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.
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2 comments:
I had a very similar situation this week on my aged care placement. it was my first session with the patient but he had been coming to physio for a long time and my session was based on checking his HEP program for d/c. When i was filling out his d/c form it had a section marked reason for d/c and i realised i couldnt think of anything to put as he had a lot of things that potentially could be helped by physio. In consultation with my supervisor she advised me that the patient had been in physio for a long time without much improvement and the walking he was doing at his low care facility was going to be as beneficial as what we could offer and no further gains could be made from physio. So i suppose my situation would not have been as frustrating as yours as i had not been treating him for any length of time. But i agree it seems weird to d/c someone who is not better. good blog :)
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