Topic 3: evidence based practice and intervention

Situation: My patient was referred to outpatient's clinic for impaired mobility and dynamic mobility due to stroke in 2000. The patient's goals were to improve efficacy of functional mobility ie. rolling, supine to sit, sit to stand, and able to get off the floor if falls over. Pt was found to have learned non-use on the L) side as the L) UL was functional however the pt did not percieve it to be part of themselves nor believe they could functionally use it.

Task: My task was to devise a program to achieve the patient's goals and also address the learned non-use on the L) as I believed it was greatly impacting their functional mobility.

Action: I researched constraint induced movement therapy in correlation with learned non-use to find evidence on the benefits and limitations for the treatment approach. I found that my patient was a good candidate as they were reasonably high functioning in the L) UL and was also a chronic stroke patient in which the majority of the studies were conducted on. I applied the principles of the CIMT approach such as forced use of the L) UL in functional activities-rolling, supine to sit, assisting with STS, putting shoes on and weight bearing activities through the L) UL to prove to the patient that their arm could indeed be used functionally.

Result: I found my actions to be successful because by the end of the session the patient was using the L) uL consistently in functional activities particularly during STS. The patient was very interested in the CIMT and the research behind it so went home to follow it up. The pt also began to recognise the functionality of their L) UL during WB exercises and was suprised to find that it could support weight and also aid with mobility thus changing their attitude towards their L) UL.

Evaluation: Overall I believe my intervention was beneficial for the patient and indirectly targeted their goals. I think my strength was being able to adapt the principles of CIMT to my patient so it was relevant and beneficial in obtaining their goals. I think my weakness was that I wasn't strict enough with the protocol, for instance the patient tended to use the R) UL after continous failed attempts with the L) and I occasionally would allow him to do so. I think for this treatment approach to be more effective I need to be vigilant with the forced use concept and strongly discourage compensatory use of the R)UL during the treatment session.

Strategies: A strategy I could use to avoid this would be to place the R) UL into a restrictive device to completely discourage use such as a sling or rigid mitt. Also by explaining to the patient the importance of not compensating with the R) UL may engrain the principles better and encourage better performance at home aswell.