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help needed w/stroke patient
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help needed w/stroke patient - May 7, 2000 6:21:00 PM
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yankeept
Posts: 44
Joined: October 29, 1999
From: Ft Lauderdale, FL
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I'm seeing a 85 y.o. female s/p "mild" stroke about 3 weeks ago. Prior to infarct she lived alone & was totally indep in her ADLs. MRI reports right lacunar infarct supplying the thalamus.
According to acute care reports, initially she had very little movement in LLE/LUE. When I performed my examination at the rehab facility, she had 4-5/5 strength in all extremities. Sensation/proprioception is intact throughout. She has a functional slight left neglect(bumping into objects) & depth perception difficulties.
The problem I have is that her balance stinks. Initially I thought it was weakness in her trunk, so I focused treatment on that problem. However, she is able to go from supine to long sit without using her hands, so I now assume her abs are strong enough.
In standing, at times she is unable to maintain a static standing position w/o losing her balance. She often falls backwards, both to the left & right. She is able to maintain a static quadriped position, but will quickly lose her balance if she tries to lift any extremity. In tall kneeling, she has trouble maintaining a static position, often losing her balance forward(to opposite of what I see in standing).
Keeping her eyes open or eyes closed shows no difference in function. She does not report any dizziness & has not shown any vestibular signs. The patient reports some visual changes in her ability to focus on objects since the stroke & has been seen by an eye doctor who has written a new perscription for the patient. The changes in perscription since the stroke does not help matters, but I feel it definitely is not responsible for what I'm seeing.
Any comments would be greatly appreciated.
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Re: help needed w/stroke patient - May 7, 2000 6:46:00 PM
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Dana D
Posts: 142
Joined: September 18, 1999
Status: offline
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Very interesting...
If you don't mind, a few questions came to mind:
What does she do to respond to a loss of balance? Do you note any type of ankle or hip strategies to try and regain her center of gravity? does she know she is losing her balance?
What are her protective responses like in response to falling?
Does she exhibit any tonal changes in her extremities?
If she exhibits left side neglect, would you think there could be some proprioceptive changes on that side as well?
How does she do with an assistive device while standing? to try and shift some of her weight in a more forward direction.... say with a walker (if her UE is functional in using a walker)
I'm curious to see what others have to say. Good luck [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
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Re: help needed w/stroke patient - May 7, 2000 6:59:00 PM
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Dana D
Posts: 142
Joined: September 18, 1999
Status: offline
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[URL=http://staff.ams.cmu.ac.th/html/todd/chapter2.htm]http://staff.ams.cmu.ac.th/html/todd/chapter2.htm[/URL]
interesting website
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Re: help needed w/stroke patient - May 11, 2000 4:51:00 AM
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yankeept
Posts: 44
Joined: October 29, 1999
From: Ft Lauderdale, FL
Status: offline
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Thanks so much for the replies. I've been on jury duty so I haven't been working with the patient & haven't had time to respond sooner.
To make a few points more clear. When I have the patient in standing without her shoes/socks on, I observed her using an ankle strategy to try to maintain her balance. When this is not enough, I feel the patient doesn't use a hip strategy then to maintain her balance. She knows she is losing her balance, but cannot do anything about it. The scary part is that she has no protective UE responses, meaning she would fall flat on her face if I let her. She tends to fall like a tree at times. She does not exhibit any changes in tone during tehse activities. She does reasonably well with a walker, although needing help secondary to the left neglect.
I need a little more time to digest what Bobcat said. However, the patient's balance varies quite a bit. When it's "good", she can maintain static standing on a level surfaces by herself. She can maintain this position against anticipated resistance. However, against unexpected resistance she will often lose her balance. Standing on any sort of foam will almost always result in a loss of balance.
Any comments regarding "treating" absence of hip strategy & loss of protective responses & possible decreased balance reactions.
I've had her sitting on a rocker board, which she does well with. When I progressed to a physioball, she can maintain a static position, but usually loses her balance with any dynamic activities.
Thanks again,
Brian
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Re: help needed w/stroke patient - May 11, 2000 8:19:00 PM
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Dana D
Posts: 142
Joined: September 18, 1999
Status: offline
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I know you had said that tall kneeling is difficult for her because she tends to fall forward... but maybe that is a place where you could spent some time practicing... Possibly try kneeling in front of her, holding hands, and giving her weight shifts (starting ant/post, then lateral) Or have her kneel and have her hands on a large ball in front of her, so she can weight shift herself forwards and backwards. This may help with some stability in her hips and help her adjust to weight shifting and movement at her hip area.
Just came to mind,(may apply to her, may not) but tall kneeling may be difficult if she has limitations in ROM at her ankles. If she has limited plantar flexion, this may pitch her weight forward while tall kneeling. If she is on a mat, try her with her feet hanging off the mat. (it's like trying to have a child tall kneel with orthotics on, won't be easy)
good luck~
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