Muscle-Stim Heel Switch

Hi everyone,

This week i had the opportunity to use e-stim which i thought i'd never touch this whole year haha but it was great to revist the parameters etc...Anyhow, I have applied it to a patient with an incomplete tranverse myelitis at C5/6 and as a result, his main problems during gait are hip hitching of the (L) leg during swing due to mainly inadequate DF and KF. I firstly got the patient to stand on a wedge to prolong stretch (L) gastrocs before applying the e-stim. My aim was to stimulate the DF but not just the strengthen them while in sitting, but to apply it during gait...

The heel switch component of it was placed in the patient's shoe, and everytime there is pressure through the heel i.e. stance phase, the e-stim is off....however as soon as the pressure is off the heel switch (during pre-swing) the e-stim turns on and it activates the (L) DFs...to the patient's amazement he began walking with a near-normal gait pattern...his hip hitching dramatically reduced and his balance improved significantly.

The treatment obviously proved interseting, but to what extent will it have in terms of effect on the recovery of the strength of DF in a pt with tranverse myelitis, I am unsure of.. Anyone have any experience with the same?

Blogging about blogs

Hi guys,
I apologise for the lateness of my last blog and just wanted to actually blog about blogs! haha. I was wondering what everyone's thoughts were on how useful they have been and what they have got out of them? I feel they are extremely helpful to get other peoples perspective on how to handle difficult patients, supervisors and placements in general. I also find it really helpful when people share the positive stuff about what has worked for them. I do feel however that there are probably too many blogs that we are required to do and often find the quality of my posts dropping a little as I struggle to find things to talk about. All in all I feel the blogs are very helpful and perhaps with a little refinement in future years will be extremely effective in helping students to make the most of their placements!

Major Issues

Hi everyone. I have had a very difficult past few days of prac which is looking like it will result in an extra placement after the PCR. The placement has been quite messy with my supervisor often away but I felt it was going okay and I was at least passable. Things kind of exploded on Tuesday, and I discovered that there had been conversations going on about things occurring that they were not happy with. Had they bothered to ask me or anyone else involved in some of these issues it could have been explained and handled with next to no fuss. Instead it's suddenly a massive problem brought up half way through my last week.

An example included that one morning when my supervisor was not at work, she had organised for me to attend a few speech sessions. That morning the speechie came and spoke to me and said that because of the sensitive nature of two of the sessions it would be better if I didn't attend. I said that was fine, and went on with some reading and preparation (this was in the 2nd week). It was then brought to me by my CCT this Tuesday (still no one at the facility spoke to me about it) that they thought it was unprofessional that I had not turned up to scheduled speech sessions as arranged.

The other situations were similar to this involving miscommunication. In hind sight I acknowledge that some issues could have been prevented by extra communication on my part, but others couldn't.

I had the OT come and yell at me in a rather unprofessional manner, for things that hadn't been classified as requirements to me, stating she didn't "give a rats" what I had been doing that morning. This was in front of my supervisor. Had I been unsure I have have clarified myself, but as far as I was concerned I knew what was expected.

My main frustration with this situation is that on the Tuesday of my final week, this all came to the surface, when it had been being discussed behind my back the entire placement. It was not brought up at mid-placement Ax. As far as I was concerned they were "reasonably happy".

I recognise what my responsibilities were, but without the feedback..?

I am still attending my final two days, despite being told I will fail the FCT assessment, and am hoping to pass my final CCT one. If I have to do another placement I will do one, but without the appropriate feedback and support I'm not sure passing this one was ever a possibility.

If anyone has been in even a slightly similar situation I would really appreciate your input.
Thanks

Non english speaking...

Hi all,
Over the duration of my last placement, I have encountered numerous clients who are non english speaking/reading. There are a few ways to tackle this situation, although generally i feel that not all of the information i need to give them gets through correctly. The ward coordinator attempts to get an interpreter for one session, where all the medical staff are able to attend (midwife, physio, doctor) to discuss and explain things to the client. this doesnt always work out though, as often you are busy at the time the interpreter is available, or it is simply too busy with everyone wanting a turn to speak to the client. I have found that family members (mother or husband) are generally quite helpful if they are fluent in english, though you cant be sure everthing is being passed on accurately. The biggest help i have found is the information sheets/brochures which are written up in all different languages (ie. postnatal advice/pelvic floor exercises/bowel and bladder information), so long as there is the language you are looking for! i think these are a great idea, and i feel they should be available in all public and private hospitals. So always ask the physios/ward coordinator if these exist, as they will help you greatly! Does anyone else have any thoughts or experiences?

Change of approach

Just wanted to share something related to one of my previous posts about trying to get compliance out of a 5 year old. My last session with this client was really successful and I came up with a few reasons for this.
Firstly my supervisor was not in the room so I felt my confidence in myself and my abilities without looking over my shoulder.
Secondly, it was mainly a treatment whereas previous sessions had involved compulsory parts of assessment that I really had to push through to get a baseline.
Thirdly, I changed my style with her. Together we constructed an obstacle course, and I think this made her feel involved and allowed her to include things that she enjoyed and found easier. Consequently I could slip parts in that were more difficult and challenging for her. I had a lot of different ideas to work with that I could bounce back and forth to if she refused one activity. Due to her compliance the session was shorter and more effective and I ended up feeling quite good about it.
I know that there were a few factors that contributed to this session, but I choose to believe my adjustments and ideas were part of it!

Activating Dorsiflexors

We have just learnt a technique from one of the senior neuro physios to activate dorsiflexors where dorsiflexion activation is a deficit. It involves applying pressure/compression between the fourth and fifth metatarsal space of the foot and this would elicit toes extension and some dorsiflexion. I've put this to the test to two of my patients (MS and BG-stroke) and they were amazed at the reflex that was elicited from the pressure applied. However the effect on the actual active-dorsiflexion in gait is yet to be observed but I am positive that this technique would prove helpful!

Final prac...

Hi everyone,
Hope the last placement of the year is going ok, not too long to go now! i just wanted to write about the differences i have found between my first placement of the year and this one...
I have found that all of the physiotherapists i am working with treat me as one of them rather than as a student, and they often make comments 'well your more a real physio now than a student' (it may just be a good placement with nice people!) and i feel that this is because we are so close to finishing. i definately have been given more responsibilities, and am left to do a couple of wards a day on my own, and even take outpatient appointments on my own (womens health). i find this really enjoyable (others hate the sink or swim scenario) as it definately makes me work harder, manage my time more efficiently and learn a lot more.
has anyone else found this on with the last few placements, or do you still feel as though a lot of the supervisors still treat you as though you are on your first placement ever?!!

personal experiences

I was seeing an elderly patient on my last prac and had just positioned her out of bed and were going though some deep exercises etc. A relatively new doctor to the area came over and began to look at her nursing notes sitting on the table at the end of the bed. The patient starting to get very agitated and scared saying she didn't like that doctor and he was not to come near her etc. The doctor hadn't even said anything to the patient before she was begging me not to leave her alone with the doctor and was crying/shaking etc. I had to reassure the patient over and over with help of the nurse, that the doctor was here to help her and he would do no harm. It took around half an hour to settle the patient before she would allow the doctor to see her. The patient revealed later it was the doctor's appearance/nationality that had caused her outbursts, which i found strange and a bit difficult to comphrehend but it did alert me to the that a lot of elderly people have had personal experiences in the past that affect how they interact with people today.

students and health professionals

Hi all,
just wanted to share an experience i had with a nurse during my last prac. I had gone into the room where the nurse was and began my assessment. I was auscultating and making sure i respected the privacy of the patient (she was female). The nurse suddenly interrupted me and began to lecture me on how i was being inappropriate and rude as i hadn't shut the blinds whilst examining. I had made sure the patient was covered the entire time throughout my assessment and explained this to the nurse but she continued to disagree and lecture me in a quite condescending manner. In the end, I did what she said. I felt as a student, she was very intolerant to me. I mentioned what happened to my supervisor and she agreed with me, but did think it was just easier to comply with the nurse. I'm sure everyone has had a similar experience with some other health professional but any suggestions on how we can change this 'student' status? and how others perceive students?

Tough one!

Hi guys,
sorry for the late post. Just with regards to a patient I saw on my cardio placement. He was post aortic valve replacement and was progressing along fine the first few days post op. After the first few days though, he started to plateau, his main problem was dyspnoea, but he was also having dizzy spells and getting sort of a tingly feeling in his hand when he was really short of breath. His ex tol was decreased and Sp02 was dropping when amb'ing. The doctors t/f'd him to Bentley for more rehab before he went home and myself and my supervisor told them several time that there was something not right about his presentation and we couldn't quite figure it out. In the end he came back to the ward and after many more tests they discovered a phrenic nerve palsy! Obviously as a student it is not my role so much to be pushing my point to the doctors but i was just wondering as a professional how much would you make your point to the doctors before giving up? Especially if your not sure what the actual problem is??

Communication with parents

I have found it difficult on my paediatric placement sometimes, to be taken seriously by the parents of the clients I see. Particularly with infants I occasionally get the impression that they think I am too young and inexperienced to know what I'm talking about (which isn't too far from the truth sometimes). Some are quite happy to be seen by a student but then speak directly to the supervisor rather than me. I try to sound confident and talk to them about ideas to help their child at home, but my supervisor will always jump in with something more relevant or effective. I'm trying to power through but I feel because of the set up I'm not being given a chance to show what I know.

Positive Support Reaction and Sit to Stand

Hi Everyone...half way there!!

Although my prac is outpatient neuro, a couple of us have had the opportunity to go down to Ward 2 which is a ward dedicated to intensive neuro rehab for inpatients. A common presentation for some stroke patients is the positive support reaction where the unaffected side is over-active and when weight is transfered to the unaffected side (e.g. in standing) the unaffected lower limb would push away towards the affected side. As part of the sit to stand retraining, the physios make the patient follow a specific pattern that causes the patient to transfer the weight to the affected side and stand through the affected side.

This technique seemed very effective to ensure patients are able to sit to stand and not have a positive support reaction from the unaffected side, however my question is, does this technique not lead to a poor pattern of movement down the line?

thanks for any input

Lumbar Rotation

Prior to my country placment i found the most challenging technique to be lumbar rotation- i found it so hard on my body. So I thought that I would like to alert everyone to a way of doing a lumbar rotation technique which I found to be far easier on my body than the one we have previously been taught at uni. Apparently this is the original Maitland way of doing lumber rotations:

Grade 1: patient side lying with both knees bent up (bend up more for low lumber or less for high lumbar), no rotation through trunk, therapist stands behind the patient in stride stance with both hands hooked over the iliac crest, line of push is down the femur, Grade 1= gentle movement, really good for acute disc/facet injuries!

Grade 2: same as above except the top hand is placed on the patients belly button (some trunk rotation) and the amplitude of movement is greater as it’s a grade 2. If done correctly the top shoulder and the pelvis should be moving in opposite directions with the oscillations.

Grade 3: same as above except the bottom leg is straightened and the therapist supports the top arm at the shoulder (fixates it)

Grade 4: same as grade 3 except the movement is just at the end of range

I found it to be a really useful technique from really acute injuries to chronic conditions. And if the patient find the technique too uncomfortable you can just drop down a grade or likewise you can go up a grade if the technique isn’t forceful enough.

Different ideas...

On my last placement at a private practice I had a ‘clash’ of ideas with my supervisor. At this particular clinic 4 of the clinicians had over 35 years of experience each- so I found that with a few different principles and clinical reasoning we had very different ideas. I know that they had a lot more experience than me but they were totally unaware of some of the various principles/tests that I had learnt at university. For example = the differentiation between the diagnosis of a lumbar facet sprain and a lumbar disc protrusion. Many of the key sings that would have alerted me to a disc problem i.e. mechanism of injury, presence of neuro symptoms, they said would indicate a facet joint problem. I obviously wasn’t going to argue but I did state the typical signs that we had learnt at uni and they said that they all could indicate either. I know that essentially both conditions are treated in the same way anyway but it was just interesting to see their provisional diagnosis compared to mine.

Hand sensory stimulation

Hi everyone

I've just finished one week of my new prac at shents neuro outpt and it has been one hell of an experience so far. Our supervisor is very experienced and has taught us several new techniques, which is starting to get difficult to remember all!

One of the techniques that we've been taught is hand sensory stimulation ( there is another word for it but i've forgotten for now...will keep you posted) It is used for stroke patients who have reduced voluntary control of the upper limb. It involves getting a rigid pencil and having the patient sit over the edge of the bed with a table in front of them to support their affected arm in front of them with the palm facing up. With the pencil, you roll it around the hyperthenar surface of the palm and then you draw lines with the non-lead side, then you colour it in again with the non lead side. After this, the hand is "grounded" which involves other techniques (then practice the Fx task such as picking up a ball). The outcome is quite effective with greater mm activation of the UL. More to come i am sure.

Apologies for the poor explaination!

theatre

hi everyone,
i have had the opportunity to view a couple of procedures in theatre this prac, and as gross as it sounds i thought it was a great experience.
whether you have the opportunity to see a cesarean, hip or knee surgery, or any other kind, i definately recommend it if you have the stomach for it.
by observing exactly what goes on in surgery, you definately find it easier to treat the patients on the ward - and with a lot more understanding/sympathy!
the surgeons are helpful also (in my small experience) and they took the time to explain things to me and teach me something interesting.
i hope most of you have had this opportunity as well, and if not then definately ask your supervisors!

Non-compliant kids

Greetings.
I have just commenced a placement of the paediatric variety, which has been both fun and challenging in the first week. I would like some assistance with the well established problem of getting kids to do what you want them to do. I had a young client (almost 5 years old), who was less than co-operative, especially when asked to do activities that she was well aware she would find difficult. Some of these things (when we finally got her to do them) she could perform quite well. My supervisor was able to get her to do things without her realising that she was doing them, but my strategy really came down to bribery with stickers. I realise that this may not always be effective, so with a child like this, with self esteem issues, how could I get her to attempt difficults tasks?

combining techniques

Hi all,
just wanted to share an treatment session where i combined a number of techniques to produce an effective treatment. We had a patient with infective pneumonia (and on Xray- a very prominent right upper lobe consolidation). The patient was intubated at the time. We decided we would position the patient in high sitting (with the help of nurses and orderlies) to provide some postural drainage, and adjust the ventilator settings to hyperinflate (hence get some increases in collateral ventilation and shear secretions etc etc) At the same time as we hyperinflated, I also provided some rib springing at end of expiration to increase lung volumes and some expiratory vibrations focused on the right upper lung zone to loosen secretions. After a few cycles lasting a minute or so each, we suctioned very large amounts of sputum via his ETT, and on auscultation there was a significant decrease of the amount of coarse crackles which were heard prior to treatment. Overall, it was very useful combining all three techniques for treatment.

mothers and babies...

Hi all,
have just started an interesting but rather emotional prac this week doing womens health. i am dealing with mothers who have just given birth (anywhere from 12 hrs to 6/7 days post so far), and therefore have some very emotional patients!
i have found that this placement, more than any others i have been on, requires a LOT of communication and how well you do your job nearly depends more on your manner/personality than skill and knowledge. there are so many different patients with differing circumstances that there is no set routine to your vistits and sessions - you just have to judge it once you get in there. some i have found quite challenging include mothers who have lost their baby during birth, and those who have very fragile family (husband) situations and no support.
it is much harder to plan your day/patients as often your timing is not the best and so you have to go and treat someone else or find something else to do. often the only 'treatment' you are able to carry out for the patient is leaving them with some pamphlets and checking up on them again later to see if they have any questions, which often isnt ideal.
however, it is great doing such a different prac and apart from the challenges i am really enjoying it, and just thought i would share some of the things i have learnt so far!

ICU patients

I have just completed my last prac in ICU. Over the four weeks, i saw a huge variety of patients-all very sick and most of the time, difficult to see. I found myself sometimes getting quite upset seeing these type of patients, especially the young head injured/spinal injured patients who are essentially the same age as you. It was hard not to get upset as from all our studies at uni of anatomy/neuro, we have the knowledge of what is happening to them and have some idea of their prognosis, which a lot of the time, was not good. From having a particular couple of patients the whole time throughout my placement, it was hard not to somehow get attached to them and their families. The patients left ICU as soon as they were medically stable but it was hard not being able to follow them through and see their progress, seeing as you have formed somewhat of a relationship with them over time. From completing this placement, I realised it gave me good perspective of what a patient looks like/deals with within an acute stage and how they are when heading into rehab (though i would have liked to see some of my patients within the rehab stage) Anyone have any thoughts about this?