Because I haven’t told much about my first practical training place, I decided to make a little summary about it and things I learned there.
So, even though the name of place was “Aima hospital”, it was more like a day-care center… some people came daily there to have rehabilitation by speech terapist, psychologist, physiotherapist etc. There’re also many people who came only for having physiotherapy. There’re two physiotherapist: my instructor and another one, both of them are teachers in the University. Patients were mainly hemiplegics, but there were also some spinalcord injuries, MSs and Parkinsons. Many patients had other problems along with motor and functional problems, for example with communication, visual and breathing.
Before I started my practical in Aima, I thought I’d learn about Bobath therapy but no, instead I learned much about neurodynamics. The principles of this method base on the idea that neural tissue needs to move freely and unimpeded. Because, if it doesn’t, it results into pain, restriction and limited motion. In this place, therapy was mainly passive and very manual: my instructor was very often hands on patients trying to affect on their neural tissue. And almost everytime, results were clearly seenable right after the treatment: either in positive or negative way. There are many ways to effect on neural tissue: increasing blood circulation in nerves (by optimizing the breathing, neural pumping), increasing the activity of parasympathetic nervous system (growling in belly is one sign about this), and increasing the space between tissues (by sliding skin and deeper tissues away from each other).
I also learned about Vojta therapy, which my instructor mainly used to improve patients’ balance, especially those whose trunk muscles were hypotonic. This method bases on pressing on the special trigger point, which is located in heel.
There are different postures in Vojta therapy, such as sitting and side-lying, but we used only prone lying posture. You can see the posture from picture above. The basic idea is that patient lies in prone and the face looks either in right or left, and the arm of this side is flexed from humeral and elbow joints. In addition the opposite leg is also flexed from the hip and knee joints. When patient is in this posture, therapist takes the ankle from flexed leg, adds dorsiflexion and presses on the heel. Purpose would be to stay in this position 4×5 mins, 2x both sides by turns. If you want to see results, you should repeat this treatment at least five times.
My instructor also taught me about the activity of motor neuron after neurological injury. Because of the injury (which can be caused by external accident, internal cerebrovascular accident or tumor etc.), the function of neuraltissue has disturbed which causes among other things spasticity and dyskinesia.
As you can see from the picture above, motor neuron causes hypertonia in muscles because it is affected by too much of exhibitators (I don’t know is it correct word) and too little inhibitators. My instructor explained me that this is the reason why we have to work first passively with patients’ neural tissue, to make their exhibitators decrease (like by increasing oxygen in neural tissues). And after this we can focus on increasing inhibitation, like decreasing the tonus. First when she explained this to me, I was like “What? I don’t understand at all, why just inhibitation isn’t enough?”. But when I tried to start with inhibitation techniques on patient, I didn’t get as much results as when I started with decreasing exhibitatory techniques.
Another big thing I also learned was protective hypertonia. First when I heard this term, I had no idea what it means… we were taught only about spacticity and rigidity as the forms of hypertonia in Finland. Protective hypertonia means that injured nerve forms a certain kind of pattern (body posture) so it can protect itself from extra injuries, like stretching. Two common patterns I saw during practical training were: 1.) femoral-pattern: hip extension+internal rotation and knee extension, 2.) ischias-pattern: hip flexion+external rotation and knee flexion. So, these are patterns where nerves in question are in their shortest lenght. I’m still not 100 % sure what is the difference between protective hypertonia and spasticity, but my instructor told me that actually in many cases it is protective in question instead of actual spasticity. But one thing I can say for sure: Damn, these patterns can be so freaking difficult to break sometimes!
My instructor highlighted the meaning of patient oriented approach, like what the patient is ready to do, what are the goals which he/she wants to achieve, and does he/she has resources to do rehabilitation at home. This is really important, especially when people don’t get much financial support for rehabilitation in Spain after 6-12 months from injury. That’s way rehabilitation with many older and chronic patients was mainly maintaining and relieving the pain once or twice in week.
Even tough I was prepared with the idea that neurological rehabilitation is a long process and patients’ have good and bad days like everyone else does, there were many new things I learned about that can affect on their condition too. For example, I had never thought that weather can affect so radically! Low pressure, wind and cold are three worst things for neurological patient. Also emotional life, like sadness, tension, angriness, and happiness, can affect very remarkably. If patient has face very big tragedy in his/her life, rehabilitation can be very difficult to fulfill. Also the meaning of rest and sleep is very important to neurological patients (as to everybody else too).
Last but not least, I’ll tell some practical things which were maybe different or similar to Finland:
1.) Filing(?) or writing down things about therapy session. In my previous practical places filing has been so important thing: you have to write all the important things down, so other professionals keep up with latest information about patient. And it has to be always in computer, nothing paper files. Here in Barcelona, my instructor writed down quite seldom, and when she did, it was on paper. She told me that she writes down usually only when she changes therapy method or something bigger happens during session. On the other hand, my previous practices have been in public health center and hospital, so I’m not sure about system on private sector.
2.) In Finland hygiene is highly determinated; washing hands, cleaning the used equipments, changing the paper on treatment table after every patient… etc. etc. Here we used sheets on the treatment table and turned it over after patients, so one sheet can be used twice. And my instructor washed all those sheets she used by herself in home (of course, with washing machine). And we used two pillows, never changed the covering.
3.) Durations of session times. In Finland, especially in health centers, durations of sessions are very exact. If you have booked 1h for one patient, it lasts then only 1h and after that you take next one. Here, or at least in my place, sessions often prolonged. But my instructor explained me that her patients understand that she may be little bit late because she wanted to do everything she could to help patients in every time. (She also said that she is a disaster with timetable 😀 ) It was very important to her that she achieved improvement. I think this was a very great feature about her: she was not only ambitious but she truly wanted to help others. She was also really “article worm”, because she wanted to keep up with latest knowledge of neurological physiotherapy and countinuously improve herself. 🙂
4.) Therapy equipment. There are some equipment we used most in Aima.
– water bottle for arm and hand functional practice
– vibrator for activate muscles (also for relax them, but it’d take so much time we didn’t do that)
– feather for testing sense of feeling
– hook for improving scar and fascial tissues
– key in rope for testing standing position
– brush for activating muscles
– that white-green-pump for soft tissue and scar improvement
– ball for practicing dynamic balance and dual-tasking
– colourful wooden rings for practicing hand function
… There was some sort of summary from my first practical place. Six weeks went so fast! I learned a lot of theory in Aima-hospital and I liked people in there because they were all so nice and kind to me. I already miss that place! But life goes on… I started at my second place yesterday, in private rehabilitation center Bettina, in Sant Cugat. I hope in next 7 weeks I’ll get some more practical experience there! 🙂
That’s all for this time! Next time I’ll write more about my exchange experiences again! Until then…