Final internship report #3 - · PDF fileInternship report 5 Introduction Description of the...

European School of Physiotherapy

Assignment #7 Clinical internship report Internship 3(Period; 06/05/2013-07/08/2013) Intern: Yagmur Hazir (500544685) Institution: Baskent University Hospital Clinical instructor: M. D. Physiatrist Mehmet Adam Clinical instructor signature: Clinical Supervisor: Pim Ranzijn Clinical supervisor signature: Intern signature: Date of submission: 02/08/2013 Date of review:

Internship Report Date: 02-08-2013 Class: LP11-31 Professor: Pim Ranzijn

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© 2009 Hogeschool van Amsterdam. All right reserved

Last update: August 4, 2013

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Table of Contents

ACKNOWLEDGEMENTS 4

INTRODUCTION 5

DESCRIPTION OF THE SITE 5

PATIENT RELATED ITEMS: 5

TREATMENTS USED: 6

EXPERIENCE DURING THE CLINICAL INTERNSHIP: 7

DESCRIPTION OF THE HEALTH CARE SYSTEM 8

PERSONAL LEARNING OBJECTIVES: 9

EVALUATION OF LEARNING OBJECTIVES: 10

PATIENT CATEGORY REPORTS 12

PATIENT CATEGORY REPORT #1 (ROTATOR CUFF SYNDROME) 12

DESCRIPTION OF THE DISORDER: 12

EPIDEMIOLOGICAL DATA OF THE DISORDER: 12

INDICATION FOR PHYSIOTHERAPY: 12

PATIENT CATEGORY REPORT #2 CEREBRAL PALSY (CP) 17

DESCRIPTION OF THE DISORDER: 17

EPIDEMIOLOGICAL DATA OF THIS DISORDER: 17

INDICATION FOR PHYSIOTHERAPY: 18

EXTENSIVE PATIENT REPORT 21

SPINAL CORD INJURY (SCI) (PARAPLEGIA) 21

MOTIVATION FOR PATIENT SELECTION: 21

DESCRIPTION OF THE DISORDER, EPIDEMIOLOGY, PREVALENCE AND INCIDENCE 21

ADMINISTRATIVE DATA OF THE PATIENT: 22

HOUR JUSTIFICATION 31

GENERAL CONCLUSIONS 31

REFERENCES 32

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Acknowledgements

I would like to thank my CIs, Physiatrist Mehmet Adam and Physiotherapist Ozlem Sayilir

Pektas for accepting me into their department. Furthermore, I would like to thank to the M.D.

and upcoming Physiatrist Emine Ece Yilmaz for sharing with me her valuable knowledge.

Finally, a special thanks to the Physiotherapist Akin Aydemir for sharing with me his valuable

knowledge and making the last 6 weeks of my internship unforgettable.

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Introduction

Description of the site

My internship place is located in the city called “Adana”, where the population is over

one million. The city is highly developed and can provide lots of working opportunities in

Physical therapy. Not only there are physical therapy departments in private and public

hospitals but also there are private physical therapy and rehabilitation clinics throughout the

city.

Baskent University Hospitals branched out throughout the country. The hospital is

an outpatient clinic and has most of the medical professional fields, including Physical

therapy. The Physical Therapy department works closely with Neurology, Rheumatology,

Orthopedics, Pediatrics. There are 6 physiotherapists work, and one works as a head of

the physiotherapy department. Besides there are 4 physiatrists working with

physiotherapists. The physiatrists take patient history, do assessment and give therapy,

however the physiotherapists apply the therapy that physiatrists approved on. There is

also 1 physical modality technician. The therapy includes hot and cold modalities,

electrotherapy and therapeutic exercises. There are separate rooms depending on

the treatment type. In the physical department, there are neck and back traction

rooms with traction machines, short wave, isokinetic and balance machines which are

used for research and therapy, hydrotherapy, EMG, hand rehabilitation, splint-orthoses,

4 physiatrists, 1 physiotherapists, child and orthopedic rehabilitation rooms available.

Patient related items:

There are more than 40 patients who are treated by physiotherapists every

day. The rehabilitation are only indicated for the patients who need and willing to join the

rehabilitation. The category below, shows what type of patients I have been able to

see so far. The rehabilitation is done by me independently.

Orthopedics:

• Supraspinatus tendinitis

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• Meniscus

• Anterior cruciate ligament (ACL)

• Muscle strains

• Frozen shoulder

• Medial epicondylitis

• Rotator cuff syndrome

• Fractures

• Osteoarthritis

• Osteoporosis

Neurology:

• Spondylosis, spondylolesthesis, radiculopathy

• Ankylosing spondylitis

• Cerebrovascular accident (CVA)

• SCI (tetraplegia, paraplegia)

• Cerebral palsy (CP)

• Polyneuropathy, mononeuropathy

• Multiple sclerosis (MS)

• Carpal tunnel syndrome

• Scoliosis

Cardiopulmonary:

• Chronic obstructive pulmonary disorder (COPD)

Other classifications

• Rheumatoid arthritis

• Scar tissue contractures

Above the mentioned patient categories, the majority of the patients who are treated are

neurological patients. They are treated by physiotherapists after a consultation by the

physiatrists. The four physiatrists may check their patients after every 10 or 5 sessions. It

can be even more frequently than it is expected.

Treatments used:

The most used intervention is electrotherapy. To be more specific, the most used

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currents are TENS, Russian, Galvanic, Diadynamics and interferential. The time of

the therapy varies from 30 minutes to an hour according to the patients’ needs.

Besides Ultrasound is also applied around six minutes. There is also an application of

Infrared and laser. The electrotherapy may be applied with Hot pack around the injury

site depending on the type of current or what patient needs. Therapeutic exercises are

ADL training, ROM, muscle re-education, strengthening, releasing the muscle spasm

etc. Massage can be applied as a soft tissue release in the rehabilitation. Besides the

therapeutic exercises done by the physiotherapists in the hospital, homework

exercises are given as well.

Experience during the clinical internship:

Experience in taking Patient History:

I was able to take the patient history for diagnosis in this internship site despite the

regulations between the hospital and the health institutions. I have had two clinical instructors

who are a physiatrist and a physiotherapist. I have observed a lot of different type of patients.

While I was working with the physiotherapists I was able to take patient history by asking

permission from specific patients and from the physiotherapists. The working opportunity

under the supervision of my CI was the most beneficial time for me because I felt

independent and believed that it will be more useful for me in the future. For this time, my

strength was to include all the relevant medical data from them.

Experience in Assessment:

Just like in patient history, I was also able to perform assessment for diagnosis and

intervention. I also have seen differential diagnosis from the physiatrists. I have observed the

usage of shortened version of the assessment scales with a determined clinical reasoning.

Experience in Treatment:

The one and only intervention for a long period of time was therapy for me, either under

supervision or independent. Mostly, I was able to treat the patient category below:

• Neurology (%40)

• Orthopedics (%40)

• Pediatrics (20%)

Therapy was my strongest part from overall internship period.

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Working hours

Monday to Friday:

From 8.30am to 6pm.

Description of the health care system

In Turkey, healthcare is coordinated by the government, as the ministry of health.

The ministry is responsible for providing health care and organizing health care

services for patients. Furthermore, they are obliged to operate public hospitals and

supervise private hospitals and clinics. They check the usage and price of the drugs. The

quality of the private hospitals is higher than the public ones. The reason is the lack of

investments on health care in all over the country. The biomedical equipment are not

well developed in public hospitals, however in private hospitals the equipment are

supplied better in order to provide better consultation and intervention for patients.

The hospitals and the medical doctors work especially in the cities because of the

highly dense population to get profit, although in rural areas there are insufficient health

care services. There are four major organizations as social insurance for citizens. These

are social insurance institutions, pension fund for civil service, social security institution

for the self-employed and green card users. Should the patients need to get any medical

consultation, they have to claim that they are registered any of the social

organizations as mentioned above in order not to pay or pay partially. However in private

hospitals patients have to pay a certain amount as an agreement between private

hospitals and the public organizations.

The most common patients who need rehabilitation are CVA patients in my internship

site. The common reasons for this disease are traffic or any trauma related

accidents, hypertension, thrombus formation, embolism etc. These reasons cause

ischemic stroke or hemorrhages. They follow the rehabilitation for weeks with the

help of a physiotherapist under the consultation of physiatrists. The rehabilitation

period depends on the progress of the patients.

In my internship site, the physiotherapists are only in close contact with physiatrists.

They receive orders from them to apply therapy. In the ‘Order Paper’, only the diagnosis

is written in these papers, however; the physiotherapists can have access to the

patient records. Physiotherapists are charged interchangably everyday to give

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homework exercises to the patients who do not need rehabilitation in the hospital.

There are ready made papers, with pictures, are given as homework exercises to the

patients. The physiatrists are in close contact with orthopedists, neurologists and other

necessary specialists.

In the country itself the physiotherapists are not allowed to open any rehabilitation

clinic or physical therapy center by themselves. They work in the rehab centers or

hospitals with the physiatrists.

My CI is a physiatrist but I work with physiotherapists in every working hour. We are

eight interns now in the hospital but this number may change after certain amount of

weeks. We are allowed to directly touch the patients and give therapy

independently with or without supervision.

Personal learning objectives:

SMART goals

1.

S Rehabilitation for 2 pediatric cerebral palsy patients independently

M 2 of these patients will be checked by my CI and given to me for rehab

A Acceptance of the intake of CP patients by the hospital and my CI

R To gain experience in rehabilitation of CP patients

T In 3 months

2.

S Using Brunnstrom Fugl Meyer assessment test and Berg balance scale on

1 stroke patient

M This patient will be checked and compared with the assessment of my CI

A Acceptance of the intake of stroke patients by the hospital and my

CI. Comparison of the results after the assessments

R To gain experience in using these tests in stroke patients

T In 3 months

3.

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S Usage of Biodex Isokinetic machine on 1 indicated orthopedics patient

M By my CI who will assess that indicated orthopedics patient

A Acceptance of the intake of the patient by the hospital and my CI

R To gain experience using an isokinetic machine

T In 3 months

Evaluation of learning objectives:

1st Learning objective:

During my 1st and 2nd internship, I could not have so many pediatric patients. Cerebral palsy

is a growing disorder amongst children, therefore; I thought i should be able to see and treat

these patients in this category. I have treated many CP patients (more than 5) and observed

at least 10 patients. They all had different interests and intelligence in movement. I have

understood that patient specificity should be a part of an ongoing investigation.

I have accomplished this goal more than sufficient for this internship.

2nd Learning objective:

Even though I have had so many neurological patients during my 1st internship, I have never

felt confident enough to make a diagnosis in the level of impairment. I have realized that my

entire school life education for neurology was not enough, therefore; I would like to have

more experience during my internships. I was very willing to see the differentiation in the

level of impairments. To be able to achive this a very good assessment skills should have

been accomplished. In this process, I have gained practical skills in not only using Fugl-

Meyer and Berg balance test but also other neurological tests with a modified approach.

I have accomplished this goal more than sufficient for this internship.

3rd Learning objective:

I have decided to acquire this goal after I came back to the internship site. When I saw the

Biodex machine, I immediately showed an interest in using this isokinetic machine because I

knew that isokinetic exercises are known as one of the best techiques according to the

evidence. My CI told me that we could use the Biodex machine on patients together. She

gave some basic manual instructions to use and she showed me how to adjust the machine

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for the patients. We have only used this machine on quadriceps muscles, however; this

machine could be used for other joints as well (i.e. shoulder). I have accomplished an extra

skill to apply into practice when I have the opportunity to see this type of machine in the

future. I have accomplished this goal more than sufficient for this internship.

Expectations

During this internship, one of my expectations is to see the differences in assessment

and treatment approaches towards patients between the private and public

hospitals. The internship place where I will be going is a private hospital and I am

expecting differences in approaches towards patients. For example, in public hospitals

in Turkey, the number of patients can be quite high, therefore; the physiotherapists

may spend less time for treating each patient. Secondly, the apparatus can be different

in quality and quantity than the public hospitals. I would like to see the variations in

treating these patients. I do not have high expectations in joining the assessment

sessions with the physiatrists. Turkey is one of the countries where the physiotherapists

are not allowed to assess the patients primarily. I will request for supervision from

physiatrists yet, I might not be able to get this opportunity.

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Patient Category Reports Patient Category Report #1 (Rotator Cuff Syndrome)

Description of the disorder:

Figure 1: Rotator cuff tear

Muscle pain, around the shoulder joint

area is a common complaint. Rotator cuff

problems are the most common problems

in the shoulder region (Lewis 2009).

Patients mostly complain about pain for

the movements that involve overhead shoulder activities that may usually cause

impairments, limitations in the activities of

daily living and diminished muscle strength

(Lewis 2009). Rotator cuff consists of four

muscles and their tendons that are

involved in stabilizing the shoulder joint.

These four muscles are supraspinatus,

infraspinatus, teres minor and

subscapularis. These four muscles

together with the attachments cover the

humeral head. Musculotendinous injury to

these muscles causes a rotator cuff

syndrome.

Epidemiological data of the disorder:

Tempelhof et al. (1999) tried to find out the age-related prevalence of the asymptomatic

rotator cuff syndrome. It was reported that out of 411 volunteers, %23 of them had rotator

cuff disorder. The patients were divided into age related four groups. Each group had

different ranges of age. Out of these four groups, in the over 80 years old group, %51 of

them had rotator cuff disorders. According to this study, it is more likely to get a rotator cuff

syndrome with an increasing age. Another study found out the same results that rotator cuff

syndrome mostly occurs over the age of 65 with a degenerative cause (Lewis 2009). There

was no information found considering this disorder, occuring in different race, ethnicity etc.

Indication for physiotherapy:

As mentioned above, the patients can have limitations, pain and weakness in the rotator cuff

muscles. Physiotherapy plays an important part in treatment and improving the quality of life.

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The physiotherapeutic approach should be optimal for each specific patient. The older and

the younger generation may have this disorder due to different causes, therefore; the

treatment should also focus on the mechanism of injury. The aim in physiotherapeutic

approach should be improving strength, range of motion and decreasing pain that is specific

to that patient (Kamkar et al. 1993). Not only the physiotherapsist-supervised exercises is

given, but also home exercises are combined in this treatment process. Even though, more

research should be done, it was reported that there was no statistically significant effect in

physiotherapist-supervised exercises other than home exercises (Andersen et al. 1999). This

may be an indication of decreasing the physiotherapists visits to benefit the health care

expenses.

In my internship clinic, the protocol can be divided as postoperative and preoperative care.

These two protocols can be patient specific as well. The protocol is followed by the

physiotherapists under the supervision of physiatrists and orthopedic surgeons. The most

used intervention is electrotherapy, progressive resistant exercises and stretching exercises

for possible limited range of motion.

Patient 1: F.S.

The patient is female and 68 years old. Medication: Gabapentin 300 mg 3*1

She is diabetic. Diagnosis: Rotator Cuff syndrome

Patient history: The patient is a housewife. She only works at home, doing household chores. She did not

have any trauma or any surgery. She came to the clinic with pain in her right shoulder. She

also had complaint in her left arm. She had been having this pain for 3-4 months. During the

night, she had been experiencing pain a bit more in her right shoulder. She claimed that she

also had numbness in her right shoulder. The patient said that she also had problems with

getting up from the bed. The household activities were not easy to accomplish anymore. One

of the most complaints were overhead activities like getting a glass or a plate from the

cupboard.

She was upset about not being able to work at home and especially cooking. She said that

her daughter in law helped her to cook. She felt dependent on activities that she wanted to

do it alone. The psychologial load was more than her carriability. She wanted to get rid of

pain as soon as possible.

Assessment: Neer test: (+) Hawkins-Kennedy: (+)

ICF injury classification: d630-d649

Specific: d630,d640, d649 (preparing

meals, doing household tasks)

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Right shoulder ROM:

Abduction: Painful arch between 70º to 180º (active and passive)

Flexion: 180º(active and passive) experiencing pain

External Rotation: 90˚(active and passive) experiencing pain

Therapy: The 15 sessions of treatment is indicated for this patient.

Electrotherapy: 20min TENS with 20min right shoulder Hot pack application. After the

application of TENS and hotpack, 10 min of Ultrasound is applied.

Physiotherapy-supervised and home based exercises: Theraband strengthening exercises in

external and internal rotation, extension, abduction and flexion. 2 sets of 10 reps 1kg

dumbbell exercises.

Patient 2: S.K.

The patient is 42 years old female. Medication: None

Diagnosis: Rotator cuff syndrome

Patient history: The patient works voluntarily in a disabled children care. She is an active person and willing

to help these disabled kids. She did not have any trauma or a surgery.

She came to the clinic with complaints in the right shoulder and pain in her upper back and

chest. It was hard for her to lift the kids from the wheelchair to the floor. She had been having

this shoulder pain for a year and a half. Although she did not have any difficulty in breathing.

The pain had gotten worse since last week. The patient was experiencing night pain. There

was no loss in apetite and weight. The patient claimed to have complaints in burping and

bloating, therefore she had a consultation from a pulmonary specialist. The scintigraphy was

taken and according to the medical doctor there were no abnormal signs. This patient was

willing to get better. Her load was lower than her carriability.

Assessment: Neer test: (+) Speed test: (-) Hawkins-Kennedy: (+)

Painful fibrosis in trapezius and rhomboids muscles.

Right shoulder ROM:

Abduction: Painful arch between 70º to 180º (active and passive)

Flexion: 180º(active and passive) experiencing pain

External Rotation: 90˚(active and passive) experiencing pain


Specific: d440 (lifting,carrying)

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external and internal rotation, extension, abduction and flexion. 2 sets of 10 reps with 1kg

and 2kg dumbbell exercises. Massage was applied for 10 min for the taut bands in trapezius

and rhomboids. Swiss ball exercises on the wall.

Patient 3: I.O.

The patient is a 55 years old female. Medication: Rantudil forte 60mg, Lansor 15mg

Diagnosis: Rotator cuff syndrome MRI results: Type II Acromion

Patient history: The patient works as a farmer. She picks up the farm products from the field. She works for 8

hours in a day, including 2 hours break in between, and she picks up the farm products from

the field She described her job as an intense physiological job. The patient came to the clinic

with complaint in her right shoulder, arm and upper back pain. She had been having these

pain for 3 days. It started with a sudden abnormal movement. The patient did not have any

neck pain. She had been experiencing difficulties in picking up and lifting the products

because of the pain. She was unable to use her right shoulder. This patient was depressed.

Her load was higher than her carriability.

Assessment: Neer test: (+) Hawkins-Kennedy: (+)

Right shoulder ROM:

Abduction, flexion, extension: Full ROM in active and passive, painful ROM

External Rotation: 90˚(active and passive) experiencing pain at the end range of motion





external and internal rotation, extension, abduction and flexion. 2 sets of 10 reps with 1kg

and 2kg dumbbell exercises.


Specific: d440 (lifting,carrying)

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This protocol was proven to be successful especially in decreasing pain. The sessions were

clear for the patients after the first session. The feedback was given to educate the patients

about their disorders. The treatment sessions were patient specific and evidence based,

therefore; it was expected to get better results in the certain amount of time. TENS was

applied for pain and three of my patients felt relieved after this stimulation. The exercises

gave benefit for long term. The patients continued to do their exercises after 3 weeks of

treatment in the hospital.

My opinion about these protocol is to be more patient specific, therefore; the patients can

adjust to their work sooner. The acute injuries can have different tissue modelling and may

require different treatment strategies. The patients can have flexion synergy because of

experiencing pain in their shoulders. This flexion synergy may cause tightness in the

shoulder muscles (i.e pectoralis major or latissimus dorsi), therefore; the structures around

the shoulder joint should be examined carefully. Stretching these muscles may diminish the

limited ROM.

I have gained great experiences in seeing the rotator cuff patients. I have seen acute and

chronic rotator cuff syndrome patients try to analyze the inter-individual differences and

similarities. For example, the three patients experienced night pain. My next step is to

research the validity and the reliability of the impingement tests for rotator cuff syndrome in

acute and chronic rotator cuff patients.

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Patient Category Report #2 Cerebral Palsy (CP)

Description of the disorder:

Cerebral Palsy is a pediatric disorder that

occurs when there is a damage to the

cerebral motor cortex in the central

nervous system (Koman et al. 2004). The

infants in pregnancy and not older than 2

year olds may have a lesion in their part of

central nervous system (CNS). This

disorder can be classified as the location

of the lesion, the level of deformity and

distribution of the abnormality. Brainstem

lesion, spasticity and hemiplegia can be

given as an example for the classification

of this disorder (Koman et al. 2004). The

symptoms may appear bilateral or

unilateral depending on the site of the

lesion. These symptoms may present itself

as spasticity, rigidity, muscle weakness,

chorea, athetosis, ataxia, dystonia,

abnormal gait etc. (Koman et al. 2004).

The development of movements in a

cerebral palsy child is slower than a

normal child. (Koman et al. 2004). This

disorder is not a progressive fatal disorder,

although; the disabilities and impairments

are long lasting and life hardening.

Figure 2: Child with CP (Koman et. 2004)

Epidemiological data of this disorder:

Cerebral palsy is a life devastating disorder that causes an irreversible damage to the

movement development. The factors that link to this disorder may vary. Fetal infection,

labouring more than 4 hours, vaginal bleeding before giving birth, anoxic birth can be given

as examples to the linked factors (Koman et al. 2004). The children who have

hydracephalus, severe quadriparesis, refractory seizures, have shorter lifespan and a high

mortality, although; the children, who do not have a comorbid condition live a longer life with

an effective care as the general population (Koman et al. 2004).

The frequency and the appearence of this disorder in the worldwide is not very well

documented, therefore; the incidence and prevalence of this disorder is still not precise

enough to make statistics (Koman et al. 2004). On the other hand, one of the few countries,

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for almost two decades an increased number of cerebral palsy has been reported in the USA

due to a better documentation than other countries. (Koman et al. 2004).

Indication for physiotherapy:

The clinical assessment determine the type of treatment. As it is mentioned above, the

abnormal motor development is the most common clinical findings in this disorder. There are

multiple management strategies that are goal-oriented and patient specific in cerebral palsy.

The severity of the condition and the age of children are also important factors for an optimal

treatment. Physiotherapy is indicated for these patients to improve the quality of life.

Botulinium toxin injections and orthotics can be beneficial together with physiotherapy.

Strength training, stretching exercises, patient specific exercise therapy and gait training are

the most common physiotherapeutic treatments. Hippotherapy is proven to be effective in

improving the trunk control, balance, weight bearing, gait and gross motor functioning in

patients with bilateral spasticity (Kwon et al. 2011).

In my clinic, the protocol is patient specific. The most used intervention is gait training,

stretching, strengthening, balance exercises, home program. Electrotherapy can be applied

as well when it is indicated. The clinical assessment is done by the physiatrists and the

therapy is determined by the physiotherapists.

Patient 1: N.K.

The patient is female and 4 years old. Diagnosis: Spastic diplegia CP

Medication: none Medical history: None, close relative marriage

Patient history: The patient was the first child from a 21 years old mother. After birth, she stayed in incubator

for 12 days. She does not have hepatitis or any disease. According to her mother, when she

started walking she had inverted feet. Her communication with other children and adults is

normal. At the age of 2, she was diagnosed as CP.

The child is very cooperative and she likes playing with baby dolls and balls. Her carriability

is higher than her load, therefore; it is expected that therapy sessions will be beneficial.

Assessment: Her mental condition is fine. She is cooperative, speaks well. The patient does not have a

dysmorphic feature, organomegaly or murmur in her heart.

Tardieu scale: R & L (lower ext) : 2/-30 V1, V2 DTR lower extremity: Hyperreflexive

Patrick’s test: (-) Clonus: (+)


Specific: d450 (walking)

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Gait analysis: Achillies tendon tightness, spastic gait with bilateral inverted feet

Therapy: The therapy includes variable neurophysical exercises for both legs, sitting, getting up from a

bed, standing still, walking exercises on parallel bar and stretching exercises for tight plantar

flexors.

Patient 2: S.Y.

The patient is female and 9 years old. Diagnosis: Spastic diplegia CP

Medical history: Prenatal Hydracephalus Medication: Botulinium toxin injection

Patient History: When the patient was 2 months old, she was operated for 4 times due to hydrocephaly and

the shunt was inserted. According to her mother, she has no problems with understanding,

talking and communication, although; her success is lower than other kids at school. She has

problems with her motor development.

The child likes to play so often and she gets bored and tired so easily while doing her

exercises. She does not want to do her exercises because she thinks they are tiring and

boring. Her carriability is lower than her load.

Assessment: Her mental condition is fine. She is cooperative, speaks well.

Tardieu scale: R & L (lower ext): 1/-70 V1, V2 DTR lower extremity: Hyperreflexive

Patrick’s test: (-) Clonus: (+)

Gait analysis: Achillies tendon tightness, bilateral spastic gait on tiptoes and with flexed

knees.

Therapy: The therapy includes variable neurophysical exercises for both legs, sitting, getting up from a

bed, standing still, walking exercises on parallel bar and stretching exercises for tight plantar

flexors.

Patient 3: M.Y.S.

The patient is male and 2 years old. Diagnosis: Right hemiplegia CP

Medical history: None Medication: None



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Patient History: According to his mother, the patient does not use his hand enough. He is using an

orthopedic shoes to correct his externally rotated leg pattern. He understand his mother and

what happens in his surroundings. He likes to play with balls, although; he can not use his

right hand efficiently to grab the big things. Due to his age, his load is higher than his

carriability.

Assessment:

Right shoulder ROM: full active and passive Right elbow ROM: full active and passive except supination.

Right hand ROM: flexors of the wrist and fingers, extension

Partial spherical, lateral and pinch grip

Patrick’s test: (-) Clonus: (-)

DTR lower and upper: Hyperreflexive No spasticity

Gait analysis: Slight externally rotated leg

Therapy: The therapy includes variable neurophysical exercises, occupational therapy for his hand,

walking exercises, and postural correction and strengthening the arms and legs.

This protocol is proven to be successful depending on the patient. Children need a different

communication style for therapy. When a different approach is achieved towards each

patient, and a communication between the physiotherapist and the child is successful, this

protocol is proven to be beneficial. Each child had different coping style with his condition

and his surroundings, therefore: the therapeutic approach was patient specific.

What I have experienced for these type of patients was different than other adult patients.

They require too much attention and a different approach. Children also have different

mental and motor development and that makes the physiotherapeutic approach more

complicated than others. I have seen more than these patients and I believe that each

patient should also be consulted by the pediatrician because some of the children were not

consulted from a pediatrician. The clinical findings from a physiatrist and pediatrician may

differ, therefore; it should be integrated.

Even though I am not interested in working as a physiotherapist who is specialized in

pediatrics, I am glad that I have gained great experiences in treating these type of patients. I

have seen inter-individual differences and learned more about the classification of this

disorder.



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Extensive Patient Report

Spinal cord injury (SCI) (Paraplegia)

Motivation For patient selection:

I have chosen this pathology to work with because of subjective and objective reasons.

Objectively, I have had an acute complete tetraplegic patient in my first internship and could

not feel comfortable afterwards for treating these type of patients because of his acute

condition. When I started my internship in this clinic she was already treated by the other

physiotherapist. I talked with her about her condition and how she improved over the course

of the treatment. She was very enthusiastic and ambitious about her condition and she was

willing to get better. Naturally, this has encouraged me to work with her. I find myself very

lucky to see this kind of SCI patient.

My internship site and the physical therapy department received a lot of neurological patients

especially CVA and SCI patients. I have experienced in treating a lot of neurological patients,

however; I have never thought i have seen enough. Because I believe that these type of

patients may have a lot of symptoms that are important to see. Before I came to his

internship place, I have made an SCI patient report by myself and the more I went in detail,

the more I found interesting things in this pathology. Classifying these patients was not easy

to present and intervene. Even though there are certain symptoms the patient is expected to

experience, according to evidence the neuroplasticity may reveal otherwise. I have seen that

these patients have to improve a lot to function independently and because of this I find this

as a challange to get the patient back to his/her partial independent life. Each patient has

different approaches to his/her condition. To be able to overcome with psychological

disturbances and physical disabilities the patient need to understand the recovery process

and accept the certain consequences.

Description of the disorder, epidemiology, prevalence and incidence

Spinal cord injuries are long lasting, life hardening disorders for individuals everywhere in the

world. The injuries occur when there is a compressive, penetrating or distracted damage to

the spinal cord. The spine is a part of the central nervous system, and in case there is a

damage, the neural and neuromuscular response get affected. Not only there are trauma

involved injuries, but also non-traumatic spinal cord diseases, affecting the spinal cord (i.e.

metastatic tumors, spina bifida). Assessment has to include motor, sensory, cranial or

autonomic nervous system, gait, coordination and mental status of the patients. Therefore;

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the level and the extent of the injury which determines the classification of this disorder

should be precise and carefully monitored.

It has been reported that in every million, 15-40 acute SCI occurs in UK (Winter et al. 2011).

The cause for this injuries involve traffic accidents, violence, falls, sports etc. In these

population young males (20-40 years old) get more effected than females (4:1 ratio) (Winter

et al. 2011). The prevalence of the non-traumatic SCI has not been reported due to lack of

documentation, different reasons etc. (Winter et al. 2011). In the USA, approximately 183-

230 000 people live with traumatic SCI (McDonald et al. 2002).

Administrative data of the patient:

Name: S.A. Age: 26 Gender: Female Insurance: SSK

Medical doctor diagnosis: SCI (L2) paraplegia Current work status: None

Occupation: preparing for university exams

Medication: Gabapentin, bactroban, eau de goulard sol, dermovate, atarax TB

Assessment

Patient History

The patient fell down from a high ground and injured herself in 2007. They went to the

hospital immediately and she had a surgery from her spine. After the surgery, she stayed

almost 3 weeks in the neurology department in the hospital. After she got discharged from

the hospital, she was referred to physical therapy. The physiotherapeutic treatment was

indicated for 3 months. At that period of time, she did exercises for transfering, sitting,

standing, walking in the parallel bars and walking with a walker. The patient used and still

using orthoses.

In 2008, she got a different consultation in another city from a physical therapy department.

According to her, a better orthoses was modified for her legs and forearm crutches for her

arms. In this year, she continued going for a physical therapy. Plus what she did in the

previous year, she also did exercises in bed, strengthening her arms, hips and abdominal

muscles.

Help seeking question

The patient would like to be more independent and go for a swimming again. Her hobbies

are swimming, walking for half an hour, cooking, go for a visit to her friends. She thinks that if

she can walk she will be independent again and she will not need for her mother all the time.

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S- Subjective

No pain sensation in her lower extremity.

Turning in the bed takes more time than usual.

She has troubles with stairs and gets tired so easily.

Due to her absent pain sensation she has injuries (i.e. burn)

The scar tissue extends to L5 level.

Medical History:

Past Medical History: None

Previous Treatment: Yes in 2007 and 2008 Physical therapy

General Health: Allergies

Taking Regular Medications: Neurontin

Recreational Activities: Not an active participant in activities

O-Objective

KATZ index

Daily Activities( scoring from 0-6 ):

Showering: 6

Clothing: 6

Toilet: 6

Transfer: 6

Continance: 6

Eating: 6 ( the patient is able to take the food by himself)

Functional independence measure (FIM)

ASIA scale

The patient is able to cooperate. There are no limitations in 4 extremity ROM.

DTR: Bilateral hyperreflexive lower extremity

Babinski: left (-/+) right(-/+)

Eating 7 Toilet transfer 7

Grooming 7 Shower transfer 6

Bathing 7 Locomotion 6

Upper body dressing 7 Stairs 5

Lower body dressing 7 Cognitive comprehension 7

Toileting 7 Expression 7

Bladder management 7 Social interaction 7

Bowel management 7 Problem solving 7

Bed to chair transfer N.A Memory 7

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Peripheral pulse is measurable.

ASIA scale

The patient received grade ‘5’ above L2 level.

Right Left

L2 2 2 Hip flexors

L3 2 2 Knee extensors

L4 0 0 Ankle dorsiflexors

L5 0 0 Long toe extensors

S1 0 0 Plantar flexors

Voluntary Anal contraction: (+)

Sensory:

Light touch Pin prick

Right Left Right Left

L1 1 1 0 0

L2 1 1 0 0

L3 0 0 0 0

L4 0 0 0 0

L5 0 0 0 0

S1 0 0 0 0

S2 0 0 0 0

S3 0 0 0 0

S4-5 0 0 0 0

A-Analysis/Assessment

The patient is 26 year old female who had traumatic spinal cord accident and presents SCI

on L2 level and disability below this level. Together with MRI and X-ray results, according to

ASIA scale the patient was classified as ‘Incomplete ASIA C’. The physiotherapy is indicated

for the disabilities the patient has shown. The patient has also spreaded atopic dermatitis,

xerosis cutis and ulcerous wounds after getting burned from a hair straightener.

The patient is aware of her problem and what she is able to do or not able to do in the future.

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P-Plan

Treatment goals Short term:

• Teaching transfering from shower to standing or to similar activities.

• Teaching how to walk through the stairs.

• Prevention of getting injured (i.e. burn) by giving feedback and strategies.

Reasoning: The patient is having problems with transfering herself from getting into shower

to standing or the other way around. This may be a big burden for the patient because it

might take time. Walking through the stairs is important for her because she has stairs at

home. Ulcerous injuries might be a long lasting problem and should be prevented by giving

feedback and reminders.

SMART short term goals

1.

S Teaching transfering from shower to standing or to similar activities.

M Functional independence measure (FIM), mobility section

A The examples will be shown and guided by the therapist to the patient

R Getting independent is important for the patient to socialize with her environment

T 2-4 weeks

2.

S Teaching how to walk through the stairs

M Functional independence measure (FIM), locomotion section

A The examples will be shown and guided by the therapist to the patient

R Walking to the stairs is important because she has stairs at home

T 2-4 weeks

3.

S Prevention of ulcers, giving feedback and education

M Getting info from the patient about her environment to create a safe environment and

answering the questions from the patient about her condition

A Giving brochures and electronic reminder to make her use while she is in a

dangerous environment

R Prevention of ulcers is important not to cause a secondary complication while doing

the therapy

T 3 weeks

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Treatment goals long term

• Strengthening the upper extremity and some muscles on lower extremity Figure 3&4: Example of lower extremity strengthening ROM:

• Improving the Cardiovascular condition

Figure 5: Example to the walking exercises for cardiovascular functioning:

Reasoning: The patient complains about getting tired so easily while doing her ADL’s. This

may be one of the reasons that she is afraid of socializing with people because that takes

time and it may concern people. Improving the strength on lower extremity, getting some

response from the muscles might give hope to the patient. When there is a possible

improvement in her lower extremity she will become more independent. Upper extremity

strength will save her some time in doing ADL’s.

SMART long term goals

1.

S Improving her strength in the upper extremity and some muscles on lower extremity

M ASIA scale key motor functioning for lower extremity, MRC scale for upper extremity

A Assistive exercises through ROM in lower extremity with sliding board, progressive

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resistance exercises in upper extremity

R To become independent and socializing with the environment

T 6- 9 weeks

2.

S Improving the Cardiovascular condition

M Using Borg scale in every walking sessions and increasing the walking distance

A Walking exercises at home and in the therapy sessions

R To be better at functioning in ADL’s without getting tired

T 6-9 weeks

Reasoning for treatment methods:

First of all, for an optimal therapy, the patient should be educated for every step in treatment

process. She also should know the prevention of causing a secondary complication that may

burden her exercises and functioning.

Upper limb functioning needs muscle strength. To become independent, like transfering from

lying to sitting position or from sitting in bed to sitting in wheelchair, the patients have to have

certain muscle strength. Neuromuscular stimulative exercises proved to be successful for

functioning, gaining independence and prevention of falling. Gaining independence not only

increasing confidence but also improve the quality of life. For this reason, the

physiotherapeutic intervention is indicated. The prognosis of this treatment is proved to be

successful for SCI patients (Sheel et al. 2008).

Even though, she did not have pressure sores directly, she should be educated on how to

take care of ulcers and prevent herself from getting another course. Pressure sores are very

dangerous complication for SCI patients. The results of debicutus ulcers may be life

threatening. Each patient has to select his own cushion according to the pressure surface of

the body (Henzel et al. 2011).

Team functions in treatment

The team functioning included physiotherapist, physical therapy physician and the patient’s

environment. Her parents were educated by the physiotherapists and physiatrists. Other

clinicians like dermatologists also had to check her allergies and ulcers regularly to prevent

another complications. The physiatrists gave necessary medications for neurogenic pain.

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The patient and his family also recommended to have psychological consultation if it is

necessary.

It was thought how to use the leg orthoses and forearm crutches to the patient.

This patient was taken care of by multiple physiotherapists in the hospital. Each

physiotherapist had the aim to accelerate the recovery process.

Treatment sessions and social contact

Our 26 year old patient has been following rehabilitation for 9 weeks in Baskent University

Hospital. She has a sister and also a very caring parents. According to her family, they were

sad in the begining about her daughter’s situation but after years they realized that they have

to make their daughter’s life easier by helping and motivating her. The patient and her family

were unaware of some of the situations in the begining of the treatment sessions. The patient

showed great confidence after 4 weeks. She did not have problems with her accepting the

situation and wanted to get better as soon as possible. Her parents have the same

psychological progress like their daughter towards the injury. They accepted the

consequences and try to get as much feedback as possible from physicians and

physiotherapists.

I personally knew that this type of injury and its consequences that is why I have dealt with

this patient successfully both mentally and physically.

Evaluation in treatment and prognosis

The patient was evaluated every week by physiotherapist and every 10 sessions by the

physiatrists. During these evaluations, the ASIA scale and functional independence score

were used. These process were very important for the patient to be able to get functional as

soon as possible. Due to fact that she had ulcers and allergies it took more time for her to be

active in treatment sessions. These secondary complications resulted in delayed progress of

the sessions. According to her dermatologist, electrotherapy could be the triggering reason

for getting allergies, therefore; after 4th weeks of treatment, application of the Galvanic and

Faradic currents were stopped. The exercises in the sliding board was a challenge for this

patient because of her ulcerous wounds. Therefore, some of her movements were adjusted

by using a small cloth underneath her feet to ease the movement in a preventive manner.

Even though she had the contradictory response from her body, there was an improvement

in her gait and cardiovascular state after 6th week. The prognosis of the treatment program

showed to be successful despite the secondary complications.

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The structures assessed and compared every week below:

Ø The flexors, extensors, abductors and internal, external rotators of the hip

Ø The extensors of the knee and 1st toe.

Ø The plantar flexors of the foot.

Ø Gait (Walking and steps for pre-walking in the stairs)

Ø Ulcerous wound healing.

Ø The psychological load and carriability.

Critical reflection

1.a. The physiotherapist as a healthcare worker: assessing, diagnosing, planning

In this competency, I felt so lucky that i could follow the assessment throughly. Despite the

fact that physiotherapist can not work with physicians officially, I had the opportunity to work

with one of the mand gained great knowledge and confidence. The experience in assessing

the patient throughly and make a differential diagnosis were achieved successfully. I have

improved myself in this competency through working with a physiatrist. I have used SOAP

notes for documentation.

In my previous internships, I have already achieved varoius treatment techniques, including

electrotherapy, therefore; treatment has always been success for me. I have treated

orthopedics, neurological, cardiopulmonary and pediatrics patients. Especially, I have

improved my treatment skills in neurological and orthopedics patients. I have always worked

independently with or without a supervision in level 3.

1.b. The physiotherapist as a healthcare worker: therapeutic measures In this competency, I have gained applied various treatment skills into practice. I have

applied EPM, kinesiotaping, mobilization and gave home exercises to the patients. I have

also recommended my thesis project outcome to the physiotherapists. I have recommended

McConnell taping in patients with PFPS.

All aspects that were achieved in level 3, therefore; I have had high scores in therapeutic

approach.

I have had all my smart goals for therapy without having any problems. When I had the

patients, I could follow every step in the treatment sessions. This competency level resulted

in a high level of working behaviour. This working behaviour between the physiotherapists

reflected upon getting a level 3 competency.

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1.c. The physiotherapist as a healthcare worker- Preventative measures

I have applied the necessary preventative measures in almost every patient. Because the

patients did not know exactly what condition they have. The feedback was given about their

condition, precautions before they do home exercises or or necessary actions while applying

the therapy. This competency was a success, therefore; I have gained a level 3 competency.

I believe that this is due to the positive experience in my past internships which I was thought

for preventative care.

2.a. The physiotherapist as a manager- organizing In this competency, I already have had a lot of knowledge in health care system, therefore; I

could apply my knowledge in physiotherapeutic documentation and organize myself

efficiently. The physiatrists used the health care system different than physiotherapists. They

had codes for every condition and they were classified by the government.

I have used the time extensively which had to be done according to the working system in

the hospital. I believe that I have applied my skills in organizing efficiently, thus i have

achieved level 3 competence.

2.b. The physiotherapist as a manager- business undertaking This competency level requires a lot of practice and skills. Even though, this competency

was hard to accomplish, I could learn beneficial skills from my CI. What i had to was

precisely organized and i applied these skills into practice. I was able to gain some good

skills in advertising the hospital and this resulted in having more patients. I could work in

level 3 in this competency.

3.a. The physical therapist as a profession developer- Conducting research

I used the evidence based literature on my reports and my thesis as a profession developer.

This has resulted in a positive outcome in the clinic. I have used my knowledge into practice

in level 3.

3.b. The physiotherapist as professional developer-innovation This competency was one of the hardest competencies to accomplish. Innovation requires

knowledge in every competence above. Not only the physiotherapeutic approach but also the

patients’ contribution to the treatment process is important. Team work should be optimal to

gain and apply the innovative skills into practice. I have had this opportunity up to a certain

amount and this has resulted in level 3 competence.

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Hour Justification

From week 1 to week 14:

Every week from 8.30 till 18.00 : 9.30hr x5= 46.5 Lunch break: 1.5hr x5=7.5 46.5-7.5=39

working hours

39x 14= 546hrs (14 weeks) Ommission days: 3

546hrs- 30hrs= 516 working hrs in total (excluding the hours for preparing reports)

General Conclusions

During this entire internship, I have gained necessary knowledge for my career in this field. I

have practiced assessment and observed most of the time due to the regulations. I have

learned more on therapy techniques that I will apply when I become a physiotherapist.

Not only this internship was about education but also about having enjoyable times during

working and after the working hours in a professional manner.

Overall, I am glad that I have had my last internship in this clinic.

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References

Andersen NH, Soybjerg JO, Johannsen HV, Sneppen O. Self-training versus physiotherapist-supervised rehabilitation of

shoulder in patients treated with subacromial decompression: A clinical randomized study. J shoulder elbow surg. 1999;

8:99-101.

Henzel MK, Bogie, KM, Guihan M, Ho CH. Pressure ulcer management and research priorities for patients with spinal cord

injury: consensus opinion from sci queri expert panel on pressure ulcer research implementation. 2011;48(3);11-31.

Kamkar A, Irrgang JJ, Whitney SL. Nonoperative management of secondary shoulder impingement syndrome. J Orthop

Sports Phys Ther. 1993; 17(5):212-24.

Koman LA, Smith BP, Shilt JS. Cerebral Palsy. 2004; 363(9421):1619-1631.

Kwon JY, Chong HJ, Lee JY, Ha Y, Lee PK, Kim YH. Effects of hippotherapy on gait parameters in children with bilateral

spastic cerebral palsy. 2011; 92(5): 774-9.

Lewis JS. Rotator cuff tendinopathy. Br J Sports Medicine. 2009; 43: 236-241.

McDonald JW, Sadowski C. Spinal cord injury. 2002; 359(9304): 417-425.

Sheel AW, Reid WD, Townson A, Ayas N, Konnyu KJ. Effects of exercise training and inspiratory muscle training in spinal

cord injury: a systematic review. 2008;31(5):500-508.

Tempelhof S, Rupp S, Seil R. Age related prevalence of rotator cuff tears in asymptomatic shoulders. 1999;8(4): 296-9.

Winter B, Pattani H. Spinal cord injury. 2011;12(9):403-5.

Hogeschool van Amsterdam

Amsterdam School of Health Professions

European School of Physiotherapy

Tafelbergweg 51

1105 BD Amsterdam

The Netherlands

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