Most of my assumptions about the Wel-Tell centre were correct. Well-Tel is a play on ho-tel, ie: a hotel for well people! It is there for those people who need an intensive burst of physiotherapy but are independent enough that they don't need to stay on the ward. Not only is this better for the patients, but it saves a whole heap of tax payer money!
Patient's were generally well versed in self care, and I found that my role was supervisory, but not the extent I had guessed. I did have to ensure patients could perform their exercise programs well enough that they could do it at home. However, it was also a great time to utilise treatments techniques that could not be done at home, things like the tilt table, hydrotherapy, hands on mobilisations and stretches and normal movement facilitation etc. So not only did I supervise, I was a hands on therapist! I was correct in saying that patients were no longer in an acute phase of rehab, but this did not necessarily mean that that they needed higher level training. Some patients did require this type of therapy as they had been admitted straight after an inpatient stay on the ward, ie: were in the final stages of motor recovery post stroke or GBS. Most of the patients however had degenerative or genetic conditions like MS or HSP (hereditary spastic paraparesis.) They did not require high level training, rather treatment to maintain or improve their current functional status.
The structure of the of the program was that patients came to the gym for 2 and half hours in the morning. Here they had one on one time with a physio, doing all those things they miss out on at home, and also work independently on their tailored programs. The rest of the day is for themselve. They can book in with the OT, speech therapist, social worker, podiatrist, attend hydrotherapy or even come back to the gym in the afternoon. It is a really well-rounded program that includes every aspect of the multi-disciplinary team!! And as I had thought, patients did make some really good friends and it was definitely a motivation to work. We were all in the gym together and it made for such a nice and supportive environment!
Aside from Wel-Tell, I was also assigned to the ward 2 gym, which sees neurological inpatients. Here I dealt with stroke patients in their acute phases of recovery. This meant my role was very hands on. I felt that my afternoon patients were much more dependent and my role was to facilitate and re-educate normal movement patterns. I felt that this gave me a really huge opportunity to see such a range of conditions throughout all phases of recovery!!
Concerns:
I did feel that I was a bit behind in my neuro, but I learnt so much! I really realised that it is all related to normal movement, and as the weeks went on I was able to more effectively not the deviations from normal and why. I may have been less confident initially, but with time it became much easier. Once you develop a rapport with the patient confidence really just comes. My supervisor did expect a lot of me, but only what was within my knowledge base. She didn't expect me to have a million different treatment techniques up my sleeve. She was aware that you only learn a few at uni and the rest comes with experience. And I did learn HEAPS of different techniques, but I think I would be still learning 20 years into a neuro career...the scope of what you can do is enormous.
I did enjoy my placement, but I also found it very confronting and overwhelming. I think experience is also needed in how to detach yourself emotionally (although I also think emotion is what can make you a great physio!) It was really hard and challenged me in more ways than I imagined. I'm not sure that it's the career path I'm cut out for, but it's an experience I'll definitely remember! I think if you can master neuro you can probably master most things...having a normal movement base is what most physio is about!!
My take home message: To be really honest I felt that neuro physio was initially quite subjective, everyone seems to do everything differently and you have different feedback coming from every angle!! (I'm also aware that it is less evidence based because it's unethical to withhold treatments from these patient groups.) But I've come to realise that it doesn't overly matter if everyone does things a different way. Nothing is really 'wrong' as such...as long as you're achieving your aim of normal movement an exercise is appropriate! You need to experiment with techniques and constantly monitor and progress. This drives home the importance of assessment. If you get your neuro impairment list 100%, you can work a treatment to suit your aim! Lastly, I wasn't expected to know everything there is to know about neuro, so don't be afraid to ask! I became aware of my own limitations and as such I knew when to ask for help and advice.
Thursday, April 22, 2010
week 5 neuro
S- I have been continuing my treatment with Mr B in the neurological inpatient gym every afternoon. Mr B suffered a L pontine stroke on the 12/03/2010 and consequently is experiencing R hemiparesis and hemisensory loss, as well as decreased arousal, mild expressive dysphasia and moderate dysarthria. Mr B is displaying excellent movement return and we have minimised the amount of tone coming in. All in all he is displaying excellent potential for a good recovery!!
However, on Monday and Tuesday we experienced 2 set-backs in therapy. On Monday he had a fall in the PT gym. My supervisor and I were practicing 2 mod A STS with Mr B as this is major goal, he is VERY focussed on achieving this as he wants to be able to transfer without the hoist. Mr B is determined, but if something is too hard he will sit down without any warning to the PT, you just have to be ready. During STS from the W/C, Mr B made it about half way, then just could not straighten his legs any further. He slipped in front of the W/C, and as he weighs 97kg my supervisor and I just could not save him, so we began a controlled lowering to the floor. He then required a 3 max A to get back into the W/C. It turned out fine, but it shattered Mr B's confidence.
The next day, shortly after Mr B's arrival he needed to go to the bathroom. He has suffered some urge incontinence since his stroke so I quickly rushed him up to the ward. Once here, I offered my assistance but as he is a standing hoist t/f the nursing staff declined, they would just have to teach me to use the hoist and he was in a rush. I decided to wait for Mr B so I could take him back to the gym and save the PCA. I was waiting in the office and heard the nursing staff talking about me. It was very unprofessional. They suggested that PT never offer to help, they were run off their feet and I was just sitting down! (Meanwhile, they couldn't have been that busy if 6 people had the time to and around and talk about me.) It really upset me as I try my hardest to be polite and helpful, I would never intentionally not offer my assistance. So, I stood up and joined their conversation...with the end result being me bullied into getting Mr B off the toilet. This was really awkward for him. After the experience, he said he was too embarrassed to come back to phsyio and absolutely dreaded it!!
T-My task was to reinstate some of Mr B's confidence and reassure him about physio generally!
A-I wheeled Mr B back to his room for the day. Once here I shut the curtains to give us some privacy. I sincerely apologised for his experience in the bathroom. I let him know that I wasn't embarrassed and had taken many patients to the bathroom before. He explained that he felt physio's were for therapy only and he was mortified that I had to see him in another light. I empathised with this and understood exactly where he was coming from. We decided to put a few strategies in place to ensure that physio WAS only therapy time. They offer patients drinks while they're in the gym. Mr B felt his drink had upset his stomach, so we opted for water only while exercising. We also pushed back his start time till 2:30. This allowed his lunch to go down (he has just started to eat normal meals so he felt he needed some time getting used to it again.) This also worked well for me, as I had a higher level patient who could come and take Mr B's earlier time slot.
We then talked about his fall. Mr B was so nervous it would happen again, and it was such a struggle for him and us to get him off the floor. I let him know that he shouldn't view the fall as a set-back. If anything, it proves he can transfer from the floor without a hoist. I told him that falls were to be expected ( I had already seen 2 in that gym!) and now hopefully he's had his and that's it! I then really emphasised his great potential for recovery! I related hard-work to his goals and hopefully inspired him not to give up. Only with therapy time will he achieve a stand-step transfer and he has already come so far! I tried not to play into his nervousness and let him know that sometimes these things happen, it is not a reason to stop. I told him that he had to be in control of his rehab, and if he feels tired he has to let us know.
R-I feel that my talk with Mr B went really well. When I left, he was no longer embarrassed and was willing and excited to continue his therapy. He felt happy with the strategies we put in place and felt more in control of his own recovery. I feel that I built on our rapport and our professional relationship had grown. I was really excited to have him back on board, he has to want to be in the gym for us to make any type of improvements!
E-I really feel I handled the situation well. I was just as embarrassed as Mr B and I could have left without talking to him. I was really proud that I was professional enough to sit down with him and analyse the events. I really learnt the importance of listening. I felt Mr B's concerns were valid, and we worked through them appropriately and professionally. I left knowing that Mr B was reassured and had regained some confidence in his abilities (and some more confidence in me!!)
However, I did not handle the situation with the nurses very well!! I felt so worried and flustered when I heard them talking about me so I just stood up and did whatever they said. Looking back, it was definitely bullying, and it was not professional. I did not need to be rude, but I could have been more assertive. I should have reminded them that I did offer assistance and I am more than happy to help out whenever required, especially as I am a student and have more time on my hands, all they needed to do was ask. But I also should have reminded them to listen to the patients wishes, it was clear that he did not want me there and as such I shouldn't have been. In those situations I need to politely point out the facts and not fall into the trap of workplace bullying! I also need to find my voice sometimes and stand up for myself. I am not rude or lazy and shouldn't let people say that about me.
S-When Mr B next comes into the gym I am going to use the following strategies
1. Relate STS practice to his goals
2.Positive feedback to boost his confidence
3.Bolster him in so he feels really safe
4.Have confidence in myself, and let him see that! I can't let him know I'm nervous too because that won't help anyone.
In regards to the situation on the ward, I let my supervisor know what happened so she was informed. We then talked through strategies together on how to deal with anything like that in the future.
However, on Monday and Tuesday we experienced 2 set-backs in therapy. On Monday he had a fall in the PT gym. My supervisor and I were practicing 2 mod A STS with Mr B as this is major goal, he is VERY focussed on achieving this as he wants to be able to transfer without the hoist. Mr B is determined, but if something is too hard he will sit down without any warning to the PT, you just have to be ready. During STS from the W/C, Mr B made it about half way, then just could not straighten his legs any further. He slipped in front of the W/C, and as he weighs 97kg my supervisor and I just could not save him, so we began a controlled lowering to the floor. He then required a 3 max A to get back into the W/C. It turned out fine, but it shattered Mr B's confidence.
The next day, shortly after Mr B's arrival he needed to go to the bathroom. He has suffered some urge incontinence since his stroke so I quickly rushed him up to the ward. Once here, I offered my assistance but as he is a standing hoist t/f the nursing staff declined, they would just have to teach me to use the hoist and he was in a rush. I decided to wait for Mr B so I could take him back to the gym and save the PCA. I was waiting in the office and heard the nursing staff talking about me. It was very unprofessional. They suggested that PT never offer to help, they were run off their feet and I was just sitting down! (Meanwhile, they couldn't have been that busy if 6 people had the time to and around and talk about me.) It really upset me as I try my hardest to be polite and helpful, I would never intentionally not offer my assistance. So, I stood up and joined their conversation...with the end result being me bullied into getting Mr B off the toilet. This was really awkward for him. After the experience, he said he was too embarrassed to come back to phsyio and absolutely dreaded it!!
T-My task was to reinstate some of Mr B's confidence and reassure him about physio generally!
A-I wheeled Mr B back to his room for the day. Once here I shut the curtains to give us some privacy. I sincerely apologised for his experience in the bathroom. I let him know that I wasn't embarrassed and had taken many patients to the bathroom before. He explained that he felt physio's were for therapy only and he was mortified that I had to see him in another light. I empathised with this and understood exactly where he was coming from. We decided to put a few strategies in place to ensure that physio WAS only therapy time. They offer patients drinks while they're in the gym. Mr B felt his drink had upset his stomach, so we opted for water only while exercising. We also pushed back his start time till 2:30. This allowed his lunch to go down (he has just started to eat normal meals so he felt he needed some time getting used to it again.) This also worked well for me, as I had a higher level patient who could come and take Mr B's earlier time slot.
We then talked about his fall. Mr B was so nervous it would happen again, and it was such a struggle for him and us to get him off the floor. I let him know that he shouldn't view the fall as a set-back. If anything, it proves he can transfer from the floor without a hoist. I told him that falls were to be expected ( I had already seen 2 in that gym!) and now hopefully he's had his and that's it! I then really emphasised his great potential for recovery! I related hard-work to his goals and hopefully inspired him not to give up. Only with therapy time will he achieve a stand-step transfer and he has already come so far! I tried not to play into his nervousness and let him know that sometimes these things happen, it is not a reason to stop. I told him that he had to be in control of his rehab, and if he feels tired he has to let us know.
R-I feel that my talk with Mr B went really well. When I left, he was no longer embarrassed and was willing and excited to continue his therapy. He felt happy with the strategies we put in place and felt more in control of his own recovery. I feel that I built on our rapport and our professional relationship had grown. I was really excited to have him back on board, he has to want to be in the gym for us to make any type of improvements!
E-I really feel I handled the situation well. I was just as embarrassed as Mr B and I could have left without talking to him. I was really proud that I was professional enough to sit down with him and analyse the events. I really learnt the importance of listening. I felt Mr B's concerns were valid, and we worked through them appropriately and professionally. I left knowing that Mr B was reassured and had regained some confidence in his abilities (and some more confidence in me!!)
However, I did not handle the situation with the nurses very well!! I felt so worried and flustered when I heard them talking about me so I just stood up and did whatever they said. Looking back, it was definitely bullying, and it was not professional. I did not need to be rude, but I could have been more assertive. I should have reminded them that I did offer assistance and I am more than happy to help out whenever required, especially as I am a student and have more time on my hands, all they needed to do was ask. But I also should have reminded them to listen to the patients wishes, it was clear that he did not want me there and as such I shouldn't have been. In those situations I need to politely point out the facts and not fall into the trap of workplace bullying! I also need to find my voice sometimes and stand up for myself. I am not rude or lazy and shouldn't let people say that about me.
S-When Mr B next comes into the gym I am going to use the following strategies
1. Relate STS practice to his goals
2.Positive feedback to boost his confidence
3.Bolster him in so he feels really safe
4.Have confidence in myself, and let him see that! I can't let him know I'm nervous too because that won't help anyone.
In regards to the situation on the ward, I let my supervisor know what happened so she was informed. We then talked through strategies together on how to deal with anything like that in the future.
Saturday, April 10, 2010
week 3 neuro
S- Today I was to perform my first treatment of Mr B in the neurological inpatients gym after assessing him the day before. Mr B suffered a L pontine stroke on the 12/03/2010 and is now experiencing R sided hemiparesis and hemisensory loss. He also has moderate dysarthria and expressive dysphasia, and since the stroke he has noticed a decrease in motivation, increase tiredness and a general flat affect. Mr B is displaying great movement return, with his number one impairments being a decrease in postural tone and stability, decrease R sided voluntary control and decrease in static and dynamic sitting balance. He doesn't seem to have the abdominal strength to save himself once outside his base of support. Mr B's main goal for now is to be able to stand up and transfer without the use of a hoist.
T-My task was to perform an initial treatment of Mr B targeting his main impairments . As he is quite difficult to transfer (due not only to his lack of voluntary control but also the fact that he is over 6 foot tall and over 90kg) I had to structure the session so that it flowed well (none of my usual sit up, lie down sit up again). I also had to maintain Mr B's interest in order to keep him focussed and motivated.
A-I decided to treat Mr B in supine first and work on his abdominal strength. I thought it was important to get this firing before he was in sitting to prepare his abs for balance work. We worked on sit-ups with a wedge behind Mr B. This made the sit-up easier for him as he didn't need to start from a fully lengthened position. We also worked on posterior pelvic tilt in crook lying, progressing to a bridge. Once we completed these, we moved to sitting. Here we worked on reaching out of his base of support with the left and right hand. We emphasised lateral tilt of the pelvis and trunk righting. Rather than growing on the reaching side Mr B seems to slump or pull down. We practiced component work when reaching with the right working first at the shoulder and breaking the movement into parts. After this, we came into standing and practiced finding the centre (Mr B pushes to the R). To end the session, I gave Mr B a list of exercises for his hand that he can do on the ward. (Previously he was squeezing a stress ball which only works to reinforce the flexor pattern of the arm.)
R-Mr B was happy with the treatment session, particularly coming up to standing. This is his short-term goal and he was so proud to be making the first steps. I was happy that he could prove this to himself, as he was feeling like the situation was hopeless prior to treatment. I also felt that the exercises we did in sitting were very successful at firing up his trunkal tone, as I could see good extensor activity happening in his back after reaching.
E-All in all I think our first treatment session together worked well. I think that the flow of the exercises worked well from a transfer perspective as well as preparing him for each new and more challenging exercise. However, I feel the work we did in supine didn't achieve the desired effect. Mr B seems to take whatever support is given him, thus in supine, he completely switches off and does very little work, which isn't really achieving anything... aside from making me work more! I also found that Mr B led his sit-ups through global extension, particularly leading with his head, so I need to think of some strategies to improve this. In sitting, reaching was very effective at firing up postural tone and preparing him for standing. On the left I made this interesting by incorporating coits, but on the right, he cannot hold coits. As such, Mr B found this a bit boring and lost interest. He is quite hard to motivate, and I became slightly disheartened as he starting yawning a lot! I also felt that reaching to the R is particularly problematic because he hinges from his trunk rather than switching it on to provide a stable base for the scapula. I feel that it would thus be best to reach to the R in standing while his trunk has max input, but his being so tall may not make this possible with only 1 assist. I do however think that we made a great start and I developed a good rapport with Mr B. I really feel that the best thing to come out of the session was proving to Mr B that there is hope and a point in trying, and that with continued work he can only get better!
S-For our next session I have decided to eliminate supine all together. I think for now it is important for Mr B to be doing most of the work and reminding his brain that he can! I do think it is so important for him to work on his abdominal strength, but I will try this in reclined sitting. I will not let him fully rest or let go in the reclined position, forcing him to do the work for himself. I will also get him to do this ab work with his chin on chest, hopefully this prevents global extension and leading with the head. To make the reaching to the R more interesting and in order to involve Mr B more in his own treatment I'm going to try and relate it to something that interests him. He previously worked full time as a bus driver and loved this job, so maybe we can look at holding a steering wheel or flicking indicators. I can also use my voice here to fire him up. Lastly, I think I will give him generally less support. He is capable of working on his own, but takes whatever you give him. I need to make sure that I give him every opportunity to do this, within reason and staying safe. Plus, this will go towards helping him see that he is indeed capable and there is much hope of being functional again.
T-My task was to perform an initial treatment of Mr B targeting his main impairments . As he is quite difficult to transfer (due not only to his lack of voluntary control but also the fact that he is over 6 foot tall and over 90kg) I had to structure the session so that it flowed well (none of my usual sit up, lie down sit up again). I also had to maintain Mr B's interest in order to keep him focussed and motivated.
A-I decided to treat Mr B in supine first and work on his abdominal strength. I thought it was important to get this firing before he was in sitting to prepare his abs for balance work. We worked on sit-ups with a wedge behind Mr B. This made the sit-up easier for him as he didn't need to start from a fully lengthened position. We also worked on posterior pelvic tilt in crook lying, progressing to a bridge. Once we completed these, we moved to sitting. Here we worked on reaching out of his base of support with the left and right hand. We emphasised lateral tilt of the pelvis and trunk righting. Rather than growing on the reaching side Mr B seems to slump or pull down. We practiced component work when reaching with the right working first at the shoulder and breaking the movement into parts. After this, we came into standing and practiced finding the centre (Mr B pushes to the R). To end the session, I gave Mr B a list of exercises for his hand that he can do on the ward. (Previously he was squeezing a stress ball which only works to reinforce the flexor pattern of the arm.)
R-Mr B was happy with the treatment session, particularly coming up to standing. This is his short-term goal and he was so proud to be making the first steps. I was happy that he could prove this to himself, as he was feeling like the situation was hopeless prior to treatment. I also felt that the exercises we did in sitting were very successful at firing up his trunkal tone, as I could see good extensor activity happening in his back after reaching.
E-All in all I think our first treatment session together worked well. I think that the flow of the exercises worked well from a transfer perspective as well as preparing him for each new and more challenging exercise. However, I feel the work we did in supine didn't achieve the desired effect. Mr B seems to take whatever support is given him, thus in supine, he completely switches off and does very little work, which isn't really achieving anything... aside from making me work more! I also found that Mr B led his sit-ups through global extension, particularly leading with his head, so I need to think of some strategies to improve this. In sitting, reaching was very effective at firing up postural tone and preparing him for standing. On the left I made this interesting by incorporating coits, but on the right, he cannot hold coits. As such, Mr B found this a bit boring and lost interest. He is quite hard to motivate, and I became slightly disheartened as he starting yawning a lot! I also felt that reaching to the R is particularly problematic because he hinges from his trunk rather than switching it on to provide a stable base for the scapula. I feel that it would thus be best to reach to the R in standing while his trunk has max input, but his being so tall may not make this possible with only 1 assist. I do however think that we made a great start and I developed a good rapport with Mr B. I really feel that the best thing to come out of the session was proving to Mr B that there is hope and a point in trying, and that with continued work he can only get better!
S-For our next session I have decided to eliminate supine all together. I think for now it is important for Mr B to be doing most of the work and reminding his brain that he can! I do think it is so important for him to work on his abdominal strength, but I will try this in reclined sitting. I will not let him fully rest or let go in the reclined position, forcing him to do the work for himself. I will also get him to do this ab work with his chin on chest, hopefully this prevents global extension and leading with the head. To make the reaching to the R more interesting and in order to involve Mr B more in his own treatment I'm going to try and relate it to something that interests him. He previously worked full time as a bus driver and loved this job, so maybe we can look at holding a steering wheel or flicking indicators. I can also use my voice here to fire him up. Lastly, I think I will give him generally less support. He is capable of working on his own, but takes whatever you give him. I need to make sure that I give him every opportunity to do this, within reason and staying safe. Plus, this will go towards helping him see that he is indeed capable and there is much hope of being functional again.
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