Case Study for Stroke Inservice
Transcript of Case Study for Stroke Inservice
By Jo MurchieOccupational Therapist
David85 year old manR CVA- 6/7/10, discharged home from
Addenbrookes26/10/10 left sided hemiplegiaupper limb less movement than lower limbPoor planning and problem solving- reduced
attention spanInattention to left sideHypersensitivity in left side on movement
Social situationLives with wifePreviously very independent- played golf 3
times a weekPrivately rented bungalowSupportive family- 4 children- all live in
London- wife often used to stay in London- not used to being together all the time!
Functional abilityOn discharge from hospital:Bed-chair -Slide board transfer with max
assistance of 1 (with physio)2 carers requiredCommode to chair- use of grab rail in
bedroom and bathroom- tendency to pull on rail rather than push up from seat
Assistance of 2 with personal careWheelchair dependent- borrowed from Red
Cross awaiting wheelchair services assessment
Expectations
‘to be having ongoing rehab’Much of the impetus coming from his wife -
very eager to know what input available for rehab, asking for +++ input and high expectations for recovery
Assessment
Initial assessment completed by physio 15/11/10
Exploration of their expectations and support required for his wife
Measurement of range of movement
Flaccid left arm
Pain on extension and supination
Pain on movement – thumb, wrist and fingers
Knee flex 75° activeLacks 10° extension
Increased tone in left leg
Normal tone and full active range of movement in right side
Hand ++ oedematus
Good trunk control- aligned in sitting- some lower back pain, wears lumbar support
Passive range of movement
Finger flexion MCP 30°IP 10 ° Thumb nil
PROM
Wrist extension 20 ° Flexion 20 °Pronation full rangeSupination ¼ range
Elbow lacks 15 ° extensionFlexion 110 °
Shoulder abduction 60 °Flexion 30 °
TreatmentAgreed twice weekly sessions 1 withOT and 1
with PTPT lower limbOT upper limb and functional activitiesJoint working on transfersRehab timetable provided with strengthening
exercises and visualisations- focussing on lower and upper limb
Provided information for support for wife
OTRetrograde massage for oedema managementPassive ranging and visualisations- slowly
bringing in challenging activities- responds well to a challenge!
Education of David and his wife re: positioning, use of bexhill armrest and tray on wheelchair
Personal care practice, using bath lift- transfer practice and facilitation of left arm during activity
Problem solving ways to include his left arm as movement started to return
Bilateral tasks, but also looking at the ideas of constraint of right arm to encourage use of left
PTEncouraging normal movement patterns-
starting with encouragement to push up from chair and not pull on his rail when transferring
Strengthening of lower body and trunkStanding practice and dynamic balance workGait re-trainingMobility practice in parallel barsMobility practice with frame
ReviewUsed DRC to review mobility progress in
parallel bars As movement in left arm improved moved
onto mobility practice with frameOn last session 13/4/11 at DRC mobility
better with a frame than in the parallel bars
Current level of abilityImproved active range of movement in arm and legReduced oedema in hand and wrist, sensation
normalising Insight into positioning of upper limb much
improvedProblem solving improvingMobility with frame improving (11 steps)
In summaryA challenge!Positive use of David’s wife’s enthusiasm,
involving her in rehab processGood progress so farGood joint working with OT and PT!
Thank you for listening- any questions?