week 1 neuro

WEEK 1
S-In the afternoons we work in the neurological inpatients gym. Here we mainly see stroke and brain injury patients in their last month or so of rehab before discharge. Patients on the ward make appointments with the physios here and can spend up to three hours in the gym! It is a real team orientated environment. All the physios work in one large room asking each other for help when required. (i.e.: if they’re having difficultly pinpointing the patient’s impairments or need extra assistance walking a patient.)

I was to see a new patient on my very first day. Ms A has multiple sclerosis and was admitted to Shenton Park that morning experiencing her 2nd relapse since her diagnosis (2003). She became aware of her condition deteriorating as she could no longer transfer with a slide board independently; she felt her balance was too poor. Ms A is fiercely independent and her ability to transfer is thus very important.

T-My task was to make the initial assessment of Ms A. Seeing as Ms A experiences most of her fatigue in the afternoon, we decided to just complete an assessment that day. We felt it may be too exhausting to include treatment in the one session as well.

A-I completed a thorough subjective examination whilst Ms A was in her chair. I tried to elicit as much information as possible about her condition, so that our objective examination could be specific from the outset to minimise her fatigue levels. While she was still in her chair we quickly ran thorough cranial nerves and sensation. We then transferred her onto the plinth to assess her motor status and tone. I quickly realised that muscle testing muscle testing was not clear-cut with Ms A. She had almost no movement in her lower limbs and I didn’t want to overly fatigue her by getting her in and out of numerous ‘gravity eliminated’ positions. I found the best way to elicit movement was to perform active assisted LL movements and document as such. It showed me the importance of palpating the muscle whilst moving it so I could feel for any muscle flickers. After these assessments Ms A came into sitting for a postural and balance assessment. She was not safe to be sitting unassisted and I noticed that her trunk was very ataxic. Because of this I decided to test her coordination looking for signs of potential new cerebellar involvement.

R- From this assessment I produced a concise impairment list, and thankfully I didn’t tire my patient out too much. She did in fact have positive results on cerebellar testing, including a new (3 week old) intention tremor. These findings will cause us to go down a different treatment path, focussing more on core stability and target type training.

E- I felt that my assessment went well. It was very important to be well organised as Ms A said asthenia really hinders her ability to participate in any kind of therapy. I thought that my subjective examination really helped to direct me to what was important, namely her new found LL worsening weakness and balance issues. I didn’t spend too much time on other aspects, such as cranial nerves as I had already asked about visual and swallowing difficulties etc. I also thought I did well in not making her moving around too much, as that is something I am usually terrible at! I’m always asking patients to sit down, stand up and sit down again!

The problem list that I came up with was reflective of her impairments but probably not prioritised well enough. I needed to remember that Ms A came in wanting to fix a specific problem, her transfers. So number one on our list should be to work on her core stability and practice transfers, and things like spasticity and LL weakness should be lower priorities. This is something I think I should do more every time I see a patient. I need to remember why they are here, what they want to achieve, and look more globally at the person.

S- The main strategy I used was preparation! Knowing that she fatigues easily meant I needed to be really well organised, focussed and specific. Before I saw the patient I wrote down what was essential to find out in my subjective examination. From here I worked out was most important to assess and tried to put that at the start of our objective examination. I also thought hard about testing positions and what would flow best. I think being well prepared was really the most important thing in making this a successful assessment.

INITIAL ENTRY (NEURO)

Tomorrow I start my Neuro placement at the Well-Tel Centre (part of Shenton Park Hospital). From what I can gather, it is a place that provides accommodation for people undergoing rehab or other services, but do not necessarily need to be admitted as an inpatient, in a ward environment. This will mean that the patients have much more independence and are in a less acute phase of their illness/recovery. For me, I think this means that the patients will be well versed in self care and will require more high level rehabilitation.

NATURE
I found it quite difficult to find much information on the Centre, but speaking to students who went previously confirmed my above ideas. The Centre is almost like a 'halfway house' for those who don't really need to be in hospital. Thus, PT sessions can be much more intensive, up to an hour of one on one work. As the patients are no longer acute, I think I will need to be prepared for 'later stage' training, ie: the final stages of motor recovery/high level balance work/coordination and power etc, all those things that make up a more 'normal' movement (as opposed to initial periods of flaccidity immediately following stroke for example.)

STRUCTURE
I have only been in outpatient and hospital settings, so as far as the structure of the Well-tel centre is concerned, I think I may be in for a whole new experience!! I imagine it will be similar to an outpatient setting, with patients seeing you at previously booked times, but then they can go back to their rooms! Similar to a hotel or boarding house! I am also curious to see if they run any group sessions. I think it would be a great way to exercise as patients there for a week or more would most likely make friends (if it's similar to a hotel environment?) -this could be a great motivation!!

ROLE
I also found out I will be dealing mostly with disorders like multiple sclerosis, acquired brain injuries, spinal cord injuries and potentially some amputees. I think my role as a student will be to perform one on one rehab sessions with these patients, involving more high level and independent activities. I think I will become more of a 'supervisor' and less of an 'assistant' as patients at this Centre are independent, and will need more supervision of programs to ensure they're doing it correctly at home. I think I will also become an educator. I can only imagine how difficult it would be to live with MS, and I think I will need to be on the ball with advice, encouragement and support. I think my role is also going to be to learn as much as I can. As I understand from Ali, there are many different ways to approach neuro rehab, and I am hoping to learn many new skills, as well as consolidate those I already have.

CONCERNS
I have SO many concerns about this placement! I feel like my past 2 placements were very MSK based, and thus I have a much better idea about the MSK subjective and objective assessments and treatment techniques. (Not to mention more confidence!) I also missed the first placement as I was doing my project. We were told that now supervisors are less lenient and expect more because it is placement number two...but I am behind. I literally haven't seen any patients since Collie last year! I don't know if I trust myself. Plus, I have my usual worry about not living up to my own expectations or those of my supervisors...but that is nothing new:)

But, if it's anything like my previous 2 placements, I will love every second of it!!