Transcript Problem-Based Learning & Neurologic Physical Therapy

Problem-Based Learning &
Neurologic Physical Therapy
Lebanon Valley College
Center for Excellence in Teaching & Learning
March 22, 2007
Philip Blatt, PT, Ph.D., NCS
Assistant Professor
Department of Physical Therapy
“We only think when we are confronted with
problems.”
John Dewey
“Conflict is the gadfly of
thought. It stirs us to
observation and memory. It
instigates to invention.”
John Dewey
“Barrage of information to the
point of overkill…we are
taking notes provoking writers
cramps.”
“No clear picture of the need to
know information separated
from the nice to know.”
“The volume of information limits our ability to interact
because we are focused on scribing every word for fear of
missing anything important.”
“Formal learning experiences reinforced
feelings of inadequacy and failure.”
“More patient contact”…
missing sense of real-life
experience.
“Promote integrative
thinking - making the shift
from fact-spewers to factchewers.”
“Testing in a board-like format”… fear that they were
not being prepared for the board examinations.
“It is absolutely essential that the oppressed
participate in the revolutionary process with an
increasingly critical awareness of their role as
subjects of the transformation.”
Paulo Freire
To PBL, or not to PBL, that was
the question.
• What are the overall goals of
the program?
• What are the specific
instructional goals of this
particular course?
• At what stage in their learning
do students take this particular
course?
http://www.fhs.mcmaster.ca/pbls/writing/intro.htm (P.K. Rangachari)
Problems, Problems…
• How long should this problem be?
• How can I ensure that students do
not miss key concepts?
• How can I make this problem
interesting, challenging?
• How much data do I provide?
• How "open-ended" should this
problem be?
http://www.fhs.mcmaster.ca/pbls/writing/intro.htm (P.K. Rangachari)
Problems, Problems…
• Will your questions increase the
learner's will as well as capacity to
learn?
• Will they help to give him a sense
of joy in learning?
• Will they help to provide the
learner with confidence in his
ability to learn?
Postman, N. Teaching as a Subversive Activity, 1969.
Problems, Problems…
• In order to get answers, will the learner be
required to make inquiries? (Ask further
questions, clarify terms, make observations,
classify data, etc?)
• Does each question allow for alternative
answers (which implies alternative modes
of inquiry)?
Postman, N. Teaching as a Subversive Activity, 1969.
Problems, Problems…
• Will the process of answering the
questions tend to stress the
uniqueness of the learner?
• Would the answers help the learner to
sense and understand the universals
in the human condition and so
enhance his ability to draw closer to
other people?
Postman, N. Teaching as a Subversive Activity, 1969.
Example - One
Linda Rizzo is a 25-year-old nurse who was a restrained passenger in a head-on motor
vehicle accident in which the driver (her friend) was killed. She sustained a depressed
skull fracture and a right acetabular fracture. Glasgow Coma Scale (GCS) in the field
was 7 and Linda was Life-Lioned to the trauma center. GCS at the EMD was 4. An
emergent CT showed subarachnoid blood and enlarged ventricles with midline shift.
Linda underwent a right frontal craniotomy of the hematoma. She was intubated and had
a diagnostic peritoneal lavage (DPL) to investigate and control internal bleeding. She
was found to have a cardiac contusion. Intracranial pressure (ICP) was 300 mm Hg, and
an extraventricular drain (EVD) was placed. Seven days later she was still unable to be
extubated successfully and a tracheostomy was performed. She requires deep suctioning
every 1-2 hours to manage copious secretions. Her ICP is currently 15 mm Hg, HR 92,
SAO2 97%. GCS 3, level 1 Ranchos Los Amigos Scale.
Linda is non-weight bearing on the right with 60-degree hip flexion precautions. She
remains on mechanical ventilation via tracheostomy and is on 6 liters of supplemental
oxygen. She is seven days post injury. You have a ÒP T Evaluate and T reatÓorder.
Lind Rizzo - Objectives
1. Describe common mechanisms of injury (coup vs. contrecoup lesions) and
pathophysiology associated with brain damage in closed head injury (CHI) (e.g. focal,
hematoma, fracture) vs. diffuse (ischemia, anoxia, axonal shearing/injury; primary
(parenchymal damage) vs. secondary (intracerebral hemorrhage, brain shift, anoxia,
increased intracranial pressure).
2. Describe important diagnostic tests such as CT scan and examination/ assessment
under medical model for head injury and other common injuries related to trauma.
3. Understand the significance of ICP for the patient as well as PT precautions, know
safe limits.
4. Describe acute medical management of CHI, including PT precautions for
craniotomy and EVD.
5. Review and discuss implications of the ventilator and tracheostomy for respiratory
status as well as how to manage this during PT treatment (lines, coughing, suctioning,
etc.)
6. Describe and recognize the implications for prognosis of the GCS and Ranchos
Scale and how these are utilized by therapists.
7. Develop and implement a plan for prioritized physical therapy examination and plan
of care including coma stimulation, importance of early mobilization, family
education, management of secondary complications and utilizing the best available
evidence for this patient including potential equipment needs and discharge planning.
8. Group reaction and reflections on the dynamics of the context for patientpractitioner interaction.
Example - Two
Joseph Taylor is a 48-year-old electrician who lives with his wife and 14-year-old daughter in
a single-family home that they have owned for 10 years. He is a typical husband and father,
independent in all activities of daily living and devoted to his family. He particularly enjoys
his daily 5-mile run with his daughter, who is training to make the high school cross-country
team next year. He also likes spending some time on his own fishing at the local lake. He and
his wife enjoy a weekly night out every Friday. He is the primary caretaker of the house and
yard, often doing the major repairs such as painting and renovations.
He battled a bout of flu during the winter and, just as he was feeling better, he began to
experience significant generalized muscle weakness, malaise, fever, and some parasthesia in
his hands. Initially, he thought he was having a recurrence of the flu.
His symptoms rapidly progressed over a 48-hour period to the point that he was having
difficulty breathing. He contacted his physician who told him to go to the emergency room
and that he would meet him there. After examination and some laboratory tests, his physician
diagnosed him with Guillain-Barre syndrome and he was admitted to the intensive care unit
(ICU). The progressive nature of the acute phase of this disorder resulted in his respiratory
status becoming so compromised that he was intubated after 12 hours in the ICU. He began to
regain some strength and was extubated 2 days after his admission. He spent 4 more days on
the neurological floor of the hospital and was then discharged to your inpatient rehabilitation
facility with orders for OT and PT evaluation and treatment to regain maximum mobility.
Joseph Taylor - Objectives
1) Systematize an aggressive plan of care to meet the patient’s goals within
the context of the physiologic limits of Guillian-Barre Syndrome. (i.e. using
the literature how quickly and using what specific techniques can your group
generate a plan of care to address this patient’s goals?)
2) Design a treatment session based on the above techniques lasting 30
minutes for this patient and practice the above techniques with your group
members.
3) If both occupational and physical therapy were involved with this patient,
what would you see as the role for each discipline to provide an appropriate,
comprehensive treatment program? How might we work together with OT
with this patient? Be specific because the insurance company is not going to
pay for duplication of services!
4) What portion of the plan of care would you delegate to an assistant?
Provide a rationale for your answer and guidance to the assistant.
5) What activities would you use to address this patient’s values? Who is this
patient? What roles and activities are important to him?
Now What?!?!?
• Look for phenomena requiring
explanation by brainstorming
• Investigate previous knowledge and
experience
• Formulate shared learning objectives
• Independent study
• Report results
– (Steps 1-5 are iterative)
• Explain the essence of the case
• Reflect & evaluate
“Knowledge rests not upon truth alone, but upon error
also.”
Carl Jung
Maudsley G. Roles & responsibilities of the PBL tutor, BMJ, 1999.
Group Process
• Roles
– Chair
– Scribe
– Minutes-Secretary
– “Troller”
– Group Member
“Education is a social process. Education is growth.
Education is, not a preparation for life; education is life
itself.”
Neuromuscular Rehabilitation
Problem-Based Component
• Six case modules
– 2 weeks each
• Discussion Boards
• Summary Review
• Online Board
Examination
• Peer-Review
– Midterm & Final
“Creativity requires the courage to let go of
certainties.”
Erich Fromm
“It is hard to believe that my tuition
is paying for Dr. Blatt’s salary and
he only taught one lecture in 16
weeks.”
“Don’t make the PBL cases so outof-the-ordinary – give us cases of
diagnoses we will actually see
more often. Give us the diagnosis
right off the bat so that the focus
is on treating; not diagnosing.”
“I do feel that Dr. Blatt is very
knowledgeable, but I wish he
shared his knowledge with us.”
“There are three musts that hold us back: I must do
well. You must treat me well. And the world must be
easy.”
“I have learned that I can not learn
it all and that is okay.”
“I have learned to use my peers as a
place to obtain knowledge and ask
for help.”
“I have learned that I have all the
skills to obtain the skills to
approach and treat my patients.”
“I felt challenged, I felt like I was
doing something clinically relevant
and most of all I was learning
neuroscience/ rehabilitation.”
“I have learned not to back down
from my opinions and beliefs.”
“The only person who is educated is the one who has learned how to learn and
change.”
Carl Rogers
The new education has as its purpose the development of a new
kind of person, one who--as a result of internalizing a different
series of concepts--is an actively inquiring, flexible, creative,
innovative, tolerant, liberal personality who can face uncertainty
and ambiguity without disorientation, who can formulate viable
new meanings to meet changes in the environment which threaten
individual and mutual survival. The new education, in sum, is new
because it consists of having students use the concepts most
appropriate to the world in which we all must live. All of these
concepts constitute the dynamics of the quest-questioning,
meaning-making process that can be called "learning how to learn."
Neil Postman (Teaching as a Subversive Activity, 1969)
Frustration once felt
We finally pruned and
sprout
To now go forth whole