I had an opportunity to see a little girl this week with her primary therapist.
This girl has been seeing by physio for long time for the conditions she has and one of main concerns is feeding problem.
Before the session, I was told she was quite easily to be distressed if separated from her mother. I was super careful handling of her during the session.
In physio treatments, she usually does not enjoy much in most of the positions we put her in and activities we provide, so it takes quite long time to settle her down unless she goes to her mother for cuddle.
Toward the end of the session, the primary therapist had to provide her mother some information regarding HEP and practice handling skills of these HEP. Because this girl was anxious in unfamiliar positions and quick movement, we decided to use a doll instead. My biggest challenge ‘how long she will be held without having too much distress?’ has started from the point. As expected, she started to cry by separating from mother and I have tried to hold her in different positions for her comfort. Nothing seemed to work well, so I started to sing Japanese songs for her. Shortly, I have got her attention and she started to listen. It was approximately ten minutes without her distress and I discovered she did not mind to listen unfamiliar language. I would say it is sometimes handy to have different language like in this type of situation, but how long does this trick last???
Friday, May 30, 2008
Thursday, May 29, 2008
Good grammar
Recently I was confronted by my supervisor about the grammar, wording and tidiness of recent home exercise programmes and patient reports that I had made. This supervisor likes reports to be written some what "wordy" and for HEP to be personal and very easily understood. She did however warn me of this personality trait on the first day of placement. As she was going though all the corrections she wanted me to make to the reports and HEP I couldn't help but to feel frustrated. I had spent the last 5 weeks getting used to writing hospital notes and trying so hard to make all notes as short as possible only to now be told to not abbreviate increase with an arrow but to write the whole word.
I don't know if you guys are finding yourselves in similar circumstances but I feel like every placement I go to I spend the whole time trying to learn how to write patient notes specifically how that facility or particular supervisor wants. Then once at the new placement I have to start from scratch all over again. With this current supervisor I don't feel that I handled the situation all too well, becoming somewhat defensive and not taking the advice for its true merit. Although I know that I am not the best english student in the world I feel that supervisors should be more open to different styles of writing sometimes or at least aware that we may be used to writing in different ways.
Later that day I apologised to my supervisor and tried to explain my feelings about the situation. I think it is a very important skill to be able to adjust your reporting methods to suit the facility you are working in, the various health professionals you are reporting to and the type of patient you have. Does anyone have any ideas, views, similar circumstances they could share and any suggestions of how to deal with such a situation?
I don't know if you guys are finding yourselves in similar circumstances but I feel like every placement I go to I spend the whole time trying to learn how to write patient notes specifically how that facility or particular supervisor wants. Then once at the new placement I have to start from scratch all over again. With this current supervisor I don't feel that I handled the situation all too well, becoming somewhat defensive and not taking the advice for its true merit. Although I know that I am not the best english student in the world I feel that supervisors should be more open to different styles of writing sometimes or at least aware that we may be used to writing in different ways.
Later that day I apologised to my supervisor and tried to explain my feelings about the situation. I think it is a very important skill to be able to adjust your reporting methods to suit the facility you are working in, the various health professionals you are reporting to and the type of patient you have. Does anyone have any ideas, views, similar circumstances they could share and any suggestions of how to deal with such a situation?
Postural dilemma - did Adam and Eve ever suffer from back pain?
I won't lie, I am a little annoyed at God for not giving us a bigger representation of the spine and core stabilising muscles on the homunculus when the hand is so huge!
Name me one fellow blogger that hasn't included postural education as part of their treatment plan for any one patient at any one time. Though I am on a musculo outpatient prac, this leading issue is widespread across all areas of Physiotherapy. We educate patients on this all the time, but how much sinks in or is forgotten is a mystery yet SO important they should probably design an outcome measure or test for it and standardise it across the nation!
Who's mum told them to "sit up straight" when they were younger? It might be because i'm from the country, but I seriously thought it was because slouching was rude, not to protect my back! (so naive) This begs the question;
Is there enough emphasis and resources allocated to the prevetnion of back pain and poor posture from an early age?
Due to prevalence of posture related chronic back pain, I would argue No!
You might wonder where I am going with this. In the last week I have dealt with at least 8 (thats 8/11!) patients suffereing from chronic LBP. Every single one of these have displayed poor-posture related changes resulting in abnormal stress on the spine leading to chronic LBP, often constant and very difficult (not to mention time consuming) to eradicate. My challenge is, as has been all the hype from previous bloggers, tailoring a similar message to different characters so that each individual fully understands how their body has changed through poor posture. As we didn't listen to our parents when they told us to simply "sit up straight", some patients bypass the importance of the postural education portion in a treatment session. In most part, this postural education is similar and the underlying concepts are the same. The challenge, however, is the delivery of the message... you really have to have a repertoire of several approaches for the variety of individuals that present.
We do gain some credibility in being (or nearly being) physiotherapists and CAN influence this, but problems can exist when you see a patient for the first time, and from your subjective and objective Ax you deduct it is a priority and perhaps the leading cause, and you don't know enough about them to establish the best approach. Dont forget the chronicity, potential yellow flags and the fact that it probably wont decrease their pain straight away so they may not see the relevance of postural activities. These are examples of just some of the battles we face in our choice to include postural education in treatment.
My first attempt was to just hammer home good posture, give a few home execises to help strengthen the core stabilisers and postural muscles, and pelvic dissociation activites to practice getting into and out-of a good pelvic postion in sitting and (if able) standing. The pt then returns the following week with no improvement in LBP, and on objective Re Ax when you ask them to perform their HEP, you note that the haven't been doing it correctly despite the emphasis you put on it in the first session. pt = unhappy, probably less confident in your ability and your back to square one! What I didnt do enough of was show them whats happening to their spine because of their posture and spend enough time just on education alone, giving them time to ask question about how it relates to their pain and more feedback on how postural correction will, in time, start to resolve if they maintain it. Also, it helps to give a time-frame. even if you dont know, tell them that due to the chronic nature, they are not likely to feel cured straight away. Then explain how the exercises relate, perhaps not giving them all at once so that they have to take the education away with them as that was he focus. I have found better compliance, and understanding of exercises (especially pf/Tr A activation ex's) since taking this approach.
Anyone else with any suggestions.. send your thoughts through!
and so i conclude;
Posture - If YOU have any comments then good,
If YOU know any helpful hints then great!
If YOU have the solution, then i will invite you over for dinner!!!!!
Until next time...
Name me one fellow blogger that hasn't included postural education as part of their treatment plan for any one patient at any one time. Though I am on a musculo outpatient prac, this leading issue is widespread across all areas of Physiotherapy. We educate patients on this all the time, but how much sinks in or is forgotten is a mystery yet SO important they should probably design an outcome measure or test for it and standardise it across the nation!
Who's mum told them to "sit up straight" when they were younger? It might be because i'm from the country, but I seriously thought it was because slouching was rude, not to protect my back! (so naive) This begs the question;
Is there enough emphasis and resources allocated to the prevetnion of back pain and poor posture from an early age?
Due to prevalence of posture related chronic back pain, I would argue No!
You might wonder where I am going with this. In the last week I have dealt with at least 8 (thats 8/11!) patients suffereing from chronic LBP. Every single one of these have displayed poor-posture related changes resulting in abnormal stress on the spine leading to chronic LBP, often constant and very difficult (not to mention time consuming) to eradicate. My challenge is, as has been all the hype from previous bloggers, tailoring a similar message to different characters so that each individual fully understands how their body has changed through poor posture. As we didn't listen to our parents when they told us to simply "sit up straight", some patients bypass the importance of the postural education portion in a treatment session. In most part, this postural education is similar and the underlying concepts are the same. The challenge, however, is the delivery of the message... you really have to have a repertoire of several approaches for the variety of individuals that present.
We do gain some credibility in being (or nearly being) physiotherapists and CAN influence this, but problems can exist when you see a patient for the first time, and from your subjective and objective Ax you deduct it is a priority and perhaps the leading cause, and you don't know enough about them to establish the best approach. Dont forget the chronicity, potential yellow flags and the fact that it probably wont decrease their pain straight away so they may not see the relevance of postural activities. These are examples of just some of the battles we face in our choice to include postural education in treatment.
My first attempt was to just hammer home good posture, give a few home execises to help strengthen the core stabilisers and postural muscles, and pelvic dissociation activites to practice getting into and out-of a good pelvic postion in sitting and (if able) standing. The pt then returns the following week with no improvement in LBP, and on objective Re Ax when you ask them to perform their HEP, you note that the haven't been doing it correctly despite the emphasis you put on it in the first session. pt = unhappy, probably less confident in your ability and your back to square one! What I didnt do enough of was show them whats happening to their spine because of their posture and spend enough time just on education alone, giving them time to ask question about how it relates to their pain and more feedback on how postural correction will, in time, start to resolve if they maintain it. Also, it helps to give a time-frame. even if you dont know, tell them that due to the chronic nature, they are not likely to feel cured straight away. Then explain how the exercises relate, perhaps not giving them all at once so that they have to take the education away with them as that was he focus. I have found better compliance, and understanding of exercises (especially pf/Tr A activation ex's) since taking this approach.
Anyone else with any suggestions.. send your thoughts through!
and so i conclude;
Posture - If YOU have any comments then good,
If YOU know any helpful hints then great!
If YOU have the solution, then i will invite you over for dinner!!!!!
Until next time...
Sunday, May 25, 2008
Talkative patients
I am currently on prac at an aged care facility. This particular patient had come into physio for problems she was having with her balance. It was not a new patient to the clinic but as its our first week it was a new patient to me so i was doing a full subjective assessment for practice and to get a better idea of the patients history.
As i was going through my set of questions i found the patient didnt mind to have a bit of chat regarding my questions as well as anything thing else she thought of and although i was retreiving most of the information that i was seeking i was also having trouble keeping the patient on track with the session and was concerned at the length of time that i was taking to do the subjective assessment but i did not want to continually interupt the patient even though their stories were not always relevant.
I realise that in the first session it is important to build rapport but the subjective assessment ended up taking over 30 minutes and this meant that the patients actual treatment time was severly reduced and this was not in the best interest of the patient.
This particular patient lives on their own and does not get out of the house a whole lot and therefore this is not only there physio session but it is one of their only, if not only, social outing for the week and so they are going to want to make the most of it. But i think it is important to try in a polite way to continue with treatment as much as possible while still maintaining rapport and allowing the patient to be content in the fact that it is both a treatment session and a social outing. As the patient would be quite likely to not be half as willing to attend physio if it was purely hard work without the social aspect to it.
I do not believe i was effective in getting the most out of the patient in a treatment sense and i am to continue with working on this throughout my placement, but i do believe i will be able to find more surreptitous ways of getting the patient back on track without being overly blunt or rude but would appreciate any stratergies other people use?
Thanks :)
As i was going through my set of questions i found the patient didnt mind to have a bit of chat regarding my questions as well as anything thing else she thought of and although i was retreiving most of the information that i was seeking i was also having trouble keeping the patient on track with the session and was concerned at the length of time that i was taking to do the subjective assessment but i did not want to continually interupt the patient even though their stories were not always relevant.
I realise that in the first session it is important to build rapport but the subjective assessment ended up taking over 30 minutes and this meant that the patients actual treatment time was severly reduced and this was not in the best interest of the patient.
This particular patient lives on their own and does not get out of the house a whole lot and therefore this is not only there physio session but it is one of their only, if not only, social outing for the week and so they are going to want to make the most of it. But i think it is important to try in a polite way to continue with treatment as much as possible while still maintaining rapport and allowing the patient to be content in the fact that it is both a treatment session and a social outing. As the patient would be quite likely to not be half as willing to attend physio if it was purely hard work without the social aspect to it.
I do not believe i was effective in getting the most out of the patient in a treatment sense and i am to continue with working on this throughout my placement, but i do believe i will be able to find more surreptitous ways of getting the patient back on track without being overly blunt or rude but would appreciate any stratergies other people use?
Thanks :)
My confused patient
I am currently on an orthopaedic inpatient placement where I have been treating an elderly man with a NOF fracture who has communication difficulties. He is from a remote community therefore to be discharged he must be able to climb up and down several stairs in order to board a plane. One nurse will be on the flight with him to assist with climbing the stairs.
I have seen this patient on 3 occasions where he has been taken to the physio gym to practice climbing stairs. Initially although I adjusted my communication, I treated this patient the same way I would any other elderly NOF fracture patient not taking into account the fact that he had never been in a situation like this before. Mr X appeared to be ignoring instructions and did not seem to be interested in the treatment at all. He required x2 mod-max assist to complete the task along with constant prompting during the first 2 treatment sessions.
I began the third treatment session by practicing his ambulation with a WZF around the gym during which I explained that he must be able to climb stairs to board the plane to return home. Even though we had already mentioned this to him he had not previously seemed to understand the relevance of the task. In this treatment session, Mr X’s performance improved significantly and he climbed the stairs with 1 person minimal assistance. I feel this improvement was due to this patient being more familiar with the whole situation therefore not feeling anxious or confused.
I am worried that he will become confused when faced with another unfamiliar situation (the plane). During the next therapy session the nurse that will be accompanying Mr X on the flight will join us to practice assisting him to climb the stairs so that when he does return home there will be one familiar element.
Looking back at the initial 2 sessions where I became frustrated with his performance and what appeared to be lack of interest in the task I realise that his behaviour reflects somebody who is confused and uncomfortable. I will be taking this experience on board when treating similar patients in the future and try to recognise when a patient is confused and not to assume they do not want to learn.
I have seen this patient on 3 occasions where he has been taken to the physio gym to practice climbing stairs. Initially although I adjusted my communication, I treated this patient the same way I would any other elderly NOF fracture patient not taking into account the fact that he had never been in a situation like this before. Mr X appeared to be ignoring instructions and did not seem to be interested in the treatment at all. He required x2 mod-max assist to complete the task along with constant prompting during the first 2 treatment sessions.
I began the third treatment session by practicing his ambulation with a WZF around the gym during which I explained that he must be able to climb stairs to board the plane to return home. Even though we had already mentioned this to him he had not previously seemed to understand the relevance of the task. In this treatment session, Mr X’s performance improved significantly and he climbed the stairs with 1 person minimal assistance. I feel this improvement was due to this patient being more familiar with the whole situation therefore not feeling anxious or confused.
I am worried that he will become confused when faced with another unfamiliar situation (the plane). During the next therapy session the nurse that will be accompanying Mr X on the flight will join us to practice assisting him to climb the stairs so that when he does return home there will be one familiar element.
Looking back at the initial 2 sessions where I became frustrated with his performance and what appeared to be lack of interest in the task I realise that his behaviour reflects somebody who is confused and uncomfortable. I will be taking this experience on board when treating similar patients in the future and try to recognise when a patient is confused and not to assume they do not want to learn.
Brooke's Week 1 Blog
My last placement was musculoskeletal outpatients. I had taken over a patient who was an 81 year old lady referred from orthopaedics with chronic large rotator cuff tears (supraspinatus, infraspinatus, subscapularis) on her left side. The patient is allergic to cortizone, therefore, cortizone injections were out of the question, and due to her age surgeons had decided not to operate, so she was referred to physiotherapy. The patient appeared to have high levels of pain and AROM for abduction and flexion were both around 45 degrees, both limited by pain. Subjective questioning of the patient was very difficult and her answers seemed very inconsistent week to week. Looking back at her initial assessment, it was queried that she may have some sort of short term memory loss, and this was confirmed after obtaining a list of her medical problems from her GP. As a result, trying to get information from her in regards to pain was extremely difficult. She could not seem to monitor her progress week to week, and could not comprehend using a pain analogue scale to rate her pain. Even getting her to use mild, moderate or severe took a lot of effort. The fact that she kept on telling me all about her right knee and focusing on this also didn't help! Treatment consisted of pain modalities including ultrasound, ice, very gentle soft tissue massage, gentle mobilisations of the glenohumeral joint, and a home exercise program of pendular exercises and active/assisted exercises. Week to week it appeared she was having no progress in objective asterisk signs (AROM) and subjectively her pain levels were up and down with no real resolution.
When it was realised that no intervention was having any positive effect I started to question whether physiotherapy could offer any further benefit to this patient. Due to her age and the extent of her injury, it seemed that full recovery would likely be impossible. As she had no progress after 6 or so physiotherapy treatment sessions it seemed that no progress at all would be made due to her function being limited by her high levels of pain.
After discussion with my supervisor we questioned whether she should be discharged. It was decided that physiotherapy had nothing else to offer as it was not having any effect, and after further questioning of the patient she appeared to be managing reasonably well with her injury. She is right handed and reported that she componsates well with her right hand. Functionally, she was able to do everything she wished to. She understood that she may never resolve her pain or return to her original level of function, and that as all the techniques we had used were having no effect, there was nothing further we could offer her. She was grateful that we had tried to make a difference. The patient was discharged and was due for an orthopaedic review in a few weeks time.
It was and extremely frustrating situation for 2 reasons. Firstly, trying to question her required a lot of repetition and re-phrasing to try and get the information needed. The patient often drifted off the subject and found it difficult to describe what she was feeling, or any progress week to week. Secondly, having no effect on her condition during and between treatments was very unrewarding. I felt bad that we couldn't help her and had to discharge her with no clear improvements. It got to a point where we had to look at her functional abilities and as she was having no major problems (as she was compensating well) discharge seemed justified.
Through this experience, I have learnt that patients don't always recover and discharge criteria is not always complete recovery of pain and function. Some chronic conditions such as this will not be resolved by physiotherapy, and therefore, further physiotherapy intervention is not indicated. In this situation we should be attempting to return the patient to the best functional level that we can. As we live in an aging population, we need to be mindful of patients such as these which may have difficulty in communicating what they are feeling. We need to be able to re-phrase and simplify questions, and be very patient.
In the future I would keep in mind that these conditions often aren't always resolved and will be prepared for that and include it in my initial education for the patient.
When it was realised that no intervention was having any positive effect I started to question whether physiotherapy could offer any further benefit to this patient. Due to her age and the extent of her injury, it seemed that full recovery would likely be impossible. As she had no progress after 6 or so physiotherapy treatment sessions it seemed that no progress at all would be made due to her function being limited by her high levels of pain.
After discussion with my supervisor we questioned whether she should be discharged. It was decided that physiotherapy had nothing else to offer as it was not having any effect, and after further questioning of the patient she appeared to be managing reasonably well with her injury. She is right handed and reported that she componsates well with her right hand. Functionally, she was able to do everything she wished to. She understood that she may never resolve her pain or return to her original level of function, and that as all the techniques we had used were having no effect, there was nothing further we could offer her. She was grateful that we had tried to make a difference. The patient was discharged and was due for an orthopaedic review in a few weeks time.
It was and extremely frustrating situation for 2 reasons. Firstly, trying to question her required a lot of repetition and re-phrasing to try and get the information needed. The patient often drifted off the subject and found it difficult to describe what she was feeling, or any progress week to week. Secondly, having no effect on her condition during and between treatments was very unrewarding. I felt bad that we couldn't help her and had to discharge her with no clear improvements. It got to a point where we had to look at her functional abilities and as she was having no major problems (as she was compensating well) discharge seemed justified.
Through this experience, I have learnt that patients don't always recover and discharge criteria is not always complete recovery of pain and function. Some chronic conditions such as this will not be resolved by physiotherapy, and therefore, further physiotherapy intervention is not indicated. In this situation we should be attempting to return the patient to the best functional level that we can. As we live in an aging population, we need to be mindful of patients such as these which may have difficulty in communicating what they are feeling. We need to be able to re-phrase and simplify questions, and be very patient.
In the future I would keep in mind that these conditions often aren't always resolved and will be prepared for that and include it in my initial education for the patient.
Understanding my patient
Hey bloggers. On one of my previous placements there was a particular patient that i learned plenty from. It wasn't so much the condition which was a left supraspinatus tendinopathy but understanding the patient as a whole. I was casually going through my subjective and rattling off all these questions and my patient seemed reluctant to answer and quite withdrawn in general. I was getting quite frustrated (trying not to show it) as i was asking pretty simple questions i thought but was getting poor responses and sometimes not much at all.
Going through the social history i realised why my patient was reacting in the way they were. A close family member had passed away in the previous week and the last thing they were really worried about was their shoulder.
Consequently, i felt quite bad because i hadn't been very empathetic prior to this during my assessment but consciously tried after this to try and change my manner and adjust and ask only the essential questions relevant to their condition and only the relevant objective assessment. Treatment was some hands on therapy and exercises the patient had to do along with some education. I tried to keep it all nice and succint as too much information would go in one ear and out the other with this patient.
This situation made me think about in the future if i come across another patient in grief as i most likely will what the best way would be to approach the patient as they still have a condition that needs to be treated to improve but also has to deal with other more important issues in their life. It also made me realise how someone being in such a state can affect your assessment and treatment.
In the future if someone is displaying the same signs as this patient i might even ask early on whether the patient is ok but it obviously has to be the right patient as some people are naturally quite shy and withdrawn. If i know their is something going on in their life earlier in the assessment i can tailor it and my manner acordingly and display a more understanding approach.
Going through the social history i realised why my patient was reacting in the way they were. A close family member had passed away in the previous week and the last thing they were really worried about was their shoulder.
Consequently, i felt quite bad because i hadn't been very empathetic prior to this during my assessment but consciously tried after this to try and change my manner and adjust and ask only the essential questions relevant to their condition and only the relevant objective assessment. Treatment was some hands on therapy and exercises the patient had to do along with some education. I tried to keep it all nice and succint as too much information would go in one ear and out the other with this patient.
This situation made me think about in the future if i come across another patient in grief as i most likely will what the best way would be to approach the patient as they still have a condition that needs to be treated to improve but also has to deal with other more important issues in their life. It also made me realise how someone being in such a state can affect your assessment and treatment.
In the future if someone is displaying the same signs as this patient i might even ask early on whether the patient is ok but it obviously has to be the right patient as some people are naturally quite shy and withdrawn. If i know their is something going on in their life earlier in the assessment i can tailor it and my manner acordingly and display a more understanding approach.
Michelle's Blog week one
Hello fellow bloggers. Before I start I just want to let you know that I’m not on placement at the moment, so if the details in my blogging sessions are a bit vague like, ages, VAS scores etc, it’s because I probably can’t quite remember.
Whilst on my musculoskeletal out-patients placement I had the opportunity to work with, at some times, a very challenging patient, but in the end it proved very rewarding of my time at SCGH. I will refer to this patient on several blogs as it was quite a complex case.
My patient was a 52 y.o female, referred for secondary impingement of the left shoulder due to trauma, resulting in RC tear or supraspinatus which was being trialled with conservative management. On my very first appointment with this patient I had spent an initial 30 minutes gaining a subjective history from the patient. The patient had an extensive PMHx and had been coming to the clinic for at least 6-8 weeks already and had seen minimal to no improvement. The patient verbalised her concerns about how she was seeing minimal improvement and her pain levels were still 8-9/10 and that she was very keen to get better because she wanted to avoid having surgery. The patient proceeded to break down into tears and was expressing her concerns about how she didn’t think that physio was working and that she didn’t like that every 4-5 weeks she would be having a different physio and thus needed to explain her situation every time. As this occurred within my very first week of prac ever, I was very overwhelmed and unsure how to proceed as this was the very first time I had seen the patient, so I hadn’t yet developed any rapport with the patient.
I discussed the situation with my supervisor and we decided that more education was needed for the patient to understand her injury and that there would be a long rehab process involved. We proceeded to use models and simple language to explain shoulder impingement and educated her on not exercising into pain.
The patient returned the following week, even though she understood the education given she presented with a very guarded posture and told me that she didn’t want to continue at SCGH and wanted to proceed with private physio where she thought she would get some more “hands on time.” Once again I discussed with the supervisor the patient’s wishes. We proceeded with the treatment session with some convincing on my behalf to at least stay for one last time. I proceeded to give her STM targeting the rotator cuff and posterior capsule, using stretching with gentle mobilisation, which she felt was one of her major impairments, and some trigger points. The patient felt immediate relief and expressed that she was extremely grateful of the treatment and listening to her concerns. She was then keen to return for an appointment the following week.
So from this I feel the dilemmas that were raised were patient’s expectations of treatment and the importance of developing strong therapist-client rapport. I know that when we are learning we need to do a full re Ax of asterix markers at the beginning and end of Rx, which for the most of it we think is very time consuming, and so does the patient. So I felt that in this patients case it was of most importance to alter my objective and minimise Ax and Re Ax to the minimum asterix markers and focus on manual treatment for patient wellbeing and patient rapport within the first few treatment sessions and to more importantly, actively listen to the patients subjective experience and think more about the psychosocial aspect of patient care.
So for future similar situations and a handy little hint for those who still have their musculo placements to come, I found that it is sometimes better to spend a bit more of your time discussing the subjective component initially to develop good rapport with your patient especially if they are a very emotional patient due to the debilitating nature of their injury. And more importantly not thinking just inside our little condition and treatment box i.e shoulder impingement in this case; graduated strengthening exercises and manual therapy to aid in joint healing and recovery. If the exercise of treatment being used is not successful, it’s ok to change tact and go on a different treatment option. In this case the previous student was treating with longitudinal glide of the gleno- humeral joint as this was the only thing that was momentarily decreasing pain, but overall pain was still 8-9/10 and there was no improvement in range or strength.
So next week I will fill you in on the more exciting part that happened with this patient regarding differential diagnosis….. Keeping you on the edge of your seat, aren’t I ???
Whilst on my musculoskeletal out-patients placement I had the opportunity to work with, at some times, a very challenging patient, but in the end it proved very rewarding of my time at SCGH. I will refer to this patient on several blogs as it was quite a complex case.
My patient was a 52 y.o female, referred for secondary impingement of the left shoulder due to trauma, resulting in RC tear or supraspinatus which was being trialled with conservative management. On my very first appointment with this patient I had spent an initial 30 minutes gaining a subjective history from the patient. The patient had an extensive PMHx and had been coming to the clinic for at least 6-8 weeks already and had seen minimal to no improvement. The patient verbalised her concerns about how she was seeing minimal improvement and her pain levels were still 8-9/10 and that she was very keen to get better because she wanted to avoid having surgery. The patient proceeded to break down into tears and was expressing her concerns about how she didn’t think that physio was working and that she didn’t like that every 4-5 weeks she would be having a different physio and thus needed to explain her situation every time. As this occurred within my very first week of prac ever, I was very overwhelmed and unsure how to proceed as this was the very first time I had seen the patient, so I hadn’t yet developed any rapport with the patient.
I discussed the situation with my supervisor and we decided that more education was needed for the patient to understand her injury and that there would be a long rehab process involved. We proceeded to use models and simple language to explain shoulder impingement and educated her on not exercising into pain.
The patient returned the following week, even though she understood the education given she presented with a very guarded posture and told me that she didn’t want to continue at SCGH and wanted to proceed with private physio where she thought she would get some more “hands on time.” Once again I discussed with the supervisor the patient’s wishes. We proceeded with the treatment session with some convincing on my behalf to at least stay for one last time. I proceeded to give her STM targeting the rotator cuff and posterior capsule, using stretching with gentle mobilisation, which she felt was one of her major impairments, and some trigger points. The patient felt immediate relief and expressed that she was extremely grateful of the treatment and listening to her concerns. She was then keen to return for an appointment the following week.
So from this I feel the dilemmas that were raised were patient’s expectations of treatment and the importance of developing strong therapist-client rapport. I know that when we are learning we need to do a full re Ax of asterix markers at the beginning and end of Rx, which for the most of it we think is very time consuming, and so does the patient. So I felt that in this patients case it was of most importance to alter my objective and minimise Ax and Re Ax to the minimum asterix markers and focus on manual treatment for patient wellbeing and patient rapport within the first few treatment sessions and to more importantly, actively listen to the patients subjective experience and think more about the psychosocial aspect of patient care.
So for future similar situations and a handy little hint for those who still have their musculo placements to come, I found that it is sometimes better to spend a bit more of your time discussing the subjective component initially to develop good rapport with your patient especially if they are a very emotional patient due to the debilitating nature of their injury. And more importantly not thinking just inside our little condition and treatment box i.e shoulder impingement in this case; graduated strengthening exercises and manual therapy to aid in joint healing and recovery. If the exercise of treatment being used is not successful, it’s ok to change tact and go on a different treatment option. In this case the previous student was treating with longitudinal glide of the gleno- humeral joint as this was the only thing that was momentarily decreasing pain, but overall pain was still 8-9/10 and there was no improvement in range or strength.
So next week I will fill you in on the more exciting part that happened with this patient regarding differential diagnosis….. Keeping you on the edge of your seat, aren’t I ???
She Just Didnt Get Better
On my last prac I treated a patient (Mrs S) following a fall at her hostel. She had advancing dementia. Previously she had been mobilising independently at her hostel. She was required to walk 50m independently to return to the hostel. As a result my treatment was based on walking to meet this goal.
The first 2 days, despite some difficulty transferring, she managed to between 30 and 50m with her 4WW and some assistance. Things were looking to be improving and I felt that in about a week or two with some intense physiotherapy, she might be able to get to the magic 50m mark. However after the weekend things had started to go backwards. She wasn’t able to mobilise at the standard she had been. Despite my best efforts to continue her mobility, as the week passed she progressively declined to a stage where she required hoist transfers, appeared asleep most of the time and resisted all oral intake and medications. During the final stages Mrs S was in bed all the time, shaking and on doses of morphine as requested by family to keep her comfortable, which also knocked her out fairly well. Finally she was transferred to a nursing home for what I would assume to be palliative care.
It was annoying for me, to have had her going along the right track and a few days later for her to revert to total dependence. I was getting frustrated about her lack of progress, despite my best interventions and trying to think of what I could be missing (in terms of my intervention) to get her back on track. Toward the end of her stay however, it was clear that she probably wouldn’t get better and that her time (to pass away) was soon.
I think that whilst in university we are totally focused on learning specific techniques to rehabilitate a patient back to their previous functional ability. From this experience it is clear to me that there will be patients, in any area, that will just not get better regardless of our efforts. At the same time, as a physiotherapist, being able to distance myself emotionally from any given circumstance is going to be important throughout my career. I believe that this situation had the potential to play on my mind outside of working hours – luckily, I found that it didn’t.
Friday, May 23, 2008
My patient with limited ROM
Hi everyone in physio group 1,
I am at paediatric placement.
One of my patients is female and had supracondylar fracture of humerus. ORIF and k-wire was proceeded on the same day and POP was placed for six weeks. POP was removed now and she has been seen by physio 1/52 afterword.
It is almost a month since POP was removed, however her elbow flexion is still limited at around 90 degrees. Her elbow extension is lack of 10 degrees as well. Supination and pronation are WFL. She has been encouraged to move and use her arm as much as possible in her normal daily activities. She does dancing and will start swimming in shortly which she loves, so she is excited about it. She likes writing and to draw pictures, however she prefers using other UL than injured UL due to ROM limitation. Nil c/o pain at elbow with activities and at rest but she feels it is stuck at around 90 degrees of flexion.
Since the primary physio of this patient is none of my supervisors (one of my supervisors was covering for the day), my data collection was limited in outside of medical chart on the first day of Rx. The information from her chart: her PROM and AROM were almost unchanged since physio treatment has started. The therapists have tried a variety of treatments; such as passive ROM, AAROM, HR agonist, passive stretching, and soft tissue massage to increase her ROM, but none of them looks like working well on her. I have tried PROM, PAMs, and soft tissue massage, however her ROM was unchanged as well. The end feel was like bone to bone. Compensating movement from her shoulder and trunk rotation in some activities was noticed due to lack of elbow flexion during the sesssion.
I have been told that some calcification might be developed at the elbow during immobilized time, however the information was unclear yet. I was also told if the calcification has been occured, there was almost nothing that we as physios could do for the particular problem.
Do you agree with this? There was no chance to discuss with my supervisors regarding this patient since most of them were off on the day, so I will discuss this issue once they are on duty to increase my knowledge for future references. Searching on internet or finding journal articles and books regarding this issue will be helpful, since I have not done my musculo placement and my techniques and tools in musculo setting is limited. Some techniques we learned at uni have applied, but it would be great if someone has other ideas what can be done to increase ROM from physio point of view in this patient. Definitely I don't want this patient to learn the compensating movement, but at the same time she has to use the UL in her daily activities. I am also interested in how to use the UL without compensating movements within limited ROM.
I am at paediatric placement.
One of my patients is female and had supracondylar fracture of humerus. ORIF and k-wire was proceeded on the same day and POP was placed for six weeks. POP was removed now and she has been seen by physio 1/52 afterword.
It is almost a month since POP was removed, however her elbow flexion is still limited at around 90 degrees. Her elbow extension is lack of 10 degrees as well. Supination and pronation are WFL. She has been encouraged to move and use her arm as much as possible in her normal daily activities. She does dancing and will start swimming in shortly which she loves, so she is excited about it. She likes writing and to draw pictures, however she prefers using other UL than injured UL due to ROM limitation. Nil c/o pain at elbow with activities and at rest but she feels it is stuck at around 90 degrees of flexion.
Since the primary physio of this patient is none of my supervisors (one of my supervisors was covering for the day), my data collection was limited in outside of medical chart on the first day of Rx. The information from her chart: her PROM and AROM were almost unchanged since physio treatment has started. The therapists have tried a variety of treatments; such as passive ROM, AAROM, HR agonist, passive stretching, and soft tissue massage to increase her ROM, but none of them looks like working well on her. I have tried PROM, PAMs, and soft tissue massage, however her ROM was unchanged as well. The end feel was like bone to bone. Compensating movement from her shoulder and trunk rotation in some activities was noticed due to lack of elbow flexion during the sesssion.
I have been told that some calcification might be developed at the elbow during immobilized time, however the information was unclear yet. I was also told if the calcification has been occured, there was almost nothing that we as physios could do for the particular problem.
Do you agree with this? There was no chance to discuss with my supervisors regarding this patient since most of them were off on the day, so I will discuss this issue once they are on duty to increase my knowledge for future references. Searching on internet or finding journal articles and books regarding this issue will be helpful, since I have not done my musculo placement and my techniques and tools in musculo setting is limited. Some techniques we learned at uni have applied, but it would be great if someone has other ideas what can be done to increase ROM from physio point of view in this patient. Definitely I don't want this patient to learn the compensating movement, but at the same time she has to use the UL in her daily activities. I am also interested in how to use the UL without compensating movements within limited ROM.
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