrical Stimulation (FES) • EMG Biofeedback • Positional Biofeedback e.g. Limb Load Monitor • Tilt table • Ergometer • Treadmill • Therapy balls If you have not already selected and applied all of these types of equipment, then you should look for appropriate opportunities to do so this week. If no opportunity exists to apply them with your own clients then you should arrange time to practice their use with your peers. Review the Blackboard website for PHTY3140/7814. Relevant information was presented as follows: Lectures: • Methods of eliciting movement recovery (Block 3: L4/5) • Gait training for neurological disorders (Block 3:L7) Practical classes: • Series of practical classes on retraining function (Block 3: Pr 3-20) Your review should consider: • Indications for use • Contra-indications • Method of application • Evidence of efficacy Guidelines for the use of electrotherapy can be found via the UQ Cybrary catalogue as follows: Electrical Stimulation PHTY3140.78 (electronic copy) Neurotronics EMPI Australia.Integrating FES into the Physiotherapy Treatment Program. EMG Biofeedback PHTY3140.80 (electronic copy) Verity Medical Ltd. Neurotrac ETS Operators Manual. Weightbearing Biofeedback PHTY3140.79 (electronic copy) BarMed Pty Ltd. BarMed Operators Manual: Portable Limb Load Monitor. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 75

WALKING AIDS AND ORTHOSES Review the following notes on prescription of walking aids and orthoses. GENERAL CONSIDERATIONS WHEN PRESCRIBINGWALKING AIDSAND ORTHOSES Before giving an aid, the following must be considered: 1. Aim of prescribing the aid 2. The client’s aims and desires (e.g. the client may not use it if they do not like it) 3. Function of the aid AN AID MUST NOT BE PRESCRIBED AND FORGOTTEN – IT MUST BE REGULARLY REVIEWED FOR FIT AND APPROPRIATENESS. CONSIDERATIONS WHEN PRESCRIBING WALKING AIDS All walking aids must be checked for: - Correct height - Safety – check integrity of stoppers - Grip or handle comfort When prescribing any walking aid, it is a good rule to assess the effect on alignment of the body, weight - bearing and weight shift and the overall quality of the gait pattern. Single Stick - In the retraining of gait following stroke, treatment approaches that attempt to establish normal ranges of hip joint movement and loading of the limb should be utilised. - Clients who use a single stick will not be loading the affected leg fully. If the aid is removed, clients are often able to achieve a more symmetrical posture with more equal distribution of weight. - Alignment of joints is also affected, as clients tend to laterally flex their trunk over the stick. - Single sticks predispose to these poor gait patterns less than do 4 point sticks. They should, however, be used more for balance than for support. - It is preferable to delay the introduction of a walking stick until the ability to weight bear & weight shift have been regained. If given too early, some clients may never gain this ability. In fact a walking aid should not be introduced at all if it can be predicted fairly soon after stroke that an independent gait of acceptable quality is probable. - Laidler (1994) states that if depression over not walking is creating stress, then advice, reassurance and more weight-bearing activities will be encouraging and beneficial. - Some elderly clients who have previously been using a stick may obviously still need it after their rehabilitation. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 76

4 Point Sticks - The disadvantages of using a quad or 4 point stick are well known. - These aids reinforce asymmetrical weight bearing and encourage unloading of the affected limb. - They should NEVER be prescribed in the early stages following stroke. - Frailty and excessive disability may be an exception to this but they should generally be considered a \"last resort\". Walking Frame (Hopper) Advantage: provides very stable base. Disadvantages: - Encourages client to lean forward, putting hips into flexion - May restrict body rotation by abolishing arm swing, thereby decreasing thoracic and pelvic rotation. - Encourages a step to rather than a step through gait pattern. - Restricts hand function - Difficult on stairs and cumbersome around house. - Can adversely affect walking speed. Rollator/Wheeled walking frame Advantages: - Provides very stable base. Allows for early mobilization. - Allows step through gait pattern - Suitable for limited weight bearing through lower limbs, but requires weight bearing through upper limbs - Appropriate for geriatric/orthopaedic clients. Disadvantages: - Is a bilateral aid – not suitable ever for hemiplegic clients - Limits hand function - unable to be used on stairs - large and cumbersome in home - Clients may become very dependent on this aid once introduced Measuring Aids Single and 4 point sticks: - Measure from greater trochanter to floor. Elbow should be in 20 – 30 degrees flexion. Crutches: - Elbow 30 degrees flexion - 2 finger width space under axilla left free - measure to point 6” out from lateral malleolus ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 77

TYPES OF ORTHOSES Ankle Foot Orthoses Indications: - For clients with gait abnormalities such as hemiplegia with foot drop during swing, mediolateral ankle instability and insufficient push-off during stance. - AFO allows safer, more effective ambulation in the following cases: - Weak or absent dorsiflexors (UMNL/LMNL) - Extensor synergy so foot plantarflexes with or without inversion - Flexor synergy so foot inverts - Knee hyperextension in combination with 1 of the above Advantages of AFO: - Assists with early mobilisation as fewer tasks to concentrate on. - Requires less people to assist. - Enables some independent and more normal gait pattern e.g. if recovery of hip and knee is ahead of ankle, rules out need for compensatory gait patterns. - Enables practise of certain aspects of gait which would otherwise be impossible e.g. normal hip and knee flexion. - Can prevent knee hyperextension if set in dorsiflexion, or can prevent buckling if set in plantar flexion. - Enables client to attempt difficult activities. Beneficial Effects on Gait: - increased speed of walking (conflicting results reported) - normalization of heel strike duration - ensures mediolateral stability during stance and adequate toe clearance during swing. Adverse Effects on Gait: - limit plantar flexion at heel-strike through foot flat, resulting in potential knee instability. Effect on Knee Stability: - Altering the dorsiflexion-plantarflexion angle of conventional AFO’s has an effect on flexion/extension moments at the knee. At heel strike, the foot does not go into plantarflexion under the normal lengthening contraction of the dorsiflexors, so the foot rocks over the posterior portion of the heel until it comes to foot flat. GFR is therefore located at the posterior part of the heel, and behind the knee, causing a flexing moment and knee instability. - Setting an AFO in 5 DF prolongs the flexion moment at the knee during early stance. - In 5 PF, the AFO decreases the knee flexion moment in early stance and increases the knee extension moment at mid-stance. - If AFO is improperly aligned for each individual, walking will be made more difficult, not easier. - Similarly, orthosis resistance to plantarflexion during swing phase should not be greater than necessary since it creates a bending moment at the knee at heel-strike, which has to be controlled by voluntary quads. Disadvantages of Constant Use: - Doesn’t allow a totally normal sequence of movements e.g. push off. - May inhibit recovery around ankle so must practice with and without AFO. - If AFO is set in DF, may not be practicing knee control, therefore must do specific knee control exercises without AFO on. - Can increase plantarflexor spasticity if top of splint lies over a motor point, or if there is a lot of movement within the splint. - Client may not be able to put it on independently Prescribing an AFO: Page 78 Must perform individual assessment. Assess: - Isolated movement - Passive ROM ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006

- Muscle tone at rest and on movement - Gait - Purpose of AFO - Consult orthotist Remember, as condition changes, type of orthosis required my change. ALWAYS REASSESS Precautions : - Be aware of increased tone either prior to or as a result of wearing AFO. - Take care with poor sensation. Reasons Not Effective : - Ill fitting. - Shortened calf (?serial plaster first). - Decreased hip and knee flexion in swing. Check: - Adequate fit on person and also into shoe (usually need a shoe size ½ to 1 size bigger to fit AFO). - Worn initially for short periods of time. - If undue reddening develops and does not disappear readily, orthosis should be modified. Dynamic check: - During early stance – does client have to make excessive effort to keep knee from buckling (ie. Too much DF). - ?Too much of an extension moment at knee causing genu recurvatum (ie. Too much PF). - During swing, look at toe drag; check if adequate clearance being provided. Consider - AFO is not a last resort, but should be considered early in gait retraining to attain normal alignment (as long as gait is practiced with and without it). - It may be used as an adjunct to treatment, only. Types of AFO 1. Solid/Rigid AFO - Prime indication is for control of strong equino or equinovarus tendencies at ankle. - Made individually of moulded polypropylene. 2. Flexible AFO (Posterior Leaf Spring) This orthosis collapses more easily into dorsiflexion, therefore gives more natural gait, better roll- over of foot, and allows forward movement of tibia on talus. However, will not provide much knee stability during latter part of stance. Indicated for clients with: - Weakness or absence of DF - Without severe plantar flexor weakness - Good to fair mediolateral stability - Absent to moderate spasticity - Adequate knee stability and motor power 3. Shoe -clasp orthosis - Attached to rigid heel of shoe. - Does not provide mediolateral stability, only toe pick up. - Collapses readily into DF, therefore does not provide much knee stability. 4. Air-stirrup brace - consists of pre-molded side supports lined with inflatable air cells that conform to the individual. - The side supports are positioned over the malleoli to limit eversion and inversion, while permitting DF and PF. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 79

- Designed to provide M/L stability for subtalar joint without resistance to PF and DF. Burdett (1988) found statistically significant decrease in: - Inversion at foot strike - Plantarflexion during swing and toe off - Maximum calcaneal angular change after foot strike. - By limiting the amount of foot inversion during gait, the AS brace may have disrupted the extensor muscle synergy and prevented excess PF. This is speculative. (ref: Physical Therapy. Vol 68, No. 8, Aug 1988: 1197-1203) - Air Stirrup is useful as temporary or long-term inexpensive substitute for an AFO for selected hemiplegics with inversion or eversion instabilities. 5. Denver T (+Denver T with Gillette Joint) Problems with conventional “in the shoe” AFO’s: - Cause excessive knee flexion moment at heel-strike, causing knee instability - Limit dorsiflexion enough to cause genu recurvatum at toe-off. Problem with external devices: - Stimulation of the ball of the foot often leads to excessive extensor spasticity. Denver T: - Designed to provide good medio-lateral stability while allowing relatively free ankle DF. - Provides mild to moderate DF assist which may be varied according to client’s requirements. - Does not provoke excessive PF resistance at heel-strike. - Precise trimming posterior to metatarsal heads prevents excessive extensor build up. - Polyethylene material is light weight and flexible. Most effective in: - Hemiplegic clients who exhibit some toe and ankle DF in or out of a mass flexion pattern, but who cannot control this throughout gait cycle. - Clients who have limited DF but loose this as they fatigue. - Clients with equinovarus pattern at stance phase and/or ankle instability. - Clients with moderate spasticity. Precautions: - Use with caution where there is sensitive skin. - Client usually requires one size larger shoe to accommodate orthosis. Not effective: Generally with clients with no DF. Moderate to severe spasticity is not a contraindication, and is usually the type of client who requires a Denver T. (ref: Orthotics and Prosthetics,1985, Vol 39, no 3, pgs 26 –29) OTHER ORTHOSES OF VALUE Lateral Flare - to control lateral border or inversion contact of foot. - Problem with lateral flare is that it often just controls the shoe, not the foot inside it. If inversion is strong, foot will come out of shoe. Knee Cages Two types: German and Swedish. Aim: - used as a training device originally to help gain knee control ie. Prevent hyperextension. - Knee braces are also valuable to use to stabilise the knee while concentrating on hip extension control. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 80

Disadvantages: - if given too early, quads’ function may never be re-educated. - Should be used as a last resort, or as an adjunct in treatment to assist selective work in hip control or effect on ankle. Client should practice gait with and without knee cage: - So he can gain sense of normal alignment when walking with it on. - So quads are required to work to control knee when cage is not on. Practice application of various orthoses on yourself and/or clients if appropriate. Observe the effect they are having on the client's movement and function and consider the reason for their prescription. If you are unsure of any of the above, please seek out the relevant staff member and clarify your concerns. As with the prescription of walking aids, an orthosis is given only after all attempts have been made to gain selective activation of muscles and normal movement control. Prescription of an orthosis must follow careful assessment and problem-solving and the therapist must monitor and reassess continuously for deterioration of gait pattern, skin breakdown and loss of muscle length or increased tone. Problem Solving : Prescription of Walking Aids and Orthoses 1. Your client is a 19 year old male, has had a head injury 6 months ago, and has moderately increased tone in his plantarflexors. He is unable to take a step without hitting the ball of his foot. What sort of AFO would you suggest for him and why? What sort of stretch would this man have to do and why? 2. Your client has Guillian-Barre. He has bilateral foot drops. What sort of aids might you suggest for him? What would you have to monitor? What factors would you consider to cease the AFO? What specific exercise or stretch would be imperative for this man to have? 3. Mr Y has had a stroke 6 weeks ago. He has moderately severe tone in his plantar flexors. He walks with moderate assistance of two therapists. It requires a lot of effort from the therapist facilitating the leg to put the foot down without stimulating the ball of the foot. What sort of AFO would be suitable for this man and why? 4. Mr Z has had a CVA 8 weeks ago. He has no return in his upper limb. He also has no active dorsiflexion, but has not lost any range in his calf, as his physio has been vigilant with stretches, and has given a ward program of self stretches. The nursing staff have put him on a rollator over the weekend, as it was the easiest way to get to the shower. What would be your plan and how would you address this problem? What sort of AFO would be appropriate, and for how long? 5. Mrs X has a hemiplegia. She is improving steadily, and you think she will achieve independent mobility. Over the weekend, her family have given her a 4 pointt stick to speed up her mobility. Mrs X is now reluctant to relinquish it. What would you do and why? 6. Mrs Q is a pusher. It is 6 months post stroke. She has only mildly increased tone in her plantar flexors. She is improving slowly, but is still requires 2 person assistance to walk, one at the foot, and the other in front. You are still walking her on a rail. What sort of aid and AFO may be appropriate to try? 7. Miss U has markedly increased tone bilaterally in her plantar flexors and knee extensors following a brainstem lesion. You have started walking her, but feel an AFO may help. What sort of AFOs would be useful to try? What amount of DF or PF would you need to have these put in? What may become a problem if they are put in DF? What aid might she need? ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 81

Feedback: Prescription of Walking Aids and Orthoses 1. A Denver-T would be appropriate in this case. It will control the inversion and plantar flexion, and have the strength to hold the foot in neutral. These are custom made. You will have to ensure calf stretches are done. You will also have to stretch into plantar flexion/inversion and eversion if this orthosis is used for any period of time. This client is very young and will continue to improve over a long period of time. He may eventually not need an AFO, and to ensure the possibility of running and higher level activities at a later date, this client will need full ROM in all directions. 2. This gentleman will need bilateral leaf-spring orthoses. You will have to monitor sensation and skin condition, as these clients often have sensation loss. You will have to monitor muscle power, as these clients sometimes change rapidly. As soon as someone no longer needs an aid, it needs to be taken from them. Constantly REASSESS. 3. Mr Y would benefit from a Denver-T, for the reasons given in question one. 4. It is completely inappropriate to give a bilateral aid to a hemiplegic client. This client will not have enough stability around the shoulder joint to use this aid. It is particularly inappropriate to give such a supportive aid this early on in rehabilitation as he will continue to improve: you do not want him becoming dependent on an aid with which he will never have to use his balance reactions and affected side again! You need to explain this very tactfully to the nursing staff, and emphasise the possibility of limiting Mr Z’s potential independent gait in the long term. Mr Z will only need a leaf spring AFO should you decide to use one. At this stage in rehabilitation, you would be using it as a treatment technique, as he may get more return. As soon as he has some active dorsiflexion, the AFO can be discarded. 5. Giving a client an aid early in rehabilitation, when the client is improving, will limit their potential. As in this case, clients become dependent easily on supportive aids. In the long term, an aid such as a four point stick (which only works if you put all your weight on it) will decrease the amount the person uses and is able to use their affected side. Thus, you ultimately make someone more unsafe, as they are unable to effectively stand and use their affected side. This becomes evident months down the track, when the client re -presents with a fractured neck of femur from falling when they have let go of the stick to reach for something and find themselves on an unusable leg. This is what you need to carefully exp lain to the client and family. Additionally, hemiplegic clients may not gain full functional recovery of their affected upper limb. If they are given an aid, you tie up their one usable arm, and make them more dependent than they need to be. 6. Late in the rehabilitation setting, with a client such as Mrs Q, it would be important to trial a walking aid and reduce dependency on the rail. Try a single Canadian crutch or single point stick initially. If the client is still not managing well you could also try a four point stick but remember that the aid is only safe if the client can keep all 4 prongs on the ground as they shift their weight onto the stick. This client will have difficultly with effectively shifting her weight to each side. Mrs Q would need only a leaf-spring AFO. 7. Miss U would need bilateral Denver-Ts, specially cast. It would be appropriate to set these in 5 degrees of dorsiflexion to create a little flexor moment at the knee and decrease the extensor effect. You may run into problems if the client is dependent on the hyperextension for stability. It is worthwhile trying a mock-up of this amount of dorsiflexion if you can before ordering expensive AFOs. This can be done by making a plaster cast, or if you can decrease the tone sufficiently, by bandaging. This lady will also need some walking aids. As she is young, Canadian crutches would be a good start. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 82

WHEELCHAIR PRESCRIPTION Review the Independent Learning Package on Manual Wheelchairs on the Blackboard Website for PHTY3140 / PHTY7814 (Module 4). Problem Solving Prescribe an appropriate wheelchair for the following clients: 1. 28 year old head-injured male with cerebellar ataxia. Is going home to live with parents on a property in Emerald. Has good sitting balance. Is independently mobile in wheelchair indoors. 2. R)CVA 68 year old female going home to live on own with full community support. Can do own transfers, but is wheelchair dependent. 3. 35 year old male. Traumatic bilateral amputee (AKA). Living in Queensland. Returning to sedentary work. 4. Head injured female, 22, semiconscious, resulting in decorticate posturing. Poor head control, no sitting balance, unable to flex knees due to extensor spasticity. Going to nursing home. 5. C5/6 complete quadriplegic. Has no triceps, grade 2 wrist extension. Has a lot of lower limb spasm. 6. 60 year old female. Severely disabled with RA. Living with husband at home. Has to be lifted. Osteoporotic and fragile skin. Can’t push own chair. Feedback on wheelchair prescription 1. 28 year old head-injured male with cerebellar ataxia. Is going home to live with parents on a property in Emerald. Has good sitting balance. Is independently mobile in wheelchair indoors. • Back wheel drive. • Collapsible. • Pneumatic tyres. • Swing-away footplates. Consider width of footplates. • Material needs to light weight, durable. • Desk arm rests. • ?High density foam cushion. 2. R) CVA 68 year old female going home to live on own with full community support. Can do own transfers, but is wheelchair dependent. • Front wheel drive. • Light weight chair. • Swing away detachable footplates. • Wide footplates if clonus. • Sheepskin covers on plates if reduced sensation. • Solid tyres (must have someone to pump up pneumatics) • Consider width of chair to get through doorways 3. 35 year old male. Traumatic bilateral amputee (AKA). Living in Queensland. Returning to sedentary work. • Amputee chair – axis set back. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 83

• Can put young person in normal para BWD chair, as long as axis is adjustable and capable of being set back (not old person). • Can weight footplates. • Desk arms • Consider back rest material. • High density foam cushion. 4. Head injured female, 22, semiconscious, resulting in decorticate posturing. Poor head control, no sitting balance, unable to flex knees due to extensor spasticity. Going to nursing home. • Back wheel drive. • Head rest. • Elongated removable side arms. • Elevating footplates. • Pressure cushion – Jay medical, as is more stable. • Optimal chair would be a tilt in space chair, if available. • Should try to obtain a wedge cushion i.e. large part of the wedge under knees à this will allow the pelvis to go into more flexion and facilitate break-up of tone. • Unfortunately, HMAS (Home Medical Aids Scheme – State government and DVA – Federal government) will not fund wheelchairs for anyone going to a nursing home (as the funding already given to the nursing home means it should cover costs involved with the care of the client –including wheelchairs). However, there are a few exceptions to this rule for young TBI clients, if they are going into long term institutionalised care (the government classes some of these facilities as hospitals, and will fund the provision of a chair). When planning discharge for a young person going into long term care, you need to investigate these options (the social worker will know how the facility is rated, or you can ring the facility directly to find out). 5. C5/6 complete quadriplegic. Has no triceps, grade 2 wrist extension. Has a lot of lower limb spasm. • Back wheel drive. • ?capstans. • Roho or Jay cushion. • Extended high set breaks. • Collapsible light weight chair. • Pneumatic tyres. • Desk arms. • Calf strap. • Consider back height; ? chest strap. 6. 60 year old female. Severely disabled with RA. Living with husband at home. Has to be lifted. Osteoporotic and fragile skin. Can’t push own chair. • Back wheel drive. • Pneumatic tyres. • Light weight, collapsible chair. • Removable desk arms; removable footplates. • Sheepskin covers for footplates. • High set extended and possibly build up breaks. • Back support. • Jay or Roho cushion. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 84

WEEK FOUR Your emphasis this week should be on reflective practice. You should be independently reviewing and upgrading your management programs. The independent learning activities for this week are on the topics of Home Visits and Discharge Planning. HOME VISITS Review the following notes on home visits. RATIONALE FOR HOME/WORK VISITS To assess the client’s functional capabilities within their own living or working environment so that any problems can be identified and appropriate rehabilitation commenced, or alternative solutions found. WHO IS INVOLVED Who is involved depends on the type of rehabilitation setting and the policies of the individual unit The following team members are commonly involved: - Client - Those living with client – relatives or friends - Physiotherapist - Occupational Therapist - Community health nurse – if appropriate - Social worker The number of people involved should be considered and kept to a minimum. Also consider the likely emotional effects of a home visit on the client. WHAT TO ASSESS 1. Mobility Level On stairs - up and down, with and without rails (if appropriate) - are rails on both sides or only one? - are there front and back stairs? - is width of step safe? On outside surfaces If it is safe and appropriate to do so, you should assess the client’s ability to manage the following: - walk on concrete - walk on grass - negotiate slopes - walk to clothesline - hanging clothes on line to assess if level of balance is functional - negotiate garden - get up from grass ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 85

Mobility inside - Check the client’s ability to walk over the different floor surfaces, e.g. thick carpets, tiles, linoleum, scatter rugs - Are there any internal steps or small steps between doorways? - Check the client’s ability to manoeuvre around kitchen and bathroom - If appropriate check the client’s ability get up from the floor Bathroom Observe the client’s ability to manage the following: - Getting on/off toilet - Getting in/out of shower and/or bath - Are modifications or aids (such as bath boards or rails) required? Relatives may need to be instructed in method of transfer and practice it under the physiotherapists supervision. Bedroom Observe the client’s ability to manage the following: - Get in/out of bed - Move around in bed (including managing the bed coverings) - May have to advise on repositioning of furniture to facilitate independence in these activities or advise on alteration of bed height. - An aid e.g., bed pole or rope ladder may assist some clients. - Relatives again may need to practice transferring client onto bed, rolling, lying to sitting, and sitting to standing from bed. Kitchen - Observe the client’s ability to manoeuvre around kitchen +/- wheelchair/aid - Check heights of cupboards - Client may need to be advised on reorganisation or relocation of frequently used items. Living Room Observe the client’s ability to manoeuvre around the living room and get in/out of armchair In cases of wheelchair dependence, it is also necessary to check the width of doorways and hallways for wheelchair accessibility. Wheelchair manoeuvrability around all rooms should be checked. The house may also need to be fitted with a ramp of appropriate gradient. NOTE: Be tactful when advising relatives on reorganisation or structural alteration of house. You can only recommend, not order. The Physiotherapist’s role in the home visit is to assess these areas and upgrade the client’s functional and physical capabilities in order to achieve greater independence. The Occupational Therapist’s role is to attempt to modify the environment to suit the client, e.g., installation of aids/appliances. A report following a home visit should always be written and included in the client’s file. Problem Solving 1. Mr P had a stroke 5 months ago. He lives alone, in a high set house which has 10 stairs front and back. Although Mr P has become independently mobile with a stick and an AFO, he still has problems with stairs. He has no upper limb return on his affected side, and has a subluxed shoulder. He is highly motivated, and is about to be discharged. What sort of alterations or factors would you need to address on his home visit? ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 86

Feedback on home visits 5. You will need to look at bathroom accessibility: how he manages to get in/out of the shower/bath as he has some residual deficit on his affected side. Look at toilet transfers and general mobility around his home – does he trip over mats, can he get out of the lounge chair? Look at outdoor mobility, stairs and presence of rails (how does he get his stick up the stairs?). Can he can position his arm at home, can he put his own sling on if he uses one. DISCHARGE PLANNING Revise independent learning activity on Prediction of Outcome from week 1. Problem Solving 1. Mr P from the previous question is about to be discharged with support. What sort of support and follow up will need to be organized for Mr P? 2. Miss R has had a closed head injury 8 months ago. She is 17 years old. Miss R has a L) hemiplegia and R) ataxia. She is still in a wheelchair and requires two person assistance to walk. She is very cooperative and very motivated, but still has significant memory problems . She was living with her family prior to the accident. She is returning home. What sort of follow up will you organize and how often? What other follow up will she need? Feedback on Discharge Planning 1. Mr P will need to have on-going physiotherapy, hopefully 3x/week, at the very least 2/week. This needs to be arranged by you. He will also probably need meals on wheels, and perhaps some home nursing support if he is not fully ADL independent. This is usually organised by the occupational therapist or social worker. Transport to/from his ongoing physiotherapy must also be arranged and you must ensure this has been done. You will need to check the protocol of the individual unit to see whose role it is to arrange transport. He may also need ongoing OT, which will be arranged by the OT. 2. Miss R will continue to improve for years, thus she needs on-going physiotherapy over a significant period. She definitely needs physiotherapy 3 times a week at this stage, and more if possible. She will need OT and speech therapy as well. She will need a lot of input from the social worker for discharge, and input from other support services such as ABIOS (acquired brain injury outreach service) post discharge. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 87

Further Independent Learning Activities Related To Specific Diagnoses CVA Problem Solving 1. What are the clinical symptoms of vascular lesions of - middle cerebral artery (left and right) - anterior cerebral artery - posterior cerebral artery - posterior inferior cerebellar artery (lateral medullary syndrome) 2. What is a lacunar infarct? 3. Describe 3 – 4 specific presentations of a lacunar infarct. 4. List the behavioural and perceptual deficits that are found in left and right MCA artery lesions. What are the implications for your management of the client? 5. What is aphasia? Which MCA lesion is more likely to present with aphasia? What are the implications for you in your subjective, objective and treatment? Feedback 1. Symptoms of vascular lesions R) Middle Cerebral Artery Lesion • L hemiplegia, upper limb affected more than lower limb • L hemianaesthesia • L hemianopia / Quadrantanopia • Visuospatial neglect/inattention/extinction • Motor impersistance • Impulsiveness • Disinterest / Poor motivation / Apathy • Anosognosia • Autopagnosia • A or Dyspraxia - constructional - dressing • Poor/loss topographical memory - route finding problems • Astereognosis • Disturbance of Size/Colour/Shape • Verticality problems • Dysarthria • Gaze Palsy • Coma, depending on the extent/type lesion (L) Middle Cerebral Artery Lesion • R hemiplegia, upper limb affected more than lower limb • R hemianaesthes ia • R Hemianopia / Quadrantanopia ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 88

• A or Dysphasia - expressive problems - reception problems - conduction disorder - global aphasia - anomia • Dysarthria • A or Dyslexia • A or Dysgraphia • Dyscalculia • A or Dyspraxia - Ideomotor /Ideational • Gerstmann’s Syndrome R/L Confusion; Finger Agnosia; Constructional Dyspraxia; Agraphia; Difficulty Calculating) • Coma, depending on type/extent Anterior cerebral artery lesion Paralysis contralateral leg and perineum /with transient paresis arm. NB: Lower limb affected more than upper limb • Cortical sensory loss, - decreased localisation in the leg/perineal area - extinction / sensory inattention • A/Dyspraxia L Arm / Anterior Disconnection Syndrome • Abulia - loss or poor ability to make decisions (mental confusion) - difficulty responding to internal / external stimuli even with intact motor ability - (similar to ideomotor dyspraxia with the extreme form being akinetic mutism) - slow to respond to commands - perseveration • Flat affect, lack of spontaneity, apathy • Slow to respond to commands / decreased mental quickness • Perseveration of movement • Distractible • Terse limited speech - a notable decrease in speech output • Incontinence • Facial / tongue weakness • Grasp/ sucking reflex Occlusion of collateral branches from the internal carotid artery cause more specific symptoms to present Posterior communicating artery • visual disturbances • hypothalamic dysfunction • motor dysfunction Anterior choroidal artery - symptoms vary according to the efficiency of the anastomosis with the posterior choroidal artery. Occlusion causes interruption to the blood supply to the ventral part of the internal capsule and the optic tract and lateral geniculate body. Occlusion of the Posterior cerebral artery (PCA) Ipsilateral lesion • homonymous hemianopia, visual neglect, visual agnosia • hemianaesthesia involving decreased touch, pinprick and position sense - (these changes can vary from profound loss to a more transient presentation with consequent poor motor control presenting as limb ataxia/inco-ordination) • poor orientation in space (mild to severe in presentation) • transient memory disturbance unless a bilateral lesion • a/dyslexia, anomia, receptive aphasia with dominant lesions ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 89

• Gerstmann’s Syndrome R/L confusion, finger agnosia, constructional dyspraxia, agraphia, dyscalculia Bilateral lesions • cortical blindness • inability to form new memories Lateral Medullary Syndrome (PICA) This lesion requires a good understanding of brainstem / cerebellar function, particularly the role of the lateral part of the brainstem and the archicerebellum. Symptoms include: • Ipsilateral loss pain and temperature to the face • Contralateral loss pain and temperature to the body • Diminis hed touch sensation • Transient contralateral paresis • Lateral rectus palsy (transient) • Ipsilateral paralysis muscles of soft palate, pharynx and larynx causing - difficulty in swallowing (dysphagia) - difficulty with phonation (dysarthria) • Dizziness, nausea / vomiting and nystagmus at rest or with eye/head movement (VOR Instability presents with poor gaze stabilisation ) • Cerebellar ataxia (truncal) / poor balance • Horner's Syndrome Ipsilateral small pupil, ptosis, enophthalmus, and warm, dry skin of face (Implications for practice: Activation of hemiparetic side and retraining for postural control, particularly central stabilisation; retraining for gaze stability and control of lateral gaze; re-education of swallowing and articulation; prevention of respiratory complications / establishing cough efficiency, and education related to sensory disturbances whether transient or persistent.) 2. Lacunar infarct. Lacunar disease refers to athero-thrombotic occlusive disease of the penetrating branches of the circle of Willis, middle cerebral stem, and vertebral and basilar arteries. These vessels give rise to small penetrating branches that penetrate the deep grey and white matter of the cerebrum and brainstem. When they become thrombosed, small (less than 2cm, many as small as 3 – 4 mm) infarcts occur and are referred to as lacunes. Hypertension is a risk factor for small vessel disease. 3. The most common syndromes are: • Pure motor hemiparesis from an infarct in the posterior limb of the internal capsule. Often the weakness may be a TIA and lead to recovery. • Pure hemisensory syndromes from thalamic infarct. • True ataxic hemiparesis from a basis pontis infarct, and dysarthria with a clumsy hand or arm, due to infarction in the basis pontis or genu of the internal capsule. • Pure motor hemiparesis with “motor aphasia” due to thrombotic occlusion of a lenticulstriate branch supplying the anterior limb of the internal capsule and adjacent white matter of the corona radiata. 4. Behavioural and perceptual deficits R) MCA (left hemiparesis) –general spatial-global deficits Visual-perceptual deficits • Hand-eye coordination • Figure-ground discrimination • Spatial relationships • Position in space • Form constancy ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 90

Behavioural and intellectual deficits • Poor judgement • Denial of disability • Inability to abstract • Rigidity of thought • Disturbances of body image and body scheme • Impairment of ability to self correct • Difficulty retaining information • Distortion of time concepts • Tendency to see the whole and not individual steps • Affect lability • Feelings of persecution • Irritability, confusion • Distraction by verbalization • Short attention span • Appearance of lethargy • Fluctuation in performance • Disturbance in relative size and distance of objects L) MCA (right hemiparesis) –general language and temporal ordering deficits Apraxia • Motor • Ideational Behavioural and intellectual deficits • Difficulty initiating tasks • Sequencing deficits • Processing deficits • Directionality deficits • Low frustration levels • Verbal and manual perseveration • Rapid performance of movement or activity • Compulsive behaviour • Extreme distractibility The implications for your management areas follows: • Distractible/ short attention span –clear environment, short instructions, highly interesting, relevant and varied tasks, simple achievable tasks • Neglect – draw attention to it, education of staff, family. Change environment so that stimuli all come from that side, obstacle courses • Difficulty retaining information/processing delays – realize this is not their fault, they cannot help it. You will not be able to expect your client to remember what you have said: they may be unsafe to leave alone in sitting as they may not have the memory, nor insight to remember that they are unsafe in standing. • Labile – again clients cannot help this. Allow them to be upset, and then gently continue with the programme. • Irritability/frustration – see distractible. Work within the irritability. More frequent shorter sessions may be necessary. 5. Aphasia Aphasia: Failure to understand (receptive aphasia), and the inability to use verbal expression (expressive aphasia) due to the impairment of the dominant cerebral hemisphere. The implications for subjective are: a. Find out what understanding and/or expression the client has (need to have read the speech pathology report). b. Simple questions may need to be yes/no (ie. Closed ended questions) c. May need to use closed ended questions to confirm/deny chart information. d. Limit the subjective, be aware of the frustration the expressively receptive client may feel, and watch for signs of this –change or cease questioning. Implications for objective and treatment: Rely heavily on non-verbal communication, such as demonstration, facial expression, tone of voice, need to facilitate movement ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 91

Cerebellar Dysfunction/Incoordination Problem Solving 1. How would your treatment differ for a client with cerebellar verses sensory ataxia? Give five treatment ideas for each condition. 2. What must you ensure you continually evaluate when treating coordination and why? 3. How would you ensure that quality movement occurs when treating hand coordination? Feedback 1) Sensory verses Cerebellar Ataxia Sensory ataxia means the client has a proprioceptive loss. They will have to compensate with vision if the proprioception does not improve. On the other hand, a cerebellar lesion has normal sensation. In both cases vision is used to augment accuracy. In treating a cerebellar ataxia, it is imperative that accuracy is executed when doing any exercise with the client. It doesn’t matter how slow it is, as long as it is accurate. You are relearning a motor skill, and if you allow a client to do the exercise inaccurately, that is what they will learn. Treatment ideas: Cerebellar: repetition of all exercises, execute all exercises slowly and accurately, use of light weights, use of targets to aid accuracy; truncal stability: use of kneeling, theraball. Sensory: PNF, weights, vision assisted gait and standing activities (i.e. mirror), weight bearing through limbs, bandaging to assist with proprioceptive input. 2) Continually Evaluate You must continually evaluate if the exercise is being executed accurately. There is absolutely no point in teaching a client to do an exercise inaccurately. This means monitoring for s moothness, dysmetria, force generation. 3) Hand Coordination To ensure accurate hand coordination, the forearms must be supported on a table. This is so that there is no shoulder elevation and rotation, and no excessive pronation/supination. Traumatic Brain Injury Problem Solving 1. List the main differences between traumatic brain injured and older CVA clients. 2. What are the implications for your management of these clients? 3. What would you need to do if a client shows inappropriate behaviour? 4. What are the challenges that TBI clients face as they re-integrate in the community? 5. What role does physiotherapy play at the community stage of rehabilitation ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 92

Feedback 1) Traumatic Brain Injuries verses CVA CVA TBI Often older age group Young 18 – 25 Not predominately male Often male Concomitant medical problems (IHD, BP, PVD, OA, Concomitant orthopaedic injuries vision, diabetes, confusion, dizziness) Focal neurological damage- Extensive neurological damage- Coup/contra-coup injury R) vs L) hemiplegia Brainstem involvement Cerebellar involvement Behavioural/cognitive deficits associated with R) or L) Hypoxic damage CVA à bilateral S & S Significant behavioural deficits- Frontal: lack of initiative/motivation Easily frustrated Sometimes aggressive Inappropriate behaviour: verbal, sexual Significant cognitive deficits- PTA Ongoing short/long term memory deficits Problem solving deficits Decreased mental flexibility Concrete thinking/difficulty with abstract concepts Poor concentration/easily distracted Poor insight Impulsive 2) Implications for Management Youth: neural plasticity à these clients will continue to improve for years. You need to ensure that you do not limit potential by introducing aids too early. The prognosis for a young head injury client will not be made for 2 years post injury. Bilateral problems : you cannot assume the unaffected side is unaffected. Look carefully for signs of ataxia. Brainstem involvement: Cranial nerves frequently involved à need to be aware of IX & X (often still on non- normal diet months post injury). Influence of tonic neck reflexes à head position vital in treatments. Often exhibit more increased tone à positioning, head position to decrease tonal influences. Early on problems with fatigue/arousal. Behavioural problems : Firstly you must remember that it is not their fault: they cannot help their behaviour- they have a head injury. Inappropriate behaviour – see question three. Cognitive problems : need to modify teaching methods, length of session and environment. Again, remember they cannot help their cognitive deficits. Young male: often these young men have left home and have been independent. Now suddenly they are dependent. It is usually the mothers who will take these young men home. Often there are serious long term social implications and effects on the family, and the other siblings. These problems often take a while to become evident. 3) Inappropriate Behaviour Limits need to be set. A client will not learn what appropriate behaviour is unless they are re-taught it. The family also needs to know that inappropriate behaviour is not tolerated. Set limits to behaviour at the beginning of the session. Should inappropriate behaviour occur, a warning can be given. A second episode should incur time out, or what other behavioural modification the neuro-psychologist has suggested. The only way behaviour is modified is if there is a consistent approach by all people dealing with the client. You need to have very good liaison with other staff members to ensure consistency is achieved. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 93

Amputee Problem Solving Describe the prothesis you would prescribe for the following clients. 1. 27 year old bulldozer driver suffered accident on way to work. Elective below knee amputation after severe fracture of (L) tibia and fibula and compromised blood supply. Now has well-healed stump with good sensation. Money not a problem due to compensation. Will return to heavy manual work. Very active. 2. 66 year old female diabetic. Peripheral neuropathy 10 years resulting in BKA. Stump now well healed but anaesthetic. Other PMH = RA with resulting bilateral hand deformities. Poor skin condition unaffected leg. 3. 64 year old female BKA for PVD. Has been fitted previously with PTB but now needs new leg due to stump shrinkage. Has always had fairly short stump and mild mediolateral instability. 4. 22 year old male. Traumatic BKA. Extensive skin grafting. W ishes to return to water sports. 5. 65 year old above knee amputee. No complications. Good muscle power, no contractures. Well adjusted to amputation and confident he will cope. Not involved in sport but goes out a lot socially. 6. 73 year old male. (R) A KA for PVD. Well healed stump, good strength and length. 7º hip flexion contracture. Copes well but has decreased confidence and is frightened of falling over. 7. 80 year old male. (L) AKA due to PVD. Has 15º hip flexion contracture and hip extensors which are only just antigravity. Also has fairly long stump. Has had LOAD and an MI in the past. 8. 25 year old male, (R) AKA on way to work (works as a house painter). Workers’ Compensation claim accepted. Exceptional athlete. Stump now stable and well healed. Going back to work. 9. 22 year old male. (L) AKA for osteogenic sarcoma. Having chemotherapy. 2 weeks post-amputation. Stump well healed. Low grade malignancy. Feedback 1. 27 year old bulldozer driver suffered accident on way to work. Elective below knee amputation after severe fracture of (L) tibia and fibula and compromised blood supply. Now has well-healed stump with good sensation. Money not a problem due to compensation. Will return to heavy manual work. Very active. Foot – some type of energy storing foot, eg, Otto bock, or flex foot. Limb type – PTK, or PTB better if sitting all day because PTK gives a lot of pressure medially and laterally. Finish – hard, if going to get dirty, better to have conventional finish. Modular leg might fall apart. 2. 66 year old female diabetic. Peripheral neuropathy 10 years resulting in BKA. Stump now well healed but anaesthetic. Other PMH = RA with resulting bilateral hand deformities. Poor skin condition unaffected leg. Limb type – Thigh lacer due to absolute sensory loss. Finish – modular – soft covering. Suspension – velcro straps due to deformities in hands. Foot – SACH. 3. 64 year old female BKA for PVD. Has been fitted previously with PTB but now needs new leg due to stump shrinkage. Has always had fairly short stump and mild mediolateral instability. Limb type – PTK. Foot – SACH. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 94

Finish – modular for cosmesis. If weight a problem, use hard finish as they are lighter. 4. 22 year old male. Traumatic BKA. Extensive skin grafting. Wishes to return to water sports. Limb type – thigh lacer. (Surfboard riders always wear thigh lacer to decrease friction). Although some people can get away with a PTK in water as less friction. Foot - ? Seattle foot with divided toe for thongs. Supervision – plastic/velcro straps. Finish – waterproof. 5. 65 year old above knee amputee. No complications. Good muscle power, no contractures. Well adjusted to amputation and confident he will cope. Not involved in sport but goes out a lot socially. quadrilateral socket, pelvic band. SACH or Greissinger foot. conventional knee joint. 6. 73 year old male. (R) AKA for PVD. Well healed stump, good strength and length. 7º hip flexion contracture. Copes well but has decreased confidence and is frightened of falling over. Foot – SACH. Limb type – quadrilateral socket. Suspension – pelvic band. Knee – safety knee. 7. 80 year old male. (L) AKA due to PVD. Has 15º hip flexion contracture and hip extensors which are only just antigravity. Also has fairly long stump. Has had LOAD and an MI in the past. Limb type – quadrilateral inlet socket. Knee – manual locking knee. Foot – SACH. Suspension – pelvic band. Finish – hard. 8. 25 year old male, (R) AKA on way to work (works as a house painter). Workers’ Compensation claim accepted. Exceptional athlete. Stump now stable and well healed. Going back to work. Foot – flex foot. Knee – hydraulic knee; Henschke Mauch. Socket – suction and maybe convert later to an ISNY. Suspension – needs a silesian bandage if going back to work as rigger/anything active. Finish – modular so can change components and make own adjustments. If really rough job, may need hard finish. 9. 22 year old male. (L) AKA for osteogenic sarcoma. Having chemotherapy. 2 weeks post-amputation. Stump well healed. Low grade malignancy. Limb type – if having chemo, stump size alters, so no suction. Give quadrilateral inlet and maybe convert to suction when 10-12 weeks post-op and no chemotherapy. Knee – conventional knee joint. Suspension – pelvic band. Finish – modular because can change components. Foot – SACH, maybe Greissinger. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 95

Parkinson’s Disease Problem Solving 1. What specific questions will you need to ask a client with Parkinson’s disease? (a) for a newly diagnosed client? (b) for a client 10 years after onset? 2. Your client has been admitted with severe Parkinson’s disease. His family have been caring for him at home and are finding it increasingly difficult to look after him. He is difficult to get out of bed in the morning, and is continually getting chest infections. The family is very keen to take Mr X home, if these problems can be sorted out. How would you address these problems? Outline a treatment plan and overall management to return this gentleman home. Feedback 1(a) Newly diagnosed: how long they have been diagnosed for - what drugs/timing and effect of drugs - main symptoms they are experiencing - any freezing, when and where - difficulty with current activities/interests - difficulty with fine manipulation e.g. writing - tremor - 1(b) 10 Years post diagnosis: - questions as above - difficulty with bed mobility/gait - dyskinesias - difficulties swallowing/coughing - history of falls 2. Mr X will be silently aspirating. This is why he is continually getting chest infections. He needs a referral to a speech pathologist immediately. Chest physiotherapy will need to be instigated. Bed mobility and strategies for the family to assist with bed mobility need to begin. Education of family and client need to be started. They all need to be taught strategies, with cues to cope with akinesia, for sit to stand, gait, turning, sitting down, freezing. A home programme of exercises to maintain ROM will be given. Don’t forget trunk extension and rotation. Rotation, reciprocal, rhythmical and repetitious movements are useful. Rocking, slow, rhythmical and repetitious is useful for decreasing rigidity. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 96

Shoulder Hand Syndrome Review the following notes on Reflex sympathetic dystrophy (Shoulder-hand syndrome or complex regional pain disorder) . This is a complex pattern of shoulder and wrist/ hand pain usually accompanied by severe non-pitting oedema in the hand. It is probably a mechanical insult that causes initial oedema and then the cycle of oedema, pain, loss of range and sympathetic nerve involvement follows. There are three recognisable stages summarised below:- REFLEX SYMPATHETIC DYSTROPHY STAGE STAGE 1 STAGE 2 STAGE 3 Sympathetic outflow Increased Decreased Decreased Vascular Vasodilated, warm Vasoconstriction, Cold sweaty cold Skin Red, shiny Cyanotic, glazed Smooth, pale, glossy Hair / nails ↑growth Loss, brittle Denudation / brittle, ridged Subcutaneous Oedema Brawny Atrophy, fat loss Joints Swollen, tender Thick, stiff Fibrosed, ankylosed Bones Normal Patchy Severe osteoporosis osteoporosis Muscles Tight Wasting, ↑ loss of ROM Atrophy, severe contracture Other causes of shoulder pain: Thalamic syndrome This results from a lesion in the thalamus and produces various feelings of hypersensitivity and hyperaesthesia. The pain can be generalised in the hemiplegic side of the body or in one limb. It is present at rest. Pre-existing shoulder / neck pain or injury following CVA. Some elderly clients have pre-existing shoulder lesions e.g. frozen shoulder, past fracture, rotator cuff lesions. These will be aggravated by the paralysis. Other clients may fall onto their affected side in having the stroke, thus injuring their shoulder or, if alone, clients may lie for hours or days before being discovered, causing nerve or soft - tissue injury. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 97

TREATMENT Treatment will depend on the cause of pain and so cannot be totally generalised. One common factor, though, is prevention of pain syndromes. PREVENTION - facilitate active movement around shoulder to support joint ( this is most important goal) - improve alignment of trunk and scapula - careful handling and positioning - improve awareness of arm and proprioception - use of appropriate support if danger of subluxation e.g. sling THE IMPORTANCE OF PREVENTION CANNOT BE EMPHASISED ENOUGH!!! PAIN TREATMENT Early intervention: The most important treatment in the management of this syndrome is early and assertive intervention. This means recognition of the early warning signs. If a person has no movement, they have the potential to develop a painful shoulder. With the development of a painful shoulder there is a likely hood of developing shoulder-hand syndrome unless vigilant attention is paid to positioning, maintaining length and client/family/staff education regarding positioning and handling. Early management of positioning means you HAVE TO support the arm somehow whenever it is dependent. In the wheelchair, a gutter splint or pillow is mandatory. Any time your client is vertical, when gravity is pulling on the arm, you MUST support it. In this case, a hemiplegic sling is advantageous. If you are unable to obtain a hemiplegic sling, a collar and cuff will give a some support. The problem with a collar and cuff is that it puts the arm into elbow flexion, shoulder internal rotation and adduction. This is the position the limb will tend to shorten in when there is lack of movement return. Thus, you must be particularly vigilant about maintaining length if you are using a collar and cuff. Positioning must be carried over onto the ward or home environment, or your treatment will have no effect. You need to show the client, relatives and nursing staff (YES ! All of them!!) how to position the arm in supine with a pillow underneath it, as well as side lying. (refer to your pre clinical notes on upper limb managment). As well as support, you must begin early movement, both passive and active. Gentle stretching must be done and most importantly, this must all be COMPLETELY PAIN FREE. Frequent, pain free, gentle passive movement will slowly gain range and decrease pain. If your client or the client’s family can be taught these activities, the carry over will be much more effective. Gaining any active movement is imperative. Begin with scapular protraction, horizontal flexion, and elbow extension. With activity around the joint, the cause of subluxation, will be decreased. Attention must be paid to increasing the client’s awareness of the limb. Often the limb is inadvertently traumatised because of neglect. A consistent approach from all health professionals is of paramount importance. This means you will have to liaise closely with the occupational therapist. You will both need to be approaching the problem in the same manner. This will require tact on your part, as you have no right to dictate how another professional treats a client. However, with good communication, a coordinated combined approach to this potentially disastrous problem is easily overcome. It may mean you will have to be persistent and have particularly relevant objective measures to indicate the severity of the problem to doctors on the ward round. Electrotherapy: Page 98 (Care must be taken to evaluate sensory loss in selection of appropriate treatment methods) - interferential - ultrasound - ice pack ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006

- heat, usually moist heat packs Mobilization: Many techniques of joint passive mobilisation may be effective in maintaining joint range and decreasing pain in these clients. Gentle G/H accessory glides, short of pain, are very effective. These can be done in the available range of flexion, abduction and external rotation. Pay particular attention to regaining external rotation, as this is often lost early. Remember to always work SHORT OF PAIN. Problem Solving 1. Your client has a gleno-humeral subluxation, limited ROM and has pain on movements when stretching into range. What are the potential problems that may occur, and what should you do about it? 2. Despite aggressive treatment by you, your client in Q1 is still not improving. You have mentioned in ward round, and nobody seems that worried about it. What should you do now? Feedback 1. This lady has the potential to develop shoulder-hand syndrome. It is sometimes referred to as regional pain syndrome or reflex sympathetic dystrophy. You need to instigate early dynamic and persistent efforts to arrest the progress of the pain cycle. Early movement, passive, active and assisted active need to be started. Grade II accessory movements SHORT OF PAIN are valuable. As well, techniques for pain, such as gentle warmth may be used. All treatments need to be done SHORT OF PAIN. Effleurage to decrease swelling should it exist needs to be started. Compression gloves should be made if there is swelling of the fingers. Positioning to keep the limb comfortable and in appropriate position will be instigated. You need to educate the client regarding all of the above (positioning/ what they can do actively/passively pain free). 2. This is where you really need to be the client’s advocate. You need to have objective measurements to support the fact the client is getting worse or not improving. In some cases medical pain management is necessary for improvement. This needs to be done sooner rather than later if there is a plateau or a worsening of symptoms. Think what it would be like to have a very painful arm in every thing you do. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 99

APPENDIX ONE Guidelines for Physiotherapy Assessment of the Adult with Acquired Brain Injury This material is designed as a guide to the assessment of brain injured clients e.g. C.V.A., Traumatic Brain Injury, Multiple Sclerosis, Parkinson's Disease etc. The process of assessment will identify the specific problems that interfere with the quality of movement. From this problem list, treatment goals and a treatment program can be developed. The assessment process will be the same clinical reasoning process for all clients but not all parts of the assessment will be appropriate for each client. For example, the Motor Assessment Scale is designed for use with clients following CVA and would not be suitable for measuring physiotherapy outcomes for a client with Parkinson’s Disease. Problems presenting in an 'early' client in an acute ward may differ from those of a client in later stages of rehabilitation. It is up to the therapist to prioritize assessment and then treatment areas as soon as possible. 1. INFORMATION FROM MEDICAL RECORD: Record only relevant information from chart including: - Personal details: name, Date of Birth, next of kin - Diagnosis - Date of Admission to Hospital - History of the Presenting Illness - Relevant Past Medical History e.g. Cardiovascular, Respiratory, Neurological, Musculoskeletal - Surgical History - Tests - X-rays; Biochemistry; CT scan or MRI, US / Doppler - Medications - Social background - Where lives, with whom, type of house, etc. - Occupation, interests, e.g. hobbies 2. INITIAL OBSERVATIONS The subjective examination and your initial observations are performed simultaneously. Your observations may include the following and should be documented on your assessment form: - Conscious level - Appearance - Posture or deformities - Skin colour - Skin condition - Oedema - Quality of movement - spontaneous and voluntary - Facial symmetry and expression - Apparent neglect - Aids and appliances - Gait and/or use of wheelchair 3. SUBJECTIVE EXAMINATION Ask relevant questions to gain information on the following and any other areas that have been introduced from the chart information or your observations. This should be a process of 'sifting' information to allow you to establish the total clinical picture and to clarify client problems as much as you can, before you proceed to your objective examination. - Client's perception of his/her present level of function Page 100 - Client's ability to participate in daily routines, e.g. details of transfers, toileting etc. - Client's perception of major problems, treatment goals (e.g. most important goal) ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006