patient with a pre-morbid disability

Whilst on my orthopaedic prac, i treated a patient who was quite disabled. He had been involved in a car accident and had a broken NOF, however was also wheel-chair bound most of the time pre-morbidly. He came across as having a mental disability as well and so when i first saw him, i used very simple language and treated him like someone who had a mental disability. After my first treatment session with him, his mum told me that he was actually fine mentally and quite intelligent. This was rather embarrassing for me as i had been treating a 19 year old like a 5 year old. It was still hard when i treated him later on because i would start using really simple words and then have to remind myself that he actually had near perfect cognition. This taught me just to take extra care when working with people with a disability and to properly check what their disability is before you see them. This would just help this happening again in the future and will help us gauge the best way to interact with them.

Perseverance

The biggest challenge doing prac in a country where they speak a foreign language is developing effective non-verbal skills to get the intended result. There are positives and negatives about working with children over here. Firstly they primarily respond by non-verbal communication anyway but it is the simple commands that hold you back. Secondly, even though you don’t need an extensive vocabulary, these children (especially the ones with Autism and ADHD) have very limited attention spans. 

One child in particular was very reserved, however constantly seeking visual and tactile sensory stimulus. Over a couple of days I noticed that he thrived off repetition and habitual activities, such as walking on the beams in a continuous circle holding your hand. He would go on all day if you didn’t stop him. Having poor core stability and balance this boy needed to progress. Reaching outside his BOS was a foreign idea for this boy. 

I attempted to gradually challenge this boy by taking my hand away. Eventually after much perseverance I was able to get his walking sideways and backwards. This activity required two of us using primarily manual handling to guide his feet. On this placement, I have learnt to pick up on small improvements as things happen a lot slower over here with the language barrier. In addition, my non-verbal communication skills have improved quite a bit.

continuing ed.

I found it very challenging having never worked with Autistic and ADHD children before. One child in particular was excessively hyperactive. He would bounce around and around on those bouncing balls without loosing any energy. Any attempt at a one on one treatment session with this child was a mission. He would follow commands of the Chinese speaking staff but obviously we struggled in that department.

 I had been allocated with two other students in this sensory integration room who are studying Occupational therapy. Sensory being one of the domains of OT, they came up with some sound ideas that I have taken on board and thought I’d let you all know about if you don’t already. 

The first technique is to firmly wrap the child like a sausage in a blanket for ~ 5 minutes. As the child can’t move their limbs, they are calmed down. It worked a treat. The second calming technique I adopted from the centre was the use of a large fitball that had rubber spikes all over it (like those easy grip catching balls). All the children laid down on the mat and for 15 mins the therapist rolled the ball up and down each child in supine and prone. I gave it a go and it almost put me to sleep. This experience has taught me to feed off other health professionals for new techniques and knowledge that may improve the effectiveness of your treatment. 

Thinking outside the square

I am currently on placement in Shanghai, China working at a children’s rehabilitation centre. I have been working with a 16yo child with quadriplegic cerebral palsy. As she is quite dependent, she tends to be left in her wheelchair off of to the side, poorly positioned. Rarely are her footplates ever down for her feet to go on which leaves her in a slouched and abnormal posture. She is not the only child in the centre that I have observed with poor wheelchair positioning and footplates not in use. With the language barrier it is hard to communicate the purpose behind our treatment. I felt very frustrated and helpless in this situation. Some of the staff are unaware of the consequences poor positioning can have on a weak and hypertonic body. With the help of an OT student who spoke fluent Mandarin to translate, we demonstrated and explained correct wheelchair positioning for this child with additional methods for support. Using what we could find we adjusted the foot plates, applied a hip and chest strap, rolled towels either side of the trunk for support and finally a sandbag in between to assist with the adduction/IR contracture. The rationale was clearly translated and the therapist was appreciative. Every day since, effective positioning has been applied for this child. This child is now more alert in this position and will participate in more activities. This experience really made me aware of the mental/emotional effects good positioning can have on someone's confidence. It just shows what you can achieve with limited resources. It is also now our aim to develop a staff handout informing them of the importance and reason behind correct positioning.

Bronchoscopy

This semester I was able to sit in on a bronchoscopy of a patient who had suffered lung cancer and had had previous surgery to implant a stent in her right main bronchus. The consultant who performed the inverstigative procedure was kind enough to explain to us the entire procedure from start to end including the process of anaesthetising the patient and its effect on the respiratory system.

Although I have been able to observe surgery and video assisted procedures before, what made this experience so valuable was that the consultant, medical students and anaesthetists all took the time to treat the procedure as an educational tool. What would of taken 10 minutes to see whether the stent was still in situ and to laser off any scar tissue ended up taking half an hour due to the consultants willingness to explain and allow us to get as much out of the experience as possible. He even ended up quizzing myself and the other physio student in a non threatening way, assuring us that we know more than we think!

I valued this expreience greatly as it was nice to know that there are other professionals out there who insist on sharing their knowledge and time rather than seeing us as annoying students and ignoring us which I'm sure we've all experienced by someone this year. It makes such a difference to our learning when people strive to get the best out of us.

wry neck pain

What is wry neck. How do we treat acute neck pain.

Neck pain as a whole is a major contributor to disability worldwide, with about 70% of the population experiencing an episode of neck pain at some point in their lives. Wry neck is a recognised syndromes causing pain in the neck it occurs as involuntary contractions of the neck muscles, leading to abnormal postures and movements of the head. Fortunately wry neck is a transient and self limiting condition that can usually recover in a few days to a week. There are usually no risks or complicating however neck pain can return. Statistics show that around 10-15% if the population has neck pain at any given time.

What causes wry neck?
The exact cause of wry neck is not know but usually results from unusual movements or prolonged abnormal postures. It is thought that one of the joints in the neck become jammed or locked, resulting in a painful, protective muscle spasm. Any one can get wry neck but is typically occurs in young people between 12– 30 years of ages

Characteristics of Wry Neck
• A sudden onset of sharp neck pain
• Pain can be anywhere in the neck extending the head, shoulder and upper back, usually worse on one side.
• Difficultly turning head in one direction
• Patient is unable to correct posture due to pain and muscle spasm.
• Palpable neck spasms on affected side.

Differential Diagnosis
It may not be Acute torticollis
• Non Specific neck pain
• Cervical postural syndromes
• Cervical spine degeneration
• Acceleration / deceleration injuries
• Cervical spine fracture
• Acute never root pain


Explaining the Symptom
As Wry neck an abnormal contraction of the muscle in one side of the neck, people may appear with their head turned to one side. Their head is rotated due to the attachments of the spasming muscle and the pull of the muscle on the neck whilst contracting. The loss of movement in the neck may be due to pain and tightness of spasming muscle.

Evidence based Treatment

What work and what doesn’t
Multi-modal treatments – stretching/strengthening exercises and mobilisation/manipulation
Proprioceptive and therapeutic exercise—Muscle energy exercise
Massage - release tight affected muscle and reduce pain
Thermotherapy - heat pack applied to painful muscle
Acupuncture—short term pain relief. Can help with muscle tightness.
Temporary use of a soft collar – collar can provide support and comfort for a short period for acutely painful necks. Not generally recommended as the neck is best kept mobile and exercised naturally

Thank you

AGED CARE LOW VS HIGH

Recently on my gerontology prac, I wondered what determined whether a patient that required aged care went into low care or high care.

There was a patient on my prac who was admitted due to hospital from an aged care facility due to functional decline, staff at the low care facility report this particular patient was to not able to return to the facility because they were unable to cope with their needs, and basically admitted the patient to hospital because they believed they required a high care facility to “cope” with this patient.

This patient’s mobility was limited in terms of distance although they were independent with a WZF up to 30 metres. If they were to return to the low care facility they needed to walk independently to the dinning room, which was 80 metres. My aim of treatment was to build to this level so that the patient could return to the low care facility. The patient’s mobility had a big influence on whether or not they went into low or high care. This reflects in the staffing and funding difference between the low and high care facilities.

From this example we see that mobility has an influence in whether a patient requiring aged care goes into low or high care, but not the whole picture.

Assessment of patients going into residential care is done by someone on the Aged care assessment team (ACAT) they ask a number of questions relating to the patients needs and determine what appropriate placement for each individual is. This essential determines the funding paid to the residential care facility.

Funding is based on three domains
Activities of daily living
Behaviours
Complex Health Care

In reflection, it is not the physiotherapist job to determine whether or not a patient goes into aged care, although in the hospital system we are the experts on patients mobility and are uniquely positioned to rehab patient to a level which achieves there maximal level on functionality. I thorough knowledge of discharge options is required to discharge patients to the most appropriate facility to care for there needs.