43095

A 72-year-old male patient suffered a cerebrovascular accident 3 days ago that involved his left middle cerebral artery. The patient is stable in the critical care unit and will be receiving physiotherapy for the first time since their admission. The patient is a widow, but his daughter or son has been present at the hospital each day. Before the initial assessment, the physiotherapist reviews the patient’s chart and notes that the patient has right upper limb flaccid paralysis and Broca’s aphasia. Upon entering the room, the physiotherapist notes that the patient’s son is present.

How should the physiotherapist proceed when communicating with the patient during their first physiotherapy session?

  • Use the patient’s son to help interpret what his father needs and wants.
  • Speak using close-ended questions so that the patient only needs to respond with ‘yes’ or ‘no’.
  • Speak slowly and use lots of demonstrations, pictures, and actions to ensure the patient understands what is being said.
  • Interact normally to prevent the patient from feeling as though they are inferior.

Feedback:
The correct answer is B!

  • Use the patient’s son to help interpret what his father needs and wants.
    • This is not the BEST option as the physiotherapist should not immediately default to using the patient’s son for communication. The physiotherapist should approach the patient and use effective communication strategies based on the type of aphasia presented.
    • The physiotherapist should gain consent from the patient to include/discuss their personal information with their son. If consent has been provided by the patient to discuss health matters with their son, the physiotherapist can gain insight about the patient from their son as this may be helpful to maximize participation.
      • For example, the son may inform the physiotherapist that his father is very sleepy in the morning and may do better with physiotherapy later in the afternoon. Or the son may inform the physiotherapist that certain facial expressions indicate frustration vs anger.
  • Speak using close-ended questions so that the patient only needs to respond with ‘yes’ or ‘no’. – Correct
    • Broca’s aphasia (also known as expressive aphasia) involves difficulty with expressing words/verbalizing while understanding spoken language remains unaffected.
    • This patient can comprehend verbal communication but will have difficulty expressing himself. For this reason, using close-ended questions can ensure clear communication for the patient.
      • If the patient is unable to verbalize ‘yes’ or ‘no’, the physiotherapist can teach them to use actions such as a head nod/shake or thumb up/down to indicate yes/no.
  • Speak slowly and use lots of demonstrations, pictures, and actions to ensure the patient understands what is being said.
    • This method of communication would be most appropriate for a patient with Wernicke’s aphasia (also known as receptive aphasia). Demonstrations, actions, pictures, and gestures can all help the physiotherapist communicate if the patient does not understand spoken language.
  • Interact normally to prevent the patient from feeling as though they are inferior.
    • The physiotherapist must adapt their communication strategies when working with a patient with aphasia to ensure effective communication. A patient with aphasia does not lack intellectual function, they are just unable to express and/or comprehend language. For this reason, the physiotherapist must ensure they find an appropriate and effective communication strategy while treating the patient like an adult and not a child. Professionalism is essential in these situations to maintain patient dignity.

Question 22

A 31-year-old patient is attending physiotherapy for the management of her acute wrist pain. She reports that the pain started 2 weeks after giving birth to her first baby. She experiences pain when lifting her baby and she is worried about dropping her child because the pain is sharp and intense. The patient is a single mother with minimal family support and financial difficulties. A physiotherapy assessment reveals mild inflammation over the lateral aspect of the wrist, decreased ulnar and radial deviation AROM and a positive Finkelstein’s test.

Based on the international classification of functioning, disability and health (ICF), which of the following will be most effective at improving the patient’s activity limitation?

  1. Teach the patient how to tape her wrist.
  2. Apply ultrasound to decrease inflammation.
  3. Encourage the patient to ask for help from family and friends.
  4. Teach the patient pacing and planning strategies.

Feedback:
The correct answer is A!

  • Teach the patient how to tape her wrist. - Correct
    • This will directly address the 'activity' of lifting her baby. In the ICF, an activity is the execution of a task or action by an individual. In this situation, it would be lifting/carrying her baby.
    • This vignette describes a patient with De Quervain’s tenosynovitis. Taping will offer support, and unload the irritable tendons and is a cost-effective solution given the patient’s financial difficulties. It will improve her ability to lift and carry her daughter and is a great self-management strategy.
  • Apply ultrasound to decrease inflammation.
    • The application of ultrasound directly addresses the patient's 'impairment'. In the ICF, an impairment is a problem in the body's function or structure (e.g., inflammation resulting in pain). Decreasing the patient's inflammation and pain directly addresses the patient's impairments.
    • While this can positively impact the activity of lifting her baby, this is a very passive treatment that may only offer temporary relief of her impairment and is not the best option in addressing the patient’s ability to lift her baby.
  • Encourage the patient to ask for help from family and friends.
    • The vignette states that this patient has minimal family support. The physiotherapist should focus on strategies that increase self-management of the condition versus relying on others for assistance.
  • Teach the patient pacing and planning strategies.
    • Pain is the main issue affecting the patient’s ability to lift her child. Unloading the painful and inflamed tendons will be more effective in the acute stage at managing the patient’s pain that directly impacts her ability to lift her child.
    • Pacing and planning strategies are helpful, but a newborn baby requires a lot of work and tending to her child (lifting and carrying her throughout the day) is inevitable, and not something that she can necessarily pace and plan around.