On my neuro placement i encountered a problem with a patient with a postive support reaction which proved to effect my treatment tremendously.
I was treating a patient who had a Right Middle Cerebral Artery infarct (TACS) on 17/06/07. Patient's main presenting complaint is left hemiparesis, left shoulder pain, inattentiveness to the left side and poor initiation of movement, motor planning and loses concentration easily. Current treatment has consisted of dynamic standing balance exs, sit to stand practice, dynamic standing balance exs and gait reeducation. The pt's progress for the last six months has been up and down with little carryover treatment session to session. Since discharge from ward 2 on 07/03/08 pts Berg Balance score has decreased from 32 to 19 0n 06/08/08.
I was really keen to treat this patient and had planned a whole treatment session with every intention to work as hard as i could to progress this patient. My treatment plan included bilateral lower limb stretches, bilateral foot mobilisations, sitting balance a-p and lateral pelvic dissociations, dynamic standing balance exs and progression to gait ed. Unfortunately little had been said in the notes that this patient had a strong positive support reaction (abnormal tone response when patients push foot against surface foot deviates into plantar flexion and inversion).
Treatment was going well until i moved from sit to stand without the pt's shoes off. The pt became distresssed and was telling me that she could not stand on her foot and that it was hurting.... In response i sat the patient down and did some SIMMS on gastroc/soleus however this proved to have little effect. I became really frustrated and called my supervisor for assistance. When my supervisor attended to the problem he advised me that there was no hope in continuing my treatment in the direction i wanted. The best plan for now was to get the patient on the tilt table to at least get a gastroc/soleus stretch, once the pt has the strong PSR it is very difficult to dampen.
I felt hopeless as i had not achieved my treatment goals in this session and did not get a true indication of what this patient was capable of. In response to my distress my supervisor showed me a good technique of hip perching in which you encourage the pt to perch their unaffected limb on the bed, raise the bed height until the patient has no contact with ground, slowly encourage pt to find affected foot and control the position of the foot.
The next week i saw the patient i tried this technique and it proved to be successful. I managed to achieve a lot in my session and really progressed the patient. Also because i had more confident in myself and the patient felt more comfortable with me and as a result was more confident in weightbearing on her affected side.
Has anyone else in the neuro field experienced any major barriers affecting treatment? How did you respond and what strategies did you implement to overcome these?
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I think you did a great job in treating your patients PSR. It can be so frustrating when you have carefully planned an entire session and for reasons that you have not and could not have foreseen you aren't able to complete them. During my neuro placement for similar patients I found that in those situations one of the biggest hurdles is to gain their trust. I remember one patient in particular the first session I saw them we did little more than stretches and active assisted exercises until I gained their trust. Keeping in mind that in some situations we won't have that luxury, for the rest of the placement I was able to try all different treatment techniques to see which worked best for them. For the majority of the time they participated in all these sessions and we were able to reach a number of goals I had set for them, but that they had also set for themselves.
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