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?