The simplicity yet difficulty of facilitating movement

I am on a neuro placement and one of my patients suffered a R sided basal ganglia stroke about one year ago. He is independent in his tranfers and bed mobility and able to ambulate with a walking stick and an AFO and stand by assistance and has signifcant perceptual and cognitive impairments. I found this patient hard as initially he did not seem to respond to my verbal and tactile feedback, although he is to be motivated and tries very hard to perform the exercises and movements I ask him to do.

Initially I tried to explain to the patient what and why he needed to do certain movements (example; equal weightbearing through LL when STS) and guided him through the taskes, continuely verbally telling him he needed to shift his weight over to his affected (L) leg. I then tried to physically get him to weight bear more through his (L) leg, by gently pushing him over to the (L) and blocking his leg from moving forwarads when he stood up. Eventually, he did do it the way I wanted him to, but as soon as I took my hands off him he reverted back to his old pattern of movement.

At his next treatment session I decided to try another approach: trick him into having to weightbear through that left leg. I decided to break down the STS task, concentrating on the initial trunk flexion and raising the pelvis just of the bed. I put a fitball just to the left of the patient (with a sandbag in front of it to stop it rolling away) and asked him to roll the ball forwads and slightly left (with his R arm) and 1/4 stand (at the same time ensureing that the patient was not rotating though the trunk, by making sure the ball wasn't too far away). It worked, with his (L) leg becoming active and visibly increasing its weightbearing. He then was able to STS with more weightbearing through his (L) without me having to remind him or put my hands on, which I was very pleased with.

This made me realise that as physios we can sometimes actually give our patients to much feedback, particulary if dealing with patients with sensory, perceptual and/or coginive impairments. I have found, pariculary with neuro patients, that if you can set up/modify the envoriment for them, they actually perform a task much better on their own, i.e. make their treatment/exercises functional. So, next time a patient is not acheiving what I am aiming for, despite all my best efforts, I will take a step back and look at how I can make the task more functional for the patient.