Looking back at my initial entry for the placement it seems that my expectations were reasonably accurate. The majority of the time I was in the gym working with patients, helping them with exercises that were going to facilitate their recovery and get them walking again. Having a knowledge of a persons comorbidities proved to be vitally important as a persons pre-existing conditions were often the factors that limited recovery and guided our clinical reasoning as to what exercises were appropriate. For example, the implications for a pt with a blister on their residual limb were different depending on whether they had diabetes/PVD or not. The former pt would have to rest whereas with the latter you could consider other possibilities such as dressing the wound to continue with their gaitj retraining.
The one thing that I found that I had missed in my initial expectations observational gait analysis. It was a major focus of our placement, especially in the last two weeks, to be able to look at a persons gait with prosthesis in situ and be able to analyse the reasons as to why a person walked in a particualr way. It was probably the area where I learnt the most because having an external factor such as a prosthesis just added another reason as to why a persons gait might be altered.
As I got more involved with pts care management plans and goal setting meetings I found that my treatment improved as it seemed to give me more direction as to what was in the best interest of the pt and what Rx would best facilitate their recovery. I think this just reiterated to me the importance of finding out a pts goals and client centred practice.
Oveall I think the ability to clinically reason and perform observational gait analysis were the areas that I most improved in and realise that I will need to continue to work on these areas throughout my career.
Sunday, August 30, 2009
Tuesday, August 25, 2009
Topic 3: Analysis annd Planning
Situation: Was working with a pt whom had undergone a left transtibial amputation and had previously been fitted with a supracondylar suspended patella tendon bearing prosthesis. As a result of ongoing issues withk suture line healing the pt had been having trouble with the fit of prosthesis causing compromise to skin integrity. It was therefore decided that the pt was going to be fitted with a prosthesis with thigh suspension to decrease the load through the distal residual limb.
Task: Get pt walking in new prosthesis and perform observational gait analysis on her pattern.
Action: As the pt had already undergone gait retraining exercsises on her original prosthesis and her residual limb had become accustomed to bearing weight, we started with some simple walking in the parallel bars.
Result: Pt was able to walk independently in the parallel bars with minimal support from the upper limbs. Stance phase was decreased on the prosthetic limb and the pt walked with an antalgic gait pattern, flexing the trunk laterally towards the prosthetic limb in stance phase. Increased lateral trunk flexion and overall antalgic gait pattern was attributed to decreased strength and control of hip abductors of the residdual limb and pain that was reported over femoral condyles on weight bearing. As a result we aimed to optimise the number of socks to reduce pain and but allow the best fit in the socket and also give the pt exercises to improve hip control.
Evaluation: Overall I think I performed well in the gait analysis part of the task. Where I could have improved was with the exercise prescription and planning part. I thought I'd give my pt exercises to improve hip abduction control and so prescribed her with standing hip abduction when standing in her contralateral limb. As one of the physios correctly advised me, it would probably be more appropriate to get the pt to stand on the prosthetic limb and maintain hip control when abducting and hitching the contralateral limb. This exercise is more specific to the situation where the pt is experiencing her decreased pelvic control i.e. when standing on her prosthetic throughout the gait cycle.
Strategies: Think about the situation when the pt experiences an impairment and prescribe exercises to be as specific to that situation and context.
Task: Get pt walking in new prosthesis and perform observational gait analysis on her pattern.
Action: As the pt had already undergone gait retraining exercsises on her original prosthesis and her residual limb had become accustomed to bearing weight, we started with some simple walking in the parallel bars.
Result: Pt was able to walk independently in the parallel bars with minimal support from the upper limbs. Stance phase was decreased on the prosthetic limb and the pt walked with an antalgic gait pattern, flexing the trunk laterally towards the prosthetic limb in stance phase. Increased lateral trunk flexion and overall antalgic gait pattern was attributed to decreased strength and control of hip abductors of the residdual limb and pain that was reported over femoral condyles on weight bearing. As a result we aimed to optimise the number of socks to reduce pain and but allow the best fit in the socket and also give the pt exercises to improve hip control.
Evaluation: Overall I think I performed well in the gait analysis part of the task. Where I could have improved was with the exercise prescription and planning part. I thought I'd give my pt exercises to improve hip abduction control and so prescribed her with standing hip abduction when standing in her contralateral limb. As one of the physios correctly advised me, it would probably be more appropriate to get the pt to stand on the prosthetic limb and maintain hip control when abducting and hitching the contralateral limb. This exercise is more specific to the situation where the pt is experiencing her decreased pelvic control i.e. when standing on her prosthetic throughout the gait cycle.
Strategies: Think about the situation when the pt experiences an impairment and prescribe exercises to be as specific to that situation and context.
Sunday, August 16, 2009
Topic Two: Communication
Situation: Spent an afternoon gym session treating one of my patients with my notre dame supervisor. The pt was a 72 yr old male had a L trans-tibial amputation as a result of an infection that he contracted after surgery for ongoing circulatory compromise in the limb. His gym programme consisted of upper and lower limb strengthening exercises. mobility training and compression therapy to manage his oedema.
Task: To give a verbal handover of the pt to my notre dame supervisor.
Action: Reviewed the pts physio and medical notes and prioritised what information would be important for a verbal handover, then deliver the information in an effective and professional manner.
Result: Focused on the pts relevant past medical history, social history, current mobility status, wound healing, pt goals and current treatment strategies.
Evaluation: Overall I gave an effective handover however probably needed to find out some more information from the pt on his social history. A persons level of independant mobility depends not only on their physical capability but also their environment hence I needed to find out more about the pts home and daily regime. Information such as whether a person has stairs or rough terrain helps guide our treatment plan so that a person can gain independance and a safe discharge.
Strategies: When giving a handover, think about the pieces of the pts history that would benefit a physios treatment plan.
Task: To give a verbal handover of the pt to my notre dame supervisor.
Action: Reviewed the pts physio and medical notes and prioritised what information would be important for a verbal handover, then deliver the information in an effective and professional manner.
Result: Focused on the pts relevant past medical history, social history, current mobility status, wound healing, pt goals and current treatment strategies.
Evaluation: Overall I gave an effective handover however probably needed to find out some more information from the pt on his social history. A persons level of independant mobility depends not only on their physical capability but also their environment hence I needed to find out more about the pts home and daily regime. Information such as whether a person has stairs or rough terrain helps guide our treatment plan so that a person can gain independance and a safe discharge.
Strategies: When giving a handover, think about the pieces of the pts history that would benefit a physios treatment plan.
Sunday, August 2, 2009
Entry Topic Week One : Analysis and Planning
Situtation: I was working with a pt that had undergone a trans tibial amputation (TTA) due to a complication of his Type One diabetes. He had been fitted with his prothesis and was progressing with his gait retraining exercises and was at a stage where he was competent in walking with two elbow crutches on slopes, grass and up and down stairs. The pt had a small blood blister just superior to the suture line on his residual limb that was healing well.
Task: As I felt the pt was quite capable with walking with two elbow crutches I decided that I might progress his gait retraining by having him walk along the outside of the parallel bars with only one hand support.
Action: I consulted my supervisor to check and confirm whether my plan was appropriate.
Result: Supervisor agreed that the pt was at a stage where he would be quite capable to progress with his gait retraining however asked me if I thought it was appropriate because of the small blood blister on his residual limb. It was decided not to progress the pt as losing an elbow crutch would increase the load on the residual limb and further delay healing which is a priority.
Evaluation: I am glad that I discussed the plan with the supervisor first as it opened my eyes to how I needed to look at the pt as a whole and made me realise that rehabilitation for amputees is not just about progressing them back to function but also preventing further complications.
Strategies: Look for all the limiting factors that can slow a pts recovery.
Task: As I felt the pt was quite capable with walking with two elbow crutches I decided that I might progress his gait retraining by having him walk along the outside of the parallel bars with only one hand support.
Action: I consulted my supervisor to check and confirm whether my plan was appropriate.
Result: Supervisor agreed that the pt was at a stage where he would be quite capable to progress with his gait retraining however asked me if I thought it was appropriate because of the small blood blister on his residual limb. It was decided not to progress the pt as losing an elbow crutch would increase the load on the residual limb and further delay healing which is a priority.
Evaluation: I am glad that I discussed the plan with the supervisor first as it opened my eyes to how I needed to look at the pt as a whole and made me realise that rehabilitation for amputees is not just about progressing them back to function but also preventing further complications.
Strategies: Look for all the limiting factors that can slow a pts recovery.
Tuesday, July 21, 2009
Expectations for 3rd Year Placement
For my 3rd year placement I am working with amputees at Royal Perth Hospital. As working with amputees is such a specialised field I feel a little unsure as to how I will go, however in saying that I am very much looking foward to the opportunity and think that it is going to very interesting.
I think the practioners will expect me to know some information on the common causes of amputations and some possible complications that need to be prevented when patients undergo such a procedure. Speaking to students who have attended the placement in previous years, I also think that they expect me to be able to help and correct pts with their exercise programs and hence have a general understanding of how certain exercises should be performed. Knowing my anatomy may also be important as they may ask questions on what a pt has lost functionally since having their operation.
I think that for much of the initial half of the placment I'll be learning how to assess, treat and devise an exercises program for specific amputations and then eventually be expected to perform my own assessment and devise a treatment plan as appropriate for that pt.
Overall I'm looking foward to the placement and since it is my first placement in a hospital it's going to be interesting to see how such an organisation works from the inside.
I think the practioners will expect me to know some information on the common causes of amputations and some possible complications that need to be prevented when patients undergo such a procedure. Speaking to students who have attended the placement in previous years, I also think that they expect me to be able to help and correct pts with their exercise programs and hence have a general understanding of how certain exercises should be performed. Knowing my anatomy may also be important as they may ask questions on what a pt has lost functionally since having their operation.
I think that for much of the initial half of the placment I'll be learning how to assess, treat and devise an exercises program for specific amputations and then eventually be expected to perform my own assessment and devise a treatment plan as appropriate for that pt.
Overall I'm looking foward to the placement and since it is my first placement in a hospital it's going to be interesting to see how such an organisation works from the inside.
Friday, November 14, 2008
Final entry
Thoughts and feelings on finishing the unit?
A bit of relief from a full on 5 weeks. I feel that I have learned a so much from my supervisor and other physios that I worked with and I think now I am more comfortable in my own ability in regards to assessing, treating and communicating with pts. In the last two weeks of the placement I found that i was getting better at working with people in general and I think this is more of an exposure thing. Kalgoorlie is a pretty laid back town and I really enjoyed getting to know people and have a laugh when working with them. It was great to get the chance to apply the skills I've learnt into a clinical situation. I was thrown straight into it and I've i have really benefited from the experience.
Most important feelings that you've learnt?
The importance of:
- A functional exam
- Performing a systematic objective
- Performing a subjective that is structured and knowing not only what to ask but why you are asking them
- Understanding conditions and how they present in the subjective and objective
- Adjusting treatment to better suit a persons needs, including manual therapy techniques that work at EOR rather than simply in neutral
- Having a pool of exercises to choose from
- Observation of posture and palpation
- Easing into tests to get a good idea of what structures are involved
A bit of relief from a full on 5 weeks. I feel that I have learned a so much from my supervisor and other physios that I worked with and I think now I am more comfortable in my own ability in regards to assessing, treating and communicating with pts. In the last two weeks of the placement I found that i was getting better at working with people in general and I think this is more of an exposure thing. Kalgoorlie is a pretty laid back town and I really enjoyed getting to know people and have a laugh when working with them. It was great to get the chance to apply the skills I've learnt into a clinical situation. I was thrown straight into it and I've i have really benefited from the experience.
Most important feelings that you've learnt?
The importance of:
- A functional exam
- Performing a systematic objective
- Performing a subjective that is structured and knowing not only what to ask but why you are asking them
- Understanding conditions and how they present in the subjective and objective
- Adjusting treatment to better suit a persons needs, including manual therapy techniques that work at EOR rather than simply in neutral
- Having a pool of exercises to choose from
- Observation of posture and palpation
- Easing into tests to get a good idea of what structures are involved
Week 5 Day 3
Thoughts and feelings?
This was a good pt to see on my last day as she was a person that presented with medial elbow pain and pins and needles that extended down to the last three digiots of her hand. It was a chance to perform a thorough objective exam and use my clinical reasoning as to why she was getting symptoms. It turned out that this lady, as result of prolonged driving, had increased tone in her pec minor and scalenes which resulted in ulnar nerve irritation and medial elbow pain. I enjoyed seeing the pattern to her symptoms unfold and being able to treat this lady so that she had no pain by the end of the Rx session with our asterisk, neurodynamic test.
How do you think you managed?
I think I did quite well. When it came to treating the lower cervical/upper thoracic spine, I was a bit unsure of what passive accessories we should perform to open up the IVF however once I had talked it through I was able to understand the reasoning behind each PAM. It was great to get such a positive effect from treatment.
What changes would you make?
Just remembering to retest your asterisk sign after each treatment method. I thinkl after the first technique I decided to retest using grip strength however I then realised that her neurodynamic test for the ulnar nerve was more of a asterisk sign.
What strategies could you incorporate?
Take the time to think about which is the best test to re-test post Rx.
Overall thoughts?
Quite pleased with how we performed the assessment and treatment. It was systematic which made it easier clinically reason as to why this pt was getting her symptoms.
I would like to ask the physio what are the usual points where nerve irritaion in the thoracic outlet can occur.
This was a good pt to see on my last day as she was a person that presented with medial elbow pain and pins and needles that extended down to the last three digiots of her hand. It was a chance to perform a thorough objective exam and use my clinical reasoning as to why she was getting symptoms. It turned out that this lady, as result of prolonged driving, had increased tone in her pec minor and scalenes which resulted in ulnar nerve irritation and medial elbow pain. I enjoyed seeing the pattern to her symptoms unfold and being able to treat this lady so that she had no pain by the end of the Rx session with our asterisk, neurodynamic test.
How do you think you managed?
I think I did quite well. When it came to treating the lower cervical/upper thoracic spine, I was a bit unsure of what passive accessories we should perform to open up the IVF however once I had talked it through I was able to understand the reasoning behind each PAM. It was great to get such a positive effect from treatment.
What changes would you make?
Just remembering to retest your asterisk sign after each treatment method. I thinkl after the first technique I decided to retest using grip strength however I then realised that her neurodynamic test for the ulnar nerve was more of a asterisk sign.
What strategies could you incorporate?
Take the time to think about which is the best test to re-test post Rx.
Overall thoughts?
Quite pleased with how we performed the assessment and treatment. It was systematic which made it easier clinically reason as to why this pt was getting her symptoms.
I would like to ask the physio what are the usual points where nerve irritaion in the thoracic outlet can occur.
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