Your last post is great re treatment for UE following stroke. It is great to
have a case study example and real practice to read about.
I have some neuro rehab experience, head injury and stroke. I have a neuro
patient at the moment who had a thalamic bleed. Her main problems are her lack
of short term memory, reduced initiation, reduced planning ability, lack of
insight and she is disorientated to time and place.
Her attention, sequencing and visual perception appears intact.
I am using an errorless learning approach.
Studies show that amnesic patients often have non functional explicit memory
(cannot remember learning context e.g. therapy sessions) yet intact implicit
memory (automatic patterns e.g. the memory we rely on when we are driving a
car, sub conscious)
Errorless learning attempts to tap into residual implicit memory in order to
teach new info to amnesic patients.
Amnesic patients taught using a trial and error method which promotes guessing
have been found to confuse recall of correct and mistaken answers. So rather
than standing back and seeing if the patient identifies the right object to
use, or the right sequence for dressing, as soon as they look like they are
struggling or going to make a mistake you stop them and correct them. Although
this sounds like too much hand holding and not very enabling it is an
approach that works for this specific client group.
Under Errorless learning techniques, performance becomes automated (like
driving a car) and laid down in implicit memory through imitative learning and
repetitive practice of perfect task execution.
As an OT I have taught this approach to physio's who have been working with
amneisc patients on their ability to sit to stand. A patient with left sided
weakness was struggling to learn the steps to encourage normal movement
patterns when sitting to standing, e.g. getting bottom to edge of seat, leaning
UB forward, maintaining midline posture and pushing through both legs. As with
many CVA patients his body was automatically compensating for his left weakness
and he was developing bad habits which in the long run were going to be a
strain on his back, and hips, and ultimately would take far more energy than
'normal' movement patterns.
I supported the physio to use an errorless learning approach when teaching the
patient new techniques to adapt to his deficits in his transfers. After much
repitition and practice and a consistent errorless learning approach from all
staff the patient learnt the techniques and carried it over to all his
transfers in all settings as it became a habit laid down in his implicit
memory.
A downside to this is that a patient who lacks motivation or initiation may
become dependent on the cues and wait for them, rather than internalising the
skills that they learn .
I am yet to see if the EL approach works with this patient. Does anyone else
have ideas for patients who have no short term memory, we are using aids such
as a calendar and diary, and a pager system is another potential.
Be great to hear any ideas from any fellow neuro OT's
Kind Regards
Lucy Simpson
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