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?
Monday, August 18, 2008
Friday, August 15, 2008
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.
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.
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.
Wednesday, August 13, 2008
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?
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?
Sunday, August 10, 2008
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.
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.
Friday, August 8, 2008
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?
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?
Thursday, August 7, 2008
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?
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?
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