Hi Guys, I'm not sure but looking back I think I have only done 3 posts and 4 comments, so here is a little bit from Shanghai, hope you find it interesting!
Today we arrived in Shanghai about 1am! (following another nervous plane ride and an even more nerve-wrecking car-ride- my understanding was always that red lights were for stopping at.. apparently not here!) In the morning we explored. My initial feeling is that I like Shanghai better then HK, not quite so crazy-busy and with a little more character. The juxtaposition between old and new, between western and eastern and between wealth and poverty is even more amazing here. You can see modern cement trucks pouring cement into rickshaws carried by old men back and forth to the building sites. In a busy intersection a bus gives way to a flock of bicycles while a taxi narrowly avoids a lady manually towing a rickshaw filled with what looks like all the furniture from her house.
We saw these men pruning trees. They were dressed in orange jump suits with helmets on but their similarity to workmen at home ended there. To prune the trees they stood in the trees amongst the power lines, with a rope far longer than the distance from the tree to the ground tied around their waist and onto the power lines! They wielded electric saws and let the branches fall onto the footpath and street, which was not petitioned off in any way, causing motorists and pedestrians to swerve and duck! Amazing! Any fraction of that picture would have had Occ Health and Safety tearing their hair out. Similarly within the first hour we had seen several groups working with welders on the footpath with no goggles or protective clothing and workers bent double, perched on top of high walls doing brick work by hand. Just another example I guess of what we take for granted, the right to a safe profession. A comment made was that this picture makes you realise that what we call “common sense” is not necessarily common. I am unsure if it is a difference in training, recourses, or the role played by the worker but here the responsibility for safety doesn’t seem to be held by anyone.
Some of my initial observations included:
- Limited play/ fun between children
- Limited age appropriate interaction
- The lerge percentage of athetoid and ataxic CP
- Poor standard of wheelchairs- no support or padding, very poor posistioning (although the comment was made that at least they don’t spend too much time in them)
- Poor manual handling- large necessity for parents to carry children
- Very poor facilitation of movement by staff and other handlers- no encouragement of independent movement between positions
- Excessive use of pull-to-sit and pull-to-stand
- The hydro pool is green- I’m hoping that’s just because its being fixed and the hygiene instruction passed on from the previous group have been taken on board
Downstairs there is a lot of very old strength-training equipment with questionable usefulness in this setting. The comment was made that there is perhaps a confusion between tone and strength, which often rings true back home as well. As this was part of my honours project hopefully I can have a closer look at this while I’m here. With this, the other comment was that the gifts given to centres such as this need to be carefully considered so that they are actually helpful and not just given to dump equipment that is not useful.
Monday, 26 November 2007
Neuro is interesting!
My clinical tutor gave me a tutorial today regarding variables used to assess and train balance, I found it quite useful and would like to share it with everyone:
1. motor planning (eg. apraxia, percepture disorder)
2. strength
3. ROM (eg, ankle DF in ankle strategy)
4. CoG (eg, move it up and down, in and out BOS)
5. Visual Spatial disorder
6. BOS
7. limit of stability (eg limit of ankle sway, limit of functional reach)
8. dural task interference (distraction)
9. endurance (eg, repetition of ankle strategy)
10. segmental movement (eg, rotation of neck on shoulder, trunk on pelvis)
11. environmental factors
If we can integrate the above variables into balance training, our exercises program and progression will be very specific. Also, try to address all these variables in one position before you move on to the next. I tried to use this principle to treat my patients with balance problem and the results were fascinating. I never thought movement re-training can be so analytical and specific-I never looked normal movement in so much details-today I not only learnt a new way to train balance but also a new way to study.
1. motor planning (eg. apraxia, percepture disorder)
2. strength
3. ROM (eg, ankle DF in ankle strategy)
4. CoG (eg, move it up and down, in and out BOS)
5. Visual Spatial disorder
6. BOS
7. limit of stability (eg limit of ankle sway, limit of functional reach)
8. dural task interference (distraction)
9. endurance (eg, repetition of ankle strategy)
10. segmental movement (eg, rotation of neck on shoulder, trunk on pelvis)
11. environmental factors
If we can integrate the above variables into balance training, our exercises program and progression will be very specific. Also, try to address all these variables in one position before you move on to the next. I tried to use this principle to treat my patients with balance problem and the results were fascinating. I never thought movement re-training can be so analytical and specific-I never looked normal movement in so much details-today I not only learnt a new way to train balance but also a new way to study.
Carer stress
Please ignore my previous entry for I made some grammar mistakes... Just read the following instead. thanks
What will be the best strategies we can use if some patient's carer showed signs of carer stress (abusing verbally to patient and complianing about slow progress of patient and blaming staff for doing their job). These was what I encountered in my neuro prac.I felt really nervous when the carer stood aside watching me treating his wife. Lucky enough, nothing happened that afternoon, he was quiet through the session. But what happen if the patient's carer started to interfere with our treatment...what strategies we can use to handle the situation? do we just clear the patient's carer from the sene or do we stop the treatment and discuss the issue with the carer? Is there any support/service available for patient's family to relief their carer stress?
What will be the best strategies we can use if some patient's carer showed signs of carer stress (abusing verbally to patient and complianing about slow progress of patient and blaming staff for doing their job). These was what I encountered in my neuro prac.I felt really nervous when the carer stood aside watching me treating his wife. Lucky enough, nothing happened that afternoon, he was quiet through the session. But what happen if the patient's carer started to interfere with our treatment...what strategies we can use to handle the situation? do we just clear the patient's carer from the sene or do we stop the treatment and discuss the issue with the carer? Is there any support/service available for patient's family to relief their carer stress?
Complicated case
A patient with multiple small strokes (mainly on prietal lobes and frontal lobes) was admitted to my ward. Talking to my supervisor we agreed that the patient presented a mixture of Parkinsonism (patient couldnt stop herself during walking and need to remind the patient to "plan ahead" during transfers or negotiating obsticles during gait), cerebellar ataxia (ataxic gait, central vestibular dysfunction evidenced by occular nerve pulsy, nystagmus and symptoms of dizziness), and frontal lobe behaviors (lack of insigt, very impulsive).However, she ambulated inderpendently (poor balance, but adequate saving response, she walked like she was drunk-she said she felt like she was on a boat when she walked). I had no idea where and how to start to treat this lady. Functionally,she was fine because she doesnt need any assistance. But her gait movement was really astonishing...The treatment I gave her was education on how to rise from floor and I gave her ankle weights to practice walking with. The theory behind using ankle weights was weights would reduce ataxia. Result of 6 minute walk test showed her improvement (from 28 to 16 seconds). But still, I would never feel that I did a good job because quality of her gait was really poor. I wondered if any neuro out patient would be interested to treat her because her functional level is very high...What is your suggestion? where can I go from here? do I just discharge her and offer her some nonspecific community class to attend?
stroke pt with WZF
I had a patient recently admitted to ward for a small stroke. She fractured her hip and had a DHS 3 month prior to current admission. She had been walking with a WZF since the DHS incert. I felt hard to treat this patient because I was tought in neuro placement that we should restore normal movement of the patient esp at acute stage. For instance, using a WZF is not restoring normal movement... What shall I do with this patient? She wasnt capable to walk independly prior to stroke. So walking with aids should be the goal of my gait retraining? But is walking with aids going to maximize patient's chance of recovery in terms of her lower limb function and core stability?
Motivation
A patient admitted to my ward with active gout and he was await for a placement to hostel. Knowing that he would end up in a hostel, the patient tended to rely nursing staff to do ADL's for him and reluctant to initiate any althought that he was capable. At physio section, the patient was polite enough to be compliant but I feel that the patient is just doing the exercises for me because he was mouning all the time and really reluctant to do the exercises. I discussed this issue with the clinical tutor and we decided that I would need to change my communication skills and emphasize the importance of independence and link exercise to functional goals.
My way of approach was like this:
I acknoledged to patient that he would go to a hostel where there staff for basic help. But the level of assistance he would get in the hostel would be much lower than in the ward. And even if he would get the same level of assistance in the hostel, however, I suggested that it would be simply nice to do things by yourself like going to toilet, getting your self a cuppa, walking to dinning room and socializing with new friends in hostel. Then I re-introduced each of the old exercises to the patient with spacific functional goals eg practiced waling is for walking to dinning room or visiting friends in other room in the hostel. I felt that patient's motivation was boost significantly and he was really trying hard to do the exercise with me FOR HIMSELF. How great was that!
My way of approach was like this:
I acknoledged to patient that he would go to a hostel where there staff for basic help. But the level of assistance he would get in the hostel would be much lower than in the ward. And even if he would get the same level of assistance in the hostel, however, I suggested that it would be simply nice to do things by yourself like going to toilet, getting your self a cuppa, walking to dinning room and socializing with new friends in hostel. Then I re-introduced each of the old exercises to the patient with spacific functional goals eg practiced waling is for walking to dinning room or visiting friends in other room in the hostel. I felt that patient's motivation was boost significantly and he was really trying hard to do the exercise with me FOR HIMSELF. How great was that!
Movement analysis
A petient was accepted for gerontology assessment in my ward for frequent falls. I did the routin assessment which is filling the geriatric assessment form for her. Her glute med strength in sidying position was definately a grade 4+ and no pelvic drop in single leg stance position. so I presume that her glude med was fine. However, my clinical tutor picked up that she had a compensated trendelenberg sign. The reason I failed to identified patient's weak glute med is that I failed to check patient's alignment as a whole ie shoulder over pelvic, relation of pelvic and CoG etc... and I was only looking for signs ie "pelvic drop".
Treatment conducted based on the diagnosis that patient had a weak glute med was very successful and patient's balance and confidence improve rapidly. I really think that as a PT, I need to make sure that analyse patient's movement as a whole not just focusing on signs.
Treatment conducted based on the diagnosis that patient had a weak glute med was very successful and patient's balance and confidence improve rapidly. I really think that as a PT, I need to make sure that analyse patient's movement as a whole not just focusing on signs.
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