Right im doing T11, will you calm down Eoin lol. Have put all of it up but the bit with the getting off the floor into the wheelchair but will add that once we have done it in tomorrow's lesson.

Scenario 11
A 35 year old female with multiple sclerosis has weak lower limbs. She uses elbow crutches indoors and a wheelchair for outdoor mobility.

Teach this patient a simple active/active assisted exercise regime (using a mat on the floor) to help maintain range of movement, flexibility and strength in the lower limb. (Focus on the hips and knees).

1. Explain to your patient that you are about to do some simple leg exercises to help strengthen their knees and hips and increase the amount they are able to move. Get their consent!!

2. Explain that if they feel tired or in unbearable pain during the exercises they should let you know and you will either take a break, proceed to less strenuous exercises or stop doing exercise altogether. It is very important patients with MS do not overdo it as they could strain an already compromised muscular system. This leads to further pain and the body and mind being overtired and overworked. MS sufferers also a very sensitive to heat, so ask them to tell you if they feel too warm and it will make their symptoms worse.

3. Ask the patient to lie down on the mat and assist them if necessary. (You could ask your physio assistant to help with this).

4. With the patient laid flat on their back, ask them to bend and bring their right leg up towards their chest using both hands. To actively assist, support their knee joint and apply gentle pressure to the leg to assist in the hip flexion and increase the range of movement. Hold for 5 seconds and release back to full extension. Repeat 3-5 times and then do the same for the left leg.
(If your patient’s muscles go into spasm then they will not be able to begin with their legs flat and stretched out. They will lie with their knees bent and feet flat on the mat).

5. With the patient still laid on her back, ask her to bring her knees up so her feet are flat on the mat. Knees should be around 30 cm apart. Ask her to roll her knees over to the left, stretching diagonally across the trunk. Gently assist with this exercise, making sure you do not straight the patient. Bring the knees back to the middle, then roll the knees over to the right and back to the middle again. Make sure both shoulders stay in contact with the floor or bed. Repeat 3-5 times each side. Make sure the patients knees do not flop over and don’t rush. This helps strengthen the muscles used for internal and external rotation.

6. Return patient to lying position with knees bent and feet flat on floor. Ask her to lift her buttocks up of the floor as high as she can. You could possibly explain that she needs to tighten the muscles as if she was squeezing her buttocks together like they are squeezing a ball. As she raises her hips, support her with one hand above and one hand below and help her push upwards if needed. Guide her so that she moves straight up and down and does not waver from side to side. Repeat 3-5 times.

7. Return patient to lying position with knees bent and feet flat on floor. Ask her to tighten her tummy so that she tilts her pelvis to flatten her back down onto the mat. Ask her to hold for 5 seconds and then release. You may need to assist the first couple of “pelvic tilts” with your hands so that the patient gets an idea of how it feels. Repeat 3-5 times.

8. Although the question asks to mainly focus on the hips and knees, it might be an idea to do an exercise for the arms to show you have thought about this aspect too (only if you have time though). In the same lying position, ask her to lift her right arm upwards in a straight line (sagittal plane) so that it points to the ceiling. Slowly lower the arm and repeat 3-5 times and then do the same with the left arm. Support the arm at the elbow as you do this.

WEBSITES to look at:
http://www.mstrust.org.uk/downloads/exercises.pdf
http://www.webmd.com/multiple-sclerosis/guide/multiple-sclerosis-exercise

Assist the patient to get into the wheelchair from the floor and then teach a relative of the above patient how to ascend and descend a kerb with the wheelchair.
(Will fill this in once demonstrated in class how to get into the chair!!!!)



Analyse the activity involved in self propelling the wheelchair, with particular emphasis on the left shoulder (glenohumeral joint) and the left elbow.

Functional Analysis
Split into four phases
Start position
Preparation for push
Push
Recovery phase

Watch the model perform several cycles of the four stages in the wheelchair. Watch the motion from different angles and as the model to perform it in normal and slow motion.

1. Starting position:
MOTIONS: The left glenohumeral joint is in extension. The left elbow is flexed. Hands are on the wheels.
BASE of SUPPORT and COG: Flexion of cervical spine means that the centre of gravity is further forward than it would be if the client was sat up in the chair straight. Base of support is large as the chair has a large surface area on the ground.
FORCES: Gravity is acting down on the chair. There is friction between the client’s hand and the wheel rail.

2. Preparation for push
MOTIONS:
The glenohumeral joint flexes slightly from extension, but it still extended. Also there is slight abduction of the joint and lateral rotation. The shoulder girdle adducts and elevates. Elbow flexes further.
MUSCLES INVOLVED:
Glenohumeral joint: Supraspinatus, deltoid, latissimus dorsi, teres major, triceps, infraspinatus and teres minor.
Shoulder girdle: Rhomboids, trapezius and levator scapulae.
BASE of SUPPORT and COG:
BOS still large as all wheels are on the ground. Client BOS is smaller as their cervical spine is further flexed so they are sat further forward with a smaller surface area on the seat of the chair. COG is further forward.
FORCES:
Friction between the wheel and the ground. Gravity acting on the chair.
If client is sat further forward there will be more friction on the front wheels than the back as there is a larger downward force acting on the wheels at the front. There is friction between the hand and the wheel rim depending on how hard the client is applying a force.

3. Push
MOTIONS:
The glenohumeral joint flexes to neutral position and the elbow joint extends fully. The shoulder joint adducts and medially rotates. Shoulder girdle abducts and there is some depression and upward rotation. This propels the chair forwards by spinning the wheels. The trunk flexes further.
MUSCLES INVOLVED:
Glenohumeral joint: Pectoralis major, latissimus dorsi, teres major, subscapularis, anterior deltoid
Elbow joint: Coracobrachialis, triceps, biceps
Shoulder girdle: Trapezius and serrator anterior
BASE of SUPPORT and COG:
BOS is the same regarding the wheelchair on the floor, but is smaller between the body and chair due to the client being sat further forwards in the chair. COG is further forwards.
FORCES:
Friction between wheels and ground as the chair moves.

4. Recovery Phase
MOTIONS:
Glenohumeral joint abducts, laterally rotates and fully extends to return to original position. The elbow flexes again. The muscles contract eccentrically in the shoulder. The shoulder girdle adducts and elevates. Spine extends to normal sitting position.
BASE of SUPPORT and COG:
BOS increased between the body and chair as the buttocks have more contact with the chair. COG is more central as the body is sat more upright.
FORCES:
Friction slows the chair down as the hands are released from the wheel rims.

Hope all this is ok...add comments please if changes need to be made!