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.
Saturday, May 29, 2010
STARES #2: Communication
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.
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 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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