Accurate Ax

On this new prac I have received a patient that I was told to treat without an initial assessment. I have since been able to assess this patient and have continued treatment based around increasing muscle strength and progression toward walking with bilateral crutches. His condition is basically non-resolving so what he has got now in terms of strength is what he will effectively remain with, give or take some small increases.
After manual muscle testing I graded 1 key muscle in particular as a grade 2 bilaterally. I then saw this patient with my supervisor (1 week later) who also performed the test again and found one side to be a 2 and one side to be a 0, meaning that my goals for function needed to be adjusted and so too my treatment plans (thanks to the local muscles tricking me).

I have always thought of accurate assessment o be important to guide treatment, but this has emphasised that fact. Had I not had the supervisor look at this patient, assessment I could well have spent 4 weeks trying to strengthen a muscle which isn’t innervated and working toward a function they may never have achieved This has emphasised the importance of careful and accurate. Definitely something to keep in the back of my mind now.

Nurse

As with all hospital-based placements my current placement requires a lot of communication with nurses. On the first day myself and another student spoke to the nurse looking after the two patients we had been allocated to organize a convenient time to see these patients. We had been told that this is especially important on this ward. I approached the nurse in what I thought was a friendly manner and addressed her as her name was written on the board. She walked off and said to the other nurse ‘I just shouldn’t answer that should I?’ I thought she must have had a problem with the way that I had addressed her but she was annoyed that I had pronounced her name wrong. She then corrected me and informed us that her name was spelt wrong on the board. I didn’t think that this was a huge issue but apparently to her it was. We tried to organise a time to see the patient but she was not being helpful at all. This just really annoyed me and demonstrated to me that even though we may try and do everything right there are some nurses that are still not going to be helpful and do not like us.

Massage

On a recent musculoskeletal placement I had a patient who presented with neck and shoulder pain. On assessment she was found to have poor posture with a lot of associated trigger points and tight muscles. I treated this patient with STM, trigger point release and a lot of postural education and training. She LOVED the ‘classic massage’ and was not so impressed with the postural education. I explained to her throughout the treatment that her pain is caused by her poor posture and that if she addresses the postural issues and does the exercises I prescribe to her the muscles will not be so tight and sore. By the end of the treatment I thought she understood and she was performing the exercises well.

The next time I saw her she had forgotten the exercises and said she had not done any of them and requested for me to do some ‘classic massage’ saying that was all she needed. This annoyed me a bit especially after I had spent so much time explaining posture to her at the previous session. The next time she came in exactly the same thing happened. This time I had a quick discussion with my supervisor and they told me not to do any massage and to advise the patient that we are going to provide physiotherapy which consists of what we determine is most appropriate for them on the day and may or may not include massage. I was told to tell the patient if she wants massage to seek a massage therapist. She decided to continue treatment and did not request massage again.

This patient reminded me that a lot of people present to physio expecting just to receive massage and I realise that for these patients it is important to explain that physiotherapy will only include massage if it is the most indicated treatment based on the assessment.

Unmotivated patient

I am currently treating a very difficult patient as a musculo outpatient. Before i saw him for the first time my supervisor had spoken to me about him, informing me he was a challenging case who he had treated in the past. He presented with (R) sided neck pain with associated migranes, as well as pain in between his shoulder blades, which he reports 'comes on every year about this time' and he cannot think of a possible cause. On objective assessment he has a hypermobile neck through out and he consistently self manipulates it which has led to an instablilty problem. He also has very tight rhomboids and the pain between his shoudler blades comes on when he retracts his scapula together. He seems to have some pyschosocial issues as he had not worked for the previous 2 years due to chronic LBP. Initially i released his tight rhomboids and tried to give him some DNF exercises to increase his stability in his neck, but he does not do his exercises. I then tried to strengthen serratus and stretch his rhomboids out but again poor compliance has left me in the same place i started after 4 weeks. When my supervisor asked me what i was hoping to do with him in my last treatment session i thought in my head im hoping for a DNA as i just can't think of what else to try with this patient. In the previous 2 years when he has been treated he has just rung physio reporting he is better now and i find myself hoping that this happens this time, and i realise this is a bad attitude to take but i am all out ideas of how to get him to take responsibilty for his rehabilitation. Does anyone have any good techniques they use?

Falls

I recently treated an in pt who had been admitted with bruising and cuts to her hand following a fall the previous evening. She had been cleared of any fractures or tendon damage and was due to be discharged. As she had been admitted for a fall i thought to do a falls assessment on her to check if she would be appropriate for a falls class which is available at the hospital. I discovered that this was her first fall in 5 years and 5 years ago she had been falling regularly and then done a physio balance which had keep her balanced for those next 5 years until now. her berg balance score was 46, making her a relatively low risk pt (mainly losing marks on single leg stance and tandem stance), and she reported that she is confident with her balance and doesn't think she will fall again as she uses a stick and a 4WW at home, therefore i was thinking maybe she would be ok with a few home exercises for her balance would be suffice. On further questioning i was asking her regarding going shopping and she said her daughter usually takes her, but she probably won't go anymore. Asking her as to why, she said because of her balance. So even tho she said she was confident that she wouldn't fall, part of the reason was because she was going to cut back on what she was doing. So this changed my thinking from a HEP back to the class as we want to keep these pt's as independant as possible and doing the things they enjoy doing, rather than just being safe and cutting out the things they enjoy and the class not only improves their balance but also their confidence. I suppose what i'm getting at is that I'm glad i completed a full in depth subjective as if i had of rushed through the berg and gone by the score she managed i may have not given her the best possible treatment.
Until next time, -a.

Hand overs

On my musculoskeletal prac I was having a few new patients but also having a lot of patients who had been treated by previous students. I found that i much prefered having new patients as that way i knew everything about them as I had been at all of their treatment sessions. However obviously where ever we work we are going to have patients who are handed over to us and I realised the importance of good note writing and hand overs. I had a previous student who had particularly bad notes and after reading them I constantly felt I didn't have a clear enough picture of the patient to plan a treatment, which meant I was wasting time when they first arrived re-doing unnecessary subjective questions. However reviewing some of my own notes i realised that I would write some things that would jog my memory as to what they were moving like but would not provide adequate information to someone else reading them. So I have tried harder to make my notes as informative as possible as it not only is harder to treat for the next physio it also reflexs badly on you as a clinicain