My beginning and last week of traineeship in Fondo (Neurological Physiotherapy)

Introduction

  This week was my first in Fondo (Neurological Physiotherapy) and last for traineeship in Finland. I was sad to finish my traineeship in Finland, because i liked the system that the physiotherapists work and also the equipments of rehabilitation. So, this week i worked with two physiotherapists and also occupational, speech and psycho therapists. My patients were only children, with only one exception, an elderly woman with 9 years old left stroke. The cases were not very hard, comparing to the previous neurological patients that i had, so the physiotherapy treatment was quiet easy, but needed fantasy and creativity to plan every time the rehabilitation for each of the children patients. 

   The sessions were in different play rooms, blue (sininen), red (punainen), green (vihreä) or yellow (keltainen) room (sali). Each of the rooms had all the needed equipment for practising and entairtaining the children. To sum up, almost every session for each of the children was quiet the same, with some variations. The aim was to activate the ones that were hypotonic and to calm and train the brain of those that were hyperactive and with problems like ADHD, which was very common.

  

Therapy - Play rooms

Main part

   A lot of children had the ADHD (Attention-deficit/hyperactivity disorder) syndrome, which is a brain disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. In total, i had three children with ADHD. Some common problems that this children had, were wide dysfunction development disorder, clampsiness, hypotonia, hyperactivity, problems with balance because of low tone, sensory modulation disorder, epileptic-seizure attack, tactile processing dysfunctions, dyspraxia and pshychiatric backrounds.

   

   Other problems that the young clients had, were also assosiated with the brain and body connection problems. Some of them had many speech problems like dysphasia, mutism, problems in words pronouncing, motor planning problems, sensitive auditory response, dyslexia. Other had also problems with motor skills and coordination like dyspraxia, low muscle tone, balance problems, difficulties in multiple and complicated activities and problems with fine motor skills. 

   I also had two children (girls from 7-10 years old) with right spastic hemiplegia, one 6 years old boy with Syndrome Down, one 7 years old deaf mute girl with hyperopia, Cerebral Palsy and a lot of postural and myosceletal problems (lordosis, scoliosis, instability because of low muscle tone),  one teenaged boy 14 years old with some phychological problems and one elderly woman with left side stroke.

   

   A very common problem was the sensory modulation disorder. 


 Sensory Modulation Disorder is one specific type of Sensory Processing Disorder (SPD). Sensory modulation refers specifically to the brain’s ability to respond appropriately to the sensory environment and to remain at the appropriate level of arousal or alertness. There are actually three primary types of Sensory Modulation Disorder:

• Over-responsivity: An exaggerated response of the nervous system to sensory input. For example, people who get motion sick easily are over-responding to vestibular input (the sensation of movement). The nervous system goes into fight-or-flight mode even when no real danger exists.

• Under-responsivity: A lack of response, or insufficient response to the sensory environment. Sometimes these people appear to be daydreaming or unfocused on what is happening around them. They may also be uncoordinated and have difficulty with motor skills development.

• Sensory-seeking: The nervous system of the sensory-seeker needs intense input in order for the sensation to be registered properly in the brain. Therefore the sensory-seeker craves intense sensations constantly.

  The physiotherapy treatment provide a fun and safe atmosphere when working with children who have sensory modulation difficulties. Treatment techniques used to improve sensory modulation focus on sensory integration therapy, and the treatments frequently incorporate activities involving vestibular stimulation and proprioceptive input, typically through the use of swings, obstacles courses, therapy balls, or some type of heavy work. 

   The children's problems that were assosiated with motor control - skills problems, included therapy tricks like: 

• helicopter swing 
• slide swing 
• bungee swing
• spinning tire swing with rope 
• swing on the wooden horse 
• slide 
• climbing on wooden wall bars 
• staying inside the yoga hammock  
• rolling on the slide with the skate board up and down 
• walking and ceeping balance on unstable surface in snake shape

   

helicopter swing

bungee swing

swing wooden horse

swing

slide

  

yoga hammock

Those that were associated with motor learning, fine motor problems and speech - concentration problems, included therapy tricks with some games like:

• constructing pyramids
• angry birds (constructing) 

• pattern matching (Play idea) 

• labyrinth spiel
• magical labirynth

• puzzle (f.e. farben-puzzle in which the child should match the same colors)

• magnetic darts

• magnetic fishing

 

• lotto old farmer game

• tower

• playskool 

• smartmax

• domino (ravensburger)

• lego creator

Conclusion

   To sum up, my traineeship in Fondo was a very good opportunity to gain experience with neurological children and to learn the different options and ways of treatment into the playrooms. I enjoyed being with children, treating and at the same time entertaining them. It was a really good experience for me, because i learned a lot of things, such us how to encourage the children to do more things, how to continue, how to exceed their fears that are associated for example with the hights and some activities that require climbing or swinging . At the end, i learned how to cooperate with other therapists, and in my opinion it is very usefull to treat a child or any of the patients, as a global entity and not only focusing to one problem!

2nd week in Lehmolan Fysioterapia

   Introduction

   My second and last week in Lehmolan Fysioterapia was as busy as the first week. I worked with new neurological patients but also with patients from last week. Me and my supervisor did quiet the same physiotherapy treatment to the patients from last week but with some new methods. I learned about a disease that was new for me, the Catch 22 Syndrome which is characterized by cardiac defects, abnormal facial features, thymic hypoplasia, cleft palate, and hypocalcemia. It results from a deletion within chromosome 22q11. This syndrome is not a simple disease. It includes DiGeorge syndrome, conotruncal anomaly face syndrome, and velocardiofacial syndrome. The authors report two cases of CATCH 22 syndrome. the Fallot's tetarlogia and bronkomalasia. It is so interesting, because everytime i learn something new and usefull for my knowledge!

   Main part

Physiotherapy treatment of a 2,5 years old girl

   Me and my supervisor went to a little 2,5 years old girl's home, to rehabilitate her. She had had the catch 22 syndrome, fallot'n tetralogia, bronkomalasia and heart problems. For these reasons, she had done surgery on her heart to open the pulmonary valve, because it was closed and wasn't working. For one year she was in the hospital and was feeding by machines and breathing by tracheostomy, so she wasn't moving at all. She has some difficulties in developement, but thanks to physiotherapy sesions, she is improving all the time and increasing the developement abilities. The treatment that we followed, included climbing and decending from the stairs, reaching objects from the window that were sticked to it, magnetic fishing game, walking with hands while laying on prone position on yoga ball, rolling and sitting on yoga ball.  Our little patient was very cooperative and happy for doing this physiotherapy-games!

magnetic fishing game

Physiotherapy treatment of Multiple Sclerosis

   A middle aged woman with multiple sclerosis came to Lehmolan Fysioterapia to have some physical exercises for improving her endourance and muscle elasticity and strength. Her left side was worse than the right side, she was also feeling pain on her cervical spine and shoulders. For this reason, we did massage on her cervical spine muscles (trapezoid). After the massage, she went to the bed by our assistance, to do some exercises. The first exercise that I did to her was balance disorders, on sitting position. The aim was to keep her balance, activating her core muscles against our resistance. The next exercise was in supine position, doing dorsi/knee/hip flexion and plantar/knee/hip extension with resistance and stretching to hamstrings, quadriceps, gastrocnemious, feet flexors/extensors. At the stretching time, there was appearing spasticity because of the muscle rest. In general, this client was quiet functional and with a lot willpower! I enjoyed working with her!

Physiotherapy treatment of Epilepsia

   An adult woman around 40 years old, was handicapped and had myoclonus epilepsy. She was very functional although and did all the exercises that we showed, at the Lehmolan's gym. The exercises included strengthen of upper-lower limbs muscles (pulldown, pushup) and balance of the core. She was very serious and sometimes had problem cooperating with other students, but in my case, i didn't face any problems with her!

Physiotherapy of Duchenne Muscular Dystrophy

    A very hard disease had a 27 years old patient, the duchenne muscular dystrophy. His muscles were totally atrofic and stiff, so I did to him only passive mobilization on his upper-lower limbs muscles from the supine position and at the end i did stretching to all the upper-lower limbs muscles from supine and lateral position. He was very adorable and was happy doing the exercises!

Physiotherapy of Paresis Erb's

  This week i had three young girls with paresis erb's. One girl was new for me and the other two were also last week. I followed the same logic of physiotherapy treatment to the young patients as last week, with some variations. They trained most of all their functionality and did a lot of athletic activities and memory games, as they were able to do almost everything.
   The new patient with paresis erb's on left upper limb, was a 14 years old girl. I evaluated her movements of both limbs, to see the limits of the movements and to compare both sides. As usual, she couldn't do the whole ROM of shoulder flexion, abduction, external rotation, elbow supination and some functional movements like brushing her hair, where she was using her core muscles to rise her hand. 

   After the evaluation, she did active exercises with and without assistance, functional and athletic activities, like swing, wooden rope ladder climbing, balance and core training. She was very active and did the exercises without special problems. At the end, I did stretching to her both hands, but most on the paretic left hand. Some of the stretching were very painfull, for example the shoulder external rotation from the middle position of the shoulder and the supination of the cubit. Although the pain, she was very patient with the stretching, because she knew that it was helpfull and good for increasing the muscle elastisity and joint ROM.
  

Physiotherapy treatment of Athetosis

   This week i worked with a 64 years old patient, with whom i worked also last week. He had athetosis,  falcate walking and difficulties in speech because of torticollis. This week he did again exercises in the Lehmolan gym room. He did warming up with static bicycle, and exercises for abdominals, back muscles, quadriceps and hamstrings. Then, he trained with the theraband his lateral abdominals and his balance. At the end, i did stretching to his lower and upper limbs to gain the muscle elastisity. I didn't face imprortant problems. The session was good!

Physiotherapy treatment of Corpus Callosum

This week, me and my supervisor visited the little girl with corpus callosum, that we had visited also last week. This week, she was in better mood and condition than the previous week. We worked more with her motor learning, motor control, balance training and retraining of standing position. I worked a lot with her on the yoga ball, to gain core balance, reflexes and myosceletal activation. I did a lot of back extension to her, shoulder abductions and facilitation on key points. After the physiotherapy, she was tired and maybe unhappy because it is hard to fix the posture to the right way. Although, this week she was quiet patient.

Physiotherapy treatment of Dystonia

   This weekend, I had two patients with dystonia, that were also last week doing physiotherapy. 

   The first one was the 59 years old man. It was the 3rd time in total that i saw him. This week he was a little bit lazy, although he did quiet much things. He trained himself by sitting on an inflatable, playing with balls (catching, throwing and kicking the balls), he did scrolling on the floor and i also facilitated him by key points. At the end, i tansfered him to the bed and from the bed to his wheelchair. My supervisor showed to me an easy way to transfer the specific patient, so that he would not lose his balance by extending his back. It was very helpfull and quiet easy by this way!

   The second patient was the one with more hypertonia than the first patient. This week he was quiet in the same condition as in last week. We trained his knee standing position and balance. We also tained hand rising by putting small balls into the basket which was on the same level as his head.

Physiotherapy treatment of Choreoathetosis

For the second time in Lehmolan Fysioterapia i worked with an elderly woman who had some signs of choreoathetosis. This weekend she did the same exercsises as the previous week, with only difference that she was improved very much, as she had more endourance and strength. The reason might was that she stopped taking the painkillers for her cervical pain etc. Her head position was also improved, as she kept her head in more right posture. She did static bicycle, pulldown-pushup, exercises for legs with resistance and balance training with the spine gym balance trainer. I enjoyed this physiotherapy treatment because i reallizes that she improved herself in just one week!

Conclusion

   To conclude, this week i learned a lot of things about the NDT/Bobath (Neuro-Developmental Treatment/Bobath). The NDT is a holistic and interdisciplinary clinical practice model informed by current and evolving research that emphasizes individualized therapeutic handling based on movement analysis for habilitation and rehabilitation of individuals with neurological pathophysiology. Using the ICF model, the therapist applies a problem-solving approach to assess activity and participation to identify and prioritize relevant integrities and impairments as a basis for the establishment of achievable outcomes with clients and caregivers. An in-depth understanding of typical and atypical development, and expertise in analysis of postural control, movement, activity, and participation throughout the lifespan, form the basis for examination, evaluation, and intervention. Therapeutic handling, used during evaluation and intervention, consists of a dynamic reciprocal interaction between the client and therapist for activation of optimal sensorimotor processing, task performance, and skill acquisition for achievement of participation in meaningful activities.

My beginning in Lehmolan Fysioterapia

Introduction

1st week:

   My first week in Lehmolan Fysioterapia was very multiple, busy and interesting. Most of the patients were neurological patients (for example cerebral palsy) and some of them had very hard disseases. I worked with my supervisor at the Lehmolan's Fysioterapia and also at client's houses and places with people with disabilities. I learned about some diseases that i didn't know before, like the corpus callosum, the hallerworden spatz and also about some physiotherapy equipment like Spine Gym Core Exerciser. I was very interested and surprised for umpteenth time in the finish way of rehabilitation!

Main part

Physiotherapy treatment of dystonia

   My first client at this traineeship was a home visit of a 6 years old boy, that had dystonia, spastisity, hypotonia, hydrocephalus, bad vision, trempling on his whole body and clone on his upper and lower limbs. He had tracheostomy for the breathing and a feeding machine. We did exercises and stretching with him, to reduse the tonus of the muscles and the clone. Especially on the hands, his tone was very big. I did extension, external rotation of his shoulder, supination and radial deviation for redusing the tone, and all the movements of the upper limbs, in order to motivate and activate the muscles. I did the same exercises at his lower limbs. Hip flexion/extension, internal/external rotation, abduction-adduction from the supine position, stretching of hip flectors and knee extensors from lateral position. At the end, we did traction-compression of the shoulder from sitting position and put AFO orthosis, in order to keep the feet in the right position. This boy was really happy and cooperative with us!

  The second dystonic client was an elderly man that came to Lechmolan's Fysioterapia to have some treatment and physiotherapy. He had many problems, like dystonia, hypotonia, variations of muscle tone and clubfoot. He was quiet funtional, as he could take of and put on his jacket, he could throw things into a basket and he could scrolle. Although, his balance and muscle tone wasn't good, because he couldn't keep balance in an appropriate position because of the quick changes of the clone. I facilitated his movements on key points of his body like pelvis, shoulder in order to manage to keep the balance from the sitting position and the back extension, and standing-walking on the knees. At the end, we played a memory game with overturned cards that had as picture differend kind of transports, and he had to find the other pair of the picture. His memory was very good and i was surprised!

   The third client with dystonia was an elderly man. His symptoms were a little bit different from the previous client, as he had hypertonia and the dystonia was milder. He had more difficulties to take of and put on his jacket and an hyperactivity everytime that he was talking about his mum. He could keep his balance standing on his knees, he could scrolle on the floor or on the bed, and also he could stand up from the floor on his knees. All the physiotherapy treatment was about improving his functionality and balance ability.

Physiotherapy treatment of Corpus callosum

   

   Our visit was to a kindergarden for treating a 3 years old little girl with corpus callosum agenesis. Her left side of the body was hypotonic and especially the major thoracic and she also was wearing the AFO orthosis because of the hypotonia of her leg musles. We didn't do a lot of exercises to this girl, because she couldn't focus with her eyes, wasn't feeling good and was crying most of the hour. We could olny do exercsises from sitting and prone position on a yoga ball and some functional movements with her hands, like touching her hair or nose or putting something on her lips. She did excessive movements and couldn't cooperate with us, so we stopped the physiotherapy after a while.

Physiotherapy treatment of choreoathetosis

   An elderly woman was born with right hemiplegia, but after some years her left side got worse and the result was left hemiplegia and couldn't move well. A couple of years ago, she did an operation to her cervical spine for improving her cervicl spine position that was in anterocollis, so they put metals, in order to keep the head at better position. The diagnosis of this woman isn't very clear, but her symptoms seem that she has choreoathetosis, because she has spasm on her face muscles and athetotic walk.

She did exercises with the machines in the gym of lechmolan's fysioterapia, for strengthening the upper-lower limbs and exercises with the Spine Gym Core Exerciser for improving her core balance by activating the deep muscles of the core like transverse abdominals and multifidus muscles and at the same time stretching the major thoracic. The client was quiet good with the exercises.

Spine Gym Core Exerciser

Physiotherapy treatment of Paresis Erb's

Two clients were this week with Paresis Erb's. The first one, was a 3 years old little girl in a kindergarden. She was very active and functional. She played a lot with us, she climbed, jumped in the trompoline. The physiotherapy included everything that could improve her paretic hand movement and functionality. At the end, she trained her handle by creating shapes with plasticine and also did passive stretching of her hands separately. In general, the development of this little client was increased, as she understood everything that my supervisor told to her, and her speach was perfect for 3 years old child.

The second patient was a 9 years old girl, that came to the Lahmolan's Fysioterapia to have physiotherapy treatment for her right paresis Erb's upper limb. I evaluated her upperlimb movements, where she had limited movements in flexion, abduction, external rotation of shoulder and supination of the cubit. After the evaluation, she did very active exercises that demanded much strength and balance of the whole body and especially of the hands. She was climbing on wooden wall bars and wooden rope ladder climbing and jumping. At the end, i did stretching to her, to gain elasticity of the muscles of the external rotators of the shoulder, the supinaton muscles and the shoulder flexors. She was very powerful, patient and very interested in physiotherapy.

wooden wall bars 

wooden rope ladder climbing

Physiotherapy treatment of Athetosis

A 64 years old man, was our client, that had many problems. The main problem was that he had athetosis, so he had damage in his cerebellum. His walking was like a scythe, he had weakness on his muscles, right latercollis and torticollis at the same time and difficulties in speach because of the wrong position of his head. He did exercises for increasing the muscle strength, like static bisycle, abdominals and exercises for back muscles. At the end, i did some stretching to the client on upper ond lower limbs. He was functional, as he could do the exercises, although he had difficulties at walking because of the athetosis and non balance.

Physiotherapy treatment of Quadriplegia

   A 52 years old woman had quadriplegia. As a result of muscle weakness, she had right scoliosis, kyphosis, forward projection of her head, she used more the right hand for the activities, she was putting all her weight on the right side and her left side was worse.

I evaluated her muscle tone and joint rate of motion by passive movements. She wasn't able to move at all her limbs, only her right hand, as her muscles were very stiff and thick. She did some functional activities like rising her hip like a bridge on the bed by assistance, throwing soft balls into the basket and throwing the cones of the bowing with a ball, with her right hand, because she couldn't move her left hand. This patient wasn't independent at all, because of the paralysis of her whole body and because of speech problems. Although, her understanding was good and she cooperated as much as she could.

Physiotherapy treatment of Hallerworden Spatz

   An adult man with Hallerwordus Spatz and autism, came for physiotherapy. He had a lot of difficulties, especially in understanding and speech, because of the autism. We waited and were activated him for 15 minutes to manage to wake and get him up from the wheelchair to the standing position. At the end, he managed to get up and walk 1-2 metres by holding a stick and by our assistance. Then, he walked on his knees because he couldn't keep the balance from the standing position. We couldn't do a lot of things with him, because most of the hour we spent to activate him to do the walking, the dressing up etc. At the end, we managed to transfer him from the bed to the wheelcair. He had epileptic seizures, so it was quiet difficult to colaborate with him.

Physiotherapy treatment of spastic quadriplegia

   We went to a place where live people with disabilities and worked with an elderly man with spastic quadriplegia. He had multiple problems such as a lot of spasticity, hypertonia in core extensors and hypotonia in core flexors, tremur on his whole body after fatigue and relaxation, difficulties in speech and poor undertanding, very stiff joints (especially knee joints, where the patella was replaced upper because of the tightness of the quadriceps), no movements on his left hand at all, poor movements at hip flexion.
   After the evaluation, we moved on physiotherapy. We did lumbar-pelvis motivation, passive flexion and rotation of lumbar, assisted scroll on left and right side, hip extension on prone position and holding the position on his elbows, motivation of his upper limbs, where the left hand was worse than the right. At the end, i did a lot of stretching to reduse the spastisity and to increase the muscles elastisity, but everything was so stiff that it was quiet difficult to gain more elastisity. When i finished with the stretching, we tried to get him up with our assistance and then he walked with the support walker and went buck to his wheelchair. We were supporting him during all the walking, because he wasn't able to walk without support. It was quiet difficult to comunicate with him, because he couldn't speak neither he was understanding many things that my supervisor was telling to him, so there were needed a lot repeats of our guidance.

Physiotherapy treatment of Multiple Sclerosis

An adult man was our patient in Lehmolan's Fysioterapia with multiple sclerosis and some mental problems. He was very functional, as he could do all the exercises. First of all, he walked on the tradmill for 10 minutes, then he did exercises for quadriceps, hamstrings, abdominals, back muscles, pulldown and pushups. At the end, i evaluated his muscle elasticity and tone and did stretching on his upper-lower limbs muscles. He had some limites in plantar/dorsi flexion and hip rotators. In general, he was independent, but the only problem was that his mood was changing all the time, for example some times he could be angry and some times happy, because of mental problems.

Conclusion

To conclude, my first impression of working in Lehmolan's Fysioterapia was very good. I found it very usefull to work with people that had multiple and complicated disabilities, because i gained more experience for my future work, so I got familiar not only with the way of the physiotherapy treatment, but also with the way of handling hard situations and syndromes. My supervisor helped me a lot, by letting me learn better about the NDT/Bobath and about diseases and syndromes that were new for me!