SITUATION:
My patient was a 28yr female who 30 weeks pregnant with her 2nd child. She self presented from the community with bilateral low back pain (LBP) with the left side greater than right and also experienced numbness and tingling into L buttock on occasions. Her symptoms were aggravated by prolonged standing at end of long day and eased with rest. No other abnormal sensations or muscle weakness were associated with her symptoms.
This patient had similar pain with previous pregnancy but at later stage which was effectively managed with physiotherapy a back brace for extra support.
There was no history of trauma or any change in activities that were related to the onset of her latest episode of LBP.
On physical examination, her LBP but not buttock symptoms was reproduced with extension and left side flexion and the symptoms in her left buttock provoked with a left unilateral PA on L5/S1. Sacro-iliac joint (SIJ) tests were negative, and the patient in fact felt relief with SIJ compression. Neurodynamic tests (SLR) were also negative.
My PPIVM assessment found increased movement on the left side L3-S1 into extension and left side flexion, but no reproduction of pain.
TASK:
My task was to treat this patient who I had performed the subjective and objective examination on who presented with what appeared to be a L5/S1 control dysfunction into the direction of extension/left side flexion.
ACTION:
My baseline assessment prior to treatment was the level of pain into extension and L side flexion.
As a treatment I then performed a grade III unilateral PA glide on L5/S1 transverse process for 30s and then reassessed.
Re-assessment of combined extension/left side flexion movement showed an increase of pain and worsening of symptoms into the buttock. Immediately I realised that I had not treated it as a control dysfunction bur as a mobility restriction and as a result made the patients symptoms worse.
Following this re-assessment my supervisor stepped in and completed the rest of the treatment session with the patient with me observing.
Her treatment consisted of lumbo-pelvic muscles stabilisation exercises, targeting the pelvic floor and transverse abdominus and gluteus medius.
The patient was also given these exercises as a home exercise program.
RESULT:
The final result for the patient was no dramatic reduction in pain following her physiotherapy session, but the pain that I flared up initially had settled. The stabilisation exercises were effective but will require the patient to continue with them independently for maximal benefit. I have booked the patient in for a follow-up treatment in one week’s time to reassess lumbo-pelvic control
EVALUATION
On reflection, I performed a sub-optimal treatment technique for this patient choosing to perform an incorrect manual therapy technique. Luckily for my patient however my supervisor intervened and the pain did ease following the stabilisation exercises.
I now realise that I should have picked up key features from the subjective & objective examinations as to whether it was a control or mobility problem in this patient. For example, pregnancy, relief with SIJ compression, increased movement on PPIVMs into direction of dysfunction all suggests control dysfunction.
Even though I knew which direction to treat into for a control dysfunction, when put on the spot I treated as mobility and am not sure why. I think because I was not 100%confident in my diagnosis and then where to go with treatment techniques, I fell back on manual therapies, which I got mixed up with. As a result of my confusion and being unsure of the optimal treatment for this patient, I treated her incorrectly and subsequently worsened her symptoms.
STRATEGIES
To improve on my performance with LBP patients, I revised key features of both control and mobility dysfunctions and LBP treatment algorithms.
I also went over our lab manuals and lecture notes in what were the best techniques for improving lumbo-pelvic muscle control, especially for pregnant patients.
In addition to these strategies, at the time of the situation I documented and then asked to go over with my supervisor the exercises she had done with the patient and the best way to progress those (as the patient improved.
I also reviewed my anatomy of the lumbar spine and handling during a PPIVM assessment as I feel that a lot of my uncertainties stemmed from not being confident in what I was feeling in regards to whether there was too much or not enough movement.
Furthermore, I have asked my supervisor to, when possible, feel a variety of lumbar spine patients (especially PPIVMs) to be able to appreciate the difference between normal’s and increased or decreased movement.
Friday, June 25, 2010
Friday, June 18, 2010
Inital entry - Tom Price
I’m looking forward to my time in Tom Price but expecting my musculoskeletal placement to be very challenging. I feel very under prepared and am concerned that my lack of previous experience in the musculoskeletal field will make the transition into the area more difficult. I am especially anxious about my knowledge of the lower limb and upper limb as they were very complex units we did in second year and so I’ve forgotten a lot of the specific details regarding assessment and special tests. Being able to conduct a thorough and correct physical examination will be essential to forming the best treatment plan for each individual patient and I hope that I will be given adequate time to prepare for each patient in the initial stages of this prac.
As this will be our final rotation I also expect that my supervisor will expect more from me in terms of my clinical knowledge but more so in terms of professionalism and communication with patients. I feel confident that I will be able to perform and effective and efficient subjective examination with clients due to the multitude of practice we have had in this area with clinical reasoning exams and thorough information provided to us.
Although I will be primarily based at the Tom Price Hospital I do to travel to Paraburdoo once a week to work and hopefully I will get an opportunity at some stage over the five weeks to visit local indigenous communities. This may be confronting at first but I have travelled to remote Aboriginal communities before and would really like to experience working as a health professional in these areas.
I am hoping that a lot of my skills in this area will come back to me as I get more patients but I believe my understanding of the basic principles of musculoskeletal physiotherapy will allow me to provide a good explanation of the processes to my patients and provide an acceptable initial consultation/treatment. As well as revising my notes on the area, it will be with further practice and clinical experience that my skills and knowledge base will expand.
My main role on this placement will be treatment of musculoskeletal conditions but I have been informed that I am also likely to see paediatric and women’s health patients as well as run exercise classes for older adults. A significant aspect of treatment in these areas will be active patient involvement and motivation to improve, rather than promoting passive approaches to recovery. I feel well equipped to educate patients on the importance of this and provide them with a mixture of passive treatment techniques and home exercises.
I am nervous about being so far from home and on placement in the area which I feel least confident about. However I am motivated to embrace this challenge and make the most of my musculoskeletal experience as well as my time living and working in rural Western Australia.
As this will be our final rotation I also expect that my supervisor will expect more from me in terms of my clinical knowledge but more so in terms of professionalism and communication with patients. I feel confident that I will be able to perform and effective and efficient subjective examination with clients due to the multitude of practice we have had in this area with clinical reasoning exams and thorough information provided to us.
Although I will be primarily based at the Tom Price Hospital I do to travel to Paraburdoo once a week to work and hopefully I will get an opportunity at some stage over the five weeks to visit local indigenous communities. This may be confronting at first but I have travelled to remote Aboriginal communities before and would really like to experience working as a health professional in these areas.
I am hoping that a lot of my skills in this area will come back to me as I get more patients but I believe my understanding of the basic principles of musculoskeletal physiotherapy will allow me to provide a good explanation of the processes to my patients and provide an acceptable initial consultation/treatment. As well as revising my notes on the area, it will be with further practice and clinical experience that my skills and knowledge base will expand.
My main role on this placement will be treatment of musculoskeletal conditions but I have been informed that I am also likely to see paediatric and women’s health patients as well as run exercise classes for older adults. A significant aspect of treatment in these areas will be active patient involvement and motivation to improve, rather than promoting passive approaches to recovery. I feel well equipped to educate patients on the importance of this and provide them with a mixture of passive treatment techniques and home exercises.
I am nervous about being so far from home and on placement in the area which I feel least confident about. However I am motivated to embrace this challenge and make the most of my musculoskeletal experience as well as my time living and working in rural Western Australia.
Sunday, June 13, 2010
Final Entry (NEURO)
FINAL ENTRY
Overall, I had an amazing time at Shenton Park and feel so lucky to have had such a positive neuro clinical placement. My initial anxieties were certainly unnecessary as I immediately realised, with my supervisor, tutor and other clinicians all very supportive and keen to assist my learning.
The placement was challenging. It was very confronting at first working with patients who had suffered severe strokes but I was able to not become overwhelmed and embrace this when it was obvious how much you could help these patients and there families in the recovery process.
I was also challenged theoretically by all the therapists who would often quiz me on neuroanatomy and my clinical reasoning behind a certain treatment. I had expected this and so had thoroughly revised these areas which allowed me to answer promptly and correctly as well as effectively reason with them. Having a sound background knowledge from day 1 meant that my supervisor was able to trust me with a variety of patients early on and didn’t feel the need to prompt me and question me as often in the later weeks. I enjoyed this autonomy and feel that it really enhanced my learning and enabled me to feel comfortable with trying different approaches to treatments.
Prior to starting this placement I did not feel completely confident in performing neurological assessments. Luckily, my I had expected more of myself than my supervisor and tutor who saw the placement as an opportunity to gain that experience and improve the efficiency of an assessment. It did take me the majority of the placement to feel I could perform a thorough and accurate assessment but now feel confident in this area.
I also doubted my ability to perform correct transfers before commencing this placement. As most of the patients I saw were very heavy, it was a great opportunity for me to practice dependent transfers and be the second pair of hands to learn how more experienced professionals performed transfers. Due to patients being so dependent I had to be certain of my postures as it was immediately apparent if I had not been in the best position. One factor that I had not previously considered was the positioning of the affected upper limb in stroke patients and how important this was. All patients were constantly reminded to protect their upper limb with their unaffected arm to reduce risk of any damage or pain at the shoulder joint.
One of the roles of therapists in this setting which I identified before commencing at Shenton Park, was that of patient motivation. Although I do still believe this is important and communication with family as well as the patient essential, this was not an area which I was exposed to and had any direct experience with on this prac. I also witnessed patients who lacked motivation and although his clinician tried to be encouraging, his lack of motivation made her job far more difficult and created tension between the patient and therapist. This is not ideal but I now realise there is only so much you can do to motivate and there must be active involvement by both parties.
Although I did not attend family meetings and goal setting meetings with my patients, I did my best to motivate my patients on a day to day basis, always maintaining a positive outlook and setting different short term goals with my patients week by week.
I feel that I am now possess the skills to develop efficient and thorough assessments, set timely and relevant patient goals as well as am confident in developing treatment plans for individual patient. I believe I’ll continue to improve my treatment and handling skills with further experience in this field.
Despite my uncertainties about this placement initially, I had a fantastic experience and learnt more than I ever could have imagined. I loved that I still felt challenged and was learning new skills up until my very last day. I certainly believe that my previous clinical experiences provided a good foundation for me to start building specific neuro skills on.
Overall, I had an amazing time at Shenton Park and feel so lucky to have had such a positive neuro clinical placement. My initial anxieties were certainly unnecessary as I immediately realised, with my supervisor, tutor and other clinicians all very supportive and keen to assist my learning.
The placement was challenging. It was very confronting at first working with patients who had suffered severe strokes but I was able to not become overwhelmed and embrace this when it was obvious how much you could help these patients and there families in the recovery process.
I was also challenged theoretically by all the therapists who would often quiz me on neuroanatomy and my clinical reasoning behind a certain treatment. I had expected this and so had thoroughly revised these areas which allowed me to answer promptly and correctly as well as effectively reason with them. Having a sound background knowledge from day 1 meant that my supervisor was able to trust me with a variety of patients early on and didn’t feel the need to prompt me and question me as often in the later weeks. I enjoyed this autonomy and feel that it really enhanced my learning and enabled me to feel comfortable with trying different approaches to treatments.
Prior to starting this placement I did not feel completely confident in performing neurological assessments. Luckily, my I had expected more of myself than my supervisor and tutor who saw the placement as an opportunity to gain that experience and improve the efficiency of an assessment. It did take me the majority of the placement to feel I could perform a thorough and accurate assessment but now feel confident in this area.
I also doubted my ability to perform correct transfers before commencing this placement. As most of the patients I saw were very heavy, it was a great opportunity for me to practice dependent transfers and be the second pair of hands to learn how more experienced professionals performed transfers. Due to patients being so dependent I had to be certain of my postures as it was immediately apparent if I had not been in the best position. One factor that I had not previously considered was the positioning of the affected upper limb in stroke patients and how important this was. All patients were constantly reminded to protect their upper limb with their unaffected arm to reduce risk of any damage or pain at the shoulder joint.
One of the roles of therapists in this setting which I identified before commencing at Shenton Park, was that of patient motivation. Although I do still believe this is important and communication with family as well as the patient essential, this was not an area which I was exposed to and had any direct experience with on this prac. I also witnessed patients who lacked motivation and although his clinician tried to be encouraging, his lack of motivation made her job far more difficult and created tension between the patient and therapist. This is not ideal but I now realise there is only so much you can do to motivate and there must be active involvement by both parties.
Although I did not attend family meetings and goal setting meetings with my patients, I did my best to motivate my patients on a day to day basis, always maintaining a positive outlook and setting different short term goals with my patients week by week.
I feel that I am now possess the skills to develop efficient and thorough assessments, set timely and relevant patient goals as well as am confident in developing treatment plans for individual patient. I believe I’ll continue to improve my treatment and handling skills with further experience in this field.
Despite my uncertainties about this placement initially, I had a fantastic experience and learnt more than I ever could have imagined. I loved that I still felt challenged and was learning new skills up until my very last day. I certainly believe that my previous clinical experiences provided a good foundation for me to start building specific neuro skills on.
STARES #3: Treatment
STARES #3
Treatment
SITUATION
My patient, Miss A, was a 36year old lady admitted to Shenton Park Hospital for rehabilitation following a decline in function associated with an undiagnosed neurodegenerative condition. Her condition predominantly manifests in cerebellar ataxia and cognitive dysfunction. Miss A previously lived at home alone but it is likely that because of her recent functional deterioration she may have to return to living with her parents.
The main findings from the initial objective examination were that Miss A was severely ataxic bilaterally in her upper limbs, lower limbs, head and trunk (left worse than right), presented with an intention tremor, had increased neural tone in both plantar flexors (left worse than right), slowed and ineffective balance reactions, moderate dysarthria and was very impulsive. She also has very poor sitting and standing posture as a result of compensatory over-activity in her scapula retractors, trunk extensors and neck extensors. Furthermore, she severely fixes her upper limbs against her trunk and clenches her fingers when her balance is challenged.
She is independent with bed mobility, transferring from supine to sitting, sitting over the edge of bed and sit to stand. She requires 1x minimal assistance for standing balance and 1x moderate assistance for a step-stand transfer. She is currently non-ambulant on the ward but ambulates 20m with 2x moderate assistance in physiotherapy. Miss A’s goal is to be able to walk 10m independently and return home to her unit (rather than living with her parents).
TASK
My task with Miss A was to devise an initial treatment plan for this patient who’s primary impairment was cerebellar ataxia taking into account the other results of her objective assessment and her reduced cognitive function.
ACTION
Following a brief subjective examination I began implementing my treatment program for Miss A. My main focus for the treatment was to improve proximal stability of the trunk and pelvis, to allow a more stable base for movement of the limbs to occur from. Drawing on my prior knowledge of important features of exercises for ataxic patients I tried to ensure exercises were closed chain and incorporated specific targets and reference points, as well as continually emphasising the importance of slow and controlled movement.
I started the patient in crook lying, doing various abdominal and trunk strengthening exercises and then progressed to 4 point kneeling, and reaching in 4 point kneeling then maintain balance and correct alignment in 2 point kneeling. From 2 point kneeling I chose to include more functional exercises of sit to stand and standing balance, again emphasising the need for slow movement. The session was concluded with 2x assisted ambulation of roughly 40m.
Due to Miss A’s cognitive impairment and impulsiveness she required continual verbal prompting to minimise her rushing the exercises and using incorrect movement patterns.
RESULT
The result of this treatment for Miss A was that she did appear to have improved trunk control and was aware that she needed to concentrate on slow and controlled movement, requiring less verbal cues as the session progressed.
Although she may have had improved trunk control and subsequently better gait pattern, she definitely did still require 2x moderate assistance.
EVALUATION
On reflection, I think that overall my treatment plan was good however my implementation lacked a few essential clinical skills. In hindsight I realised that Miss A was fixing a lot through her scapula retractors and cervical extensors, which I didn’t pick up on at first as I expected to see her fixing via weight bearing with her upper limbs. She also fixed with her ULs against her trunk in every position she was in despite me changing her UL placement in an attempt to minimise this.
As a result of this I allowed the patient to move and perform exercises with incorrect movements, rather than enforcing error-free practice with correct timing as should be a priorty when treating ataxic patients. The incorrect movements were also influenced by her impulsiveness and tendency to rush movements and exercises.
I now realise that I should have started with my own formal postural assessment and included techniques aimed at relaxing the overactive muscles through her neck, thorax and upper limbs. Once that was completed I then should have started with the simplest postural control exercises in crook lying until she could perform them satisfactorily and then progress, rather than continuing to progress exercises with poor and incorrect recruitment.
STRATEGIES
Strategies I used to improve my subsequent treatment sessions with Miss A were revising my musculoskeletal lab manuals and text books to gain ideas about different muscle relaxation techniques. I also asked my supervisor whether she could direct me to any good references on reducing muscle overactivity or give me any techniques she used and found effective.
I also reviewed my neurorehabilitation texts and course material to get further insight into management techniques of ataxic and impulsive/cognitively impaired patients.
From this research I came across methods to minimize fixations in ataxic patients which included making the patient feel safe, using reference points and targets to improve quality of movement as well as emphasising error-free practice with correct timing.
Treatment
SITUATION
My patient, Miss A, was a 36year old lady admitted to Shenton Park Hospital for rehabilitation following a decline in function associated with an undiagnosed neurodegenerative condition. Her condition predominantly manifests in cerebellar ataxia and cognitive dysfunction. Miss A previously lived at home alone but it is likely that because of her recent functional deterioration she may have to return to living with her parents.
The main findings from the initial objective examination were that Miss A was severely ataxic bilaterally in her upper limbs, lower limbs, head and trunk (left worse than right), presented with an intention tremor, had increased neural tone in both plantar flexors (left worse than right), slowed and ineffective balance reactions, moderate dysarthria and was very impulsive. She also has very poor sitting and standing posture as a result of compensatory over-activity in her scapula retractors, trunk extensors and neck extensors. Furthermore, she severely fixes her upper limbs against her trunk and clenches her fingers when her balance is challenged.
She is independent with bed mobility, transferring from supine to sitting, sitting over the edge of bed and sit to stand. She requires 1x minimal assistance for standing balance and 1x moderate assistance for a step-stand transfer. She is currently non-ambulant on the ward but ambulates 20m with 2x moderate assistance in physiotherapy. Miss A’s goal is to be able to walk 10m independently and return home to her unit (rather than living with her parents).
TASK
My task with Miss A was to devise an initial treatment plan for this patient who’s primary impairment was cerebellar ataxia taking into account the other results of her objective assessment and her reduced cognitive function.
ACTION
Following a brief subjective examination I began implementing my treatment program for Miss A. My main focus for the treatment was to improve proximal stability of the trunk and pelvis, to allow a more stable base for movement of the limbs to occur from. Drawing on my prior knowledge of important features of exercises for ataxic patients I tried to ensure exercises were closed chain and incorporated specific targets and reference points, as well as continually emphasising the importance of slow and controlled movement.
I started the patient in crook lying, doing various abdominal and trunk strengthening exercises and then progressed to 4 point kneeling, and reaching in 4 point kneeling then maintain balance and correct alignment in 2 point kneeling. From 2 point kneeling I chose to include more functional exercises of sit to stand and standing balance, again emphasising the need for slow movement. The session was concluded with 2x assisted ambulation of roughly 40m.
Due to Miss A’s cognitive impairment and impulsiveness she required continual verbal prompting to minimise her rushing the exercises and using incorrect movement patterns.
RESULT
The result of this treatment for Miss A was that she did appear to have improved trunk control and was aware that she needed to concentrate on slow and controlled movement, requiring less verbal cues as the session progressed.
Although she may have had improved trunk control and subsequently better gait pattern, she definitely did still require 2x moderate assistance.
EVALUATION
On reflection, I think that overall my treatment plan was good however my implementation lacked a few essential clinical skills. In hindsight I realised that Miss A was fixing a lot through her scapula retractors and cervical extensors, which I didn’t pick up on at first as I expected to see her fixing via weight bearing with her upper limbs. She also fixed with her ULs against her trunk in every position she was in despite me changing her UL placement in an attempt to minimise this.
As a result of this I allowed the patient to move and perform exercises with incorrect movements, rather than enforcing error-free practice with correct timing as should be a priorty when treating ataxic patients. The incorrect movements were also influenced by her impulsiveness and tendency to rush movements and exercises.
I now realise that I should have started with my own formal postural assessment and included techniques aimed at relaxing the overactive muscles through her neck, thorax and upper limbs. Once that was completed I then should have started with the simplest postural control exercises in crook lying until she could perform them satisfactorily and then progress, rather than continuing to progress exercises with poor and incorrect recruitment.
STRATEGIES
Strategies I used to improve my subsequent treatment sessions with Miss A were revising my musculoskeletal lab manuals and text books to gain ideas about different muscle relaxation techniques. I also asked my supervisor whether she could direct me to any good references on reducing muscle overactivity or give me any techniques she used and found effective.
I also reviewed my neurorehabilitation texts and course material to get further insight into management techniques of ataxic and impulsive/cognitively impaired patients.
From this research I came across methods to minimize fixations in ataxic patients which included making the patient feel safe, using reference points and targets to improve quality of movement as well as emphasising error-free practice with correct timing.
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