Therapeutic Skills - Scenario 6

Therapeutic skills, Scenario 6 (T6)

Scenario 6
You are working on a medical ward. A patient has had a stroke with a flaccid left side hemiplegia. When you arrive the patient is lying unsupported in a poor postural position on their right side.

Using pillows/ towels and appropriate handling, demonstrate how you would position this patient so he/she is lying in a supported position on their right side. The patient is conscious but unable to help.
Using the philislides then turn the patient onto their left side.
From this side lying position, analyse the activity occurring at the shoulder girdle/ shoulder complex, as the patient is encouraged to pick up a tissue from the bedside locker.

What is a stroke?
- Something that causes bleeding in the brain
- Lack of oxygen to the brain
- Happens in one side of the brain, but affects the opposite side of the body
- Infarct = blood clot
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Things to consider
- Speech affected?
- Consciousness
- Vision
- Continence
- Pressure sores (Tissue viability)
- Motor power / control
- Lack of sensation?
- If patient is paralysed, movement will be passive
- Reduced proprioception?
- Altered tone?
- Flaccid limbs? (Very floppy, decrease in tone; heavy)
Therapeutic Skill
Correct uniform?;
Correct footwear?;
Remove all jewellery;
Wash hands;
Introduce yourself to patient;
View notes of patients previous assessment;
Question patient about any contraindications
- High blood pressure?
- Osteoporosis?
- Fungi or bacterial diseases?
- Has the area been recently fractured?
- Allergic to anything?
- Circulation ok?
- Other contraindications (skin disorders, early bruising, open wounds, varicose veins, DVT, abnormal body temp etc can be visually seen so do not need to be asked about)
Screening for dignity and privacy; professionalism;
Sensory tests. Ask patient of they can feel your touch on both their flaccid side and their fully functional side; pin prick and brush, hammer or heat, with the patients eyes closed (show them what to expect by doing it on their hand first, with eyes open)
Look at patients current posture;
Decide on action needed to take to ensure better postural alignment;
Tell the patient what you are going to do, even if the patient is unconscious it is important to maintain conversation;
Remember patient will have no postural control;
Ask patient for permission;
Position patient at the most appropriate side of the bed; to allow large surface area for support of limbs;
Start to change patients posture, starting with the head, then the shoulder, lower limb then upper limb;
Use pillows to support posture; so patient is fully supported;
Excess pillows may be needed; pillows may become squashed due to weight of limbs;
Tell patient you are about to begin, ask for permission again;
Support the head;
Bring the shoulder being rested on through, as it is much comfier forwards;
Encourage flaccid arm in an extended position; carefully supported with pillows;
Spread fingers as this protracts the shoulder;
Place pillow behind the shoulders;
Bring leg forwards slightly; so legs are not resting on each other; foot inverted;
Support with pillows;
Place pillows behind spine for support;
Ensure pelvis is posturally aligned with rest of the body;
Use extra pillows to maintain posture if necessary;
Ask patient if the posture is comfortable;
Maintain conversation with patient at all times;
Continue to ask patient if they are comfortable with movements and posture;
Check alignment again.
Rehabilitative Handling Scenario
After positioning patient, remove pillows;
Inform patient of next move;
Ask for permission to perform the move;
Place philislides appropriately under patient; head, hips and legs (rolled appropriately for ease of removal);
Allow assistant to support patients posture meanwhile;
Slowly pull the philislides one by one, allowing the assistant to support the patient while getting them to a prone lying position;
Have the patient lying in a prone position;
Ask the patient if the movement was ok;
Ask patient to turn head in direction you wish to place them, or move their head passively if the patient is not able to do so;
Take right arm across the body;
Bend leg at the knee, and place right ankle over the left leg; so legs are crossed;
Meanwhile the assistant is supporting the patient in anyway possible;
Slowly roll patient over onto flaccid side using philislides and help from the assistant;
Moving each philislide a little at a time to prevent tipping the patient over;
Allowing the assistant to support the patient to roll forwards;
Place patient in a stable position;
While the assistant is supporting this position, the physiotherapist can remove the philislides;
Re-position pillows for support, stability and postural alignment; (as explained previously);
Ensure arm and shoulder is pulled through;
And lower limb is supported;
Patients will spend a lot of time on their unaffected side; to be lying on their affected side would help to bring back sensation in limbs; this is very important.
Functional analysis
Start Position
Patient in left side lying position, posturally aligned, left arm slightly extended, right leg slightly flexed at the hip, feet inverted. Abdominals contracting isometrically to maintain posture. BOS fairly large as it includes the bed and the floor space underneath. COG through the shoulder girdle at the lateral aspect of the head of the left humerus, at the pelvic level resting on the lateral aspect of the left greater trochanter, and at the feet on the lateral surface of the left maleolus.
Phase 1
The whole movement occurs in the sagittal plane and the coronal axis.
As the model begins to lift the right arm to start to reach over to the bedside table, there is slight abduction of the upper extremity at the glenohumeral joint. The middle fibres of the deltoid muscle and supraspinatus abduct the arm by contracting eccentrically. By abducting the shoulder the scapula rotates laterally. This is facilitated by the upper and lower fibres of the trapezius. These movements occur in the sagittal plane.
Phase 2
As the model begins to reach over for the tissue, the shoulder begins to flex; this occurs in a coronal plane. Muscles that flex the shoulder are pectoralis major, biceps brachii and the anterior fibres of the deltoid. These muscles are contracting eccentrically. As the model reaches for the tissues there is slight further abduction at the shoulder. While flexing the shoulder the scapula further rotates laterally, caused by both the upper and the lower fibres of trapezius, and elevates. Elevation is facilitated by the upper fibres of the trapezius; this occurs in the coronal plane.
Phase 3
After grabbing a tissue the model begins to bring her arm back in towards her, in a coronal plane. This is extension of the shoulder; this is facilitated by the posterior fibres of the deltoid, pectoralis major, latissimus dorsi, teres major and triceps, all contracting concentrically. While extending the shoulder, the scapula also depresses. Depression is facilitated by the lower fibres of the trapezius; this occurs in the coronal plane. The upper extremity also begins to adduct slightly. This is facilitated by teres major and latissimus dorsi; both contracting concentrically. With slight adduction comes slight medial rotation on the scapula. Rhomboid minor and rhomboid major facilitate this action. Both adduction and medial rotation occur in the sagittal plane.


Phase 4
As the upper extremity gets closer and closer back towards the trunk of the body, there is further adduction occurring at the shoulder; caused by the same muscles contracting concentrically. This is occurring in the sagittal plane. Also further medial rotation of the scapula, also occurring in the sagittal plane. This leaves the model in their original start position; in left side lying position, posturally aligned, left arm slightly extended, right leg slightly flexed at the hip, feet inverted. Abdominals are contracting isometrically to maintain posture. BOS fairly large as it includes the bed and the floor space underneath. COG through the shoulder girdle at the lateral aspect of the head of the left humerus, at the pelvic level resting on the lateral aspect of the left greater trochanter, and at the feet on the lateral surface of the left maleolus.
Mechanical principles
Gravity is involved. Inertia has to be overcome to initiate movement. COG isn’t really affected as the upper extremity isn’t large or heavy enough to transfer the COG through it. The LOG remains with the BOS and there is no change in the overall body alignment.