Topic 2- Treatment

Situation: Patient B is a 77yo who presented with Progressive Supranuclear Palsy. Progressive Supranuclear Palsy (PSP) is a Parkinson's Plus condition (movement disorder) and is a chronic, progressive neurodegenerative disorder. Its main clinical features include prominent neck dystonia, pseudobulbar palsy, behavioural and cognitive disturbances, Parkinsonism (including rigidity and bradykinesia), early dysphagia or dysarthria, gait disturbances, poor equilibrium, falls and more. Patient B was referred to the Physiotherapy department at Osborne Park Hospital- Parkinson's Clinic with a history of more than 1 fall per day. Patients with PSP often find themselves with trunk posture in extension (compared to Parkinson's where they have a flexed, stooped posture), subsequently these patients often find themselves falling backwards. During assessment of this patients the patient reports, and during observation it is evident that the patient has difficulty with turning.

Task: My task was to aim to decrease the number of falls the patient has per day (this was the goal of the patient) with some treatment. My goal for the session was to correct the patient's turning strategy to help prevent some of the falls that are occurring.

Action: Once I determined the aim of my treatment session, I first thought it would be important to discuss the reasons for falls, the function of the basal ganglia and the need to break the old habit and create a new one. The patient was a physicist, and was there for highly educated. I thought that I might be able to gain more from my treatment if he understood the background and reasons for my treatment. The next thing I did was to teach the patient turning strategies and how it was important 'not to cross his feet over', ' take big steps' and 'not step backwards'. Once the patient understood this I got him to practice a 90 degree turn, with lots of repetitions, encompassing this good technique. It took looks of prompting and cues to get him not stepping backwards or crossing his feet however he did get a good feeling for taking more steps to get around. After I felt he was getting hang of it, I then progressed it to a full clock turn. The patient did well however required prompting to lift his feet about 1 inch off the floor each time.

Result: I was happy with my treatment of this patient. He understood the correct technique of turning and could pick up his own mistakes. I discovered however, out of the treatment session he would forget the correct technique. When I asked him to walk over and have a seat, he crossed his feet over. I understand it will take a while to break the old habit and unfortunately that means he will encounter some more falls in the coming weeks but I have written cue cards and will continue practicing with the patient. It does point out the need to practice in different environments.

Evaluation: Upon reflection of this treatment session, I think I did well in explaining the reasons behind his falls and getting his attention. The patient did well with the techniques but could not transfer them to other environments or situations. My supervisor also gave me feedback on my performance and said it was good however I need to be a bit firmer with him. That makes sense and I can understand the need to be firmer with him to get the acquired result. It took me a while to come to terms with the fact that due to PSP the person at times struggles to keep their eyelids open. It made me feel like I was being boring or the patient wasn't interested but I had to remind myself it was a part of the disease.

Strategies: Strategies I would use in future would be to be firmer with the patient but letting him pick up his own mistakes and stopping him everytime he makes a mistake rather than letting some slide. In terms of not being able to transfer the skill to another environment, I would get the person walking and take him to different rooms and randomly ask him to turn to practice that automotricity and new skills.