Sunday, August 11, 2013

The Dedicated-True story of an adapive fitness clients progress with aggressive training

Hey Team,

I came across a progress report that I wrote for an adaptive fitness client who was recovering from multiple strokes that I worked with for over 6 years and thought I would share it for those that are interested.

This clients name has been switched to The Dedicated, it is a real account of our progress made together.

Take a look at our journey together, and see how an aggressive adaptive fitness program  and consistent hard work took The Dedicated from dependence in a tilt in space wheelchair, to walking with hand held support.

Devon Palermo Adaptive Exercise Progress Report

Client: The Dedicated

Disability: Multiple strokes, gait/coordination disturbance

Initial assessment for Adaptive exercise: March/2006

To whom it may concern;

The Dedicated was initially evaluated for an adaptive exercise program in March of 2006, at that time The Dedicated presented in a tilt in space wheelchair dependent for propulsion. The Dedicated was non-ambulatory, and required maximum assistance if not completely dependent for all transfers. In the home The Dedicated utilized the following: Hospital bed, standing frame, Wheelchair, and portable ramps for negotiation of steps in the home, as well as necessary aids for self grooming, The Dedicated also utilized the care and assist of a caregiver. The Dedicated was able to communicate with me verbally, but often required assistance from a caregiver when unable to express verbally what was wanting to be said.

Standing was assessed which required max assist-dependent effort with max assist for verbal cues. Sporadic volitional control of the lower extremities was demonstrated when weight bearing and The Dedicated could only stand for seconds at a time. The Dedicated expressed an intense fear of falling when standing supported. we tried weight bearing through the knees with upper extremity support through the elbows on a bed. Positioning required max assist-dependent with max assist verbal cueing. Just as with standing The Dedicated demonstrated sporadic volitional control with glute and lower extremity activation which prompted me to focus solely on weight bearing exercises to improve muscle control by overloading the central nervous system.

The Dedicated agreed to begin in home training 3x a week to work on strengthening the lower extremities and improving standing tolerance.

An exercise program was demonstrated to the caregiver to perform on days we could not meet for training. Exercise program consisted of Leg strengthening exercises that could be performed in the bed. These exercises required max assist for verbal cues to be performed properly secondary to The Dedicated having much difficulty with awareness of left versus right/ right versus left and the sporadic volitional control of the leg muscles.

After several months of working on weight bearing exercises in standing and on the knees and with the exercises performed while laying in bed, I began to note improvement in volitional control of the lower extremities. The Dedicated was now able to respond with muscle activation consistently with verbal cueing, though at times The Dedicated would confuse which lower extremity The Dedicated was attempting to control.
I decided to start implementing core balance and proprioception through the use of a physio ball. The Dedicated required max assist for set up, but was able to maintain balance while sitting on a physioball with moderate assist and moderate assist verbal cueing. I decided to continue with weight bearing exercises while including the newer core stability exercises.

As strength improved in the lower extremities, we were able to work on standing with close supervision after min to moderate assist going from sit-stand and with verbal cues for upright posture.Standing had exhibited tremendous improvement going from seconds to minutes. Soon we began to implement dynamic balance exercises, reaching across midline, standing with eyes closed, etc...

With the improvements noted in standing, I decided to attempt walking with The Dedicated. This proved to be a VERY difficult task. Secondary to fear and lack of coordination with movement, walking ended up being a very maximum assist of 1, almost dependent. Verbal cues were expressed for upright standing, activation of muscles for standing, breathing, and lower extremity  advancement.

As we continued to push with the very difficult task of walking, slowly The Dedicated’ walking began to improve. Requiring less physical assist going from max/dependent to mod/max, and the verbal cues for advancement of the lower extremities decreased, though cues were still required for breathing, balance, and posture. Due to the improvements noted, The Dedicated requested to increase our visits. We would shift from 3x a week to 5 x a week sometimes with sessions lasting two hours depending on the day.

Through the first two years of working with The Dedicated privately, The Dedicated continued to attend physical therapy. The physical therapist and I conversed regularly on the improvements that were made in the home and would apply them to treatments in PT. The Dedicated was able to benefit from the use of the Lite gait and Lokomat while in PT. It is my belief that of all the tools presented for trial with treatment, the Lokomat made the most significant improvements by increasing confidence, decreasing fear of falling, and forcing an upright position in standing.

The Dedicated would go to PT for Lokomat training 3x a week for 20- 50 min ambulation sessions in addition to the home training. Lokomat use improved  coordination of the lower extremities with ambulation while not in the lokomat, it also improved endurance for walking while training. Another benefit of the use of Lokomat is that it positioned The Dedicated in an upright proper walking alignment by use of the exoskeleton, The Dedicated was unable to lean . Lokomat training continued well over the normal recommended amount of 12 sessions secondary to improvements.

Once discharged from physical therapy the focus at home became solely walking. We tried several assistive devices. (platform walker, standard walker, neck brace for positioning) Nothing seemed to benefit posture with walking, but we stayed consistent and kept pushing forward.

We began to increase our distances going from 25 ft 2x in the hallway of the home initially to over 400 ft in the hallways of the condominium lobby, to up and down stairs with mod assist and verbal cueing and finally  to over 1000 ft with standing rest breaks as needed.

The Dedicated soon requested trial of walking in the pool. I thought it a good opportunity to work on balance in standing using the buoyancy of the water. Due to the decreased muscle mass on the left leg, we had to use a water weight to decrease the buoyancy of the left leg. Pool ambulation and balance exercises in the water had now become a staple in our exercise sessions during the summer months over the course of 4 years. Ambulation on land after being in the pool did seem to improve requiring less verbal cues for movement and improved fluidity of leg movement.

Currently The Dedicated has been given an exercise program to complete with caregivers in addition to the walking exercise that is performed 3 x a week with me.

The home exercise program consists of standing balance, transitioning from sit-stand, dynamic balance exercises, and ube interval training x 40 minutes with rest breaks as needed.
Total of 6 years working with The Dedicated in aggressive adaptive training has yielded positive results that even surprised the doctors who followed the The Dedicated’ care.
The Dedicated has overcome many challenges, but worked very hard to do so.
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Keep Pushing, Never Give Up!