Problem-Based Learning & Neurologic Physical Therapy

Lebanon Valley College

Center for Excellence in Teaching & Learning

March 22, 2007Philip 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.”

“Formal learning experiences reinforced feelings of inadequacy and failure.”

“The volume of information limits our ability to interact because we are focused on scribing every word for fear of missing anything important.”

“No clear picture of the need to know information separated from the nice to know.”

Postman, N. Teaching as a Subversive Activity, 1969.

“More patient contact”… missing sense of real-life experience.

“Testing in a board-like format”… fear that they were not being prepared for the board examinations.

“Promote integrative thinking - making the shift from fact-spewers to fact-chewers.”

“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

http://www.fhs.mcmaster.ca/pbls/writing/intro.htm (P.K. Rangachari)

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?

Postman, N. Teaching as a Subversive Activity, 1969.

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?

Example - OneLinda 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 “PT Evaluate and Treat” order.

Lind Rizzo - Objectives1. 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 patient-practitioner interaction.

Example - TwoJoseph 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 - Objectives1) 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?

Maudsley G. Roles & responsibilities of the PBL tutor, BMJ, 1999.

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

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.”

John Dewey

Neuromuscular RehabilitationProblem-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

“There are three musts that hold us back: I must do well. You must treat me well. And the world must be easy.”

Albert Ellis

“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 out-of-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.”

“The only person who is educated is the one who has learned how to learn and change.”

Carl Rogers

“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.”

“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.”

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 feltWe finally pruned and sproutTo now go forth whole