STARES #3: Treatment

STARES #3
Treatment
SITUATION
My patient, Miss A, was a 36year old lady admitted to Shenton Park Hospital for rehabilitation following a decline in function associated with an undiagnosed neurodegenerative condition. Her condition predominantly manifests in cerebellar ataxia and cognitive dysfunction. Miss A previously lived at home alone but it is likely that because of her recent functional deterioration she may have to return to living with her parents.

The main findings from the initial objective examination were that Miss A was severely ataxic bilaterally in her upper limbs, lower limbs, head and trunk (left worse than right), presented with an intention tremor, had increased neural tone in both plantar flexors (left worse than right), slowed and ineffective balance reactions, moderate dysarthria and was very impulsive. She also has very poor sitting and standing posture as a result of compensatory over-activity in her scapula retractors, trunk extensors and neck extensors. Furthermore, she severely fixes her upper limbs against her trunk and clenches her fingers when her balance is challenged.

She is independent with bed mobility, transferring from supine to sitting, sitting over the edge of bed and sit to stand. She requires 1x minimal assistance for standing balance and 1x moderate assistance for a step-stand transfer. She is currently non-ambulant on the ward but ambulates 20m with 2x moderate assistance in physiotherapy. Miss A’s goal is to be able to walk 10m independently and return home to her unit (rather than living with her parents).

TASK
My task with Miss A was to devise an initial treatment plan for this patient who’s primary impairment was cerebellar ataxia taking into account the other results of her objective assessment and her reduced cognitive function.

ACTION
Following a brief subjective examination I began implementing my treatment program for Miss A. My main focus for the treatment was to improve proximal stability of the trunk and pelvis, to allow a more stable base for movement of the limbs to occur from. Drawing on my prior knowledge of important features of exercises for ataxic patients I tried to ensure exercises were closed chain and incorporated specific targets and reference points, as well as continually emphasising the importance of slow and controlled movement.

I started the patient in crook lying, doing various abdominal and trunk strengthening exercises and then progressed to 4 point kneeling, and reaching in 4 point kneeling then maintain balance and correct alignment in 2 point kneeling. From 2 point kneeling I chose to include more functional exercises of sit to stand and standing balance, again emphasising the need for slow movement. The session was concluded with 2x assisted ambulation of roughly 40m.

Due to Miss A’s cognitive impairment and impulsiveness she required continual verbal prompting to minimise her rushing the exercises and using incorrect movement patterns.

RESULT
The result of this treatment for Miss A was that she did appear to have improved trunk control and was aware that she needed to concentrate on slow and controlled movement, requiring less verbal cues as the session progressed.
Although she may have had improved trunk control and subsequently better gait pattern, she definitely did still require 2x moderate assistance.

EVALUATION
On reflection, I think that overall my treatment plan was good however my implementation lacked a few essential clinical skills. In hindsight I realised that Miss A was fixing a lot through her scapula retractors and cervical extensors, which I didn’t pick up on at first as I expected to see her fixing via weight bearing with her upper limbs. She also fixed with her ULs against her trunk in every position she was in despite me changing her UL placement in an attempt to minimise this.

As a result of this I allowed the patient to move and perform exercises with incorrect movements, rather than enforcing error-free practice with correct timing as should be a priorty when treating ataxic patients. The incorrect movements were also influenced by her impulsiveness and tendency to rush movements and exercises.

I now realise that I should have started with my own formal postural assessment and included techniques aimed at relaxing the overactive muscles through her neck, thorax and upper limbs. Once that was completed I then should have started with the simplest postural control exercises in crook lying until she could perform them satisfactorily and then progress, rather than continuing to progress exercises with poor and incorrect recruitment.

STRATEGIES
Strategies I used to improve my subsequent treatment sessions with Miss A were revising my musculoskeletal lab manuals and text books to gain ideas about different muscle relaxation techniques. I also asked my supervisor whether she could direct me to any good references on reducing muscle overactivity or give me any techniques she used and found effective.

I also reviewed my neurorehabilitation texts and course material to get further insight into management techniques of ataxic and impulsive/cognitively impaired patients.

From this research I came across methods to minimize fixations in ataxic patients which included making the patient feel safe, using reference points and targets to improve quality of movement as well as emphasising error-free practice with correct timing.