I am on my neuro prac and this has happened just recently. One of the patients who was recently admitted to the ward following a stroke was taken to the physio gym to progress with rehabilitation and treatment. The patient proves to be a VERY strong "pusher" and is unable to maintain the vertical postition in standing as he pushes his COG over to the affected side, however due to his hemiplegia he requires the assistance of 3 people to sit to stand and remain in standing. The decision was made to attempt to provide some treatment for the patient on realignment using the tilt table with the senior physio.
At the start of the treatment session the patient displayed exceptionally high tone in the right biceps, internal rotators, adductors and wrist flexors - your typical flexor synergy of the upper limb. He is also very overactive on the unaffective side and has impulsive behaviour. The patient was incrementally raised on the tilt table, and signs for postural hypotension noted. While the physio was providing some mobilisations on the affected foot and positioning the feet the patient suddenly lost all tone in the right upper limb and his head became fixed in a side flexed position. The situation did not follow a typical lack of oxygen to the brain as in postural hypotension as the expected signs would be sudden loss of postural and voluntary control. We found it odd that the patient had fixed his head and we were unable to move it - it looked more like the patient was having a fit, or another stroke.
The patient was rapidly taken back to a horizontal position and his vitals taken - all of which returned normal values. The situation was discussed with the doctors who diagnosed the event as 'poor perfusion'. Subsequent events have since occurred, however it seems the medical staff are not taking the situation seriously as they insist that we promote standing ASAP yet disregard these incidences which would seemingly be a contraindication to stand. In this situation I think it is necessary to go with your instinct and if you don't feel comfortable continuing with the treatment session due to patient saftey then don't!
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That's a scary situation when something like that happens to your patient right in front of you. It makes it hard to know what course of action to take when such an adverse reaction to standing happens and the doctors just dismiss it. I suppose it makes it even harder when the diagnosis doesnt really make sense to us. In situations like this I think it's important to ask the senior PT for advice or even ask the doctors to explain what is happening, just so that you can feel safe enough and have good justification to try standing them again.
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