Treatment Approaches for Activity-Based Tasks

Treatment Approaches for Activity-Based Tasks

Introduction

• This lecture focuses on management strategies for activity or functional assessment tasks.
• Specific tasks include bed mobility, transfers, sitting, and standing balance.
• Essential readings are required for theoretical understanding, which is not covered in this lecture.
• Remember the principles of RAMP (restore, adapt, maintain, and prevent).

Key Principles

• Focus: Primarily restoring or adapting function.
• Neuroplasticity: Task-specific and repetitive practice.
• Dosage: Repetitions are essential, but so is "repetition without repetition" (variety to maintain motivation).
• Clinical Reasoning: Determine contributing impairments by analyzing normal movement patterns versus the patient's ability.
• Challenge Level: Choose an appropriate challenge level that is motivating but not unsafe.
• Holistic Approach: Treat contributing impairments as well as functional/activity considerations, considering patient goals for person-centered care.

Motor Learning Principles

• Feedback: Providing appropriate feedback is crucial.
• Hierarchy: Patients need to achieve certain levels before progressing:
  • Sitting balance before sit-to-stand.
  • Standing balance before stepping and walking.
• Equipment: Gantries and sling lifters are for assessment, not therapeutic practice.

Progression of Therapy

1. Bed Mobility: Including rolling, bridging, and moving side to side.
2. Lie to Sit: Transitioning from lying down to sitting.
3. Sitting Balance: Maintaining balance while seated.
4. Transfers: Less dependent to more independent transfers (e.g., slide board or pivot transfers).
5. Sit to Stand: Using a lifter initially, then progressing to without a lifter.
6. Standing Balance: Maintaining balance while standing.
7. Stand Pivot/Step Transfers: Transfers involving standing and pivoting or stepping.
8. Walking and Gait Training: Addressed in a later lecture.

Bed Mobility

• Specific Impairments: Address deficits in active range of motion (AROM) for hip and knee flexion, and strength in lower limb, trunk, or upper limb.
• Equipment: Use slide sheets, rails, cotsides, bed sticks or poles, and triangles.
• Exercise: Typically bed or plinth-based for dependent patients.
• Functional Practice: Complete full task practice rather than part practice.
• Assisted Practice: Verbal cueing, stabilizing feet, assisting hips and pelvis for bridging, and facilitated rolling practice.
• Therapy Focus: Impairment-based strengthening and AROM, addressing length or tone, providing equipment, or functional task practice.

Slide Sheet Technique

• Two-person assist using a slide sheet to move a patient up in bed.
• Communicate the movement plan to the client and gain consent.
• Ensure the bed breaks are on and the bed height is appropriate.
• Technique:
  • Roll the patient to one side.
  • Place the slide sheet underneath.
  • Roll the patient back.
  • Move the patient up the bed.
  • Use flat hands and avoid grabbing during manual handling.
  • Ensure clear communication between workers and a lead therapist.
  • Prioritize patient safety and reassurance.
• Instruct patient to cross arms, slide knees up, push through legs, and raise head on the count of three.
• Use legs to lift, bend knees, and maintain a low position.

Lie to Sit

• Method: Focus on the roll and tip to sit method.
• Retraining: Repeated practice with graduated verbal cueing (bending knee, placing hand across, pushing with leg, rolling, and tipping up).
• Movement Analysis: Identify why the patient completes the movement differently or cannot complete it.
• Factors: Deficits in hip and knee flexion, unilateral deficits (affected vs. unaffected leg).
• Impairment Therapy: Target deficits like trunk weakness using trunk impairment scale activities and core exercises.
• Upper Limb Strength: Consider upper limb strength for pushing up.
• Equipment: Bed pole to assist, but aim to wean patients off it.
• Full Movement Practice: Practically completed as a full movement task.

Management of Sitting Balance

• Goal: Achieving and maintaining independent static sitting.
• Technique: Two-person assist, with one therapist at the front and one at the back.
• Interval Training: Short bursts of attempted sitting with verbal and manual facilitation.
• Feedback: Use a mirror for visual feedback, verbal feedback, or force plates and computer games for additional feedback.
• Focus: Orientation to midline, achieved in short bursts with perturbations or reaching.
• Progression: Prop and support initially, then unweight arms and add head turning. Progress to perturbations and reaching outside the base of support.
• Challenges: Use faster, unexpected movements, and change the sitting surface or foot position. Also consider vision occlusion.
• Impairment Training: Address strength-based training in the affected leg, hip, and trunk.

Video: Management of Sitting Balance

• Need postural control, motor control, and perceptual ability (eyes, vestibular system, sensory systems).
• Hierarchy of challenge: Grade up or down.
• Base of support: Feet, bottom, and thighs on the plinth.
• Static sitting balance: Time it.
• Dynamic sitting balance: Reaching, perturbations, eye movements, head movements.
• Progression:
  • Close eyes.
  • Look side to side, up and down.
  • Turn head while fixating on a finger.
  • Catch and throw a ball or balloon.
  • Ensure trunk movement.
• Change base of support:
  • Unweight one foot.
  • March in sitting.
• Stability of base of support:
  • Use a disc or foam.
  • Pelvic tilting.
• High-level tasks:
  • TheraBand exercises.
  • Trunk twists.
• Supporting patients with no sitting ability:
  • Facilitate trunk and pelvis.
  • Use key points of control (sternum, thoracic/lumbar spine, pelvis).
  • Practice letting go and re-engaging.

Management of Sit to Stand to Sit

• Movement Analysis: Slow speeds of movement and muscle activation may be challenging.
• Muscle Weakness: Lower limbs, pelvis, trunk, tibialis anterior, hamstrings, quadriceps, and soleus are important.
• Coordination: Requires coordinated hip, knee, ankle, and trunk movement.
• Stability: Both anterior-posterior and lateral stability.
• Balance: Ability to grade muscle responses to control the movement.
• Weight Bearing: Uneven weight bearing between left and right sides is common in stroke patients.
• Deficits: Perception of orientation to midline, somatosensory and perceptual deficits, lack of good foot placement, reliance on upper limbs, deficits of trunk control, and fear.
• Clinical Reasoning: Determine contributing factors.

Management Strategies

• Setup: Bottom forward in the chair, feet back, trunk forward.
• Management Strategies: Bottom shuffle technique, bunny hop option.
• Trunk Control: Facilitate practice in safe ways to gain confidence.
• Extension Phase: Range of movement and strength of hip and knee, controlled plantar flexion, hip and trunk extension.
• Upper Limb Reliance: Address lower limb strength or balance issues.
• Weight Bearing Symmetry: Use a split stance or put one foot on a small step or foam.
• Feedback: Mirror, force plates, video games.

Video: Management of Sit to Stand

• Setup: Plinth, chair, rails.
• Strategies:
  • Practice pulling up on a rail.
  • Block the knee.
  • Tricep push-ups on the armrest.
  • Stand lifter with loosened straps.
  • Practice quarter squats.
  • Gym ball for trunk lean.
  • Hugging patient to move bottom forward.
  • Functional practice with assistance.

Management of Bed to Chair to Bed Transfers

• Patients work on sit to stand and standing balance, using slide board transfers and pivot transfers.

Slide Board Transfers

• Sitting balance, trunk, and upper limb work are essential.
• Practice moving up and down along the side of the plinth.
• Analyze contributing impairments.
• Motor planning, upper/lower limb strength, and fear need to be addressed.
• Educate on completing the transfer, including wheelchair setup, board placement, foot position, leaning forward, propping, and lifting.
• Focus: Full task practice and addressing impairments.

Pivot Transfers

• Completed as full task practice, considering contributing impairments.

Management of Standing Balance

• Principles: Similar to sitting balance, using vision, somatosensory, and vestibular input.
• Priority: Achieve and maintain independent static standing balance and midline.
• Dependent Patients: Two-person assist with support.
• Midline Orientation: Focus on equal weight bearing, knee control, weight shift, and unweighting of the upper limb.
• Progression: Resistance from perturbations, reaching and movement outside the base of support.
• Challenges: Vision occlusion, distorted vision, chaotic backgrounds, eye movement, head movement, surface variation, dynamic movements.

Video: Standing Balance Management

• Postural Control: Eyes, ears, sensory systems.
• Variables to Manipulate: Vision, vestibular, proprioceptive.
• Need muscle strength, motor control, and perceptual abilities.
• Hierarchy of Exercises: Easier exercises for more severe deficits, harder exercises for more capable patients.
• Safety: Plinth, chair, wheelchair.
• Options: Eyes open vs. eyes closed; head moving.
• Base of Support: Feet apart, feet together, one foot forward.
• Surface: Foam.
• Progression Examples:
  • Support knee and remove hand from plinth.
  • Weight shift.
  • Catch and throw ball/balloon.

Management of Step Transfers

• Analysis of what they are doing to determine the contributing factors.
• Usually completed as complete task practice, addressing impairments like somatosensory deficits, strength, and balance.
• Setup: Consider space and assistance for safety.
• Walking Gantries: Used to progress walking transfers safely.