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