S: I was treating a 63 year old male with idiopathic Parkinson's disease (PD). The main tasks he was having difficulty with/main impairments identified were turning in confined spaces and walking (poor step length, arm swing and heel strike). His walking had improved over the past few sessions and I had begun to address turning. I had taught him a 'clock turn' the week before in different contexts i.e. open space initally then smaller spaces i.e. toilet. The clock turn is one technique or strategy that can be used to help people with PD to turn in smaller spaces. The week before, the patient had reported and it was observed that he was twisting on his knee (which had a history of being painful secondary to cartilage damage) or pivoting on his foot and tended to cross his feet over to turn. During the session last week he performed the clock turn relatively well with verbal prompts and feedback and was encouraged to practice this at home. I also gave him a handout about turning i.e. not crossing feet over, picking the feet up, etc and had drawn a diagram to assist with the turn.
T: to re-evaluate the patient's clock turn/ effectiveness of this technique in improving the patient's ability to turn and modify it if it was not found to be effective
A: In my subjective assessment, I enquired whether the patient had been practicing turning using the clock turn strategy at home. He had, therefore I asked him to demonstrate it. It turned out he had been practicing the turn wrong. I went through the clock turn as I had the week before with him however he seemed to find it very difficult and continued to twist his knee which aggravated his knee pain. Therefore, I taught him another strategy to turn by getting him to march on the spot/shift weight side to side first then step around ("step, step"). I taught this in varying contexts. I also gave him a cue card to take home to remind him of these steps and reminded him to refer to the handout on turning. I also told him to not worry about the clock turn technique but the diagram I had drawn for him previously would still help assist the turning in smaller spaces. I also recounted what we had gone through in the session to help consolidate what he had learnt and ensure when he went home and practiced he was clear on what to do.
R: The patient was able to turn using the new strategy fairly independently i.e. with mental rehearsal of the steps himself and twisted on the knee only occassionally. He only required occassional prompts to pick his feet up during the turn. He turned with more 'fluidity' than he did using the clock turn. He found the marching before commencing the turn to be very helpful and reported this was much easier to concentrate on than the steps involved in a clock turn.
E: I thought I did well in changing the strategy used to assist the patients turn and didn't try persist with something that wasn't working well for him. I also thought it was good that I recounted what we had covered in the session. It would have been ideal to practice the new strategy for a longer period of time to ensure there was carry over however this is not necessarily something I could have had full control of as the session was only for 45 minutes. The patient had potentially been practicing the clock turn wrong and misunderstood the technique taught in the previous session for a number of reasons such as:
- I could have not explained it simply or clearly
- I overloaded him with too much information
-practice of the technique wasn't sufficient or consistent enough to ensure the patient understood the technique
- the diagram needed to be backed up with more or more concise written instructions to ensure it made sense
- a combination of the above or the patient had simply forgot or had not practiced what we went through
S: Strategies I could use to prevent the above happening would be to make my communication more clear and consistent. For example, using short and simple instructions and making sure I repeat these and not add more prompts or instructions along the way and therefore make them more wordy. This would prevent any confusion or overloading the patient with information. In terms of communication and intervention, I also need to make sure I match my verbal instructions to what I write on the patient's cue card and make sure they are consistent with each other especially if I were to change one or the other. I could also manage my time a little better and allow for time for the patient to perform the task more independently or say the steps of the strategy out loud. Therefore 'weaning' the level of verbal support I give to ensure that the patient has in fact understood what I have taught in the session. I also need to be more considerate that as part of PD and/or older age the patient could potentially have a poor memory or poor cognition which influences the learning of a new task.
Sunday, July 25, 2010
Final entry - placement 4
Upon finishing this final placement, I feel much more confident with my skills in regards to physiotherapy. I do think that I still need to work on my clinical reasoning and treatment but I am hoping this will come with more time and experience. I did feel quite nervous throughout this placement which I think was due to knowing that this was the final one and after being through three previous placements there is more expected of us. There was also the thought that graduation is coming up and even though this is exciting it is also terrifying!
I did make the assumption initially that working in Parkinson's would be simple which was the wrong assumption to make! I think the simple part is knowing which strategies to use but these may not work for an individual patient and if so you need to take the principle behind these strategies and be creative to ensure the individuals needs are met and you are demonstrating best practice. It was also challenging to treat a Parkinson's patient who presented with say a non-Parkinson's specific problem because not only did you have to manage this problem but take into consideration the features of Parkinson's disease (PD) that would impact on your management. For example, I had a patient who came into the clinic for treatment of acute on chronic ankle pain. One of the strengthening excercises I gave him was sit to stand which is commonly a difficult task for people with Parkinson's! However it was very suitable to treat his remote mechanical contributing factors that would assist in treating his ankle pain.
I dealt with more elderly patients during the placement which I wasn't concerned about to begin with. However one factor I didn't take into account which I have actually been told before was remembering to speak slowly, simply, clearly and loudly in communicating with older patients. This was even more significant in dealing with Parkinson's patients as some had cognitive and memory deficits. I did work on this as the placement continued although I could definitely continue to work on this.
I was expecting to have to use various outcome measures. I think the placement taught me the value of these measures. For example, instead of just looking at the numbers, I learnt to ask myself what these numbers meant and how they represented a patient's functional status and what they meant for their treatment path. As an example, whenever I performed the 20mwt my supervisor encouraged me to calculate the person's gait speed and step length from this which helped make the person's results much more meaningful to me and assisted in my clinical reasoning. I was a little worried about knowing the effects of medications and being able to time them with my treatment however I learnt that patient's appointments were made to be for the same time on the same day each week which took the pressure out of this! I did come to learn things such as the names of various medications and at what stages of PD they were given and their side effects. I found this aspect of the placement very interesting.
One thing I did not consider or comment on prior to commencing the placement was that I would obviously be working with other members of the multi-disciplinary team. Throughout the placement I had the most contact with occupational therapists (OT's). This was great in that I learnt a lot more about their role and this helped me to know when it was appropriate to refer a patient for OT. I also learnt a lot more about the role of social workers which was particularly important for people with Parkinson's.
To conclude, I feel I am much more knowledgeable about Parkinson's disease and can appropriately and soundly manage people with PD which I will most defnitely come across when working in a clinical setting in the future considering it is a common disease. This last placement really helped consolidate in my mind aspects which I need to improve on in regards to becoming a physiotherapist but also helped me to realise what I have achieved this year and how much I've grown especially in terms of my confidence. Specifically, I have learnt that the real world is never as simple as what we learn from the books and that one can learn a lot from being continuously challenged by different situations. These experiences help to shape how you will choose to manage your patients and experiences as a physiotherapist.
I did make the assumption initially that working in Parkinson's would be simple which was the wrong assumption to make! I think the simple part is knowing which strategies to use but these may not work for an individual patient and if so you need to take the principle behind these strategies and be creative to ensure the individuals needs are met and you are demonstrating best practice. It was also challenging to treat a Parkinson's patient who presented with say a non-Parkinson's specific problem because not only did you have to manage this problem but take into consideration the features of Parkinson's disease (PD) that would impact on your management. For example, I had a patient who came into the clinic for treatment of acute on chronic ankle pain. One of the strengthening excercises I gave him was sit to stand which is commonly a difficult task for people with Parkinson's! However it was very suitable to treat his remote mechanical contributing factors that would assist in treating his ankle pain.
I dealt with more elderly patients during the placement which I wasn't concerned about to begin with. However one factor I didn't take into account which I have actually been told before was remembering to speak slowly, simply, clearly and loudly in communicating with older patients. This was even more significant in dealing with Parkinson's patients as some had cognitive and memory deficits. I did work on this as the placement continued although I could definitely continue to work on this.
I was expecting to have to use various outcome measures. I think the placement taught me the value of these measures. For example, instead of just looking at the numbers, I learnt to ask myself what these numbers meant and how they represented a patient's functional status and what they meant for their treatment path. As an example, whenever I performed the 20mwt my supervisor encouraged me to calculate the person's gait speed and step length from this which helped make the person's results much more meaningful to me and assisted in my clinical reasoning. I was a little worried about knowing the effects of medications and being able to time them with my treatment however I learnt that patient's appointments were made to be for the same time on the same day each week which took the pressure out of this! I did come to learn things such as the names of various medications and at what stages of PD they were given and their side effects. I found this aspect of the placement very interesting.
One thing I did not consider or comment on prior to commencing the placement was that I would obviously be working with other members of the multi-disciplinary team. Throughout the placement I had the most contact with occupational therapists (OT's). This was great in that I learnt a lot more about their role and this helped me to know when it was appropriate to refer a patient for OT. I also learnt a lot more about the role of social workers which was particularly important for people with Parkinson's.
To conclude, I feel I am much more knowledgeable about Parkinson's disease and can appropriately and soundly manage people with PD which I will most defnitely come across when working in a clinical setting in the future considering it is a common disease. This last placement really helped consolidate in my mind aspects which I need to improve on in regards to becoming a physiotherapist but also helped me to realise what I have achieved this year and how much I've grown especially in terms of my confidence. Specifically, I have learnt that the real world is never as simple as what we learn from the books and that one can learn a lot from being continuously challenged by different situations. These experiences help to shape how you will choose to manage your patients and experiences as a physiotherapist.
Sunday, July 11, 2010
week 3 post, prac 4 : evidence based-practice
S: I took over one of my supervisors parkinson's patients. The patient was a 73 year old female who had been diagnosed with parkinson's approximately 6 years ago. Her main presenting problem was with walking. Variations that could be identified from her notes in regards to her walking included reduced thoracic rotation/ rigid trunk; nil arm swing bilaterally; poor foot clearance and a tendency to shuffle. Her most recent intervention addressing these problems was a home exercise programme (HEP)involved an arm swing exercise to be done prior to walking (this involved standing on the spot and swinging each arm alternately with a chair in front to assist in reaching); heel- toe exercise to improve her heel strike; strategies to manage her shuffling e.g. written cue cards to remind the patient to place her heels down first and to think long steps. On subjective assessment, the patient reported she had tried to swing her arms more during walking but was forgetting to practice doing this. She found that the cue cards were helping her to take slightly longer steps when she could refer to them.
T: to assess the patient's gait for myself as well as carry out my supervisors planned aims for the session which included re-evaluating her HEP and progress with her walking.
A: I analysed the patients gait which confirmed the findings from her notes and reviewed her home exercise programme. I modified her arm swing exercise by prompting her to reach for the corners of the chair i.e. left arm to right side or chair to further encourage thoracic rotation as there was little rotation occurring when she reached just generally for the back of the chair. I progressed the exercise by including leg lifts (marching). After 5 mins of doing this exercise I got the patient to practice walking for 10-15 mins along the corridor using the cues she already had as well as a new cue: "imagine reaching for the sides of the chair". I said the cues out loud to assist the patient, then encouraged her to say these to herself either out loud or in her head. I then got the patient to transfer what she had learnt and got her to walk outside on pavement for 5 minutes. I also encouraged her to mentally rehearse walking with long steps, arm swing, etc before going for a walk at home. Lastly, I gave her a copy of the modified arm swing exercise and of a new cue card and advised her to place this in her pocket/bag or take it with her for a walk as a reminder.
R: The patient understood the progressed arm swing exercise and responded well to the cues in regards to the chair during the exercise and while walking. Her gait appeared to improve when I repeated the cues verbally as she walked. It remained improved when I got her to say the cues to herself however this was only temporary as she found it difficult to think about the cues and perform them at the same time. She did have some difficulty thinking about her arm swing and long steps, etc when walking outside and shuffled occassionally.
E: I thought I did well in choosing to modify her arm swing exercise and in how I modified it. Evidence-based practice in relation to neurology suggests that task-specific practice, practicing functional tasks, mental rehearsal and repetition are amongst some of the key principles of rehabilitation. Most studies performed I believe have been mostly based on stroke patients however I think they could be applicable to other neurological conditions. I tried to use this to guide the session by modifying the arm swing exercise to make it slightly more functional i.e. to mimic a more normal gait pattern and by getting the patient to repeat the arm swing exercise then repeat walking using the cues/ strategies. I encouraged the use of mental rehearsal however it was difficult to evaluate how much this helped her as I didn't give her much time to do it during the session and asked her to do it more when at home. I think I utilised the common treatment approaches typically used for parkinsons e.g. breaking tasks down. I thought it was a good idea to get her to practice walking on a different surface (outside) to make the skills she had learnt transferrable to a new environment which is an integral part to learning and consolidating new skills. However, it may have been more effective to focus on improving her walking indoors in that single session then progressing this at a later stage by doing it outdoors. I did give her a lot to think about by doing this as well and could say that she was having to multi-task a fair bit which is difficult for a person with parkinsons disease. It is discouraged in later stages of the disease so I thought it may be alright for this particular patient. It is questionable how much "carry over" there would have been from the session that would really make a difference to her walking as it was a complex task and it is likely she will need a few sessions and lots of practice to see any significant change to her gait. Ideally it would be great to spend hours with the patient to ensure there is some carry over. Finally, it would be hard to the patient to read her cue card and for example walk along a busy street and talk to her husband all at once. It is a lot to think about so it is difficult to establish how transferrable or practical what was learnt in the session is to her everyday life.
S: Strategies I could use would mainly be to focus more on one task during the session instead of getting the patient to try perfrom multiple tasks. Learning may be consolidated better this way. This also means slowing down the process of progressing the patient especially in treating parkinsons patients. It might be beneficial to research if the above principles for rehabilitation are that applicable to parkinsons patients.
T: to assess the patient's gait for myself as well as carry out my supervisors planned aims for the session which included re-evaluating her HEP and progress with her walking.
A: I analysed the patients gait which confirmed the findings from her notes and reviewed her home exercise programme. I modified her arm swing exercise by prompting her to reach for the corners of the chair i.e. left arm to right side or chair to further encourage thoracic rotation as there was little rotation occurring when she reached just generally for the back of the chair. I progressed the exercise by including leg lifts (marching). After 5 mins of doing this exercise I got the patient to practice walking for 10-15 mins along the corridor using the cues she already had as well as a new cue: "imagine reaching for the sides of the chair". I said the cues out loud to assist the patient, then encouraged her to say these to herself either out loud or in her head. I then got the patient to transfer what she had learnt and got her to walk outside on pavement for 5 minutes. I also encouraged her to mentally rehearse walking with long steps, arm swing, etc before going for a walk at home. Lastly, I gave her a copy of the modified arm swing exercise and of a new cue card and advised her to place this in her pocket/bag or take it with her for a walk as a reminder.
R: The patient understood the progressed arm swing exercise and responded well to the cues in regards to the chair during the exercise and while walking. Her gait appeared to improve when I repeated the cues verbally as she walked. It remained improved when I got her to say the cues to herself however this was only temporary as she found it difficult to think about the cues and perform them at the same time. She did have some difficulty thinking about her arm swing and long steps, etc when walking outside and shuffled occassionally.
E: I thought I did well in choosing to modify her arm swing exercise and in how I modified it. Evidence-based practice in relation to neurology suggests that task-specific practice, practicing functional tasks, mental rehearsal and repetition are amongst some of the key principles of rehabilitation. Most studies performed I believe have been mostly based on stroke patients however I think they could be applicable to other neurological conditions. I tried to use this to guide the session by modifying the arm swing exercise to make it slightly more functional i.e. to mimic a more normal gait pattern and by getting the patient to repeat the arm swing exercise then repeat walking using the cues/ strategies. I encouraged the use of mental rehearsal however it was difficult to evaluate how much this helped her as I didn't give her much time to do it during the session and asked her to do it more when at home. I think I utilised the common treatment approaches typically used for parkinsons e.g. breaking tasks down. I thought it was a good idea to get her to practice walking on a different surface (outside) to make the skills she had learnt transferrable to a new environment which is an integral part to learning and consolidating new skills. However, it may have been more effective to focus on improving her walking indoors in that single session then progressing this at a later stage by doing it outdoors. I did give her a lot to think about by doing this as well and could say that she was having to multi-task a fair bit which is difficult for a person with parkinsons disease. It is discouraged in later stages of the disease so I thought it may be alright for this particular patient. It is questionable how much "carry over" there would have been from the session that would really make a difference to her walking as it was a complex task and it is likely she will need a few sessions and lots of practice to see any significant change to her gait. Ideally it would be great to spend hours with the patient to ensure there is some carry over. Finally, it would be hard to the patient to read her cue card and for example walk along a busy street and talk to her husband all at once. It is a lot to think about so it is difficult to establish how transferrable or practical what was learnt in the session is to her everyday life.
S: Strategies I could use would mainly be to focus more on one task during the session instead of getting the patient to try perfrom multiple tasks. Learning may be consolidated better this way. This also means slowing down the process of progressing the patient especially in treating parkinsons patients. It might be beneficial to research if the above principles for rehabilitation are that applicable to parkinsons patients.
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