T11 Scenario...new one!!!

Hope this one is better...

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). The assistant is also able to demonstrate exercises if needed. Before you start, you could quickly demonstrate the exercises on the mat so the patient knows what to expect and also to make it easier for the patient to see the demonstration.

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. Lie patient flat again and ask them to flex their knee and lift their right leg. Ask them to circle their leg in the air, fairly slowly so that it is a controlled movement. Assist by holding their knee and foot as this exercise is difficult to do with any muscle weakness and so they will need a lot of guidance and support. Do 5 circles with each leg, allow the patient to get their breath back and rest if they are tired. Then repeat.

9. 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.

10. If your patient is able to turn to lie on their side (the likelihood is they will be able to in the exam so its worth doing this – however make it clear that they can stop if they get tired or if its difficult etc so its more realistic) then you can assist them in exercises on their side. You may need to help with the turn: bend both knees and ask them to turn their head. Then guide their body over as they twist their knees over to the side. An exercise you can do is to ask them to lift their hip up to the ceiling (abduction). It doesn’t have to be a big movement, just allow them to go as far as their ROM allows. Repeat 5 times on this leg.
Then you can do (if you have time) another exercise on this side before turning over. This is to extend the underneath leg at the knee and hip and flex the other leg on top so that it crosses over in front. The patient can then lift their underneath leg slightly off the ground 5 times. You will need to support and stabilise their leg and body as you do this. If they need extra support, use your assistant as well.
Once completed, assist the patient in turning to their other side to complete the exercises on their other leg.

11. If your patient is able to lie on their front, ask them to lift their legs individually up to the ceiling to work their extensor muscles. Do each leg 5 times.

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.

Your patient will be laid on their back so it may be an idea to assist them in sitting up so you can demonstrate the motion from the floor to the chair. Before you begin, check that your client has a stable chair they can get into at home.
Pull up a mat and the chair next to the patient’s mat. Lie on the mat as the patient would and bend your knees up so your feet are flat on the floor.
Turn your head to the right/left (whichever way you are going) and turn your knees the same way. Bring your arm on the outside over to help you turn.
When you are on your side, use your upper body strength to push up and turn over so you are knelt forwards on your hands and knees.
Shuffle around on your hands and knees to face the side of the wheelchair. Remove the side of the chair you are facing.
Put both hands on the far arm of the chair for support and kneel up on the knee next to the chair.
Push up with your leg enough to sit of the corner of the chair. Explain to the patient that they must not push down all their weight onto the chair and to use their legs as much as possible.
Once sat on the corner of the chair, shuffle round to the middle and replace the side of the chair.
Make sure whilst doing this your assistant is holding the wheelchair still as we all know the brakes can be a bit dodgy.

Now let the patient try the manoeuvre. Things to make sure you do are:

Keep close to the patient so you can support if he/she struggles with the process.
Guide the patient’s knees over if they need assistance.
Give the patient constructive feedback if they are not quite doing it right as the examiner will be looking for this. If necessary guide the patient.
Make sure your assistant is available to support the dodgy wheelchair.

Once in the wheelchair, your assistant turns into the carer/relative. Firstly demonstrate how to guide the wheelchair up and down stairs.
Explain the importance of good posture and not lifting the chair with your arms to the carer.
When taking the chair up the stairs, position the chair close up to the step so that the front wheels are next to the step and you are not approaching from an angle.
Put your foot on the tipper and guide the chair forwards to rest the front wheels on the step.
Get a good grip on the handles and keeping a straight back push the handles to lift the patient’s back wheels up onto the step. DO NOT LIFT!!! If you are weaker like me then you should get as close to the back of the chair as possible and use your body weight to help in moving the chair up the step. Even resting your knee against the back of the chair can help.
Bringing the chair back down, you should go down backwards the way you came up. Move the back wheels to the edge of the step and pull back gently and slowly to lower the large wheels to the ground.
Using the tipper, tip the chair up to lift the front wheels off. Keep one leg behind as it keeps your balance better as you move the chair backwards to clear the front wheels. Once cleared, slowly lower the chair keeping your foot on the tipper to support the weight.
Give the chair to the carer. Watch carefully what the carer does and give comments as to their posture and positioning and technique if needed, until they can perform the manoeuvre safely.

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

Functional Analysis
Before you start, check your model is suitability clothed so you can see their movements clearly. Check they know what they are going to do!

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.

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

1. Starting position:
MOTIONS:
The left glenohumeral joint is slightly flexed and abducted in the wheelchair on the armrests. The elbow joint is flexed at around 80 degrees on the armrest depending on the patient, this is a judgement call.
MUSCLES INVOLVED:
There are no muscles contracting as the client is relaxed.
BASE of SUPPORT and COG:
The base of support is good as all four wheels are on the floor with a large surface area on the floor and the body is sat back in the chair. The LOG is down the centre of the body and the centre of gravity is central. The patient is well balanced.
FORCES:
Gravity is acting down on the chair. There is friction between wheels and the floor preventing movement of the wheels.

2. Preparation for push
MOTIONS:
The glenohumeral joint extends, abducts and medially rotates (inwardly). The elbow joint flexes to around 110 degrees depending on the client. Extension/flexion occurs in the sagittal plane, abduction in the coronal plane and rotation in the transverse plane.
MUSCLES INVOLVED:
Extension of shoulder: Posterior deltoid, Pec. Major. (Concentric contraction)
Abduction of shoulder: Middle deltoid, Supraspinatus. (Concentric contraction)
Medial rotation of the shoulder: Anterior Deltoid, Pec. Major, Teres Maj.
Flexion of elbow: Bicep (Concentric contraction)
BASE of SUPPORT and COG:
BOS still large as all wheels are on the ground. Client BOS is the same as they are sat back in the chair. The COG is further back in the body and the client’s weight is further back.
FORCES:
Friction between the wheel and the ground. Gravity acting on the chair.
If client is sat further back there will be more friction on the back wheels than the front as there is a larger downward force acting on the wheels at the back. There is friction between the hand and the wheel rim depending on how hard the client is applying a force. There is gravity acting down on the patient as they lift their arms.

3. Push
MOTIONS:
The glenohumeral joint flexes through neutral position to in front of the body and the elbow joint extends fully. The shoulder joint adducts and laterally (outwardly) rotates. Flexion/extension are in the sagittal plane, adduction is in the coronal plane and rotation is in the transverse plane.
MUSCLES INVOLVED:
Flexion of shoulder: Anterior deltoid, Coracobrachialis (Eccentric)
Adduction of shoulder: Pec. Major, Lat. Dorsi, Coracobrachialis (Eccentric)
Lateral rotation of shoulder: Posterior deltoid, Teres Min., Infraspinatus.
Extension of elbow: Triceps (Eccentric)
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. The clients weight is further forwards so the COG is further forwards.
FORCES:
Friction between wheels and ground as the chair moves. Gravity acting down on client and chair. Patient has to act against friction to create a larger force to build momentum. Friction between the client’s hands and wheelrims.

4. Recovery Phase
MOTIONS:
The glenohumeral joint abducts, medially rotates and fully extends to return to original position. The elbow flexes again. See planes as above.
MUSCLES INVOLVED: see phase two.
BASE of SUPPORT and COG:
BOS increased between the body and chair as the buttocks have more contact with the chair now the patient is leaning back again. 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. Gravity acts down on the patient as they move their arms backwards. Momentum decreases as the chair slows down.

Let me know if changes need to be made??xx