Excellent Posting

Hi all

Just a short note to complement you on your blogs to date.  The description of the circumstance, your actions, reflection and future handling of similar situations has been excellent.  I also congratulate you on your openness and honesty.

I have posted a couple of comments (usually empathetic, positive and hopefully helpful).  If there is anything your specifically would like me to comment on, please let me know.

Regards

John

And your problem is?

I have treated a patient on two occasions over the past few days for back pain complaints. Her initial complaint was primarily 6/10 pain in the lumbothoracic area, and 4/10 pain in the area of upper trapezius. I performed a relatively full assessment of the Tx and Lx spine, and the only significant finding was that she sat in excessive flexion and maximal posterior pelvic tilt. I treated this with active movement into some anterior tilt (she actually had quite good lumbopelvic dissassociation) and posture reeducation, which made her feel much better. She also pointed out to me that she believed that her interpretaion on pain is heavily dependant on how happy or sad/anxious It was a bit of an odd presentation (given that some answers to subjective questions were quite abnormal), but I just went along with what she was telling me.

I saw her 3 days later, now with 6-7/10 pain in triceps area, 5-6/10 pain upper trap, 4-5 lumbopelvic area. I was feeling pretty tired, and didn't really feel like treating a patient such as this. But then I thought to myself that the time I saw the patient 3 days beforehand I was able to make her symptoms much better - if I can make her happy, why not?

I continued on with posture corrections and education, which was effective. I did not investigate the arm pain any further, but at the conclusion of the treatment session she reported that this pain had gone or 'been cured'. I just provided her with some empowerment to help her help herself.

I later read in her notes that she had been living alone for some time and was feeling very isolated, and also at times quite paranoind.

So does it matter if you can't find a comparable sign? In this case I don't believe so. I established that posture was really the only point of concern at this stage, and ensured that I was not missing or overlooking any other factors. I just gave my undivided attention to the patient, made her feel that I was improving her sypmtoms and provided general reassurace.

Of course each case is very different and there are many factors that need to be considered. THe approach of the biopsychosocial model incorporates the notion of pain is strongly influenced by social and psychological aspects - something to keep in mind.

Dealing With Parents

Sorry for the late post guys, my internet hasn't been working all day, but my trusty Grandpa managed to fix it!

Whilst I was on my paeds placement, there was, understandably, quite a lot of interaction with parents. There was a situation which arose numerous times, where the parents were very particular and in some ways demanding in what they wanted with their child. This is understandable as they obviously just wanted what was best for their child, however sometimes what they wanted wasn’t realistic and wasn’t always the best thing for them.

In some ways this can be frustrating, because you as the physio also have the best interests of the child in mind; however the actions you want to take may be different to those of the parents. For example, one parent wanted their child to progress to a new style of walker; however my supervising physio didn’t think the child was ready. As a student, it wasn’t really my place to make those decisions, which is probably a good thing because I don’t yet have the experience to make that call. However, it does make me think, what would I do in this situation? Is it best to let the parent try their way, knowing that it may not work, or would it be best to try and explain to the parent that their child isn’t yet ready to progress, or isn’t at the level they think they are. I think either way it’s difficult because one way or another the parent’s view of where their child is at will be changed, and quite often this can be a depressing thing for a parent of a disabled child.

In the example I used above, it was decided by the physio to organize a time for the parent to come in and try the new walker, with two other highly experienced physio’s present. This gave the parent both a chance to see whether or not it would work and also, if it didn’t, to have this explained by people who really knew what they were talking about. I think if I was placed in the position of my supervising physiotherapist, I would have done the same thing. But those resources aren’t always available; if that was the case I believe that the best thing to do would be to sit down with the parent and explain to them in a sympathetic way why you don’t think what they’re suggesting is the best thing for their child right now. It’s also important to be really well informed yourself, that way your argument has a lot more force. If you had tried your hardest to do that and the parent was still very adamant about what they wanted then maybe it is best to let them try, as actions sometimes speak louder than words, as long as the child is not being put in danger. However, it’s very important to have compassion in these situations and try and see things from the parent’s point of view as well as yours.

Language difficulties

Hello all,

Last week I had to go and visit a patient who had just been discharged from hospital after a short stay following urine retention. The patient is 5 years post left-sided stroke (right hemi). On the RITH referral form, the treating physio from the hospital (who happened to be a fellow student- not from this group) had written down that an interpreter would probably be required with this patient, because Yugoslavian is his first language and he knows very little English.

For our first visit, we did not take an interpreter with us because our main aim was just to assess the home environment and determine whether or not the patient was safe in his home. We also wanted to first assess just how difficult communication would be before taking up the time of an interpreter, in case it wasn't necessary.

Upon talking to the patient, he was having great difficulty producing words/communicating what he wanted to say, and was hesitating/stuttering a lot. It seemed though, that the patient was understanding pretty much everything we said to him. I became immediately suspicious that perhaps the communication difficulties were caused by expressive dysphasia post stroke, as opposed to a language issue. His wife was home and spoke fairly good English (she was also Yugoslavian), so I asked the wife in private whether or not the patient understood/spoke English well and she informed me straight away that he understands English quite well, but that since his stroke he had been having great difficulty producing the desired words whether he be attempting English OR Yugoslavian (expressive dysphasia).

It therefore became apparent that we would be wasting our time bringing in an interpreter- as the patient in the most part, was just producing random sounds or the very beginning of words. This scenario made me wonder whether the previous physio had even spoken to the wife about the client's language before assuming it was a problem with understanding English. While in some situations it may be quite rude to direct questions about the patient to their family members, in other situations it is entirely appropriate.

As long as you speak to the patient's family in private and ensure you are not coming across as not believing the patient or ignoring what the patient has to say- often in scenarios like the one above, a lot can be gained by having a quick word to the family about what the patient was like previously. After all, they have known the patient a lot longer than we have- what we might assume to be a personality change following stroke for example, may well just be how the patient was all along.

Good luck with final assessments everyone!

Informing Patients About The Big Picture

While on my musculo placement I treated Mark* who came in with knee pain after hyperextending his knee as a result of a tackle during a game of soccer four weeks ago. Initial examination lead to a diagnosis of a lateral meniscus tear/sprain with possible strain of popliteus, Mark also demonstrated general ligamentous laxity throughout (including both knees). Initial treatment consisted of mainly RICE to remove swelling, VMO exercises, taping and hamstring/quad co-contraction to prevent further damage and promote stability. Mark was seen for the next two weeks with treatment consisting of progressing HEP and further taping, he was progressing well and had an important game to play in the following Sunday. Mark was advised that his knee would most likely be okay to play but should probably take this game off if able.

Mark returned the following week in a bad way. Mark reported falling with his knee collapsing laterally while running in a straight line without being tackled, mark reported hearing a pop. Assessment revealed further damage to lateral meniscus, laxity and pain over LCL and possible damage to ACL/PCL. Mark was thus referred on to an orthopaedic surgeon.

This situation lead me to reflect on whether I should have advised Mark not to play soccer, I talked to my supervisor regarding this situation and she concluded that this event was unavoidable and it was highly likely that it was going to happen at some point due to Mark’s generally lax ligaments, this was further evident by the untraumatic and seemingly trivial mechanism of injury. With this information in mind I still can’t help but think that if we had worked on his ability to co-contract for a couple of weeks more Mark may have been able to avoid such an injury

If I was to be confronted with this situation again I think I would try to convince my patient to avoid sport for a longer period explaining to them the possible detrimental effects of returning to sport too early. This situation has taught me the importance explaining the big picture and giving a detailed timeline of likely progress etc to patients so they are fully aware of the situation at hand and they can make informed decisions.

*Fictitious names used

Interaction with Patients' Families

Hey guys, last week of placement, hope everything is going well!

Something I never really considered when we did our communication units (remember those?) was the fact that we also have to interact with patients families. While I’m sure at some point it was mentioned, the focus was upon the patient and common situations you may face e.g. the emotional patient, indigenous patient, non-English speaking patient.

Recently on my cardiopulmonary placement I have had several patients who always have visitors, mainly their partners or children. As this is my first real ward based placement I have been surprised with the amount of interaction I have had with the patients’ family. Naturally the family is concerned for their husband/father etc and as a result have many questions to ask of me.

Last week I was approached by a patients' wife in the hallway. Her husband is currently recovering from an emergency procedure for a perforated duodenal ulcer, following which he developed some complications and spent some time in ICU. He is now quite de-conditioned and I have been working with him to build up his strength. While in physio terms he is making good improvement, in medical terms his recovery is slow. His wife was very teary talking to me, which I found difficult as I had never been exposed to this before. I did my best to comfort her, pointing out how far he had come since his stay in ICU; however I tried to avoid giving false hope or saying something like “he’ll get better”. In my opinion it is wrong to use such statements as they may in fact be wrong, but you can still provide encouragement and point out the positives.

In the future I’m sure I’ll feel uncomfortable in the same situation, however like anything, the more you are exposed to something the easier it becomes. This placement has made me realise that not only is it important to develop communication skills with patients and allied health staff, but families also.

Enjoy your time off, or good luck with your next placement.

Confidence is key

I always find it very hard when we have to do the Continuing Ed presentations or have to present on one of our patients when on prac. Even though I’m now 21, close to graduating as a physio, and I do know what I’m talking about, I still get really nervous and find it hard to deal with presenting in front of a group of people, even if it’s just an informal patient presentation with my supervisor and my peers. And I don’t think I’m the only one either. I don’t feel comfortable, get very nervous, start to confuse myself about where I’m up to, start to doubt myself and my opinion and then rush through to the end of the presentation.
As health professionals we will have to keep doing these presentations once we graduate and we will have to participate in “round table” discussions with other members of the allied health and medical professions regarding patient management and treatment. So it is very important that we are able to deal with speaking in front of people and be confident with our opinions, and be able to justify our decisions when under pressure. Whilst we have to do presentations as part of our course, we never really got taught any techniques to help us deal with this, or were given any advice about how to prepare yourself for that situation.
This is a pressing issue at the moment, since we just had our Sem 2 orientation and were told more about the PCR, which I think will be a good test of our knowledge and ability to justify our decision making. However I also think that there will be quite a few people, myself included, who will be, for lack of a better word, freaking out about an oral exam. I get worked up enough as it is about the thought of a Continuing Ed session!
It will be interesting to see what the PCR practice sessions involve, but for the moment I think it is important for us to remember that we are all adults now, we have a lot of knowledge and we are getting more and more experience as we get through our different pracs, so we need to reflect that in our presentations. Being confident, and always keeping in mind that we are (nearly) health professionals, with opinions that matter, should help keep the nerves at bay, especially if we are well prepared for whatever situation we are in. It also helps to keep in mind that when you are presenting a Continuing Ed session that your peers aren’t there to judge you and they won’t try to find fault with your presentation, they are simply there to listen and learn from you. So think back to those important lessons from women’s health and just remember to breathe...

communicate differently to different people

Hi guys, hope you guys enjoy your placement, I am going to talk about the differences between the communication of colleagues, patients and family members. I am now at neuro placement and I find that communication is particularly important in this area as in I got to deal with different people everyday and also explain the same information or message in different ways, which I find it challenging.

First of all, communicate with the patient who has dysphasia and dysprexia. How? He hardly understand you and can only say ‘yes’ or ‘no’, also poor ability to follow command. Sometimes the command we learnt at school will not be so helpful in this case because those patients will have unbelievable response like when I asked the patient to side steps to the middle of the bar but he ended up turning himself in a circle. Therefore verbally command got to be very simple and concise and also rather than saying ‘bend both knees up, hand on the tummy, reach over and turn to the side, drop your leg down to the edge of the bed at the same time push up from the hand and sit up’, simply saying ‘sit up’ will make the life more earlier for you as well as your patient because those patients just do not have these kind of concept and sequence in their mind so commands have to be functional. More importantly, providing manual input at the same time gives them feedback for those patients to follow the movement you want him to do which improve their motor learning.

Communicate with the family member is challenging as they will ask you some questions that you have no idea to how to answer it, and they will remember every single word you say. So I think that confidence is an essential element as they really trust what you say about the condition and the exercise program. If you do not show confident enough they will not trust you that will affect the rapport or relationship between you as a therapist and the patient’s family. It is challenging for the student since we have not qualified yet, but it does not mean we cannot do it. Just say ‘I don’t know’ or ‘not sure’ and give them direction of what people what should ask for and it will be fine.

Finally, communicate with the supervising physios, well you cannot talk too much or talk very little to them and the quality of the content is very important. Before treatment tell them what you are going to do on the patient and suggest some possible treatment progression, after the treatment tell them what u ended up doing and what they are up to because that is what they mean by communication.

Last but not least, communication is vastly helpful tool for us to deliver my message to someone from not knowing to knowing. Since we are in a people orientated profession, we must encounter different people from different background or group in some sort so that we need to fine tune and adapt the content we speck accordingly to our target group and deliver the message that they will understand.

Hands Off

Hi guys
i am currently on my neuro placement and one of my new patients is fiercely independant he does not like recieving help for any tasks or even like to see that you are guarding him if he does he will knock your hands away and become quite frustrated. This is also the case with any treatment techniques you are trying with him he does not like you to put your hands on and guide him in any way as he sees it as a negative thing where you are incenuating he is unable to do the technique properly or independantly and he doesnt want to be seen as an invalid. His wife also rang the physio department to tell us he had tried to climb a ladder on the weekend even though there is no way he is at this level yet.

I found this quite difficult for me to handle especially the first time i saw him as obviously it is better to be safer and guard them closely if you have never seen them before and do not have an accurate idea of their safety and functional mobility. Also with neuro alot of the techniques are very hands on and facilitation is required to insure the correct movements patterns etc.

'I think sometimes as physio's we forget that we are invading peoples personal space and since were so used to touching people often forget that they may not be so used to this, especially if it is the first time we are treating them and they are unfamiliar with us. I have learnt from subsequent treatment sessions that it is best to explain exactly why im putting my hands on before i place my hands on the patient, ie to feel the movement that is taking place is or to faciltate certain muscles or just act as a guide and that it is not because i think he is incapable in anyway. I also make sure that if i start the task with guidance i take my facilitation away as long as it is appropriate so that he spends time doing the technique by himself and this way he doesn't get so upset . Since he likes to be so independant he is going to keep trying to do things at home which are beyond his current capabilities but the important thing is to practice some of these higher level activities in the clinic so if he does try and do them at home he has at least spent sometime practising at the clinic and will hopefully be a bit safer.

A complicated shoulder... and a complicated patient

I would like to write a few words about a patient I have been treating over teh past week or so.

A very long and complicated story but essentially he fell onto his shoulder about 5 weeks ago. He has no pain at rest but movement into abduction, and to a lesser extent flexion, is painful and looks pretty average.

My initial feeling was that although we could not perform a thorough Ax due to the high irritability of the patient's injury (and the fact that we had to improvise in treating the patient on a couch in a locked ward!) that there was some joint involvement as PROM was just as painful as AROM. However, we decided to let it be for a few days to see if it would improve before requesting further investigations.

I have seen this patient with 3 different physiotherapists - this has been very interesting to see 3 different approaches, but on the other hand there has been little continuity between sessions, as I have not been doing much of the Rx - I just need to pass information on to the next physio.

After 2 or 3 sessions of fairly vigorous testing, we can't work out exactly what the patient's trouble is, so I am currently in the process of negotiating with the patient's doctors to get some imaging of the shoulder.

This patient is a little more complicated than usual as he has been admitted to this particular facility for an acute episode of his schizophrenia. Our testing of this patient's shoulder involved many, many tests that elicited a pain response, which should be considered in two ways. Firstly, people with schizophrenia generally have a much higher pain threshold than the norm. This worked to our benefit, as we could be fairly confident that if a test was positive (painful) that the patient was feeling 'the pain.' Secondly, and of more concern was the patient's emotional response to us continually causing him pain - the tests were important, but I was wary not to irritate him so that he may become aggressive (common in paranoia).

At each treatment session I get a new piece of information from the patient, particularly about what stresses he has placed his shoulder under since the time of injury. I am not sure if this is because he genuinely didn't think to mention them before, if it is due to a building rapport with him at each session, or if it is due to an improvement in his mental state from new medications (antipsychotics). I am inclined to think it is the second one, or prehaps a combination of all three.

So to summarise, I have drawn a few conclusions:
1) In a facility where no formal detailed physiotherapy notes are written, it is much easier for one therapist to continue with a patient's Rx, rather than 'passing the pipe around'
2) You really need to make a judgement on what you can take from your patient subjectively and what you can't. In this case I was inclined to believe the patient as his story was fairly consistent - new pieces of information were added each time, but if you listened carefully the 'core story' remained the same.
3) And as for judging someones psychological state - I think it has 3 components: experience, reading the notes and then just gut feeling.

No "F" Bombing in the pool please

On my orthopaedic inpatient placement I assisted in a daily 1 hour hydrotherapy session for lower limb outpatients. The session did not follow a group exercise format; rather each patient went through their individual exercise program independently. The class was fairly laid back and many of the participants treated it as much a social outing as an exercise/rehab class. One patient in particular, Jim*, loved having a chat and cracking jokes. Jim* had a great sense of humour, however some of his jokes were often rude and of a sexual nature, all within earshot of elderly ladies!

Jims’ jokes were funny, but they were also inappropriate in this setting. The first time it happened I was shocked and felt slightly embarrassed due to the presence of the elderly ladies. While I did not laugh to encourage him, I also said nothing. Following the class that day I mentioned to my supervisor that Jim was being inappropriate. Apparently this was commonplace with this patient and my supervisor had previously told him to tone it down.

Having had several conversations with Jim in the pool, I knew that he was a kind hearted man who meant no harm; he just didn’t have any discretion. Next time he said something inappropriate, rather than me telling him off, I pointed out to him that most of these women were the same age as my grandmother, and I wouldn’t want my grandmother hearing such things! He reacted positively to this and was well behaved for the rest of the session.

If confronted with the same situation in the future, whether the patient were harmless or not, I would feel confident to let that patient know that their comments were inappropriate. As physiotherapists we have a duty of care to ensure all of our patients are safe and comfortable, and therefore must nip such situations in the bud.

*Fictitious name

Referring to other Allied Health Professions...

During my Rehabilitation in the Home placement I have quickly come to realise how little we as physiotherapy students, know about what the other health professions have to offer. When a new referral is made to RITH- the staff at the hospital place a tick next to what profession they think the patient needs to be seen by (eg physio, OT, social work, speech). If physio is the only box that is ticked (which is often the case), it doesn't necessarily mean that physio will be the only treatment required. When visiting/assessing the patient for the first time, you are responsible for making further referrals if necessary. How are we supposed to refer a patient on to another health profession like OT, when we have never been taught what OTs have to offer?

I have learnt a lot about the different treatments and assistance OTs can offer (and to a lesser degree- social work and speech) during this placement, but I still feel there is so much I do not know. For example- I knew hardly anything about all the different pieces of equipment OTs can prescribe- shower benches, rails, leg lifters for getting into bed, devices for putting on shoes and socks, devices for picking up objects from the floor, tray-mobiles, etc, etc, as well as what else OTs can assist with- eg upper limb retraining, cooking, personal care, etc. I knew hardly anything about what social work actually involves- organising assistance with shopping, cleaning, showering, meal preparation, financial assistance, helping people apply for hostels, etc, etc. And I still know hardly anything about speech therapy- what to look for, what types of conditions speech therapists can help with, etc, etc.

I guess what I am saying is, I think this is a very important area that physios out in the workforce are required to have extensive knowledge about- but is extremely neglected in our course. During 3rd year sometime (before we begin clinics in 4th yr), I think it would be a wise idea to run a couple of lectures about the other allied health professions. Even just a 1 hour lecture about each of the following- speech, OT and social work- run by a qualified person in each area, would be of great use to graduating physios. A brief explanation of what types of services each profession can offer, as well as what we as physios need to look out for when considering a referral, will at least give us some idea, and will allow us to better serve our patients.

The whole allied health team at RITH work in very close communication with each other so if I ever have any questions or need help- there is always an OT/speech/social worker close by to ask. However in some of the hospitals, private practice, etc- these opportunities are harder to come by. I am concerned that had I not had this RITH placement, I may have graduated with very minimal knowledge in this area. I will be feeding this back to the School of Physio in eVALUate and I suggest that if any of you agree with me, do the same! They are more likely to take notice and do something about it if they are receiving similar feedback from several students.

Complicated Patient Presentations

During the first week of my musculo placement, I had a new patient booked in with a referral for a condition which I thought would be quite easy to treat so I wasn’t too worried. However, when the patient came in, I discovered during the subjective that it was not just a simple condition; she had multiple areas of pain, none of which pointed to the condition stated on the referral. I freaked out a bit because I had no idea what to focus on because all the pains were related and I wasn’t sure what the cause was. It took me a long time to so my subjective as I had to go through every pain and ask for a VAS score etc. I went a talked to my supervisor after both my subjective and objective and due to the fact that I had freaked out a bit I missed a few important things in my assessment that would have made the situation a bit clearer. However, with my supervisors help the problem was deciphered and was actually quite simple.

When working in the musculoskeletal area, there is no doubt that all of us will come across patient situations like this. More often than not patients do have multiple areas of pain, as students, we have our supervisors there to help us work through what the most important areas are to treat, and also in this case which area may be causing all the other pains. However when we get out into the big wide world, we’ll have to make these clinical judgements on our own. In my limited experience, I’ve found that one of the easiest ways to do this is to simply ask the patient which area is causing them the most problems and focus on that as in reality we may only have 20 minutes to treat in. The other important thing is to complete a really thorough subjective and objective and this will make a big difference to your clinical decisions.

Since seeing this patient in my first week, I’ve been trying to not go into any patient consultation with preconceived ideas of how the patient is going to present, because chances are it may be completely different to what you were thinking. With this mindset, I feel that I’m less likely to freak out when a patient who I thought would be uncomplicated turns out to be quite complex.

The Stock Standard Assessment Approach

While on the general medicine cardio placement the majority of patients I had to treat were very sick, usually elderly patients with COPD or severe pneumonia, but there were some younger patients with cystic fibrosis who had come in with an acute exacerbation. These younger and often quite active patients require a different assessment, requiring you to think about the individuals previous exercise tolerance. Assessment thus needs to modified and although standard assessments such as the six minute walk test can be used they are often unsuitable and not adequate in determining appropriate treatment. I approached my supervisor about this and they recommended a modified incremental shuttle walk test developed especially for cystic fibrosis patients, which is kind of like a normal beep test with varying levels of difficulty. This is the gold standard but is sometimes impractical and not very functional to use as an outcome measure and thus the individuals desired or previous exercise tolerance becomes a quick and easy outcome measure (eg. How many flight of stairs a patient can walk up, or how long they can ride on a exercise bike for). These can also form the basis for treatment as well.

Reflecting back on this experience it is very important to consider the previous and desired exercise tolerance of a patient in both assessment and treatment of patients. This experience has taught me that you cannot have a standard and set assessment for every patient, you need to consider each patient’s desired goals for treatment and modify assessment and treatment according to the individual. This experience has not only influenced how I treated patients on my cardio placement but will continue to influence how I will treat patients in the future.

"Little" Interruptions

During my musculo prac there were a couple of occasions when my treatment sessions were interrupted by some of my clients’ family members, including my end of prac evaluation! It was something that was very hard to deal with, particularly when it was the client’s child. For my evaluation, in one of the small Curtin clinic treatment rooms, there was my client, her 12 month old child, her mother, the assessor and myself!!! Having a small child in a room with a plinth (especially when the child was roaming the floor-where the electrical cords for the plinth were) is not a good idea, and having a 4 year old moving the plinth up and down when you are trying to perform a rotation PPIVM is very irritating and could be dangerous.

But what do you say to the mother/caregiver? Do you tell the client to get their child to stop, or do you take matters into your own hands? How long do you wait for the person to stop them before you get fed up?

As someone who doesn’t have a huge amount of experience with young children, and doesn’t have that much patience with them, it was very hard for me to not yell at the 4 year old- his mother had not told him to stop and it was having a big impact on her treatment-and since she had acute LBP it was very important! The child was playing with the up/down button for the plinth during Ax and climbed all over his mother during my attempted Rx. It was a lot easier to deal with the 12 month old because I could just ask the grandmother to take her out of the room for safety reasons and then get on with the evaluation, however when you are dealing with an older child it’s completely different.

When a child is old enough to know better it is more frustrating when they act out, and they are harder to discipline. But it is not up to you, it’s up to the parent, so a polite remark to the parent is far easier and they are more likely to do something. It is not acceptable for you to shout/discipline someone else’s child however it is also not acceptable for them to interrupt the parent’s treatment session, so it is very important that we are assertive enough to take control of the situation. It also helps if you can find something for the child to do, I let the 4 year old move the plinth up and down, but only when I wanted him to, and as soon as he was bored with that he was allowed to draw on one of the magazines. Once I let the child feel involved in the session he stopped being so disruptive and we could get on with his mother’s treatment. You just have to remember to stay calm and get the parent to take care of their child, then you can take care of your client.

put your hands on please

Hi guys, I hope you guys went fine in the mid placement assessment. And I would like to share something about my mid placement assessment. I am at neurosurgery ward and I have a patient who has fat emboli syndrome 4 months ago. During past 4 months he has improved significantly, from the assessment finding he has full ROM, normal tone, normal sensation, independent transfer and independent ambulation without walking aid so that he is a pretty high level balance patient. Up to dated treatment is to work on his single limb balance and gait retraining since he has hip hitching during stance phase.

On the mid placement assessment, I reported to my supervisor what I have been doing on this patient and then we have discussed what they will be doing on him during this treatment. During the treatment, I did internal and external standing balance and single limb stand as my assessment. Then I got the patient in to 2 pts kneeling and walked forward, backward, and sideways in order to improve the core stability and hip abductor strength. After that I got the patient in to standing with feet together with eyes open and close, tendon standing and single leg standing, and finally gait retraining to address the hip hitching issue.

I knew that it was not a decent treatment but I thought I went ok but I could not imagine that I had such a strong but constructive comments. First of all, I need to assess more high level balance assessment not ‘only’ single limb stand alone. Secondly, I should put my hands to guide the patient during 2 pt kneeling no matter how good the patient is. And finally I forgot to reassess the patient after the treatment.

On my self reflection after my assessment, I realized that the importance of hands on to the patient. It actually gives them a very essential sensory input for them to correct the abnormally motor pattern even in this ‘high level balance’ patient group. Also in neuro, it does not allow you to make a minor mistake as well. It was a safe treatment but it is not enough in this point. It has room for improvement especially my hands on skill as well as assessment skill.

An encounter with a patient with manic depression

I thought I’d share with you my experience with a particular new patient I saw for an initial assessment this week. At my musculo OP placement, we always discuss our patients for the day at a morning meeting. Literally all I knew about this patient was that she had LBP, and a fairly extensive list of medical problems that included alcohol-induced liver cirrhosis and manic depression from the referral letter. Discussion that morning focused a little on some difficulties I may encounter with such a patient with manic depression, depending on how well-controlled it was. I think in general, it’s fair to say that this patient caused some apprehension in all of us involved in that discussion.

The obvious issue to me was, How much can I discuss this condition with her? Would such a person prefer that I openly ask her questions about her condition and ask questions about how it may affect physiotherapy? Do I risk offending her? I didn’t feel right just ignoring the topic. I thought I’d share my reasons why… and then leave it to you guys to share your opinions.

I think depression is so largely misunderstood. The “down” mood, low motivation, lack of interest, poor concentration, cloudy mind, and irritation is so out of the person’s control. A lot of frustration arises from that, because these ppl are often afraid of being perceived as too lazy “to snap out of it”. I thought it was important to make it clear to the patient that I understood that, that I wasn’t intimidated or afraid to talk about it.

I asked questions and said things that indicated to her that I understood that She was separate from The Condition. I started off conversation with “I’ve been left some very good notes in a referral letter from your doctor. I understand you suffer from manic depression.” I asked questions like, “I’m asking because I’d like to know how it may affect your ability to deal with your back problem, and how I can help.” Instead of saying “on a day that you are particularly down”, I’d say “on a particularly down day when it’s affecting you”. I felt this forthright approach worked well with this patient. The patient was comfortable talking to me about her condition. I feel like I’ve built good rapport with her. She tells me honestly that sometimes she doesn’t do her HEP because “she can’t be bothered”. Not something you’d like to hear, but there’s something to be said about the honesty there, right?

I think it’s important to develop a fine-tuned ability to detect who you talk to in this way, and who you don’t. This frank approach may not be suitable for a patient who is very introverted, cut-off and non-talkative. What do you guys recommend as your approach in this situation?

Honesty on placement

Hey guys, I owe you a couple of those blog things!

I’m on a musculo OP department at the moment. The list of stories about my difficulties on this placement is endless… *sigh* But I’ll begin with this.

My trouble lies in the fact that I admit my own inexperience, and often simply… don’t trust my findings. When you consider that, for example, in PPIVMs, it is normal for C1-2 to have more rotation than C2-3. Or that C5-6 is apparently supposed to have more flexion than C3-4. How do you know that when you feel one segment to be stiffer than the next, that the difference is normal, expected for age, or actually a finding? This comes largely with experience, right?

Here’s another thing I have trouble with. Assessing PAIVMs, and trying to ID stiffness, pain onset (1/4 range, ½ range etc), pain limitation (so P1 vs P2), muscle spasm onset (??). Yeh. Double you tee eff. Often, I’m still working on being confident that I AM on the right segment (only in the Cx area, John. Only in the Cx), or working out whether the pain is joint or muscular.

Problem to me is the system of this musculo OP clinic. You go in, do your S and your O, then report to your supervisor, who in fact doesn’t really see the patient, and doesn’t double-check your findings. I find it hard then, when I report my findings to my supervisor, and he asks me questions about them. Sometimes, I say, “To be honest, I don’t really know, because I don’t trust my own findings 100%… I’m not sure when I find some stiff segments, whether this is normal age-appropriate findings for this particular lady, or really of concern”. Because these findings are directly impacting treatment decisions, I think honesty here is important. I have a very intimidating supervisor who is not easily impressed by such honesty. I feel like I’m often met with some disapproval.

Fortunately, my supervisor usually does come through with some wisdom about what I should assess further and helps me clarify my findings, so the embarrassment is more tolerable. But this has stressed me out initially on this placement. Regardless, I’ve tried to stick to this approach, even though time and time again, I am looking like an idiot. At the end of the day, I am learning lots this way, right? But sometimes I wonder if I would learn more by having a supervisor verifying your assessment techniques and findings.

Anyone with similar stories they'd like to share?

To believe your patient or not...

I saw a patient on Thursday with my Curtin tutor for an ongoing elbow problem, and at the conclusion of our very brief session with the patient, she mentioned that her ankle was causing her some grief. She reported that she was diagnosed with cellulitis in that ankle about 4 months ago. After a brief observaion of her ankle, which appeared swollen and warm to touch, I made arrangements to see the person on Friday, the following day.(Arranging to see patients at this particular facility can be very difficult as we require a nurse to be with us whilst treating the patient for our own safety).

We also noted that this patient had an infected ingrown toenail, which she reported she was on antibiotics for, but the severity of it was cause for concern. As we left this ward we mentioned to th patient's doctor and nursing co-ordinator that we felt she should be seen by a podiatrist for her toe. While discussing that we would like to return the following day to review the patient's ankle, they said that the patient was unlikely t be experiencing any real discomfort and that she was constructing an injury/complaint in order to get more medications (she has a history of this).

We felt that given her fairly awful-looking ankle, this may be a case of the boy who cried wolf - she may have sought additional medications in the past, and now that her foot is actually sore, she is being ignored. So we returned that next day to see her.

The Importance of Details

Hello all, I am currently on a rehab in the home placement and treated an interesting patient for the first time on Friday. In the interest of saving time during treatment, I like to gain a good understanding of my patients prior to seeing them for the first time so that I can develop a rough plan of what the session will entail. To gain this understanding, I must rely on reading the notes of other health care professionals.

Prior to seeing this particular patient, I had read a summary of his problems from the notes as follows: Current problems/diagnosis- 91 yr old patient had just been discharged from hospital following a 9 day hospitalisation following constipation. As a result of the hospitalisation, he had become quite deconditioned and needed physio input to increase his exercise tolerance, balance and strength. Past medical history was stated simply as: falls, DVT, hip dislocation, leg length discrepancy (compensated by raised shoe). Considering the complexities and comorbidities of a lot of elderly patients around this age that I had previously come across, this patient sounded quite simple!! I planned to do my subjective and then objective, including a functional assessment of the client in his home, balance assessment, gait assessment and a couple of simple objective measures like the TUG and Repeated Sit to Stand. My rough plan for this initial treatment was some walking, basic strengthening exercises like sit to stand, heel raises, etc and perhaps some education about how to get up off the floor.

When arriving at the patient's home I quickly realised how non-simple the patient was... that "hip dislocation" mentioned in the PMH turned out to be hip dysplasia that the patient has had since he was 3 yrs old (ie the hip is still dislocated and always has been!), meaning functionally the movement and strength in that hip (and entire lower limb) is pretty minimal and it was fixed in flexion. On top of this, the "leg length discrepency" mentioned in the PMH (which I imagined was fairly minor) was actually a 10cm discrepency due to the hip dislocation! As a result the patient had a gigantic, heavy custom-made shoe which he had to wear whenever ambulating (for those of you who have seen Summer Heights High... think Pat, the rolling lady from Perth). All of a sudden my plan had to be changed quite significantly- the patient always took the shoe off when sitting and put it on again once standing- this meant measures like TUG and Repeated Sit to Stand were useless because the patient would spend most of the assessment taking his shoe on and off. My treatment too, had to be completely re-considered.

This situation raised 2 important issues- the first being note writing: as health professionals, we all need to understand that our notes will be read by others, and should offer an accurate picture of the patient and their progress. Obviously patient notes cannot be too detailed, otherwise we would never have time to actually treat patients, but within reason, the important details should be written. Providing a hand-over to another therapist who has never seen the patient before is often difficult. Because you are so familiar with the patient, it is hard to imagine reading the notes from the other therapist's perspective who has no prior knowledge and as a result, often we can neglect to mention important details. A simple modification to the PMH notes I read could have been "Permanent hip dysplasia since age 3 yrs with resulting 10cm leg length discrepency and minimal hip function". Even a simple change like this would have offered a more accurate clinical picture and consequently made that first treatment session run a lot smoother.

The second issue is treatment planning: having a rough plan prior to treating a patient can definitely help the session run more efficiently and give you a greater sense of confidence, but you should always be prepared to be flexible! We must be prepared that we may have to completely change our plan depending on various patient/therapist factors, and not panic in the process.

Importance of a Holistic Approach to Treatment

I am currently on my Cardiopulmonary placement on a surgical ward. The patients I see are typically post-op patients with decreased lung volumes and impaired airway clearance and therefore my treatment mainly revolves around ambulation and ACBT’s.

Recently I had a day 2 post-op patient who had an abandoned Ivor-Lewis procedure (removal of lower oesophagus and upper stomach due to carcinoma). Upon examination the patient was found to have decreased breath sounds bibasally. We went for a walk which the patient managed well without pain or breathlessness. The patient had nil attachments and his obs and haemoglobin were stable, so I encouraged him to ambulate regularly by himself explaining it would help to prevent post-op complications. On subsequent days I would visit the patient for treatment, each time he would report to me that he had not ambulated since the last time I saw him.

I could not understand why the patient was not ambulating despite my encouragement and rationale for the importance of doing so. I became frustrated with this so brought up the issue with my supervisor. She suggested it may have something to do with the fact that his operation was abandoned because it was inoperable, the tumour was attached to his abdominal aorta also and therefore the prognosis wasn’t good. The patient may be finding it hard to cope with such a prognosis.

I think that because patients in the surgical ward typically have the same cardiopulmonary problems it can be easy to become programmed to treat every patient the same. Since this patient I have made an effort to read more into the history of the patient prior to seeing them in order to see if there are any considerations for treatment. It is important to have a holistic approach to treatment, taking into consideration psychosocial factors, rather than just treating the patient as an impairment or group of impairments. Sometimes for a treatment to be effective, psychosocial issues may have to be dealt with first.

Have a good week :)

Outcomes of Family Meetings

Whilst on my Gerontology placement, family meetings, involving a representative from all members of the multidisciplinary team and the pt's family would be called sometimes to discuss discharge planning and Rx to date. I found this situation quite daunting the first time i had to deal with it as i wasnt sure what i was meant say or how to put it as i knew that what we had to say was going to be distressing to the pt, as she was adamant that she wanted to return home to continue living independantly whilst myself and the other teams felt she was more suitable for placement in a hostel as she was suffering from severe end stage OA in multiple joints bilaterally which was severley hampering her functional ability, so much so that she could only raise her shoulders about 10 degrees, took five minutes to get into bed on her own, and could only walk 15m i 4ww.

After explaining her current mobility to the family and explaining there wasnt much room for improvement no matter how much Rx we gave her, and with heavy emphasise from the whole team that it would be in her best interests to try and place her now whilst she was borderline low/high level care and there was the chance we could get her into low level where the facilitys are much nicer as we were scared if we waited any longer she would be high level care. Despite our best efforts the pt and family were adamant that she would return home. This upset and frustrated me quite a bit as it was very clear that she was not going to be able to manage on her own, however I understood it was still her decision to make so I just had to do my best in her remaining time there to assist her to do things as easily as possible and prepare her for a return home.

The lesson i learned from this situation is that although you may not agree with the decision the pt makes if they are cognitively in the right state to make it you have to accept it even though you know it is not in their best interests, in these meetings there is no need to feel anxious or nervous as no one is there to bite your head of or respond negatively to what you have to say they just want to hear your proffessional opinion and become informed, and even though you are a student you are still are seen as a proffessional to the family so be confident in your knowledge and dont be afraid to speak up or offer your opinion because they appreciate it very much.

Dealing with patients who can't speak english

While on my cardiopulmonary placement I was asked to treat John*, a patient with tuberculosis who could only speak a couple of words of English (a translator was not available until the following week). John was put in a vacuum sealed isolation room, anyone entering the room had to wear a mask, gown and gloves, as well as washing any equipment used. I was asked to assess John’s respiratory system and exercise tolerance and give him some exercises to prevent muscle wasting and maintain cardiovascular fitness. Initially I was overwhelmed by this as John wasn’t allowed to go outside his room and limited equipped was allowed to be brought into the room. Added to this was the fact that John didn’t speak much English, so the exercises had to be fairly simple and explained well with pictures so that John could perform them independently, due to the fact that I was instructed to limit unnecessary contact with John to limit exposure.

At first I didn’t quite know how to explain things to John I was using asking him lots of questions (some of which he could answer mostly he would look at me blankly) and then I started using both hand gestures as well as words to describe what I was saying, and this seemed to work a lot better. I would demonstrate to John each exercise I wanted him to perform, as well as showing him the pictures I had drawn of the exercise so that he could associate them and perform them correctly. To test if John understood how to perform each of the exercises I would ask him to show me at subsequent visits. The next hurdle to overcome with John was figuring out a way to tell him how many reps of each exercise he should perform, luckily John had an understanding of numbers and after counting out loud with John a couple of times he could understand how many reps he was supposed to perform of each exercise.

Reflecting back on this situation it wasn’t as difficult as I thought it might be to deal with a person with language difficulties. If I had to deal with this situation again I wouldn’t be as anxious and would probably respond in a similar way but by using more hand gestures and demonstrating exercises instead of relying on verbal means so that a patient can understand. This situation has helped me to understand the significance of demonstrating exercises to not only patients who have language difficulties but all patients as sometimes it is hard for patients to understand the smaller but very significant subtleties of exercises, and by asking the patient to perform the exercise and prompting them it leads to a greater understanding of the exercise itself and how it is meant to be performed to gain the most benefit.

*Fictitious names used

Never say Never

Hi guys, I hope you guys are enjoying the placement. I am currently in my neuro placement and I would like to share my little experience with you guys. I am treating a patient who had a 6 months post head injury during work. On assessment, he presents with L hemiparasis with no voluntary control of hamstrings and ankle DF/PF, no voluntary control of upper limb and no sensation in the L side, but he has no problem with cognition and perception. Treatments up to date include gait retraining and UL retraining.

During treatment, even though there was no muscle activation in UL he is still very motivated and keen for the exercise and welcome to let me to do any stuff on his UL. On the next day during physio session with him, he became quiet and inattentive that was different from what he behaved normally, then I asked him what happen and after a while he started tell me that the doctor told him his arm is not going to come back. Then he asked me if it is true and how many chance his arm can function as he was, at that moment I did not know how to answer question because I have no experience at all and also I did not want to give him a false hope, so I consult my supervisor and she explain to my patient that there is no guarantee the arm will come back and there is no guarantee the arm will not come back either, the arm still need physio input rather than give up but be ready to the worst and be realistic.

On my self reflection, initially I was quite upset to treat neuro patient because on the one hand I as a therapist do not know when his arm will be activated again, on the other hand I also need to give him motivation and think positively. But one thing I learnt in this incident is that never say never. No one will exactly know the time frame of the neuro recovery because it varies from person to person and no one will fully understand the brain activity, it makes neuro rehabilitation full of potential. At the same time I learnt that the goal needs to be realistic otherwise patient will not have a false hope that will impact on the patient significantly. So in the future, I will know how to deal with this kind of situation and I will not be upset but think positive.