Final Internship report 1# - · PDF fileAssignment #7 Clinical internship report ... works closely with Neurology, Rheumatology, ... The ministry is responsible for

European School of Physiotherapy

Assignment #7 Clinical internship report Internship 1(Period; 26/06/2011-16/09/2011) Intern: Yagmur Hazir(500544685) Institution: Cukurova Universitesi Balcali Hastanesi Clinical instructor: Clinical instructor signature: Clinical Supervisor: Clinical supervisor signature: Date of submission: Date of review:

Internship Report Date: 16-09-2011 Class: FES21 Professor: Pim Ranzijn

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© 2009 Hogeschool van Amsterdam. All right reserved

Last update: August 26, 2013

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Table of contents Acknowledgements……………………………………………………………………......4

Introduction………………………………………………………………..........................5

Description of the site………………………………………………………….5

Patient related items………………………………………………………………………7

Experience during the internship…………………………………………………………8

Personal learning objectives……………………………………………………………….9

Evaluation of the learning objectives…………………………………………………….10

Patient Reports…………………………………………………………………………….12

Patient Category 1(CVA)……………………………………..........................12

Patient Category 2(Frozen Shoulder)…………………………………………16

References…………………………………………………………………..........................20

Extensive Patient Report…………………………………………………..........................21

References…………………………………………………………………………………..28

Personal Evaluation………………………………………………………………………..29

Competencies……………………………………………………………………………….30

Critical Reflection………………………………………………………………………….31

New Learning Objectives………………………………………………………………….32

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Acknowledgements

First of all, I would like to thank my CI Sibel Basaran who accepted me as an intern to this

Physical therapy department. I also would like to thank to the Physiotherapists I worked with

closely; Alper Akin, Yildiz Sahin, Cumali Sahin, Volkan Deniz, Selda Aslan, Safine Havuc,

Zahide Ozer, Filiz Kurtulus and Gulhan Kapuagasi. Thank you all for sharing with me your

valuable knowledge.

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Introduction

Description of the site

My intership 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.

Cukurova Universitesi Medical Faculty and Research Hospital, known as ‘Balcali Hastanesi’

in public, is one of the biggest hospital in the Southern east of Turkey. The hospital has all the

medical professional fields, including Physical therapy. The Physical Therapy department

works closely with Neurology, Rheumatology, Orthopedics, Intensive care, Pediatrics and

burn departments. There are 9 physiotherapists working actively and one physiotherapist as a

head of the physiotherapy department. Besides there are physiartists working with

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

however the physiotherapists apply the therapy that physiatrists approved on. The therapy

includes hot and cold modalities, electrotherapy and therapeutic exercises.

In Turkey, health care is coordinated by the government, 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 decide the usage and price of the drugs. The quality of the public hospitals is

lower than the private ones. The reason is the lack of investments on health care in all over

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the country. The biomedical equipments are not well developed in public hospitals, however

in private hospitals the equipments 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 is

insufficient health care services.

There were three major organizations as social insurance for citizens. These were, Social

Insurance instituation, Pension fund for Civil servants, Social Security Institution for the Self-

employed. Now it has been changed into two categories. 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. 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’, besides therapy, the short

patient history and assessment are written as well; although, only therapy is applied. One

physiotherapist is charged everyday to give 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 physiotherapists try to get their right from the

government to be more independent like other well developed countries. The current situation

for physiotherapists are limited that they can not use their knowledge efficiently for 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 under the supervision

of physiatrists.

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My CI is a physiatrist but I work with physiotherapists in every working hour. Besides,

according to the rules, I have to change my physiotherapist every week. We are eight interns

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

Patient related items

There are almost 70 patients who are treated by physiatrists every day. The rehabilitation are

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

below shows which patients I was able to treat. The rehabilitation was done by me under the

supervision of physiotherapists; however I was able to give electrotherapy by myself.

Neurology:

• CVA patients

• Guillian Barre syndrome

• Cerebellar ataxia

• MS

• Disc herniation

• Radiculopathy

• ALS

Pediatrics:

• Cerebral palsy

Orthopedics:

• Fractures

• Joint replacements

• Amputated patients

• Osteoartritis, osteoporosis

• Supraspinatus tendonitis

• Frozen shoulder

• Meniscus

General pathology:

• Lymph oedema

• Hemophilic arthropathy

• Rheumotoid arthritis

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• Poliomyelitis

•

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

neurological patients. They are treated under the supervision of physiatrists by

Physiotherapists. It is also important to mention that my CI is not the only physiatrist in the

department therefore the patients treated are not only her patients.

Treatments used:

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

TENS, Russian, Galvanic and Diadynamics. The time of the therapy varies from ten to twenty

minutes according to the patients’ needs. Besides Ultrasound is also applied around six

minutes. There is also an application of Infrared. The electrotherapy is applied with Hot pack

around the injury site about ten to twenty minutes. Therapeutic exercises are ADL training,

ROM, muscle re-education, strengthening, releasing the muscle spasm. Massage is not

applied in the rehabilitation. Besides the therapeutic exercises done by the physiotherapists in

the hospital, homework exercises are given as well.

Experience during the internship:

Experience in taking Patient History:

Unfourtanetely, I was unable to take the patient history for diagnosis in this internship site

because of the working rules between physiatrists and physical therapists. Although I was

able to take patient history for one week under the supervision of my CI. Specifically I took 8

complete anamnesis for diagnosis and intervention. 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. Not being able to extend this period due to the rules was my overall weakness

for taking patient history.

Experience in Assessment:

Just like in patient history, except one week opportunity, I was also unable to perform

assessment for diagnosis and intervention. It was inevitable for me to not being able to

perform assessment like patient history because the physicians make the diagnosis.

Experience in Treatment:

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

supervision or independent. I was able to apply therapy for 12 weeks with the

physiotherapists. Mostly, I was able to treat the patient category below:

• CVA(22patients)

• Orthopedics(36 patients)

• SCI(11patients)

Therapy was my strongest part from overall internship period. After 4 weeks I was confident

enough to give the therapy by myself.

Additional experiences:

My additional experience was my being able to give treatment to intensive care patients under

the supervision of physiotherapist. The most seen patients were neurological patients in this

intensive care department.

Personal Learning Objectives

I expect from my 1st internship that my CI will give me the opportunity to assess and give

therapy to the patient by myself as much as possible. It is certain that self intervention is

necessary to gain experience. I am aware of the fact that Physiotherapist do not take patient

history by themselves in my hospital. My goal is to be able to work with Physiatrists to take

patient history if it is possible in my situation. I chose this hospital because I expected that

there will be variety of patients. During my internship I want to see different type of patients

to gain experience and to choose a specialty in the future.

SMART GOAL1

S- I would like to use pain relief techniques of EPM on twenty orthopedics patients.

M-Measurable by my CI.

A-Attainable by practicing with my CI in the hospital.

R-The goal is relevant to gain experience on EPM.

T-This will be achievable in three months.

SMART GOAL 2

S-I would like to learn upper and lower extremity taping.


A-Attainable by practicing more than ten times.

R-Relevant for sports physiotherapy.


SMART GOAL 3

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S-I would like to give exercise therapy on at least ten Stroke, Parkinson and SCI patients.


A-Attainable by practicing on neurological patients.

R-Relevant to gain experience on therapy for neurological patients.


Evaluation of the learning objectives

I expected from my 1st internship that if my CI could give me the opportunity to do patient

history and assessment as much as possible. Although, due to the regulations, I was unable to

achieve this process partially. I was able to take patient history and do assesment only for one

week. My second expectation was to see variety of patients. This expectation turned out to be

successful. I was able to treat a lot of patients.

For my first internship, my first SMART goal was to gain experience in electrotherapy. I

totally believe that I achieved this goal successfully. I was aware of the fact that In Turkey

electrotherapy application was highly used in all over the country. I used different tecniques

of electrotherapy including TENS, interferential, Galvanic and Russian stimulations. I was not

only able to give electrotherapy on orthopedics patients but also all variety of patients in

patient category list.

SMART GOAL1

S- I would like to use pain relief techniques of EPM on twenty orthopedics patients.


A-Attainable by practicing with my CI in the hospital.

R-The goal is relevant to gain experience on EPM.


The second SMART goal was to acquire knowledge about taping. I was able to achieve this

goal partially. I had a chance to learn the taping for the site of scapula and ankle. I expected to

know more about knee and finger taping although I could not have a chance to learn more in

detail for both lower and upper extremities for different joints.

SMART GOAL 2

S-I would like to learn upper and lower extremity taping.


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A-Attainable by practicing more than ten times.

R-Relevant for sports physiotherapy especially.


My third and the last learning objective was to gain experience in exercise rehabilitation for

neurological patients including CVA, Parkinson and SCI patients. I was able to achieve this

goal very successfully for CVA and SCI patients; however not in Parkinson patients. The

reason why I could not do any therapy for Parkinson was that the physical therapy department

had not done consultation for Parkinson patients.

SMART GOAL 3

S-I would like to give exercise therapy on at least ten Stroke, Parkinson and SCI patients.


A-Attainable by practicing on neurological patients.

R-Relevant to gain experience on therapy for neurological patients.


My strengths were the lectures I have had before for specific pathology that is why I had

gained a lot of knowledge before I applied treatment for these patients. My weakness were my

being unable to do patient history and assessment because of the procedure in the institution.

Although, the opportunity I got from my CI which was to work with her, was beneficial

during my internship time. I did not have troubles with any other thing except my weakness

mentioned above.

My next action would be to work with an internship site who has the same procedure as in the

Netherlands.

Working hours

Monday to Friday:

From 8.30am to 4.00pm

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Patient Reports Patient category Report #1- CVA

Cerebrovascular Accidents(CVA), also known as ‘Stroke’, are any impaired blood flow or a

clot of artery which cause brain cells death by an emboli or thrombosis leading to insufficient

oxygen supply to these brain cells or a hemorrhage( a sudden bleeding in the brain

tissue)(Sacco et al. 2006).These pathological conditions can differentiate Stroke as either

‘Hemorrhagic’ or ‘Ischemic’. This blood flow or artery blockage lead to neurological

disturbances in the body(Sacco et al. 2006). The patients may have slurred speech, sudden

weakness of the extremities or visual disturbances. The patients who suffer from stroke are

not able to understand or respond to any speech(Sacco et al.2006). Acute weakness of the

arms or legs lead the patient unable to move which causes serious disabilities in daily life

activities. These patients are unable to use their unilateral side of their body, which, this

condition is known as right or left sided hemiplegia.

The epidemiological results vary between Western and third world countries. For example, in

Canada the yearly rate of new cases treated with strokes include 50.000 patients. In the

current statistics of today there are 15 million people who have suffered of a stroke( Lindsay

et al. 2010). Commonly, strokes only occur in people that are older than 40 years of age, since

these are typically more at risk to suffer from as hypertension, high blood cholesterol,

overweight and cardiovascular disorders leading to a predisposition for a stroke(Lindsay et al.

2010).

In some third world countries where sickle cell anemia is still common, strokes can also occur

in young children(Lindsay et al. 2010). Of the people suffering stroke, 15% occur as cerebral

hemorrhages, and about 80% have a cerebral infarct or ischemic attack (Peppen et al. 2004) It

is also notable that the patients who has had once CVA, die after having second stroke

because of the damage of the first one(Peppen et al. 2004, Lindsay et al. 2010). Worldwide

there are 100.000 new strokes occurring per year and that does not even include all

countries.(Lindsay et al. 2010).

In Turkey, according to a study in the West of Turkey followed up by 6 months in 2000

patients that ischemic stroke is the most common type of stroke(77%). Secondly primary

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intracerebral hemorrhage(17%) and thirdly subarachnoid hemorrhage(%4). The most common

cause is hypertension(%63). Hypercholesterolemia(37%), diabetes mellitus(35%), ischemic

heart disease(23%), atrial fibrillation(20%) and smoking(%17) are the following causes of

stroke(Kumral et al.1998).

It is inevitable that physiotherapeutic treatment is indicated for CVA patients to improve their

functions in daily life. Besides physiotherapy, the patient also may need speech therapy for

swallowing or speaking or occupational therapy for dexterity of the hands and the arms.

CVA patients need physiotherapy because regaining the functions of the extremities is

important to walk or to do daily tasks.

The protocol, used in my internship site, can be considered similar for each patient, although

there may be slight differences according to the progress of the patient. The interventions are

Electrical stimulation and exercise therapy. The patients undergo this treatment four to six

weeks follow up according to the progress of the patient.

Three of the patients were male, over 40years old and had Left sided CVA about 4 to 6

months ago. Patient 1 had a later stroke due to a past intracranial mass excision. The second

patient had hypertension and had Hemorrhagic stroke. The third patient had hypertension as

well and had Ischemic stroke.

Patient 1: B.N.

Assessment: Conscious, aphasic. FAS(4).

Brunnstrom: 3/4 Hand: 2

Ashworth: 1+/1 Achillies tendon is tight.

Babinski: (+) Clonus: (-) Hoffman: (-)

Peripheral arteries are palpable.

Groove sign: (-)

Therapy: Russian Electrical stimulation on Right upper extensor muscles with 2500Hz, %50

dutycycle for 20min. Passive and assistive ROM on both upper and lower extremity. Assistive

and self Walking exercises on metal bars. To increase the intensity in walking 5 or 6 wooden

obstacles were used for the patient. He had occupational therapy for his hand from

physiotherapists as well.

The patient followed treatment for 5 weeks in hospital. He was also asked to repeat walking

exercises by himself on the bars.

ICF injury classification: d450

Specific: d4503

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The patient was not able to work, do hobbies or communicate properly with his family and

friends. He was very active before he had had stroke that’s why the psychological load was

high enough to cause unhappiness. The patient was always complaining about not being able

to do daily care tasks properly.

Patient 2: S.T

Assessment:

Conscious. Cooperative. Aphasic. FAS(4)

Brunnstrom: 1/3 Ashworth: 1/1

Babinski: (+) Clonus: (+) Hoffmann: (+)

Deep tendon reflexes are slightly visible.

Therapy:

Russian Electrical stimulation on Right quadriceps muscle with 2500Hz, %50 dutycycle for

20min. Passive and assistive ROM on both upper and lower extremity. Assistive and self

Walking exercises on metal bars. To increase the intensity in walking 5 or 6 wooden obstacles

were used for the patient. Walking and turning exercises with a crutch are applied as well.

The patient is willing to get better that is why his load was lower than his carriability. Even

though he could not do the daily tasks properly he was very motivated to do exercises and

willing to go home as soon as possible. He could not work for almost a year. He used to work

as a mechanic in a company.

Patient 3: M.A.

Assessment:

The patient is conscious, aphasic. FAST(4)

Spasticity: (-) Brunnstrom: 5/6 Hand: 5

Babinski: (-) Clonus: (-)

Deep tendon reflexes are normal.

Right shoulder internal rotation: 70˚ external rotation: full ROM

Groove sign: (+) Achillies tendon is tight.

Therapy: Russian Electrical stimulation on Right Deltoid muscle with 2500Hz, %50

dutycycle for 20min. Passive and assistive ROM on both upper and lower extremity.


Specific: d4503

ICF injury classification: s73018

Specific: d4453

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Increased intensity walking exercises with higher wooden obstacles. Right deltoid TENS for

pain in his shoulder for 20min.

The patient was not able to work after his injury. He has been in rehab for more than 6 weeks.

The pain was a barrier for him to be able to do his tasks. That is why his load was higher than

his carriability. The reason for pain was not classified.

This protocol had been shown through all patients to be successful. Russian electrical

stimulation was done to give any beneficial functional movement to the muscle. This

stimulation had two functions for these patients: either help the patient to move or to gain

control of upper extremity movements. After 5 to 6 weeks the patients were able to walk in

control and independent; however, the upper extremity functions stayed limited for all three

patients especially with the movements in supination, extension of the wrist and fingers.

My opinion about the protocol is to give more occupational therapy exercises on hands.

Besides, while taking patient history it was not asked what the patients’ want to improve

specifically that is why the patients could not gain benefit from occupational therapy.

I learned that stroke patients may have frozen shoulder as a secondary complication. I also

saw that patients differ from each other even though they all had the same disease. Another

thing which was important that while taking their history they all had similar lifestyle.

Besides these patients, the other patients who also had stroke, that all had hypertension, bad

lifestyle, high cholesterol diet or poor physical condition.

Finally, I think this was a great success for me to see a lot of these type of neurological

patients. Now I know pretty much what to look for in patient history and assessment for

stroke patients, although, I should look more for different therapeutic interventions according

to patients’ needs.

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Patient Category Report #2 -Frozen Shoulder(Adhesive

Capsulitis)

Even though there is uncertainty in terms of definition and diagnosis, Adhesive capsulitis also

known as ‘frozen shoulder’ is a painful condition in the shoulder and because of the pain and

limited range in the shoulder, it effects the daily life of people(Dudkiewicz et al.

2010)According to one of the earliest findings of frozen shoulder is that this condition may be

caused by insufficient synovial fluid in the joint capsule which leads to hardened and

thickened synovial joint. The second finding was that celluar changes of infiltrated

inflammation in the synovial layer may also the reason of this condition(Dudkiewicz et al.

2010). Frozen shoulder is categorized into three phases to differentiate the patient’s condition

in what stage he is. These are the stiffness, painful and thawing phases. The painful phase is

the stage that patient feels pain at night and worsens when he lies on the affected shoulder.

This stage may continue 2 to 9 months. The second phase, stiffness phase, is the stage where a

range in the shoulder is reduced with alleviated pain. This stage may continue 4 to 12 months.

The third phase, thawing phase is the recovery stage which lasts for a longer

period(Dudkiewicz et al. 2010). It has been researched that the prevalence of this disease

changes from 20% to 33% in the world. It is also stated that the incidence of frozen shoulder

is gradually increasing(Mintken et al. 2010). It is important to state that secondary Frozen

shoulder may occur after some conditions or diseases. For instance after an injury or surgery

adhesive capsulitis may occur. The patients who have diabetes or who have had CVA

accident recently may also have this disease(Page et al. 2010). The Frozen shoulder patients

need physiotherapy to increase the limited range and decrease the pain over the shoulder. It

has been researched that painfree gentle active exercises are the most effective intervention

for these patients(Page et al. 2010).

The patients who have Frozen shoulder are usually between 40 to 60 years old. Women are

more effected than men(ratio 2:1). These patients usually injure their non-dominant shoulder.

The sedentary workers are more affected because their lifestyle is usually with lack of

activity. Among these patients %11 of them are diabetics.

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In my clinic, the most used intervention is Electrotherapy and exercise therapy. There may be

gentle massage and kinesiotaping as an additional intervention. To be more specific, they

have been treated these patients with 20min TENS with hot pack, 10 min US and for 20 min

with active exercises.

I chose 3 patients that I have treated for 4 weeks. These three patients were female and over

40 years old. Two of them have diabetes.

Patient 1: D.T.

The patient is 61 years old.

Assessment:

Hawkins: +/- Neer: +/- The patient is Diabetic.

Abduction: 60˚ Flexion: 60˚ External Rotation : 30˚

While doing ROM the patient was compensating with a scapulathoracic movement.

Therapy:

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

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

20min Stretching and multiple exercises with lifting a stick, turning side to side with a stick,

trying to touch a point on the wall, turning the metal exercise wheel on the wall.

According to her history, this patient had been suffering with pain in day and night until she

had physiotherapy. She was so upset about not being able to work at home anymore. Her

psychological load was higher than her carriability. She had Frozen shoulder after she had a

trauma on her glenohumeral head. She said she used to be an active person in the farm,

although due to her condition which she had been having for months, she claimed that she had

developed a frozen shoulder.

Patient 2: S.O.


Assessment:


Specific: d4300( lifting, turning)

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Hawkins: +/- Neer: +/- The patient is Diabetic.

Right shoulder ROM:

Flexion: 90˚ (active) 110˚(passive)

Abduction: 80˚(active) 110˚(passive)

External Rotation: 30˚(passive)

Therapy:





This patient lead a sedentary life. She did not work and was in pain only at night and when

executing tasks. She had frozen shoulder after a surgery on her shoulder because of a

dislocation and glenoid fracture.

Patient 3: N.K.


Assessment:

Hawkins: +/- Neer: +/-

Right shoulder ROM:

Flexion: 60˚ (active) 70˚(passive)

Abduction: 80˚(active) 90˚(passive)

External Rotation: 30˚(passive)

Therapy:









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This patient was admitted to the hospital after having traffic accident. Due to this accident had

been having painful and limited shoulder. The patient is hypertensive. She was very

cooperative and willing to get better. She took extra homework exercises to decrease her

limitation which showed her carriability was higher than her load.

This protocol had been shown through all patients to be successful. It is important for

physiotherapists to make an accurate diagnosis to determine the best treatment for each

patient. Even though there is no proved evidence that claims there is the best intervention for

this disease, there are applications which are beneficial for each patient. It is wise to look for

evidence based literatures for specific intervention. 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 4 weeks of treatment in the hospital.

My opinion about the protocol is to give more specific exercises for each patient because I

observed that each of them has different life and expectancies. To fulfill these expectancies

we should look for details in the patient history.

The most remarkable thing was that one of the patients above told me that her pain was

diminished suddenly after executing the exercises. I personally did not expect and believe this

because I have been observing that recovery takes time.

I have had a great opportunity to see Frozen shoulder patients with different limited range and

competencies. I gained insight into assessment and patient history.

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References

Dudkiewicz I, Oran A, Salai M, Palti R, Pritsch M et al. Idiopathic adhesive capsulitis: long

term results of conservative treatment. 2004;6:524-6.

Kumral E, Ozkaya B, Sagduyu A, Sirin H, Vardarli E, Pehlivan M et al. The ege stroke

registry: a hospital-based study in the aegean region, izmir, turkey. 1998;8(5):278-

288

Lindsay MP, Gubitz G, Bayley M, Hill MD, Davies SC, Singh S et al. 2010. Canadian best

practice recommendations for stroke care: The canadian stroke strategy. 2010;

179(12); 1-25.

Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Keirns M, Whitman JM et al. Some

factors predict successful short-term outcomes in individuals with shoulder pain

receiving cervicothoracic manipulation: a single-arm trial. 2010;90(1):26-42.

Page P, Labbe A et al. Adhesive capsulitis: use the evidence to integrate your interventions.

2010;5(4):266-273.

Peppen RP, Kwakkel G, Wood-Dauphinee S, Hendriks HJ, Wees PJ, Dekker J et al. The

impact of physical therapy on functional outcomes after stroke: what’s the

evidence? 2004;18(8);833-862.

Sacco RL, Adams R, Albers G, Alberts MJ, Benavante O, Furie K et al. Guidelines for

prevention of stroke in patients with ischemic stroke or transient ischemic attack.

2006;37:577-617.

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Extensive patient Report

SCI(Tetraplegia)

Motivation For patient selection

First of all I find myself very lucky to see many SCI patients. My internship site and the

physical therapy department received a lot of neurological patients especially CVA and SCI

patients. I have developed an interest and confidence into neurological rehabilitation. 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 evidences 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. My second reason to choose this

patient was that this patient was very young and has a minor chance to get better different

than the other tetraplegic patients accoording to the physicians.

There is also an interesting fact about the distribution of this pathology. According to

evidences, 650-900 million US citizens are affected by SCI per year. Of these 650-900

million people, there are 52% which are tetraplegic (level C1-C8) and 48% which are

paraplegic (level T1-S5)(Cuccurullo et al 2010). Acoording to another evidence, 20% of the

tetraplegic fall under the category of ASIA- A and 32% under the categories B, C, D, with

9%, 5% and 18% respectively. Unfortunately, there is no information given as to why the

numbers of tetraplegic in the category of D are so high compared to the 20% with ASIA A

and the 9% and 5% of ASIA B and C; however, a hypothesis could be the type of traumatic

accident, as the severity of the patients varies upon whether there were multiple and complex

fractures or singular isolated fractures. In respect to the percentage of paraplegic, there are

27% with complete ASIA A and 21% incomplete B, C and D with 6%, 4% and 12%

respectively. Again, no sufficient data is given on why the numbers are distributed in such a

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way. However, other literature suggests that this distribution has changed over the last 30

years, as the amount of tetraplegic and the amount of incomplete lesions is increasing

(Wyndaele et al 2006).

The administrative data of the patient

Name: Mr. B Medical doctor diagnosis: SCI(tetraplegia) Complete ASIA A

Age: 16 C5-C6 fracture/ C7 complete tetraplegia

Gender: Male Medication: Clexane, Ventolin, Desefin, Iliadin, Clindoxyl gel,

Osmalac

Occupation: Student Insurance: SSK( full coverage)

Medical history: No hypertension, No cardiac ptoblem, No lung disease, No kidney problem,

No gastrointestinal problem, No thyroid problem, No history of operation, No smoking

Patient History The patient jumped from a higher ground to the water and fell on shallow water on the 17th of

july in 2011. He suddenly felt weakness of his body and tried to come up to the surface of the

sea. He was in shock and unable to talk according to his friends. They immediately called the

ambulance and sent him to the hospital. He had an operation after 5 days. He was admitted to

the rehabilitation on the 1st of August. After the operation there were movements on the arms.

Help seeking question

The patient wants to walk and play basketball again. He wants to be independent.

S- Subjective

Clinimetrics: KATZ index

Daily Activities( scoring from 0-6 ):

Showering: 0

Clothing: 0

Toilet: 0

Transfer:0

Continance:0

Eating: 1( the patient is able to take the food by himself)

O-Objective

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Clinimetrics: ASIA scale

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

Deep tendon reflex is measurable on upper extremity but lower extremity is not possible.

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

Clonus: left (-) right(-)

Peripheral pulse is measurable.

Bulbocavernosus reflex: (-)

Cremaster reflex: (-)

ASIA scale

Right Left

C5 4 3+ elbow flexors

C6 3- 3- wrist extensors

C7 3- 3- elbow extensors

C8 0 0 finger flexors T1 0 0 finger abductors

L2 0 0 hip flexors

L3 0 0 knee extensors

L4 0 0 ankle dorsiflexors

L5 0 0 long toe extensors

S1 0 0 plantar flexors

Voulntary Anal contraction: (-)

Sensory:

Light touch Pin prick

Right Left Right Left

C2 2 2 2 2

C3 2 2 2 2

C4 2 2 2 2

C5 2 2 2 2

C6 1 1 1 1

C7 1 1 1 1

C8 1 1 1 1

T1 1 1 1 1

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T2 1 1 1 1

T3 1 1 1 1

T4 1 1 1 1

Furthermore: T5 and below T5, received ‘0’ for both ‘Light touch’ and ‘Pin Prick’ sensation

on both ‘right’ and ‘left’ side of the body.

Any anal sensation: (-)

A-Analysis/Assessment

The patient is 16 year old male who had traumatic spinal cord accident and presents SCI on

C5-C6 level and disability below this level. Together with MRI and X-ray results, according

to ASIA scale the patient was classified as ‘Complete ASIA A’. The physiotherapy is

indicated for the disabilities the patient has shown.

The patient is not aware of his situation and has expectations of complete recovery.

P-Plan

Treatment goals short term

1. Prevention of ortostatic hypotension.

2. To teach how to prevent pressure sores.

3. To give biofeedback and educating the environment.

Reasoning: It is important to control secondary complications following after SCI. The more

we take care of these as physiotherapists, the better the patient will experience an increase in

functioning. It is important to realize the process of recovery. The education of the

environment plays an important role to prevent not only physiological but also psychological

effects.

Treatment goals long term

1. Improving the functioning of upper extremity.

2. Strengthening the mucles on upper extremity.

Reasoning: Strengthening the upper extremity will give benefit to the patient for lifetime.

The better the functioning, the quicker the patient will gain independence.

SMART short term treatment goals

1. S- To prevent orthostatic hypotension.

M- Measuable by checking the blood pressure by physicians and physiotherapists.

A- Attainable by tilting the bed for tetraplegic patient.

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R- Relevant to prevent cardiovascular impairments.

T-4- 6 weeks.

2. S-To teach how to prevent pressure sores.

M- Measurable by physicians, physiotherapists and the environment.

A- Attainable by teaching the patient how to move actively.

R- Relevant not to gain any debicutus ulcer which may be life threatening.

T- 3-4 weeks.

3. S- Informing the patient and educating the environment.

M-Measurable through discussions and questions from the patient.

A-Attainable by giving feedback regularly to the family and to the patient.

R-Relevant to understand the recovery procedure and prevention.

T- 3-4 weeks.

SMART long term treatment goals

1. S-Improving the functioning of upper extremity.

M- Measurable by physiotherapists by checking ROM for any limitations.

A-Attainable by moving actively the upper extremity.

R- Relevant for the ambulation and transfers independently.

T- 8 weeks or more.

2. S- Strenghtening the muscles on upper extremity.

M-Measurable by muscle grading scale through physiotherapists.

A- Attainable by resistive ROM.

R- Relevant for transfers and become independent in wheelchair.

T- 8weeks and more.

Reasoning for treatment methods

One of the expected complications of SCI patients is that orthostatic hypotension. Even

though there is no certain explanation how this mechanism occurs, the patient may experience

this distressing pathology after an injury. The factors, which have been researched, may be

lack of tonic symphatetic control, skeletal muscle pumping activity, impaired baroreceptor

regulation and cardiovascular deconditioning. Besides the positioning as a treatment, the

patient also has to take care of his adequate salt and fluid intake. It is important to realize that

orthostatic hypotension may cause fatigue which diminishes the quality of life and

discouraging the patient for rehabilitation. Because of the factors mentioned above the

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rehabilitation is indicated for SCI patients. The physiotherapeutic interventions include

moving the extremities as much as possible, changing the position of the patient while he

stays immobile in bed(Claydon et al. 2006).

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).

Pressure sores are very dangerous complication for SCI patients. The results of debicutus

ulcers may be life threatening. Moving and tilted back and forth in bed are beneficial and

useful for the prevention of these sores. Another important factor is that 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 nurses. While

staying in the hospital the patient was controlled by physicians every day through nurses. The

blood samples were taken frequently to see if there was an infection anywhere in the body.

The physicians gave necessary medications. The nurses took care of bowel and bladder

management by checking the catheter when the physicians thought that it was necessary. The

patient and his family also took therapy from psychiatrist.

The patient uses neck orthoses to prevent falling of the head while doing therapy or when it is

necessary.

This patient was taken care of by multiple specialists in the hospital. Each specialist had the ai

m to accelerate recovery process.

Treatment sessions and social contact

Our 16 year old patient has been following rehabilitation for 6 weeks in Balcali Hastanesi. He

has 3 sisters and one brother and also a very caring parents. His family was very sad in the

begining about his son’s situation but after 3 weeks they realized that they have to make his

son’s life easier by helping and motivating him. The patient and his family were unaware of

the situation in the begining of the hospitalization. Their expectations from recovery was

unrealistic. For example the patient wanted to play basketball and walk again which would

not be possible in his condition. The closest possibility was to play basketball in the

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wheelchair that is why while therapy sessions in the last 2 weeks after he was becoming

aware of his condition, I gave this opportunity as a suggestion. The patient showed great

confidence after 4 weeks. He accepted his situation to get better although he showed the signs

of denial from time to time. His parents have the same psychological progress like their son

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 of treatment and prognosis

The patient was evaluated every week with small sessions by physicians. During these

assessments the muscle strength, his ability to move in bed were graded. Besides there were

extra medication given for his infection in the 4th week.

The prognosis of the treatment program showed to be successful. After six weeks the patient

got use to move in bed with his arms minimally. Furthermore, he knows how to prevent the

pressure sores. He is willing to get better.

The structures assessed and compared every week below:

Ø The Flexors of the arm

Ø The flexors of the elbow

Ø The abductors of the shoulder

Ø The extensors of the wrists partially(extensor carpi radialis longus and brevis).

Ø The ability to move.

Ø The reaction to orthostatic hypotension.

Ø The psychological load and carriability.

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References

Claydon VE, Steeves JD, Krassioukov A et al. Orthostatic hypotension following spinal cord

injury: understanding clinical pathophysiology. 2006;44:341-351.

Henzel MK, Bogie KM, Guihan M, Ho CH et al. 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.

Kirshblum S, Gonzalez P, Cuccurullo S, Luciano L et al: Physical medicine and rehabilitation

board review. 2nd ed. New york: Demos medical publishing; 2010. p. 535-607.

Sheel AW, Reid WD, Townson A, Ayas N, Konnyu KJ et al. Effects of exercise training and

inspiratory muscle training in spinal cord injury: a systematic review.

2008;31(5):500-508.

Singh R, Sing R, Rohilla RK, Siwach R, Verma V, Kaur K et al. Surgery for pressure ulcers

improves general health and quality of life in patients with spinal cord injury.

2010;33(4): 396-400.

Wyndaele M, Wyndaele JJ. Incidence, prevalence and epidemiology of spinal cord injury:

what learns a worldwide literature survey? Spinal Cord. 2006;44:523-9.

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Personal Evaluation

This internship process was a successful period for me. I was able to see a lot of patients in a

different working environment. I was able to observe hospital situations regarding

interventions through different specialists. I have had experiences in working with 9

physiotherapists for one week. I saw that the treatment applications may differ from each

physiotherapist. Besides, for one week I was able to be with physical therapy physician and

gain knowledge more in patient history and assessment. I also attented weekly assessments

for each patient in the physical therapy department with different physicians. In these

assessments I was able to learn different opinions from every physicians. The last diagnosis

process was remarkable to see. Even though the initial expectations were not fulfilled, I can

not say that I am not satisfied. The things I expected before was to take a chance to work with

Physicians more than physiotherapists because the rules and regulations between Turkey and

The Netherlands are different.

Unfourtanetly, I can not say that I have totally developed professional skills through this

internship period. I could not do assessment or patient history properly for all patients. The

only opportunity for me for this internship site was to see variety of patients. During the time

I was with physiotherapists, after 4 weeks I could not improve any competence level due to

the discrepancy between physiotherapists and physicians. I was able to learn applying

different tecniques of electrotherapy with different injury sites. I mostly could observe the

benefits of electrotherapy.

I could not see any cardiovascular patients because the physical therapy department did not

receive these type of patients.

Another obstacle was that I was unable to apply my massage skills in this internship site to

practice in different body types.

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Competencies

I gained special knowledge and competencies about neurological patients because the

majority of the patients were these type of patients. I have seen a lot of CVA, SCI, shoulder

pathology patients during my entire internship. I was able to gain insight into rehabilitative

tecniques on almost every patient. The rehabilitation includes ROM, strengthening, giving

exercises under the physiotherapist supervision and exercise prescription as home exercises.

The patients I have treated were not complicated but in each patient there was almost different

alignments as in the body structure. I personally would agree that this overall internship could

be considered as Level 1 internship.

I have gained remarkable confidence in treating neurological patients. The competences I

have gained are application of electrotherapy and using rehabilitation tecniques on

neurological patients.

Competences to develop

The competences that should be developed through the following year:

-Applying note taking in patient history.

-Assessing and diagnosing for each patient.

-Applying and developing Massage tecniques.

-Usage of evidence based more often.

-Be precise in giving feedback to the patient.

The learning objectives I have to formulate for the following internship is to gain more

knowledge about patient history and assessment for each specific patient. The level should be

in a higher level because by that time my education period will be over. I will be working on

this by reviewing previous literatures and practicing as much as possible on real patients.

Hour Justification:

From monday to friday every day of the week from 8.30 to 16.00 for 12 weeks.

The total time spent in the hospital is 450 hours.

The total time spent for lunch break is 90 hours.

The total patient contact hours is 360 hours(450-90).

There were 3 omission days. The final total patient contact hours is 342.

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Critical reflection

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

As a health care worker I was able to assess, diagnose and do planning partially by asking the

patient to gain knowledge for his/her condition. I understand the relevance of taking patient

history for further intervention. I took assessment notes weekly with PMR physiatrists. I

observed a lot of orthopedic assessments with the help of the physiotherapists. The

therapeutic exercises were including the evaluation of ADL and gait training. One of the most

things I have developed was to evaluate neurological patients; however I was unable to

evaluate any pulmonary and cardiac status.

1.b. The physiotherapist as a healthcare worker: therapeutic measures

Therapeutic measures were the most successful intervention from the other competencies. I

was able to apply gait training with different levels and being creative to increase the

intensity. The most used mobilisation tecnique was Kaltenborn for shoulder patients. I applied

massage on shoulder patients with my own responsibility. Electrophysical modalities were the

most used intervention in the department that is why I learned a lot for EPM. I was able to do

taping tecniques on ankles and shoulders of the patients.

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

In this competency, I observed that prevention of infective diseases through patients were the

most important thing while touching the patients. The environment education, giving

feedback to the patient also play an important role in recovery process.

2.a. The physiotherapist as a manager- organizing

I spent certain amount of patient contact hours which was valuable for me to learn a lot of

things. I worked closely with 9 physiotherapists and a PMR physiatrist.

2.b. The physiotherapist asa manage- business undertaking

I learnt that the new and the previous procedures in Health care laws and insurance and aware

of them. I had difficulties with adjusting in the beginning but it changed after a while.

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

I used evidence based literatures on each patient category and tried to apply on each of them. I

also look for and used evidenced based literatures with my CI. The level of this competency

was 2.

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3.b. The physiotherapist as professional developer-innovation

I always worked with the other health care specialists and with the patients with a

professional attitude.

General conclusions

First of all, this internship gave me opportunity to work on different variety of patients. The

neurological patients were the most common patients who followed long term rehabilitation.

Although I could be more happy if I had chance to do more patient history and assessment.

The second and the last conclusion is about electrotherapy. Because I have had the

opportunity to do mostly therapy, I could give different currents on each patient.

New learning objectives

For the new study phase:

My plan for the new study phase is to extend my knowledge for pediatrics patients,

Cardiopulmonary patients and neurological patients.

For the internship to come:

My plan for the next internship is to practice in patient history taking, assesssing, diagnosing

and analysing.

If I could achieve these goals, I would be able to partially say my knowledge is complete to

become a physiotherapist.

Hogeschool van Amsterdam

Amsterdam School of Health Professions

European School of Physiotherapy

Tafelbergweg 51

1105 BD Amsterdam

The Netherlands

Documents

Final Internship report 1# - · PDF fileAssignment #7 Clinical internship report ... works closely with Neurology, Rheumatology, ... The ministry is responsible for