Monday, February 4, 2008
Fantastic Reflections
Just wanting to congratulate you all for the contributions you have made to this blog over the course of the last placement. There have been a wide range of issues discussed with teamwork and communication being recurring themes through many of them. It is clear that you are all experiencing examples of good and poor communication in teams, which is hopefully highlighting the importance to you of this skill. Remember to keep your posts about clinical issues and include concluding statements about what you have learned from the scenario and how you might change clinical practice based on your experiences.
Sunday, February 3, 2008
Progressions in Lumbopelvic Motor Control Exercises
Hi guys,
In the last couple of weeks of my musculoskeletal placement I starting having patients with motor control issues of the lumbar spine. For each of these patients the reason they actually came into the clinic was for an acute onset of low back pain. But after a few sessions and their pain started to decrease, it became apparent during re-assessment that their underlying problem was a motor control disorder of the lumbar spine.
Their pattern of pain changed from onset at the start of most active movements to the onset low back pain only in the mid ranges of active movements. For example, the patient would only complain of low back pain at about ¼ - ¾ range flexion but no pain at both ends of the range. This is a good indication that these patients were experiencing a lack of lumbar control when their passive structures were not able to give them stability. They also presented with poor activation of the local muscle system and an inability to find neutral lumbar spine.
Therefore, treatment became focused on teaching activation of the lower abdominals and multifidus as well as finding a neutral lumbar spine on the stability ball. This leads me to my blog this week, as I was able to teach the first stages of lumbopelvic motor retraining but then found that I was less than effective on providing progressions for these patients.
So I was able to progress the patients from TA activation in crook-lying to a sitting position but was unsure of how to make the task more functional and still ensure the patient was using the LMS and not reverting back to abdominal splinting.
Patients were also practicing finding their neutral spine while sitting on the stability ball but where I got stuck was in teaching progressions for lumbopelvic dissociation. We talked about the importance of dissociation in labs but I was unsure of how to actually make these exercises more functional.
So if you guys have some ideas about progressions for lumbar motor control disorder cases that would be much appreciated as I’m sure these types of patients will be a fairly common occurrence.
Thanks
Gareth
In the last couple of weeks of my musculoskeletal placement I starting having patients with motor control issues of the lumbar spine. For each of these patients the reason they actually came into the clinic was for an acute onset of low back pain. But after a few sessions and their pain started to decrease, it became apparent during re-assessment that their underlying problem was a motor control disorder of the lumbar spine.
Their pattern of pain changed from onset at the start of most active movements to the onset low back pain only in the mid ranges of active movements. For example, the patient would only complain of low back pain at about ¼ - ¾ range flexion but no pain at both ends of the range. This is a good indication that these patients were experiencing a lack of lumbar control when their passive structures were not able to give them stability. They also presented with poor activation of the local muscle system and an inability to find neutral lumbar spine.
Therefore, treatment became focused on teaching activation of the lower abdominals and multifidus as well as finding a neutral lumbar spine on the stability ball. This leads me to my blog this week, as I was able to teach the first stages of lumbopelvic motor retraining but then found that I was less than effective on providing progressions for these patients.
So I was able to progress the patients from TA activation in crook-lying to a sitting position but was unsure of how to make the task more functional and still ensure the patient was using the LMS and not reverting back to abdominal splinting.
Patients were also practicing finding their neutral spine while sitting on the stability ball but where I got stuck was in teaching progressions for lumbopelvic dissociation. We talked about the importance of dissociation in labs but I was unsure of how to actually make these exercises more functional.
So if you guys have some ideas about progressions for lumbar motor control disorder cases that would be much appreciated as I’m sure these types of patients will be a fairly common occurrence.
Thanks
Gareth
Poor professionalism
Hey guys,
This week on placement I had to deal with a nurse who was less than friendly and showed some very poor professionalism which I was extremely disappointed with. I was treating a patient who is doubly incontinent and for some reason always decides to empty his bowel once in physiotherapy (after being transferred to the plinth).
The first two times I saw this patient he emptied his bowels while in physiotherapy; the protocol is to call the nurse down to change him, which on both occasions they did so promptly (and I did help out a little, which was quite an experience). The nurse was appreciative of this.
As this patient was going to be used for my final Ax with my Curtin clinical tutor I had pre-warned her that the session may be interrupted by a change of pad. After transferring the patient to the bed a familiar smell started to waft around the patient and sure enough like clock work the patient had once again opened their bowel.
This time I went to personally find the patient’s nurse to request a change. Upon requesting the patients nurse that their patient required a change I was greeted with the response “For f*#@!k sake, I’m busy I have a meeting to attend”. The nurse then walked away, I was totally shocked and really disappointed with this reaction; I had never even met this nurse before. Now I can understand that people may get stressed and be under pressure at work from time to time but you still have to maintain a certain level of professionalism. If this outburst was due to me being a student then her behaviour is even more disappointing and inappropriate.
I returned to the physiotherapy gym and waited for her, instead she sent down two other nurses to her ‘dirty work’. I hope she felt really bad about the way she handled herself and was too embarrassed to come face to face with me, as she didn’t even apologise when I passed her in the hallway later that day.
I felt really disappointed with the whole situation and generally I feel that as a student quite often we get treated as second rate people by other staff when on prac.
That’s my gripe, hope everyone enjoys their last 4 week placement in Perth.
Cheers
This week on placement I had to deal with a nurse who was less than friendly and showed some very poor professionalism which I was extremely disappointed with. I was treating a patient who is doubly incontinent and for some reason always decides to empty his bowel once in physiotherapy (after being transferred to the plinth).
The first two times I saw this patient he emptied his bowels while in physiotherapy; the protocol is to call the nurse down to change him, which on both occasions they did so promptly (and I did help out a little, which was quite an experience). The nurse was appreciative of this.
As this patient was going to be used for my final Ax with my Curtin clinical tutor I had pre-warned her that the session may be interrupted by a change of pad. After transferring the patient to the bed a familiar smell started to waft around the patient and sure enough like clock work the patient had once again opened their bowel.
This time I went to personally find the patient’s nurse to request a change. Upon requesting the patients nurse that their patient required a change I was greeted with the response “For f*#@!k sake, I’m busy I have a meeting to attend”. The nurse then walked away, I was totally shocked and really disappointed with this reaction; I had never even met this nurse before. Now I can understand that people may get stressed and be under pressure at work from time to time but you still have to maintain a certain level of professionalism. If this outburst was due to me being a student then her behaviour is even more disappointing and inappropriate.
I returned to the physiotherapy gym and waited for her, instead she sent down two other nurses to her ‘dirty work’. I hope she felt really bad about the way she handled herself and was too embarrassed to come face to face with me, as she didn’t even apologise when I passed her in the hallway later that day.
I felt really disappointed with the whole situation and generally I feel that as a student quite often we get treated as second rate people by other staff when on prac.
That’s my gripe, hope everyone enjoys their last 4 week placement in Perth.
Cheers
Maximising recovery for our patients
Hey guys
If there is one take home message I have learnt from my neuro placement is that with our assessment and treatment of neurologically impaired patients, we are alwyas looking for movement, which will ensure that they are given the best opportunity for recovery. What this means is that we have to give our patients the opportunity and the time to show us what they can do, not just assume what they cant.
For example, one of my patients (mentioned in my first blog) who suffered a TACS affecting almost her whole left hemisphere, was left with global aphasis, right hemiparesis and, initially, very little movement on her left side as well. Given the nature of the stroke and the areas it affected, I had a picture in my mind (as we should) of her impairments. And after examination, these impairments were found to be present. Initially this patient was treated by loking after her chest, passive movements and positioning. This went on for a few treatment sessions and it wasnt until my supervisor came and sat in on a session that I realised how much more we could be doing. For some reason I had this block in my mind, in that I was performing passive movements and stretches on this patients, not even attempting to see if she was capable of anything more. My supervisor then took her through some movements, with heaps of encouraging feedback and found that she was activating some of these muscles, on her hemi side! I would have totally missed this progress if not for her.
A couple of weeks after this as I saw this patiens with my Curtin tutor, who was very suprised that we had not stood this patient yet and wanted to know why. Again, I had not given my patient every opportunity to show us exactly what she could do, instead just assuming that I knew what she couldnt. And she stood and is improving. While she may not walk in any functional way, we have all learnt the importance of being upright and weight-bearing, and standing a patient after a neurological insult is something that needs to be achieved as soon as the patients is able.
So it is crucial that we do not hold pre-conceptions about what patients can do and will achieve, but give them every chance to suceed.
Cheers guys, and enjoy!
Bini
If there is one take home message I have learnt from my neuro placement is that with our assessment and treatment of neurologically impaired patients, we are alwyas looking for movement, which will ensure that they are given the best opportunity for recovery. What this means is that we have to give our patients the opportunity and the time to show us what they can do, not just assume what they cant.
For example, one of my patients (mentioned in my first blog) who suffered a TACS affecting almost her whole left hemisphere, was left with global aphasis, right hemiparesis and, initially, very little movement on her left side as well. Given the nature of the stroke and the areas it affected, I had a picture in my mind (as we should) of her impairments. And after examination, these impairments were found to be present. Initially this patient was treated by loking after her chest, passive movements and positioning. This went on for a few treatment sessions and it wasnt until my supervisor came and sat in on a session that I realised how much more we could be doing. For some reason I had this block in my mind, in that I was performing passive movements and stretches on this patients, not even attempting to see if she was capable of anything more. My supervisor then took her through some movements, with heaps of encouraging feedback and found that she was activating some of these muscles, on her hemi side! I would have totally missed this progress if not for her.
A couple of weeks after this as I saw this patiens with my Curtin tutor, who was very suprised that we had not stood this patient yet and wanted to know why. Again, I had not given my patient every opportunity to show us exactly what she could do, instead just assuming that I knew what she couldnt. And she stood and is improving. While she may not walk in any functional way, we have all learnt the importance of being upright and weight-bearing, and standing a patient after a neurological insult is something that needs to be achieved as soon as the patients is able.
So it is crucial that we do not hold pre-conceptions about what patients can do and will achieve, but give them every chance to suceed.
Cheers guys, and enjoy!
Bini
Allied health team
Hi everyone,
This week it has really honed on me how important it is to work effectively as part of the Allied Health Team. Since this week was our last week on prac my supervisor was asking me to think about discharges of the patients I was currently managing. In the area of Cardiopulmonary physiotherapy majority of the patients fall into the older age category and therefore a more complex discharge arises. In considering allowing the patient to go home, we, as physiotherapists- a key component of the health team, need to ensure that the patient is safe for discharge and will be able to cope at home on discharge.
In planning these discharges I developed my knowledge and skills at working with the entire health team. I realized the importance of continued communication with all members of the team to ensure all the required services were in place including home help, rails for the bathroom and any required aids the patient may need on discharge.
I guess it enabled me to recognize the importance of communication within the hospitals and developing effective working relationships with other key allied health team members.
Just a little insight into my thoughts as I had run out of interesting patients to discuss. Looking forward to sharing my Musculo experiences with you next week!!
Hope everyone enjoys there final 4 weeks prac in Perth!
Debs
This week it has really honed on me how important it is to work effectively as part of the Allied Health Team. Since this week was our last week on prac my supervisor was asking me to think about discharges of the patients I was currently managing. In the area of Cardiopulmonary physiotherapy majority of the patients fall into the older age category and therefore a more complex discharge arises. In considering allowing the patient to go home, we, as physiotherapists- a key component of the health team, need to ensure that the patient is safe for discharge and will be able to cope at home on discharge.
In planning these discharges I developed my knowledge and skills at working with the entire health team. I realized the importance of continued communication with all members of the team to ensure all the required services were in place including home help, rails for the bathroom and any required aids the patient may need on discharge.
I guess it enabled me to recognize the importance of communication within the hospitals and developing effective working relationships with other key allied health team members.
Just a little insight into my thoughts as I had run out of interesting patients to discuss. Looking forward to sharing my Musculo experiences with you next week!!
Hope everyone enjoys there final 4 weeks prac in Perth!
Debs
Ask for help if you need it.
Hello everyone,
This week I learned the importance of asking for help when you need it. I was asked to do a 6 MWT for one of the patients on the ward. I was thinking a 6MWT is very straight forward process however on this occasion there were additional factors which complicated this test. First of all my patient did not speak English and his family was not around for translating. Secondly he was on portable oxygen and third the ward did not have any hand held oximeters available so I had to push the machine along side. I did not feel confident I could have control my patient. With the additional equipment I didn’t think I would be close enough to the patient to record relevant information and guard him as I administered the test.
I had seen this patient before hand which was a positive, we walked him 40 m and he de-saturated to 80 % spO2 while on 2 L of oxygen via nasal prongs. So I was aware and ready for him to de-saturate again. Despite documenting these findings in the notes the doctors still ordered a 6MWT to see if he was appropriate for home oxygen.
I prepared the hallway before hand with chairs positioned at each end of the hall. In the back of my mind I wanted to ask my supervisor to help me however did not want to be a burden therefore I convinced myself I would be alright on my own. But knew in my heart I was nervous conducting the test.
We began the test and I tried to explain to my patient the procedure. However I don’t think he understood very much. He began the test at 97 % spO2 on 2L within the first minute he was down to 87 %. At 1 min 30 he was at 84 % and I asked him how he was doing and showed him the chair was available because in class they tell us 85 % sit them down. I observed carefully for signs hypoxaemia however it was difficult as he had an abnormal breathing pattern and was unable to communicate effectively with me. He continued walking to the other end and at 2 min 20 seconds he was at 74 %. At this point I told him to sit down due to his sats and his heart rate being 165. I aborted the test. It took him 6 min to recover to 93 %. But I still had not recovered from the stress I felt during the test.
After the test I really did not feel happy with how the test was conducted. He was safe and nothing ended up happening. However I believe if I had of asked for help the test would have been much safer and more reliable. After speaking to my supervisor she said never hesitate trust your gut if you think you need a second pair of hands then just ask.
So if you find your self in a similar situation learn from what I did and ask for help.
This week I learned the importance of asking for help when you need it. I was asked to do a 6 MWT for one of the patients on the ward. I was thinking a 6MWT is very straight forward process however on this occasion there were additional factors which complicated this test. First of all my patient did not speak English and his family was not around for translating. Secondly he was on portable oxygen and third the ward did not have any hand held oximeters available so I had to push the machine along side. I did not feel confident I could have control my patient. With the additional equipment I didn’t think I would be close enough to the patient to record relevant information and guard him as I administered the test.
I had seen this patient before hand which was a positive, we walked him 40 m and he de-saturated to 80 % spO2 while on 2 L of oxygen via nasal prongs. So I was aware and ready for him to de-saturate again. Despite documenting these findings in the notes the doctors still ordered a 6MWT to see if he was appropriate for home oxygen.
I prepared the hallway before hand with chairs positioned at each end of the hall. In the back of my mind I wanted to ask my supervisor to help me however did not want to be a burden therefore I convinced myself I would be alright on my own. But knew in my heart I was nervous conducting the test.
We began the test and I tried to explain to my patient the procedure. However I don’t think he understood very much. He began the test at 97 % spO2 on 2L within the first minute he was down to 87 %. At 1 min 30 he was at 84 % and I asked him how he was doing and showed him the chair was available because in class they tell us 85 % sit them down. I observed carefully for signs hypoxaemia however it was difficult as he had an abnormal breathing pattern and was unable to communicate effectively with me. He continued walking to the other end and at 2 min 20 seconds he was at 74 %. At this point I told him to sit down due to his sats and his heart rate being 165. I aborted the test. It took him 6 min to recover to 93 %. But I still had not recovered from the stress I felt during the test.
After the test I really did not feel happy with how the test was conducted. He was safe and nothing ended up happening. However I believe if I had of asked for help the test would have been much safer and more reliable. After speaking to my supervisor she said never hesitate trust your gut if you think you need a second pair of hands then just ask.
So if you find your self in a similar situation learn from what I did and ask for help.
Patella tendon rupture info
Hi all,
Thanks lads for the useful info re; my last post on the subject. With this post I thought that I could provide some info on the subject, an updated treatment protocol sourced from one of the Orthopods at the facility, and some info on my patient.
Patella tendon rupture is fairly rare, third in terms of number of injury to the knee extensor mechanism after patella fracture and quad tendon rupture. Surgery is nearly always indicated so as to allow recovery of motion and strength. Post surgery the Rx protocol is as follows.
0-3d= No WB, knee brace locked in ext, no exercise or modalities.
4-13d= TWB, knee brace locked in ext, active flx to 45 and passive ext to 0 (no active ext), swelling control with ice, gentle medial lateral glide, isometric hamstring exs, contralateral quad exs.
2-4w= PWB, knee brace locked in ext, active flx to 90 and passive ext to 0 (no active ext), isometric quads (no SLRs) + above.
4-6w=WBAT and crutches discontinued when good quads control, knee brace locked in ext, full active flxn and passive extn, + above.
6-12w= WBAT, knee brace discontinued when good active quads control and normal gait are obtained, aggressive medial/lateral glides, SLR without reistance + above, and stationary cycling at 8 weeks.
12-16w=FWB, quads strengthening and neuromuscular retraining.
16-24w = FWB, running and sports/work specific training.
>6m= may return to jumping and contact sport when 90% of strength of contralateral extremity.
Of course this protocol is slighty different for every pt. My pt was a fit guy (boxer), however he had received no PT Rx since discharge (well over 3months post op when seeing me)!! Thus his AROM was only 5-80 deg and he also had decreased strength with severe quads wasting and quads lag. He had seen the orthopod the week before who immediately took him off the sticks, removed the brace and referred to the clinic for physio. So my initial Rx session focused on increasing ROM. I found the old hold/relax quite good for this with immediate beneficial effects.
One interesting part of my Ax was palpation of the tendon. It felt really wide and flat, unlike normal, where it is quite narrow with palpable edges. My supervisor said that this was quite common in these tendon injuries and often occurred after achilles surgery too. He said that narrowing of the tendon and scar mangement was an important part of physio treatment. As we have not been taught much about this at school I thought I would open this up to the crew and see if you have any ideas on this. I was reading in Brukner and Khan that cross friction massage is one option.
Thats it, hope you were not all bored to death, take it easy!
Nico
Thanks lads for the useful info re; my last post on the subject. With this post I thought that I could provide some info on the subject, an updated treatment protocol sourced from one of the Orthopods at the facility, and some info on my patient.
Patella tendon rupture is fairly rare, third in terms of number of injury to the knee extensor mechanism after patella fracture and quad tendon rupture. Surgery is nearly always indicated so as to allow recovery of motion and strength. Post surgery the Rx protocol is as follows.
0-3d= No WB, knee brace locked in ext, no exercise or modalities.
4-13d= TWB, knee brace locked in ext, active flx to 45 and passive ext to 0 (no active ext), swelling control with ice, gentle medial lateral glide, isometric hamstring exs, contralateral quad exs.
2-4w= PWB, knee brace locked in ext, active flx to 90 and passive ext to 0 (no active ext), isometric quads (no SLRs) + above.
4-6w=WBAT and crutches discontinued when good quads control, knee brace locked in ext, full active flxn and passive extn, + above.
6-12w= WBAT, knee brace discontinued when good active quads control and normal gait are obtained, aggressive medial/lateral glides, SLR without reistance + above, and stationary cycling at 8 weeks.
12-16w=FWB, quads strengthening and neuromuscular retraining.
16-24w = FWB, running and sports/work specific training.
>6m= may return to jumping and contact sport when 90% of strength of contralateral extremity.
Of course this protocol is slighty different for every pt. My pt was a fit guy (boxer), however he had received no PT Rx since discharge (well over 3months post op when seeing me)!! Thus his AROM was only 5-80 deg and he also had decreased strength with severe quads wasting and quads lag. He had seen the orthopod the week before who immediately took him off the sticks, removed the brace and referred to the clinic for physio. So my initial Rx session focused on increasing ROM. I found the old hold/relax quite good for this with immediate beneficial effects.
One interesting part of my Ax was palpation of the tendon. It felt really wide and flat, unlike normal, where it is quite narrow with palpable edges. My supervisor said that this was quite common in these tendon injuries and often occurred after achilles surgery too. He said that narrowing of the tendon and scar mangement was an important part of physio treatment. As we have not been taught much about this at school I thought I would open this up to the crew and see if you have any ideas on this. I was reading in Brukner and Khan that cross friction massage is one option.
Thats it, hope you were not all bored to death, take it easy!
Nico
Subscribe to:
Posts (Atom)