Case studies in neurological physiotherapy

CHAPTER SIX Case studies in neurological physiotherapy

Introduction

Neurological physiotherapy covers a broad area of practice spanning intensive care, acute, rehabilitative and community services. New ways of working have seen an increase in physiotherapists working in community and primary care settings, a number of case studies presented touch upon the differences experienced when working in these areas. The case studies based in acute settings highlight transferable skills which may impact on the approach to treatment of the patient with neurological impairment.

Physiotherapy practice in neurology can be focussed on prevention, maintenance, restoration, prevention or in palliative care. The case studies presented in this chapter aim to touch upon each of these areas, highlighting the role of the physiotherapist, the need to develop an underpinning knowledge of the pathophysiology of a condition in order to set appropriate goals and the need to work as part of a multi/inter disciplinary team.

In neurological physiotherapy the evidence base for treatment interventions is a developing one (Pomeroy & Tallis 2002). Moves have been made by a number of researchers to identify what constitutes neurological physiotherapy. Studies by Ballinger et al (1999), Davidson & Waters (2000), Lennon & Ashburn (2000) and Lennon (2003), have begun to address this issue mainly in the form of surveys and focus groups. These studies have sought to isolate the components of neurological physiotherapy treatment and what concept of treatment physiotherapist’s professed to use. Previous studies by Nilsson & Nordholm (1992), Carr et al (1994), and Sackley & Lincoln (1996) as cited in Davidson & Waters (2000), identified that the main approach used by physiotherapists in the United Kingdom, although eclectic in nature, was based on the Bobath concept. This was supported by Davidson & Waters (2000) who reported that the majority of physiotherapists questioned (88%), professed to use the Bobath approach, although the majority of these also used other approaches in the treatment of their clients. The second most popular approach was identified as the Motor Re-learning Programme (MRP), though this was practised by only 4% of the respondents.

Much of the evidence available informing neurological physiotherapy practice supports the MRP as an effective treatment approach in the management of neurological conditions. However, given the low numbers of physiotherapists reported to be practising MRP in the UK and the eclectic approach reported, a similar approach has been taken when compiling this chapter. It is therefore suggested that any preparation for a new area of clinical practice should include familiarisation with the approach adopted in that area.

CASE STUDY 1 Acute stroke

Subjective assessment

PC

68-year-old male admitted via A&E following collapse at home

CT scan shows infarct of right middle cerebral artery

Chest X-ray (CXR) – patchy shadowing right base

HPC

Found in garden at home by wife – drowsy, uncommunicative and had vomited. Thought to have suffered collapse several hours previously

Ambulance called and patient transferred to A&E

On arrival to A&E patient was drowsy but appeared to be able to respond to basic commands, though was not recognizing stimuli from the left

Left sided weakness, reduced tone and reduced reflexes

PMH

Atherosclerosis

Bilateral OA knees

DH

Simvastatin – for atherosclerosis

Commenced on IV antibiotics and IV fluids in A&E along with 300 mg aspirin

SH

Lives with wife in a semi-detached house with bedroom and bathroom upstairs

Retired plumber

Objective assessment

Referred by ward staff to assess chest and initial bed mobility.

Bed mobility

Patient unable to participate in attempts to alter position, due to level of consciousness. Dense low tone noted throughout left upper and lower limbs

No subluxation evident at left glenohumeral joint

Respiratory

RR 10 breaths per minute

Oxygen saturation – 94% on 28% oxygen via face mask

Palpation – reduced basal expansion bilaterally

On auscultation – reduced air entry with bronchial breath sounds in right basal lobe

CASE STUDY 2 Stroke rehabilitation, upper limb hypotonicity

Subjective assessment

PC

72-year-old female with right-sided hemiplegia primarily affecting the upper limb following CVA 6/52

Low tone in upper limb proximally with subluxation of glenohumeral joint

Increased tone in right wrist, fingers and elbow, with moderate associated reaction evident on activity

HPC

Complained of severe headache immediately prior to collapse at local bingo hall

CT scan showed extensive haemorrhagic stroke affecting the thalamus. Intracranial pressure was monitored closely in the acute stages, though surgical intervention was not indicated

Transferred to stroke rehabilitation unit after 2/52 once medically stable, where significant improvements have been made

PMH

Smoker – 30 per day

Previous myocardial infarction × 3 in past 5 years

DH

SH

Lives alone in ground floor flat in sheltered accommodation

Retired cleaner

Goes to bingo twice weekly

Objective assessment

Independently mobile on ward, returned to previous level of function with regard to mobility.

CASE STUDY 3 Stroke rehabilitation, gait disturbance

Subjective assessment

PC

55-year-old male admitted via A&E following collapse

CT scan showed sub-arachnoid haemorrhage (SAH) of the left anterior cerebral artery (ACA)

Current problems relate to standing balance, unable to stand unaided. Mobilising few steps in therapy sessions only

Keen to return home, but unable to do so while balance remains problematic as wife works away from home for periods of time during the week

PMH

Chronic low back pain, attributed to driving as part of job, manages with medication

Nil else of note

DH

Ibuprofen prn for back pain

SH

Lives with wife in a terraced house with bedroom and bathroom upstairs. Toilet facilities available downstairs

Alcohol consumption 40+ units per week

Sales representative for engineering company

Two children – both live away from home

Objective assessment

Sitting

Kyphotic posture in sitting with decreased lumbar lordosis. With verbal prompting, able to anteriorly tilt pelvis and increase lumber lordosis

Static sitting balance good – able to withstand challenges to balance and effectively recruit equilibrium reactions

Dynamic sitting balance – difficulty recruiting activity at right hip when reaching outside base of support on the right. Able to correct with verbal prompting, though fatigues quickly

No evidence of increased tone in sitting, though tendency to overuse left lower limb to assist with weight transfer to right

Slight weakness in right upper limb though no tonal change

Sit to stand

Sit to stand – independent

Weight bearing left > right with overuse of left upper limb evident

Retraction of right hip and hyperextension of right knee during extension into full stand minimal weight bearing through right lower limb

Decreased activity tibialis anterior with ankle remaining in plantarflexion throughout transfer

Standing

Weight bearing left > right with retraction at right hip, hyperextension of right knee and right ankle in plantarflexion

With facilitation to extend right hip, able to transfer weight to the right, though complains of fear of falling

CASE STUDY 4 Head injury, acute phase

The following patient is on intensive care following admission via A&E 2 weeks ago.

Subjective assessment

PC

28-year-old male, admitted to ICU with extensive head injury following an assault

Ventilated and sedated, though sedation is being reduced as ventilator weaning commences

Evidence of increasing tone once sedation began to be reduced, which has caused concern for staff involved in nursing interventions

PMH

Fractured pelvis and right femur 2 years ago in motorbike accident

Nil else of note

Family history

Parents and sister live nearby, close family network

DH

Extensive medications at present

SH

Self-employed electrician

Lives with a friend in a rented two-bedroom terraced house, all bedroom and bathroom facilities upstairs

Parents live nearby and are concerned at meeting rental payments on their son’s home

Previously very fit and active, enjoyed socialising with friends, motorbiking and surfing

Objective assessment

Lying in supine

Increased tone in upper limbs bilaterally, with upper limbs demonstrating severe flexor patterns

Flexion at wrists, fingers and elbows with adduction and internal rotation at shoulder joints

Attempts to lower tone in order to move upper limbs prove difficult. Movement of the upper limbs away from the chest wall is possible with slow stretching and tissue mobilisation though cannot be maintained with positioning

Increased tone into extensor pattern in the lower limbs. Severe increase in tone which prevents any movement into flexion at the hips and knees. Ankle joints are held in plantarflexion. Unable to affect level of tone within the lower limbs with handling

On repositioning to assist with nursing care, rolling performed via a log-rolling technique due to difficulties with increased tone in the lower limbs. On rolling increased tone within the neck and trunk extensors evident

Further assessment postponed due to patient agitation

CASE STUDY 5 Head injury, long-term rehabilitation

You have been asked to see the following patient in the community. She suffered a head injury 4 years ago and is seeking advice on exercise and social activity, having previously been discharged from physiotherapy 2 years ago.

Subjective assessment

PC

22-year-old female, suffered a head injury 4 years ago following an RTA in which she was a passenger

With rehabilitation made a good recovery and has now been in part-time paid employment for 6/12 as an administrative assistant

On starting work, complained of high levels of fatigue. This has now settled

Keen to focus on physical performance as mobility levels have decreased over the past few months which the patient attributes to a lack of exercise

Complains of right leg feeling weak, with a fear of her knee giving way if walking any distance

HPC

RTA 4 years ago, in which the patient sustained a head injury, fractured left tibia and fibula and facial fractures

MRI scan showed damage to the temporal and parietal lobes on the left due to a blunt piercing trauma

Underwent extensive surgery and rehabilitation at the time of injury

Discharged home 8/12 post injury using a powered wheelchair for mobility, transferring with the assistance of one to step round, with mild increased tone in the right upper limb and lack of selective control of movement

Rehabilitation commenced on an out-patient basis, on discharge 2 years ago mobilising independently with a walking stick to aid balance. Walking approximately 50 m both indoors and outdoors. Good upper limb function, able to carry out most functional tasks, with just fine control affected

Unable to drive on discharge due to epilepsy following head injury, though has now returned to driving

PMH

ORIF left tibia and fibula following RTA

Nil else of note

DH

SH

Lives alone in a one-bedroom ground floor flat

On discharge from hospital, lived with parents, moved to own accommodation 1 year ago and has lived independently since

Parents are supportive, but now only call when needed as daughter has worked hard to achieve her independence following her RTA

Works part-time as an administrative assistant at a local architects, looking to increase hours to full-time once she feels physically able

Returning to a more active social life – enjoys going out with friends, bingo and cinema

Objective assessment

Mobilising independently indoors at time of visit. Reports using stick at work as works in an open-plan office and doesn’t feel safe. Mobilises without stick only in familiar environments, such as home and parent’s home

Gait indoors – reduced stance phase on right, with an increased base of support throughout gait cycle. Reduced heel-strike on right, with decreased eccentric control of plantarflexion to achieve foot-flat

Outdoor mobility – using walking stick in left upper limb. Overusing when weight bearing on right, with elevation and abduction of left shoulder evident during stance on right. All other observation as indoor mobility

Lower limb strength – all lower limb muscles tested using Oxford Scale. All major muscle groups – grade 5, except right quadriceps, hip extensors and dorsiflexors, which were assessed as Oxford Scale grade 4

Berg balance scale – 38 out of a maximum 56. Patient reported that fear of falling meant that she often ‘gave up’ rather than having to stop due to physical factors

CASE STUDY 6 Spinal cord injury at C3

The following gentleman was discharged 4/52 ago from a regional spinal unit. He has 24-hour care provided at home by a dedicated nursing team. You have been asked to see him by the lead nurse in the team due to difficulties with positioning.

Subjective assessment

PC

45-year-old man who suffered an incomplete disruption of C3/4 following a motorbike accident

Recently discharged home, ventilated and has a 24-hour package of care provided by a dedicated nursing team who all undertook an extensive training package at the regional spinal unit once appointed to their post

Contracted a chest infection 2/52 ago. Has had a full course of antibiotics but was unwell at the time and nursed in bed

Nursing staff report difficulties in achieving a good sitting posture in attendant powered wheelchair since chest infection. This has prevented participation in social activities and restricted engagement with family members

HPC

Sustained an incomplete disruption of C3 15/12 ago following a motorbike accident

Requires full ventilatory support and regular suctioning to clear excess secretions. Staff are trained in respiratory management and provide manual hyperinflation and suctioning at regular intervals

Paraplegic; reports being able to feel pain though unable to localise. No other recognised sensation present or motor control

During chest infection did not require hospital admission and was managed at home with antibiotics and increased respiratory management

Chest is now clear and staff are happy with respiratory procedures in place. Suctioning technique reviewed by senior nursing staff for all team members to ensure correct sterile technique adhered to during procedure

Passive movements usually performed twice daily to all joints of upper and lower limbs through range. During chest infection unable to perform all movements fully due to positioning and marked increase in tone

Tracheostomy tube changed during chest infection, communicates effectively by staff lip reading

PMH

Mild asthmatic – controlled well with inhalers

Nil else of note

DH

Extensive medications

Of note – Baclofen

SH

Lives in a four-bedroom detached home. This has recently been extensively adapted to accommodate needs.

A large ground floor extension has been built which includes: ramped access, bedroom for the patient, bathroom with level access shower and sluice, a generator (to provide power for the ventilator in the event of a power cut) and accommodation for nursing staff

Lives with wife who works full time as a teacher and two boys aged 8 and 10

Previously worked as a pharmacist at local chemists

Previous social activities included motorbike holidays with friends, hill walking and helping out with son’s football team

Objective assessment

You are asked to focus your attention on seating and positioning difficulties.

Observation

Patient positioned in powered adjustable bed, upper limbs supported on pillows maintaining alignment throughout

End of bed raised to position lower limbs with hips in approximately 70° flexion and knees at approximately 30° flexion

Ankles plantarflexed and inverted

Passive movement

Passive movements performed to all upper limb joints

Shoulder extension difficult to assess due to positioning in bed

Full range of movement available at shoulders and elbows, though distal increase in tone noted toward end of range. Patient complained of pain on movement, though unable to localise

Full range pronation available, marked increase in tone noted at approximately neutral when moving toward supination, with wrist and fingers developing flexor pattern

Nursing staff present report that this has become an increasing problem since chest infection and they are concerned about skin integrity. Patient reports hand position causing concern though wants to be able to sit out in wheelchair so that he can spend more time with his sons

Once blood pressure stabilised, patient hoisted into wheelchair to enable assessment of lower limb alignment and sitting position

Sitting posture

Tilt in space wheelchair, with rear wheels set back to accommodate the weight of the portable ventilator

Gutter arms to provide support for upper limbs, which can be positioned into pronation with wrists and fingers in neutral position after approximately 5 minutes to allow tone to settle following hoisting

Head support in situ though able to maintain alignment of head independently

TABLE 6.1 Upper Limb ROM

Lateral trunk support maintaining trunk position

Hips at 90°, positioning aided by gravity as hoisted into wheelchair in tilted position

Increased tone at knees into extensor pattern, unable to flex knees passively beyond 140° on right and 130° on left to place feet on footplates

Increased tone at both ankles, held in plantarflexion and inversion. Unable to achieve neutral position at ankles to place feet onto footplates

Patient complained of pain and fatigue after approximately 10 minutes in wheelchair and returned to bed

CASE STUDY 7 Spinal cord injury at T5

The following patient has recently been transferred to a rehabilitation unit following a period of care for a spinal fracture at T5. Surgical intervention was required to stabilise the fracture site and decompress the spinal cord. The patient is now wearing a brace, which is due to be reviewed in the next few weeks.

Subjective assessment

PM

DH

SH

Lives with parents in terraced house. All facilities upstairs. Parents have converted second reception room on ground floor into bedroom which is separate to main living areas

Occupational therapists have undertaken an initial home assessment and temporary ramps and a commode have been provided. Referral to social services occupational therapy for assessment for home adaptations has been arranged

Keen to commence weekend leave from the rehabilitation unit

Student at university studying law. Lives in halls of residence, but was due to move into shared housing with friends at start of next academic year

Has been in contact with local university about the possibility of transferring her studies to allow her to live at home. Agreement has been reached re: transferring studies. New academic year starts in 2/12 time, though can delay starting second year of studies for a year to allow further time for recovery

Both parents work full-time, younger brother who also lives at home is due to start college in 1/12

Active sportswoman enjoys rock-climbing, netball and hockey and represented university sports teams in the previous year

Objective assessment

Brace in situ throughout assessment.

Lying

Full range of movement both upper limbs (within limits of position)

Patient reports decreased muscle strength throughout upper limbs (Grade 4+ Oxford Scale) and atrophy Previously had good upper-limb strength due to rock climbing

Full passive range of movement available in both lower limbs, low tone throughout. No active movement or sensory discrimination evident on full assessment

Lying to sitting

With assistance from one, able to push through upper limbs to move into long sitting

Requires assistance from one to move lower limbs over edge of bed to achieve sitting. Able to adjust sitting position by pushing through upper limbs to lift trunk. Facilitation from one required to maintain balance during transfer

Unsupported sitting

Able to maintain sitting posture through overuse of upper limbs to increase base of support

Overuse of thoracic and cervical extension to maintain sitting posture

Unable to move within base of support in sitting or release upper limbs to enable function

Transfers

Requires maximum assistance of two to transfer weight laterally and place banana board

Able to initiate movement along banana board by pushing through upper limbs though requires facilitation to maintain balance and reposition lower limbs during transfer

CASE STUDY 8 Multiple sclerosis, relapsing–remitting

You have been asked to see the following lady in an out-patient setting by the multiple sclerosis (MS) specialist nurse following a recent relapse.

Subjective assessment

PC

35-year-old lady complaining of difficulties maintaining balance in standing, particularly when carrying out ADLs

Has tripped several times and feels unsafe when mobilising outdoors. Currently not leaving the house without someone to accompany her

Recent relapse mainly affected right lower limb, recovery slower than with previous relapses

Confidence affected considerably

Unable to drive at present as patient ‘does not trust’ right leg when braking

HPC

Diagnosed with MS 4 years ago following three incidents of illness accompanied by loss of movement in lower limbs. Has previously returned to full normal functional levels following these incidents

GP referred to consultant neurologist, who diagnosed MS following a number of investigations

Reviewed 6 monthly by Consultant and 3 monthly by MS nurse

5/52 ago complained of feeling unwell with associated loss of movement in right lower limb. Contacted MS specialist nurse who arranged for admission to day unit for intravenous methyl-prednisolone

Good recovery initially, though remaining symptoms have persisted

PMH

Caesarean section × 2 for youngest two children

Nil else of note

FH

Sister has MS now uses a wheelchair for mobility

DH

SH

Lives with husband and three young children aged 3, 5 and 7

Housewife, previously worked as a personal assistant before giving up work to care for children full-time

Active member of Parent Teachers Association, helps at children’s school three times weekly

Goes to gym four times a week, enjoys cooking and family days out

Objective assessment

Arrives for therapy session mobilising with husband, reports ‘linking’ as feels unsafe mobilising outside own home independently. Husband reports that his wife has been maintaining her balance by holding on to furniture while walking around the home.

Standing posture

Large base of support, with knees pushed back into full extension to adopt close-packed position of the joint

Pelvis – anterior tilt, with increased lumbar lordosis

Centre of gravity falling posterior to the knee joint

Shoulders elevated bilaterally, unable to release upper limbs to ‘relax’ into standing posture

Standing balance

Balance assessed in standing by applying small forces anteriorly, posteriorly and laterally to central key point. Patient asked to push against the pressure to maintain midline standing

Unable to activate postural control mechanisms at the ankles to correct for postural threat. Equlibrium reactions evident immediately. Correction achieved by movement of upper limbs or by stepping left leg to increase base of support

No attempts to increase BOS by stepping right lower limb

Further progression of balance assessment abandoned due to patient confidence and health and safety concerns

CASE STUDY 9 Multiple sclerosis, secondary progressive

You have been asked to see the following gentleman at home by the home care team, who have reported increasing difficulty with transfers on visits to assist with personal care.

PC

Uses a powered wheelchair for indoor and outdoor mobility

Currently using a banana board with the assistance of one for all transfers

Home care staff have reported increased difficulties with transfers, with one member of staff having injured her back during transfer from bed to shower chair

Sacral pressure sore – district nurse visits three times weekly for dressing. Recently provided with higher pressure relief mattress and wheelchair cushion

District nurses have expressed concerns about the shearing forces experienced during banana board transfers which they feel may be a contributing factor to pressure sore development and healing

HPC

56-year-old gentleman, diagnosed with MS 20 years ago

Initially presented with relapsing–remitting clinical presentation. Began to deteriorate physically 3 years ago without any acute periods. Consultant Neurologist diagnosed with secondary progressive MS

Reported recurrent UTIs 5 years ago. Continence specialist nurse diagnosed detruso-sphincter dyssernygia. Initially managed with medication and self-catheterisation to address retention. Upper limb function deterioration led to increasing difficulty with self-catheterisation, has therefore been catheterised for previous 2 years

Reported difficulties with fatigue, with increasing difficulty with transfers and carrying out functional tasks as the day progresses

Under the care of the speech and language therapist for swallowing difficulties, currently on a modified diet including syrup thick fluids and soft diet

PMH

DH

SH

Previously worked as a solicitor. Retired 10 years ago due to deteriorating health

Lives alone in a large detached bungalow, adapted to allow wheelchair access throughout. Level access shower and ramped access in situ

Divorced 12 years ago, two grown children live locally and are very supportive of their father

Active role in local church, though this has decreased in recent years and now plays a largely administrative role

Objective assessment

Transfers

Currently transferring with banana board with the assistance of one

Assessed with two due to moving and handling safety concerns raised by home care staff

Lateral trunk support removed to allow movement of trunk in sitting

Assisted to flex left hip to remove wheelchair footrest Significant increase in tone into hip flexion and knee extension on movement – facilitation provided to accept base of support and decrease tone – took some time to settle. Assistance required to reposition right lower limb, though no significant change in tone noted

Maximum assistance from two to transfer weight laterally and step each hip forward to achieve perch sitting with both feet in contact with the floor. Extreme difficulty in moving to perch sitting with minimal participation achieved by patient

Transfer attempt abandoned due to risks perceived to staff members

Patient reported that transfers were much more difficult later in the day due to levels of fatigue, though at time of assessment, participation not affected

Questions

1. Secondary progressive MS is one form of the condition. What forms of MS are there, and how can these be classified?

2. What risk assessment needs to take place when evaluating moving and handling intervention?

3. Beta-interferon is a disease-modifying drug recognised as providing benefit to some people who have MS. Why is this gentleman not prescribed this drug?

4. What would your advice be with regard to moving and handling in the short term?

5. What might the possible psychosocial implication of your advice be for this gentleman?

6. Noticeable soft tissue adaptation and increase in tone in the upper limbs may lead to difficulties for this gentleman in using the powered wheelchair. What treatment interventions might you access in order to manage this problem?

7. If banana board transfers are no longer possible, access to a car will be difficult. What other options are available?

CASE STUDY 10 Parkinson’s disease

You are asked to see the following gentleman at his home by the Parkinson’s disease specialist nurse who reviewed him at her clinic 1 week ago. He has been finding transfers increasingly difficult. His medication has been changed, but increasingly difficult home circumstances have triggered an urgent referral.

Subjective assessment

PC

83-year-old gentleman diagnosed with Parkinson’s disease 10 years ago

2/12 ago, started to experience difficulties with transfers – particularly sit to stand and getting out of bed

Wife has been finding it difficult to cope. They are both extremely worried and feel that they may need to move into residential care but don’t want to leave their home

PMH

Osteoarthritis right hip

Left ventricular failure

Recurrent chest infections over past 12 months

DH

Sinemet (CR) – controlled release – medications are released over a 4–6-hour period to prevent fluctuations of levadopa levels

Ropinirole – dopamine agonist – just commenced as symptoms worsening. On low dose currently being closely monitored by specialist nurse, who is visiting at home every 2 weeks

Furosemide – diuretic used to treat heart failure

Coproxamol – to control pain from OA hip

SH

Lives in a two-storey house with bathroom and bedroom upstairs. Two hand rails fitted to stairs – reports no difficulties

No other aids/adaptations in situ

Lives with wife who has RA and osteoporosis, she is finding it increasingly difficult to support her husband

Retired HGV driver

No regular social activities due to difficulties experienced when leaving the house

Objective assessment

General

Atrophy of quadriceps and gastroc’s evident. Able to achieve knee extension in sitting, but with difficulty Quads strength 4/5 on Oxford Scale

Supported sitting

Kyphotic sitting posture, with protracted and depressed shoulder girdles

Mask-like face and considerable pill rolling tremor. No other added movements noted

Sitting in deep armchair, with low seat height – feet raised on stool to prevent ankles swelling

Difficulty adjusting position in sitting. Unable to initiate weight transfer to alter base of support. Chair cushion very soft contributing to difficulties

Sit to stand

Attempts made to stand independently, though unable to adjust position in chair to move forward to stand. Using upper limbs to push on arms of chair, while extending within trunk. Unable to bring centre of gravity forward over changing base of support to achieve stand

With facilitation and verbal prompts able to ‘slide’ forward in chair using upper limbs to initiate movement. Unable to achieve anterior pelvic tilt independently to allow lateral weight transfer to move forward in chair

Mobility

Mobilising independently, with festinant gait and slouched posture evident. Freezing noted at doorways. Patient reports this has been a difficulty for a number of years, which he overcomes by imagining a ticking clock, then transferring weight laterally in time with the clock

Climbs stairs independently with reciprocal gait pattern using stair rails for balance only. No apparent difficulties noted

Bed mobility

Experiencing marked difficulty rolling – initiates movement by reaching forward with right upper limb. Dining chair placed by the side of the bed, which patient reports he uses to pull on to assist with roll. No movement initiated at head or lower limbs

With verbal prompting able to move lower limbs into crook lying, turn head in direction of movement and reach upper limb across the body in the direction of movement. With light facilitation at the knees able to roll to left without difficulty. Patient reports concerns that his wife would be unable to offer this degree of support as she is in increasing levels of pain

In side lying able to drop feet over side of bed, though required assistance to push upper body into sitting position. Mattress very soft, offering little resistance to downward force needed to achieve this movement

Tags: Clinical Case Studies in Physiotherapy A Guide for Students

Mar 15, 2017 | Posted by admin in PHYSICAL MEDICINE & REHABILITATION | Comments Off

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