Code Blue

Hi everyone,

I thought I'd share a story with you about how important it is to be checking pt. obs often. I had a pt. who was day 2 post vascular surgery. He was performing very well that being said. I checked his CXR and was clear. Checked his bloods on iSoft and there wasn't anything there for the day, the day before was clear. I went into his room checked his obs which were stable so I proceeded with Rx. Everything went great, was able to Amb him 2xA with PF 30m in the corridor and back to his room for DBX's and LL ex's. Session went well. Nurse asked me 20 min later to help him to the shower so I did and everything was great. 15 min later the same nurse finds me and asks me to get him back to bed with her. We are halfway back to his bed with the PF when he starts to look not so well. His legs start to go wobbly so I got my leg in under his bottock so that he was sitting on my knee. His head went back and he lost consciousness. At this point the nurse hit the code and before I knew it there was over 10 people in the room yelling orders. I got him safely onto the ground and got out of the way!

In the end he was fine and had a vaso-vagal collapse. He ended up having a Hb level of 60! The numbers hadn't been put up on iSoft yet however so was of no fault of mine. He ened up getting a blood transfusion and everything was good in the end. Just wanted to let you know how important iSoft can be in patients post surgically.

Brent

Bcoz people can get nasty

Hello everyone!

This week I have been experiencing a mixture of excitement, happiness, fear and anxiety – it being the last week of placement; not being 100% sure about passing it and also the upcoming PCR!

I would like to share with you my experience with a particular patient over the last four weeks of my musculo placement. It has been a roller coaster ride which I didn’t particularly enjoy, unfortunately. This lady has a # of the (R) head of humerus managed conservatively, coupled with a history of DM, obesity and being a current smoker (these certainly are factors which can contribute to delayed union of her # -about 10/52 post now). From week 1 through week 4, it has been a friendly-nasty-friendly again-nasty again encounter with this patient. What I found particularly difficult with this case is that although exercises given were demonstrated, practiced and prescribed accordingly with no pain, this patient tends to come in the next time complaining of more pain due to the exercise. The session became ‘challenging’ as she tends to be agitated and unhappy; it was made more difficult as I was totally ‘thrown off track’ when I recalled how successful the previous session supposedly went. It definitely hurts when patients direct their anger at you, especially when you have followed the correct procedures including telling them should any exercise cause pain, stop and let us know. What I learned from here is that firstly, I need to strengthen myself further mentally and emotionally to deal with such cases; secondly, it is very crucial to document what you have done, what you have explained during the session and what you have evaluated so as to protect yourself. I have also documented my experience with this patient in a more objective manner in the transfer summary so that the next student taking over knows what to emphasize and what ‘precautions’ to take.

I believed my experience with this patient did certainly contribute to professional development. I can see myself handling situations whereby patients reported being worse more confidently. When handling a not-so-friendly patient, I think it is really important to remain calm, confident and composed (including controlling emotions such as anger’ & ‘frustration’ which I really experienced!!!); acknowledged that they got worse and then direct their attention towards what is more important, and that is what can be done now to make them better. What I did with this patient was that I told her since the exercises gave her pain, then we have to modify accordingly and I would perform an assessment on the shoulder to ensure that no additional damage or problems have occurred. I suggested the usage of hotpack for the muscle soreness she also complained of and reinforced to her that she needs to be compliant towards the advice to stop any exercise which results in shoulder pain. Towards the end of the session, the storm has calmed, atmosphere was less tense and she was friendly again (but I was certainly and I still am, slightly overwhelmed…). It will be great learning experience if anyone can share with me your not-so-friendly experiences with any patients, the emotions you went through and how you deal with the situation!

Cheers, Peiying ~

Monday Arvo

Hey guys, I thought I would tell you about an incident that occurred on monday afternoon on prac. I was walking out of a pts room with a physio when the wife of another patient came and told us that a patient was falling out of bed. We assumed we were going to get the pt back into bed. When we got there the pt was lying on his back with his legs over the side of the bed. He was quite drowsy but trying to open his eyes and breathing. There was some fluid in his mouth. The physio sent me to get his nurse, I looked for his nurse then I was going to grab any old nurse when the emergency buzzer went off. It was a bit chaotic but the patient had stopped breathing soon after I left so the physio had pushed the button and started CPR before the Dr took over. As it turned out this pt was a DNR and resus efforts were stopped once his file was found. The whole process from when we went in to the room for the first time and when the patient was dead was less than 10 minutes but it didn't feel like it.

This was the first time i've ever seen someone die and it wasn't particularly pleasant. However you then go and see your next patient and try not to think about it and focus on them. It didn't hit me or the other physio until we got home and had our separate mini meltdowns.

Preceding this incident, I asked my supervisor about what exactly happens in the case of emergencies i.e. if you're the one there do you start CPR etc. She said it was a silly question and it wouldn't happen. The reason I asked this was that one of my patients is a DNR and I wanted to know the different procedure in the case of a DNR compared to the normal situation. I know it seems obvious but I didn't want to get into the position then not be 100% sure I was making the correct decision.

Obviously it did happen and I would have felt better about having talked it over prior to it happening. As it happened 2 more pts died on the ward today thankfully I wasn't involved. This ward had a 31 day run of one person dying per day so it does happen.

I thought this might be a good post for people just to quickly think about what they would do in that situation, if you are 100% sure that what you would do is the right thing, and also in case you, like my supervisor, think it isn't going to happen, it does so it's a good idea to have thought about it a few times.

Hope everyones enjoying their last week of prac,
Anna

prevention of spasticity

Hey everyone….we’re almost there, can you believe it’s all coming to an end!!!

So this week I am going to discuss and ask about spasticity. My fellow prac mates and I did a presentation on spasticity and the different methods of managing it. This topic seemed relevant to us, as we are working in a neuro out patients clinic and work with patients who are already suffering from spasticity.

Following our discussion we were told by one of the physiotherapists that she would have preferred we talked about the prevention, rather than management, of spasticity. I understand that avoiding compensatory movements is an important way to avoid developing spastic muscles, but I am not familiar with other techniques as I haven’t had to implement any while on prac. Is avoidance of compensatory movements the primary method of prevention? Are there any further techniques you guys used in an acute neuro rehab setting? If anyone could shed some light on the subject for me I would really appreciate it :)

Patient Loss

Hey all,

I have a patient that hasn't been changing much from Rx session to the next. I continually read the notes before each Rx because that is the protocol in place. I will admit that there were times when I felt like this was a waste of my time because things have not been changing with him. Last week I was reading his notes before seeing him and read that his wife of 60 years had passed away that day. I was extremely thankful that I had read the notes. I was able to go see him and treat him with the care and respect that he deserved to help him through the situation. I ended up having a 2o min yarn with him rather than doing Rx because he wasn't up to it. In the end he was very appreciative of everything. If I hadn't read the notes prior it would have been a much more difficult situation to say the least.

Brent

The Learning Experience

Hey Guys
This week I would like to share with you my experience with preferred learning styles. I would also like to request your opinions and experiences.
Throughout my current placement I have had two great ongoing patients. I’ve found these patients both challenging and unique. I have had to delve into the Neuro genre to implement techniques specific to each syndrome. It has been great to be able to track and observe their progress since almost day 1 of admission. It has meant that I have had to use different approaches in order to treat each patients syndrome.
On this placement I have two supervisors which has been fantastic. One has been involved in Neuro for 30 years!! The other 5 years. I must admit the first week, I felt very incompetent when all they needed to do was gently touch a patient and they moved in the right direction. My forceful hands however, were not so fluent, unfortunately they just haven’t had the time to develop that skill. As both patients had different syndromes, different techniques were required. I literally pulled and requested advice and suggestions from both of my supervisors. I realised that the Neuro from uni only skims the surface of everything that is out there.
I had a discussion with one of my supervisors in regards to the advantages and disadvantages of having more than one supervisor on a prac. Personally I feel it’s a great opportunity to have more than one. It meant that I could learn different techniques and approaches and continued to do so over the weeks.
I’m just wondering how everyone else feels about this? Is it a good opportunity to have more than one supervisor or is it just overwhelming at the moment with everything we are required to remember?
It would be great to hear your opinions.
Heidi.ience....

benefits of prac

Hey guys,

This week I just wanted to make a comment on the benefits of clinic and how important they are to our careers. Obviously they're a hugely important part of our course, helping us to put all our theory into practice and consolidating everything we've learnt. The point i wanted to make is that through the whole course to this point i've had it in my head that i'd work in a hospital after i finished, i really enjoyed cardio classes and lectures and thought i'd enjoy working in this area, and while finding neuro challenging, i also found it interesting, i also found musculo interesting but perhaps tended to not consider working in this area because it's traditionally the area that everyone wants to go into in physio.

After completing cardio and neuro pracs, and being 3 weeks into musculo i can definitely say without a doubt that I'm enjoying musculo so much more than cardio or neuro. I know that we can't base our entire opinions on only 4 weeks of experience, and that alot more than just the specialty influences how much we enjoy a placement, our supervisors, tutors and patients all affect how we enjoy a placment, but I'm enjoying this one so much more than the other 2, that i think this is definitely the area i want to work in. I was quite worried coming into this prac, just because of how broad musculo can be, but i think that i've handled it fairly well. Having a great supervisor and everyone creating a really fun work environment has really helped, but i just think it's interesting how much my interests have changed in the last 3 months.

Enjoy the final week guys,

James

congestive heart failure

Hi guys,

The other day I was going to do a 6mwt with a patient with congestive heart failure at arrox 10am. On the day of the test the patient had her IDC out in the am and hadn't been producing much urine since it got taken out. She described it as only a few trickles. You must keep in mind that this patient is on a fluid restriction and the day before she had diarohhea. After talking with her I found out that she was feeling fine and better then the day before. I reported this to my CCT and said that the pt is feeling good and that we can go ahead with the test. My CCT found this to be inappropriate and unsafe. She felt that the pt might be retaining water again and as a result stressing her and putting more stress on her heart might be unsafe. I spoke to my clinical supervisor later on that day about it and she feels that its borderline and that it is not an absolute contraindication. How do you guys feel about it? would you have went on and did the test?

What if I tell you that later on that day she did use the urinate and that the doctors discharged her. She didn't get a 6mwt done and she didn't get a HEP due to that.

danger!

Hi guys. Only one week to go! I am completing my cardio placement on the medical respiratory ward of a major Perth hospital, and was in an interesting situation earlier this week.

I am currently treating a lovely 67 year old lady who was admitted with an infective exacerbation of bronchiectasis. I had been progressing my patient’s mobility through walking sessions twice daily, and Tuesday morning’s session was no different. My patient wanted to walk to the hospital’s news agency to buy some magazines, so we turned this into a treatment session. The ward was on level 5, and we needed to get to the ground floor, so we headed for the lifts. As we entered the lift, the doors snapped shut, and cut my patient’s arm. Unfortunately, the door hit directly over a bruise on the patients arm, so there was a substantial amount of blood. I had some tissues on me, so I immediately applied pressure over the area, and we slowly walked back to the ward. I made the nurses aware of this and they dressed the wound appropriately. I filled out an incident report form and made my supervisor aware of the situation. I felt bad for my patient, so in my lunch break I went down to the news agency and bought her the magazine she was after.

Looking back, I should have held the doors open before my patient entered the lift, but I guess I just did not expect then to suddenly close on us. So that’s the advice I give to you. Good luck

frustrating

Though it may not sound like it, I am actually really enjoying my neuro prac and learning so much from this placement, despite copping the brunt of a nurses bad mood.

My patient is a 60 yr old woman, right hemi, aphasic, anosagnosia dysphasic, beginning to say no and don’t. She has been progressing really well over the last 2 weeks but is starting to become frustrated at not being able ot verbalise, or maybe the realisation of what has happened to her is starting to happen.

The other day we were in the middle of her session when she started to become very distresses and angry and kept repeating “don’t…don’t…don’t” and started to fight us off. She was attempting to get up on her own and was refusing our help. It got to the point where this patient could have become violent, but we were able to manage her appropriately at the time. When we calmed her down, I took her back to her room only to be yelled at by the nurse for being 20 minutes late for lunch – it was 1220, I was under the impression lunch was at 1230 as I have returned her at this time every day of this placement with no one saying a word of her being late. She angrily (and loudly) continued to tell me I was in the wrong in front of other staff, patients and their families, making me feel quite inferior. I apologised and tried to tell the nurse what had happened in the gym, but she shook me off and didn’t want to know. The nurse proceeded to put the patient back in bed, at one stage dropping the pt’s hemi arm and being quite careless with my patient, and more or less told me to go away. I apologised again for the inconvenience and apologised to my patient.

I know we are supposed to stay on board with nurses as they can make life difficult for us if they want, but how are we supposed to if they won’t even listen to us? Arrgghh…I’ve done wrong again…so frustrating.

fan

PCR

Hi Guys just a fairly quick post today. I'm on my cardio prac and i'm wondering what we include in our problem list for our Cardio PCR. As Caroline said there are a lot of other problems outside of the 10 problems. Some people consider these as considerations some as problems. So my question is: when it comes to the PCR do we incorporate these other problems into the problem list or do we put them into the considerations to treatment sectio. Everyone i've asked has just said as long as you can justify your choice, you will be fine. I was wondering if anyone has any idea which is the best way to go with the problem list or if you've heard anything extra to what i've said. Thanks, Anna

Shoulder woes

Hello everyone! One more week to go! Yes!

I am currently on my musculo placement and this entry is on a case of (R) full thickness supraspinatus, infraspinatus and subscapularis tear in a 90 year old lady managed conservatively. Sadly, this lady’s previous improvement has declined and reached a plateau. As I understand from the previous PT’s notes, she was once able to perform Abd and F of 155deg before pain kicks in and during those 3 treatment sessions, trigger point release was the main intervention. Those ranges are indeed more than ‘functional’! However, currently she’s at 90deg for F and 60deg for Abd (passively 100deg for F and 90deg for Abd). The other findings were elevated and protracted shoulder girdles; stiff AP and caudad glide compared to (L) with pain reproduction; multiple trigger points in Utrapz, Levator Scap, rhomboids, teres major, pec major + minor, supraspinatus and infraspinatus. Previous treatment I did included postural practice and trigger point release (but unfortunately, not for all those muscles described above). I reviewed the mechanics of the shoulder girdle and in summary, the rotator cuff is important to provide dynamic stability to the GHJ. So I thought there’s no way this shoulder can be without pain! I had the opportunity to discuss this case with my Curtin tutor and accordingly, a full thickness tear need not necessarily mean total distraction from the attachments; it can be a through thickness ‘hole’ so rotator cuff ain’t entirely gone (I interpreted this as we can still work on them). In addition, the multiple trigger points could be due to frequent muscle guarding with pain; I also think that it could be due to ‘overworking’ of muscles to compensate for the dysfunctional rotator cuff. What I find hard in this case is that the patient does not seem to be compliant towards working on posture and avoiding aggravating activities… I believe I have to keep educating and reinforcing (does anyone have any other strategies to deal with this…?). She also tends to tense up the shoulder. The multiple trigger points is definitely a big issue so I committed my very last session with her to releasing all those which I managed to identify! I also noticed with abduction that pec major appeared to be very taut so I spent quite abit of time working on that as well. She was definitely quite sore post treatment and as expected, there were no improvement in ranges. I then got her to show me her main functional limitations which included combing hair and she was able to do that quite ‘effortlessly’ (I should have assessed this prior as well). I certainly hope that with the extensive work on the trigger points, there will be some improvement by next week… I will also work on providing a HEP next session. If anyone has encountered such presentation before or have any ideas on what else I should assess and treat, I will be really grateful! Thank you!

Cheers, Peiying ~

Past medical history

I’m on cardio placement and more and more I see how important is to have a big picture of the patient. Initially we tend to focus on the problems related to the area that we are doing the placement on or on the reason for the referral. In cardiopulmonary we often tend to focus on those 10 problems and sometimes “forget” all the other conditions of the patient or just have as “considerations for treatment”. I found that in a lot of cases the other conditions, related or not related to cardiopulmonary needs to be really high up on the problem list. Examples of that are OA (that can affect on mobility and exercise), effect of medications (eg. Decrease consciousness, nausea),Hb level, patient orientation (eg. confusion or dementia), etc. Also if the patient main problems are pulmonary we cannot forget the cardiac part as well. A lot of the respiratory patients have cardiac hx as well. Today I had a patient that was admitted with increased cough and SOB. He has severe bronchiectasis, emphysema,ex-smoker, IHD,OA, Hx TIA. The focus of previous physios was on his airway clearance, strategies to reduce WOB and exercise tolerance. A 6MWT was done and there was no information regarding leg pain (which in his Hx was one of the limiting factors of his walking, not only SOB).In this patient definitely the pulmonary side needs to be treated first, but the cardiovascular symptoms need to kept in mind and addressed accordingly in a mid-long term.
Other example is one of my “mobility” patients, which also has bilateral atelectasis. I have been doing breathing exercises with him, active exercises for ULs, LLs and a walking program. He also has Hx of IHD and recurrent TIAs. Everything was going fine and today when I went to see him, he was having speech problems. He was extremely upset because he couldn’t communicate as normal and was sometimes dysarthric. No one noticed that and I actually was the only one to pick that up (even though it was obvious) and record on the notes. He possibly had another TIA overnight. I informed the staff and hopefully something will be done. He was supposed to be one of the “easy” patients, but what I learnt from that is how important is to keep reassessing the patient and be aware of past medical history.

I hope the last week of placement goes well for everyone!

Prioritising probelm lists

Hey guys,

Throught this week as we start doing more and more PCR practice, the question has come up about prioritising problem lists. I'm on musculo prac at the moment and we were talking about whether we prioritise problems from the patients perspective or our perspective, or a combination of the two, or if we do them solely on what is most limiting the person functionally.

In cardio i always prioritised by what would be most likely to kill the patient if it was not addressed, in neuro, because i was in an inpatient setting i thought about the main reasons they were unable to go home at this stage.

I was just wondering what you guys think of this, and how you prioritise your problem lists if it's not using one of these ways?

Thanks alot, enjoy the last couple weeks,

James

Pt refusing Rx

Hi everyone,

I have a patient on my cadio placement that continually refuses Rx from physiotherapy. She is severely limited in her mobility and physio could vastly improve her prognosis for the future regarding independence. She has severe dementia and thus does not listen to reasoning that I try to evoke to her regarding the importance of participating. My question to you guys is do you have any strategies that you would like to pass on that may help in convincing this lady to partake in Rx? Also, is it ever ok to procede with Rx in a patient who is refusing when they have dementia and don't know what is best for themselves?
Cheers
Brent

prioritisation of Ax and Rx

Hi guys,

Im on my Cardio placement right now. I had a patient the other day who has been having severe back pain following a fall. While I was treating the patient I thought that it was his back pain limiting his ability to walk and as a result I tried to Ax his back. Half way through the Ax my supervisor stopped in and stopped me. She brought up a very good point. To Ax his back and do a proper musculo Rx for this patient will have probably taken me an hour at least. She helped me understand that I would probably not fix the problem in one Rx and as a result probably be wasting a lot of my time which I don't have. A better way to approach this patient would be to do lots of small walks throughout the day to improve his mobility which is the most important thing for the patients discharge. We can't forget about the back pain and have to keep it as a large consideration for Rx and try to see the pt after pain meds. Also to deal with the back pain we should be thinking of where to refer him to when he is D/C. This small discussion has helped me see what the priorities are for my ward and will help me manage my time much more effectively. I hope that it helps you too.

Shadi

Modification and priorities of treatment….

The weeks are flying by... not long to go now. I hope everyone is enjoying their placements.

I am currently on my neuro placement and I must admit it is the most physically and mentally challenging so far. It is certainly time to dust of all those cranial nerve, cerebellar and cortical examination assessments.

I would like to share with you my encounter with one patient in particular who confronted by practical neuro skills. This patient sustained a cerebellar infarct two weeks or so ago. My problem is that the majority of my patients not only present with the impairments associated with their current admission but also at least three additional co-morbidities. This not only challenges my repertoire of skills and techniques but confronts and often opposes the methods we have learnt in neuro.

For example the patient above, presented with typical cerebellar impairments i.e.; nystagmus, dizziness, decreased hearing, feeling light headed and leaning to the left. Sounds relatively straight forward right? Let’s add his PMHx; a (R) rotator cuff repair where his shoulder could not passively move past 90 degrees and a (L) THR which causes him a lot of pain and cramping. So if we all think back to our neuro labs, I theoretically want to have him weight shift to the right, with an appropriate arm reach to improve alignment and correct his posture. This was not going to happen. I had to quickly adjust my treatment plan so that I could be more effective in prioritising his impairments.

At first this wasn’t easy and I didn’t feel like I was doing a very good job at treating him. My hands didn’t seem to feel right and his impairments made him very difficult to treat. I felt quite frustrated and thought I should be doing a much better job than I was. It took me a couple of days to realise, after talking to a few other newer staff on my ward that I shouldn’t feel like I should be an expert yet, I’m far from that!! At the moment we do only have very basic skills, our hands are still adjusting and feeling their way around and our repertoire of techniques are very simple. It takes years of practice to achieve a high level in any area. Sometimes there is not specific way to handle patients and it’s just a case of moving your hands around until you achieve the desired result.

So my thought is, for all of us who do feel slightly incompetent with certain techniques at the moment don’t!! Even though our supervisors make it look so easy, we can’t expect to be experts straight away (even though we want to).

Heidi

‘Traumatized’ by a ‘simple’ case of trauma

Hello guys! Halfway!

I am doing my musculo outpatients at the moment. Initially when I received this case of a patient with (R) bi-malleolar # and ORIF done (11 weeks post-op now, WB as tolerated), I really didn’t think it could be too complicated. He presented with two areas of pain, Pa – anterior ankle and Pb – posterior and inferior to medial malleolus which bothered him during standing (immediate Pa) and walking (Pa during stance, Pb during both stance and swing but more on stance). He also has constant ‘altered sensation’ over the lateral dorsum of foot and tightness around the ankle. Physical examination revealed the following asterisks – Obs: swelling anterior ankle, calf wasting, knee hypertension, anterior pelvic tilt, low abdominal tone. Gait: using w/f (which already ‘abnormalizes’ walking), decreased WB + tibial translation over foot. Functional tests in standing: heel raise – unable to perform on (R), repro Pa + Pb; stand on medial borders – decreased range on (R), nil pain; stand on lat borders, nil pain. ROM: decreased actively for df (Pa repro with OP) and ev (no Pb repro); OP of pf repro Pa; inv repro pulling at Pb. Resisted ms testing: weaker pf, FHL and FDL; tib post (L) = (R) and repro pulling at Pb. Palpation: TOP of both Pa (which seems to be in region of ATFL) and Pb. Glides: decreased talocrural AP and subtalar lat. Treatment so far has been AP glide on talocrural jt, education on ice + elevation, gave a tubigrip, active-assisted ankle ROM exercises and correction of the way she uses her w/f. Pa and Pb haven’t been getting better.

We hypothesized Pa could be ATFL sprain during the time he had the # (would have to check the ant drawer test) – supported by area of pain, TOP, pf OP repro pain; swelling present and confined at ant ankle would not do this ligament good and is a contributing factor to decreased df besides decreased AP glide. As he tries to put weight over the foot, there is restriction to forward translation of tibia; compression forces ant ankle repro Pa. Pb seems to be ‘muscular’ in nature (pointing to tib post) – area of pain, repro with AROM inv and resisted tib post, TOP and repro in gait. From footflat to mid stance, pronation of foot for shock absorption should occur with eversion at subtalar joint – he has decreased lat glide which I thought could limit this resulting in increased forces to the medial ankle. During this time, the tib post is also active to internally rotate tibia. These could explain Pb repro during stance. From mistance to toe-off, foot supinates which involves tib post (but with w/f, I think this part of the gait cycle is not relevant). In swing, foot returns to neutral so I believe a component of pronation occurs again which could explain Pb repro. Negating evidence is present most definitely, I was expecting Pb with ev but nil. It also occurred to me there could be tarsal tunnel syndrome (with the swelling, screws, her hx of arthritis and area of pain) but again, the negating evidence is lack of Pb with ev. Perhaps I need to do a more specific test on the post tibial nerve for this. I am still thinking of other possible causes of Pb...

Does anyone have any ideas on what else I need to assess / treat to come up with appropriate diagnoses and solve his problems? I would really really appreciate some help! Thank you!!!

Cheers Peiying ~

Difficult Patient

Hi Guys, i'm on my inpatient cardio prac at the moment however i'm seeing a fairly diverse list of patients. This patient is a mobility patient who presented following a fall and I have seen him 5 times, 2 for assessment 3 for treatment. He is complicated by the fact he has severe L hip pain, currently managed R hip pain, some form of blood poisoning and he is undergoing chemotherapy at the moment. His Berg is within the range of requiring a walking frame.

There have been 2 days where I have been unable to treat him. The first time his hip pain had been aggravated by balance exercises we had been workin on. He didn't blame me, he blamed his hip and appeared to be quite down about it all. This was quite hard because one it appears that my treatment caused this man pain and no benefits and two he blamed himself. I will also mention that because of this patients cancer treatment he is not allowed to take pain medication above the strength of panadol. He says the panadol does nothing for his pain.

The most recent treatment refusal was due to the patient having had chemotherapy in the morning. His medical problems are interfering with his treatment for impaired balance. The doctor does not seem to be concerned with this L hip and is mainly concerned with the blood poisoning. However this patient was admitted d/t a fall caused by poor balance. This area is not able to be treated as well as needed and so he will be discharged using a frame but with no real balance improvement. I will talk to my supervisor about this but I was wondering what you guys would do in my situation. I am considering talking to his doctor about his hip. Other than that i'm not really sure what else I can do. Any advice would be appreciated.
Thanks, Anna

Doing wrong?

Can you believe it - only two weeks to go!

Currently on my neuro placement, I had to do a telephone handover yesterday to another hospital as one of my patients was being transferred. She was a 31 year old with right hemiplegia, LL gowland 5 of leg and foot, UL stage 2 arm stage 1 hand. Aphasic but able to verbalise yes, no, good, bad, ok.

When this placement started my patient was walking independently, bed mobility was independent - able to roll to the left and to the right by herself. When I handed over this information, the physio more or less yelled at me questioning why I was letting her roll to both sides, this should never be allowed and gave me stern warning to never let this happen with another patient ever again. This patient has just begun to move in a flexor synergy (UL) but has a significant increase in tone of the right finger flexors. When I told the physio this she blamed me for this increase in tone "because you let her use these faulty movement patterns...this wouldn't have happened otherwise...you have managed this patient poorly."

This converstaion left me quite confused. If I stopped this lady from rolling to both sides, is this not taking away some of her independence??? Don't we want our patients to have as much independence as possible? When I assessed her rolling to the left, though she found it slightly difficult, she was still able to do it with no assistance. Is it right to stop her doing this? Secondly, I thought the increase in tone was becuase she was recovering? How are we supposed to stop this from occuring at all?

Though this lady is sadly no longer my patient, if I have made a huge mistake with her i'd like to stop if from happening again with anyone else. Can anyone share the light?

Fan

Prioritizing problems

Hi everyone. I’m on my cardiopulmonary placement and in the past two weeks I have been exposed to a large range of patients. What I have been learning is that in the process of analysis of patient’s problems, there are a lot of other problems that need to come in the number one of the list, such as pain, anxiety, drowsiness, nausea/dizziness, besides the 10 physiotherapy respiratory problems. I have noticed that either in surgical or medical patients those other problems influence totally in the patients symptoms, therefore in the other problems and, consequently, treatment. Other things like, surgical procedure (complications of, wound, pain Mx) and PMH also play a big role. For example, the patient that I mentioned on my last blog (thanks Peying for the comment) that had really weird responses when I tried to stand him up for the first time, at end I found out that it was pure anxiety. The day after he was mobilizing fine, no problems at all. Another patient that I had today, post-lobectomy, his main problems was drowsiness and nausea. Because of that, it was really difficult to get the patient out of bed. Initially, the drowsiness was the main issue because I didn’t really know how he was feeling and he wasn’t responding much to command. After liaising with nurse, his pain medication was changed and he was more responsive, so we could sit him out of bed. When I came back after 2 hours to put him back to bed, he was extremely nauseous, vomiting after mobilizing. That again, impacted on his progression. At the end, my intervention number one was liaise with staff regarding his medication and then start the deep breathing, SOOB, ambulation…
What I learnt from that is we need to have a big picture of our patients, not only from what we assess, but be aware that we are part of a team that need to work together for the best of the patient.
Good luck on the next two weeks!

pulmonary rehab

Hi guys. I hope prac is going well for all. I’m on my cardio placement and this morning observed a pulmonary rehabilitation class. All eight of the patients in the class are COPD patients and the class consists of a 20 minute walk and then upper limb and lower limb exercises. I know PCR is around the corner so I thought I would give you a brush up on how to calculate the goal distance for a patient to walk in 20 minutes.

At the start of a patient’s program, they are required to do a 6-minute walk test (walk as far as possible in 6 minutes). So if a patient walked 200m in 6 minutes (minimum distance required to be eligible to enroll in pulmonary rehab), you can multiply the distance by 10, to get their calculated 60 minute distance (= 2000m). Then divide that by 3 to get the 20 minute distance (= 666.67m). Then because you don’t need them to do a maximum effort, you get their 80% sub max effort (= 533.33m).

So if a patient walks 200m in the 6-minute walk test, their goal 20 minute walking distance is 533.33m. Hope that was of some use.

It works!

Hey guys, hope everyone's enjoying their placements.

I'm on musculo at the moment, and on that note, nice work Caroline, so far i have the least number of DNA's or cancellations out of everyone, which was 0 until a patient got his day's confused, you must have made a good impression :-)

I don't really have a question or anything, just wanted to share my experience of my first new patient, which made me feel like i made a difference.

Just to give a basic outline, my patient is a doctor, she presented with cervical and right shoulder pain, that had been intermittent over the last few years. It was clear from assessment that it was a postural loading problem as it was mostly sustained postures that elicited the symptoms, with an acute movement impairment disorder, resulting in the acute episode of cervical and shoulder pain that had brought her to physio. Assessing her AROM i found she had about half range left rotation, which brought on the pain she complained about. After my palpation and PAIVMS and PPIVMS i had found a couple hypomobile segments, and a number that were TOP, but had failed to reproduce her symptoms, so i decided to reassess her PAIVMS in the restricted range, as soon as i did this i managed to reproduce the pain she had presented with, with a left unilateral PA on C2/3. This gave me a bit of a thrill when my patient said "yes that's the pain!" and i pumped the air with my fist. After this little display of enthusiasm i did a left unilateral PA on C2/3 in the restricted rotation range GIII 3x45sec and reassessed to find she had full range left rotation with no pain, and she left a happy patient.

This was a great start to my placement for me and i just thought i'd share it with you all, and hope that you all get similar results with your treatments :-)

James

Hey guys….just a reminder I’m doing my neuro placement in an out patients department. I have an elderly patient who has hereditary spastic paresis and has been having quite a bit of trouble in the last few weeks. She has been noticing a decline in her functional abilities over the past 12 months due to progressively diminishing strength and increasing tone, particularly in her lower limbs. She has remained independent with her mobility, using a manual wheel chair while at home and doing all transfers and bed mobility on her own. However, these tasks are getting more and more difficult as she gets weaker. Her husband has been helping with her ADL’s (dressing, personal care, etc.), but is quite frail and has been told he should no longer assist.

During our session today she requested to be taught a slide board transfer to allow continued independence with more ease. Unfortunately, she was not strong enough to maneuver the slide board on her own to get it under her bottom and most likely would not be able to move her body across the slide board on her own.

Following this attempt I suggested that we continue to work on the strength of her legs to maintain the strength that she has. She then became quite upset and began crying, saying that she has been told that for the last year and has just continued to decline. She is becoming very frustrated and losing hope.

In response to this I suggested we try a different slide board to see if she would have more luck, as she did not want to hear that we should just keep working on strength. We managed to use this new slide board, but with my assistance. We have decided to practice with the slide board a little bit each session to see if she can become more independent. She was happy with this, but remained quite down during the session.

The reality of her condition is that she will continue to deteriorate; there is not much that can be done to avoid this. My question is how can I discuss this reality with her in a sensitive manner, as I am sure it will come up again. She know the prognosis of her condition, but is having a hard time accepting how quickly her decline has been over the last year.

Theatre

Hi guys,

I was recently given the pleasure of getting to watch a patient's surgery from the ward I am placed on. I was able to treat him both pre and post-op. Getting to see his cardiac surgery and follow up with him helped to put everything into perspective for me. From the amount of trauma that the patient is put under to the incredible amount of blood loss that he underwent I was amazed with the whole situation. It was a great learning experience that I suggest everyone who can get the chance to witness a surgery to do it. Makes understanding what the patient is going through much easier.

Brent

Discharge planning

Hi guys,

Im on a short stay ward for my Cardio placement. I couldn't have asked for a better place to be. Its really giving me insight about the programs that are available when a patient leaves hospital. It is also giving me insight about the importance of preventing readmission. These programs are not only important for a patient physically but they are also important to a patient mentally and socially. I challenge you all; the next patient you see wheather it is inpatient neuro or out patient musculo, look up what other programs they can be involved in to help with their condition either physically or mentally. I bet you will be surprised at how much stuff is out there waiting to be utilized.

Good luck on the rest of your prac.

Shadi

Code Brown!

I am currently completing a cardio placement on a general respiratory ward and am enjoying the experience. On Tuesday, I was conducting a treatment on a patient in the High Dependency Unit of the ward. The patient was in with acute septic shock and secondary E. Coli pneumonia, with associated acute renal failure. The patient was unconscious, and so we my supervisor and myself) were performing airway clearance techniques on him.

The patient obviously had no control over his bowels, and whilst we were treating him, he was incontinent, and it was quite a runny stool. We were obviously wearing gloves whilst treating so we did not come in direct contact with the patient. Once we finished treatment, we thoroughly washed our hands and arms before leaving the unit. Some time later in the day, I was told that 5 of the 6 patients had begun passing severe diarrhea, and there was a risk of noro-virus outbreak, and HDU was then deemed restricted access.

Luckily, there was no case of similar symptoms outside of HDU, therefore the precautions we took to maintain self-cleanliness were quite effective. So I stress to you, wash your hands and equipment after each patient to reduce the risk of any cross contamination.

Pain and Anxiety

Hi Guys hope prac is going well.
I am now on my Cardio prac. I have a fairly large mixture of patients (surgical, medical, ICU etc.). The patient I’m going to talk about is a Day 1 surgical patient. He had a reversal of a complex abdominal procedure. He was c/o very high levels of pain and did not want anyone to touch him. My supervisor asked him if it was ok for a student to treat him which he said no to which meant I was in there assisting my supervisor. The pt was very anxious and in pain so the pain team were contacted.
He was gotten out of bed Day 1 and ambulated up and down the hall. Once the patient was up out of bed there was no real mention of pain. He didn’t press his PCA during the walk. He was sat out of bed for a few minutes and then returned to bed. By the end of the session he was extremely grateful that we got him up out of bed and was planning to go for another walk in the afternoon with the nursing staff. His pain dropped significantly from pre treatment to post treatment. While some of it was due to mobilisation the majority was a decrease in anxiety levels. He was so anxious about having to get up out of bed he was increasing his pain levels. What I learnt from this patient is that it is always a good idea to quickly check their level of anxiety. It’s amazing how much anxiety contributes to a patient’s pain levels.
Hope everyone has a good second week.
Anna

Faking it???

Hey all...two pracs down two to go!!! Hope your all surving.

I’m on to my neuro placement at the moment and the patient in this case isn’t my own but a patient I was sitting in with, with another student.

The man is a 50 year old MS patient who is a ‘frequent flyer’ in the hospital system. Socially, he is in the middle of a separation, and is on the waiting list for a Homeswest home as he has exhausted any other options for accommodation on d/c. He was admitted 6/7 ago with incontinence (bowel and bladder) that had been rectified 1/52 before this admission (i.e there was a week between admissions). On speaking to the nursing and other medical/allied health staff, it appears they believe his symptoms are not legitimate and he is trying to ‘buy time’. In other words, medical staff believes he is soiling himself on purpose to stay in hospital. His Dr’s told him he was staying in hospital for 1/12.

On initial PT Ax, he was x2max A with transfers on/off bed, and in/out of chair. He was unable to stand independently because his legs were giving way. Long story short, two days later, he was STS independently, walking with a stick with standby assistance, had fantastic saving responses, and caught smoking in his room (nursing staff informed).

Ethically we have to treat this patient and obliged to give care to him, but at what point do you say…we know this isn’t legitimate. How much Rx do you give this man knowing the fact that he’s there because he’s scared to go anywhere else and therefore exaggerating his symptoms to stay put and also knowing that there are so many people in the community that are in desperate need of that bed. He is essentially wasting valuable medical (and physio) resources. As I said before, he isn’t my patient, but watching on, I find this unbelievably frustrating that something like this is allowed to happen. Where would you guys go with this?

fan

Communication is the key...

Hello all,
Onto my next placement, which is both challenging and interesting. I'm learning so much which is fantastic.
This week I would like to share another 'communication' situtation. The current placement I am on is involved in a comprehensive study to do with stroke, stroke rehabilitation and stroke prevention. The inclusion criteria is very specific and in order to recruit patients it must be done immediately following the incident. A large number of the patients are unable to sign for consent due to there stroke hence it is up to family members to do so for them. Unfortunately, under some instances the patients do pass away before the signature has been obtained. The other day I was able to observe my supervisors fantastic communication skills, with a patients family whose husband had unfortunately passed away before the signature was obtained.
It is a a challenging process. My supervisor had to show compassion and understanding, at the same time trying to obtain a consent signature. In this instance she needed good listening skills and effective communication to help the family through this tough period but also get the signature.
She did a great job. A lot of it inovolves listening. Family members love to release their emotions and ask a lot of questions. It is a very time consuming process. My supervisor, spent a great deal of time with this family. The family greatly appreciated this and once the purposes of the study were explained to the patient, in terms of benefits the family was more than happy to sign.
This was a great experience to observe and learn from.
From this situation I have learnt that when we graduate we are not only going to have to be great physio's but also great listeners and definitely communicators.
Hope everyone's placements are going well.
Heidi.

When to stop pushing?

Hey guys…hope your first week of prac has been good.

I’ve just started my neuro clinic, working in an out patient’s department. I am enjoying it so far, but haven’t got to see too many patients yet. One patient I did work with briefly, while helping another student, left me questioning how much you should try to encourage and push your patients who don’t have a good attitude. This patient had had a stroke about 4 years ago and has been living at home, leading a normal life for a couple years now. About a month ago his GP recommended a 2 month period of physio to reinforce proper gait and normal movement. As this patient has been without physio for some time now, he had developed poor habits and compensatory patterns which we are trying to correct now. During his last session, the one which I was helping with, we were working on weight transfer to his affected side. While our supervisor was helping the patient was working really well and had a good attitude. As soon as he left, the patient became very aloof and was not trying hard at all. He made comments about these physio sessions being pointless because he just starts walking the way he had been as soon as he leaves. I proceeded to question whether he practices walking with better gait at home or does any of the exercises at home. He reported that he doesn’t and appeared to have no interest in improving his gait or movement patterns. He said he hasn’t noticed any difference in his movement since he started physio and is only going because his GP and wife want him to. This leads to my question, how much I should have pushed him to be compliant, practice walking, do his exercises, etc. If the patient already has a bad attitude, I feel too much pushing/encouragement may turn them off even more. What do you think would be the best way to handle a situation like this?

Fast-paced musculo?

Hello everyone!

Staying +ve has helped me got through the 1st week of my musculo placement! (Though I almost cried in front of my FCE today…!) Hope everyone’s doing well!

One patient after another really wasn’t easy. I was trying very very hard to keep to the time limit so that the next patient did not have to wait too long. To me, outpatient musculo is really fast-paced, you got to work fast, think fast and treat fast (+ effectively)! Today, I realized this ‘pace’ is not always possible, at least for me at this stage as a baby physio… I saw a 90 year old (!!!) patient whom besides having a musculoskeletal problem, also has a balance problem described as ‘horrible’. I tried to ‘rush’ still, but it’s just not possible. Considering the age and balance issue, the session warranted more considerations and precautions. Things I tried to do included - keeping the time in standing for observation to a minimal - minimize change in position and providing adequate supervision (but I found minimizing change is really hard as I still couldn’t organize in my head all the different assessments to be done in the different positions) - frequently checked if patient is feeling well – specifically instructed not to move about when I left the cubicle - spent more time in education and practice of posture correction & exercises, as I noted this would help the patient remember better. I tried to be very cautious with hands-on as well as the skin was so fragile!!! I also learned from this case that I made a very serious mistake the last few days! Apparently I was just literally ‘reading through’ and not absorbing important information... Because I couldn’t recall at all what’s the patient’s medical history and surgical history during the session. This happened to another patient as well who reported dizziness after every change in position and I couldn’t recall the relevant medical history. Perhaps I was rushing through so that I can be on time… Also, part of me could have subconsciously assumed these were not as important in a musculo outpatient setting which is very wrong! My perception of musculo involving younger, 'healthier' patients really needs correction. There were just so many other things patients brought in with them, like their fall history, stroke history, social circumstances (eg: how husband could not be depended on to help with chores because he's cheating on her), anxiety, depression etc. Once again, I learned that it’s always about a holistic approach when it comes to patient care; it doesn’t matter whether it is inpatient or outpatient! I need to spend the time to look at the whole / bigger picture! Hopefully I will get more efficient over time and find the right ‘balance’ in a more fast-paced musculo setting! :)

All the best to myself n everyone for next week! :D

Cheers Peiying ~

Day I post-op

This week I saw a patient Day I Post radical prostectomy He had GA and the surgery was uncomplicated. He doesn’t have any relevant PMH. When I say him, his obs were stable, he had TED stockings, leg pumps and normal attachments. He was on PCA. When I took the leg pumps out he started to complain of numbness and P&N`s on his knees and superior 1/3 of legs. After SOEB those symptoms continued and he started to complain of involuntary movements on his Right knee (kn ext). His muscle strength on his quads and hamis were normal bilaterally and there were no signs that the leg pumps were too tight. Obviously, he got really anxious about that and frustrated because he thought he could stand up easily. I was with my supervisor and she said that she has never seen that before. We called the nurse and the doctor, but none of them had an explanation for that and said that we could continue the treatment. At the end, we stood up the patient, did a bit of stepping on the spot, but the patient was a bit unsteady so we put him back to bed.
Has anyone seen this happen before? Any ideas on the reason for those symptoms and how I could have managed that differently will be appreciated.

Impaired Airway Clearance

Hi guys,

Today at the PCR practice session we got to discussing one of the cardio case studies and it was brought up that one of the problems for the problem list that the pt has is impaired airway clearance based upon the fact that he has increased mucous production. I know that this is what we are generally taught to use as a sign for IAC. I got to thinking though... if someone is producing sputum doesn't that mean that they are clearing their airway fine by themselves? I don't understand why that would mean that they have impaired airway clearance... unless they only produced it due to physio Rx. It makes sense to me that say if they have an innefective cough that they would have IAC but I just can't link the other situation. Can somebody make it fit together please or let me know if I'm wrong in any way.

Cheers
Brent

The athlete's shoulder

Hi guys, good luck for your new placements. I have just completed my musculoskeletal outpatient’s placement and I thought I would share with you a patient that I was treating. A 23 year old male presented with right shoulder pain which was diagnosed as sub-acromial impingement with GHJ instability, after a fall during basketball 6/5 ago, and resultant ongoing shoulder pain. On observation of his scapulohumeral rhythm, it was evident that the way tipping of the inferior angle of the right scapular, due to tight an overactive pec minor, and under active lower traps.

My plan was to work on the patient’s ability to stabilize his scapular through lower traps activation (scapular retraction exercises), but first I needed to release his pec minor. With pec minor released, the pt’s impingement tests all became negative, but I still needed to address the underlying factor of impaired scapular stability.

I tried some basic lower trap exercises in prone, however as this patient had large superficial muscle bulk, there was massive teres major activation and not even a flicker of lower traps. In sitting, I had a little more success, but there was still mass compensation by surrounding muscles. So I trialed the use of EMG biofeedback, over lower traps, and performed the same scapular retraction exercises. After a few attempts, he got the hang of it, and eventually was able to isolate lower traps. Once he could isolate the muscle group in a few different positions, I began to incorporate scapular stabilization during all of his upper body exercises in his gym program, such as lat pull down, seated rows, pull ups and bicep curls. As this allowed the pt to continue going to the gym and doing the exercises that he enjoyed, he was highly compliant.

Over the four weeks, the patient’s pain levels significantly reduced and his scapulohumeral rhythm became much more symmetrical and aligned, which I thought was a positive rehabilitation outcome.

Putting it all together

Hey guys,

Hope you all went great in your previous placement, and best of luck for the final one.

On my recent placement in neuro inpatients i got a good understanding of how the treatments we do with our patients influence the final outcome, and in the end how they all come together and things seem to fall in place to acheive what we're trying to do.

I know that sounds a bit vague, so I'll give you the example that made me think this.

My patient is a man who had a left MCA infarct around 7 months ago, and is due for discharge in about a month. It was difficult to assess my treatments from his perspective as he was quite dysphasic and it was very difficult to gauge his responses, he would basically just do what i asked him to, down to the letter, and trust that i knew what i was doing. I found that while this was a little overwhelming at first, it really gave me a chance to have some faith in myself, and trust in myself that my treatments and techniques would help him reach the goals he was aiming for.

The focus of his last month of inpatient rehab was on his walking, getting him safe and independent. In my assessment i noticed he was retracting his pelvis during gait, particularly right stance, and decided that the main reason for this was his lack of posterior pelvic tilt during stance. Using this assessment i focused my attention on facilitating his pelvic tilt, first in sitting, then progressing to standing. He was very good at both of these positions, and i could tell he had obviously been taught this before, but he was still unable to PPT during gait. So once I had him doing it in standing, i progressed him to stride stance, and attempted PPT in this position, which proved much more difficult, but eventually he seemed to get the hang of it. From there i worked on his weight transfer from his back leg (left) onto his front foot (right), with emphasis on acheiving PPT prior to weight transfer. While he seemed to grasp this concept well, i was still skeptical on whether my hour or so that I'd spent on teaching him this would actually have an impact on his gait. At the conclusion of the session we attempted to put it all together and walk back to his room, as we did at the end of every session, and lo and behold everything just seemed to fall into place and it was his best walk to date. True, the next day he was retracting again, but now he knew what i wanted from him in the treatment session it was much faster to facilitate him into PPT and to work on other aspects of his gait with the aim to acheive independence.

What I'm getting at in the extremely long winded blog, is that we do know our stuff, we can indentify the impairments that need to be addressed in order to acheive our aim, and if we go into a session with some sort of plan, follow it through, and you'll see results. Obviously it's important to continually re-assess and evaluate our treatment, and adjust if necessary, but make sure you always give it a go first and i think you'll find more often than not that you've got it right.

Anyway, it was exciting to see all the things that I'd been working on with my patient finally fall into place and work how I'd visualised it in my head, and I thought I'd tell you all about it :-)

James

Who knew the big toe was so important!

Hey guys…2 down, 2 to go!! I hope you all had an enjoyable and successful second prac and are ready for the home stretch J

I’m going to write about an interesting patient I had during my musculo prac. This patient had experienced a partial Achilles rupture in late September. She was in a BK POP for 9/52, a walking cast for 1/52, followed by using a heel raise for approx. 2 months. She presented to the clinic in early Nov. with 4/10 heel pain after about 30min walking, decreased global ROM, mainly DF and big toe extension, decreased strength of PF’s, abN gait pattern and swelling. Following 2 months of treatment, consisting of PAMS, physiological movements, STM, A/AROM exercises, and theraband strengthening exercises the patient had regained full ankle ROM in NWBing positions, had an improving gait pattern, only hyperextension of knee remaining, and only minimal swelling. Her heel pain, strength and extension of her big toe were the main problems when I began treatment with her.

Determining the cause of her heel pain took a little bit of assessment, but I eventually determined that it was the cause of shortened, tight FHL and the lack of extension of her big toe. The lack of ROM was altering her gait pattern, thus affecting the load acceptance and transfer during walking. I found this extremely interesting and never would have considered this without the guidance of my supervisor. Simply by improving her extension, with AP glide of the 1st MTPJ at end range ext., physiological extension, and STM of the deep posterior compartment (FHL), her gait improved, decreasing her knee hyperextension and her heel pain improved. Over the week following this patient’s heel pain decreased to 2/10 and it took an hour to come on (vs. ½ hr).

Just thought you all may find this interesting as well, it may help if you ever have a patient with unexplained heel pain. Take a look at the patients toe ROM, it’s more important than I previously realized.

Making a Difference

Hi guys,

This last month during my neuro placement I have realized how important we are to patients. Looking at it from a patients perspective; all they want to do is be able to get up and walk and we are the ones working with them towards that goal. This is the only thing that kept me motivated throughout my placement. The point of the story is that no matter how hard things get at prac and how crappy things are going with the supervisor and how stressed you are; just remember that we are here for the PATIENTS and that we are making a difference in their lives and it means a lot to them. Good luck in the new placement, see you guys soon.

Shadi

The younger patient

Hey guys

Onto the last prac, I hope that everyone is enjoying the placements so far, not long to go now.

The next patient I would like to share with you is a young teenager with patellafemoral pain. She came to the clinic with her mum accompanying her each visit. The mother was very pleasant however, often overbearing and demanding throughout the assessment and treatment. She often answered all of my questions, explained all about her daughter’s pain and finished her daughter’s sentences. Unfortunately, during the second treatment I found myself directing everything toward the mother rather than the patient!!

I could sense quite a lot of frustration on the daughter’s behalf. I understood that the mother wanted to be involved however I could see that the patient wanted to take control of her own injury. I was beginning to find the situation a little frustrating.

I decided it was time to change the way I approached the younger patient and her mother. Firstly I positioned the patient so that I could sit directly in front of her. I would then sit the mum in a chair away from the patient. I started asking questions directly at the daughter waiting for her to answer the questions. If her mum answered them, I would ask the question again and keep asking until the daughter answered. Slowly, the session changed. I got a lot more out of the daughter and a lot less from the mother. The most rewarding thing was seeing the daughter’s whole personality change. She went from being timid and shy, to taking control of the treatment session. She asked lots of questions and got more involved in trying to learn her HEP properly. It was definitely a big lesson for me on how to approach the younger patient to ensure that they are in control of their injury and that they guide the session.

The Benefits of Team Meetings

Hi guys, this is a development from my last post. My patient is a 57 year old man with a L hemiplegia. I was worried about his emotional state when he wasn’t progressing well in physio. I spoke to his Physio and she said that he did take things in and felt upset but did not express this publicly. Hence I resolved to not tell his family about negative aspects in front of him and to stress the positive side when speaking to them.

Every two weeks there is a team meeting for each patient and involves the specialist, his various interns, residents etc, the Physio, OT, nurse and social worker. Every person gives a run down on how the patient has progressed in their area of expertise. A lot was said about the patient’s family dynamics.

His wife had a lengthy appointment with the social worker. The wife told her that her husband was an absolute gentleman prior to the stroke but was now quite mean to her. She said he was always very nice to everyone at the hospital but once out of the hospital he became quite nasty towards her. She also felt he didn’t appreciate the effect his stroke had on her and how it had changed her life. Other people present at the meeting had spoken to the patient who had no real understanding of the impact his stroke was having and would have on his wife in the future.

I was quite surprised when this was brought up as I had never even thought that he might be a different person outside of treatment. It was absolutely valuable information and I only wish it had come earlier in my treatment of this patient. One thing I have gained from this is the importance of effective communication between health professionals in hospitals. If there was no team meeting the patient and his wife would continue to be treated as they were. However following the discussion at the meeting people will take into account the information discussed and act accordingly.

The second thing I have learnt is the importance of treating not just the patient but also the family when needed. The big concern is that there is only so much this patient’s wife will be able to take before something snaps. The worst thing for this patient’s outcome would be if his wife left him, became depressed or had a mental breakdown. All 3 of these are very realistic outcomes if things continue as they are.

Sorry this is a bit long, hope everyone’s prac went well.
Anna

Hands on isn't always the best approach!

Hey guys...one prac to go!!!

I had an interesting patient who was referred to the outpatient clinic for OA of Lx spine and knees. She presented with 20 year history of Lx pain, pain in the Cx, Thx, knees, wrists...just about everything. This woman was so focused on pain, appeared depressed, was a single mother to an 8yo daughter and 22yo son (the son she rarely sees) and didn't speak english very well. After my subjective i walked out of the cubicle and thought "what on earth am I going to do with this woman? Objectively, ROM was WNL for everything except her knees, terrible posture, tight around the cervical region, Gr2+ muscle strength in the LL's.

So after being completely flustered about what to do, I eventually decided to take a hands off approach, with education+++, no mention of the word "pain", postural correction exercises, refer to hydrotherapy, muscle strengthening for her LL's. She came back next session with Lx spine feeling fantastic, decreased neck pain and primary problems now with her knees.

I guess I learnt a lot from this patient about chronic pain behaviours and how we really need to educate these patients (of which you can never do enough of) about avoiding activity cycling patterns, stress management, provide information about pain management and their condition and i feel that manual therapy really doesn't have to happen with all our patients. This woman is proof - she thought i'd worked a miracle just by correcting her posture! I think someone in this case could possibly become dependent of someone performing manual therapy and if you can give them some pain relief by not doing any, then it makes it so much easier from a management perspective.

Fan

When air's not in the right place

A pat on the back for everyone in this blogging group!

It has been a Pneumothorax week for me! So how I can not reflect on it? Haha… I did, and realize I thought I knew things which I don’t really know! *bad*

The 3 cases I saw really served as a very good source of revision for me on what are the different causes of pneumothorax. Things are falling into place and I am really beginning to appreciate clinical experience more than before! Hope this entry will help you guys gain some insight as well!

Pneumothorax (PTx) = air into the pleural space. The 3 different clinical presentations I encountered:
1. Bilateral PTx post MVA
2. (R) PTx post assault
3. (R) PTx post CABG

I have always thought that PTx is caused by something penetrating, resulting in a hole and hence air entry. So initially I thought the first two scenarios must have involved some broken ribs, glasses, knives etc. But nope, none of these. That’s when I searched for more information and found 3 possible mechanisms: spontaneous, penetrating injury and blunt blows/non-penetrating injuries. (1 ‘?’ solved!)

I must digress slightly and share with you it was not easy seeing a patient who has been assaulted… I had my qualms before I went in and my heart just sank when I saw this patient. Young, bruises on face, arms and haemorrhage in the eyes. Yet the face behind those injuries is angelic. There are definitely many serious issues involved here (as we understand from the nurse and case-notes) which I won’t disclose but I sincerely hope everything will be alright as this patient is far too young… Nevertheless, I maintain the professionalism needed of us. I didn’t have a different look on my face or ask insensitive questions or provided the treatment differently. I think that this was the best approach. I was glad it went well according to my FCE who was with me.

Back to PTx. For the 3rd case, the ‘?’ in me was, is it common to have PTx after cardiac surgery? Got my answer that it is often a consequence of opening the chest wall and particularly after harvesting IMA. I think that another reason will be the insertion of lines such as the CVP line as well as drain.

For this case, I had another query. This patient was in the ICU with post-op course complicated by PTx. Was also hard to wean off ventilator. PT’s treatment and mobilization were delayed due to these reasons. Although the PTx was detected early post-op, I could not understand the delay in inserting the ICC. I guessed it could be because the doctors were waiting to see if it would resolve spontaneously? And also, since it was not a tension PTx, there was no medical emergency. I guessed the wait is worthwhile if it can spare the patient from something invasive? But at the expense of other possible post-op complications eg: atelectasis, consolidation (her x-ray didn’t look too good, very much reduced lung volume)…??? Any thoughts on this guys? Cya on Monday!

Cheers, Peiying ~

Postural Loading disorder + motor control

Hi guys. This week I had a case of postural loading disorder with motor control dysfunction component at the musculoskeletal outpatient clinic that I think it is interesting to share with everyone. The patient complained of pain on upper Lx after sitting. No history of injury. Asking about his hobbies I found out that the position of the sport (1h/per day) that he has been palying for 2 years was in full Lumbo-thoracic flexion. He use to get pain during and after training, but now the pain is gone after he started some Lx mobility exercises. Assessing his ROM, his active Lx fl was full and pain free, ext was full and painful 8/10 at EOR and he was hinging at T12-L1. He had a slumped posture and the apex of his kyphosis was around T-12-L1 (spot where he was complaining of pain). PIVMS were hyper (into ext) at L1 and PAIVMs stiff L4-S1 and painful at T12 and inter space T12-L1. At the end of the O/E a found out that he had a flexion and extension motor control disorder. When I was assessing his ability to find neutral spine in sitting, after a few verbal and manual cues, he could adopt neutral spine and his pain was gone. As my first intervention I gave him some education & hand out about core stability (local and global system), taught him to adopt neutral spine + TA activation in sitting, standing and 4 pt kneeling and started to add arm movements. That was as much I could give him before he would start activating global muscles. My supervisor suggested me that I could tape him vertically from around T11-L2 (including the segments that were at fault) so he could have a feedback to don’t flex the spine in sitting. This case it was quite straight forward, because the symptoms decreased immediately once the neutral spine was adopted. Usually loading disorders that come after sustained flexion after prolonged periods of time cannot be reproduced during the assessment, so my supervisor showed me another way to reproduce the pain by pressing down on the patient’s shoulder loading the spine for a few seconds to bring the pain one. Then we can ask the patient to adopt the neutral spine and then press again and assess if the pain relieves or not. That is a way to show the patient why keeping the neutral spine and practicing that is important. It also a way to have an objective measure for ax and re-assessment for the time that pain comes on.
I think it is always good to have another ways to assess objectively what we are looking for if the common assessment procedures don’t reproduce the patient’s symptoms. I hope this become useful for you guys if a patient with this sort of presentation come across in the future.