Question 15

15. What interventions would you consider at this point?

A. Based on this pts inability to walk independently without holding onto furniture or railing, I would focus on balance exercises with Joe. (Carley)
B. I would work on some cognitive exercises with Joe such as the immediate recall activity we did during his initial eval. (Missy) Joe has some memory impairments. What could Joe work on that could compensate for these impairments?
What type of balance exercises would you do?
A. For basic balance exercises, we would need to practice just standing without an assistive device. This could progress to standing on uneven surfaces. (Amber)
B. From basic balance exercises I would progress Joe to exercises with his eyes shut and possibly on a bosu ball (Kelly)
C. For beginning balance exercises I would suggest aquatic therapy for Joe as aquatic therapy is a "safe" enviornment to work on balance and strength without the risk of falling (Kelly). Aquatic exercises would be good for strengthening. He would be safer (less risk of falls), but that would be because the water takes away some of the need for balance (we are somewhat bouyant and the water would slow down a fall so the patient could recover better). We would not know how well he would handle balance exercises in the pool till we got him there. What types of activities would you do in the pool?
I would just get him walking in the pool to start, he could hold onto the edge. Or he could put on the aqua jogger belt for safety. I would not start him in too deep of water until his balance got better.
E. I would have him do some water resistant exercises only onto the side of the pool and using the water as resistance for leg movements (abduction, adduction, flexion, extension). These exercises can also be used with his arms. Once Joe get's some of his strength back from those exercises, his muscles will be stronger to help with his balance. (AMANDA)
Balance is actually easier in deeper water (chest deep vs. hip deep: more bouyancy, and more resistance to movement if the patient starts falling), but patients at risk for falls may not feel as safe in deeper water. He could perform a LE exercise program (strengthening hip flex/ext/abd/add, heel raises (gastroc/soleus strengthening), toe raises (DF strengthening), squats (to gain balance and stability for lowering into and out of a chair)) to start and then we could progress to more functional activities and increase resistance by going deeper into water or attaching a theraband to his aqua jogger belt (PT would pull on band behind him as he moves forward, side to side, etc.) (Megan)
Some of these activities would become easier in deeper water, while some would become harder. Which ones would be easier, and which would be harder?
A. A simple exercise such as marching would start out easiest in shallow water. Joe could begin by simply marching while holding onto the side and as his strength and balance increases he could move to possibly walking the width of the pool. Eventually he could possibly move to deeper water to make it more difficult. (Betsy)

Also, exactly how would you do the strengthening exercises in water? Would you simply have him flex, ext, ABD and AD the hip while in water?

C. part 2. I agree with Kelly, my Mom is a MS patient and she really enjoys her aquatic therapy. She says that her land therapy is going much better because she can improve her strength in the water without it being too tiring! (Megan)
D. First I would start Joe off in the parallel bars just for extra precaution and then progress him to some of the uneven surfaces that were suggested previously in Amber and Kelly's answers. (Sara)
E. I think Joe could benefit from balance exercises sitting on a Physioball as well. (Marley)

F. One study published in PTJ noted buoyancy- and flotation-resisted motions at the knee and hip with the patient side-lying being supported by the therapist with an innertube around the patients' waist. The study was a case report that examined following a specific aquatic exercise program for a 30 y/o female patient with MS. (Steph)
(Exercise in 94 degree Water for a Patient with Multiple Sclerosis.)

G. LE stretching exercises to increase Joe's ROM (Erin)

H. Commenting on the water workouts: I would start Joe off with simply flexing, extending, abducting, and adducting to work on form and to help him know what I was looking for. I would then work him up to the movements with additional weight added on to him. I would then progress to Megan's theraband suggestion. I really like the aquatic therapy idea because he would be doing regular therapy as well and this might make things more fun/interesting for him and motivate him to work hard. (Denise)

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