Sick Patient

Hi guys,

I am working on an acute stroke ward and had a patient who became very sick during Rx. He vomitted on his clothing and self when we were in the physio gym off the ward. We (another student and I) didn't know what to do so I alerted his nurse as to what happened, cleaned him up as well as we could using towels and took him back to his room. His nurse subsequently was upset with us for not getting him into clean clothes. My question is what would be the correct thing to do in this situation? Should we be changing the patient or leaving it to the nurse to do?

Thanks
Brent

Copping wit stress

Hi guys,

I just want to know how you guys are handling these pracs. Im going crazy, does the school realize what its doing to us? Im getting homework from prac plus revision so that Im ready for my patients the next day plus homework for the school. Essentially I have no time to myself or anything else. Because I have so much to do I don't get anything done well and am not taking as much as I can from these pracs. If this continues for another month I just might go crazy!!!! and on top of that I probably will fail my PCR due to lack of time to study. How are you guys doing it? I need some advise before I go postal.

Out of the blue!

Hi guys,
I am doing musculo outpatients at the moment and was confronted with an interesting situation. I have been treating a patient who had a left sided total knee replacement in December of last year, and she has been progressing quite well. On the Saturday morning just gone (Australia Day), I was at my local supermarket stocking up for the big weekend ahead, when I heard a voice call out from behind me, “Hi Stephen. Look how well I’m walking.” Sure enough, it was my patient from outpatients. I instantly froze and became quite confused as to what I should do...
a) I could have said a quick hello but informed my patient that I was unable to discuss any matters regarding her treatment due to confidentiality reasons.
b) I could have had a good old chat, and put my shopping cart down, and observed her walking.
c) I could have ignored her and ran away!

I decided to go with the first choice. I said hello, but told her that I was unable to discuss anything regarding our work at outpatients. I was seeing her early in the coming week, so I simply said I’ll see you during the week and have a great weekend.

I was not exactly sure as to how I should have responded in that situation. If anyone knows what to do if it happens again, I’d love to know. Thanks guys.

Patient compliance

Hey everyone, hope you all had a great long weekend and are ready for the last week of our second prac (YAY!!)

Coming to the end of my musculo prac I'm actually quite suprised that I haven't had many problems with patient compliance. I do, however, have one patient who sprained his ankle (ATFL) quite a while ago. He had been in a POP and off work (as a laborour) for 5 weeks and has now been back working for 2 weeks. He returned to work before his ankle was 100% better and now re-injures it at least 2 times a week either through forced PF or DF due to the uneven surfaces at his work sites. On top of this, he is too tired to do any of his HEP, but managed to attend his pre-season rugby training this past week.

I am getting fairly frusterated with this situation because I end up spending the majority of our session trying to determine what is causing all of his new pains, from his most recent re-injury, and have very little time to do any treatment with him. I have tried to educate him about returning to sport, protecting his ankle at work and have put alot of focus of our HEP on increasing proprioception and strength, to avoid this further injury.

I am not sure what to do next with him, since he is not complying to the program and is no longer improving due to his continuous re-injury. How much effort do you put in before you decide that treatment is no longer beneficial and it is time for D/C?

Communication with patients' family

Hi guys, hope everyone’s travelling well going into their last week of prac 2. This is about my L Hemi pt who is closing in on the 5 month mark of recovery. He is lucky enough to have a very involved family with his wife and adult daughter spending as much time with him every day as possible.

His wife and daughter are getting increasingly frustrated with him due to his impulsive behaviours and lack of attention. These have been getting more frequent in the last month and a half, according to his wife. For example on Friday I asked him to get ready to stand up. When I came back he had already transferred himself to the plinth which he is not allowed to do given he is a hands on assist. This is just one example out of many of the things that are making his family frustrated.

Naturally when I see his family they want to know how he is progressing. I try to give them as realistic a picture as possible while placing a strong emphasis on the positive points. However due to frustration more than anything his family tend to concentrate on the negative aspects of his progress. While my pt comes across as a very happy guy, I worry whether what is being said is affecting the way he feels.

Should I try and talk to them without my pt being present? Should I modify what I tell them so that they don’t know about anything negative? Maybe I should ask them whether they think my pt would be upset when he is not progressing. If anyone has any ideas or has been in a similar situation please let me know.

Thanks, Anna

Exercise overload...

Hey guys
I have had two similar and interesting patients who I have been treating over the past two weeks, both sustained fractures to their ankles. They were both managed conservatively and have been WBAT not long after their injuries. I’ve found them both challenging and interesting to treat.
So I have a request in regards to your suggestions on how to educate patients in regards to exercise prescription and compliance.
My follow up appointments with these patients proved engaging. Immediately following my hands on treatment both showed good results and were happy with the treatment and management I suggested. Both however came back in a lot worse pain and with a lot more stiffness!! Obviously I was not only concerned that my treatment had done this but also quite curious as to what activities they had completed over the past week. My first patient told me she had needed to move office in the week and had been carrying heavy boxes on and off for eight hours a few days before. The other one had a inspection for her house and had not only spent a whole weekend cleaning but also being an avid softballer and wanting to return to her sport tried to go for a run!! I found this very interesting (and I must admit I had to smile), because both of them had then avoided the home exercise program I prescribed due to the pain and both were wondering why they were worse.
I educated both patients in regards to what they should and shouldn’t be doing in regards to exercise, rest and activity. It’s hard to say whether they have taken it all on board but I’m sure I’ll find out this week. If anyone has any suggestions on how to approach this situation I would be happy to hear them.
Hope you are all enjoying your placements!

Myofascial Pain and Trigger Point Therapy

I am on my musculoskeletal placement and have had regular questions in regards to advances in Botulinium Injection into trigger points to relieve myofascial pain. I thought this was an interesting topic to share as the results are very relevant to us as physios. Firstly I’ll explain myofascial pain. It’s a regional skeletal muscular condition presenting with stiffness and pain, characterised by the presence of trigger points in affected muscle areas. Trigger points are focal, palpable, hypersensitive bands of tight muscle. On palpation, trigger points can produce muscle twitch and referred pain.

Despite many postulated mechanisms, the pathology of MPS still remains elusive and appears to involve a complex interaction of numerous pathogenic mechanisms including abnormal motor end plate activity together with peripheral or central sensitisation.

Botulinum Toxin A is a potent neurotoxin produced by a bacterium which acts by blocking Ach release at the neuromuscular junction. BTX has been under investigation since 1968 and has been widely used for the treatment of focal muscle overactivity for greater than 15 years.

A number of small clinical trials have shown some beneficial effect with BTX treatment in patients with myofascial pain syndrome. For example in a small double-blind placebo controlled study of six patients, TP injections of BTX significantly reduced pain by 30% in four of the patients. In another small study involving 33 patients, significantly more patients were asymptomatic after just one injection of BTX in the cervicothoracic muscles when compared to those injected with saline. In a third study involving 40 patients, pain reduction after just two months was significantly more pronounced with a single injection of BTX.

In clinical studies however, results are mixed. When BTX is compared to a control group, limited or no BTX benefits have been found. A study by Ferranke (2005) did not find that injection of BTX directly into TPs to improve pain relief in patients with MPS. They did not find any significant difference between the placebo and BTX groups with respect to pain threshold or use of medications. Another study by Ojala (2005) similarly compared small injectate volumes of saline with injectate of BTX. They did not show any difference in pain scores at the TP between the two groups.

So why is this all important to us as Physios you ask?

Research has hypothesised that other therapies combined with BTX are essential to achieve reduction of myofascial pain (Taimela et al, 2000). A study by Porta (2000) stressed the importance of combining BTX injections with physiotherapy and pharmacological agents. Another study by Wheeler et al (2001) also suggested that physiotherapy is a necessary programmatic element before injection sessions and suggest that it may be a requisite for long term pain relief. They explain that as chronic pain implies, the presence of postural and other factors that predispose the patient to pain conditions will persist beyond normal tissue healing periods if not addressed and treated. Hence physiotherapy plays a key role in maintaining long term relief following any form of surgical intervention.

So here are some suggestions how we can help anyone with painful trigger points before they opt for the more invasive trigger point injections: massage, pulsed ultrasound, dry needling and stretching techniques that invoke reciprocal inhibition. Use of elbows, feet or various tools to direct pressure directly upon the trigger point often occurs, to save practitioner's hands.

A successful treatment protocol relies on identifying trigger points, resolving them and, if all trigger points have been deactivated, elongating the structures affected along their natural range of motion and length. In the case of muscles, which is where most treatment occurs, this involves stretching the muscle using combinations of passive, active, muscle energy techniques and PNF stretching to be effective.
So on a final note, its all great for your patients to want a quick fix to their pain but unless the underlying cause of their pain is dealt with, the trigger points are more than likely going to re-occur.

Time management issues

Now I know that this topic has been bought up before but it's now three weeks into my musculo outpatients and I'm still struggling to get my assessment and treatment times short.

I had a patient present to the clinic with a supraspinatus tear with secondary impingement. My patient wasn't able to communicate in english very well (as with most of my patients) and also had an extensive past medical history. Throughout the subjective assessment there were a number of occasions where she looked quite upset and on the verge of tears.
My supervisor has been telling me that at this stage of the placement, the subjective and objective should be complete in 15 minutes and that my time management skills are still below par. The subjective with this lady took 40 minutes. Yes she tended to elaborate and get side-tracked quite quickly, but I made sure to bring her back to her presenting problem and at times when she looked like she was going to cry I felt unbelievably rude at having to divert her attention and focus on the assessment. When I went to speak to my supervisor all he did was look at his watch, not a confidence booster at all.

I have been working so hard on my time management with absolutely no improvement. How are you supposed to just cut people off without seeming rude or heartless, whilst trying to build some sort of rapport with your patients at the same time? Is just an experience thing?

Fan

PCR question

Hi guys. This week at the musculoskeletal placement we were discussing some PCR questions and this one was quite challenging. If guys want to have a go answering it will be interesting to see the different answers.I will summarize the case and the questions. Mrs A is a 25y.o female who was referred to physio following a motorcycle crash 3 months previously where she landed on her L shoulder. She also hit the left side of the head on the floor on impact. Since then she reported weakness (constant) in her R arm and pain (deep constant dull ache-sharp 3-7/10) and stiffness on the R side of the neck. She has been managing her pain with pain killers and at this stage feels that the weakness is more of an issue. 24H pattern: am-stiffness and pain in the neck for 1/2h, eases with movement, day-no pattern activity dependent, pm-1/2h getting to sleep, doesn’t wake her. Agg: R rot when reversing the car P2 6/10 increases imm, decreases 2min to neutral, holding the phone b/n sh and ear P2 5/10 increases imm, decreases 2min to neutral. Eases: heat, painkillers, NSAIDs, head still. O/E: Atrophy R scap & sh muscles, guarded posture, elevated R sh. AROM Cx PP 4/10, Ext FROM P1 EOR, *R Rot ½ ROM P2 Cx, *R SF ½ ROM P2 Cx. GHJ clearing: nil pure fl, abd or R ER. Neuro: reflexes – *R deltoid, biceps, braquioradialis absent, * strength – GH abd and elbow fl 0/5, sensation normal. PPIVMS: R Rot and R SF C4/5, C5/6 hypo, PAIVMs PA and unil PA C4,5,6,7 PCx and hypo, Palpation: upper trps hypertonic ++. No imaging.
Questions:
What is your probable diagnosis and classification and substantiate this from the subjective and objective. I will give some options: C5,6 cervical sprain with neurogenic pain/ Cervical traumatic radiculopathy with neuropathic pain.
What would your short and long term manage for this patient be?
If the neuro was clear how would this change your Mx for this patient?
Next week I send the answer discussed with the supervisor.

Good luck all on the last week of this placement!

Professional Practice – You are a PT, not God

Hello Guys!

The 3rd week passes really quickly! Do you agree?

This week I was down, sadly. I am in some form of ‘professional crisis’. The ward was relatively quiet this week so I had time to see the ‘lower priority’ cases for general mobility. But it turned out that these cases weren’t as easy to handle as I thought. It’s definitely more than a frame or a stick and ‘let’s go for a walk.’

How do you feel if
a cardiac surgery patient tells you he still has dull aching on his (L) upper chest and palpitations which the doctors have noted but still persisting?
a hemicolectomy patient with stage IV cancer tells you his large gapping abdominal wound hurts badly and on top of that, he’s going to the toilet many times due to loose stools?
a renal failure patient bumping into things tells you his vision is bad and glasses makes his vision worse?

I feel ‘helpless’. Because these aren’t the problems we as PTs can directly intervene to help them feel better quickly. But they are important to the patients. For some of them, walking and exercises although important, might not be their immediate concerns/worries and priorities. I just wished I could do more for them… So it really affected my mood. I was then told by a close friend “You are a PT, not God.” That’s when it dawned upon me that there’s only so much I can do within my abilities; that there’s only so much any professional can do within his/her abilities… I might not have the capabilities to solve those problems but I have the resources to perform referrals. This is why a multi-disciplinary team approach/communication is so essential. And also, after I have done what I can, I guessed I got to learn to just ‘let go’. I tend to ‘bring work home’ and this drains me out quickly…

2nd related issue I have is how much to push. I was told to rehab the patient in the 2nd case I mentioned above prior to d/c. I saw him a couple of times but a number of these he went “not today love…” He had issues with a poorly healed wound and loose stools. I noted he has been ambulant with a wheeled walker to and fro the toilet which he said totally drained him out (he’s big as well). So I let him have his way a few times. My thinking is that he is a palliative case, he’s ambulant and we have arranged for him to have follow-up rehab at home. He had a point when he said he didn’t want to over-exert himself because he’s for home soon and didn’t want anything to go wrong. I felt really scared/nervous when I had to report to the PT those times he said no as I think it reflected on my ability/competency… I just think that if I had insisted on a walk, compliance/cooperation would be even lower subsequently... Do you think the PT will see my point? Does anyone think I am wrong? Is there a better way to handle this kind of situation? And gauge how much to push?

Last lap guys!

Peiying ~

Information overload

Hey guys,

I know that it's inevitable as students that we receive guidance and feedback from a number of sources, but i think that this needs to be controlled in some situations. For example, on my current placement in a neuro inpatient setting, I have my facility supervisor giving me feedback and helping me out when i ask for it, i have the other senior physio helping out alot and guiding me and helping me with treatment techniques while teaching me new ones, I have the physio directly responsible for my patients, who oversees most of what I do, and I have my Curtin tutor. As of this week, the physio directly responsible for my patients has rotated to another area, and someone new has replaced them, and on top of this my Curtin tutor has now changed, giving me a grand total of 6 different physio's giving me input on my patients.

This is good in some respects that I get a number of different view points, and a number of different inputs on my performance, but it also brings to attention the fact that every physio will see a patient differently, and will pay attention to different parts of their movement or assessment. I've found this difficult in that when I'm treating my patient, one of them will come up and ask what I'm doing and why, and after explaining they'll bring attention to another aspect of the task that needs treatment and think this needs priority.

So far I think I'm taking this reasonably well and taking on what everyone is saying and picking out the parts that i consider important, but considering 2 of these people will be assessing me and deciding whether i pass or fail this clinic, is it natural to consider their input the most relevant, simply because thats what they want to see? I'm trying to juggle all these different perspectives, and occasionally being told the complete opposite regarding a selected treatment or assessment, to what I was told by somebody else.

Now i think I've rambled on and completely confused the issue, but thats pretty much where my head is at at the moment, any kind of ideas or guidance would be most welcome :-)

James

Skin Irritants

Hi guys,

I had a patient when I was on my Musculo prac who liked to use skin irritants as a pain relief following her TKR. By skin irritants I mean using Deep Heat or any product like it. I knew that it wasn't effective in reducing the cause of the symptoms but for her it helped in reducing the symptoms. I was unsure on whether or not to mention to her that they produced no 'real' benefit to her knee. I talked to my supervisor and he said to educate her on the importance of ice but that telling her about the uselessness of the product wouldn't help her and therefore should be left alone.

I'm still not sure how I feel about this. I agree with what he said but at the same time I feel that by not saying anything I am promoting it. She will inevitably speak to other people about what she has gone through and recommend the product to others.

Does anybody have an opinion?

Thanks Brent

Confidence

Hey guys,

I know that during the course of our clinics, and our careers, that we'll be told we're not doing something right, or be given some feedback about a part of our performance. I've found on this placement and the last, when I've been told something like this, it really lowers my confidence in my own ability, and i start thinking that I'm doing terribly, and then that affects everything else I'm doing, which in turn lowers my confidence more.

This happened on my last placement, to the point where i really feel i didn't get as much from the placement as it should have, and i don't want the same thing to happen here. I was just wondering if anyone is familiar with this feeling, and if you have any method of coping with it?

Thanks for the help guys and good luck for the rest of your clinic,

James

The Irritable Patient

I am currently doing Musculoskeletal Outpatients placement and am currently treating to a patient with high irritability. Patient A was driving and got T-boned by a truck in December 2007, sustaining an undisplaced fracture of the posterior aspect of the right twelfth rib.

Patient A presented with right sided mid-back pain which was described as sharp and stabbing which was aggravated by normal basal breathing, bed mobility, trunk movements in all directions, right or left shoulder movements, walking and prolonged standing. On initial assessment, the pain was reproduced with all trunk movements, especially to the left (opening up on the right), and the patient was extremely TOP and quite swollen over the lower Thoracic spine and surrounding soft tissues. When questioned about pain coverage, the patient said that he had been taking Tramadol up until 4 days prior to this session, and he had gone off them because he had began to suffer form hallucinations. The patient was unable to get into the prone position on the plinth due to pain so, much of the assessment was conducted in supported sitting with the patient leaning forward on the plinth. I soon realized that this patient was quite irritable and would not tolerate a great deal of manual therapy.

After consulting with my supervisor I decided to manage this patient with the following plan:
1. Education regarding –
- Going to GP for advice on pain cover
- The importance of gentle active movements as pain allows to maintain/improve mobility of joints and muscles in the affected area
- The importance of deep breathing exercises as pain allows
2. Gentle soft tissue massage of surrounding structures (not directly over rib 12) to help mobilize the swelling and reduce some of the over-activity of the surrounding guarding muscles (patient was in supported sitting)
3. A HEP was provided which included gentle active movements, deep breathing exercises, shoulder and trunk AROM exercises for him to do in his swimming pool

Although I did not perform a great deal of manual therapy, I felt that this was a successful session in that the patient received a lot of education and reassurance, which seemed to put his mind at ease, and also some swelling management to aid the healing process. If anyone else has any ideas how to manage a patient in a similar situation, it would be great to get some more ideas.

Sport specific Ax

Hi everyone, this case made me think how important is to Ax closely the functional task (sport specific) before setting goals and expectations for treatment.
This week I had a young boy (14yo) coming in to the musculoskeletal outpatients with history of 2 years of LBP and Cx pain. I found quite strange at first, because he seemed to me a healthy and sportive teenager. The subjective Ax showed an insidious Lx pain worse with sustained flexion and at the end of the day (mainly after training). The boy was quite quiet, so I couldn’t get much information out of him. No previous trauma or injuries. He usually surfs (bodyboard) which doesn’t bring the pain, swims and trains for surf life save (paddling kneeling on the board) 4x/week one hour each, which are the aggravating factors. In the objective assessment Lx Flexion relieved the pain and extension caused pain. I kind of got confused because that didn’t match with a flexion pattern. AROM was full in all directions. During extension seemed that he was hinging at one level. He had increased Tx kyphosis and a slumped posture in sitting. All para spinals muscles were TOP. Some segments normal on PPIVMS and some hiper (where he was hinging), PAIVMs painful on L4,5,S1; poor propioception and kinaesthesia awareness. After assessment I was thinking that it was more of a motor control disorder, but then I asked him to show me on the bed, as it was the surf board, how he is used to paddle. That surprised me and made me think that his problems were more of a loading disorder. Basically, he kneels on the board, the Tx stays in full flexion, Lx flat and Cx in hiperlordosis…and he stays in that position for more than 40 min every day. After that, he told me that his symptoms were worse after the training and stays throughout the day. My intervention in the first day was STM on para spinals for symptom relief, Lx mobility home exercises (advised to do after the training and hopefully refief the pain caused by that sustained loaded posture) and some core stability exercises in functional positions. I thought it was enough and in the next sessions I would just progress those exercises. When I was talking to another classmate that use to be a lifeguard he told me that the technique of my patient was wrong and less effective. Actually the correct posture for that sport is neutral spine and more hip flexion rather then spine flexion. That information was really helpful, because my plan for next session will be quite different. I guess if I had kept only doing mobility and core stability exercises without modifying his load ( posture during training) I would probably had a minimum effect on his symptoms. Hopefully in the next sessions I will not only decrease his symptoms but also improve the effectiveness of the way he is paddling.
If anyone has any suggestion on this case, please let me know. I’m seeing again this patient next week.

Difference of Opinion

Hey guys, this post is of a similar nature to last weeks post. My pt’s background is a large R sided TACI with strong frontal lobe involvement. His stroke was roughly 5 months ago and he is a 2 person assist when walking. His has a 30 yr history of intermittent hip pain which has been increasing in frequency since the stroke. The pain is mainly provoked during large amplitude hip extension during walking and prolonged hip extension at rest.

On Friday of week one he was given an injection into the area of hip pain. This Dr (resident) and another returned nearly a week later to check the results. The injection did not appear to have any impact on his pain. The Dr’s then instructed me to start giving this patient hip stretches which they would review the results of later. I suggested to them that this was possibly not as important as his other treatments some of which would have to be sacrificed to enable the time spent on stretching. The Dr’s were fairly dismissive of this and I had the feeling that even if the pts Physio had been there, she would have had the same result. There was not opportunity to explain my rationale and it certainly felt like an order.

My pts’ Physio chose not to come over at the time for various reasons including not wanting to get into a disagreement with the Dr’s. Needless to say I spoke to her afterwards about the issue. She agreed with me 100% in my reasoning as to why I would not include a stretching program for this patient’s hip. Just quickly these reasons include the length of stay in rehab (4/12) combined with slow progress, the likelihood of stretching actually succeeding, the cause of his pain during gait and also the pt’s reliability in reporting pain. At this stage most treatment is aimed at gait and upper limb maintenance. We feel that the reason he gets this pain during gait is because he takes large, fast, uncontrolled steps with his R leg causing sudden end range hip extension and stress on the anterior hip structures. This is something we had already been working on. This has resulted in a shorter more consistent and controlled stride length bilaterally. There have also been less reports of pain.

My plan is to ask that pt’s Physio to speak to the Dr’s when they return next week so that it is not up to me to explain our choice in treatment. This will enable me to observe the interaction without being directly involved. I was wondering if anyone else has been in a similar situation before and how they handled it.

Thanks, Anna

Professional Practice – “I will get my sister to bash you up!”

Hello guys!

This week’s entry relates to my current CP placement. It’s interesting what you can get to experience in the inpatient setting! Especially when it comes to surgical patients with PAIN! Therefore, I have learned it is extremely important to ensure optimal pain control. To help me understand better, my Curtin Tutor has taught me to imagine having my own chest split apart – nasty pain indeed! Do remember to look at the meds chart (what pain meds have been given and what time) / acute pain service form, perform a subjective ax and then liaise accordingly with the nurses regarding additional administration if necessary before mobilization :)

Now, you must be wondering what’s with this ‘bashing’? Recently, I saw this chap on POD 1 after thoracotomy. HPC was assault. Two ICCs inserted, together with the ‘usual’ attachments nasal prongs, PCA and IDC. High priority for Chest PT and I was glad to be given this case! But the picture turned ugly and real challenging when I went in to see him. He was obviously uncomfortable and every response was accompanied by aggressive, nasty swearing. His answer to my pain question - “Two tubes stuck into me, what you think? Nurses kept asking this stupid question!” He was on PCA but I guessed it still wasn’t sufficient for him. He went on to talk about how he has gone through a lot in his life. Somehow, I thought I could empathize with him and the pain he was going through. So I put up with all the F*** off!!! (Would you have done the same?) All that was going through me was that he needs to get up and I will try. I did not take what he said personally. I could finally calm the storm a little when he expectorated some thick brownish sputum which was unusual for him – that got him concerned when I told him if these were to accumulate, he would get a chest infection. The PT then came along to give me a hand (thank god!). She was assertive which I thought was essential to deal with this patient but that got him nasty (again!), saying he would get his sister to bash us up and that he did not need our help. We had to then put up with him, walked 20m and eventually popped him on the edge of the bed as he refused to SOOB.

I thought the treatment was incomplete as I hadn’t done my SMIs, supported coughs and evaluation. I was also worried about him sitting on the edge. It didn’t occur to me that I had absolutely no sense of danger till the PT signaled to me repeatedly to maintain a distance from him She also told me that in fact, I need not have put up with him; it could be documented that treatment was not provided or modified as patient was verbally aggressive and has a violent tendency. We informed the nurses (who had the same –ve experiences) and the nursing manager who said she would contact security to speak to him.

I was abit disoriented after that session as I never knew before that this was regarded as one of those circumstances we would not treat our patients. I had this conflict / dilemma in me as I believe he does need our help… in the end, I quickly popped into his room again (a safe distance away!) and told him to perform hourly SMIs and supported coughs. He nodded his head :)

What I learned from this is that patients are going through a lot in addition to their pain...; they can have some social issues going on too and that they may not necessarily appreciate our interventions initially... But at no time should we compromise our own safety. We need to learn to judge the situation and modify interventions accordingly. Hopefully, that will still enable us to achieve our main goal of getting them well again asap! :)

Peiying ~

Patient's expectations

Hello everyone,

Hope the second week of prac went well for everyone! Mine was definitely less stressful, thanks for all the suggestions for time management. It’s nice to hear that I wasn’t the only one stressed that week :)

This week we were asked to go through our file of patients and call those who had not been seen yet to see if they wanted a follow up session. One of the patient’s I contacted was rather abrupt and not planning on coming back for any further sessions. He had reported that his ankle, which had been fractured, was not good at all when I asked him at the beginning of the conversation. I then proceeded to ask if he was interested in coming back to have more sessions to improve his ankle condition. His reply to this was, “what are you going to do for me?” He said that physio didn’t do anything for him the first time he came, that’s right, he only came ONE time, and he doesn’t feel physio helps at all. I proceeded to tell him we can do techniques to help his ankle move easier and easy any pain as well as provide him with exercise to stretch and strengthen his muscles. I was caught a little off guard, not expecting to have to defend physiotherapy. I was also rather annoyed that his expectations of physio were so unrealistic! He expected to go to one session and be fixed; when this didn’t happen he turned his back on physio treatment completely. I suppose this is a frustration that will continue on throughout my career since there will always be people who want to be better immediately and don’t want to do any work themselves. Does anyone have any suggestions as to how I could have better handled the situation? I didn’t get a chance to explain that it would take a long time and a lot of work on both our parts to get his ankle back to normal, or as close to normal as possible, as he was quiet abrupt and ended the conversation quickly. I should probably accept that there will be many patients like this, but I’d like to become comfortable enforcing the effectiveness of physio and the importance of patient compliance.

Good luck on your 3rd weeks :)

I don't know what I'm treating!

Hey all, hope week 2 is treating you all well!.

This blog is kind of a continuation from last week in that one of my non-english speaking patients is causing me a bit of grief. My patient is a young man (24) who presented with low back pain with pain radiating into the left buttock, thigh and calf (lateral pain). From what i could gather it looked as if he had an opening up/stretch pattern so gave him exercises into extension and did PAVMS at the affected segments.

My problem with this patient is that his symptoms keep changing and he is not consistent with what he's telling me, and as a consequence, I don't know what i should be treating. Sometimes it appears to be an opening up pattern but half way through the Ax/Rx it may change to a closing down pattern of restriction. Is it possible to have both??? I have a feeling that he might be telling me what he thinks I want to hear because functionally, he is quite able, or maybe he doesn't know how to differentiate between pain, ache, or stretch (and I have asked on many occasions!).


Example of my frustration: Lx flexion ROM is decreased and on assessment it may increase Pb and on another re-assessment it may increase a different pain altogether. Nothing is consistent!!! His neurodynamic tests are variable - before treatment he could get SLR to 80 degrees (60 with DF) with increased Pb and Pc (not Pt) and after treatment he got to 60 SLR (45 with DF) and said it felt better and only Pc!!! I could be completely overlooking somehting but if Rx was effective, shouldn't his SLR increase and pain should centralise????
When i speak to my supervisor he gives me a look of "are you assessing this man properly? because what you telling me doesn't make sense" and as a result I feel quite stupid. I'm making sure everything is done by the book Ax/Rx wise but feel like I'm getting nowhere! Can anyone help?

Proffesional communication

Hi guys,

Ill try to keep this one short. I want to know how you guys feel about this and how you would have handled the situation. At the begining of the week I wrote notes in the integrated notes. I forgot where the PHYSIO stickers were so I wrote in the colum physio where the sticker should be affixed with the plan to go and ask my supervisor where the notes are. Things came up and I forgot to ask her. Later on that day she read the notes and realized I hadn't put a sticker on it. She made a big deal of this, didn't give me a chance to explain and then went on to say "I don't want to keep nagging you like this, nagging is what we do to primary school kids" Essentially she was calling me a primary school kid. Obviously she made me feel like I was 1 foot tall. I didn't say anything back becuase if my last prac taught me anything; it is to keep your mouth shut!! I don't feel that this is right and we shouldn't be scared of defending ourselves because of fear of failing the prac. Anyways, how would you guys have handled the situation?

Hope everybody's prac is going well!!

The subtleties of neuro

Hi guys, hope everyone's enjoying their placement. I'm currently on a neuro inpatient placement and really enjoying it, they take a bit if a different approach to what we're taught at uni so it's alot of new stuff to learn, but finding it really interesting and think I'm catching on pretty quick.

One of the issues I've faced so far is with my observation skills, mainly analysis of movement and some assessment of posture and resting tone. I've found it quite overwhelming having so many things and areas that need to be observed, and some of the changes can be so tiny and so subtle that I find them really easy to miss. At my placement they tend to assess tone through observation, comparing muscle bulk and alignment between sides. There are quite obvious changes such as internal rotation at the hip, or lateral flexion of the spine, and there are the smaller changes such as the level of the creases at the base of the posterior ribs, marginal differences in thoracic extensor bulk, and the patients belly button being off center.

I know some of you have done neuro already, and those of you who haven't may have some ideas, but I was wondering if any of you had a systemic approach to observation of movement and posture in a neuro patient, something which you find helps you pick up everything, or if it's solely just one of those things that comes with practice.

Thanks for your help, and enjoy the rest of your placements,

James

Treatment or management?

Hi guys. I’ve just started musculoskeletal outpatients and last week I had a challenging patient. I was asked to assess a 50 year old man with a referral from his case manager (workers compensation) asking to give home exercise program for his lumbar spine and education regarding his condition. The first assessment was quite challenging for me. When I asked the first question “as far as you are concerned what your main problem is at this stage?” he answered me “my case manager wants me to go back to work, but I don’t think I am able to. I want to get the disable pension, but they won’t give me because they know that I play tennis regularly for more then 2 hours...”.This start already took me out of track and the yellow flags came into my mind. In summary, the history showed an insidious low back stiffness (no pain), aggravated with sustained flexion and after tennis (>3hs) eased with standing and walking. The patient hasn’t been working for 11 years, but now is very active overall and thinks that the reason of his problem is degeneration and what will help him is “manipulation and stretches as he sees the physio do on the football players on TV”. He had previous treatments which he believes didn’t change his condition. He already mentioned that he doesn’t do home exercises given by the physios. The physical examination showed good general AROM with mild contra lateral Lx pain on OP in combined extension and sideflexion; several segments of Lx stiff on PAIVMs and PPIVMs and poor standing and sitting posture. My first intervention was AP mobilization on stiff segments of Lx which reduced the mild pain on combined active extension and sideflexion, general mobility Lx exercises and education regarding alternate sitting and standing positions. I reinforced and that the manual therapy will give him a temporary relief and the importance the mobility exercises to have better results. I also mentioned that in a medium to long term we would start some posture corrections. When I finished the session I asked if he was happy with that, he said “yes, that’s great! What about that stretch/massage that I see on TV?”. I said that from my assessment findings I didn’t think it was necessary and his condition would be better managed with active exercises, posture correction and some changes during his ADLs and this will hopefully help on his quality of life.

Now I don’t know if I should keep the hands on treatment or only manage his condition. There is only a little pain response on his active movements and the patient is quite active. I am afraid that it will reinforce his beliefs that only passive treatment will help him. I also not sure if I should contact his case manager and say that I think that he is physically able to work, but in a different position, may be doing lighter activities, even though he clearly showed that he is not interested on that.

Any ideas would be appreciated.

Caroline

Patient Compliance

Hi guys. I am currently doing Musculoskeletal Outpatients and am thoroughly enjoying the placement. One of the issues I have been confronted with in my first week of prac, is patient compliance with their home exercise program. I currently am seeing a patient who suffered a fractured medial malleolus during a game of soccer 3 months ago, surgery was required and an ORIF was performed of the ankle.

Currently the patient is complaining of pain in the anterior, medial, lateral, and posterior aspects of the ankle, which is aggravated by extended periods of walking, standing and also any single leg standing activities. There is still substantial residual swelling and the medial malleolus is significantly larger than the unaffected side. When questioned about the HEP that was prescribed by a student at his initial consultation in December ’07, which consisted of ROM, muscle strengthening, and proprioception activities, he admitted that he had only done them ‘once or twice in the last month’. His reason for not following his HEP was simply that he always forgets to do it. The problem was however, that he was quite concerned that his ankle was still ‘fat and painful’, and he then went to say that he was told by his doctor that it should ‘getting better by now’.

I thought that my primary management of this patient should be education, regarding the healing process and the importance of a structured rehabilitation program to be carried out in both the short and long term. I also informed him of the risks involved in not managing his ankle in the correct way and the long term consequences which can occur. I modified his HEP a little, so he could complete it easily at work which was his request.

I guess the lesson I learnt from this situation, is not matter the patient’s problem, education is paramount so they are fully aware of their problem and understand the importance of rehabilitation to optimize their recovery of function. If anyone has any ideas regarding increasing patient compliance that I could have handy if a similar patient comes through the door that would be great.

Steve

Communication between peers

Hi Guys, hope every one's placement is going well so far. I'm doing a neuro placement at the moment. During the first week I witnessed a conversation that made me very uncomfortable. I was treating my patient and a junior doctor walked over to discuss an appropriate time for an injection for one of his joints. While this was happening my supervisor walked over to have a word with this Dr. I tried not to pay to close attention to what was said given it wasn't involving me and I still had my patient with me.

The gist of things was that my supervisor had sent this Dr a four page page regarding another patient. The supervisors point was something along the lines of waiting for a response and treatment for that patient. The Dr's side was something along the lines of finding it very derogatory for someone to send him a four page page and that he didn't need to be reminded and he would get to the patient when able. There was also a fairly big argument over whether the patient in question had already been performed. This was all conducted within 1 foot of me and therefore my patient.

I felt that the whole conversation was unprofessional because it was conducted in front of all the patients receiving treatment at the time, especially my patient. Luckily my patient is a very happy go lucky sort of person so it seemed to have no impact on him. However there are several patients who can get quite emotional at the best of times. My supervisor is very important to them so seeing this argument could well have upset them. I actually found it disturbing because there seemed to be a fair bit of animosity between them and I also felt very uncomfortable sitting there with my patient while they talked over me.

Eventually I just started treating and talking to my patient while they continued talking. I'm not sure if that was the right thing to do or whether I should have done anything differently. If anyone has been in this position or has any advice I would appreciate it.
Thanks, Anna

The aches and pains of Fibromyalgia

Hello everyone

I am currently on my Musculoskeletal outpatients placement. I must admit it has been a challenge so far, however I am thoroughly enjoying the opportunity to develop and apply the skills we have acquired at university.

I am currently treating a patient with the debilitating condition of fibromyalgia. This condition proves extremely difficulty and demanding to all aspects of the physiotherapy assessment and treatment session. I thus thought it would be very useful to offer you some suggestions which I have found useful when dealing with not only this condition but also the anxious, depressed and stressed patient often associated with fibromyaligia.

Fibromyalgia is a complex condition where a patient will present with long-standing pain which can encompass the entire body. The patient may also experience tender points in joints, tendons and muscles. The aches and pains of my patient involved her arms and legs, but in particular through her mid-thoracic and chest regions. These aches and pains are constant, she is painful and stiff first thing when she wakes up, they progressively become intolerable as the day progresses so by the time bed comes round she is totally exhausted but because she is still in pain she can’t sleep! As you can appreciate this condition has dramatically decreased her social activities, employment and ultimately her quality of life. In addition to the aches and pains, she feels constantly fatigued, she has difficulty sleeping, irritable bowel syndrome and huge amounts of anxiety and depression.

Dealing with this type of patient can be very frustrating and overwhelming. Every part of the body I assessed was painful! What and where are the main sources of pain? Is that the same pain? Is it a different pain? These are just a couple of questions I had to continually ask throughout the long treatment session. It is not easy to comprehend the pain and suffering that these patients are going through. The level of pain they are experiencing is overwhelming and relentlessly affects their quality of life.

The first approach I found to help deal with her pain is to show compassion and empathy. To understand the disorder and to understand the symptoms that the patient is experiencing educate yourself, the internet has a huge amount of information. Once your educated you can educate your patient. There are also many organisations that specialise in Fibromyalgia and other related diseases such as the National Fibromyalgia Association. Pass these details onto your patient so they can learn more about the disorder and speak to other people who are dealing with similar problems. Suggest activities such as hydrotherapy and stretching that aren’t too tiring but provide warmth, circulationg and promote a general feeling of well-being.

The emotional side of this disorder is probably more challenging than the pain. My patient was pessimistic and depressed. Its important for you therefore to remain optimistic, provide many words of encouragement and suggest lifestyle changes that may be promoting additional stress in their already challenging life.

I hope this helps with your clinical situations. Enjoy the rest of your pracs and if anyone has any more info that may help this type of patient feel free to make a comment.

Heidi.

Ultrasound

Hi everyone,

I previously did a musculoskeletal outpatients placement where I had seen many patients post TKR. One of the main problems these patients faced was with reduced ROM due to increased swelling. In order to reduce swelling my supervisor at the prac suggested supra-patella US to reduce intra-articular swelling. My Curtin tutor then questioned the safety of this technique re the metal implant and possiblity of burning the patient. The parameters that we were using were 1 MHz, 1 W/cm2, Cont, 8 min duration. My supervisor and tutor had a good working relationship and in the end discussed and came to a conclusion that it would be safe to perform. This was just based upon our own reasoning however. I was wondering what your thoughts are or if anybody is aware of any research regarding this situation.

Cheers
Brent

Time Management (for LESLIE)

Hi guys, I hope all of your placements are going well so far! It’s hard to believe we’re already one week down of this second clinic.

I have to say this first week in Musculo outpatients has been a bit of a challenge for me. I have really been enjoying the work, but have found it difficult to manage my time effectively. The first couple of days were the worst, having to come home and continue to do work until very late into the night.

We have been given 1hr sessions for our follow-up treatments and 1.5hr sessions for the initial assessment and treatment. Although this sounds like a fair amount of time to get everything done, I still seem to spend about a half an hour extra with each patient. This then leaves no time to do documentation, stats, any other paper work, or review for the next patient. I have been having to work through lunch and then stay on for about 1.5-2hrs after work to get paper work done and then still have to review for the next days patients when I get home.

This may just sound like I’m complaining, but I have really been stressed out over the week and need to find better ways to manage my time. Towards the end of the week I began to do my treatment documentation (S and O) during the treatment rather than taking messy notes and re-writing later, which has seemed to help. I am searching for anymore tips from those who have done their musculo placement or from anyone that has some good ideas. I am really hoping that things will ease up a bit as I get to know my patients and get into the routine of this prac.

Can’t wait to hear any suggestions you have.

P.S. this is Leslie, I will be posting my blogs under Trudi’s name
until I am sent a new invitation.

Leslie

Professional Practice/Communication – how to manage caregivers?

Hi guys!

This first entry is on my Dec placement doing neuro outpatient. Patients are allocated 1.5hours each and sometimes they are accompanied by their caregivers. I had the opportunity to work with this patient who has a very supportive spouse when it comes to rehab. I would like to share on this particular session which upset me. As part of my subjective, I asked if there were any new issues/concerns. The reply was ‘no, everything has been well!’ However, later during the session I noted that the spouse had gone to look for the Senior PT who then came along and addressed my patient’s sit to stand! Accordingly, the spouse was experiencing some difficulties facilitating STS at home. I could be too sensitive but at that moment I interpreted the look on the PT’s face as ‘Haven’t we gone through STS training during tutorial this morning? You mean you still don’t know what to do?’ (!!!) Eventually, I took over the session again but noted that the spouse had his arms folded and appeared to be rather inpatient, looking at his watch a couple of times. My immediate response was to explain to him what I was doing so as to engage him. That earned me serious ‘interrogation’, which I felt the component of ‘respect’ was lacking... All my confidence was swept away and that definitely affected the session... I chose to re-direct my full attention onto the patient then, who had been cooperative all along, pretending the spouse wasn’t there… My rationale at that point was if I couldn’t engage the caregiver then it’s alright as the main focus should be on the patient. Hopefully though, the spouse’s body language and attitude would not affect the patient negatively. (Not too sure if my rationale then was right? Any comments/opinions on this will be great!)

This got me thinking what will be the best way to manage caregivers who are present during a fairly long PT session. This is worth looking into as they are important people in patients’ lives and have the potential to influence rehab. I believe as students, it will definitely take some time for trust in our competency to be built up. Appropriate explanation of rationale + education to patients & caregivers and a display of confidence are absolutely critical during every session. I believe in engaging caregivers during a session so that they are empowered and feel involved, that they know they can help their loved ones get better. At the same time, they help to motivate/encourage patients and provide an additional pair of hands during treatment. I think the problem arises when the treatment doesn’t require an extra pair of hands. Then, it might be a good idea to ask if they would like to stay during the session or perhaps wait at the waiting area with a nice cup of tea and magazines if available! I believed what happened to me was partly due to the fact that I was ‘new’ to that caregiver and was feeling nervous. But I guessed this is normal at this stage and will improve as we gain more patient/caregiver contact experiences! Do let me know if there are any other suggestions on managing caregivers! All the best for 2nd week!

Peiying ~

It's all about communication

Hi guys, I hope your all doing well having survived week one of the new placement!
I have to say the first two days of this musculoskeletal outpatients made me feel completely useless! Previous supervisors have always commented that my communication with patients has been a strong point, and up until this week I always thought that it was too.

The first two days of this clinic saw me with 5 out of 6 patients with very limited English speaking abilities. Not only did this make it hard for me to try and get a thorough subjective and objective examination and get all the relevant information that I needed to treat these patients, they didn't appear to understand what I was trying to say! As a consequence, one of my treatment sessions lasted for a little over 2 hours!!!

Frustration at yourself (and with the patient) is a very hard feeling to try and conceal and I think maybe on one occasion the patient may have picked up on this. Aside from this being completely unprofessional, it really made my doubt my abilities as a physiotherapist - if i can't communicate with my patient how on earth am I going to succeed?

As the week progressed I learnt how to direct my questions to get an appropriate response, and the use of non-verbal communication is a fantastic thing that i really under-use! Treatment sessions have decreased in time (slightly) and that useless feeling disappears when you see that they are getting some relief from their pain/improvement in their condition.

I guess that what Physio is about - being able to communicate with everyone. We can't choose our patients and have to be able to adapt ourselves and the way we are around each patient so they understand and trust us. What a learning curve...

Fan

Professional Practice

Professional Practice

Hi guys,

During my first week of Prac I had an incident that I think you guys would like to hear about. I had completed a PT session with a client; I transferred him back into his wheelchair and was putting all the parts of the wheelchair back on it. I picked up the footplate and while handling it I grabbed onto the calf pad which isn’t actually attached to the footplate and the footplate dropped out of my hand onto the pt’s hemiplegic foot, this cut his middle toe and bruised the dorsum of his foot. When this occurred I thought it was the end of the world and that I was the worst physio in the world. Luckily the staff at the hospital were very supportive and helped me work through the paper work that needed to be filled out and assured me that it was an accident and that they have all had a similar situation.

The things that I learned from this unpleasant experience is the importance of being extremely careful and knowledgeable with the equipment at all times but especially with hemiplegic pts because they can not protect themselves. The second lesson that I have learned is that accidents do happen and that there is no need to stress out. The more appropriate thing to do is to understand the situation and to know about the process and procedures that you must go through to ensure the well being of your pt and yourself.

The process at my hospital is:
1) Notify a nurse to dress the wound
2) Notify the pts doctor of the injury
3) Fill out an AIMS form
4) Write out what occurred in the integrated notes
5) Notify your supervisor

I hope this never happens to any of you guys but if it does, don’t stress, that will not help the situation in any way. Go and find out from your supervisor what the procedure is that you have to go through and take care of the situation.

Good luck with the rest of prac!!!

Happy New Year

Hey guys.. just testing the blog system out. Hope you all had a great Christmas and Happy New Year. See you all soon. Heidi