I have just completed my second placement for the year at the Parkinson's Clinic at Osborne Park Hospital. The clinic is a popular choice for therapy for people with Parkinson's disease living north of the river. They treat patients with Parkinson's Disease, Parkinsonism, Idiopathic Parkinson's disease, Progressive Supranuclear palsy and Multi systems Atrophy. In regards to the placement, I had 3 supervisors- all of which had an extensive knowledge and loved what they do. We run groups (including high level, low level and carers groups), did 1 on 1 therapy, annual time trials, and lots of referrals to other members of the multi disciplinary team. This placement was great in terms if its continuing education. Continuing education was run for all physiotherpists once a week and students where also required to attend tutorials run by a physiotherapist on topics such as documentation, Parkinson's Disease, and Assessments.
My experience on this placement was that there were not many patients to see per day, especially for the first few weeks. Each consultation is 45minutes long which limits the number of patients you can see per day. There were also a huge number of cancellations and people not attending appointments due to poor cognition or clashes with other appointments. I had plenty of free time where I was encouraged to do some further reading, so I watched videos, read books and journals to extend my knowledge on Parkinson's Disease. On my placement, I had 3 supervisors all of which had a large knowledge base and loved what they do. It took me a while to adjust to constantly being supervised and to the different ways each supervisor liked things done.
In regards to issues which arised in my initial entry, I feel a lot more confident in the area of Neurology especially in regards to treating patients with Parkinson's disease. I have a clearer understanding of the condition, the role of the multidisciplinary team and treatment options, then I did prior to the commencement of this placement. I feel I could explain the pathophysiology of Parkinson's to the patient and how it effects them, I have a greater understanding of the challenges facing physiotherapists and the fluctuations of the disease from day to day and between people. The travelling has also not been an issue at all.
As a take home message for future students, I would say be prepared for fluctuating degrees of the disease, as well as exercise progression and the strategies used in Parkinson's Disease. Having a sound understanding of the condition and the function of the basal ganglia also helps greatly.
From this placement I have consolidated an understanding of Parkinson's disease, Parkinson's plus conditions, the importance of the multi disciplinary team, exercise prescription, the role and importance of the carer, surgical management, consolidated my assessment skills and deciding on a prioritised problem list for the patient.
Saturday, April 24, 2010
Topic 3- Communication
Situation: A 74 year old Vietnamese woman with a 5 year history of Parkinson's disease, was referred to the Physiotherapy department at the Parkinson's Clinic for review of Parkinsons and for decreased mobility and falls. The patient attended the clinic with her son, who brought her in in a wheelchair. Patient C lives at home with her husband and son, who is the primary carer. Patient C does not speak much english but the son is able to translate. Currently, patient c only ambulates around the house (indoors and out). Her endurance is about 5-10 mins before she requires a rest. She uses a walking stick but requires a wheelchair for longer distances. She had a fall 3 months ago where she fell out of bed. This fall resulted in a Colles Fracture of her left arm. The fracture has healed and patient is still doing the hand therapy exercises prescribed to her by the hospital. She has been approved for a high-level package (for a nursing home) but the family do not intend to use it just yet but instead are just planning for the future. She is also currently waiting for a hospital bed to be delivered to assist with her bed transfers. She currently has difficulties with her balance, endurance, strength, bed mobility and transfers, sit to stand and car transfers. The son also reports freezing and difficulties turning in confined spaces.
Task: My role was to undertake a subjective and objective assessment of this patient to determine difficulties experienced and to treat them accordingly.
Action: Because patient C could not speak much english, I had to plan how I was going to tackle this task. I decided it was important that I only used simple words and short sentences with the patient. I was able to use the son to try and translate where necessary but I felt to really build up a rapport with the patient it would be best to try and get as much detail from her first and then let the son confirm or add information where required. It was also important that I used eye contact with this patient to let her know I was interested in what she had to say and to help her understand what I was asking. With my objective assessment it was important to also use very short, simple instructions. I reviewed her bed mobility, sit to stand, strength and balance but chose not to assess her walking in that session due to time, history of fatigue and because the patient had left her walking stick in the car and it would waste time in this session getting it. Therefore I informed the son and patient to bring the walking stick in next week so I could do the 20m walk test, the 6 minute walk test and timed up and go. For the remainder of the session I educated the son on possibly using a plastic bag to assist with car transfers, answered his questions (with the help of the physio) regarding the home care packages, and discussed the possibility of teaching him manual handling.
Result: I successfully completed the subjective assessment and the majority of the objective assessment. I was able to identify problems that the patient was having, including bed mobility, turning, balance, strength and endurance as well as freezing and bradykinesia. I explained my findings to the patient who understood and was happy to attend 1 on 1 physiotherapy.
Evaluation: I was very nervous before seeing this patient. I was unsure whether I would be better to talk directly to the son or to the patient. I decided to aim my questioning to the patient and just use the son as required for translating of the get more details. The patient did actually speak more english then I thought she would and therefore it was easier to engage with the patient. It was also easier to gage the patient's understanding of my questioning or instructions then I believed it would. I believe my strengths were that I used simple language and short sentences, used demonstrations where possible, maintained eye contact and involved the patient as much as possible. My weakness was that I got stuck a couple times with my questioning where I could not come up with another way of asking the same question when the patient could not understand and I could have further simplified some subjective questioning.
Strategies: The strategies I believe would assist to better my assessment of patients who speak little english include practicing simplifying questions and different ways of asking the same questions, for example in regards to festination and dyskinesia.
Task: My role was to undertake a subjective and objective assessment of this patient to determine difficulties experienced and to treat them accordingly.
Action: Because patient C could not speak much english, I had to plan how I was going to tackle this task. I decided it was important that I only used simple words and short sentences with the patient. I was able to use the son to try and translate where necessary but I felt to really build up a rapport with the patient it would be best to try and get as much detail from her first and then let the son confirm or add information where required. It was also important that I used eye contact with this patient to let her know I was interested in what she had to say and to help her understand what I was asking. With my objective assessment it was important to also use very short, simple instructions. I reviewed her bed mobility, sit to stand, strength and balance but chose not to assess her walking in that session due to time, history of fatigue and because the patient had left her walking stick in the car and it would waste time in this session getting it. Therefore I informed the son and patient to bring the walking stick in next week so I could do the 20m walk test, the 6 minute walk test and timed up and go. For the remainder of the session I educated the son on possibly using a plastic bag to assist with car transfers, answered his questions (with the help of the physio) regarding the home care packages, and discussed the possibility of teaching him manual handling.
Result: I successfully completed the subjective assessment and the majority of the objective assessment. I was able to identify problems that the patient was having, including bed mobility, turning, balance, strength and endurance as well as freezing and bradykinesia. I explained my findings to the patient who understood and was happy to attend 1 on 1 physiotherapy.
Evaluation: I was very nervous before seeing this patient. I was unsure whether I would be better to talk directly to the son or to the patient. I decided to aim my questioning to the patient and just use the son as required for translating of the get more details. The patient did actually speak more english then I thought she would and therefore it was easier to engage with the patient. It was also easier to gage the patient's understanding of my questioning or instructions then I believed it would. I believe my strengths were that I used simple language and short sentences, used demonstrations where possible, maintained eye contact and involved the patient as much as possible. My weakness was that I got stuck a couple times with my questioning where I could not come up with another way of asking the same question when the patient could not understand and I could have further simplified some subjective questioning.
Strategies: The strategies I believe would assist to better my assessment of patients who speak little english include practicing simplifying questions and different ways of asking the same questions, for example in regards to festination and dyskinesia.
Saturday, April 10, 2010
Topic 2- Treatment
Situation: Patient B is a 77yo who presented with Progressive Supranuclear Palsy. Progressive Supranuclear Palsy (PSP) is a Parkinson's Plus condition (movement disorder) and is a chronic, progressive neurodegenerative disorder. Its main clinical features include prominent neck dystonia, pseudobulbar palsy, behavioural and cognitive disturbances, Parkinsonism (including rigidity and bradykinesia), early dysphagia or dysarthria, gait disturbances, poor equilibrium, falls and more. Patient B was referred to the Physiotherapy department at Osborne Park Hospital- Parkinson's Clinic with a history of more than 1 fall per day. Patients with PSP often find themselves with trunk posture in extension (compared to Parkinson's where they have a flexed, stooped posture), subsequently these patients often find themselves falling backwards. During assessment of this patients the patient reports, and during observation it is evident that the patient has difficulty with turning.
Task: My task was to aim to decrease the number of falls the patient has per day (this was the goal of the patient) with some treatment. My goal for the session was to correct the patient's turning strategy to help prevent some of the falls that are occurring.
Action: Once I determined the aim of my treatment session, I first thought it would be important to discuss the reasons for falls, the function of the basal ganglia and the need to break the old habit and create a new one. The patient was a physicist, and was there for highly educated. I thought that I might be able to gain more from my treatment if he understood the background and reasons for my treatment. The next thing I did was to teach the patient turning strategies and how it was important 'not to cross his feet over', ' take big steps' and 'not step backwards'. Once the patient understood this I got him to practice a 90 degree turn, with lots of repetitions, encompassing this good technique. It took looks of prompting and cues to get him not stepping backwards or crossing his feet however he did get a good feeling for taking more steps to get around. After I felt he was getting hang of it, I then progressed it to a full clock turn. The patient did well however required prompting to lift his feet about 1 inch off the floor each time.
Result: I was happy with my treatment of this patient. He understood the correct technique of turning and could pick up his own mistakes. I discovered however, out of the treatment session he would forget the correct technique. When I asked him to walk over and have a seat, he crossed his feet over. I understand it will take a while to break the old habit and unfortunately that means he will encounter some more falls in the coming weeks but I have written cue cards and will continue practicing with the patient. It does point out the need to practice in different environments.
Evaluation: Upon reflection of this treatment session, I think I did well in explaining the reasons behind his falls and getting his attention. The patient did well with the techniques but could not transfer them to other environments or situations. My supervisor also gave me feedback on my performance and said it was good however I need to be a bit firmer with him. That makes sense and I can understand the need to be firmer with him to get the acquired result. It took me a while to come to terms with the fact that due to PSP the person at times struggles to keep their eyelids open. It made me feel like I was being boring or the patient wasn't interested but I had to remind myself it was a part of the disease.
Strategies: Strategies I would use in future would be to be firmer with the patient but letting him pick up his own mistakes and stopping him everytime he makes a mistake rather than letting some slide. In terms of not being able to transfer the skill to another environment, I would get the person walking and take him to different rooms and randomly ask him to turn to practice that automotricity and new skills.
Task: My task was to aim to decrease the number of falls the patient has per day (this was the goal of the patient) with some treatment. My goal for the session was to correct the patient's turning strategy to help prevent some of the falls that are occurring.
Action: Once I determined the aim of my treatment session, I first thought it would be important to discuss the reasons for falls, the function of the basal ganglia and the need to break the old habit and create a new one. The patient was a physicist, and was there for highly educated. I thought that I might be able to gain more from my treatment if he understood the background and reasons for my treatment. The next thing I did was to teach the patient turning strategies and how it was important 'not to cross his feet over', ' take big steps' and 'not step backwards'. Once the patient understood this I got him to practice a 90 degree turn, with lots of repetitions, encompassing this good technique. It took looks of prompting and cues to get him not stepping backwards or crossing his feet however he did get a good feeling for taking more steps to get around. After I felt he was getting hang of it, I then progressed it to a full clock turn. The patient did well however required prompting to lift his feet about 1 inch off the floor each time.
Result: I was happy with my treatment of this patient. He understood the correct technique of turning and could pick up his own mistakes. I discovered however, out of the treatment session he would forget the correct technique. When I asked him to walk over and have a seat, he crossed his feet over. I understand it will take a while to break the old habit and unfortunately that means he will encounter some more falls in the coming weeks but I have written cue cards and will continue practicing with the patient. It does point out the need to practice in different environments.
Evaluation: Upon reflection of this treatment session, I think I did well in explaining the reasons behind his falls and getting his attention. The patient did well with the techniques but could not transfer them to other environments or situations. My supervisor also gave me feedback on my performance and said it was good however I need to be a bit firmer with him. That makes sense and I can understand the need to be firmer with him to get the acquired result. It took me a while to come to terms with the fact that due to PSP the person at times struggles to keep their eyelids open. It made me feel like I was being boring or the patient wasn't interested but I had to remind myself it was a part of the disease.
Strategies: Strategies I would use in future would be to be firmer with the patient but letting him pick up his own mistakes and stopping him everytime he makes a mistake rather than letting some slide. In terms of not being able to transfer the skill to another environment, I would get the person walking and take him to different rooms and randomly ask him to turn to practice that automotricity and new skills.
Subscribe to:
Posts (Atom)