How much pain is too much?

I have a patient whi is 4/52 post carapl tunnel release and jus tin the pat 1/52 or so, her pain has increased to the point where she only has to lightly touch herhypothenar eminance or palmer aspect of her writs and it can shoot terrible terrible pains. is this normal, i felt too inexperienced to advise her whether she needed further review fom her surgeon or just to reassure this that this is normal and thoug movement is painful, it will do no harm, and the pain should start to resolve with regaining of function. I havent seen many carpal tunnels, and certainly arent an expert on hand therapy, am i missing something. She has gone backto work full time caring for a boy with CP which involves alot of manual handling so i gave her a splint just to provide protection, keep wher wrist inneutral and remind her not to use it too much really. It was great for the first week but her symptoms seemed to have worsen since she has been coming to see me. Am i stirring her symptoms up by too much gentle mobilisation. I am a little stumped and would appreciate any advice, or comments by those who have seen similar presentations.

I have liased witht he OT's who have lots of experience in the area, and they seem to think im doing all the right things, but my query is given the surgeon doesnt visit very often and only takes priority cases when he does, should i refer back for an opinion on this excessive pain, or keep going the way i am?

communicating with aboriginal patients

Hey guys,

Thought I might share with you some specifically remote experiences i have had that i have found challenging. I know we did a section at uni on indigenous health adn have designed various programs "culturally sensitive" for various assignments, but it is not until you get out and make a few mistakes that those lectures etc. kick in!

A fair few of my patients are indegenous and my best advice... your subjective and objective ax is NOT the priority. For practitioners to establish rapport with our patients we are taught how important body language, eye contact and communication. Well i tried it and failed miserably, a thorough history is important, but sometimes you dont have to retrieve it so formally, or even in one session. In fact, the most success i had was talking about the footy, looking at the gorund, having a play with the affected areas and discovering patellofemoral symptoms. Specifics abou pain, mechanism of injury, past history of similar things, aggravaitng factors were just not attainable, and holding their attention was short. Also, management through exercise was what i wanted to achieve, but i have discovered promoting this striaght up with education ++ is too much and I was more successful with hands on manual therapy and as they got to know me, then introduce simple exercises (one at a time) was amore successful approach.

Does anyone else have any advice about cultural sensitivity? do you agree/disagree with my approach?

Physio Vs Nurse

Hey gang, hope prac is going well

In my placements so far i have been lucky enough to be working with very friendly,helpful and knowledgable nurses. On placement at the moment i had my first bad experience with a nurse.

A dependent patient was to be hoisted from their recliner chair into bed following a PT session. Another physio student and I returned the patient to the room and we saw the nurse was busy so we volunteered to hoist the patient back into bed. It was something that i have not come across in my previous placements or been exposed to at uni but at placement we had a brief introduction to hoists and how to use them. Therefore, we proceeded to place the material underneath the patient and then hoist the patient back into bed. When we placed her down the patient was slightly off centre in the bed and the nurse stormed over and proceeded to abuse both of us for the transfer and address us in a derogatory manner. She labelled us "bad physios" and "not to let physios do a nurses job"and was confrontational for the rest of the week.

My initial reaction was one of anger as i thought we had done quite well for something that was essentially new to both of us as the patient was hoisted safely back to bed but just needed some simple realignment. Thus, my instinct in this case was to become confrontational as i felt there was no need for her to criticise us.
Taking a deep breath i did what i needed to do to realign the patient and then once she was stable left the room without saying anything to the nurse. I knew the right thing to do was to maintain a professional demeanour as becoming confrontational would only ignite the situtation and not be of benefit to anyone involved.

This type of situtation is something i have learnt a lot from. I know now that if something similar happens in the future the best way is to maintain your cool and deal with the situation at hand.

Questions in subjective

I had two patients with Parkinson's disease in this week in different days at my placement. Both of them were females and I and another student had to conduct subjective, objective, and treatment to these ladies.

I am sure you already have experienced how important the relationship is which built between your patient and you during the subjective and that would affect onto your treatment. In truth, I had been having difficulty conducting subjective in most of my placements, but these PD patients made me realized more so than any other patients.

I know I don’t use the phrases that most English speakers use. I have tried to learn and use them, but the words seemed not to come out my mouth easily. Plus many phrases are still new to me.

During subjective with first PD patient, I was asked what I meant by her many times. As the subjective went along, I could tell the patient got frustrated by my questions. Then another student took over from the middle of subjective. As you can guess, the subject part went well smoothly. When it came to the objective, the patient looked at another student all the time and I have got the impression that I was not there. Which was understandable, but I felt I was useless at the same time. Another student and the patient, of course, were having a good conversation in following sessions, but not happening to me. The same thing happened again with the second PD patient.

At this stage, I kind of reluctant to see these patients as I know what is coming. I keep trying to have normal conversation with them, but the answers are always going to the different direction. To listen to the conversation what the patient and another student have makes me to compare myself more. I just want to know how I can make the questions easy to understand in general. Does anyone have any idea or suggestions? I just need to have some strategies I could use for future patients.

aggressive patients

In my new placement at ward 1 Shenton Park we often have to deal with patients that have altered cognition and behavioural problems as a result of their head injury. A patient that I was asked to help out in the gym was known to have issues with aggression and being instructed what to do and didnt often actually turn up for his sessions. I tried to help him with starting his exercises but it became quite clear that he didnt feel he needed help and resented being told what to do. I decided to step back and let him do what he wanted and was going to come back later. On returning I found him doing some exercises that he should not be due to a recent clavicle fracture. I therefore tried to explain that he should not be doing this exercise due to this but was continuely cut off by the patient whose answer to everything was that someone told him he couldnt do it so he was going to anyway. This patient did not like females telling him what to do and would do everything that he was told he should not. As I continued to try to reason with him he got more worked up and was not doing any exercises. At this point I decided to walk away from the situation and let the supervisor try to further talk to the patient. It was finally the male physio assistant that got through more to the patient but he still left the gym withthe same attitude and not really acheiving much withthe situation.

Looking back at this I dont think I handled the situation veyr well but I also don't know what I could have done differently to try to make it more effective. The patient clearly did not respect me or anything I had to say and his long standing attitude was unchanging. Does anyone have any circumstances where they have had to deal with similar patients or any ideas on what I could have done?

Helpful Advice

Hi everyone,
I recently had my rural prac and I was given some good advice from my supervisor that I thought I might share with you all.

I was in outpatients one afternoon when the patient I was expecting didn't turn up. So my supervisor told me I could sit in on her new patient who was due in about 5 minutes. She told me it was a stroke patient and asked me to perform the subjective and objective assessment. Seeings as though I havent had my neuro prac yet, I had a mini freak-out as I realised I had no idea what to do!

I spoke to my supervisor about the fact that I wasn't confident with neuro which was when she gave me the advice which was that if you are in this sort of setting and I patient comes in with a condition that you know very little or nothing about, or arent overly confident in that area, it is best to simply ask the patient what their problem is. If you look at the patient from a hollistic and more functional approach, and find out what they are having trouble with, and what they would like out of physio (goals and expectations), you can use this to guide your treatment. Therefore, you dont need to always do a specific assessment, but guide your assessment and treatment by the patients problems.

I have learnt from this that as long as you can find out what the patients problems are, and provide an effective treatment based on this, you dont need to be an expert in every area. I think this will help in the future if I am faced with a patient im not sure about.

Overall if you follow what the patient says and improve their perceived problems, they will be happy and satisfied with the treatment you have provided. So pretty much you cant go wrong!!

Impressed

Hi everyone,

Just a note to - again! - let you know I am reading all your posts, and to also let you know that I continue to be more and more impressed with all of them.

Trudi

paeds

I’m doing paediatrics at the moment and the thing I think I mostly find difficult is being able to change my attitude. By this I mean, that I am so used to treating adults for the last 6 months, my supervisor’s are encouraging me to let the barriers down, be silly, make jokes and just have some fun with it all. I think I’m finding it so hard because I still am trying to portray that professional image, whereas with kids, I don’t think it matters as much as it does with our adult population of patients. Kids don’t want to do physio if there is some authoritarian figure trying to tell them to do something, especially if they are in pain. I’m also finding it hard not explaining everything in detail, as kids don’t particularly need to know because they wouldn’t understand, let alone don’t want to know the nitty gritty of why you are doing something. It’s hard I think because it is changing everything we have learned in the last 3 years and putting it completely back to front and upside down and changing all the key things that we have had drummed into us.

Did anybody else have this same issue to any extent, and was there anything that you did to help bring out the inner child in you?

Neuro/Safety

I am on a neurology placement at the moment

A patient i was allocated was an elderly gent who had a CVA following a 70% occlusion of his left ICA. Upon assessment his voluntary control of UL and LL was surprisingly good but there was some associated balance deficits mainly in standing but when it came time to assess his perceptual deficits it was evident he was suffering from expressive aphasia. During his subjective he often became frustrated as he could string sentences together but would be unable to verbalise key words unless i stated them then he would agree or disagree.

We finally got into the gym and from my previous chat with him i had gathered he was understanding me and answering my questions well. We were working on his dynamic sitting balance and other issues and he had performed quite well. When it came time to end the session there was 1 last t/f to perform from plinth to w/c. Once we were in standing i asked him to step towards his right towards the w/c once he had shifted his weight onto his left with close guarding and he proceeded to step in the complete opposite direction comprising his balance and safety. We eventually safely negotiated our way to the w/c. Because of the nature of the stroke i was talking to the Dr/OT and was querying receptive aphasia/ideamotor,ideational apraxia all of which they considered not present in this gentlemen.

This situation showed me that although we sometimes tend to take a person ability to perform certan tasks for granted it pays to underestimate their abilities slightly to ensure safety. I will now monitor my patients closely to ensure tasks are done correctly and safely.

Interpreter

On a recent placement I had a patient who had moved to Australia from Indonesia less than 10 years ago and spoke very good conversational English and therefore I saw her initially with no interpreter. On further questioning I found that although her English initially appeared to be good she struggled with a lot of the questions during the subjective examination. I continued to rephrase the questions and used simple and common terms and managed to get enough information to perform an objective assessment and treatment. Next time I booked her in I also booked an interpreter and asked for ‘Indonesian.’ At the next appointment I attempted to gain further information from the subjective examination although the patient was still having trouble even with the interpreter. I was not sure why I could not get a thorough subjective from the patient.

At the next appointment a different interpreter was used and I was relieved that I was finally able to gain a thorough subjective examination. Following the appointment the patient told me that the interpreter from last week was Malaysian and therefore didn’t speak true Indonesian, which is why she had trouble understanding, whereas this interpreter was from Indonesia and spoke true Indonesian. This made both the patient and myself a lot happier. Really I feel that an Indonesian interpreter should have been booked in for the initial assessment and realise that it is important for gaining as much information from the patient as you can to provide an effective treatment, as well as making the patient feel as comfortable as possible.

L CVA

Hi, my placement now is in neuro.

My patient was suffered from L CVA. This patient did surprisingly well on initial assessment without any major complaint, compare to the result showed on MRI.

As we know the results from MRI and presenting S & S of a patient sometimes do not match, but I was still surprised how capable this patient was physically.

The major problems on this patient were dysphasia (expressive > receptive) and dyspraxia. As we all have learned the strategies to address for dyspraxia/apraxia at uni, I was using some of them such as ‘simple commands/instructions’, ‘visual, tactile & kinesthetic input’ and ‘demonstration’ as much as possible.

In terms of addressing for dysphasia, my patient and I made a rule as ‘thumb up’ for ‘YES’ and ‘thumb down’ for ‘NO’. This patient seemed to understand the simple instructions or commands, but some of the responses from this patient were not clear in my head. It could be from my instruction which made this patient confused, could be from cognitive involvement, or could be decreased concentration by long Ax. I have realized there were many possibilities could contribute to this patient which made me difficult to write a note on this patient.

On the 3rd day, this patient presented having difficulty to grab a cup on R UL. During this patient was performing this task, it seemed easier to hold a cup from top using index finger inside and rest of fingers and thumb were outside. As this patient was asked to hold from side way which we normally do, this patient was capable but having difficulty more than from top. At this stage, this patient started having tears in front of me. Imagine how stressful or frustrate knowing the activities or tasks not be done smoothly or taking longer than used to be. In addition, this patient was unable to express self verbally.

I have explained to this patient that it was not the exactly same situation but I could relate to my experience how frustrate not being able to express self. That explanation made this patient more in tears. I have realized I should not say anything to emphasize this patient’s emotion, but it was too late. I started to encourage this patient on keep trying and practicing to get better. At the end of the session, this patient held my hands say nothing but keep nodding the head. Did it mean this patient understood the reasons for having PT Rx or where this patient was heading to? Hopefully this patient was happy with my explanation on the session.

I have learnt that those patients especially who suffered from stroke need lots of encouragement and important to let them see their improvement in each PT treatment even though it was small.

Time limits

Im on my rural prac at the moment covering the wards at the regional hospital. I have one patient who has an extensive medical history. He was transferred from one of the tertiary hospitals in Perth back to this hospital in his home town. I had treated him twice for his cardiorespiratory impairments, one large component of which is ambulation.

There was one comment that he made which made me think about how we do things as a ward physio. His comment was that we dont spend enough "quality" time with patients, that we have a quota and need to fill it. After some conversastion about what he had said, I went away thinking that perhaps there are occassions that we may not be compassionate enough to patients, especially if we have a large caseload to complete that day. Whilst I understand that we cannot spend an hour with each patient in a ward setting, perhaps an extra 5 minutes here and there with the more deconditioned patients might go some way toward keeping their faith in the profession. The next time I saw the patient, I did this and he seemed to respond a little better to the session - so perhaps there is something in this (or maybe its just this patient).

post treatment soreness

As I was finishing my musculo prac I had to call any patients on my list that I had not seen during my prac to see if they still wanted some treatment or if they could be discharged. One man that I called had been seen once by the previous student about neck pain but had not returned since. I managed to call this patient who upon questioning whether he required more treatment said that he didn’t want to come back because last time he had gone home sorer than he had arrived. I further questioned him as to how he then went for the week after treatment and although the patient was somewhat vague on details he said that his neck had recovered back to normal by the following day but he could not say whether he had felt any better after this.

I therefore explained to him the side effects of post treatment soreness cue to manual techniques and that this was very normal. I suggested that he come in again, get some treatment and see if over the week it did indeed improve his pain levels, ROM etc. If it didn’t help we come try different techniques or again try to same technique but monitor responses over a longer time. I also explained how when dealing with a chronic disorder such as his neck it did take time and a number of sessions to have an effect on the pain and that he should not be looking for a miracle cure that is going to fix everything instantly. Treatment was an ongoing process along with self management to control the pain levels. The patient agreed to come back and try further treatment.

This made me more aware of just how important it is to warm patients of post treatment soreness and how first impressions are so powerful. This patient was willing to dismiss physio as a possible treatment all because he had some increased pain immediately post treatment and was not aware of what this meant. Anyone with similar experiences?

Neck and upper shoulder pain

One out of my five neck and upper shoulder pain patients was very curious why I was focus on postural correction and more on Tx area on the day of this patient’s initial visit.

First of all, English was not this patient’s first language, thus it took more than it should on SE. It was difficult to obtain the correct information from this patient as expected; however, this patient was required huge amount of time on explanation of SE questions. I did not mind taking longer to explaining since I could relate it to myself; however, it needed to be rushed to go through the initial Ax due to I was under pressure with time Mx.

Second, this patient never had any physio Rx before and did not have any information regarding physiotherapy beside massage. That’s quite common in general, and I am capable to educate these people who don’t know much about physio that there are lots of Rx that we can provide and also importance of self-Mx.

What made me more difficult treating this patient was informing this patient to focus in different area where this patient did not complain about. I assume it was not that much of issue if I explained to English speakers, even though my English was not good enough. Letting the non-English speaker understand the simple and basic concept of treating on or dealing with different area was really challenged for me. Obtaining informed consent was even harder due to the patient was still in doubt.

During Rx, I was stopped by this patient many times and told where the actual pain was. I assumed this patient thought I did not understand what this patient’s problem was since I was non-English speaker as well. About the point where the postural education was introduced, this patient got very curious why. That was the last intervention for the day, thus all I could say was ‘just trust me’ to the patient. I was sure the patient was still uncertain. At the end of the session, the patient was emphasized on HEP which included correcting posture.

By the third visit, this patient got so much better in posture and Sx. This patient was very happy with the progress and not much c/o pain.

What I have learnt from this was it is sometimes better to leave it less word and let the patient see the improvement first. I thought it worked well on this patient, because this patient was curious what the outcome would be from Rx and self-Mx. Fortunately, I have got enough trust from this patient and this patient was able to see good progress by following HEP what was told to do in such a short period of time.

Aggressive patient

I was recently on placement where i was chalenged by a confrontational patient. The patient had been in the public hospital outpatient system for many years and had continuing chronic LBP that first arose following a flexion/rotation lifting injury and prior to this there had been no major incident of spinal pain of any description. This middle aged man had been in pain since the incident with the only relief coming from acupuncture and upon subjective he appeared depressed, frustrated and even angry at times regarding his condition. Objcctively, it was clear there was elements of central sensitisation occuring with extreme tenderness to light touch over the erector spinae bilaterally and with slight pressure there was an explosive pain response. The supervisor confirmed my suspicions and thought the best way to treat this gentleman was to manage his condition and not perform any manual treatment. As i entered the cubicle i explained what was occuring and how any treatment could exacerbate his condition whereas managing his condition has been proven to be beneficial in such conditions.
He quickly snapped at me that i haven't done anything and verbalised his disapproval at the course of treatment. It took me a good 10-15min to explain in depth how his condition was not improving and how physio applied before he started to appear to trust what i was saying. Following this the patient came to all alloctaed physio sessions and complied with treatment until i left the placement.

This situation initially surprised me as i was being intimidated by the patient and my decision making was being questioned. Only after an extensive explanation did the patient understand why we were doing the things we were. It made me realise these types of chronic patients often need much more verbal input and support to facilitate their treatment/management then acute/sub-acute patients. I will now hopefully be able to identify these types of patients and give succint xplanations as to why hands on therapy is not always indicated as most patients do expect it.

Yellow flags

I had a new patient come in last week due to bilateral medial knee pain after a long winded subjective I managed to uncover that he had also had bilateral arthroscopies on both knees, shoulders and one elbow and ankle, sciatica which he informed me was form his "piriformis syndrome", flat feet for which he had orthotics made for but then he remade for himself because he didnt like the first ones, spondylolythesis in his lower Lx (when xray reports showed only spondlytic changes) but had had rods put in his back which his body had eaten away and his spine was now only held together by 'the glue used with the rods', this knee pain that got worse if he ate chicken treat or was around pesticides, but if he cleansed his liver it got better. It also helped this knee pain to do back/yoga type exercises. He had also made himself a machine that he could use to work on both his back mm and his abdominals. But the main reason he had come in today was to try some US on his knee to see if it helped because he wanted to buy one for himself over the internet.

Now I hope you are thinking exactly what I was, 'ummmmmm where do i start with this one?'. This man obviously had quite alot of yellow flags going off about his beliefs regarding his 'allergic arthritis', his chronic pain and his self diagnoses over the internet but how are you supposed to confront the patient about this. His large stack of Xrays and previous surgeries shows that he has seen many people over many years about his problems. I was left with no choice but to say (after not finding any major signs inobjective assessment) that I did not think that his pain was mechanical in origin and that PT was not indicated, especially not US. But also I found that I was quite drawn in by his story during subjective assessment that it was not until I stood back afterwards that I really put together everything he was saying and realised that this man did have alot of psychological issues along with the physical problems. Other health professionals had obviously also had been sucke din by the story considering all the surgeries that he had managed to get them to do and it seemed that they were all now just 'handballing' him on to other people. I found myself quite unprepared to handle such a patient. Should I try to correct all these long standing views, should I suggest he goes back to his GP to get further help? Does anyone have any ideas or has had any similar cicumstances that they have learnt from?

Family issues

On one of my previous pracs i was in a situation where i was allocated an elderly gentleman to treat. He presented to the department with his wife, son and daughter and i promptly introduced myself as a 4th year physiotherapy student and gave them a brief overview of how our session would include a part where i would be asking some questions (subjective) and doing some assessments (objective) based on his presenting problem then the appropriate treatment.

The family seemed to co-operate intially but just prior to the session starting the son and daughter insisted that a qualified physiotherapist assess and treat their father as they did not want a student as their fathers physio. This took me by surprise and from there i explained how although i am a student a thorough assessment will be performed followed by a discussion with the supervising physiotherapist to ascertain the best course of treatment. I told the family members they could ask questions at any time and even speak to the supervising physio but eventually the elderly gentleman and his family agreed to allow me to treat him and things went well from there.

This situation made me realise as we are students patients often judge us based on this and not our level of skill as a clinician. To overcome such obstacles i feel as though it's important for us to communicate clearly how the patient is going to be assessed thoroughly and treated accordingly based on the decisions of not only myself the student but also the supervising physio during our 4th years as students. Once we are new graduates such situations will most probably not arise as with a qualification comes a certain level of trust from a patient but until then such situations must be dealt with appropriately.

Trigger thumb

I had an opportunity to see a patient who presented ‘trigger thumb’.
On the initial evaluation, this patient presented c/o discomfort when heard the ‘clicking’ sound. Sometimes the thumb got stuck in one position and nothing could be done to release discomfort beside wait till resolved itself. There was no pain association with this condition at all.

In PE, there were no activities or any thumb movements which could possibly bring up the Sx such as ‘clicking’ sound or stuck the thumb in certain position. NAD on other exams, eg. AROM, PROM, PAMs, sensation and no patient’s discomfort at all. Basically I was treating this patient with no S & S of ‘Trigger thumb’ on the day. There was not much physio contribution in terms of intervention according to the literature and books, thus STM, gentle stretching and US were my first choice for this condition.

After each Rx component, clicking the thumb became visible more and more with thumb flexion. By the end of US, the thumb was clicking all the time. At that point, I felt very terrible because all what I did made the patient worse. Before the Rx started this patient was instructed there was limited what we could do to this condition and the Rx may or may not contribute to release the S & S, and this patient understood well. But even so, I did not expect the S & S would get worse.

On the 2nd visit, the patient reported there was still ‘clicking’ sound in occasion, but no ‘stuck in one position’ of the thumb since last Rx. The patient thought the previous Rx did help some and was happy to do the same thing again. I was not 100% sure the previous Rx did help or not, but the patient was happy to proceed the same Rx so the same procedure was conducted.

Again, no S&S pre Rx and S&S was brought up post Rx with every thumb movements. At that stage, I was thinking any of my intervention was some how triggering the ‘trigger thumb’, even though the patient reported it helped some.

I need to come up any other techniques in terms of physio intervention which at least do not increase S&S for this patient’s next visit. Does anyone have any idea? I searched in several books, but no luck.

There is most common Rx used for non-surgical Rx that is corticosteroid injection to the tendon sheath or mid-axial area, but this is not conducted by physio. Taking NSAID is another way to reduce inflammation. If the conventional Rx failed, surgical procedure would be the option to release the narrowed tendon sheath. Percutaneous procedure is getting popular recently, over open-cut procedure, which is releasing A1 pulley and very safe, effective, and quick procedure (takes 15 mins under local anesthesia in Dr’s office) without any complications. Again, this is not done by physio. So anyone has any idea?

Self Mx chronic neck pain

I have a 60 yo patient at the moment who suffers from chronic neck pain and decreased ROM. She has global hypomobility of the Cx spine, tight suboccipitals, scalenes, UT and LS and bad posture. Previously she has had some improvement with Cx PAIVMs Rx along with STM and postural advice. She is currently doing a HEP consisting of gentle AROM, muscle stretches and some postural correction exercises (which she admits she does not do often). During her recent visit she reported that she was no longer getting much pain from the neck but instead the stiffness was more of an issue and she often found the muscles to be quite stiff and painful when she stretched them.

After SE and OE I was left to decide how to progress this patient. My first thought was that I neede to free up some of the PAIVMs with manual treatment but what level and direction would I do as there was global stiffness and pain throughout the whole Cx spine and the pain ws quite central. After talking to my supervisor about my findings and the long term goals of this patient I realised that although I could do some manual treatment today to free up a few of the restricted joints, in the long run, with the extent of arthritic changes within the neck, it would not be of any benefit. Therefore for this patient Rx was more outweighed by Mx for long term affect. Therefore this would include helping teach her to self massage tight muscles to both increase general AROM and help maintain a neutral posture, teach her appropriate stretches for all of the mm that were continually getting tight and most importantly educating her on the importance of a neutral posture and ongoing Mx.

The patient had not been putting as much emphasis on maintaining a neutral posture as she should have been due to both lack of knowledge and the inability to easily get into a neurtal position due to her tht suboccipitals. Therefore it was important to explain the pathophysiology behind her neck pain and how everything linked together. I then booked the patient in to be seen again the next week. I thought that this follow up was important to see if she was becoming affective in self Mx her condition, correct any errors th exercises and posture and reinforce withthe patient the importance of self Mx for the long term treatment of her neck problem.

The patient is yet not come back in at the moment so I do not have any follow up details. I would liek to know however if anyone has any other ideas as to self management techniques or any experiences in which they have had a similar patient, and the relative sucess rate for self Mx of this kind of condition?

Patient expectations

Hey gang hope all is well,

I was recently on a prac where i came across a gentleman who had been referred to the clinic from a public hospital. He had a longstanding history of widespread thoracic and cervical OA and spondylosis that had been primarily managed from the previous physios with hydrotherapy and exercise therapy. The man was middle aged and not as old as i had expected upon presentation.
Following the examination and discussion from my supervisor we conluded that this man would benefit from gentle mobilisations of the affected segments and soft tissue work of the tight/tender musculature along with some exercises for home and general education and advice.

As planned i proceeded with the manual conponent of the treatment which seemingly worked with improvements in the restricted ranges but as i was about to proceed to show him his home exercises he quipped: "is that all your going to do can't you fix me up".

From here i had to explain his situation and pathology and tell him that although manual treatment is beneficial his home exercise program is of paramount importance as we only see him for a short time in the clinic whereas he is at home for long periods of time. I had to make him realise that although treatment is an important component, management of his condition is even more important.

This encounter made me realise that people attneding physio often see it as a "quick fix" and that we should be able to fix their pathology single-handedly. It often has to be explained that both parties have the power to influence their condition and that their role away from the physio clinic is even more important to improve. I will now be able to identify patients with this attitude in the future and hopefully educate them on how it is both our responsibilities to favouable influence the condition.

Physical Examination

This is not from what I have done for the intervention, but something what I have learnt from PE on one of my patient.

I had a nice and generous patient to do the initial evaluation this week. The main presentation the patient brought in on the day was general weakness with no pain associated in anywhere else. The investigation was still under going, so there was no specific Dx at that time.

After conducting usual SE, PE was begun without paid any special attention. At the muscle power section of LL, the patient was asked to do the heel raise in standing. From SE, this patient did not have complaint regarding walking and running, and used public transportation to come to the hospital, so I would not think this heel raise was going to be difficult for this patient.

All of a sudden, this patient started into tears. I thought the task was in pain, but it was not. The patient was never asked to do this task before and thought to be no problems. Thus this patient was very disappointed and this patient thought to fail the test. Only one leg had difficulty doing it (could not even do it once) and that made the patient more into disappointment.

I explained to the patient these tasks were not the test or exam to evaluate whether pass or fail, and it was very important info to obtain for us and must be done before starting of physio Rx. I thought the patient was well explained beginning of PE, but I assumed it was not clear enough. After the 2nd explanation, I was told the patient understood clearly, but not satisfied the result from the task. The patient was explained the reasons behind in detail, however the patient was not ready to accept the condition yet at that time.

I assume the patient’s personality is involved in part. According to the patient, if there is an issue, it should be solved or cured right away. Since the condition started, the patient tried to find the solution via lots of trials but seemed not working well. So the patient was struggled, and the heel raise was now another thing the patient realized could not do.

As this patient is still in the process of acceptance the condition, I agree that finding the activities this patient is now unable to do which was no problems before is distress. So what I have learnt from this experience, well explanation and the way of conducting the muscle power or neurological examination should be more sensitive depending on the conditions what you are dealt with. Even though it is part of our PE to go through, the result from PE might impact on our patient.