Neuro Sit to lie and Gait Exam, questions and answers PDF

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Callum Hodge

School of Health and Life Sciences BSc (Hons) Physiotherapy Session 2019 - 20 Student Matriculation Number:

S1819550

Programme:BSc (Hons) Physiotherapy Level:

2

Module Code:

M2B123877

Module Title:

Neurorehabilitation

Assignment Title: Coursework Submission Date: 7th May 2020 Word Count:

2195 words

This assignment is my own work. It has not and will not be presented for assessment for any other module or piece of work which accrues credit for the award for which I am currently studying.

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1. FUNCTIONAL TASK – SIT TO LIE 1a) Missing or abnormal components Head: He flexes his neck to concentrate on hand position – there could be a potential proprioception issue. Shoulders: Left shoulder appears to be protracted, which enables his hand to lift his leg. Elbow: From sit to lie, he uses right elbow to break his fall. He also uses his right elbow as a prompt to help himself get up from lying, also will help him to gain momentum. Wrists: Appears unaffected but uses his right hand to lift up leg and swing it round to lie down. Trunk: Mr Smith cannot sit himself up without arms, therefore this shows muscle weakness in the trunk. Hips: When he is going from sit to lie, his left arm assists with hip flexion on the left side. In lie to sit, Mr Smith has to again self-lift his legs as there is no hip flexion present. Knees: He is wearing jeans so can’t see what his knees, but no missing or abnormal components noted. Ankles: Ankles are placed on the ground, showing capable dorsiflexion. However, they look quite ridged and stiff. Possible indication of Mr Smith previously wearing a brace. b) Possible impairments Sensory impairments:  Potential proprioception issues due to the difficulty at lying down  Sensory and visual loss (Direct impairment) Motor impairments:  Hypertonia (Direct impairment)  Muscle atrophy, muscle weakness and paresis (all direct impairments)  Potential mechanical fatigue (Indirect impairment) Cognitive impairments:  Written on his case study, he has history of depression (Indirect impairment and yellow flag)  Potential anxiety too Q2 a) Subjective: Top three questions 1. Is his sleep affected? If yes, how severe? 2. When getting out of bed, can he do it independently? 3. Has he ever had any previous falls? If yes, when was his most recent fall? b) Objective: Top three assessments 1. Assessment of tone 2. Assessment of strength 3. Proprioception testing (Gross – shin slide and Fine- holding distal phalange, moving it up/down) c) Treatment (Rx): Treatment 1) – Sit to lie training  Educate Mr Smith on how lie down efficiently. I will teach this in steps i.e. begin to place hands on bed to prepare for lying down, lift his leg and practice swinging it round, initiate trunk extension and rotation to get into the lying position (and to gain momentum), once in lying position shuffle around to get comfortable and make sure body is in a straight line.  Teach each movement separately, i.e. lifting his leg onto the bed, get Mr Smith to practice repetitions of this movement until he is comfortable and near the autonomous motor learning stage.  Regression - practicing each movement with a physiotherapist who is assisting him throughout the treatment.  Progression - reducing the assistance of physiotherapist and practicing movements on his own but supervised. Another progression could be varying the high and angle of the plinth, making it more challenging. Treatment 2) - Strength training  The structures I need to strengthen are his hip flexors (rectus femoris, psoas major, iliacus, and sartorius).  At the beginning, the following exercise must be done without gravity. Mr Smith will lie down on a bed and slide his leg up towards him and back down, repeating this movement. To eliminate gravity, I can 2

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place a slide-sheet underneath him, making the exercise easier. The next progression is adding the effect of gravity into the exercise. Mr Smith could stand up, holding a chair or plinth and lift his leg high off the ground, forcing his hip to flex. A progression/regression could be increasing/lowering the height he must lift his foot. His final exercise could include sets and repetitions of holding his leg in the air for a period of time (5 seconds). For additional strength training, adding ankle weights to any exercise will make it more challenging.

Treatment 3) – Proprioception training (Fine)  Patient in sitting, I will ask him to close his eyes and put his hand out. I will place and rub different items with different textures on his palm, and he has to tell me what they are. E.g. rub a cotton ball on his hand and he has to tell me what is feels like. Is it soft/hard, wet/dry, sharp/blunt and hot/cold?  Another proprioceptive test could be to hold the patient’s most distal phalange, and with the other hand, move gently move it up or down. Get the patient to feedback which movement you did and repeat ten times, so the patient is not guessing. If he gets more than eight correct, he passes the test. d) Analysis Some assistance is needed in the form of assistance of 1, especially when performing all 3 treatments. However, A01 would be reduced to supervision of 1, as assistance will only be taken away if his technique improves. Overall, muscle atrophy and muscle weakness are the patient’s main issues in the body. It is noted that there is weakness located in his hip flexors and trunk (core), resulting in impairing his ability to lie down and sit up. The focus of the Ax and Treatment is to review and improve his lie to sit technique and muscle strength via a treatment plan involving education training on sit to lie, alongside strength training of his hip flexors/core. e) Plan - SMART Goals Short term goals:  To improve the ability of sit to lie, so he doesn’t have to depend on his wrist to lift his legs within 2 weeks.  Perform sitting to lying efficiently without breaking his fall with his elbow or wrist, and to lie down more controlled within 2-3 weeks. Long term goals:  In 6-8 weeks, Mr Smart will aim to independently move both of his lower limbs in sit to lie, without using his hands to help him.  In 6 weeks, he will aim to be able to lift his feet off the ground an extra 15cm. Advice/ home exercise  Stretches - stretch plantar flexors by sitting down, back against wall and pull toes towards chest.  Strengthen – strengthen hip flexors and core muscles by sitting on a chair, marching on the spot.  Advice – do not to over-train. Maintain good posture when exercising. Drink plenty water.  Mobilisations – continue to keep mobile by incorporating some easy physical aerobic activity.

2. FUNCTIONAL TASK GAIT 1a) Missing or abnormal components Head: Seems to be protracted, neck slight flexed, looking down at his feet to see where he is placing them. Shoulders: Are protracted and elevated Elbows: Cannot fully extent elbow, potential limited ROM in elbow extension. Wrists: No missing or abnormal components noted. Wrists are gripping onto his walking aid. Trunk: Flexing trunk forward, affecting his centre of mass. Impacting on his balance during gait. Hips: Limited hip extension, Mr Smith forces his hip to hike up on life side due to his plantarflexion, so foot can clear the ground and not scuff. Knees: Knee extension is poor on both sides. Left side appears to be more affected, limited ROM, muscle weakness and potential hypertonia in quadriceps and hamstrings, meaning it is hard/stiff to move. Ankles: His hypertonia limits his range of movement and his left ankle is stuck in plantarflexion. 3

b) Possible impairments Sensory impairments:  Sensory and proprioceptive impairments on his left limb  Clonus in left ankle Motor impairments:  Hypertonia in left limb (increased muscle tone)  Muscle atrophy and muscle weakness observed on left side. Also has paresis (direct impairment) Cognitive impairment:  Written on his case study, he has history of depression (Indirect impairment and yellow flag) Q2 a) Subjective: Top three questions 1. Has he ever had any previous falls? If yes, when was his most recent fall? 2. Are there any daily activities he struggles with? i.e. Personal hygiene, toileting, cleaning, cooking. 3. Do you have any aggravating factors? If so, what is the time to onset? Intensity of the symptoms? b) Objective: Top three assessments  Strength assessment  Tone assessment  Proprioception assessment (Gross – shin slide and Fine- holding distal phalange, moving it up/down) c) Treatment (Rx): Treatment 1) – Strength training of lower body  To strengthen the quadriceps, he could sit on the end of a plinth and fully extend his leg and then slowly return to normal. A physiotherapist will be beside him to help raise and lower his limb if needed. Progression for this exercise will be adding an ankle weight to increase the load on his quads.  A functional exercise I will use is sit to stand. Mr Smart will sit down on a raised plinth, so it is easier, then as he progresses, I will lower the plinth to increase the distance he has to travel from sit to standing. The aim of this exercise is to fully lower the plinth till it is the height of a regular chair.  Finally, the last strength training treatment will be a single leg stand. This will improve his balance and strength in the lower limbs. To begin with, I will have 2 plinths either side of him for support, a chair behind for safety reasons and I will be in front of him in case he falls forward. Mr Smart will stand up unsupported and lift one leg off the floor and alternate between each leg. This will also improve his balance whilst walking. A regression would be unsupported standing on both legs. A progression would be placing his foot onto a box, then back down. Another progression would be integrating weight shifts as the physio touches both sides of his hips (gain consent before doing this), this will challenge and strengthen his standing balance Treatment 2) – Stretching of lower body  Incorporate gait positional stretches to lengthen key muscles associated with gate. Lengthening primary hip extensors (glute maximum and all 3 hamstrings) by doing a passive straight leg raise. As well as lengthen his knee extensors (all 4 quadriceps) by lying supine and passively bending his knee and moving his lower leg towards his back.  Can also include a stretch for the plantar flexors (flexor hallucis longus and brevis, flexor digitorum longus and brevis) as Mr Smith struggles to clear the swing phase when walking due to hypertonia in his left ankle. The stretch would be passive dorsiflexion. All stretches would be done to his end range of movement, I wouldn’t put the patient in any discomfort or pain. Treatment 3) – Supported gait training  Start training by placing a plinth about waist height beside his right hip. This plinth will be used as additional support for Mr Smart to lean on whilst walking. He will be able to balance a bit better, allowing him to fully concentrate on foot placement and movement of the lower limb.  Physiotherapist will stand in front of him and help place his foot in the correct position, showing him where the correct positioning is. Visual aids such as cones or coloured taped lines can be used to support him in placing his foot in the correct place. A chair will be placed behind him for extra safety. 4

When talking about the motor learning stage, he is at the 1st stage known as the cognitive stage. So, this means he will require lots of feedback, motivation, encouragement and verbal instruction.  Regression for this training could be to include a body weight supported treadmill training (BWSTT), as it will reduce the weight going through his limbs, making his gait cycle a lot easier.  Progressions for this training could be removing the plinths, walking a further distance, removing the visual aids or increasing the speed of his walking. d) Analysis Assistance is needed in the form of assistance of 1 physiotherapist when performing the treatments due to his balance and mobility issues. An extra therapist can place a chair behind him for additional safety. Overall, Mr Smith’s main issue is his lack of foot clearance during the swing phases. This is caused by his lack of hip flexion/knee extension. Additionally, his balance is an issue due to his muscle atrophy and weakness. The focus of the Ax and Treatment is to review and improve Mr Smith’s gait ability via a treatment plan including strengthening and stretch training of the lower limbs as well as supported gait. e) Plan - SMART Goals Short term goals:  Use BWSTT for 2 weeks in order to reduce and delay the onset of fatigue within his gait ability.  Become more comfortable at completing daily activities such as cooking and cleaning within 2 weeks.  With regards to knee extension, I would like to see Mr Smith improve ROM to 0° in both knees over the course of 2-3 weeks.  Improve get up and go time by 15% within 2 weeks Long term goals:  Improve his overall walking distance, without fatiguing, to at least 80-100 metres over 5-6 weeks.  Improve walking speed. Calculate how fast he currently walks, then set a goal to improve it in 6 weeks. Advice/ home exercise  Stretches - stretch plantar flexors by sitting down, back against wall and pull toes towards chest.  Strengthen – strengthen hip flexors, quads and core by sitting on a chair, marching on the spot.  Advice – do not to over-train. Maintain good posture when exercising. Drink plenty water.  Mobilisations – continue to keep mobile by incorporating some easy physical aerobic activity to keep the joints moving and prevent them from stiffening up and prevent a sedentary lifestyle. 

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