Hey guys, I’m on my neuro prac at the moment, and I know it’s only been one week but I can’t help but get the feeling that I’m not actually making that much of a difference…
I have a patient who has had a thalamic stroke and presents with cerebellar symptoms of disdiadochokinesia and dysmetria. However, because it is a thalamic stroke the impairment is motor control rather than cerebellar.
The patient tends to lean to the left during gait due to a flexion resting position of the left knee in standing. I have tested tone and there is no notable increase in tone compared to the right, hamstrings feel a bit short and tight but equal left and right, the patient also has full hip extension range and good active hip extension, so it’s not a hip problem…
The patient also told me after 2 days of treating him that he also used to walk with a slight limp. Upon asking the patient if he knew if the limp was on the left, he couldn’t recall. So I know that when the patient brings weight to the left he has trouble balancing and falls to the left, but I think a lot has to do with the persistent knee flexion. The question is what else could I possibly assess to determine if the knee is a result of the stroke or if it was like that prior to the stroke i.e contributing to his limp in the first place and therefore I am not going to have much of an effect on treating the left lower limb in regards to its length issue…??? Also the dysmetria causes the patient to have quite a narrow base and he has trouble slowing the movement down, so when he stops to turn around his feet often get caught up underneath him and he loses his balance.
I have leant a bit about thalamic stroke since treating this patient, which has been the most interesting part about it, and I like the fact that it is a little bit challenging, but this is a question for Trudi, do you know if there are any good articles on thalamic stroke or not that could help me with this patient???
Monday, June 30, 2008
Tuesday, June 24, 2008
safety issues during assessment
At my recent prac I had an in-depth conversation with a supervisor about safety issues arising during assessment that we didn’t quite see eye to eye about. This issue was whether or not you needed someone standing behind a child when they are attempting to kick a ball that is rolled to them. This supervisor felt that there should always be a person behind every child just in case they miss time the kick, stand on the ball and fall backwards. I can see that this could possibly occur but would it really happen enough to warrant there having to be someone behind at all times? There are a number of other assessment tasks during which patients could possibly fall backwards including hopping, walking backwards and using the space hoppers but we rarely stand close by during these tasks. I felt that it would really depend on the skill levels of the child and you could gauge their need for supervision based on your assessment findings so far but using this method the supervisor was jumping with patients that I did not deem necessary. I guess it is better to be safe than sorry but you can also be over cautious also. In the end I followed the supervisors wishes and had each child supervised but I was still unconvinced. Any suggestions/comments?
Monday, June 23, 2008
Dark treatment room
A patient I had seen during my placement had multiple problems. One of them was intellectual problem and it needed to be addressed in physio Rx session.
It is common to have persistence to particular object/thing if a patient has this problem. For example, light at the ceiling or light from windows.
This patient was not the exception and was distracted by any lights most of Rx session. One of the main goals in this patient was propped long sitting or long sitting with one UL free with good trunk control and balance independently > 5 mins. I had been trying different strategies to ↑time with good quality of trunk control/balance.
Have you ever tried this strategy before that treating a patient in a completely dark room?? It is quite fun to do.
Because I wanted to eliminate lights as much as possible during PT session, a room without windows (a meeting room) was chosen w/out lights and with cause-effect toys for this patient. The cause-effect toys are kind of OT area, however when it is available it is great toys to use for PT Rx as well. Two toys that I chose for this patient were switch toys. One part is a switch and it’s about 20 cm diameter rounded shape. It’s very easy to press with less weight to turn on. Another part is an actual toy and it does some activities such as making noise or moves when the switch is on.
Since this patient likes lights, I used a fan and a stuffed toy with lights. I was not sure this patient would interest or not, but it worked. This patient has been sitting with the switch-toy (on and off) without losing balance for about 10 mins. This patient also was able to prone on elbows with pressing a switch with both hands and stayed in this position for > 5 mins which never happened before.
I thought that Rx was successful in terms of Physio point of view and this patient was satisfied with what this patient wanted which was lights in session. It was hard to measure how much this patient understood regarding ‘cause-effect’ concept, however the time this patient spent in two positions were definitely improved.
It’s sometimes good for patient to have completely changed Rx area and different environment around. This could make to change some of the patient’s perceptions and improves some skills in different areas in the session.
It is common to have persistence to particular object/thing if a patient has this problem. For example, light at the ceiling or light from windows.
This patient was not the exception and was distracted by any lights most of Rx session. One of the main goals in this patient was propped long sitting or long sitting with one UL free with good trunk control and balance independently > 5 mins. I had been trying different strategies to ↑time with good quality of trunk control/balance.
Have you ever tried this strategy before that treating a patient in a completely dark room?? It is quite fun to do.
Because I wanted to eliminate lights as much as possible during PT session, a room without windows (a meeting room) was chosen w/out lights and with cause-effect toys for this patient. The cause-effect toys are kind of OT area, however when it is available it is great toys to use for PT Rx as well. Two toys that I chose for this patient were switch toys. One part is a switch and it’s about 20 cm diameter rounded shape. It’s very easy to press with less weight to turn on. Another part is an actual toy and it does some activities such as making noise or moves when the switch is on.
Since this patient likes lights, I used a fan and a stuffed toy with lights. I was not sure this patient would interest or not, but it worked. This patient has been sitting with the switch-toy (on and off) without losing balance for about 10 mins. This patient also was able to prone on elbows with pressing a switch with both hands and stayed in this position for > 5 mins which never happened before.
I thought that Rx was successful in terms of Physio point of view and this patient was satisfied with what this patient wanted which was lights in session. It was hard to measure how much this patient understood regarding ‘cause-effect’ concept, however the time this patient spent in two positions were definitely improved.
It’s sometimes good for patient to have completely changed Rx area and different environment around. This could make to change some of the patient’s perceptions and improves some skills in different areas in the session.
Monday, June 16, 2008
Difficult Patients
For my final post I wanted to talk about a particularly difficult patient I encountered on one of my patients. Unofrtunately for me he, he really didnt like doing anything I asked him to, and decided he would do his own thing instead. There was nothing I could say that would make him listen to me. He would constantly question everything and no amount of convincing would work. Luckily for me I only needed to treat him for 3 days as it was the last day of my placement.
This situation got me thinking about the difficult patients we need to deal with and ways to approach these treatment sessions. It is often hard not to get angry and show your frustration, however, im sure we've all learnt that getting angry at them definately wont get us anywhere.
These difficult patients force us to consider new options to make treatment sessions effective and to encourage compliance from our patients. I have found that continually reinforcing the reason why we want them to do the things we ask and giving the patient some power in what they are doing can improve compliance.
In the future I think its important that we have a number of options available to try if we come across a patient who is somewhat difficult to deal with, and have the ability to brainstorm new ideas if necessary without letting frustration and anger get in the way.
This situation got me thinking about the difficult patients we need to deal with and ways to approach these treatment sessions. It is often hard not to get angry and show your frustration, however, im sure we've all learnt that getting angry at them definately wont get us anywhere.
These difficult patients force us to consider new options to make treatment sessions effective and to encourage compliance from our patients. I have found that continually reinforcing the reason why we want them to do the things we ask and giving the patient some power in what they are doing can improve compliance.
In the future I think its important that we have a number of options available to try if we come across a patient who is somewhat difficult to deal with, and have the ability to brainstorm new ideas if necessary without letting frustration and anger get in the way.
Near fall
During my placement for neuro, I was treating a lot of patients who had suffered strokes, both L and R hemi's. This particular patient was a L hemi and as it was a outpatient facility they had progressed quite well in their rehab and was sent home and was coming to us for continuation of their gait re-training. I was not the therapist for this particular patient, a fellow student was, but i had seen the patient in the gym in the previous weeks and had thought they looked good in their walking.
The student treating the patient had decided to trial walking on various surfaces, so i went along to give extra safety as it was their first time walking up a slope and on grass. The patient ambulates with a walking stick and was very chatty and walked well up and down the slope without any incidences of loss of balance. They also managed the grass quite well, but had a slight trip due to their decreased activation in their dorsiflexors and their toes caught the grass, however they recovered without assitance.
During the entire walk we were both close to the patient and as we made our way back into the door we were not expecting anything to happen as he was now back in the room and they had managed so well outside. As we walked through the door they looked over to the corner and this caused both myself and the other student to look in that direction also. In the split second that we looked away from the patient they began to fall to their L. My fellow student was still in a very close position and had to catch the patient and then helped straighten them up. It was a very near fall and if the other student not been so close the patient would have fallen for sure, also if the fellow student had not been as strong as this particular student then the patient may have still fallen and taken the student with them.
I suppose what I am getting at here is this importance of close supervision and not becoming distracted as i believe if we had not looked where the patient was looking we would have noticed earlier that they were losing their balance and much less effort would have been required to help the patient maintain their balance. I have also noticed the importance of this on my current prac with the elderly. When doing balance work with them in some of the more difficult positions even in the time it takes to look down at my stopwatch the patient can start to fall let alone if you become distracted and look away for a few seconds!!
To deal with this I now make sure i focus when i have a patient who is a falls risk, not letting anything distract me and if i need to look away for a few seconds, for whatever reason, i make sure the patient stops the exercise and is in a safe position, either sitting down or holding onto parallel bars before i turn away or leave them. Near falls are quite frightening for the patient and for the therapist and i hope that occasion was my last.
The student treating the patient had decided to trial walking on various surfaces, so i went along to give extra safety as it was their first time walking up a slope and on grass. The patient ambulates with a walking stick and was very chatty and walked well up and down the slope without any incidences of loss of balance. They also managed the grass quite well, but had a slight trip due to their decreased activation in their dorsiflexors and their toes caught the grass, however they recovered without assitance.
During the entire walk we were both close to the patient and as we made our way back into the door we were not expecting anything to happen as he was now back in the room and they had managed so well outside. As we walked through the door they looked over to the corner and this caused both myself and the other student to look in that direction also. In the split second that we looked away from the patient they began to fall to their L. My fellow student was still in a very close position and had to catch the patient and then helped straighten them up. It was a very near fall and if the other student not been so close the patient would have fallen for sure, also if the fellow student had not been as strong as this particular student then the patient may have still fallen and taken the student with them.
I suppose what I am getting at here is this importance of close supervision and not becoming distracted as i believe if we had not looked where the patient was looking we would have noticed earlier that they were losing their balance and much less effort would have been required to help the patient maintain their balance. I have also noticed the importance of this on my current prac with the elderly. When doing balance work with them in some of the more difficult positions even in the time it takes to look down at my stopwatch the patient can start to fall let alone if you become distracted and look away for a few seconds!!
To deal with this I now make sure i focus when i have a patient who is a falls risk, not letting anything distract me and if i need to look away for a few seconds, for whatever reason, i make sure the patient stops the exercise and is in a safe position, either sitting down or holding onto parallel bars before i turn away or leave them. Near falls are quite frightening for the patient and for the therapist and i hope that occasion was my last.
Poor Compliance
Over the two placements I have had, the thing that I have found most difficult about treating patients is when we have to treat patients who have a very poor internal locus of control which affects their motivation to help themselves and be compliant with exercise.
Especially in my musculo placement I found that a lot of people come in just to get a massage, despite education and advice if it was regarding postural education, they would listen in the session then return the following appointment reporting that they had not done any of the exercises, and when you ask why not there was always a very poor excuse regarding their non compliance.
This is the part of the job that is less rewarding as it makes you almost question how good you are as a therapist and whether or not you just aren’t doing it right.
So from my time on my placements I’ve been able to get over the point that it isn’t us as therapists who aren’t doing there best to help these patients, sometimes we just have to give in to defeat and realise that sometimes the patients just don’t have the drive to help themselves and to get better, despite coming to physio, they really do just want the quick fix and that’s just not what we do. We can only give the patients the tools and advice to help them, help themselves and in many cases people do need our manual techniques to help them on their road to recovery but especially with postural pain patients as we all know, its advice, education and active exercises that makes up the majority of the treatment session.
And once again it’s when you realise that you can not do anything more for the patient in regards to their impairment, that’s what makes you a better physio in the end. Because for a patient to get better, they need to either want to get better or have self motivation to help them on their way to get better and reach there goals and they’re the patients that make the job rewarding.
Especially in my musculo placement I found that a lot of people come in just to get a massage, despite education and advice if it was regarding postural education, they would listen in the session then return the following appointment reporting that they had not done any of the exercises, and when you ask why not there was always a very poor excuse regarding their non compliance.
This is the part of the job that is less rewarding as it makes you almost question how good you are as a therapist and whether or not you just aren’t doing it right.
So from my time on my placements I’ve been able to get over the point that it isn’t us as therapists who aren’t doing there best to help these patients, sometimes we just have to give in to defeat and realise that sometimes the patients just don’t have the drive to help themselves and to get better, despite coming to physio, they really do just want the quick fix and that’s just not what we do. We can only give the patients the tools and advice to help them, help themselves and in many cases people do need our manual techniques to help them on their road to recovery but especially with postural pain patients as we all know, its advice, education and active exercises that makes up the majority of the treatment session.
And once again it’s when you realise that you can not do anything more for the patient in regards to their impairment, that’s what makes you a better physio in the end. Because for a patient to get better, they need to either want to get better or have self motivation to help them on their way to get better and reach there goals and they’re the patients that make the job rewarding.
defensive parents
I recently helped out at a torticollis clinic with my supervisor, in which about 9 parents came to find out information about the condition, the presentation, advice and management. During this session I was asked to go around the room and help parents assess their childrens' range, direction of preference and presence of head tilt. One mother that I tried to help had come with her 4 month old twins and was assessing them both with her mother. I started trying to help her with one of the babies, the one that seemed to have more of a preference for looking in a particular direction. During this assessment the mother started to become quite defensive, suggesting excuses for why her baby did not look as far in one direction. I went on to explain that this was an issue when tryingto assess a baby as we can not always get them to do what we want an dsuggested that she try doing another assessment while at home wherer the baby may not be quite as distracted. But regardless after assessing the baby for a short time I considered our findings to most likely be accurate. Again when I asked the mother if she felt her child had a head tilt, she said no even though throughout the assessment I had considered that he had. I tried to point this mild tilt out to the mother, explaining what I was seeing but again she become defensive. At this point I felt that I was getting no where with the mother as sh seemed to be taking everything I was saying as critisism rather than advice therefore I backed off for abit to thinik about what I could do.
Eventually I went to help the mother again, this time trying to explain the common presentations of torticollis and why it was all happening and rather than I guess "preaching" to the mother my thoughts onn her childrens presentation, I instead asked for her thoughts and guided her with her observations. I guess I learnt from this situation that although something might be quite obvious to us as trained professionals, that doesnt not mean that parents and patients will find it so obvious. As a result we need to be very careful with how we present our findings to patients and the advice that we accompany this with. It can be very scary to a parent to be hearing that their is something different about their baby especially when they dont understand the consequences of the findings. It is therefore important to explain not only what you have found but why, the severity and what that means for the child. Anyone with similar situations, comments, suggestions?
Eventually I went to help the mother again, this time trying to explain the common presentations of torticollis and why it was all happening and rather than I guess "preaching" to the mother my thoughts onn her childrens presentation, I instead asked for her thoughts and guided her with her observations. I guess I learnt from this situation that although something might be quite obvious to us as trained professionals, that doesnt not mean that parents and patients will find it so obvious. As a result we need to be very careful with how we present our findings to patients and the advice that we accompany this with. It can be very scary to a parent to be hearing that their is something different about their baby especially when they dont understand the consequences of the findings. It is therefore important to explain not only what you have found but why, the severity and what that means for the child. Anyone with similar situations, comments, suggestions?
Sunday, June 15, 2008
Running Out of Ideas
Due to an un-eventful week at prac, I have decided to go all the way back to my first prac which was neurology. While having simple skills to treat a patient from what we were taught at university, early in my prac I felt as if I didn’t have a wide enough range of treatment ideas to either keep the sessions interesting/non-repetitive, or to find techniques that would work for different patients. As a result of this, I felt as if I wasn’t going to achieve much progress with my patients, especially since I only had one or two ideas per impairment and, of course, not every patient responds equally to them.
I discussed this with both my Curtin tutor and my clinic supervisors. While they would always be able to offer something new, I would often find that this idea would work on one, but not the other patient. So here I was again, stuck for treatment ideas that I could at least trial on different patients to see who would respond well.
Finally, I was directed toward a book that was recommended by the Curtin tutor. I picked up the book and pretty much couldn’t put it down for the rest of the weeks I was there. It provided many different ideas for treatment which I put into practice. At last, I wasn’t stuck with a lack of ideas to try.
I have found that reading any resources available to me was very beneficial for developing my knowledge base as a treating physiotherapist. It sounds like a simple resolution, but I know that there are people who wouldn’t bother reading books for various reasons (I was almost like that myself) and just rely on what they have been shown or taught at uni. This is definitely a practice that I will take into all my other pracs to assist with my knowledge. I have been doing it since and I find that it has helped to different extents on the other 2 placements.
It all happened pretty quickly
My blog this week currently revolves around my current placement where i do a bit every day on the wards and in the outpatient department. I was on the wards in the morning and was seeing an elderly gent who i was mobilising and prescribing bed/chair exercises to following a humeral fracture managed conservatively. He has a very extensive PMHx as a lot of the elderly patients in hospital do which was somethihng i tried to keep in mind every time we did a PT session. I saw him in the morning and went through our treatment session and he seemed to cope really well and then left him out of bed for the rest of the morning and lunch.
I cam back in the afternoon to try and push on with some more treatment but his notes had disappeared when i went to look for them which was pretty odd. I kept searching to no avail then looked outside his room where there were multiple doctors, nurses and machines. It was then i realised something had happened.
I approached one of the doctors to try and ascertain what had happened. As the patient had previously issues with his hypertension and heart failure he was on captopril (ACE inhibitor). He became bradycardic late the afternoon before and was taken off the captopril. He consequently went into tachycardia early afternoon and heart failure.
I couldnt believe the transformation in just a few hours where my patient had gone from doing well to a life threatening position. It just makes me realise that when dealing with patients it is always wise to be thinking about their PMHx when treating them and what effect it might have. Especially in the elderly who are more prone to co-mobid conditions it is always worthwhile monitoring them during treatment and if they are improving or worsening. Even though this event occured when he wasnt under my supervision i am now a little more careful when confronted with these type of patients and will monitor them more closely.
I cam back in the afternoon to try and push on with some more treatment but his notes had disappeared when i went to look for them which was pretty odd. I kept searching to no avail then looked outside his room where there were multiple doctors, nurses and machines. It was then i realised something had happened.
I approached one of the doctors to try and ascertain what had happened. As the patient had previously issues with his hypertension and heart failure he was on captopril (ACE inhibitor). He became bradycardic late the afternoon before and was taken off the captopril. He consequently went into tachycardia early afternoon and heart failure.
I couldnt believe the transformation in just a few hours where my patient had gone from doing well to a life threatening position. It just makes me realise that when dealing with patients it is always wise to be thinking about their PMHx when treating them and what effect it might have. Especially in the elderly who are more prone to co-mobid conditions it is always worthwhile monitoring them during treatment and if they are improving or worsening. Even though this event occured when he wasnt under my supervision i am now a little more careful when confronted with these type of patients and will monitor them more closely.
Saturday, June 14, 2008
Group Rx
I had an opportunity to be in a group session which involved with multidisciplinary members, such as OT, ST, and SW.
There are about six or seven patients allocated in one group and this session runs as a six week block. The aim is provide information and educate family members from professional perspectives, such as how to play and what to watch in ADLs, resource availabilities, and exchanging/sharing personal experiences. The most important thing being in this group is get to know each other via this group, so they can become supporters for other members who may have similar concerns or less experience. It is a great system I think, because they can help each other and it could be sometimes easier to discuss any issues with other group members rather than contacting medical professionals. Of course, their medical professionals are there for the medical advice, but it is always good to have friends who they can have a conversation regarding many things in general.
It was really helpful for me to open my eyes how other professionals involved in patients. We have learnt physio point of view through our course, of course, so it was great to see others’ thought and concept, and skills how to apply in play.
For instance, regarding one patient I have been assessing in hydro but never assessed on land. I wanted to see the movement, balance and equilibrium reaction with gravity and different surfaces. After collecting all the details of stable surface, I put this patient into a ball pool to see the balance and trunk stability. OT student was outside of the pool and took this patient’s hand and placed it on the balls. This patient always put hands into mouth, so the OT student wanted to check sensory/tactile information of the hand.
ST was using different tone of the voice in the conversations/singing to check in which tone the patients reacted most through the session.
There are many things we as professionals need to focus in specialized area, however I think it is very important to be aware of what other professionals do since we treat a same patient. We could easily liaise with specialized professionals and refer to them, if we pay little more special attention in others’ area.
I will definitely apply this experience to my future prac and career.
There are about six or seven patients allocated in one group and this session runs as a six week block. The aim is provide information and educate family members from professional perspectives, such as how to play and what to watch in ADLs, resource availabilities, and exchanging/sharing personal experiences. The most important thing being in this group is get to know each other via this group, so they can become supporters for other members who may have similar concerns or less experience. It is a great system I think, because they can help each other and it could be sometimes easier to discuss any issues with other group members rather than contacting medical professionals. Of course, their medical professionals are there for the medical advice, but it is always good to have friends who they can have a conversation regarding many things in general.
It was really helpful for me to open my eyes how other professionals involved in patients. We have learnt physio point of view through our course, of course, so it was great to see others’ thought and concept, and skills how to apply in play.
For instance, regarding one patient I have been assessing in hydro but never assessed on land. I wanted to see the movement, balance and equilibrium reaction with gravity and different surfaces. After collecting all the details of stable surface, I put this patient into a ball pool to see the balance and trunk stability. OT student was outside of the pool and took this patient’s hand and placed it on the balls. This patient always put hands into mouth, so the OT student wanted to check sensory/tactile information of the hand.
ST was using different tone of the voice in the conversations/singing to check in which tone the patients reacted most through the session.
There are many things we as professionals need to focus in specialized area, however I think it is very important to be aware of what other professionals do since we treat a same patient. We could easily liaise with specialized professionals and refer to them, if we pay little more special attention in others’ area.
I will definitely apply this experience to my future prac and career.
Friday, June 13, 2008
Trace week 4
I am on an orthopaedic inpatient placement where most patients have been fairly straight forward total hip or knee replacements. One patient that I had however was quite interesting. It is standard protocol that patients get up to go for a walk with a pulpit frame day 2 following their surgery and so far most patients have been fine except for the occasional complication with low blood pressure. However, this patient was very unusual in that she was not cognitively all there despite being fine in the pre-op clinic only a couple of weeks before, when transferred to the edge of the bed she was unable to sit on the edge of the bed with less than 2 assist, she appeared to have problems with depth perception and very was very weak and unable to move in bed without maximal assistance of 2 people.
Everybody started to panic that this woman had had an undetected stroke or was in the early stages of a stroke. The neuro physio took a look at her that afternoon and she had improved immensely. They put the behaviour down to being knocked around by the PCA as there was no neurological deficit. This incident really pointed out to me that although you may be working in one field of physiotherapy you must always be looking out for other problems that could be present as the physiotherapist may be the first person to pick this up. I had previously thought that anything like this would have already been picked up by the medical team but this situation really highlighted how important it is to always be aware and on the look out for anything like this and that if you do suspect something you can never be too careful and always make sure that it gets checked out.
Everybody started to panic that this woman had had an undetected stroke or was in the early stages of a stroke. The neuro physio took a look at her that afternoon and she had improved immensely. They put the behaviour down to being knocked around by the PCA as there was no neurological deficit. This incident really pointed out to me that although you may be working in one field of physiotherapy you must always be looking out for other problems that could be present as the physiotherapist may be the first person to pick this up. I had previously thought that anything like this would have already been picked up by the medical team but this situation really highlighted how important it is to always be aware and on the look out for anything like this and that if you do suspect something you can never be too careful and always make sure that it gets checked out.
Monday, June 9, 2008
No more Mr. Nice Guy
I have a patient on my prac who has an interesting condition which was originally treated as a benign paroxymal positinal vertigo, but has had persistent vertigo, dizziness and nausea upon almost any movement of her head. She is able to reduce symptoms by sitting still. A balance assessment was performed and she scored very poorly and most exercises were ceased due to her dizziness. Her ambulation is severly impaired by her condition and she reports that she has incidences where she has to grab onto the nearest bit of furniture or her husband to prevent her from falling on a daily basis. I think it is only a matter of time before she has a fall.
Treatment to date has focused on trying to give her accomadation and substitution strategies, giving her exercises where she provokes her symptoms in a controlled setting to try and give her body some desensitisation to it, and hopefully this will cause her to be able to deal with it better when she is in a everyday situation. She is very compliant and motivated to try and improve her condition, however has reported that the exercises have had little effect.
I have spoken to my supervisor and we both agree that the exercises are probably not going to change her condition all that much and think it is more important now to begin to focus on her safety. However my supervisor advised me that the patient is not very keen when walking frames are brought up. I was cautious in how i approached it trying to reason with the patient that her walkin is not very safe and that she should consider using some sort of aid. She was positive with this idea when a walking stick was brought up, but as she does have a problematic side and reports she loses balance to both directions i suggested a 4 wheeled walker was going to be a much safer option. As soon as i mentioned this she went rather quiet and did not seem happy at all. I left the topic at this time and went on with some other aspects of her treatment.
It is hard as it is obvious that the patient does not like the idea and people sometimes have psychological issues regarding using a frame as it makes them feel like they are gettin worse or older. I do not want to push the issue on her because i could see her not wanting to come to physio anymore, but i also think that this is the best option for her safety. My next plan is to try and show her that she is safer with the walker by tryin to get her to use it while we repeat a dynamic gait index test or a timed up and go. I think if i am able to get her to try these things with the walker she may realise how much easier it is, but as i said before if she does not want to try it i dont want to push the issue so much that she does not return. Tough gig.
Treatment to date has focused on trying to give her accomadation and substitution strategies, giving her exercises where she provokes her symptoms in a controlled setting to try and give her body some desensitisation to it, and hopefully this will cause her to be able to deal with it better when she is in a everyday situation. She is very compliant and motivated to try and improve her condition, however has reported that the exercises have had little effect.
I have spoken to my supervisor and we both agree that the exercises are probably not going to change her condition all that much and think it is more important now to begin to focus on her safety. However my supervisor advised me that the patient is not very keen when walking frames are brought up. I was cautious in how i approached it trying to reason with the patient that her walkin is not very safe and that she should consider using some sort of aid. She was positive with this idea when a walking stick was brought up, but as she does have a problematic side and reports she loses balance to both directions i suggested a 4 wheeled walker was going to be a much safer option. As soon as i mentioned this she went rather quiet and did not seem happy at all. I left the topic at this time and went on with some other aspects of her treatment.
It is hard as it is obvious that the patient does not like the idea and people sometimes have psychological issues regarding using a frame as it makes them feel like they are gettin worse or older. I do not want to push the issue on her because i could see her not wanting to come to physio anymore, but i also think that this is the best option for her safety. My next plan is to try and show her that she is safer with the walker by tryin to get her to use it while we repeat a dynamic gait index test or a timed up and go. I think if i am able to get her to try these things with the walker she may realise how much easier it is, but as i said before if she does not want to try it i dont want to push the issue so much that she does not return. Tough gig.
communication
On my current clinical placement I recently realised how necessary it is to communicate with other staff members. I always realised it was important to know what was happening in all aspects of care with the patient however if I couldn’t understand somebody’s writing in the integrated notes I wasn’t too fussed skipping over it. One of my patients is an elderly woman who has been in hospital for several months due to repeated NOF fractures and a total hip replacement. She has been mobilising with a WZF and we thought she would be fine to be discharged with this as she had reported having only one step on entry to her house.
As this patient does not always have the best memory I looked through her notes and realised there were several different entries from different people stating the number of steps this woman has to enter her house ranging from 0 to 4. Obviously if there is any more than 1 she would not be able to be discharged with a frame and must be able to use crutches if she is to return home. I discussed this with the OT who had not realised there were variations in the notes. Through further discussion with other staff members we were able to ascertain that this patient will require to be uisng elbow crutches to enter her house.
Although I always knew it was important to discuss things with other staff members this situation strongly reinforced it. Since this, I have always made certain I read the notes thoroughly and whenever I am not clear on anything I will always discuss it with other staff.
As this patient does not always have the best memory I looked through her notes and realised there were several different entries from different people stating the number of steps this woman has to enter her house ranging from 0 to 4. Obviously if there is any more than 1 she would not be able to be discharged with a frame and must be able to use crutches if she is to return home. I discussed this with the OT who had not realised there were variations in the notes. Through further discussion with other staff members we were able to ascertain that this patient will require to be uisng elbow crutches to enter her house.
Although I always knew it was important to discuss things with other staff members this situation strongly reinforced it. Since this, I have always made certain I read the notes thoroughly and whenever I am not clear on anything I will always discuss it with other staff.
Objective Assessments- Are They All Really Necessary?
I was recently on my muculoskeletal placement. As I took over a patient list from the previous student at the facility, I had not done the initial assessment on majority of my patients. One particular patient had presented with anterior knee pain. After several treatment sessions she had been making no progress and in recent visits had complained of lateral hip pain. When reviewing her file, I realised that she had not been assessed for tight ITB, which I found rather odd because we have been taught that decreased length of ITB can be a contributing factor to patellofemoral pain. On assessment, it was found that the patient did infact have a very tight ITB with possible trochanteric bursitis. Treatment consisted of ultrasound over her greater trochanter, and soft tissue massage of her ITB. This had an extremely positive effect of pain and knee ROM.
I felt pleased that we had managed to identify this contributing factor and significantly improve the patients condition. The patient was also very happy with her progress seeings as though previous to this, physiotherapy was not having much of an effect.
Through this situation I have realised the importance of performing a thorough initial assessment in order to determine all the key impairments, and therefore guide treatment. It has shown that for all patients we should perform all necessary objective assessments, even though some of them seem a waste of time because we never know what conclusions we may draw from them.
I felt pleased that we had managed to identify this contributing factor and significantly improve the patients condition. The patient was also very happy with her progress seeings as though previous to this, physiotherapy was not having much of an effect.
Through this situation I have realised the importance of performing a thorough initial assessment in order to determine all the key impairments, and therefore guide treatment. It has shown that for all patients we should perform all necessary objective assessments, even though some of them seem a waste of time because we never know what conclusions we may draw from them.
when is enough really enough?
I had a 13 month old patient Amy* last week who was brought in by her mother. This child had not yet started crawling and therefore fher mother had brought her in to see if we could help. Amy, who is an only child, was a very clingy baby who was quite attached to her mother. During the treatment session Amy started getting distressed due to the activities and positions we were putting her in as part of her assessment. She started crying and her mother was required to settle her down. At this point, gauging how distressed she had become, the supervisor and I decided that we had probably reached our limit with Any for the day and instead we should now try to simply provide advice for the mother on what we had seen so far though the use of a doll rather than handle Amy. Once we got the doll out however we noticed how interested Amy was in the doll and how her mood had improved. Taking this opportunity we instructed Amy's mother on what we wanted her t do with Amy so we could continue our assessment, while we distracted Amy with the doll. Amy's mood continued to improve and I was eventually able to hold Amy again, being somewhat more cautious this time and finish what needed to be done.
While I was in this session I was constantly watching Amy to decide when it was time to halt treatment or when she was simply being abit grizzly but was still able to continue. As in many other sessions with young children, there is line between the child crying out a little because they dont like the position you have put them in and a child who has had too much and needs a cuddle from mum. But as I young adult myself who has not had all that much contact with young children in my life I often find it hard to decide when to draw this line. When I first started this placement, if the child even made a peep I would stop what I was doing but as time has gone on and I have been around alot more babies I have learnt the differnce between this grizzly cry that I can actually deal with myself compared to a child who is really uncomfortable and needs their mother to console them. And then once they have been consoled when is the appropriate time to start treatment again, or has we got as much out of the child as we can for that day. With Amy I guess I realised that you dont have to abandon a treatment session as soon as a child becomes distressed because they can easily change their mood again. You just ned to keep watching them.
While I was in this session I was constantly watching Amy to decide when it was time to halt treatment or when she was simply being abit grizzly but was still able to continue. As in many other sessions with young children, there is line between the child crying out a little because they dont like the position you have put them in and a child who has had too much and needs a cuddle from mum. But as I young adult myself who has not had all that much contact with young children in my life I often find it hard to decide when to draw this line. When I first started this placement, if the child even made a peep I would stop what I was doing but as time has gone on and I have been around alot more babies I have learnt the differnce between this grizzly cry that I can actually deal with myself compared to a child who is really uncomfortable and needs their mother to console them. And then once they have been consoled when is the appropriate time to start treatment again, or has we got as much out of the child as we can for that day. With Amy I guess I realised that you dont have to abandon a treatment session as soon as a child becomes distressed because they can easily change their mood again. You just ned to keep watching them.
Sunday, June 8, 2008
3 down...one to go
The pt I was assisting with was a 5 year old boy who had a pretty bad strain of the flu, required ventilation and as a result of complications etc ended up with hypoxic brain injury. He is now VERY weak, has just regained sitting balance, requires 2 people to stand him and is cortically blind.
This blog isn’t really one about what should I do or how I do it. As we all know, the prognosis for this isn’t particularly great. Sure he is a child so chances of recovery might be pretty good, but for instance if I had gone through this situation at his age – the list of things I would have missed out on between the ages 5 and 21 is quite large. When I thought about his situation and how it might affect his life to come, I was quite saddened by it all.
However, the thing that struck me and made me feel better (and when I think about it, all of the children I’ve treated or been a part of treating) is how happy and upbeat he was despite the fact that he now has major physical limitations compared to his pre-morbid state. When comparing it to adults – it is quite a different outlook on life – the kids just want to get out there and get on it.
This and other children I’ve had dealings with in this prac definitely made me reflect on the varied outlook that children and adults have. I think everyone could take a lesson from these children as they don’t seem to be pre-occupied with their disability, they are more pre-occupied with life. As a result it is obviously important for us to focus on what they can do during our time rehabilitating them to maintain this outlook. I know Id definitely like to be as upbeat as these children if something terrible happens to me.
Saturday, June 7, 2008
I am reading!
Hello all of you,
Just a quick note to let you know that I am indeed reading all your posts! I think they're fantastic and you're all reflecting really well.
I'm particularly impressed with not only your reflection on certain situations, but your improvisation in treatment techniques, your ability to draw information from your patients, and the extent to which you are using your intuition in assessing and treating your patients.
Well done. I'll endeavour to comment on certain posts as you go.
Enjoy your placements.
Trudi
Just a quick note to let you know that I am indeed reading all your posts! I think they're fantastic and you're all reflecting really well.
I'm particularly impressed with not only your reflection on certain situations, but your improvisation in treatment techniques, your ability to draw information from your patients, and the extent to which you are using your intuition in assessing and treating your patients.
Well done. I'll endeavour to comment on certain posts as you go.
Enjoy your placements.
Trudi
What should i do?
Hey blogging buddies
Ive got a pretty interesting case that i wanted to discuss
I saw the patient on a Tuesday and the incident had happened on a Saturday afternoon whilst playing Rugby. In the last 5mins of the game the patient became concussed as he was accidently kneed in the head at the bottom of a ruck and immediately came off with a blood nose and did not return for the remainder of the game. He was advised to not fall asleep until at least 10pm at not to drink alcohol for at least 3 dayswhich are pretty standard instructions following a concussion. He did not have any injuries apparent following the incident. The patient followed instructions but awoke the next morning in agony unable to elevate his right arm at all. He was referred to a doctor on campus as he was friends with te rugby club who ordered an X-ray with no significant findings and then directly to the outpatient department.
Upon examination there was no obvious deformity around the GHJ and ACJ. His AROM was reduced globally with elevation movements being the most provocative and limited and pain over the deltoid insertion whilst PROM was quite well preserved with all movements nearing EROM. Empty can and full can in 30 degrees of scaption were painful but IR and ER in neutral, Speeds and lift off werent. The stability tests around the shoulder were all clear indicating that most likely there wasnt a dislocation and palpation along the anterior shoulder wasnt provocative. Palpation over supraspinatus in the supraspinous fossa was painful.
After discussing with my supervisor we most likely thought it was a supraspinatus tear.
Treatment consisted of mainly a HEP aimed at maintaining mobility and preventing secondary complications along with reducing pain. Pendular exs, Cx ROM, shoulder rolls, Thx rotn and elbow/wrist and finger exs were advised along with ice, a sling aimed at unloadng the GHJ and some education as to what we thought had happened.
Everything went well and we were keen to send him off for some investigations to confirm the structure involved went he informed us he was already going for an US on that Friday.
I thought great and booked him in for the following Monday hopefully knowing the exact structures involved and then the best course of Rx.
The following Monday came and the patient had not turned up to his appointment. I tried to contact him to find out why he didnt attend and what the results where but there was no answer. I tried to contact the Doctor involved but he was not answering his pager as well. There was no investigations put up onto PACS so i cant have a look at his US so most likely it was done privately. Ive tried to contact him over the past 2 weeks to no success.
Consequently, i have no idea what has occured to this patient. Did he have surgery? Is he being managed conservatively somewhere else?
Really i am just wondering what people think about what should be done now? I have been trying to contact him to no avail so should i just give up? Or should i try and get to the bottom of whats going on?
Maybe i should have things more clear upon the conclusion of our 1st session and discussed the potential outcomes and options folowing the US.
Ive got a pretty interesting case that i wanted to discuss
I saw the patient on a Tuesday and the incident had happened on a Saturday afternoon whilst playing Rugby. In the last 5mins of the game the patient became concussed as he was accidently kneed in the head at the bottom of a ruck and immediately came off with a blood nose and did not return for the remainder of the game. He was advised to not fall asleep until at least 10pm at not to drink alcohol for at least 3 dayswhich are pretty standard instructions following a concussion. He did not have any injuries apparent following the incident. The patient followed instructions but awoke the next morning in agony unable to elevate his right arm at all. He was referred to a doctor on campus as he was friends with te rugby club who ordered an X-ray with no significant findings and then directly to the outpatient department.
Upon examination there was no obvious deformity around the GHJ and ACJ. His AROM was reduced globally with elevation movements being the most provocative and limited and pain over the deltoid insertion whilst PROM was quite well preserved with all movements nearing EROM. Empty can and full can in 30 degrees of scaption were painful but IR and ER in neutral, Speeds and lift off werent. The stability tests around the shoulder were all clear indicating that most likely there wasnt a dislocation and palpation along the anterior shoulder wasnt provocative. Palpation over supraspinatus in the supraspinous fossa was painful.
After discussing with my supervisor we most likely thought it was a supraspinatus tear.
Treatment consisted of mainly a HEP aimed at maintaining mobility and preventing secondary complications along with reducing pain. Pendular exs, Cx ROM, shoulder rolls, Thx rotn and elbow/wrist and finger exs were advised along with ice, a sling aimed at unloadng the GHJ and some education as to what we thought had happened.
Everything went well and we were keen to send him off for some investigations to confirm the structure involved went he informed us he was already going for an US on that Friday.
I thought great and booked him in for the following Monday hopefully knowing the exact structures involved and then the best course of Rx.
The following Monday came and the patient had not turned up to his appointment. I tried to contact him to find out why he didnt attend and what the results where but there was no answer. I tried to contact the Doctor involved but he was not answering his pager as well. There was no investigations put up onto PACS so i cant have a look at his US so most likely it was done privately. Ive tried to contact him over the past 2 weeks to no success.
Consequently, i have no idea what has occured to this patient. Did he have surgery? Is he being managed conservatively somewhere else?
Really i am just wondering what people think about what should be done now? I have been trying to contact him to no avail so should i just give up? Or should i try and get to the bottom of whats going on?
Maybe i should have things more clear upon the conclusion of our 1st session and discussed the potential outcomes and options folowing the US.
Medical Miracle
On my cardiopulmonary placement, I was lucky enough to spend my time in an intensive care unit. I was on a rotating roster which meant I spent one week in one part of the ICU and the following week in another part. I first met this patient in my 3rd week of prac, when they were admitted as a multi trauma victim from a 3m fall from a quad bike accident. The patient sustained at least 14 rib fractures, resulting in lung contusions, an occipital skull fracture and multiple lacerations and grazes to the rest of his body.
For the duration of my 3rd week, when initially doing rounds we were not treating this patient for his chest due to the extent of his chest injuries and his chest x-ray was continuing to show that it was essentially clear from any chest pathology. On one occasion the family were present and they enquired as to who we are and why we weren’t treating the patient. My supervisor explained that his chest essentially looked free from infection and that physiotherapy wasn’t indicated due to the extent of his injuries. The family were fine with this and seemed very hopeful and optimistic of recovery for their relative.
After an initial few days in hospital the patient was showing no signs of improvement as they were not breathing spontaneously with the ventilator as the patient was being de-sedated, nil response to verbal command or painful stimuli. Things were not looking good for the patient and the doctors believed that it was time for end of life discussions with the family.
When I returned in my final week, to my surprise the patient was still on the ward, he had a surgical trache inserted, and had developed critical illness polyneuropathy (neuromuscular weakening in critically ill patients) however, the patient was now awake, alert, moving all limbs to command and mouthing words to the hospital staff. I was in complete surprise, and said to my supervisor, “wasn’t this the patient that they were talking about end of life discussions with the family??”
We soon learnt that on the Friday before they had begun rehab sessions with the patient using the pink chair (a rehabilitation chair used in ICU) doing active and active assisted movements of the upper and lower limbs and moving from supine to sitting over the edge of the chair. I then proceeded to work with the patient during that week, running the rehab sessions twice daily. The patient showed huge improvements in strength and the amount of manual assistance required decreased over the duration of the week.
This blog really was to reflect on how amazed I was at the patient’s recovery and the patients own determination to get better. I ended up walking out of each session with him with the biggest smile on my face just knowing how far he had come, and to be honest I was absolutely amazed at the turn around in events. I used the patient’s motivation to my advantage using lots of positive reinforcement, even though by the end of each session he was exhausted, he was still keen to go for an afternoon session.
This was just a happy story, despite all the patients that don’t get better in the ICU, this patient defied all odds and survived. And even though we as physios didn’t have an initial role in the recovery process and chest maintenance, we were able to help in the rehabilitative phase and for this particular patient, proved to be very rewarding for the patient and to me.
The main learning tools I got from this placement were, when to justify when physiotherapy treatment is not indicated, and that every little bit counts with these patients. By this I mean a daily chest check and passive ROM can make the world of difference when the patient is de-sedated and extubated and now progressing into the rehabilitation phase. I was also more importantly able to develop my clinical reasoning skills within a very challenging environment.
For the duration of my 3rd week, when initially doing rounds we were not treating this patient for his chest due to the extent of his chest injuries and his chest x-ray was continuing to show that it was essentially clear from any chest pathology. On one occasion the family were present and they enquired as to who we are and why we weren’t treating the patient. My supervisor explained that his chest essentially looked free from infection and that physiotherapy wasn’t indicated due to the extent of his injuries. The family were fine with this and seemed very hopeful and optimistic of recovery for their relative.
After an initial few days in hospital the patient was showing no signs of improvement as they were not breathing spontaneously with the ventilator as the patient was being de-sedated, nil response to verbal command or painful stimuli. Things were not looking good for the patient and the doctors believed that it was time for end of life discussions with the family.
When I returned in my final week, to my surprise the patient was still on the ward, he had a surgical trache inserted, and had developed critical illness polyneuropathy (neuromuscular weakening in critically ill patients) however, the patient was now awake, alert, moving all limbs to command and mouthing words to the hospital staff. I was in complete surprise, and said to my supervisor, “wasn’t this the patient that they were talking about end of life discussions with the family??”
We soon learnt that on the Friday before they had begun rehab sessions with the patient using the pink chair (a rehabilitation chair used in ICU) doing active and active assisted movements of the upper and lower limbs and moving from supine to sitting over the edge of the chair. I then proceeded to work with the patient during that week, running the rehab sessions twice daily. The patient showed huge improvements in strength and the amount of manual assistance required decreased over the duration of the week.
This blog really was to reflect on how amazed I was at the patient’s recovery and the patients own determination to get better. I ended up walking out of each session with him with the biggest smile on my face just knowing how far he had come, and to be honest I was absolutely amazed at the turn around in events. I used the patient’s motivation to my advantage using lots of positive reinforcement, even though by the end of each session he was exhausted, he was still keen to go for an afternoon session.
This was just a happy story, despite all the patients that don’t get better in the ICU, this patient defied all odds and survived. And even though we as physios didn’t have an initial role in the recovery process and chest maintenance, we were able to help in the rehabilitative phase and for this particular patient, proved to be very rewarding for the patient and to me.
The main learning tools I got from this placement were, when to justify when physiotherapy treatment is not indicated, and that every little bit counts with these patients. By this I mean a daily chest check and passive ROM can make the world of difference when the patient is de-sedated and extubated and now progressing into the rehabilitation phase. I was also more importantly able to develop my clinical reasoning skills within a very challenging environment.
Thursday, June 5, 2008
Creativity
I have seen this patient for several times and was excited to see the improvement each time this patient came. One biggest problem on this patient at the moment is fluctuating trunk muscle tone. The motivation in movement on this patient is very high, but the fluctuating muscle tone interrupts as this patient tries to do something. It is difficult in coordination and co-contraction of the muscles in this patient, thus most of activities or movements become hard for this patient to control. There are older siblings in the family and this patient wants to join them in play, but extensor tone kicks in most of the time as this patient moves. This patient’s mother tries very hard to give all the siblings enough needs, however it is sometimes challenging for everyone in the family.
I have been thinking how I could possibly help this patient and also the family to have enjoyable time at home without difficulty. Because of this patient’s fluctuating tone, someone has to hold or give this patient appropriate support in sitting or standing if this patient wanted to be in the position. My plan for this patient was regular Rx such as muscle strength, wt shifting and transferring, but also I started to think the various positions for this patient in play at home. Kneeling position was the one of the challenging position for this patient to be held and thus less practicing in, so I thought it would be great if this patient could have kneeling equipment at home. Has anyone seen it before? I personally have never seen it so I did not have any luck to find the equipment where I am at, of course. We as physio students are able to put a patient into this position and hold manually in physio session, however it is always nice for mother and a child to play together face to face at home. Hence I really wanted to find an easy way for this family w/out any difficulty. I used a standing table to make it to be a kneeling table for this patient with cushions and rearrangement of Velcro, and tried it in the Rx session. Excitingly, it worked on this patient. This patient played for 20 mins with toys in both hands which never happened before in kneeling position without fluctuating trunk. Head control was beautifully in midline and never flipped backward and hip extensors were activated most of the time to keep in this position. Also, WB on hands and elbows were occurring and both hands never went to this patient’s mouth during the activities. Both this patient’s mother and I were very excited regarding what was happening in the session. Fortunately, this patient got permission to borrow this equipment for practice at home and mother was very happy to be able to play with this patient in up-right position without being held by mother. Also this patient will be able to play with other siblings as well.
What I have learnt from this session is we need to be creative not just only in treatment activities, but also in equipment wise. Some equipments are customize made and it is limited in some facilities. Making appropriate equipment for patients ourselves with whatever equipments we are allowed to use in the facility is one of our tasks as physio students.
I have been thinking how I could possibly help this patient and also the family to have enjoyable time at home without difficulty. Because of this patient’s fluctuating tone, someone has to hold or give this patient appropriate support in sitting or standing if this patient wanted to be in the position. My plan for this patient was regular Rx such as muscle strength, wt shifting and transferring, but also I started to think the various positions for this patient in play at home. Kneeling position was the one of the challenging position for this patient to be held and thus less practicing in, so I thought it would be great if this patient could have kneeling equipment at home. Has anyone seen it before? I personally have never seen it so I did not have any luck to find the equipment where I am at, of course. We as physio students are able to put a patient into this position and hold manually in physio session, however it is always nice for mother and a child to play together face to face at home. Hence I really wanted to find an easy way for this family w/out any difficulty. I used a standing table to make it to be a kneeling table for this patient with cushions and rearrangement of Velcro, and tried it in the Rx session. Excitingly, it worked on this patient. This patient played for 20 mins with toys in both hands which never happened before in kneeling position without fluctuating trunk. Head control was beautifully in midline and never flipped backward and hip extensors were activated most of the time to keep in this position. Also, WB on hands and elbows were occurring and both hands never went to this patient’s mouth during the activities. Both this patient’s mother and I were very excited regarding what was happening in the session. Fortunately, this patient got permission to borrow this equipment for practice at home and mother was very happy to be able to play with this patient in up-right position without being held by mother. Also this patient will be able to play with other siblings as well.
What I have learnt from this session is we need to be creative not just only in treatment activities, but also in equipment wise. Some equipments are customize made and it is limited in some facilities. Making appropriate equipment for patients ourselves with whatever equipments we are allowed to use in the facility is one of our tasks as physio students.
Wednesday, June 4, 2008
Watch your mouth
Apologies on the late blog as i'm sure you all have been losing sleep over not seeing mine yet...i was having computer difficulties.
On my first prac i was in one of the large hospitals and i got myself into a bit of trouble because i was talking in a public area and did not realise who was listening. It was on my 3rd last day at the placement and i was speaking to another student about how the placement had gone because that student was taking my place the following week on the ward. I explained to him that it had been a quite enjoyable prac and that it was pretty cruisey. After the conversation i thought nothing more of it and had pretty much forgotten what i had even said.
But the next day my curtin clinical supervisor took a quiet moment to mention to me that i should watch what i say in public areas. At first i had no idea what she was talking about being oblivious to the fact that anyone was listening to my conversation the day before. My supervisor explained that one of the big bosses of the physio department had been walking past in a corridor and heard that i said the prac was cruisey, and had then spoken to my clinical suprevisor and was quite angry about what i had said. Luckily for me my supervisor had seen me over the previous weeks and had gotten to know my personality somewhat and that i was a rather laid back person and she explained to the big boss that it was not that i was saying the prac was slack and that i was doing no work, it was more an indication that it wasn't flat out every second of the day with no time to stop and breath. My supervisor told me that she had to spend 5-10 minutes calming the person down and reasoning with her that i was a motivated student who was working hard and not bludging and not to take what i had said out of context as she did not know my personality. My supervisor re-iterated to watch what i say and how easily a simple conversation heard by someone else could have made a successful prac a lot less successful and not only could i get my self into trouble in the short term, it would not help when looking to get jobs after graduating, especially when its the boss that hears you!!! I felt terrible that my supervisor had to get me out of such a situation and was thankful that she made the effort to help.
So basically what i'm getting at is the same message that i was given...be careful what you say in public areas...
i'l c u next week...same bat time, same bat channel
On my first prac i was in one of the large hospitals and i got myself into a bit of trouble because i was talking in a public area and did not realise who was listening. It was on my 3rd last day at the placement and i was speaking to another student about how the placement had gone because that student was taking my place the following week on the ward. I explained to him that it had been a quite enjoyable prac and that it was pretty cruisey. After the conversation i thought nothing more of it and had pretty much forgotten what i had even said.
But the next day my curtin clinical supervisor took a quiet moment to mention to me that i should watch what i say in public areas. At first i had no idea what she was talking about being oblivious to the fact that anyone was listening to my conversation the day before. My supervisor explained that one of the big bosses of the physio department had been walking past in a corridor and heard that i said the prac was cruisey, and had then spoken to my clinical suprevisor and was quite angry about what i had said. Luckily for me my supervisor had seen me over the previous weeks and had gotten to know my personality somewhat and that i was a rather laid back person and she explained to the big boss that it was not that i was saying the prac was slack and that i was doing no work, it was more an indication that it wasn't flat out every second of the day with no time to stop and breath. My supervisor told me that she had to spend 5-10 minutes calming the person down and reasoning with her that i was a motivated student who was working hard and not bludging and not to take what i had said out of context as she did not know my personality. My supervisor re-iterated to watch what i say and how easily a simple conversation heard by someone else could have made a successful prac a lot less successful and not only could i get my self into trouble in the short term, it would not help when looking to get jobs after graduating, especially when its the boss that hears you!!! I felt terrible that my supervisor had to get me out of such a situation and was thankful that she made the effort to help.
So basically what i'm getting at is the same message that i was given...be careful what you say in public areas...
i'l c u next week...same bat time, same bat channel
Monday, June 2, 2008
Trace week 2
I am currently on placement in a hospital setting where I go between 3 different wards throughout the day with a total of 6 different physiotherapists who may ask me to see a patient or supervise me while I am working with a patient. At first I enjoyed getting a lot of different opportunities and opinions however after awhile it became difficult to manage. It was obvious there was not enough communication between the staff members, and between myself and the staff as on a number of occasions I was expected to be in several places at the same time and was not given any indication which patients I was expected to see during the day. This made it difficult to manage my time effectively and on several occasions physios got annoyed.
After awhile it became too difficult so I spoke to one of the physiotherapists. I told her that I was finding it hard to know where I was meant to be and who I was meant to be seeing. She agreed with me and had recognised that there were several people trying to bark orders. To overcome this and to make things more clear to both myself and the other staff members we make a list every morning of what events I have on during the day and what patients I am to see. This had made things a lot easier and I can now effectively manage my time.
On all my previous placements I have only had 1 or 2 physios therefore have never had a problem like this before. I didn’t really know whether to speak up about it or persevere with the situation as it was. I am very glad that I did say something before it became too much as we were able to reach a simple and effective solution.
After awhile it became too difficult so I spoke to one of the physiotherapists. I told her that I was finding it hard to know where I was meant to be and who I was meant to be seeing. She agreed with me and had recognised that there were several people trying to bark orders. To overcome this and to make things more clear to both myself and the other staff members we make a list every morning of what events I have on during the day and what patients I am to see. This had made things a lot easier and I can now effectively manage my time.
On all my previous placements I have only had 1 or 2 physios therefore have never had a problem like this before. I didn’t really know whether to speak up about it or persevere with the situation as it was. I am very glad that I did say something before it became too much as we were able to reach a simple and effective solution.
I had my gerontology placement this semester and quickly found out that treating some of these elderly patients can be much more difficult than I originally had imagined. One of the biggest boundaries to a successful treatment session was keeping the patient's attention to the current task. With a limited amount of time available for treatment (follow up appointments were 30 minutes) it was very important to be time efficient. This, however, was sometimes very challenging as the patients could be very chatty, and I often found myself in conversations that were very hard to get out of. Reasons it was difficult to switch the focus of the treatment back to physio-related tasks were often because the topics patients would talk about were often very important to them, and as some of the patients lived alone, they could be quite lonely with limited people to talk to.
It could sometimes be extremely frustrating trying to keep patients motivated to the treatment session. I often felt bad having to cut the patients off and switch their attention, but this was necessary due to the time constraints.
This situation has taught me that although we sometimes would love to sit down and have a chat with these patients, we need to keep in mind that our purpose is to provide a service as a physiotherapist and in order to provide an effective treatment, we need to ensure that we keep focused on the task at hand. Therefore, we should get to know a few techniques to use when confrunted with these situations for future patients.
It could sometimes be extremely frustrating trying to keep patients motivated to the treatment session. I often felt bad having to cut the patients off and switch their attention, but this was necessary due to the time constraints.
This situation has taught me that although we sometimes would love to sit down and have a chat with these patients, we need to keep in mind that our purpose is to provide a service as a physiotherapist and in order to provide an effective treatment, we need to ensure that we keep focused on the task at hand. Therefore, we should get to know a few techniques to use when confrunted with these situations for future patients.
group treatment compliance
At my current placement I help run a childrens play group for developmentally delayed children. In this group there is one child who has a fairly severe intellectual disability and is very hard to control. Even with the parents taking part in the class he often does not follow instructions and will instead run of to do his own thing. Trying to get tis child to do want the rest of the class is takes alot of time and some things he will just never do. I had to ask myself was this patient suitable for the group treatment scenerio? In order to get him working we would have to somewhat neglect the other children who were doing the right thing, meaning that they didnt get as much benefit from the class. At the same time the group scenerio is benefitting the child through the team work and positive role models he is witnessing.
I would guess that in an individual treatment session this child would not get any more benefit as he will not like the added attention and will still refuse to do the tasks that he doesn't like. Maybe instead if an extra physio was involved in the group to work with that child in particular so the other children are not disadvantaged in anyway everyone would be happier. Otherwise we also noticed that the child preferred gross motor activities especially jumping on a trampoline, over fine motor activites. After being allowed to jump on the tramp ie during the obstacle course, the child was much more compliant with any following activites. As a result maybe changing the structure of the session by having this obstacle course just before the fine motor tasks would increase compliance? I guess the question is how much should you modify a class or the benefit of one person and when do you have to draw the line in saying that they are simply too disruptive to be in the class? Next week we will be trying the trampoline idea.
I would guess that in an individual treatment session this child would not get any more benefit as he will not like the added attention and will still refuse to do the tasks that he doesn't like. Maybe instead if an extra physio was involved in the group to work with that child in particular so the other children are not disadvantaged in anyway everyone would be happier. Otherwise we also noticed that the child preferred gross motor activities especially jumping on a trampoline, over fine motor activites. After being allowed to jump on the tramp ie during the obstacle course, the child was much more compliant with any following activites. As a result maybe changing the structure of the session by having this obstacle course just before the fine motor tasks would increase compliance? I guess the question is how much should you modify a class or the benefit of one person and when do you have to draw the line in saying that they are simply too disruptive to be in the class? Next week we will be trying the trampoline idea.
Old school physio
Hey gang
The outpatient department im on at the moment primarily deals with chronic pain which is often very hard to treat and if there are improvements if often takes a prolonged period of time. This kind of brings me to the point of this blog which is based around one of the older musculoskeletal physios at the outpatient department.
On my second day i was assigned to sit in with her as she assessed a patient with chronic neck pain for the first time. Through the subjective the physio was really loud and almost confrontational towards the patient and once the subjective had been done did a brief objective. Treatment wise after the assessment on this first session she educated the patient for about 15 minutes about the condition, her posture and exercises to be performed at home. The patient hadn't been given an oppurtunity to practice the exercises or ask questions through the session and there wasn't any exercise sheet given at the end.
A few days later the physio called me in to see how this patient was going following her first session. The physio ask her to recap the exercises and to no great surprise she had completely forgot the exercises and when she attempted to perform them it was done poorly. Instead of the physio being understanding and trying to correct her she proceeded to blast the patient about not caring and accusing her of not wanting to get better. The patient was speechless and so was I. The patient left the cubicle at the end of the session seemingly in a worse mood then when she came in. I doubt very highly as to whether she would like to see the same physio in the near future.
Now, im definetely no gun but this physio had pretty much abandoned the basics and when it all went pear shaped blamed the patient. From my point of view i don't think the patient was to blame at all as she had been given very little direction with her home exercise program and not surprisingly didn't do them that well.
What i've kind of gathered following the interaction between this physio and the patient is that you need to build rapport initially with your clients and go through the processes we've all been taught. Trying to explain the key points concicely is of upmost importance as education seems to be a major role when it comes to treating certain patients. If i blabber on for 20 minutes the pt will not remember much of what ive said and it becomes pretty pointless. If exercises are explained well or an exercise sheet is given a situation like the one explained above can be avoided.
The outpatient department im on at the moment primarily deals with chronic pain which is often very hard to treat and if there are improvements if often takes a prolonged period of time. This kind of brings me to the point of this blog which is based around one of the older musculoskeletal physios at the outpatient department.
On my second day i was assigned to sit in with her as she assessed a patient with chronic neck pain for the first time. Through the subjective the physio was really loud and almost confrontational towards the patient and once the subjective had been done did a brief objective. Treatment wise after the assessment on this first session she educated the patient for about 15 minutes about the condition, her posture and exercises to be performed at home. The patient hadn't been given an oppurtunity to practice the exercises or ask questions through the session and there wasn't any exercise sheet given at the end.
A few days later the physio called me in to see how this patient was going following her first session. The physio ask her to recap the exercises and to no great surprise she had completely forgot the exercises and when she attempted to perform them it was done poorly. Instead of the physio being understanding and trying to correct her she proceeded to blast the patient about not caring and accusing her of not wanting to get better. The patient was speechless and so was I. The patient left the cubicle at the end of the session seemingly in a worse mood then when she came in. I doubt very highly as to whether she would like to see the same physio in the near future.
Now, im definetely no gun but this physio had pretty much abandoned the basics and when it all went pear shaped blamed the patient. From my point of view i don't think the patient was to blame at all as she had been given very little direction with her home exercise program and not surprisingly didn't do them that well.
What i've kind of gathered following the interaction between this physio and the patient is that you need to build rapport initially with your clients and go through the processes we've all been taught. Trying to explain the key points concicely is of upmost importance as education seems to be a major role when it comes to treating certain patients. If i blabber on for 20 minutes the pt will not remember much of what ive said and it becomes pretty pointless. If exercises are explained well or an exercise sheet is given a situation like the one explained above can be avoided.
Sunday, June 1, 2008
Children and physio
I have been treating a young girl recently and an issue concerning how hard to push young children has come to mind. This girl has a history of avoiding physio but at other times she really enjoys getting out of bed and into the gym. I have a feeling that she has learnt what to say to get out of physio, for example expressing sickness or headaches…or she might be telling the truth.
Differential Diagnosis
This is the same patient as I referred to last week. The patient was referred to the clinic with a HPC of slipping on wet grass and falling onto their L elbow, resulting in partial rotator cuff tear and as a result, secondary shoulder impingement. The patient also presented to the clinic with central mid to lower cervical pain 8/10, worse L than R and sharp pain down the lateral-posterior aspect of their L arm 6-7/10 at rest 8-9/10 upon arm movements above 90 degrees. The patient had also been seeing a chiropractor early on in the treatment for her neck pain, with still little to no relief.
Since being treated the pain has remained the same, with minimal improvements in shoulder range and the patient reports that her main concern is that she is not getting much more than 3 hours of sleep per night due to the pain in her neck and arm. Since the patient had been coming for some time now, the initial objective assessment had already been completed and the cervical spine ROM cleared. However I was quite concerned that since coming to the clinic the patient had seen little improvement, still experiencing high levels of pain and irritability during treatment. The pieces of the puzzle didn’t seem to quite fit, so I discussed with my supervisor my concerns and that I wanted to alter the previous treatment given as this had not made the patients condition any better.
I proceeded to do a full neuro Ax and found the patient tested positive to Radial nerve sensitivity, bringing on the exact pain the patient was experiencing. From this everything else started to make more sense. The shoulder wasn’t getting any better as it was limited due to the neck pain caused by the neural sensitivity. So the treatment changed to optimise opening up of the intervertebral foramina with techniques like cervical distraction and physiological lateral flexion. The patient experienced immediate relief of pain and as a reassessment tool had significant increases in shoulder range when the radial nerve provocation was provided and desensitised with its respective manoeuvres. The patient’s mood was significantly higher for my last few treatments as she was experiencing pain relief for days at a time and was even able to get more than 3 hours of sleep at night.
What I learnt from this experience was that it’s really important to stick with your gut instinct. If someone else has seen the patient previously it’s ok to question their findings and discover them for yourself. Also with a case like this she may not have initially had the neural sensitivity to the degree in which she did by the time I had treated her, so it could have been missed, but since Cx ROM was cleared, the previous student felt no need to test neural tissue as there was no indication at the time. Also what I learnt was that you need to be quite thorough in clearing the cervical spine as a source of pathology especially with shoulder injuries because there is a significant correlation between shoulder pathology referred from the cervical spine. So I’m not saying her condition was all cervical spine, there was a component of the cervical spine and also the shoulder pathology itself, but as my supervisor said, you treat the proximal symptoms first, because as they resolve there is often a degree of resolution of the distal pathology.
Since being treated the pain has remained the same, with minimal improvements in shoulder range and the patient reports that her main concern is that she is not getting much more than 3 hours of sleep per night due to the pain in her neck and arm. Since the patient had been coming for some time now, the initial objective assessment had already been completed and the cervical spine ROM cleared. However I was quite concerned that since coming to the clinic the patient had seen little improvement, still experiencing high levels of pain and irritability during treatment. The pieces of the puzzle didn’t seem to quite fit, so I discussed with my supervisor my concerns and that I wanted to alter the previous treatment given as this had not made the patients condition any better.
I proceeded to do a full neuro Ax and found the patient tested positive to Radial nerve sensitivity, bringing on the exact pain the patient was experiencing. From this everything else started to make more sense. The shoulder wasn’t getting any better as it was limited due to the neck pain caused by the neural sensitivity. So the treatment changed to optimise opening up of the intervertebral foramina with techniques like cervical distraction and physiological lateral flexion. The patient experienced immediate relief of pain and as a reassessment tool had significant increases in shoulder range when the radial nerve provocation was provided and desensitised with its respective manoeuvres. The patient’s mood was significantly higher for my last few treatments as she was experiencing pain relief for days at a time and was even able to get more than 3 hours of sleep at night.
What I learnt from this experience was that it’s really important to stick with your gut instinct. If someone else has seen the patient previously it’s ok to question their findings and discover them for yourself. Also with a case like this she may not have initially had the neural sensitivity to the degree in which she did by the time I had treated her, so it could have been missed, but since Cx ROM was cleared, the previous student felt no need to test neural tissue as there was no indication at the time. Also what I learnt was that you need to be quite thorough in clearing the cervical spine as a source of pathology especially with shoulder injuries because there is a significant correlation between shoulder pathology referred from the cervical spine. So I’m not saying her condition was all cervical spine, there was a component of the cervical spine and also the shoulder pathology itself, but as my supervisor said, you treat the proximal symptoms first, because as they resolve there is often a degree of resolution of the distal pathology.
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