Discharge?

Stroke rehabilitation can be frustrating at times particularly in the outpatient setting when you are only seeing the patient for three hours a week. It is very difficult to determine whether the patient is improving within one session or even over a week. I am currently treating a patient who had a right mca stroke. The patient can ambulate independently and perform all transfers safely so now we are working on her left upper limb.

The patient has poor scapula control due to increased tone in teres major and latissimus dorsi, weakness of serratus anterior and rhomboids and stage 5 recovery of her arm and hand. Over the past four sessions with this patient I have performed SIMMs to her teres major and latissimus dorsi, stretched the upper trapezius and neck flexors, performed passive accessory mobilisations to the shoulder and have stretched the elbow and finger flexors. I have also worked on shoulder stability in an air splint with external rotation and weight bearing through the upper limb in 4 pt kneeling. Functional tasks have included reaching, grasping and releasing. In order to improve her sensation and proprioception I have done sensory work and stereognosis testing.

This patient has shown little improvement over the past couple of weeks and in the last session I tested her stereognosis and the patient couldn't even identify if she was picking up an object or her hand was empty. As a therapist I begin to question whether my treatment techniques are having an effect or if because this patient is over 8 months post stroke my techniques won't improve her motor patterns. It is difficult to decide whether this patient should be discharged or similar treatment should continue. I am trialling hydrotherapy with this patient to improve range of movement and shoulder stability. Hopefully by using this new approach I will begin to see improvements in the patients upper limb.