Last Post

My patient is a 19 yr old WAFL football player with a 3yr Hx of bilateral groin pain L > R, he only played 12 games last yr. Treatment to date has consisted of massage, dry needling of adductor longus, NSAIDS and cortisone injections; all of which have had little change on his functional status. When i started treating player X at the beginning on pre-season i assessed his lumbopelvic stability and found he had poor control in single limb stance and he had an active lumbar extension pattern with poor TA recruitment. Therefore treatment consisted of glute med/TA retraining in NWB positions which progressed over 2/12 to functional football related postures. I slowly introduced running into his program then progressed distances and speed as well as direction changes etc. When pre-season games started i began him with 10 min a quarter and slowly increased his game time, on monday training he goes to the pool for recovery. Happily he is now playing painfree and dominating in the midfield.

The Manipulator

The Road to the End!

Hi everyone,
So as the final core prac comes to an end I have had the opportunity to experience running the whole ward!!
Our supervisor is keen for us to manage a large case load to ensure we get an understanding of what it would be like to be in charge of a whole ward should be get a hospital job upon completing our degrees!!!
So it’s fair to say that fitting in 12 cardiothoracic patients a day has been a challenge especially when some of them need to be seen twice!! It has been a good learning experience however, but means you are on the run from the beginning of the day. And have to accommodate patients having showers, going to xray and just general hospital craziness. It means that you have to learn to manage your time optimally and be flexible to change your plans quickly.
I do sometimes feel like we are being taken advantage of, especially when you see the supervisor sitting down doing emails etc, but I suppose that is what happens when you’re a student! At least it will teach me how I would like to treat any students I may have on pracs!

It has been great to see over the duration of these pracs the progressions of lots of patients-allmost all getting better or seeing improvements that the next person can take over from. It does make you keen to get out there and make a difference!
All the best.

Patella instability.

Hi all, sorry for the lateness of this post.

I would like to discuss one patient that I was seeing on my musculo placement. She presented with a recurrent history of bilateral patella dislocation, with the last incident occurring 3 years previous. The first patella dislocation she experienced was when she was 12 years old. The patient was a self employed cleaner, and consequently performed repetitive bending with her job. She also participated in martial arts, and was keen to continue with this, although was concerned about her knees.

On examination both patellae had an obvious medial tilt in the resting standing posture, and the patella lateral glide apprehension test was positive (and marked). The patient was extremely tight in the lateral structures, especially the ITB, with glut med weakness. VMO activation was extremely poor bilaterally. Crepitus was noted on patella compression. Bilateral proprioception was also decreased, and the patient complained of instability with single leg squat combined with internal rotation.

Perceived single leg squat stability improved with external medial glide applied to the patella. Initial treatment consisted of STM and heat applied to the lateral structures in an attempt to loosen these, VMO retraining +++, HEP for ITB stretching, and taping for medial glide and tilt initially to the right (worse) knee. At the next session the patient stated that the knee felt much improved.

Subsequent treatments continued with glut med and VMO retraining, and bilateral knee taping. The patient felt much more assured of her knee stability, and was more confident with her work as a result. The lateral structures also felt considerably looser.

As this was such a chronic condition I felt the short term improvements were worthwhile, and encouraging. Any other suggestions?

Dale.

hello all soon to be physios.

I must apologise for my late entry but to be truthful with PCR looming I totally forgot to make an entry. So here I am writing my entry 2 hrs before I sit my PCR so that should get me back in the good books???Well my last week in neuro was great. I got to consolidate the skills that I had picked up on the way. However the last week was a test of my patience. I had a new pt on the ward who had suffered a brainstem stroke and apart from the usual impairments that go with the pathology he had significant short term memory loss. It was like banging my head off a brick wall. I tried all approaches to try and get carryover between sessions but it was impossible. In fact for example when teaching STS between the first and 5th repetition the pt had forgotten my cues entirely. I felt as if I was stuck on replay. The sad thing was, he was trying really hard in therapy and was making progress (with continuous prompting by yours truly) but when left for second to do his own thing all previous information was gone. So I thought of the usual strategies to try and make tasks move from being cognitive to automatic ex. written cues in his room that he and nursing staff would have to adhere to when he was STS. But unfortunately the ward was extremely busy and nursing staff short so I doubt very little that much time would be given to my little project. I was stuck, and still am. I know I won't be seeing this pt again but I know this will happen again, then what???Any ideas welcomed...
ps best of luck with the PCR today
see you all tonight,yay...

The 4^th week of inpt neuro placement was spent on preparing for final assessment, progressing patient’s treatments, writing handover summary. Nothing significant, hence I thought: maybe I will list a summary of learning points from this placement:

a)Evidence-based practice in neuro

- not that I went to read up on all the current research. Reading up on the clinical practice guidelines for Stroke rehabilitation (sept 2005) gave me an overview of some of the current research points and level of evidence for some of the stroke rehab techniques. For instance, I was curious about the use of FES for stroke patients with subluxed shd as I had 2 stroke patients (acute, subacute) with 1 – 3 fingers shd subluxation. Research revealed that there is some short term improvement, however, nothing is conclusive or very little research is done about the long term effects/ improvement for subluxed shd. Hence, ?usefulness of FES?

- The clinical supervisors also shared that UL WB ex has been shown in research to help address UL ataxia problems.

- N finally from what I can recall about what Anne said before about ax, rx and re-ax.

b) Communication

I realized from all 3 placements, communication skills is an essential component of physio – if we can’t communicate properly or phrase the questions properly, we won’t be able to get a good subj ax fr patients for musculo for instance, and this is essential in directing our obj ax; We won’t be able to give an effective patient education with regards to explaining condition, or teaching exercises; Patients may not be compliant to our treatment plans, coz they are clueless about what they’ve to do or what’s going on or how our Rx can help them.

Communication skills were also important in terms of verbal/ written handover to fellow colleagues, and other allied health stuff, because very often in inpatient settings, the patients require multi-disciplinary team approach.

c) Teamwork

I learnt from my neuro placement it is not just about teamwork with other allied health professionals, but also teamwork within the physios. Throughout the whole placement, we’ve to “share” patient cases; or require assistance of another physio to treat a patient requiring 2person (A). We’ve to come together to plan the treatment for a specific patient, and to cooperate on who leads the treatment session. Sometimes we may even have differences regarding our thoughts about the patient, or even scoring the different outcome measures. Nonetheless, this has helped me learn from my peers and receive feedback on how I can improve my handling or clinical reason better.

I guess this sort of end my blog (for now) for this clinical education unit. It was good fun meeting new pals and going through placement together, learning about one another, and for me, experiencing a new culture.

All the best for tomorrow’s PCR!!

Common sense...or lack there of it

Hello everyone hope everything is going well for the PCR!! So I thought for my last entire I would talk about a patient of mine who has been testing my patience!! This man presented to the musculo outpatient clinic with a history of chronic pain and fibromylagia. This was not his first time to the clinic; he has attended at least 6 different times with various complaints. His complaint this time was of neck and shoulder pian/stiffness. My assessment did not reveal anything of concern, ie: ROM was full, Cx mobility was normal… he only had some tightness of his UT and LS. When I questioned him why he thought he had this problem he stated it was because he has his computer set up so that the screen is to the right of him, so he has to constantly look to the right while typing. So my obvious suggestion was put your screen so that it is face on, that way you don’t have to keep your head turned. He thought that was a brilliant idea and would try it and see if that helped.
He returned two weeks later and said he had adjusted his screen and that seemed to help, but he was still getting some neck pain and pain between his shoulders. Again, with further questioning I discovered that he was using a sun lounger as his computer chair. That’s right….a sun lounger!! I thought to myself….are you kidding me, do people not have any common sense…..surely you would have thought to yourself this can’t be good for my posture or neck. But he obvious did not so again I educated him on the importance of having a proper supportive chair and how the one he was using was not ideal!! So I have come to realise, what seems so obvious to us as physios is not obvious to the rest of the population and that is why education is so important.

Potential

A big Hi to dear all again. Looks like all of us have completed clinics for the 3 main disciplines of Physiotherapy and are into the mad rush to prepare for the scary PCR.

Things are running around my head and I'm sitting here facing my notebook not knowing exactly what to type cos throughout these 12 weeks of placements, I have learnt and pondered so much that there's just too much to share. Guess a choice of just one is unavoidable.

Recalling the day I entered the Neurology outpatient department for the first time, my heart just sank cos I've always thought yours truly was hopeless at neuro and being in an outpatient setting, its difficult to actually see gains from treatment just by the nature of the duration since their stroke(which will "de-moralize" me even further). But of course, through reading your blogs and hearing the experiences of others, I've always had the belief that these patients do get better with treatment. Just that I've never experienced it myself yet. Not until this placement.

Here's a case to share:

Just a brief summary of this patient: 66 year old lady with a (L) MCA infarct about a year an a half ago. She has been coming to the outpatient department for treatment for about 8 months. Her current functional status: ambulating independently with a quad stick inside her home, and utilises a motorised wheelchair for longer distances and outdoors.
Her current physiotherapy problems is with the quality of her gait(largely compensatory) and her impairments are as follows:

Trunk
· ↓ ability to weight transfer to R when standing and during functional tasks
· poor pelvic postural stability(weak gluteus medius/maximus)
· poor dissociation of pelvis and shoulder girdle
· ↓ activation of trunk extensors

R Lower limb
· ↓ R lower limb strength(quads)
· ↓ ROM at R ankle joint (arthropathy; oedema due to heart failure)
· ↓ muscle activation throughout

So naturally, I started to work on her gait pattern by correcting her alignment, stretching tight muscles of LL as well as simple strengthening of her hip extensors/quads and giving her lots of instructions for correction.

Well, those techniques up there didn't work very well. In fact, it didn't really work for 2.5 weeks.

But my supervisor took one look and went: "Let's practice with her sit to stand. Focus on weight bearing on the right LL and get the gluts and quads firing up. Get her left leg on a small step to discourage WB-ing on that leg."

Ok, so we did just that for that session(practising standing up using almost 75% support of her right LL and maintaining good alignment in those semi-squat positions ie buttock almost touching chair but we disallowed her to sit). And guess what?

Her gait improved! No more Trendelenberg sign, no more retraction of her L hip in stance and no more hyperextension on her L knee during mid-stance. She could control her pelvis and knee really well. Walked that beautiful "catwalk" for the next 30metres. Just by practising a functional task. With a very good carry over effect. Beyond my expectations. Felt so happy for her.

You know sometimes we have big plans for the patients and it doesn't materialize? And then for those patients we don't have big plans for they just go way above what we actually thought of them?

Guess in every patient we have, there's always a potential we can tap on. A great potential. And because of this potential we can see in them, it gives me the hope that they can really get better.

At least I've experienced it myself.

All the best for PCR.

Patient progress

Just a quick update on a patient I have mentioned previously with a L TACS who has aphasia as well as R sided neglect, anosognosiaand is a pusher. She has recently become very agitated and frustrated every time we see her she shouts "NO" and "Dont" which has progressed to repeating " Dont do these things to me". It is difficult so know what is frustrating her but we think it is because she is starting to relise her deficits. It still does not help as and there goes consent out the window before we even ask the question. We have taken a more relaxed approach and just allowed her to do whatever she wants. When she is ready to transfer we act as a guide and safety net. When she stands from sitting we are the support where needed and prevent falls. She seems OK with these techniques but it is difficult to get her to perform the reaching and alignment task to help her pushing. She has however progressed so that she can transfer with assit of 1 so that her family can help and this allows her to go on day out with them which should help her mood and rehab. This just shows that in some cases in order to allow rehab we just have to make do with what we can from the patient and that just because the patient is aphasic does not mean that we can just do whatever we think we need to but need to still achieve the goals the patient wants to.
Best of Luck everyone with the PCR.

Power of Plasticity

Well here we are a few days out from PCR, doesnt seem that long ago the journey started. My blog this week is about a 60yo male who had a massive R sided infarct ~ 4 yrs ago. He had a complicated post stroke course and required two craniotomies to relieve the pressure caused by his increased ICP. CT scans 4/52 post stroke showed a massive black space where his R hemisphere previously resided in his skull !!! The initial prognosis was originally very poor for this man as you can imagine and he was given no chance of walking or going home. However, a touch of anosoagnosia combined with an enormous level of determination has resulted in amazing Fx gains in the last 4 yrs. He nows lives at hm again, is independant for all ADLs, mobility and amb and has just joined the running group at RPH-SPC gym where he is improving weekly. To me this tells of just how plastic the human brain is, and how we can never give up on pt regardless of their Dx as anything is possible with perserverance (and a little perceptual dysfunction).

Peace

The Manipulator

sweet success!

Hard to believe just how close we are hey! Well this past week was a delight, as it saw my successful completion of my Cardio prac and additionally I could say that, in a few cases, I had helped some people go home from this large urban hospital.
Carrying on from my last post- about the pt. from the sub-continent, this week I continued to treat her. The session with the interpreter was really helpful (always remember to speak with the pt. whilst doing so) and then I taught the family how to do some basic ACBT's with modified percs and finally liaising with her doctor I set up a family meeting where management of her condition was discussed. I felt like a REAL physio!
This grateful women was a quick study, learning how to swap out her oxygen from the wall to her ambulant O2 (and get the ball at the top of the line just right), then when she was SOB she did all the strategies to relieve this in textbook fashion!
I am sure all of us has had these glimpses into the start of a challenging and rewarding career and I wish you all the best for the PCR. Chao, Matt

week 3 blog (HAND)

Hello everyone, how’s the last placement?

Somehow… I realized my 3^rd week blog is missing? *_* so here goes:

Wanted to blog about the hand and the homunculus. What happened during the 3^rd week of placement was steph did a tut on the hand. She taped my hand into a “hemi-hand with flexor synergy” – flexed wrist and finger flexors. Before she did that, she got me to do a timed finger tapping and finger opposition test as outcome measure. So.. my (L) hand was taped in that position for 20min.

It was amazing what happened during that 20min.. I changed from an alert mode to fatigue mode. I wasn’t sure whether i) it was due to me feeling as if I’ve suddenly lost the function of my hand at that point in time, hence totally lost interest in what was going around me; or ii) the cells representing the hand in homunculus has switched off (Recall: The lips, hands, feet and sex organs have more sensory neurons than other parts of the body, so the homunculus has correspondingly distortedly large hands.), iii) it was close to lunch time :P. I just felt totally “switched off” and had to attempt to keep myself awake thoughout the 20min of tutorial. Even the rest noticed my quick change in upright posture to a passive slump posture while sitting on the wheely stool, n my (L) elbow resting in flexed position on my lap. At that point in time, I really empathize with the stroke patients – having lost the function of the hand… N this really got me thinking about what the clin supervisor shared during 1^st week of placement: they noticed that patients who had UL rehab felt very tired the next day.

After 20min of “pseudo-stroke-hand”, I felt total relief when the tape was removed. A reassessment of the timed finger tapping and finger opposition test showed slower timing; (can’t remember whether it was) (R) or (L) nystagmus, and slower lateral movement of eye to (L) side? on vision testing. My 2 clinical placement classmates then did hand mobs and stretches for my hands, n I felt much more “wakened up”. My (L) hand felt as if it was alive again.

This was an interesting experience, something which I would have never tried myself. This tut has certainly got us thinking about the hand more, and its representation in the homunculus, and how hand mobs, UL rehab are equally important in our treatment plan.

Alternative Approaches

My whole Cardio placement has been smooth sailing, that was up until this week where I had to treat a number of complex patients, not so much complex in their clinical presentation or pathophysiology but more so language barriers. On Wednesday the ward had four new patients which I was given, a Polish lady with little english and was really drowsy, a Turkish man also with little english, an Aboriginal man who I could not understand one word of, and an elderly man suffering from delirium (almost sounds like the start of a joke). Actually, my initial assessments were a joke. My subjective examinations and time management suddenly went pear shaped because of the inherent difficulty trying to extract important information, such as previous mobility, and cardio related problems. The one thing I failed to really pick up on was there are many other ways of skinning a cat. If I had of gone through old notes, spoken to other allied health staff and/or called relevant sources such as next of kin, hostels/nursing homes/retirement villages I would have obtained all my subjective info in half the time and my treatment would have been a lot more effective. So in reflection, and words of wisdom I can share is don’t waste your time persisting in playing charades and word association games in getting your subjective material with patients who don’t speak the lingua franca. Good luck with your PCR’s my little oompa loompa’s.