Situation
I was presented with a patient who had been referred for physiotherapy assessment following a fall 5/52 ago and subsequent admission to Fremantle Hospital for head trauma and minor soft tissue injuries to his left arm. No issues were found upon assessment at hospital. The patient had fallen in his kitchen when attempting to reach an object at height and had fallen over due to “loss of balance”. The individual had fallen 2 weeks prior to this incident when he tripped over an object on the ground. No injuries occurred on this occasion. The patient lives at home alone but receives assistance for all DADLs every day and is independent with most PADLs. He has a daughter and friend close by who also assist and transport him as required. There are 3 x single steps in his house with rails next to all. He attends weekly exercise classes at the local recreation centre and is able to walk approximately 80m before becoming fatigued and requiring a rest. The main focus of the referral is to treat for decreasing functionality & impaired balance as required. The patient’s physiotherapy focused goal is to improve his balance and confidence with walking/activity.
Task
It was my task to determine exactly what his issues were from a functional point of view and treat as required. This would involve a thorough geriatric assessment and then creation of a treatment program to address the patient’s limitations.
Action
My examination began by clearly explaining to the patient the purpose of the session and how it would progress. Knowing the recent history of the patient I was able to prioritize the tests so that if he fatigued the most important tests would have been conducted. In a seated position I performed as many manual muscle tests for both UL and LL and also full ROM for the UL and the ankle. I then had the patient perform sit to stand with minimal hand use and from there I carried out static and dynamic balance testing. This alone would give me qualitative measures but also forms part of the Berg Balance Scale measure. The remainder of the BBS was completed as well as a 10mspwt and Timed Up & Go test. The patient was slow with most movements so I decided to gain quantitative timed measures of functional movements such as sit to stand, rolling, supine to stand etc. This would also allow me to assess his techniques with certain movements and suggest more efficient methods to achieve the same result. In the supine position I also conducted further strength tests. The individual was not able to perform the Step Test which was to be expected due his very poor single leg stance ability. To determine the patient’s response to external perturbations I performed the Pastor-Marsden test which resulted in a score of 2, meaning he required at least 2 steps back to prevent himself from falling. Through out all proceedings an informal gait analysis was performed.
I then prescribed exercises to be continued at home to target the impairments indicated. This was to be carried out twice a day and in addition increase his walking distance when under supervision and when he feels confident to do so.
Result
The test results showed that the individual had poor dynamic balance and diminished lower limb strength. His ability to respond to sudden disturbances to balance was impaired and he scored a BBS of 36/56 with scores less than 45 indicating a potential falls risk. The exercises prescribed were able to be performed well by the patient but there are questions about his ability to comply and continue them with effective techniques.
Evaluation
The Geriatric assessment is relatively standard but there is no need to complete the full assessment with each patient and I think I was able to guide the session in the most appropriate way based on findings that presented as the session progressed. The individual did not have severely impaired cognition but as I have found with most geriatric patients they do seem to misunderstand what appear to be simple instructions. The session did take longer due to decreased efficiency of movement between the different tests due to miscommunication. My understanding of the BBS is not sufficient to complete without being guided by the test details and I had to refer to it with most tasks. I felt I complete the manual muscle testing, TUG and 10mspwt well with the patient understanding my instructions clearly. When shifting from the assessment to the intervention I had to take time to decide what interventions I was going to use which for the sake of efficiency of a session will have to be sped up future.
Strategies
During the time I have a patient I will simplify instructions so as to not confuse the patient and also explain the progress of the session step by step instead of confusing them with too much information. I will need to take the time to learn the exact details of the BBS and how to most efficiently carry out the test with fast transitions between tasks. As I learn the basic exercises and interventions possible I will learn to pick and choose the most appropriate activities based on the patient presentation. I anticipate this will become easier as I am exposed to more patients but developing a list of standard interventions will put me in a position to more easily add more exercises to my repertoire.
Friday, June 25, 2010
Saturday, June 19, 2010
Initial Entry - Rotation 4 - Moss St
This will be my first hospital based placement for the year since Joondalup during 1st rotation. This placement is based at Moss Street which from my current impressions is an offsite outpatient facility for patient’s who have been discharged from the main Fremantle Hospital campus following neurological or general geriatric care. I have been on a Gerontology placement in 3rd year so believe that I am prepared for what situations may present.
There will potentially be Parkinson’s Disease exposure which I only had minimal exposure to, so I will need to be prepared for the types of presentations possible and intervention options. For outpatients though it will need to be a lot of education and programs that they will be able to continue at home.
Being an outpatient setting and following referral on from Fremantle Hospital there will need to be a lot of communication with people/groups who have seen the patient and with those who will be referred a patient (ie. RITH). Gaining a complete picture of the patient’s ability and needs will be necessary to deliver handovers and know how to be best deal with a patient’s situation. I will hopefully be able develop a clear idea of the roles of a great deal of health professionals and how best to treat patients for on going support and care.
Being the 4th placement for the year I imagine that I will be handed the reigns of many patient’s very early on and look forward to accepting the challenge. Having the support of my supervisor and other staff will still be important to be able to learn from them and have them guide me with areas that I may not completely understand.
Overall I am looking forward to last placement for the year to both be challenged and gain as much knowledge as possible from the final clinical placement that I will face as a student.
There will potentially be Parkinson’s Disease exposure which I only had minimal exposure to, so I will need to be prepared for the types of presentations possible and intervention options. For outpatients though it will need to be a lot of education and programs that they will be able to continue at home.
Being an outpatient setting and following referral on from Fremantle Hospital there will need to be a lot of communication with people/groups who have seen the patient and with those who will be referred a patient (ie. RITH). Gaining a complete picture of the patient’s ability and needs will be necessary to deliver handovers and know how to be best deal with a patient’s situation. I will hopefully be able develop a clear idea of the roles of a great deal of health professionals and how best to treat patients for on going support and care.
Being the 4th placement for the year I imagine that I will be handed the reigns of many patient’s very early on and look forward to accepting the challenge. Having the support of my supervisor and other staff will still be important to be able to learn from them and have them guide me with areas that I may not completely understand.
Overall I am looking forward to last placement for the year to both be challenged and gain as much knowledge as possible from the final clinical placement that I will face as a student.
Sunday, June 13, 2010
Final Entry - Rotation 3: TCCP
I found the placement very challenging but also a great opportunity to see physiotherapy from a very different perspective than what the majority of our education is based on. I also found it very satisfying to help people with a condition that affects not only them but their whole family, and that the services we provide improve their health and well being.
I was involved with 3 different streams; Adults, children and international clients. With all three I was involved with determining what the patient’s impairments were and designing a program to best target the improvement of these deficiencies. Often programs were already in place but as the individual improves modifications need to be made. I felt that I was able to effectively communicate with the patient and also the previous physio about the main problems facing them and where intervention should be targeted.
I was involved with the hydrotherapy program a lot and was required to write up programs for many patients based on information from the treating physiotherapist. All the patients derive immense benefit from these sessions, not only from a physiological point of view but also a social and psychological perspective. Many patients enjoy getting out into the community and interacting with people with similar conditions and I found this to be an important part of hydrotherapy and other services provided.
From day 1 I was given patients and asked to assess and treat as required. This was very daunting to begin with but as time went on I became more comfortable with the process and I found it important to approach things from the point of view that we are treating them to gain as much function and independence as possible. With each patient this differs and it is this important fact that makes the assessment stages critical to find out what their individual needs are.
I was involved with 3 different streams; Adults, children and international clients. With all three I was involved with determining what the patient’s impairments were and designing a program to best target the improvement of these deficiencies. Often programs were already in place but as the individual improves modifications need to be made. I felt that I was able to effectively communicate with the patient and also the previous physio about the main problems facing them and where intervention should be targeted.
I was involved with the hydrotherapy program a lot and was required to write up programs for many patients based on information from the treating physiotherapist. All the patients derive immense benefit from these sessions, not only from a physiological point of view but also a social and psychological perspective. Many patients enjoy getting out into the community and interacting with people with similar conditions and I found this to be an important part of hydrotherapy and other services provided.
From day 1 I was given patients and asked to assess and treat as required. This was very daunting to begin with but as time went on I became more comfortable with the process and I found it important to approach things from the point of view that we are treating them to gain as much function and independence as possible. With each patient this differs and it is this important fact that makes the assessment stages critical to find out what their individual needs are.
Week 5 STARES - TCCP
Situation
Over a 3 week period I was required to assess a 6 year old boy from Indonesia who had never been to the centre before and in fact had not had a clear diagnosis made up to this point. He travelled to Perth with his mother & grandparents seeking advice and guidance as to the best management for this child. To date he had been through many services & facilities in Indonesia to treat his condition.
The family noticed at the age of 2 he was not developing as well as other children and did not start walking until the age of 4. He is not able to speak and communication is very difficult, especially in English. Nothing motivates him to do anything and to date we have not been able to request him to perform any activity or action. This is despite the fact that he is able to perform most functional tasks but very irregularly and only when he wants to which is most likely a response to him being over-cared for and not needing to develop any independence.
He is able to walk with a wide base of support but his gait pattern is very unstable and he uses his hands in high guard to stabilise himself. He was not witnessed performing any functional floor movements or transfers between different postures although his family mentioned they have seen him sit to stand and roll on the floor. His favoured resting position is cross legged with his head resting on the floor in front.
Task
To carry out a thorough assessment & determine what the child’s main impairments are. Also to determine what the family’s main goals are and in what areas they would best like to see their child improve
Action
Initially a full subjective history was taken to gain a full understanding of the situation and determine what the family’s main concerns were. After this the objective assessment began which involved measuring his ROM and functional ability where possible. The child was hypermobile at the majority of joints and was unresponsive to all requests to perform any functional tasks. I then attempted to determine exactly what the child could do by simply observing him in a relaxed environment just going about his normal activities. I was able to observe his balance and mobility. At all times I continually guided the family as to what I was doing at what the aim of physiotherapy at the centre was.
Result
The patient was hypermobile and his strength was unable to be determined but as he could sit and stand it was assumed that he had the necessary strength and stability to be able to achieve most functional activities. The only movement I saw the child performing was lowering himself against a wall into a sitting position, walking and sit to stand only twice. The family was very keen to assist in anyway and were eager to understand as much as they could.
Evaluation
The child was very difficult to contend with but I managed to get a baseline understand of what his main impairments were and where our energies needed to be focused. I felt I communicated with the family effectively and even though I did not have the knowledge of some of the staff I still felt that I was able assist them with understanding the situation. Knowing what to do in terms of intervention was a struggle and I needed some guidance with regards to treatment ideas.
Strategies
Continual involvement of the family and analysing the situation thoroughly should have been the focus of my treatment. The child could do many of the movement but building the foundations of having him understand that he can do them and not require someone else’s assistance would be the focus. My knowledge of facilitation techniques for children needs improvement.
Over a 3 week period I was required to assess a 6 year old boy from Indonesia who had never been to the centre before and in fact had not had a clear diagnosis made up to this point. He travelled to Perth with his mother & grandparents seeking advice and guidance as to the best management for this child. To date he had been through many services & facilities in Indonesia to treat his condition.
The family noticed at the age of 2 he was not developing as well as other children and did not start walking until the age of 4. He is not able to speak and communication is very difficult, especially in English. Nothing motivates him to do anything and to date we have not been able to request him to perform any activity or action. This is despite the fact that he is able to perform most functional tasks but very irregularly and only when he wants to which is most likely a response to him being over-cared for and not needing to develop any independence.
He is able to walk with a wide base of support but his gait pattern is very unstable and he uses his hands in high guard to stabilise himself. He was not witnessed performing any functional floor movements or transfers between different postures although his family mentioned they have seen him sit to stand and roll on the floor. His favoured resting position is cross legged with his head resting on the floor in front.
Task
To carry out a thorough assessment & determine what the child’s main impairments are. Also to determine what the family’s main goals are and in what areas they would best like to see their child improve
Action
Initially a full subjective history was taken to gain a full understanding of the situation and determine what the family’s main concerns were. After this the objective assessment began which involved measuring his ROM and functional ability where possible. The child was hypermobile at the majority of joints and was unresponsive to all requests to perform any functional tasks. I then attempted to determine exactly what the child could do by simply observing him in a relaxed environment just going about his normal activities. I was able to observe his balance and mobility. At all times I continually guided the family as to what I was doing at what the aim of physiotherapy at the centre was.
Result
The patient was hypermobile and his strength was unable to be determined but as he could sit and stand it was assumed that he had the necessary strength and stability to be able to achieve most functional activities. The only movement I saw the child performing was lowering himself against a wall into a sitting position, walking and sit to stand only twice. The family was very keen to assist in anyway and were eager to understand as much as they could.
Evaluation
The child was very difficult to contend with but I managed to get a baseline understand of what his main impairments were and where our energies needed to be focused. I felt I communicated with the family effectively and even though I did not have the knowledge of some of the staff I still felt that I was able assist them with understanding the situation. Knowing what to do in terms of intervention was a struggle and I needed some guidance with regards to treatment ideas.
Strategies
Continual involvement of the family and analysing the situation thoroughly should have been the focus of my treatment. The child could do many of the movement but building the foundations of having him understand that he can do them and not require someone else’s assistance would be the focus. My knowledge of facilitation techniques for children needs improvement.
Sunday, May 30, 2010
Week 3 STARES - TCCP
Situation
On this occasion I was to implement a session to treat a 4yr old boy with spastic hemipelgia who had just undergone botulinum toxin injections on his right hamstrings, gastroc and biceps 3 days prior. I had previously assessed and treated this boy on 2 occasions with good compliance and success with the majority of the interventions. As with many children with similar conditions his gait pattern was impaired and the use of his right arm was affected which was to be the main focus of the sessions. The main reason his gait pattern was impaired was due to his limited dorsiflexion which was also to be a target of the intervention sessions.
Task
To carry out an intervention session to treat the patient’s main impairments and teach him the correct technique to walk and also throw. The session was also be used to educate the parents on what activities and exercises should be performed at home to consolidate what occurs during the physiotherapy sessions.
Action
A full program was planned to keep the child busy and interested in the interventions that were planned to target his impairments and improve his ability to function. His mother stated that his walking pattern had improved slightly despite only receiving the Botox treatment 3 days prior so a quick assessment of his ROM into dorsiflexion could be determined. It was found that his dorsiflexion had improved slightly well ahead of the anticipated time when changes are meant to occur. No formal assessment was made of his right arm but it was evident that his ROM had improved since his elbow extension when throwing was almost to full extension.
During the session the child became very disruptive and aggravated with every activity which made keeping the session on track very difficult. I was constantly attempting different techniques to motivate the child to complete the activities as planned. I had to involve the mother to try calming him but nothing would change the situation and we had to terminate the session early.
Result
The patient was very difficult to work with and get the required results out of him so the early termination of the session was necessary. I was able to educate the mother on the importance of stretching in terms of improving and maintaining his dorsiflexion since we did manage to complete some dorsiflexion stretching prior to his behavioural changes
Evaluation
The child became very difficult to deal with and I feel that I dealt with the situation as best I could by attempting to focus in on certain activities that he became interested in at different times such as stairs or the treadmill. Unfortunately this did not appear to work. I also gave the mother and child alone time to try and calm the situation for 5minutes but this did not appear to work either. Having the session over a shorter period of time and focusing in on only 3 different activities would have been of benefit as the initial exercises were completed well with good compliance.
Strategies
Involvement of the mother and also planning a shorter program by tackling the main areas could potentially have made the session more effective and maintained the child’s interest. Also focusing on the education of the parents since at home is where most of the improvements will be made on a daily basis. Understanding how the child will respond to different exercises by targeting his interests would also give each activity a much greater chance of succeeding.
On this occasion I was to implement a session to treat a 4yr old boy with spastic hemipelgia who had just undergone botulinum toxin injections on his right hamstrings, gastroc and biceps 3 days prior. I had previously assessed and treated this boy on 2 occasions with good compliance and success with the majority of the interventions. As with many children with similar conditions his gait pattern was impaired and the use of his right arm was affected which was to be the main focus of the sessions. The main reason his gait pattern was impaired was due to his limited dorsiflexion which was also to be a target of the intervention sessions.
Task
To carry out an intervention session to treat the patient’s main impairments and teach him the correct technique to walk and also throw. The session was also be used to educate the parents on what activities and exercises should be performed at home to consolidate what occurs during the physiotherapy sessions.
Action
A full program was planned to keep the child busy and interested in the interventions that were planned to target his impairments and improve his ability to function. His mother stated that his walking pattern had improved slightly despite only receiving the Botox treatment 3 days prior so a quick assessment of his ROM into dorsiflexion could be determined. It was found that his dorsiflexion had improved slightly well ahead of the anticipated time when changes are meant to occur. No formal assessment was made of his right arm but it was evident that his ROM had improved since his elbow extension when throwing was almost to full extension.
During the session the child became very disruptive and aggravated with every activity which made keeping the session on track very difficult. I was constantly attempting different techniques to motivate the child to complete the activities as planned. I had to involve the mother to try calming him but nothing would change the situation and we had to terminate the session early.
Result
The patient was very difficult to work with and get the required results out of him so the early termination of the session was necessary. I was able to educate the mother on the importance of stretching in terms of improving and maintaining his dorsiflexion since we did manage to complete some dorsiflexion stretching prior to his behavioural changes
Evaluation
The child became very difficult to deal with and I feel that I dealt with the situation as best I could by attempting to focus in on certain activities that he became interested in at different times such as stairs or the treadmill. Unfortunately this did not appear to work. I also gave the mother and child alone time to try and calm the situation for 5minutes but this did not appear to work either. Having the session over a shorter period of time and focusing in on only 3 different activities would have been of benefit as the initial exercises were completed well with good compliance.
Strategies
Involvement of the mother and also planning a shorter program by tackling the main areas could potentially have made the session more effective and maintained the child’s interest. Also focusing on the education of the parents since at home is where most of the improvements will be made on a daily basis. Understanding how the child will respond to different exercises by targeting his interests would also give each activity a much greater chance of succeeding.
Sunday, May 16, 2010
Week 1 STARES - TCCP
Situation
On the 4th day of my placement I was to briefly assess and treat a 4 yr old boy with spastic hemiplegia on his right but also with a slightly affected left side. He had been in on several occasions previously and had been through two treatments of Botox and was due for a third in two weeks. The main issues the boy faced were an impaired gait pattern and decreased right upper limb function. The main issue from the parents point of view was his impaired upper limb function while from the health professional’s perspective his impaired gait was the major issue. The boy was very communicative and happy to be involved in the process and the parents were very supportive and understood the importance of sessions with the centre.
Task
To determine what the individual’s issues are by performing a musculoskeletal assessment, gait analysis and functional capacity assessment. During this session it was not intended to treat the patient as such but simply get an idea of what his current limitations are.
Action
As I have found to be important when attempting to assess and treat children is the development of rapport. Fortunately the child in this case warmed very quickly to us and he was very willing to be involved in the process. Initially I assessed his lower limb range of motion and tone. The main issues found were increased tone in his right leg with dorsiflexion and knee extension. He also had decreased standing balance on his right leg. His gait showed impaired right foot clearance, circumduction, inability to extend his knee and high guard with his upper limbs. His reaching ability was also impaired predominantly when reaching to the right.
Result
This highlighted to me that the main area to work on was strength in the patient’s right lower limb, his gait pattern and also his ability to use and function with his upper limbs.
Evaluation
I believe that I conducted the musculoskeletal assessments correctly but need to improve my ability to apply and determine exactly what each of the more functional tests are inferring. I need to know what to be looking for and how it all applies to the big picture.
Strategies
On the next occasion I will know exactly what I am going to do and to keep the patient involved bring in a an incentive of some form to give him a goal. Sticking at one task for a while then completely stopping it and moving on to another would also ensure the patient is able to focus further. With time being able to find ways to keep a child involved while still keeping on task from a physiotherapy point of view will be an important skill to fine tune.
On the 4th day of my placement I was to briefly assess and treat a 4 yr old boy with spastic hemiplegia on his right but also with a slightly affected left side. He had been in on several occasions previously and had been through two treatments of Botox and was due for a third in two weeks. The main issues the boy faced were an impaired gait pattern and decreased right upper limb function. The main issue from the parents point of view was his impaired upper limb function while from the health professional’s perspective his impaired gait was the major issue. The boy was very communicative and happy to be involved in the process and the parents were very supportive and understood the importance of sessions with the centre.
Task
To determine what the individual’s issues are by performing a musculoskeletal assessment, gait analysis and functional capacity assessment. During this session it was not intended to treat the patient as such but simply get an idea of what his current limitations are.
Action
As I have found to be important when attempting to assess and treat children is the development of rapport. Fortunately the child in this case warmed very quickly to us and he was very willing to be involved in the process. Initially I assessed his lower limb range of motion and tone. The main issues found were increased tone in his right leg with dorsiflexion and knee extension. He also had decreased standing balance on his right leg. His gait showed impaired right foot clearance, circumduction, inability to extend his knee and high guard with his upper limbs. His reaching ability was also impaired predominantly when reaching to the right.
Result
This highlighted to me that the main area to work on was strength in the patient’s right lower limb, his gait pattern and also his ability to use and function with his upper limbs.
Evaluation
I believe that I conducted the musculoskeletal assessments correctly but need to improve my ability to apply and determine exactly what each of the more functional tests are inferring. I need to know what to be looking for and how it all applies to the big picture.
Strategies
On the next occasion I will know exactly what I am going to do and to keep the patient involved bring in a an incentive of some form to give him a goal. Sticking at one task for a while then completely stopping it and moving on to another would also ensure the patient is able to focus further. With time being able to find ways to keep a child involved while still keeping on task from a physiotherapy point of view will be an important skill to fine tune.
Sunday, May 9, 2010
Initial Entry - Rotation 3: TCCP
My third placement for the year will at The Centre for Cerebral Palsy. I am looking forward to becoming involved in a facility and program that helps individuals who can potentially have very significant impairments and functional limitations. I have been involved in the centre previously during 4P and took great satisfaction from helping and also being involved with people who work there who have a real passion for improving the lives of the patients.
I am expecting to be involved with the planning and implementation of individualized programs for each patient after thorough examination of their deficits and impairments. I have not been exposed to the specific nature of an examination for someone with cerebral palsy but expect that it is very similar to the standard musculoskeletal examination but with the addition of testing an individuals tone and level of spasticity.
As I found previously hydrotherapy is a large component of many of the patient’s programs and I envisage some time in the hydrotherapy pool will be involved. Onsite sessions may be at a patient’s school or education facility or possibly in their home environment. The exact nature of the treatment is not very clear to me at this stage but from lecture material I would think a lot of stretching, strengthening and conditioning work will be involved.
Due to the specialized nature of the Cerebral Palsy centre I believe that I will be observing and assisting my supervisor during the early stages but as time passes become more independent and involved in the entire of process of assessment through to implementation of a long term plan to maintain and potentially improve an individuals situation. I hope that there will be some elements of continuing education and exposure to some of the more difficult patient scenarios.
From previous reports I have found that it can be a very rewarding placement being involved in an aspect of physiotherapy that is not often considered by many following graduation. As with most placements there is a certain amount of nervousness but I expect this to dissipate rapidly as I become more and more involved.
I am expecting to be involved with the planning and implementation of individualized programs for each patient after thorough examination of their deficits and impairments. I have not been exposed to the specific nature of an examination for someone with cerebral palsy but expect that it is very similar to the standard musculoskeletal examination but with the addition of testing an individuals tone and level of spasticity.
As I found previously hydrotherapy is a large component of many of the patient’s programs and I envisage some time in the hydrotherapy pool will be involved. Onsite sessions may be at a patient’s school or education facility or possibly in their home environment. The exact nature of the treatment is not very clear to me at this stage but from lecture material I would think a lot of stretching, strengthening and conditioning work will be involved.
Due to the specialized nature of the Cerebral Palsy centre I believe that I will be observing and assisting my supervisor during the early stages but as time passes become more independent and involved in the entire of process of assessment through to implementation of a long term plan to maintain and potentially improve an individuals situation. I hope that there will be some elements of continuing education and exposure to some of the more difficult patient scenarios.
From previous reports I have found that it can be a very rewarding placement being involved in an aspect of physiotherapy that is not often considered by many following graduation. As with most placements there is a certain amount of nervousness but I expect this to dissipate rapidly as I become more and more involved.
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