I am currently on a neuro inpatient placement where a majority of the patients are in varying stages of recovery post CVA. A patient I am currently treating is a 51 y.o woman who suffered a (L) parietal lobe haemorrhage 1 month ago. She now presents with expressive dysphasia and ® sided weakness UL>LL. Although her static and dynamic balance in sitting has progressively improved with daily physio sessions, over the past week it has been difficult to progress her functional mobility to include sit to stand and static standing balance. Her physical impairments contributing to these AL’s include (R) sided weakness, decreased activation of R hip and knee extensors and poor trunk stability, although over the past week it has been evident that her psychological and language impairments are the primary barrier to treatment progressions.
During the first treatment session for the week, I observed the senior physio’s perform balance exercises in sitting to improve her dynamic balance and passive Rom and stretches of her R UL. The patient was fairly compliant though became increasingly teary and frustrated throughout the session, especially when trying to communicate verbally. When the physio’s suggested sit to stand practice, she began to cry and refused to participate. The physio tried to comfort her at first, then chose to use quick prompts in an effort to encourage the patient to stand. Neither technique was effective and the patient was returned to her room. The following day, with supervision from the senior physio, myself and another student brought the patient to the gym, though she was not overly keen. Again she became frustrated through out the ex’s in sitting so we immediately progressed to sit to stand practice before her emotions limited her physical treatment. With a lot of prompting- both verbal and physical, we managed to get her into standing with 2 max assist. Once in standing she began to cry and curse, and when verbal comforting and prompting to take deep breaths failed, we sat her back down. She was emotionally stressed and crying, and on refusal to participate further, we took her back to her room. The following day she refused treatment, despite outlining the benefits of physio treatment and the other student and I abandoned further attempts to encourage her to consent.
As this was the fist time I have encountered an emotional patient with a language impairment, I was taken aback and confused as to how much persistence was appropriate. My initial reaction was to cease the treatment session immediately with concerns that if we pushed her too hard now, she would not want to participate in future physio, which is imperative to her rehabilitation.
Due to concern of future treatment of the patient, I liaised with the other health professionals treating her including the OT and speech therapist and both revealed that she behaves the same with them. So I enquired as to the strategies they employ to over come this challenge and they said persistence is appropriate if you give her time to recover through out the session and if you slowly talk her through the treatment with constant verbal encouragement.
In the future I will explain to the patient the importance her participation in physiotherapy sessions and the benefits of performing exercises such as sit to stand in her overall rehabilitation. If and when she does become emotional I will verbally encourage her and give her frequent breaks instead of ceasing the session other wise her functional mobility will not progress. I will hopefully develop my clinical judgement skills in determining the appropriate level of persistence as I don’t want to discourage the patient from participating in future physio. Any suggestions on approaches to treatment would be much appreciated.
During the first treatment session for the week, I observed the senior physio’s perform balance exercises in sitting to improve her dynamic balance and passive Rom and stretches of her R UL. The patient was fairly compliant though became increasingly teary and frustrated throughout the session, especially when trying to communicate verbally. When the physio’s suggested sit to stand practice, she began to cry and refused to participate. The physio tried to comfort her at first, then chose to use quick prompts in an effort to encourage the patient to stand. Neither technique was effective and the patient was returned to her room. The following day, with supervision from the senior physio, myself and another student brought the patient to the gym, though she was not overly keen. Again she became frustrated through out the ex’s in sitting so we immediately progressed to sit to stand practice before her emotions limited her physical treatment. With a lot of prompting- both verbal and physical, we managed to get her into standing with 2 max assist. Once in standing she began to cry and curse, and when verbal comforting and prompting to take deep breaths failed, we sat her back down. She was emotionally stressed and crying, and on refusal to participate further, we took her back to her room. The following day she refused treatment, despite outlining the benefits of physio treatment and the other student and I abandoned further attempts to encourage her to consent.
As this was the fist time I have encountered an emotional patient with a language impairment, I was taken aback and confused as to how much persistence was appropriate. My initial reaction was to cease the treatment session immediately with concerns that if we pushed her too hard now, she would not want to participate in future physio, which is imperative to her rehabilitation.
Due to concern of future treatment of the patient, I liaised with the other health professionals treating her including the OT and speech therapist and both revealed that she behaves the same with them. So I enquired as to the strategies they employ to over come this challenge and they said persistence is appropriate if you give her time to recover through out the session and if you slowly talk her through the treatment with constant verbal encouragement.
In the future I will explain to the patient the importance her participation in physiotherapy sessions and the benefits of performing exercises such as sit to stand in her overall rehabilitation. If and when she does become emotional I will verbally encourage her and give her frequent breaks instead of ceasing the session other wise her functional mobility will not progress. I will hopefully develop my clinical judgement skills in determining the appropriate level of persistence as I don’t want to discourage the patient from participating in future physio. Any suggestions on approaches to treatment would be much appreciated.
1 comment:
I have experienced pts such as this on my last neuro prac. It is hard to know if they are reacting this was due to frontal lobe injury, out of frustration at their situation, due to fatigue or being pushed too hard or a combination of the above. I found it helpful in some cases to provide a distraction when they start crying. such as keying them in to the enviroment around them "look at that person mowing hte lawn outside the window" etc. I found that this makes them forget about their worries as thay are often quite distractable in the neuro setting and this is just enough to get them through the physio session.
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