Navigating Operational Challenges

Introduction

A stroke rehabilitation setting is an essential part of patient’s recovery after a stroke episode. The main goal of stroke rehabilitation is to assist the stroke patients to relearn skills lost as a result of damage to their brain cells. Thus, ensuring that patient’s quality of life is improved, and affected stroke patients regain mobility without depending on family members or carers. They are many approaches to stroke rehabilitations. Some of these approaches used by health practitioners include mobility training, motor-skill exercises, communication disorder therapies, cognitive disorder therapies etc. They are varieties of health specialist that make up the multiple disciplinary teams (MDT) of a stroke rehabilitation setting. MDT that is involved in the functional needs/recovery of patients includes physicians, occupational therapist, qualified/advanced physiotherapist, rehabilitation nurses, social workers, speech and language therapist. It is important to highlight that duration of time, a patient spend in a stroke rehabilitation setting is dependent on the severity and related complications of their stroke. The practitioner sets goal according to the time framed i.e. short goal, medium goal or long goal to defined patient’s improvement and finally to reassess patient’s progress (van de Port, et al, 2012). Although, treatment plan is prone to change as the patients recovers and relearn the lost skills. This essay will look at a patient named Mr. Watson, a pseudonym is assigned according to the General Data Protection Rule (GDPR, 2018) who was under the supervision of a qualified/advanced physiotherapist and experts in neurological complication treatments. Mr. Watson was seen in a stroke rehabilitation setting by a student physiotherapist. This essay will discuss the general overview of the patient, alongside the patients presenting symptoms, patients’ brief assessment and the recommendation regarding decisions. Additionally, this essay will discuss the rationale for choosing the essential neurological physiotherapies intervention based on suitable evidences provided.

Case Study:

Mr. Watson, a 52-year-old male got admitted to the accident and emergency department (A&E) after he unexpectedly collapsed at home. Mr. Watson was said to have experienced severe headache while performing DIY at home and then collapsed within few minutes. Ambulance was called immediately, and he was admitted to the hospital. Upon arrival to the hospital, diagnostic assessment such as CT scan, angiogram, blood pressure (BP) measurement were conducted before he was transferred to the neurosurgical unit where the emergency coiling course of action was done. After the successful completion of his surgery he was transferred to the Intensive Care Unit and Neurosurgical High Definition Unit where he spent 3-days and 6-days, subsequently. Afterwards, Mr. Watson was recommended to a neurological rehabilitation unit for follow-up and close monitoring for any association in elevated risk of re-occurring bleeding during the sub-acute phase of his stroke (Langhammer, et al, 2011). The medical findings from the CT scan and angiogram conducted on the Mr. Watson reported that the patient had suffered Sub-Arachnoid Haemorrhage (SAH) of the left Anterior Cerebral Artery (ACA) as a result of the ruptured berry aneurysm on the ACA. His BP was found to be 220/113 mm/Hg. Previous medical history indicates the patient had a premedical history of hypertension which has been managed with medication for years until his recent lack of adherence to his medication. The patient confirmed that the lack of medication adherence was as a result of work-related stress. Mr. Watson social background history revealed that he lived with his wife and their child at home, he consumed alcohol about 40 units per week. The current problem of the patient was gait disturbance which was the inability of patient to walk and stand without aid thus, resulting to reduced mobility (Langhammer, et al, 2011). Therefore, the patient was referred to the stroke rehabilitation setting for neurological physiotherapy. The fundamental focal point of his referral was to assist the patient to figure out and relearn how to utilize the two sides of his body again. As well as recapture the physical strength and mobility that he had lost as a result of his stroke. This aspect of physiotherapy empowers individuals to relearn lost capacities, recover autonomy as well as reduces the recurrence of future stroke and improve in post-stroke mobility (van de Port, et al, 2012; Langhammer, et al, 2011).

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Critical Analysis of one Treatment/ management plan A description of the treatment / management plan

As evident a stroke may influence various territories of our body. Basic areas which can be upgraded through Neurological Physiotherapy include the following:

  • Improving strolling
  • Improving arm and hand work after Stroke
  • Decreasing post-stroke shoulder torment from shoulder flimsiness or shortcoming
  • Improving mobility with the application of foot dragging
  • Diminishing spasticity in appendages and muscles
  • Focussing on frail and spastic muscles
  • Reinstructing patterns of movement through natural and technological interventions, for example,

Functional Electrical Stimulation (FES), Saebo items, Mirror treatment (Tyson, et al, 2009; Eum, et al, 2013). The patient was observed with Kyphotic posture while sitting and also with reduced lumbar lordosis. The static sitting balance was good and was also able to endure challenges with regard to balance and the efficacy in recruiting stability reactions. The dynamic sitting balance showed difficulties in recruiting the right hip without any support at the base. No significant evidence of increased tone was observed in the posture of sitting although there was a tendency to use the left lower part of limb along with moderate weakness in the right upper limb without any tonal changes (Asai, et al, 2017). The patient was also able to correct dynamic sitting balance with the help of verbal messages, however exhausted rapidly. In the standing position, the weight bearing capacity of the left side was greater in comparison to the right side with the retraction of the right portion of hip, right knee hyper extended and plantarflexion of the right ankle. With assistance to expand right hip, the patient had the option to move weight to one side, however whined with the dread of falling (Langhammer, et al, 2011). As the patient was suffering from moderate weakness in the upper limb and muscle weakness, physiotherapy was recommended as per the NICE guidelines to regain the lost functions and movement ability (NICE, 2013). Progressive resistance exercise was also recommended to the patient for effective strength training. Most of the training offered influenced multiple areas such as posture, balance, motor learning, strengthening activities of upper limb and cognitive or perceptual training. In our practice the patient received the degree of therapy that they could tolerate as per the RCP guidelines (López-Miñarro, 2011). Therefore as recommended in the NICE guidelines he was assisted with trunk control, sitting balance, sit to stand independently, saggital balance, pelvic mobility, hand and wrist splint to increase the grasping capability, electrical stimulation, walking training along with AFO for 45 minutes for 5 days as per the seven days training programme. The repetitive tasks assisted him with recapturing mobility and relearning the ordinary activities (NICE, 2013). It was suggested to him to continue the treatment until he could keep up or progress work either autonomously or with help from others.

Evidence of development of clinical knowledge

A haemorrhagic stroke is the condition of bleeding into or around the cerebrum. Such strokes represent roughly 20 % all cases considered (Fujimoto, et al, 2012). It is also referred as Intracerebral Hemorrhage or Subarachnoid Hemorrhage. The cells of brain die when they no longer get oxygen and supplements from the blood (the condition is known as Ischemic Stroke) or when they are harmed by abrupt bleeding into or around the cerebrum (the condition is referred as Haemorrhagic Stroke). At the point when blood supply to the cerebrum is interfered with, some cells die, while others faces the danger of death (Fujimoto, et al, 2012). Around then, PhysioFunction's profoundly specific neurological physiotherapists can convey custom-made stroke recovery programs. Postural kyphosis, or "round back", is the after effect of poor stance (Asai, et al, 2017). Postural kyphosis is regularly joined by "hyper lordosis" of the lumbar (lower) spine. It is clear based on scientific evidences that, stroke patients cannot satisfactorily contract the hip when the extensor muscles of trunk are constricted. Moreover, it is hard to keep up the trunk in a perpendicular position when the patient is in a seating position because of the inadequacy of the stomach muscles (López-Miñarro, et al, 2011). In this manner, when stroke patients endeavour to perform the sit-to-stand development, with a retroverted pelvis and kyphotic trunk, the standing up activity is influenced because of the inadequacy of pelvic anteversion and extension of trunk. However, the recuperation of sitting parity is regularly thought to be fundamental for acquiring autonomy in other crucial activities, for example, sit-to-stand, coming to and seating down (Verheyden, et al, 2014; Ferrarello, et al, 2011). The early evaluation and management of the control of trunk should be underlined after stroke (López-Miñarro, et al, 2011). Numerous researchers have proposed that the trunk control or sitting parity in the initial stage of stroke patients, can anticipate a late stage exercises of the day to day living (Wajngarten, et al, 2019; Asai, et al, 2017, Fujimoto, et al, 2012). The sit-to-stand task should be performed more often and this capacity is viewed as an essential for upright mobility and for performing other significant day by day exercises, for example, movement from one place to another (Wajngarten, et al, 2019). The sit-to-stand development symbolizes a frequent functional moving of body that should be polished in the beginning time of recovery (Asai, et al, 2017). The sacral sitting stance, which is a trademark stance of patients suffered from strokes, isn't perfect for easily executing the sit-to-stand development. Patients suffered from strokes may embrace this stance because of the need to build sitting stability. These patients possess less solidness in the sitting situation in contrast to age-coordinated sound subjects. The purpose behind this is clarified in various reports. Among patients who suffered from strokes, the movement of the rectus abdominis and latissimus dorsi muscles on the influenced side of the body is decreased and postponed in contrast with both the unaffected side and control subjects (Fujimoto, et al, 2012). Also, the temporal synchronization between the relatable muscular pairs in stroke patients is lower in contrast with sound subjects (Verheyden, et al, 2014). Therefore, the accompanying elements can likewise be viewed in regard to the sitting position: initially, stroke patients can't flex enough the hip when the extensor muscles of trunk are contracted; also, it is hard to keep up the trunk in a vertical position when the subject is seated because of the deficiency of the muscles of abdomen (Wajngarten, et al, 2019). In this way, when stroke patients endeavour to play out the sit-to-stand development with a retroverted pelvis and kyphotic trunk, the standing up activity is influenced because of the inadequacy of pelvic anteversion and extension of trunk. Moreover, Ferrarello et al. recommended that decreased strength in the muscle and amplitude of trunk among stroke patients bring about decreased pelvic portability, evidently as a procedure to secure against a potential danger of loss of parity when coming to in the sitting position (Ferrarello, et al, 2011). Therefore, to execute the sit-to-stand development easily, the pelvis must be inclined forward to flex the hip joint, and the trunk must be flexed so as to: (1) utilize the hip expansion time; (2) diminish the extension time of knee; and (3) venture the focal point of gravity inside the base of help (Fujimoto, et al, 2012; López-Miñarro, et al, 2011). Pelvic mobility is considered to be a significant job in the sit-to-stand development among stroke patients and also older individuals. Another important consideration is keeping up sagittal balance is critical to both sitting and standing. Sagittal balance, or "neutral upright sagittal spinal alignment," is a postural objective of ergonomic, surgical and physiotherapeutic intercession (Ferrarello, et al, 2011). Kyphotic bend and flow of the spine adversely impacts the personal satisfaction (QOL) in post stroke patients and old individuals (López-Miñarro, et al, 2011). In this aspect, another author López-Miñarro et al. detailed that the sagittal balance was very much kept up in subjects who had both a decent thoracic range of motion (ROM) and great lumbar ROM and strength in back muscle, which demonstrates that these elements are likewise related in keeping up sagittal parity (Ferrarello, et al, 2011; López-Miñarro, et al, 2011). Although the level of lumbar lordosis during sitting position has weak association with age, it was not seen to be influenced by the way of life, the degree of physical exercise, or by the work life of the person (Park, et al, 2013). -

Use of a relevant clinical guideline to the condition .

  • Physiotherapy was offered as he had shortcoming in their trunk or upper or lower appendage, distribution in the transmission of sensory information or parity troubles after stroke that affect work.
  • As the patient had difficulties associated with movements after stroke he was treated by physiotherapists who have the important aptitudes for preparing the analysis and evaluation.
  • Treatment after stroke was continued until the individual can keep up or progress work either autonomously or with help from others (for instance, recovery associates, relatives, carers or health specialists) (NICE, 2013).

Strength training

  • Strength training was considered for him due to muscle weakness after stroke. This incorporated dynamic building of strength through increasing reiterations of body weight exercises (for instance, sit-to-stand redundancies), loads (for instance, dynamic resistance exercises), or on machines, for example, stationary cycles (NICE, 2013).

Hand and Arm Therapies

As the patient had shortcoming in the upper appendage he was not offered with wrist and hand splints after stroke. As wrist and hand splints was considered for the upper appendage shortcoming for people who are at risk after the stroke. Joint range, delicate tissue length and arrangement were kept up. Delicate tissue length and reactive scope of movement was expanded. Functioning was encouraged (for instance, a hand splint to help grasp or capacity) (NICE, 2013).

Electrical Stimulation

A preliminary of electrical incitement was considered as he had proof of muscle constriction after stroke however could not move his arm against resistance. Electrical incitement treatment was guided by a certified recovery professional. It was done to improve strength while rehearsing functional activities with regards to a far reaching stroke restoration program (NICE, 2013).

Walking Therapies:

Walking training was also offered to him as he was unable to walk without assistance. Similarly as per the guidance Ankle Foot Orthoses (AFO) was also applied based on the relief experienced, ease during strolling and speed (NICE, 2013). NICE suggests at least 45 minutes of therapy for five days for a period of seven days as a major aspect of seven day specialist stroke recovery training. High intensity therapy is expected to relearn lost capacities. Recovery should proceed for whatever length of time that the individual is indicating benefit by the treatment in terms of accomplishment their concurred objectives. Access to community restoration services should be adaptable to help longer term needs. After 24 hours of stroke, physiotherapists should start recovery programs in short continuous spells, concentrated on getting up, standing and strolling. This repetitive task assists individuals with recapturing mobility and relearning ordinary activities. Virtual reality programme might be valuable along with normal consideration however should not be replacing the standard treatment procedures (NICE, 2013).

CSP competency framework

The CSP's Physiotherapy Framework is an asset intended to advance and create physiotherapy practice. The Physiotherapy Framework characterizes and portrays the practices and supporting qualities, information and abilities required for contemporary physiotherapy practice:

  • At all levels - from a help specialist through to a senior level enlisted physiotherapist
  • Over an assortment of work related jobs - clinical, instructive, administration, administrative, research and backing
  • In an assortment of settings - wellbeing and social consideration, industry and working environments, training and improvement, and in look into research conditions over every one of the four countries of the UK (CSP Framework, 2013).

The psycho-motor knowledge utilized by the physiotherapy personnel to apply specific physiotherapy- practice skills is most relevant to their practice. Without physiotherapy values and information, the explicit practice aptitudes and development, the manual treatment, electro-physical modalities and the other physical methodologies remains simply as a physical strategy. The physiotherapy workforce likewise utilizes functional aptitudes/methods, for example, First Aid or Manual Handling that are imparted to different gatherings of staff that work in the wellbeing and prosperity economy. Similarly as with information, a person's expertise base will progress with their encounters and setting of training, yet experts must exhibit their abilities, identifying with practices and their individual extent of training. The Physiotherapy Practice Skills are: Imparting, helping other people learn and to create, management of self as well as other people, advancing coordination and collaboration, putting the individual at the focal point of training, regarding and advancing decent diversity (CSP Framework, 2013).

Benefits and Limitations of the Plan of Care

As the patient was suffering from moderate weakness in the upper limb and muscle weakness, physiotherapy was recommended as per the NICE guidelines to regain the lost functions and movement ability (NICE, 2013). Progressive resistance exercise was also recommended to the patient for effective strength training. Most of the training offered influenced multiple areas such as posture, balance, motor learning, strengthening activities of upper limb and cognitive or perceptual training. In our practice the patient received the degree of therapy that they can tolerate as per the RCP guidelines (Ntamo, et al, 2013). Electrochemical gait training was not offered as it is still subjective to research for application (NICE, 2013). The knowledge of family members is considered to be relatively poor and it was also not possible to include them in all sessions. But after discharge the patient will require input from their carers the most during these activities (Ntamo, et al, 2013).

External Factors that might have affected the treatment

The management of BP is very crucial for stroke patients and it requires accurate diagnosis. The tolerance of the patient was another crucial factor depending on which the number of sessions provided was evaluated. The funding and the availability of special room for the activities might have affected the regime.

Reflection on Management Plan

As my patient had suffered from sub-arachnoid haemorrhage of the left anterior cerebral artery and ruptured berry aneurysm it affected the sitting posture, muscle strength, dynamic sitting balance and capability of movement due to gait disturbances. Therefore as recommended in the NICE guidelines I helped him with trunk control, sitting balance, sit to stand independently, saggital balance, pelvic mobility, hand and wrist splint to increase the grasping capability, electrical stimulation, walking training along with AFO was recommended to him for 45 minutes for 5 days as per the seven days training programme. The repetitive tasks assisted him with recapturing mobility and relearning the ordinary activities (NICE, 2013). According to my practice guidelines I suggested him to continue the treatment until he can keep up or progress work either autonomously or with help from others. According to the CSP competence framework, I enquired the patient about his difficulties tried to understand his emotions in an empathetic way and provided strength and confidence to him throughout the process. I also educated the carers and the family members of the patient about the various therapies and the significance of it (CSP Framework, 2013). I could understand that the patient suffered from this clinical condition specifically due to the forgetfulness of taking the medication related to hypertension as it is the most prevalent risk factor for stroke. So I also informed the patient and his family members about the importance of the antihypertensive medications prescribed to him related to prevention of further strokes due to hypertension. The management of BP is very crucial for stroke patients and it requires accurate diagnosis. As evident from a scientific study about 64% of strokes are reported due to hypertension and emergeny conditions due to hypertension arise if BP is above 180/120 mm of Hg (Wajngarten, et al, 2019). Throughout the process, I evaluated my interventions and enquired myself if anything else could be done for him. I also read through many scientific papers which guided me about the relevant interventions appropriate for his conditions and also raised my confidence. I discussed my management plan with my senior and neuro specialist for any possible recommendations and guidance at the time of crisis. I observed that he was showing improvement with day by day practice though getting tired very often. I could feel that the patient was feeling helpless about his present conditions as he was unable to move or perform any activities without assistance like before, therefore I constantly assured him that the interventions recommended for him based on his conditions would help him to restore his initial strength with practice.

Conclusion

The study provided a detailed analysis of the advanced neurological physiotherapy plan of care for a stroke patient according to the guidelines and framework adopted for physiotherapy practice.

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References:

Asai, H., 2017. Pelvic Movement in Aging Individuals and Stroke Patients. Clinical Physical Therapy, p.41. Chartered Society of Physiotherapy, Physiotherapy Framework, 2013. https://www.csp.org.uk/system/files/documents/2018-06/csp_physiotherapy_framework_condensed_2013.pdf (Accessed on 31/03/2020). Eum, R., Leveille, S.G., Kiely, D.K., Kiel, D.P., Samelson, E.J. and Bean, J.F., 2013. Is kyphosis related to mobility, balance and disability?. American journal of physical medicine & rehabilitation/Association of Academic Physiatrists, 92(11), p.980. Ferrarello, F., Baccini, M., Rinaldi, L.A., Cavallini, M.C., Mossello, E., Masotti, G., Marchionni, N. and Di Bari, M., 2011. Efficacy of physiotherapy interventions late after stroke: a meta-analysis. Journal of Neurology, Neurosurgery & Psychiatry, 82(2), pp.136-143. Information Commissioner’s Office. 2018. Guide to the General Data Protection Regulation (GDPR). (Online). Available at: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/ [Accessed on 31/03/2020]. Langhammer, B. and Stanghelle, J.K., 2011. Can physiotherapy after stroke based on the Bobath concept result in improved quality of movement compared to the motor relearning programme. Physiotherapy Research International, 16(2), pp.69-80. López-Miñarro, P., Muyor, J. and Alacid, F., 2011. Sagittal spinal and pelvic postures of highly-trained young canoeists. Journal of Human Kinetics, 29(1), pp.41-48. McGlinchey, M.P. and Davenport, S., 2015. Exploring the decision-making process in the delivery of physiotherapy in a stroke unit. Disability and rehabilitation, 37(14), pp.1277-1284. National Institute for Clinical Excellence NICE impact stroke, 2019. https://www.nice.org.uk/Media/Default/About/what-we-do/Into-practice/measuring-uptake/NICE-Impact-stroke.pdf (Accessed on 31/03/2020). National Institute for Clinical Excellence, NICE Stroke rehabilitation in adults 2013, Clinical guideline [CG162]. https://www.nice.org.uk/guidance/cg162/chapter/1-Recommendations#movement [Accessed on 31/03/2020]. Ntamo, N.P., Buso, D. and Longo-Mbenza, B., 2013. Factors affecting poor attendance for outpatient physiotherapy by patients discharged from Mthatha general hospital with a stroke. South African Journal of Physiotherapy, 69(3), pp.13-18. Park, S.K., Yang, D.J., Kang, J.I., Lee, J.H. and Yoon, J.H., 2013. Biomechanical analysis of sitting up from a lying posture in stroke patients. Journal of Korean Physical Therapy, 25(2), pp.103-109. Tyson, S.F., Connell, L.A., Lennon, S. and Busse, M.E., 2009. What treatment packages do UK physiotherapists use to treat postural control and mobility problems after stroke?. Disability and rehabilitation, 31(18), pp.1494-1500. van de Port, I.G., Wevers, L.E., Lindeman, E. and Kwakkel, G., 2012. Effects of circuit training as alternative to usual physiotherapy after stroke: randomised controlled trial. Bmj, 344, p.e2672. Verheyden, G., Ruesen, C., Gorissen, M., Brumby, V., Moran, R., Burnett, M. and Ashburn, A., 2014. Postural alignment is altered in people with chronic stroke and related to motor and functional performance. Journal of Neurologic Physical Therapy, 38(4), pp.239-245.


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