SITUATION:
My patient, Mr M, was 58 year old male who suffered a left sided MCA infarct three months ago. He has been undergoing intensive rehabilitation at Shenton Park Hospital since then with great success. At present his main impairments are in speech, as he has severe expressive dysphasia and mild receptive dysphasia, reduced joint range of motion into shoulder flexion, extension and abduction (with pain at end of range) and decreased muscle length of pectoralis major and latissimus dorsi on his right side. He is currently independent in all functional mobility tasks, using a step-stand transfer to transfer from chair to bed and ambulating independently without an aid over 15m but for longer distances requires a walking stick.
Before seeing this patient I was given a brief handover regarding his limited ability to communicate effectively. Mr M has extreme difficulty communicating verbally as he can only say ‘no’, and does so repetitively, with minimal ability to vary his tone of voice. His main method of communication is via hand gestures, predominantly a ‘thumbs up’, and facial expressions, always greeting people with a smile and ‘thumbs up’ combination.
TASK:
My task in this situation was to treat Mr M’s lack of range at his shoulder with mobilisation and muscle lengthening techniques. More important than this though was that I also had to establish an effective method of communication with this dysphasic patient as it was known he had pain in his shoulder and so I needed to closely monitor this throughout my treatment.
ACTIONS:
After introducing myself, my initial thought was that I needed to confirm what signals/gesture he used to say ‘yes’ and ‘no’. For Mr M, he was able to say ‘no’ and used a ‘thumbs up’ sign as ‘yes’.
After instructing the patient with verbal cues to move into supine lying, I assessed his shoulder joint range and muscle length as a baseline assessment, also noting any pain.
Mr M did get pain in his shoulder which I monitored by continually through by asking about pain to gain a yes or no response, I closely observed his facial expressions too looking for any wincing or watery eyes. Although it was difficult communicating with this patient I wanted to try and gain rapport with him and speak to him as I would other patients. To do this I used clear and concise closed questions and pointed to objects I was referring too. This was effective until he wanted to answer with more than yes/no and tried to explain things to me. I did not know what to do in this situation and it was very unclear to me what the message was he was trying to get across despite many unsuccessful guesses. At this point I had to discard what he was saying and continue with my treatment.
Mr M obviously had something that we wanted to say to me as he kept pointing to things and saying ‘no’, ‘no’, ‘no’, which got confusing as he was not using the word no in the appropriate context, making me question his use of the word previously in the session. In an attempt to understand Mr M, I brought out paper and a thick marker for him to write down what he was talking about. I thought this method was going to work well until I realised his handwriting was basically illegible and he was only able to write very simple words. Unfortunately, after multiple attempts and asking my supervisor if she could understand what he was trying to say, we were again unable to work out what he wanted. At this point I re-assessed his shoulder and concluded my treatment with him as my supervisor required my assistance with another patient.
RESULTS
Despite a successful treatment on his shoulder with the re-assessment indicating an improved range of motion my ability to communicate well with this patient was questionable. The result of my inability to find appropriate methods of communication with this patient meant that I was unable to have longer, more meaningful conversations with the patient which led to me not able to develop as good a rapport with this patient as I’ve been fortunate enough to gain with other patients. At times, Mr M also became slightly frustrated at his inability to explain himself and gave up trying to communicate with more than the signalled yes/no response.
EVALUATION
This was the first time I had been exposed to this speech impairment in the clinical setting and had not been given an opportunity to prepare for this prior to seeing the patient and I definitely believe that my communication skills were sub-optimal in this setting. In regards to my communication with this patient I felt quite disappointed in myself following this session as I thought I knew more strategies and tools I could implement to communicate with dysphasic patients. The disappointment was predominantly due to the fact that Mr M obviously had something he really wanted to be able to tell me, based on his multiple attempts, but I could not decipher what that was. On a more positive note, I do believe that I effectively established signals for yes and no which allowed me to monitor his level of pain throughout the treatment and stop when the pain got too much.
STRATEGIES
I explored a number of avenues to get more ideas on methods of effective communication with dysphasic patients. Initially I asked my supervisor (who has been treating Mr M since his admission) what methods she has found to be most effective with this patient. She suggested using pen and paper for him to try and write words, which I had tried with him, and also instead of him writing, you write words or draw images that he can recognise and say yes/no as to whether that’s what he is trying to say, for example drawing family members. I also asked my supervisor if there were any resources/handouts that she was aware of that I could read for other possible strategies I could try with this patient and for future patients.
Additionally I reviewed our university course materials on methods of communication with speech and/or cognitive impairments which I found to be very beneficial in directing me to further readings specific to dysphasic patients.
Saturday, May 29, 2010
Saturday, May 15, 2010
STARES 1; Neuro Assessment
SITUATION
My patient, Mr S, is a 63yr male who has been attending rehabilitation at Shenton Park hospital for the past 2 months following a left LACS (from an internal capsule infarct in the area of the L anterior choroidal artery), presenting with right sided ataxic hemiparesis symptoms.
From his history I expected his main impairments to be co-ordination deficits in his right upper and lower limbs possibly combined with altered tone (likely hyperreflexia) and hemianopia. Consequently, a reduced functional capacity and an inability to ambulate were also aspects I considered prior to meeting the patient.
Mr S is a very positive and motivated patient with an extremely supportive family.
Prior to his stroke he worked full time as a farmer and is very keen to get back to work and return to playing golf. From reading his progress notes, he appears to have progressed well so far with his rehab.
No discharge date has been set for the patient as yet.
TASK
Prioritised re-assessment of the patient in a 60 minute time frame identifying key measures most important to determine an initial impairment list based on my findings so that I could begin to build a treatment plan for this patient. As neuro examinations are timely I was not expected to complete the full assessment in the one session but prioritise so that the rest of the tasks could be completed in later sessions.
ACTION
After introducing myself to the patient, performing a brief subjective assessment and explaining what I was going to be doing, I began the re-assessment process.
I chose to objectively assess, time permitting, vision, co-ordination, tone, joint ROM and Gowlands motor recovery scale in my initial examination.
In an attempt to use my time effectively, I began with the vision and coordination tests with the patient sitting over the edge of the bed with their feet supported, and then I moved onto the tone and joint ROM assessments in supine and concluded with Gowlands.
Vision was an essential inclusion to ensure patient is able to see what you as therapist are doing as well as identifying any hemianopias/quadrantopias that may be present increasing the likelihood of neglect/inattention. I assessed visual field, visual acuity, eye follow, convergence and divergence to thoroughly examine if any of the cranial nerves involved in vision were affected. These tests were all negative.
The ataxic presentation required a thorough assessment of co-ordination to determine the extent of any cerebellar signs and as this was a re-assessment, whether there had been any improvements made since the initial assessment. The tests I included were rebound phenomenon, finger-thumb/heel-knee, rapid supination-pronation/toe-tap, finger-nose/heel-shin, pendular reflexes and bridging. I examined the unaffected side first to have a reference point as to what was probably normal for the patient. I then moved to the affected signs where Mr S demonstrated a mild level of co-ordination difficulties with the right upper limb and a moderate level in his right lower limb.
As patients with ataxia often fix their limbs to feel safe and supported, assessing tone and joint ROM to determine if any specific areas were becoming stiff and sore, potentially limiting function, had arisen I believed was very important. I was most concerned with the shoulder and hip joints as they are most at risk of developing further musculoskeletal complications if tone is increased and joint ROM is lost.
Due to the time limitations I only assessed tone, using the Tardieu scale, in key muscles which in the upper limb were biceps, triceps and wrist and finger flexors; and in the lower limb, hip adductors, hamstrings, quadriceps and gastrocnemius/soleus. The patient had increased tone in his right hip adductors (Tardieu = 2) and right plantarflexors (Tardieu = 3). I found no abnormalities in tone on the left side.
I assessed ROM in were the shoulder giving the number of degrees of flexion, abduction and external rotation and then the elbow, wrist, hip, knee and ankle stating whether the patient had full, ¾, ½, ¼, or no range in that joint. These were all assessed in supine, except for hip extension range which I assessed in prone. Reduced range into abduction and external rotation were noted on the right side but the patient did not report any pain with these movements. Reduced range was also apparent in the right ankle into dorsiflexion and hip into adduction and flexion. No loss of range was evident on the left side.
The Gowlands motor recovery scale is a measure of voluntary control which has been validated within the stroke population. This assessment also allowed me to have a general look at the patient performing functional movements as well as aspects of a balance assessment. The patient was positioned according to the standard starting instructions and although ideally I would have assessed his unaffected side first, I was running short of time so just documented that it wasn’t tested. The patient scored a 4 – postural control, 4 – leg, 2 – foot, 5 – arm, 4 – hand.
RESULTS
Although I managed to complete all the essential components (except for Gowlands on the left side) it took me 75 minutes, 15 minutes longer than the time frame I was given. Luckily the patient didn’t have any other appointments to go to so I was able to take the extra time required to finish.
My supervisor agreed with the assessment tasks I had chosen however said that for next time I should include a better assessment of functional tasks and mobility level for reassessment as his mobility status on the ward may be able to be changed.
EVALUATION
Although the assessment was completed to an adequate standard for my first attempt, there are a few things I will be able to work on and improve. Firstly, my time management skills were not the greatest, however I think the reason it took me longer than anticipated was due to the fact my handling was not ideal and I was not familiar with all the tests so lacked a degree of confidence. As a result of this I performed some tests, for example tone, a number of times to be sure I was certain of my result.
When I realised that I was running short of time, I got nervous and flustered, losing my place in the Gowlands and getting mixed up with the scoring on a couple of occasions. Although it probably didn’t contribute excessively to time, my handling was not optimal in terms of patient comfort and providing good, firm sensory input to the affected limbs.
STRATEGIES
I believe that the best strategy for me to improve my assessment skills is practice, practice, practice! Not only will this help to improve my confidence, but also have better handling skills and feel like I only need to perform an assessment once to have a definite result. With an improvement in all of these factors I think my assessment will be more efficient and not so time consuming.
Another way I plan to improve my time management is to make a list of which Gowland stages are performed in each position so the patient doesn’t have to change position all the time. I also plan to watch video of the Gowlands assessment do improve that specific aspect of my assessment.
Furthermore, I asked my supervisor if there were any resources I could revise on assessment protocols and how to be as efficient as possible, she said she would have a look and get back to me but went through specific aspects of my assessment with me which she believed could be improved.
My patient, Mr S, is a 63yr male who has been attending rehabilitation at Shenton Park hospital for the past 2 months following a left LACS (from an internal capsule infarct in the area of the L anterior choroidal artery), presenting with right sided ataxic hemiparesis symptoms.
From his history I expected his main impairments to be co-ordination deficits in his right upper and lower limbs possibly combined with altered tone (likely hyperreflexia) and hemianopia. Consequently, a reduced functional capacity and an inability to ambulate were also aspects I considered prior to meeting the patient.
Mr S is a very positive and motivated patient with an extremely supportive family.
Prior to his stroke he worked full time as a farmer and is very keen to get back to work and return to playing golf. From reading his progress notes, he appears to have progressed well so far with his rehab.
No discharge date has been set for the patient as yet.
TASK
Prioritised re-assessment of the patient in a 60 minute time frame identifying key measures most important to determine an initial impairment list based on my findings so that I could begin to build a treatment plan for this patient. As neuro examinations are timely I was not expected to complete the full assessment in the one session but prioritise so that the rest of the tasks could be completed in later sessions.
ACTION
After introducing myself to the patient, performing a brief subjective assessment and explaining what I was going to be doing, I began the re-assessment process.
I chose to objectively assess, time permitting, vision, co-ordination, tone, joint ROM and Gowlands motor recovery scale in my initial examination.
In an attempt to use my time effectively, I began with the vision and coordination tests with the patient sitting over the edge of the bed with their feet supported, and then I moved onto the tone and joint ROM assessments in supine and concluded with Gowlands.
Vision was an essential inclusion to ensure patient is able to see what you as therapist are doing as well as identifying any hemianopias/quadrantopias that may be present increasing the likelihood of neglect/inattention. I assessed visual field, visual acuity, eye follow, convergence and divergence to thoroughly examine if any of the cranial nerves involved in vision were affected. These tests were all negative.
The ataxic presentation required a thorough assessment of co-ordination to determine the extent of any cerebellar signs and as this was a re-assessment, whether there had been any improvements made since the initial assessment. The tests I included were rebound phenomenon, finger-thumb/heel-knee, rapid supination-pronation/toe-tap, finger-nose/heel-shin, pendular reflexes and bridging. I examined the unaffected side first to have a reference point as to what was probably normal for the patient. I then moved to the affected signs where Mr S demonstrated a mild level of co-ordination difficulties with the right upper limb and a moderate level in his right lower limb.
As patients with ataxia often fix their limbs to feel safe and supported, assessing tone and joint ROM to determine if any specific areas were becoming stiff and sore, potentially limiting function, had arisen I believed was very important. I was most concerned with the shoulder and hip joints as they are most at risk of developing further musculoskeletal complications if tone is increased and joint ROM is lost.
Due to the time limitations I only assessed tone, using the Tardieu scale, in key muscles which in the upper limb were biceps, triceps and wrist and finger flexors; and in the lower limb, hip adductors, hamstrings, quadriceps and gastrocnemius/soleus. The patient had increased tone in his right hip adductors (Tardieu = 2) and right plantarflexors (Tardieu = 3). I found no abnormalities in tone on the left side.
I assessed ROM in were the shoulder giving the number of degrees of flexion, abduction and external rotation and then the elbow, wrist, hip, knee and ankle stating whether the patient had full, ¾, ½, ¼, or no range in that joint. These were all assessed in supine, except for hip extension range which I assessed in prone. Reduced range into abduction and external rotation were noted on the right side but the patient did not report any pain with these movements. Reduced range was also apparent in the right ankle into dorsiflexion and hip into adduction and flexion. No loss of range was evident on the left side.
The Gowlands motor recovery scale is a measure of voluntary control which has been validated within the stroke population. This assessment also allowed me to have a general look at the patient performing functional movements as well as aspects of a balance assessment. The patient was positioned according to the standard starting instructions and although ideally I would have assessed his unaffected side first, I was running short of time so just documented that it wasn’t tested. The patient scored a 4 – postural control, 4 – leg, 2 – foot, 5 – arm, 4 – hand.
RESULTS
Although I managed to complete all the essential components (except for Gowlands on the left side) it took me 75 minutes, 15 minutes longer than the time frame I was given. Luckily the patient didn’t have any other appointments to go to so I was able to take the extra time required to finish.
My supervisor agreed with the assessment tasks I had chosen however said that for next time I should include a better assessment of functional tasks and mobility level for reassessment as his mobility status on the ward may be able to be changed.
EVALUATION
Although the assessment was completed to an adequate standard for my first attempt, there are a few things I will be able to work on and improve. Firstly, my time management skills were not the greatest, however I think the reason it took me longer than anticipated was due to the fact my handling was not ideal and I was not familiar with all the tests so lacked a degree of confidence. As a result of this I performed some tests, for example tone, a number of times to be sure I was certain of my result.
When I realised that I was running short of time, I got nervous and flustered, losing my place in the Gowlands and getting mixed up with the scoring on a couple of occasions. Although it probably didn’t contribute excessively to time, my handling was not optimal in terms of patient comfort and providing good, firm sensory input to the affected limbs.
STRATEGIES
I believe that the best strategy for me to improve my assessment skills is practice, practice, practice! Not only will this help to improve my confidence, but also have better handling skills and feel like I only need to perform an assessment once to have a definite result. With an improvement in all of these factors I think my assessment will be more efficient and not so time consuming.
Another way I plan to improve my time management is to make a list of which Gowland stages are performed in each position so the patient doesn’t have to change position all the time. I also plan to watch video of the Gowlands assessment do improve that specific aspect of my assessment.
Furthermore, I asked my supervisor if there were any resources I could revise on assessment protocols and how to be as efficient as possible, she said she would have a look and get back to me but went through specific aspects of my assessment with me which she believed could be improved.
Saturday, May 8, 2010
Neuro prac: Initial entry
After having the last five weeks off to do my Honours project I am anxious but very much looking forward to getting back to the clinical side of things. When I found out that my Neuro placement was going to be on Ward 2 at Shenton Park I was really pleased. I have heard that although this placement is challenging it is also very rewarding.
In what will be the third round of rotations I believe that my clinical supervisors will have higher expectations in terms of professionalism, communication, time management and other transferable clinical skills. I think that these attributes are essential to demonstrate from day 1 to make a good first impression. Having a thorough knowledge of neuroanatomy will be also a key to knowing what type of deficits to expect in a patient before seeing them.
I am aware that I will be expected to be competent with neurological assessments, which is probably the area I feel least confident about. This is mainly due to the fact that I have never worked with stroke patients before and despite the practice I have done on 'normals', I know it's going to be a extremely different on the ward and will require the ability to prioritise assessments and make modifications for each individual.
As well as assessment, another area which I feel that I may lack some practice in is transfers of Neuro patients. Similarly, despite the extensive practice of transfers we have had in various labs over the years, I have found that when I’m put into the situation I am focused on the patient and often forget basic manual handling postures. I think this will be vital to remember in this prac due to the safety aspect involved for not only the patient but also myself.
One area which I think physios working in this field have a key role in is motivating the patient. This will involve me communicating with the patient and their family, as well as other staff members to form goals that are achievable and relevant to the patient. I see goal setting as a key aspect of management in this patient group as the progress is often very slow and treatment sessions long, up to three hours I’m told! As a result of this it’s important to have something the patient can focus on and aim towards plus see the improvements they are making. I think this is especially relevant at Shenton Park as the patients are relatively very young and most often have great rehabilitation potential. I am hoping that my previous experiences in working in multidisciplinary teams and involving families in patient care will assist me in this area.
On the whole, I don’t feel entirely confident with my abilities in a Neuro field but I think my previous clinical experiences will provide a good foundation for me to start from and improve when I am placed into the specific environment and have a better understanding the area. From this prac I hope to develop efficient and thorough assessment skills, improve my skills of patient goal setting and motivation as well as by the end of the placement feel confident in developing comprehensive treatment plans for any individual patient.
In what will be the third round of rotations I believe that my clinical supervisors will have higher expectations in terms of professionalism, communication, time management and other transferable clinical skills. I think that these attributes are essential to demonstrate from day 1 to make a good first impression. Having a thorough knowledge of neuroanatomy will be also a key to knowing what type of deficits to expect in a patient before seeing them.
I am aware that I will be expected to be competent with neurological assessments, which is probably the area I feel least confident about. This is mainly due to the fact that I have never worked with stroke patients before and despite the practice I have done on 'normals', I know it's going to be a extremely different on the ward and will require the ability to prioritise assessments and make modifications for each individual.
As well as assessment, another area which I feel that I may lack some practice in is transfers of Neuro patients. Similarly, despite the extensive practice of transfers we have had in various labs over the years, I have found that when I’m put into the situation I am focused on the patient and often forget basic manual handling postures. I think this will be vital to remember in this prac due to the safety aspect involved for not only the patient but also myself.
One area which I think physios working in this field have a key role in is motivating the patient. This will involve me communicating with the patient and their family, as well as other staff members to form goals that are achievable and relevant to the patient. I see goal setting as a key aspect of management in this patient group as the progress is often very slow and treatment sessions long, up to three hours I’m told! As a result of this it’s important to have something the patient can focus on and aim towards plus see the improvements they are making. I think this is especially relevant at Shenton Park as the patients are relatively very young and most often have great rehabilitation potential. I am hoping that my previous experiences in working in multidisciplinary teams and involving families in patient care will assist me in this area.
On the whole, I don’t feel entirely confident with my abilities in a Neuro field but I think my previous clinical experiences will provide a good foundation for me to start from and improve when I am placed into the specific environment and have a better understanding the area. From this prac I hope to develop efficient and thorough assessment skills, improve my skills of patient goal setting and motivation as well as by the end of the placement feel confident in developing comprehensive treatment plans for any individual patient.
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