PHS 250 - Week 2 Lecture PDF

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Week 2 lecture...

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Week 2: Physio Practice Thresholds Role 1: Physiotherapy practitioner  Working in partnership with clients (client centred)  Informed by research with evidence (research informed)  Preventing and minimising impairments, activity limitations and participation restrictions (guided by ICF)  Considering personal and environmental influences

Role 2: Professional and ethical practitioner    

Professional language and attire Obtaining and documenting informed consent Respecting privacy and confidentiality Organisational skills and self management

Role 3: Communicator  Interaction with clients, clinical educator, other health professionals  Develop skills in clinical documentation, handovers and referrals, discharge summaries

Role 4: Reflective practitioner and self-directed learner  Critical reflection and self-directed learning  Feedback from peer and tutors/educators  Apply principles of evidence-based practice, quality improvement and risk managementUnderstanding professional boundaries and roles

Role 5: Collaborative practitioner  Working with clients and other health professionals in relation to client care

Role 6: Educator  Use education to empower themselves and others, including education peers

Role 7: Manager/leader  Organise and prioritise workload and resources  Lead others within relevant professional/ethical/legal framework

Evidence-Based Practice Steps 1. Ask a clinical question

2. 3. 4. 5.

Acquire best evidence Appraise evidence Apply evidence Audit process and impact

Critical Appraisal of Article 1. 2. 3. 4. 5.

Identify study design Compare research question with study design Identify level of evidence Describe methodological quality of the article Describe research and clinical implications

Documentation What do you need to document? 1. 2. 3. 4. 5. 6. 7. 8.

SE - subjective Examination OE - Objective Examination Rx - Treatment Re-assessment Plan (P) - goals, progression, prognosis You must document informed consent to assessment and treatment You should also document refusal of treatment and the reason why You must obtain informed consent to share confidential client information with third party

Other documentation requirements 1. Display client name and medical record number (MRN) at the top of every page 2. Provide date, time (24 hour clock) and type of consult (PT) 3. Write legibly in black pen within space provided with no lines being left blank 4. Be concise and accurate 5. Ensure your writing is legible 6. Clearly identify errors and corrections (cross out, print “written in error” and initial and date) 7. Notes to be signed with name and position printed after signature in parentheses 8. Student note to be co-signed by supervisor at the time of duty 9. Do not add time/date/amend entries retrospectively 10. Include only approved abbreviations (and not in assessment, plan)

Documentation structure:  SOAP o S: Subjective o O: Objective (includes Rx & //)

o A: Assessment o P: Plan  SOAPIER o S: Subjective o O: Objective o A: Analysis o P: Plan for Rx o I: Interaction o E: Evaluation ie. Rx-Ax o R: Review

Gait Gait cycle Gait cycle = Heel strike to heel strike with same foot -> Synonymous to stride (2 steps)  2 phases o Stance -> Heel strike -> toe off (60% of the time) o Swing -> toe off -> heel strike (40% of the time)  Double limb support at 0-10% of gait cycle and 50-60% of gait cycle during walking => No double limb support and period of time with no feel on the ground running

Stance Phase - Heel strike to toe-off 1. Loading response (between initial contact and opposite toe off) 1. Heel contact = instant heel comes into contact with ground 2. Foot flat = entire plantar surface of the foot comes in contact with the ground b. Mid stance = body’s weight passes directly over supporting lower extremity (opposite toe off to heel rise) c. Terminal stance (opposite foot in contact with ground) 1. Heel off = instant heel comes off the ground b. Pre swing/Toe off = instant when toes come off the ground (other foot in loading response)

Spatial description of gait  Stride = sequence of events between successive heel contacts of the SAME foot o Stride length is the distance between two successive heel contacts of the same foot (normally around 144 cm)  Step = sequence of events between successive heel contacts of the OPPOSITE feet o Step length is the distance between successive heel contacts of the two different feet

o Step width - lateral distance between the heel centres of two consecutive foot contacts o Foot angle - degree of toe out

Temporal description of gait  Cadence - number of steps per minute (i.e. step rate) o Normal rate 1.87 steps (110 steps/min)  Stride tiem - time for a full gait cycle  Step time - time for the completion of a right OR left step

Stance phase - Early to mid swing Eccentric activation of:  Hip: o Abductor (e.g. gluteus medius, minimus, TFL) control hip adduction o External rotators (e.g. posterior gluteus medius, deep external rotators) to control internal rotation  Knee: o Extensors (e.g. quadriceps) to control knee flexion  Ankle/Foot: o Dorsiflexion (e.g. quadriceps) to decelerate plantarflexion o Inversion (e.g. tibialis posterior) to control eversion o Toe extensors (e.g. EHL, EDL) to decelerate plantarflexion and toe flexion Concentric activation of:  Hip: o Extensors (e.g. hamstrings, gluteus maximus + assistance of adduction) to extend hip o Internal rotators (gluteus medius, minimis, adductors) to internally rotate hip early to mid stance Isometric activation of:  Hip: o Extensors (e.g. hamstrings/gluteus maximus) at heel contact o Adductors (e.g. adductor magnus) at heel contact  Ankle/Foot: o Dorsiflexion (e.g. tibialis posterior) at heel contact

Stance phase - Mid to late stance Eccentric activation of:  Hip: o Abductors (e.g. gluteus medius, minimus, TFL) to control hip adduction especially at mid stance o Flexors (e.g. iliopsoas, rectus femoris, sartoris) control extension and stance prior to toe-off

 Knee: o Extensors (e.g. quadriceps) to control flexion the knee under load  Ankle/Foot: o Plantarflexors (e.g. gastrocs, soleus) to control dorsiflexion at early to mid stance o Inversion (e.g. tibialis anterior + posterior) to control eversion early to mid stance o Evertors (e.g. peroneus longus + brevis) to control inversion mid to late stance Concentric activation of:  Hip: o Extensors (e.g. gluteus maximus, hamstrings) to extend hip o Flexors (e.g. iliopsoas) primed to flex hip at toe off o Abductors (e.g,. Gluteus, minimus, TFL) to abduct the hip in mid to late stance  Knee: o Flexors (e.g. hamstrings, gastrocs) to flex knee end stance Isometric activation of:  Hip: o Adductors (e.g. adductor magnus) coactive with flexors and abductors at toe off

Swing phase Eccentric activation of:  Hip: Extensors (e.g. iliopsoas, rectus femoris, sartorius) to flex hip and take step forward  Knee: Flexors (e.g. hamstrings) to decelerate knee extension end swing Concentric activation of:  Hip: o Flexors (e.g. iliopsoas, rectus femoris, sartorius) to flex hip and take step forward o Abductors (e.g. gluteus medius, minimus, TFL) to abduct hip end of prepare for heel contact o Internal rotators (e.g. gluteus medius + minimus, TFL) to internally rotate hip  Knee: o Flexors (e.g. hamstrings, gastrocs) to flex knee in early to mid swing o Extensors (e.g. quadriceps) extend knee from mid to late swing  Ankle/Foot o Ankle dorsiflexion (e.g. tibialis anterior), inverters (tibialis ant + post) and toe extensors 9e.g. EHL, EDL) to dorsiflex ankle, invert foot and extend toes throughout swing (to clear ground and prepare for heel control)

Stance and swing phase - knee Concentric activation of:  Knee flexors (e.g. hamstrings, gastrocs) to flex knee end stance and early to mid swing  Extensors (e.g. quadriceps) extend from mid to late swing Eccentric activation of:  Knee extensors (e.g. quadriceps) to control knee flexion during stance  Knee flexors (e.g. hamstrings) to decelerate knee extension end swing

Ensuring patient safety when mobilising Contraindications to assessing gait  If mobilising a patient and assessing gait results in movement or weightbearing o In the region of a dislocation or unhealed fracture o Immediately after surgery that will interrupt the healing process  NB surgery orders regarding weight-bearing: FWB, PWB, NWB, TWB, WBAT (weight bearing as tolerated) o If patient is not medically stable or does not have medical clearance to mobilise o If patient does not give consent or have the capacity to mobilise

Precautions to assessing gait             

Immediately after soft tissue injury Instability, hypermobility or suluxed joints New united fracture Osteoporosis or bone fragility Spine injury Vertebrobasilar insufficiency (VBI) e.g. Dizziness, Diplopia, Dysarthria, Nausea High pain and irritability associated with mobilising Prolonged immobilisation or surgery Blood disorders otr bruising e.g. Haemophilia, Hematoma Patients taking pain or muscle relaxant medication Patient fatigue History or risk of cardiorespiratory problem e.g. Aneurysm, Pacemaker, Arrhythmias Identify hazards and control risks

Safety issues before mobilisation 1. Review medical background => cardiorespiratory dysfunction, medication, previous mobility and exercise tolerance 2. Ensure sufficient cardiorespiratory reserve => HR, BP, ECG, SpO2, RR 3. Check weight-bearing status and medical clearance => FWB, PWB, WBAT, NWB, TWB 4. Subject & objective examination

Monitoring during/after mobilisation 1. Medical observation => HR, BP, SpO2, patient distress 2. Subjective questioning 3. Objective monitoring...