Stroke case study physical therapy
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Search Search. Toggle navigation p Physiopedia. Each site developed internal auditing methods to ensure that data collection forms were used as intended. Verbal reports of progress and challenges or questions about form use were discussed during weekly telephone conferences that included the project team and at least one clinical representative from each site.
Data collection forms allowed physical therapy providers to describe treatment sessions in terms of categories of activities: prefunctional, bed mobility, sitting, transfers, sit-to-stand, wheelchair mobility, pre-gait, gait, advanced gait, and community mobility. Therapists could identify one or more activities that they worked on with the patient within a session.
Within each of these activity categories, therapists recorded the amount of time spent on the activity with the patient and up to 5 specific interventions that they used during the performance of that activity. Interventions reflected both specific techniques, such proprioceptive neuromuscular facilitation PNF or neurodevelopmental treatment NDT , as well as general theoretical approaches to intervention, such as motor relearning. Twenty-seven types of equipment were listed.
One category was provided for writing in interventions not provided on the form. This large list of interventions, developed through the effort of those providing care at the sites involved in the study, allowed therapists to choose from a broad range of possible interventions defined by them in ways that they would understand. The forms also allowed therapists to record the amount of time patients spent being examined and evaluated, in co-treatment with other disciplines and in therapy sessions that included more than one patient.
Additional information was reported regarding which providers gave the care during the session, including physical therapists, physical therapist assistants, and students Figure. Data regarding patient characteristics were collected from patients' medical records following their discharge by trained data abstractors from each institution.
Data collection organizational chart. Descriptive statistics were derived to examine characteristics of the patients and characteristics of their episodes of care, including length of stay, number of days physical therapy was provided, number of physical therapy sessions per day, and number of days physical therapy was provided divided by the total length of stay.
The content of treatment sessions was described by determining the duration of each session, the proportion of all physical therapy time spent directed to the activities listed above, and the proportion of those activities that included specific interventions. We also examined the proportion of all physical therapy sessions in which more than one patient was treated by a single provider and the proportion of sessions for which physical therapists, physical therapist assistants, or students were involved in care.
The patients included in this study participated in 21, physical therapy sessions during inpatient rehabilitation. The mean length of stay in the rehabilitation setting, or episode of care, was Patients received physical therapy, on average, The average number of physical therapy sessions per day was 1. Table 3 provides data on the types of interventions therapists used in facilitating therapeutic activities with their patients. Interventions Used to Facilitate Activities a. Gait training, prefunctional activities, and transfer training activities were the most frequently addressed activities Gait activities were defined as activities focusing on skills needed for ambulation over level surfaces and stairs.
Interventions provided most frequently to address gait were balance training, postural awareness training, and motor learning included in Balance training was identified as intervention designed to help maintain the body in equilibrium with gravity both statically and dynamically. Postural awareness training was defined as an intervention designed to improve awareness of the alignment and position of the body in relationship to gravity, center of mass, and base of support.
Case studies in neurological physiotherapy | Musculoskeletal Key
Motor learning was defined as providing practice or experiences leading to change in the capability for producing skilled actions. Prefunctional activities were those determined to be in preparation for later functional activity or activities that physical therapists provided on behalf of the patient without necessarily having direct contact with the patient.
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In all sessions that addressed prefunctional activities, the interventions most frequently provided were strengthening exercises, balance training, and motor learning included in Strengthening exercises were described as interventions where muscular contractions were resisted by an outside force applied manually or mechanically.
Transfer activities were defined as activities focusing on relocating the body from one surface to another. The interventions most frequently provided to address transfer ability were balance training, postural awareness training, and motor learning included in Equipment was used most commonly during gait activities and included 4-wheeled walker, ankle-foot orthosis AFO , and straight cane included in Patient and caregiver education was most frequently included during transfer activities, advanced gait activities, and community mobility activities.
To our knowledge, this study is the first to describe physical therapist management of patients with stroke in terms of specific interventions provided during an episode of care in multiple inpatient rehabilitation settings in the United States. Over the past 30 years, the literature on physical therapy interventions for patients with stroke has described these interventions largely in a nonspecific and qualitative manner.
The finding that some interventions described in our study have been used in stroke rehabilitation for the past 30 years is not surprising because the basic armamentaria of physical therapists have not changed dramatically and the focus of care continues to be directed toward reducing impairments and facilitating function or adaptation to impairments. In our study, physical therapists identified and defined interventions that they used in practice and could choose up to 5 different interventions to describe their approach to an activity. Other generic interventions, such as balance training, postural awareness, and motor learning interventions, however, were selected more often.
The fact that the physical therapists in our study infrequently chose techniques such as PNF during their sessions with patients provides evidence of this shift in therapeutic approach to management of patients with stroke.
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The results suggest, however, that advances in scientific theories of motor control and motor learning may have had an influence on physical therapist practice. The results of our study indicate that functional activities are a focus for physical therapist practice in stroke rehabilitation. That is, the majority of physical therapy session time was spent in functional activities. We also observed that many procedural interventions were integrated into more than one functional activity.
Therapists used interventions to address a range of impairments in the context of functional activities. For example, the following procedural interventions were incorporated into transfer activities: balance training, postural awareness, motor learning, NDT, upper-limb activities, strengthening, motor control, cognitive training, and perceptual training. Thus, an approach in which functional training and neurofacilitation were separate activities 19 seems to have been replaced by functional training that incorporates a multidimensional approach.
An approach to neurorehabilitation focused on functional activities, as advocated by Carr and Shepherd, 20 disseminated via the proceedings of the II-STEP Conference in , 21 , 22 and interpreted by Shumway-Cook and Woollacott, 18 seems to have been adopted by physical therapists involved in stroke rehabilitation.
A Simplified Guide To Physical Therapy For Strokes
They further recommended that gait re-education be offered, although no specific techniques could be recommended on the basis of evidence. Duncan et al 23 reported that adherence to AHCPR guidelines was associated with improved functional outcomes in patients. The recommendations from both sets of guidelines are broad and recognize the patient's impairments as important factors in determining the appropriate approach to intervention. If the 3 approaches to intervention suggested in the AHCPR guidelines are valid, however, our findings indicate that therapists use all 3 approaches in their care of patients.
An approach to care that includes several activities at each session is consistent with findings related to care provided by physical therapists to patients with musculoskeletal conditions. In our study, motor learning interventions were defined by consensus among the participating therapists as targeting impairments in the neuromuscular system and providing practice or an experience leading to change in the capability for producing skilled action. Motor control interventions were defined as targeting impairments in the musculoskeletal system and encouraging purposeful movement and postural adjustment by selective allocation of muscle tension across joint segments.
Some people might argue that the definitions of motor control and motor learning are inadequate because they could define the basis for many types of interventions such NDT or wheelchair mobility.
Because a therapist in our study could identify up to 5 types of interventions for each activity, motor control, motor learning, and NDT, for example, could have been selected to describe a therapist's approach to facilitating an activity with a patient. The literature supports the fact that a lack of a conceptually sound, theory-driven system for classifying interventions is a problem that limits advances in the understanding of rehabilitation in stroke.
A remediation approach also might include the use of modalities such as biofeedback or functional electrical stimulation. Despite some evidence suggesting the efficacy of electromyographic biofeedback 26 , 27 and functional electrical stimulation 28 , 29 in stroke rehabilitation, these interventions, which were first introduced in the late s, are not supported by the guidelines and appear not to have been adopted widely by therapists in our study.
Recently, there has been interest in 2 new approaches to stroke rehabilitation that might be considered to represent a remediation approach to intervention. These approaches include constraint-induced movement therapy, extensive practice for involved upper-limb rehabilitation, 17 and weight-supported gait training. In some patients, this activity may involve teaching the patient a compensatory strategy for safely moving from surface to surface.
Interestingly, in patients with stroke, the greatest functional impairment as well as the greatest improvement has been shown to be in locomotion and transfer ability. The focus on gait training also is supported by the RCP guidelines. At first glance, this finding does not appear consistent with either set of guidelines. In our opinion, however, teaching the family can often be accomplished in relatively few sessions, and we would not expect family members to be present during most sessions. Education of patients and families in our study tended to be most prevalent in addressing high-level advanced gait and community mobility and low-level transfers activities.
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Took up walking 3 Years ago following Dx Prediabetes. Walks 5 - 6 days per week for between 30 - 45 mins. Social Beer Drinker 10 - 15 Standard Drinks per week with 3 - 4 per session, although sometimes after Golf may be more.