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.
Tuesday 20 November 2007
Importance of the Allied Health Team
I had the opportunity to spend a lot of time on my rural prac working very closely with paediatric OT’s and SP. The team feeling on prac was amazing. Everyone had their role and was valued by the other team members. Weekly meetings were held to discuss common children and prioritise current issues so as not to overwhelm families with too much information from different allied teams. Often there would be joint treatment sessions with OT’s/SP or PT/OT or SP/PT or OT/SP/Dietetics.
I also had the opportunity to work with these various professions in different play groups. One person would lead the session for the day and coordinate the activities (a combination of gross and fine motor skills, language and communication skills, and social/behavioural skills) in preparation for these children to start kindy the following year.
I don’t think I’ve ever seen the “allied health team” at work before like I did here. And although we discuss the importance of the team approach at uni, I very rarely ever see it on prac. People tend to be too preoccupied with their goals and treatments than seeing the patient as a whole. It reinforced the need and desire to work hard towards maintaining a team approach as we begin to ready ourselves for the work force next year.
I also had the opportunity to work with these various professions in different play groups. One person would lead the session for the day and coordinate the activities (a combination of gross and fine motor skills, language and communication skills, and social/behavioural skills) in preparation for these children to start kindy the following year.
I don’t think I’ve ever seen the “allied health team” at work before like I did here. And although we discuss the importance of the team approach at uni, I very rarely ever see it on prac. People tend to be too preoccupied with their goals and treatments than seeing the patient as a whole. It reinforced the need and desire to work hard towards maintaining a team approach as we begin to ready ourselves for the work force next year.
What are our obligations to notify DCP?
What are our obligations to notify DCP?
I was recently conducting a home visit with my supervisor to see a child who was almost 12 months old and was severely delayed in his motor development. He was as yet unable to roll between supine and prone, was only just starting to sit independently.
The child is the youngest of 6 children (aged up to 17) and all children are still living at home. The 17 year old female recently had a child who is now 2 months old and is also living with her partner in the family home. 3 step children lived in the area and would occasionally stay. The family’s financial situation was very poorly and on initially entering the house I observed a lot of rubbish and old mail and broken furniture that would be dangerous to young children.
As we continued our assessment of the child, I noticed a dark spot in the child’s fair coloured hair. On closer look it was a flea. We found several others on the child’s body. The mother was extremely embarrassed by this and apologetic. We completed our assessment and left.
Following this I was discussing with my supervisor if the family accessed appropriate support services and whilst they were known to local services the family often did not attend appointments. I continued to ask further questions as to what our obligations to notify services such as Dept of Child Protection about the living conditions and the fact that flea’s were found on the baby. My supervisor defended the mother as she believed she was trying to do the right thing by her family but wasn’t getting help from her partner that had led to this situation. Despite this I continue to be concerned by what I saw…maybe there are other families living in worse conditions (I was recently in Derby and did some worse housing conditions) however I did not feel it was safe for a child to live in that environment.
Since the subject was closed in my supervisor’s mind I couldn’t ask the question…what are our obligations to notify DCP?
Weeks later and I still wonder about this poor child.
I was recently conducting a home visit with my supervisor to see a child who was almost 12 months old and was severely delayed in his motor development. He was as yet unable to roll between supine and prone, was only just starting to sit independently.
The child is the youngest of 6 children (aged up to 17) and all children are still living at home. The 17 year old female recently had a child who is now 2 months old and is also living with her partner in the family home. 3 step children lived in the area and would occasionally stay. The family’s financial situation was very poorly and on initially entering the house I observed a lot of rubbish and old mail and broken furniture that would be dangerous to young children.
As we continued our assessment of the child, I noticed a dark spot in the child’s fair coloured hair. On closer look it was a flea. We found several others on the child’s body. The mother was extremely embarrassed by this and apologetic. We completed our assessment and left.
Following this I was discussing with my supervisor if the family accessed appropriate support services and whilst they were known to local services the family often did not attend appointments. I continued to ask further questions as to what our obligations to notify services such as Dept of Child Protection about the living conditions and the fact that flea’s were found on the baby. My supervisor defended the mother as she believed she was trying to do the right thing by her family but wasn’t getting help from her partner that had led to this situation. Despite this I continue to be concerned by what I saw…maybe there are other families living in worse conditions (I was recently in Derby and did some worse housing conditions) however I did not feel it was safe for a child to live in that environment.
Since the subject was closed in my supervisor’s mind I couldn’t ask the question…what are our obligations to notify DCP?
Weeks later and I still wonder about this poor child.
Parents Handling skills of their child
I was somewhat intrigued on my prac by the number of children who presented with torticollis. What I noticed with most of these parents and spent a lot of time discussing with my supervisor was the parent’s poor handling skills.
A lot of parents noted that they placed their child on their stomach for ‘tummy time’ however none of the parents we saw would roll their child to place them in prone, but would lift them in an almost A-P direction, turn them then place them down on their stomach. Additionally when going to pick up their child, very few added any rotation to the movement. For most of these children they did not know how to roll or reposition themselves as they are never given an opportunity to do so. I was amazed by the number of parents who did not appear comfortable positioning/handling their child and verbally expressed their lack of confidence in doing so…
With demonstration and practice of some handling techniques involving how to roll and pick up their child differently, most parents would come back the next week and tell us how much their child had improved and would now roll to both sides and was now more comfortable in turning their head to both sides as well. The parents also told us how they now felt more comfortable in handling their child and placing them in varying holds and play positions.
In this age with fewer siblings, or fewer family members around (parents/grandparents), are we lacking the opportunities to play and hold little babies anymore and learn these basic skills?
A lot of parents noted that they placed their child on their stomach for ‘tummy time’ however none of the parents we saw would roll their child to place them in prone, but would lift them in an almost A-P direction, turn them then place them down on their stomach. Additionally when going to pick up their child, very few added any rotation to the movement. For most of these children they did not know how to roll or reposition themselves as they are never given an opportunity to do so. I was amazed by the number of parents who did not appear comfortable positioning/handling their child and verbally expressed their lack of confidence in doing so…
With demonstration and practice of some handling techniques involving how to roll and pick up their child differently, most parents would come back the next week and tell us how much their child had improved and would now roll to both sides and was now more comfortable in turning their head to both sides as well. The parents also told us how they now felt more comfortable in handling their child and placing them in varying holds and play positions.
In this age with fewer siblings, or fewer family members around (parents/grandparents), are we lacking the opportunities to play and hold little babies anymore and learn these basic skills?
Post Botox Guidelines
Whilst on rural prac, I spent most of time working in paediatric community physiotherapy. One of the most common conditions I was working with was Cerebral Palsy (CP): spastic diplegic/quadriplegic of varying severity. We had several children referred from PMH post botox treatment (each had injections into either gastroc or hamstrings). They were referred with an attaching form asking for “intensive physiotherapy”.
However on further investigation, no one seemed to know what the best practice/guidelines for physiotherapy treatment was post botox. I spoke to PMH, TCCP and various other experienced paediatric physiotherapists. Each had their own idea of treatments (techniques, frequency, duration of therapy) but with no consensus.
I then proceeded to do a literature review to investigate the recent research into this area. Although there is a lot of literature about the benefits and best practice for botox injections there is very little information about physiotherapy input. Almost every article recognised the importance of physiotherapy and other allied health input, stressing that botox should only be used as an adjunct to physiotherapy, however as to what type of physiotherapy is best is not clear.
Obviously, maintaining muscle length, muscle strength and gait re-education are all important, but how do you justify to a government agency that a child needs 3 x week input of 45-60 mins of therapy for 6 weeks to maintain and improve the gains from botox injections. How do we treat according to evidence based practice when there is none. There is a variety of ideas about physiotherapy post botox, inlcuding:
Duration: between 4 weeks of “intensive” or “comprehensive” intervention up to 8 months.
Frequency: 1 x week up to 7 x week
Types of intervention (not specific): strength, balance, stretching, gait reeducation, functional training (no indications of strength reps or sets or even which muscle group – often suggested you need to strengthen the botoxed muscle as much as its antagonist)
Therefore, we saw our clients 1 x week for 60mins to monitor gait, ROM, muscle length, and took them through strengthening exercises (concentric and eccentric) and provided a home exercise program. The plan is to provide treatment over a six week block. At that point in time, there were not the resources to be able to provide further therapy. My supervisor plans to conduct her own informal research and see what improvements she gains/maintains by conducting relatively similar treatment protocols (type, frequency, duration).
Whilst very few conclusions can be drawn from the lit review about best practice post botox, it does indicate an area that is lacking…maybe a good research project for the future…..?
However on further investigation, no one seemed to know what the best practice/guidelines for physiotherapy treatment was post botox. I spoke to PMH, TCCP and various other experienced paediatric physiotherapists. Each had their own idea of treatments (techniques, frequency, duration of therapy) but with no consensus.
I then proceeded to do a literature review to investigate the recent research into this area. Although there is a lot of literature about the benefits and best practice for botox injections there is very little information about physiotherapy input. Almost every article recognised the importance of physiotherapy and other allied health input, stressing that botox should only be used as an adjunct to physiotherapy, however as to what type of physiotherapy is best is not clear.
Obviously, maintaining muscle length, muscle strength and gait re-education are all important, but how do you justify to a government agency that a child needs 3 x week input of 45-60 mins of therapy for 6 weeks to maintain and improve the gains from botox injections. How do we treat according to evidence based practice when there is none. There is a variety of ideas about physiotherapy post botox, inlcuding:
Duration: between 4 weeks of “intensive” or “comprehensive” intervention up to 8 months.
Frequency: 1 x week up to 7 x week
Types of intervention (not specific): strength, balance, stretching, gait reeducation, functional training (no indications of strength reps or sets or even which muscle group – often suggested you need to strengthen the botoxed muscle as much as its antagonist)
Therefore, we saw our clients 1 x week for 60mins to monitor gait, ROM, muscle length, and took them through strengthening exercises (concentric and eccentric) and provided a home exercise program. The plan is to provide treatment over a six week block. At that point in time, there were not the resources to be able to provide further therapy. My supervisor plans to conduct her own informal research and see what improvements she gains/maintains by conducting relatively similar treatment protocols (type, frequency, duration).
Whilst very few conclusions can be drawn from the lit review about best practice post botox, it does indicate an area that is lacking…maybe a good research project for the future…..?
Monday 19 November 2007
X-Rays
As far as X-ray's are concerned can anyone please clarify exactly where we as physio's stand? I have received conflicting answers from a variety of sources. Some people saying that we can order them, but then they aren't covered by medicare, and others saying that it's better coming from a physio and if we believe it's warrented it should be done? I think the former sounds more familiar.
Recently I have come across three situations in which I believed an X-ray necessary. One patient had a fall and the next day started to complain of hip pain (worse than he had the previous day); secondly a lady presented to the outpatients department with a severe 'ankle sprain' which was very bruised and with some tingling in the toes a few days on; thirdly a lady with CVA and consequent global aphasia with very internally rotated hip, no increase in adductor tone and obvious pain (facial expressions) on hip and knee flexion - she however pointed to her knee as the source of the pain. The third case in particular was rather worrying and both my supervisor and I thought that an Xray to exclude dislocation of the hip, or infact a knee problem, was warrented. The nurses said I could order the Xray but agreed to inform the Doctor for me anyway, and the next day and X-ray was ordered and performed.
We are in a unique position to screen for if not diagnose fractures and dislocations, due to the fact our science is largely movement based. So once again I pose the question? Can we order X-rays? Secondly is it better for the patients hip pocket if we don't?
Recently I have come across three situations in which I believed an X-ray necessary. One patient had a fall and the next day started to complain of hip pain (worse than he had the previous day); secondly a lady presented to the outpatients department with a severe 'ankle sprain' which was very bruised and with some tingling in the toes a few days on; thirdly a lady with CVA and consequent global aphasia with very internally rotated hip, no increase in adductor tone and obvious pain (facial expressions) on hip and knee flexion - she however pointed to her knee as the source of the pain. The third case in particular was rather worrying and both my supervisor and I thought that an Xray to exclude dislocation of the hip, or infact a knee problem, was warrented. The nurses said I could order the Xray but agreed to inform the Doctor for me anyway, and the next day and X-ray was ordered and performed.
We are in a unique position to screen for if not diagnose fractures and dislocations, due to the fact our science is largely movement based. So once again I pose the question? Can we order X-rays? Secondly is it better for the patients hip pocket if we don't?
Communication skills
I thought that my communication skill has improved immensely over this year but that was until I met my last patient on my last prac. She has been complaining of LL weakness and sensation chances and recently had a fall and admitted to hospital. She showed signs of demyelination after a EMG was performed. But the horror was that she spoke no English at all.
This little but quite voluptous asian lady would be slumped in her bed everytime I saw her and in the nursing notes it would describe that she refuse to cooperate. The challenge was to explain to her that she needs to get up and moving or at least sitting upright in a chair but without using English. I drew stick figures and made some very interesting gestures but all I managed to get out of her was a smile as if 'you want me to do that, no way!' I had such a difficult time with her to get her to move. I spoke to my supervisors but they came up with the same techniques but they did ellaborate on handling skills. My supervisor told me that in order to get someone to move just the hand placements will be sufficient enough to guide them. But the issue with this lady is that she doesn't want to move, she quite like the idea of being provided for...any thoughts on this?
This little but quite voluptous asian lady would be slumped in her bed everytime I saw her and in the nursing notes it would describe that she refuse to cooperate. The challenge was to explain to her that she needs to get up and moving or at least sitting upright in a chair but without using English. I drew stick figures and made some very interesting gestures but all I managed to get out of her was a smile as if 'you want me to do that, no way!' I had such a difficult time with her to get her to move. I spoke to my supervisors but they came up with the same techniques but they did ellaborate on handling skills. My supervisor told me that in order to get someone to move just the hand placements will be sufficient enough to guide them. But the issue with this lady is that she doesn't want to move, she quite like the idea of being provided for...any thoughts on this?
difficulty running class
I run/ ran weekly pre-primary balance/strength/coordination classes at prac. There are 6 kids in each class and we run a circuit type of class which required at least one person supervising at each station. We routinely run into issues regarding parent help with the activities especially in the last week. One of the parents with twins in the class told me that "she was here to gassbag and not be our slaves",two of the others went out to smoke and one other staued in the waiting room, leaving 2 mothers to help as out over 6 stations. The session ended up being really hectic as we had to continually run around checking for child safety and technique. My supervisor was going to say something to the parents about their lack of help, but chose not to in the end. She said since I was running the class I could have said something along the lines of could you please help out more during the next week, but I didn't feel like it would have been appropriate for a student who doesn't have any kids etc to say something like that. Would you guys agree, or would you have said something?
Friday 16 November 2007
Impingement
In the last three weeks alone I have had three patients present to me with cervical and shoulder pain – all with classic shoulder impingement symptoms. For these patients I have found that the lower traps exercises are good, and mostly they are compliant with completing them. All presented with cervical 'stiffness', but on PAIVM assessment it was more the thoracic vertebrae showing signs of hypomobility. Treatment included mobilisation to the thoracic spine, soft tissue massage to the affected area, and a home exercise program including lower traps exercises and postural re-education. All three patients responded favourably within one week, and are continuing to improve on both a subjective and objective level. My supervisor reported that thoracic mob's can often work wonders, especially when all else has failed with nerve symptoms, for example tingling in the hands, which you would think would respond to cervical work, when it doesn't thoracic mobs sometimes help. He reported this may be due to the fact that all sympathetic nerve fibers originate from the thoracic spine, whereas the parasympathetic nerves come from the cervical and lumbosacral spine. Has anyone else found this whilst on clinic?
Pts and their notes
Hello all,
This week I saw a pt who had had surgical repair on his flexor tendons after punching his fist through a window. Prior to seeing him, I had a look in his medical notes, which reported that alcohol was involved and there was a domestic dispute. From this information, I wasn't all that keen to see him, especially as he was booked in for my final assessment with my Clinical Tutor. However, during the assessment, I asked how the injuries happened, and he explained that he had an argument with his sister and he punched his hand through a window. He was very remorseful, and said that he would give anything to be able to change what happened. He was very keen to be doing exactly what we told him, and was very compliant. What I learnt from this: don't judge pts by their notes, always ask them what happened because it may be different to what you assume from the limited information in the notes. Everyone makes mistakes, and we as physios are not there to judge people, but to treat them and help them.
This week I saw a pt who had had surgical repair on his flexor tendons after punching his fist through a window. Prior to seeing him, I had a look in his medical notes, which reported that alcohol was involved and there was a domestic dispute. From this information, I wasn't all that keen to see him, especially as he was booked in for my final assessment with my Clinical Tutor. However, during the assessment, I asked how the injuries happened, and he explained that he had an argument with his sister and he punched his hand through a window. He was very remorseful, and said that he would give anything to be able to change what happened. He was very keen to be doing exactly what we told him, and was very compliant. What I learnt from this: don't judge pts by their notes, always ask them what happened because it may be different to what you assume from the limited information in the notes. Everyone makes mistakes, and we as physios are not there to judge people, but to treat them and help them.
Thursday 15 November 2007
Patients getting worse
My fellow student and I were treating a man for "chest physio" post MBA and pneumothorax. He spent a week on the ward and during that time, he was extreemly confused and unsure of what time of day it was or how he got there. He started telling stories of incedents that were not related ot his injury. Treatment consisted of ambulation, ACBT, incentive spirometry, and ROM exercises as he was on suction for the ICC.
Within the stay, he started to improve but rapidly declined. The ICC on the left was removed. He contracted a pleural effusion on the right so another ICC had to be inserted. When we arrived on the ward this week, there was a mad rush as the patient began to crash.
He was rushed into surgery with a HR of 170 bpm and on 12L O2 via Non-Rebreathing mask. He is now ventilated in ICU. We went to see him yesterday and he is very ill. We both feel terrible because it was so hard to get him to take deep breaths (plus his sputum was frank heamoptysis!!) and had we tried different stratergies, could it have been prevented? How much of a role do we really play?
Within the stay, he started to improve but rapidly declined. The ICC on the left was removed. He contracted a pleural effusion on the right so another ICC had to be inserted. When we arrived on the ward this week, there was a mad rush as the patient began to crash.
He was rushed into surgery with a HR of 170 bpm and on 12L O2 via Non-Rebreathing mask. He is now ventilated in ICU. We went to see him yesterday and he is very ill. We both feel terrible because it was so hard to get him to take deep breaths (plus his sputum was frank heamoptysis!!) and had we tried different stratergies, could it have been prevented? How much of a role do we really play?
Doctors and getting patient to ambulate
On this, our final prac, I came across a rather interesting situation. One difficult patient, who is a long term admission, has recently been refuing to ambulate. Many different stratergies have been implemented to no avail.
The doctors have decided to offer the patient a bribe - if he walks downstairs with the physiotherapists, he is allowed to have a can of beer. How ethically correct is that? And seeing as were the ones that have to take him for that drink, can we decline if we don't approve?
The doctors have decided to offer the patient a bribe - if he walks downstairs with the physiotherapists, he is allowed to have a can of beer. How ethically correct is that? And seeing as were the ones that have to take him for that drink, can we decline if we don't approve?
Monday 12 November 2007
Getting a job
I'm not sure if I am alone in this one and I am not suggesting that the physio course has an abundence of room for more information to be squeezed in but...In trying to get a job I realised there are quite a few things I didn't know about, just basics and most things I have chatted to a lot of my supervisors throughout the year and most have been more than helpful but I just think if people have had less helpful supervisors or prehaps juniors who havent known as much about recruitment then this whole thing could be pretty tricky! I just think maybe some of the practical basics could maybe be included earlier in the semester, the careers expo was really great but I think some of the info would have been more helpful earlier. Just the really practical stuff, what to ask who? when to ask? when to send applications etc.
...Anyone else feel the same way?
...Anyone else feel the same way?
Difficult parents
On my paeds placement, I have been finding that it is the same parents that regularly fail to bring their children in for appointments. This one particular family have missed their appt 4 times in 3 weeks and when they bring their child in for treatment they constantly question what we are doing with them and why. Whilst it is good that they are asking questions, as soon as me or the senior PT explain why we are doing a certain treatment or that their child is slightly delayed in a certain area, the parents become very defensive. I completely understand how hard it must be to sit there and listen to someone say that your child is not doing things that he/she should be doing at a certain age, but it's not like we don't say it tactfully and we always point out the things they are doing well before hand. Due to the fact that they seem to miss more appointments then they attend, they don't do their child's HEP with them and everyhting we do with their child they don't like (no matter how much we explain why we're doint it), i feel as though my time would be better spent with a family that appreciate what we are doing for their child. Also, because this family dont attend regularly we are blocking up times that other clients could be getting treatment. In saying this, the child is the main focus, and they're not the one causing the issues. Just wondering if anyone has any ideas how I could manage the situation more appropriately (I have tried asking the parents what they would like me to work on with their child but they don;t know themselves).
hyperactive child
For my mid place Ax i was assessing this young boy who had suspected DCD as well as significant behavioural issues. He was very in tune with what his limitations were and as soon as he knew he couldn't do something he would play up / run off in the middle of my Ax, therefore a lot of my Ax was spent trying to calm him down and focus his attention to the tasks at hand. Whilst this Ax was going on his mum was freaking out saying that his co-ordination / behaviour was not normally as poor as he was showing during the Ax. The difficulty was that my facility tutor had asked me to fill out the entire Ax form as it was the first time that I did a full sensori motor Ax but the Ax procedure is long and rather boring for a child to complete. Needless to say, whilst i was supposed to testing half of the items the child was bouncing off the walls and I couldn't focus him back onto the tasks despite trying to make the Ax into a game and as fun as possible. At the time i felt like i was doing the best i could be doing, but after I felt as though i would have got more out of the vhild and session if I picked out the key areas first and just Axd those parts. I also would have been able to chat to the mum more and re-assure her that her child was not doing as poorly as she thought. Any thoughts on juggling the pt and the carer at the same time as completing an Ax form??
Sunday 11 November 2007
CRPS
I am treating a pt at the moment who underwent a fusion of some of the carpal bones 8 weeks ago, after years of pain in the wrist. She was immobilised in plaster for 6 weeks, but all the fingers were immobilised as well, and now she has a very stiff hand. She is also very hypersensitive, and my supervisor has said that in her experience, hypersensitivity is usually one of the first signs of CRPS (chronic regional pain syndrome). I am treating her for the hypersensitivity, as well as for the decreased ROM in the hand and wrist. She also has many chronic pain behaviours, and I have been trying to not focus on the pain during our treatment sessions. I am finding this difficult, particularly as she volunteers information about the pain without me having to ask about it. I feel as though I am ignoring her when she does give me this information as I am trying to not focus on the pain. I know that this is for the pt's benefit, and that progress will be slow, however I still find it difficult because I will not really see much progress because of the limited time that we have on placement, but just have to trust that what I am doing is making a difference. But, I suppose that that isone of the reasons why we have supervisors, and that we need to make use of their knowledge and experience in treating pts. What does everyone else think?
Bargaining
I am currently on my neuro prac and have come across a young adult with an intellectual disability and severe cerebellar ataxia due to an unkown cause. He experiences severe vertigo when turning his head and is very fearful of rolling in bed due to his dysmetria. He is also fearful of standing despite adequate support. My partner and I have been trying several strategies to help overcome his fear such as aligning ourselves in his field of vision and positioning ourselves in a front on position with transfers so that he feels safe, however he still feels very fearful of falling and this means that we are often only able to get a maximum treatment session of about 15-20minutes. We feel that he would show greater improvements if we could get more time out of him, but no matter how much we bargain with him he still constantly asks to be returned to his room. Has anyone faced a similar situation and have any useful strategies for gaining his trust in us as students and therefore hopefully leading to a more productive session?
Wednesday 7 November 2007
oral dyspraxia
Sorry everyone I was going to blog while I was on my deferred overseas prac because it will probably be more interesting but I just remembered I have to comment and there is probably no point if nobody else is blogging too...so here is my 2nd delayed post.
On prac today the physios were talking about oral dyspraxia as opposed to expressive aphasia. As I understand it oral dyspraxia is when the patient knows what he/she wants to say but has trouble articulating the words voluntarily. Pts with dyspraxia apparently may be able to sing or speak in another language words that they cannot speak appropriately in English. English is apparently very hard to recall when you have dyspraxia and some patients find it easier to learn a new language, particularly one that is more phonetic. Apparently the reason singing may be easier is not completely understood, it may be to do with the rhythm or maybe because the words are already learnt and therefore more automatic. Has anyone else come across this distinction on prac? The physios suggested using singing of previously well known songs may be helpful to tap into some of that more automatic communication. Sounded interesting but I haven’t seen it in practise yet, has anyone else?
On prac today the physios were talking about oral dyspraxia as opposed to expressive aphasia. As I understand it oral dyspraxia is when the patient knows what he/she wants to say but has trouble articulating the words voluntarily. Pts with dyspraxia apparently may be able to sing or speak in another language words that they cannot speak appropriately in English. English is apparently very hard to recall when you have dyspraxia and some patients find it easier to learn a new language, particularly one that is more phonetic. Apparently the reason singing may be easier is not completely understood, it may be to do with the rhythm or maybe because the words are already learnt and therefore more automatic. Has anyone else come across this distinction on prac? The physios suggested using singing of previously well known songs may be helpful to tap into some of that more automatic communication. Sounded interesting but I haven’t seen it in practise yet, has anyone else?
Scapulothorasic posture
I have a pt, a 22 year old boy post with a TBI post MVA, with decreased truncal tone, ataxia and decreased segmental control of lumbopelvic movement among many other things. He remains in PTA and is unable to remember from one Rx session to the next. He also has marked bilateral scapular winging, thoracic stiffness and tight lats, pecs and teres. We had been focusing on his lumbopelvic mobility, increasing AP tilt and facilitating pelvic tilt within functional movement including gait and sit to stand. We have had some success in increasing his AP tilt and Lx mobility but this didn’t transfer into functional movement. Our supervisor assessed the pt with us today and suggested that working on his thoracic stability and posture and scapulothorasic posture may actually be more beneficial. We did some thoracic mobs, PNF style scapular strengthening, muscular releases and postural retraining with lateral thoracic support. I was quite surprised that this actually made a much bigger difference to sit to stand and walking ability. Our supervisor explained it that the pelvis and lumbar spine need a stable base of the scapulae and thorax to work off. Not really life-changing I know but I just thought this was interesting because I have always thought to work from the bottom up with the trunk and this was just another way to look at things.
Tuesday 6 November 2007
Elbow splints
Hi everyone,
Last week on prac (I'm doing hands at Freo), my supervisor was referred an inpt who required an elbow splint. She told me that she had never done an elbow splint before, but had seen one done. She started doing this just before I went to have lunch, and was finding it difficult. After I came back from lunch I was with my CCT, and she was still working on it. Eventually the splint was finished, but it required 3 sheets of thermoplastic material and the OT's to come and help to make the splint (the physios and OTs work together in the hand therapy clinic). The moral of the story: no matter how much clinical experience you have, there is always something you don't know how to do, and that even supervisors have their "student" moments, when they feel totally incompetent, and they have to ask someone for help. It was a bit comforting to see that someone who had a lot of clinical experience still needed to ask for help, especially as I often try to figure things out on my own, and find it difficult to ask for help.
P.S. I got to see surgery on Monday afternoon, of a repair of a Dupuytren's contracture, which was pretty cool. Then I saw the pt today (day after surgery), which was also pretty cool, because I saw what the pt was like before, during and after surgery.
Last week on prac (I'm doing hands at Freo), my supervisor was referred an inpt who required an elbow splint. She told me that she had never done an elbow splint before, but had seen one done. She started doing this just before I went to have lunch, and was finding it difficult. After I came back from lunch I was with my CCT, and she was still working on it. Eventually the splint was finished, but it required 3 sheets of thermoplastic material and the OT's to come and help to make the splint (the physios and OTs work together in the hand therapy clinic). The moral of the story: no matter how much clinical experience you have, there is always something you don't know how to do, and that even supervisors have their "student" moments, when they feel totally incompetent, and they have to ask someone for help. It was a bit comforting to see that someone who had a lot of clinical experience still needed to ask for help, especially as I often try to figure things out on my own, and find it difficult to ask for help.
P.S. I got to see surgery on Monday afternoon, of a repair of a Dupuytren's contracture, which was pretty cool. Then I saw the pt today (day after surgery), which was also pretty cool, because I saw what the pt was like before, during and after surgery.
Palliative Care
An issue that has been raised a few times throughout my rural placement has been physio’s role in palliative care. I have been asked on a few occasions to provide a falls risk assessment / mobility assessment on palliative and terminal care patients. I have at times struggled with this as in my mind, this is probably not a top priority for patients, especially if they are trying to sleep.
In the end I decided to reach a compromise. I introduced myself to one of the patients, told them what I was there to do, and gave them the option of wether or not they wanted treatment. On most occasions when the patient was sleeping I decided to come back later, however when it was evident the patient was awake I tried to do an assessment, but often didn’t really achieve even basic falls risk / mobility… in fact didn’t get past sitting. Obviously, like any patient care is warranted, and patients have the right to refuse this. The only thing I’m questioning are priorities.
Has anyone else come across a similar situation?
In the end I decided to reach a compromise. I introduced myself to one of the patients, told them what I was there to do, and gave them the option of wether or not they wanted treatment. On most occasions when the patient was sleeping I decided to come back later, however when it was evident the patient was awake I tried to do an assessment, but often didn’t really achieve even basic falls risk / mobility… in fact didn’t get past sitting. Obviously, like any patient care is warranted, and patients have the right to refuse this. The only thing I’m questioning are priorities.
Has anyone else come across a similar situation?
Monday 5 November 2007
Difficult patients
On prac, i was faced with a young man hwo had suffered a pneuomothorax following a stabbing injury. He sufferes from Bipolar disease andis a known drug addict. Earlier in the shift, it was reported that he was verbally abusive to nursing staff. He had also been for a smoke earlier with an ICC in place!!!
On approaching this patient, I was already cautious. He was sitting in bed, alert and very talkative. He continued to tell me how the pain medications he was being given were insufficient as he was an addict and needed somehting stronger. I tried to explain why he had the drain in place adn taht smoking whilst having an ICC was not appropriate. We offered nicotene patches but he was convinced he needed 2 patches as he was an addict. He continued to tell me about his habits of inserting needles into his arms and how only certain veins work.
When his family arrived, he was bragging about how 15 people had to hold him down to insert the ICC in the first place. He was easily distracted, he wouldnt listen to me and I felt very uncomfortable around him.
I chose to seek advice from my supervisor and he agreed to see this patient. I chose that I was unhappy treating this patient as I was not comfortable to get close to him. Upon reflecting, I realised that next year I would most likely have to treat this patient. Where can we draw the line? In this situation, there was someone else to treat the patient, but this might now always be the case.
On approaching this patient, I was already cautious. He was sitting in bed, alert and very talkative. He continued to tell me how the pain medications he was being given were insufficient as he was an addict and needed somehting stronger. I tried to explain why he had the drain in place adn taht smoking whilst having an ICC was not appropriate. We offered nicotene patches but he was convinced he needed 2 patches as he was an addict. He continued to tell me about his habits of inserting needles into his arms and how only certain veins work.
When his family arrived, he was bragging about how 15 people had to hold him down to insert the ICC in the first place. He was easily distracted, he wouldnt listen to me and I felt very uncomfortable around him.
I chose to seek advice from my supervisor and he agreed to see this patient. I chose that I was unhappy treating this patient as I was not comfortable to get close to him. Upon reflecting, I realised that next year I would most likely have to treat this patient. Where can we draw the line? In this situation, there was someone else to treat the patient, but this might now always be the case.
Sunday 4 November 2007
Being judgmental
I am currently on a paeds prac. Last week whilst on prac I was faced with the following situation, and from the very outset (ie reading the pt notes) I found myself being rather judgemental. From the notes and my supervisor, I was told that my 18 month old pt had been in and out of foster care from an early age. Although the babies mother had recently been found injecting herslef on a park bench at 2am in the morning WITH the child sitting next to her, she was fighting for permanent custody of her. Being fully aware of how the foster care system runs as I had a foster sister for many years whilst growing up, I was aware that the childs mother will probably be granted these rights and my supervisor confirmed my suspiscions. So, before I even met the childs parents I was thinking 'how could you do this to your child? They would be so much better off in foster care if youre on drugs etc' THEN the family walked in... my supervisor and i just looked at each other secretly going OH DEAR. The parents were swearing their pants off infront of their 18 month old, they both had their OWN pants hanging down by their knees, they stunk of smoke and alchol and had food bits dangling off them. Not to mention the fact that they were both morbidly obese but still managing to wear pretty much nothing. So at this time for one of the first times in my life I was lost for words. The little child ended up beinf one of the cutest little things I have ever met but simply delayed because she was ignored for the first 6 months of her life. As the session progressed, i found myself getting more and more annoyed because the parents didn;t even speak properly to their child and every single leyer of clothes the child had on ie 3 was covered in dirt and food and reaked of ETOH and cigarettes. Anyway, as much as i kept on telling myself to not let my frustration show, it totally did and my supervisor could tell (but luckily didn;t mind cause she was really annoyed too). Just wondering if anyone has effective stratergies to hide their unwanted feelings?
Awkward situation
On my last prac (late entery) i ran daily hydrotherapy sessions. On one occasion, one of the new pts began to reveal highly personal information to do with being abused as a child (aurthorities were aware of this). At this time there were 5 other clients also in the pool. As the session went on the details became more and more graphic and the whole class were giving their 2 cents worth, which ultimately lead to the other class members revealing their personal information, including further abuse and the likes. As the lesson went on a tried harder and harder to focus the class on their exercises to pretty much no avail. To make matters worse 2 PT assistants were sitting at the edge of the pool staring at me as if to say "do something" whilst i just stayed away from the conversation entirely whilst trying to take control of the class. I could see that some of the class members were quite awkward, but i couldn't exactly tell the person that was speaking about their abuse to quiten down. All in all, the session was quite unproductive and quite uncomfortable. Just wondering if anyone else would have handled it differently ie other than just carrying on with the session as if nothing had been said??
Thanks.
Thanks.
Saturday 3 November 2007
A cultural experience
I've been feeling like a bully recently to one of my patient on prac. This gentleman in his late 50s suffered a pontine infarct which gave him mild L sided weakness and a mild ataxic gait. He has no aphasia or perceptual deficits ,orientated to TPP and is independent on ambulation.
It all seemed straight forward when I read the notes and gathered what I'm going to do with him, until I met him. He showed severe depression and was crying in his room. He constantly repeated to me "why me, my mother/nephew/cousins died of stroke and now it's going to happen to me".
After the 1s treatment session which took ages because half the time I was trying to settle his emotions, he saw and felt some positive changes to his condition. In the next session, he all of a sudden became over confident in me as well as himself. When I took him for a walk to observe his gait, he decided, 'I'm going to get better now' and started to run without telling me. I literally had to physically restrain him and tell him "NO" like a child and yet he still struggled to continue. I never trusted him from that occasion on.
In the subsequent treatments, I made sure that specific instructions were given and that all boundaries are clear cut, but this patient still goes off on his own tangent and jeopardise his safety. His impulsive behaviour was getting to a point where I was reluctant to discharge him even though he was physically fit to go home with a HEP.
I couldn't figure out why the patient's behaving like this when I've explained infinite times about his condition, the likely prognosis and for him it was very positive after liasing with doctors. Until the OT came in and said he's Greek, which openned a whole new ballgame.
My patient's behaviour is perfectly normal for a man of his age from a greek background. He's the leader in his extended family. He doesn't want to be a burden on his family so therefore tries really hard in therapy and conseqently overestimates his abilities. Until he's tried it out for himself, he will persist. I suppose I'm generalising here a bit, but this was an interesting experience.
It all seemed straight forward when I read the notes and gathered what I'm going to do with him, until I met him. He showed severe depression and was crying in his room. He constantly repeated to me "why me, my mother/nephew/cousins died of stroke and now it's going to happen to me".
After the 1s treatment session which took ages because half the time I was trying to settle his emotions, he saw and felt some positive changes to his condition. In the next session, he all of a sudden became over confident in me as well as himself. When I took him for a walk to observe his gait, he decided, 'I'm going to get better now' and started to run without telling me. I literally had to physically restrain him and tell him "NO" like a child and yet he still struggled to continue. I never trusted him from that occasion on.
In the subsequent treatments, I made sure that specific instructions were given and that all boundaries are clear cut, but this patient still goes off on his own tangent and jeopardise his safety. His impulsive behaviour was getting to a point where I was reluctant to discharge him even though he was physically fit to go home with a HEP.
I couldn't figure out why the patient's behaving like this when I've explained infinite times about his condition, the likely prognosis and for him it was very positive after liasing with doctors. Until the OT came in and said he's Greek, which openned a whole new ballgame.
My patient's behaviour is perfectly normal for a man of his age from a greek background. He's the leader in his extended family. He doesn't want to be a burden on his family so therefore tries really hard in therapy and conseqently overestimates his abilities. Until he's tried it out for himself, he will persist. I suppose I'm generalising here a bit, but this was an interesting experience.
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