While on my rural placement, I was involved in running Stay on Your Feet exercise classes numerous times a week. One of the classes was targeted at individuals with a lower functional level so the class was performed mostly in sitting. I was running these classes quite well, with good participation from all individuals. However on one session I decided to vary the routine somewhat as a bit of a change. The new components added more overhead upper limb movements, with all individuals completing these components. After the class some participants commented that they had shoulder problems and the added components were too strenuous.
The next session I reduced the time spent in these overhead upper limb activities and this was received well by the participants. From this experience I have realised that in the group setting it is imperative to always state at the beginning of the class that some activities may not be able to be completed by individuals who have particular injuries and that it is ok for them to sit out that activity or complete an alternative option. It also high lighted the importance of watching for signs that individuals are struggling with exercises and alter the exercise program accordingly. In the future I will always offer alternative exercises for activities that may be challenging and remind participants not to complete exercises that cause pain or discomfort.
Tuesday, December 2, 2008
Monday, December 1, 2008
Look at the bigger picture
In my rural placement, I had a 16 year old patient who had undergone an ACL repair about 8 weeks ago and is now attending outpatient rehab classes. He did his ACL while playing cricket for the school team. Each time he came to rehab, his only question is when can I start cricket again. He was someone who is not really vigilant with HEP and is really desperate to get back to his games. I explained to him that his knee needs time to heal and returning to cricket has to be a gradual process. Each time he came he complained of a knee pain but subjectively reported no change of his activities over the week. His progress was much slower than you would expect for someone at that age who had undergone an ACL repair. His muscle was still weak, he still had poor proprioception, some swelling around the knee and his range had plateud.
After the second session with him, I had a discussion with my supervisor as I suspected something just did not quite add up to the picture. I gave the mum a call and asked her some clarifying questions and all she said is that he still doesn’t do much. Just few days after that, I had another patient who goes to the same school as him asked how is his knee and I told him I can’t really discuss other patient with him. Then he responded jokingly, it must be doing well because he plays cricket now but he plays like a looser. Immediately the picture added up. So the next time he attended rehab, I asked him in an appropriate manner not to make him feel like I am accusing him. He eventually admitted that he started cricket about 3 weeks ago and since then he’s been having the knee pain. I then gave him an intensive education session and told him that if he does not back off from his sport he is going to damage the repairs and potentially not able to ever return to his sport again. He seemed like he had understood me as he said he is going to try and be a bit more active in his rehab. From then on, his swelling reduced and his knee range started improving.
This encounter had highlighted the importance of looking at things at the bigger picture and making sure that it all adds up. It is important to realize that when a patient is not progressing, we have to try and seek the barrier to this so that we are able to achieve better outcomes in the rehabilitation process and prevent any potential risk of further injury.
After the second session with him, I had a discussion with my supervisor as I suspected something just did not quite add up to the picture. I gave the mum a call and asked her some clarifying questions and all she said is that he still doesn’t do much. Just few days after that, I had another patient who goes to the same school as him asked how is his knee and I told him I can’t really discuss other patient with him. Then he responded jokingly, it must be doing well because he plays cricket now but he plays like a looser. Immediately the picture added up. So the next time he attended rehab, I asked him in an appropriate manner not to make him feel like I am accusing him. He eventually admitted that he started cricket about 3 weeks ago and since then he’s been having the knee pain. I then gave him an intensive education session and told him that if he does not back off from his sport he is going to damage the repairs and potentially not able to ever return to his sport again. He seemed like he had understood me as he said he is going to try and be a bit more active in his rehab. From then on, his swelling reduced and his knee range started improving.
This encounter had highlighted the importance of looking at things at the bigger picture and making sure that it all adds up. It is important to realize that when a patient is not progressing, we have to try and seek the barrier to this so that we are able to achieve better outcomes in the rehabilitation process and prevent any potential risk of further injury.
Treat them all the same.
During my neuro placement, I had a new patient and the handover notes was that the patient was a prisoner in shackles, he had two prison guards with him 24/7 and was a left hemiplegia with no sitting balance. The notes also did mention about him having a psych review and that he was diagnosed with bipolar disorder and mild psychosis.
This is my first time having to treat a prisoner in shackles and that really made me worried. We had to get permission from the prison authorities to unshackle the patient for rehabilitation and that made me worried as I had all the “what if’s” running through my head. Well, I tried to calm myself down and felt that if I treated him just like any other patient I will do fine and besides, if anything happens there is two guards to help restrain him. When I met him, I introduced myself and gave him a brief explanation of what the treatment is going to consist of. He did not respond much to what I had said and just looked away. Then I asked him, if he had anything bothering him and his reply was, “like you care”. That is the first time I had met a patient who spoke that way. I then just said politely to him, I’m only here to help and I need him to allow me to. So I asked him again, if he has any concerns? Then he said that his neck been hurting for a week now and it disturbs his sleep at night. I then decided to assess and treat his neck before looking at his sitting balance. He then became more interactive and looked pleased that I actually listened to his concerns and acted upon them. He then appeared more compliant to the treatment session which I thought was impossible at the beginning of the treatment just by the way he appeared to me. He then became a patient in my caseload for the next two weeks I was there. He became more and more compliant each session and this helped his rehabilitation progress smoothly. By the end of the two weeks we achieved sitting balance and I started working on standing balance.
This was an invaluable experience. It had thought me the importance of treating each patient with dignity and respect regardless of what their background is in order to have a positive contribution to the rehab process. Just by listening to him and making him feel that his concerns were important, he became a more compliant patient.
This is my first time having to treat a prisoner in shackles and that really made me worried. We had to get permission from the prison authorities to unshackle the patient for rehabilitation and that made me worried as I had all the “what if’s” running through my head. Well, I tried to calm myself down and felt that if I treated him just like any other patient I will do fine and besides, if anything happens there is two guards to help restrain him. When I met him, I introduced myself and gave him a brief explanation of what the treatment is going to consist of. He did not respond much to what I had said and just looked away. Then I asked him, if he had anything bothering him and his reply was, “like you care”. That is the first time I had met a patient who spoke that way. I then just said politely to him, I’m only here to help and I need him to allow me to. So I asked him again, if he has any concerns? Then he said that his neck been hurting for a week now and it disturbs his sleep at night. I then decided to assess and treat his neck before looking at his sitting balance. He then became more interactive and looked pleased that I actually listened to his concerns and acted upon them. He then appeared more compliant to the treatment session which I thought was impossible at the beginning of the treatment just by the way he appeared to me. He then became a patient in my caseload for the next two weeks I was there. He became more and more compliant each session and this helped his rehabilitation progress smoothly. By the end of the two weeks we achieved sitting balance and I started working on standing balance.
This was an invaluable experience. It had thought me the importance of treating each patient with dignity and respect regardless of what their background is in order to have a positive contribution to the rehab process. Just by listening to him and making him feel that his concerns were important, he became a more compliant patient.
Wednesday, November 26, 2008
Do whatever it takes..
I was in paediatrics unit in my rural prac. One of the greatest challenges I faced was to create compliance of a paediatric client. It was my first time working in this area and I thought to myself, they’re only kids how hard can it get. Then I had my first patient and the notes read.. a bit of autism and a bit of developmental delay. Well, how different can they be to other kids? So I started doing assessment like I would normally do and 5 minutes into the session things started to fall apart. The little boy started to cry and just wanted to do his stuff, like pretend to fly. I was frustrated because I was thrown into the deep end left to figure things out for myself for the first time. So I kept myself together and thought to myself that I have to take control of the situation before it gets me. So i went with the flow and played with him. By playing with him I actually won him over for another 5 minutes. So I tried my best, modified every single assessment to make it “fun” and it was not easy.
Can you imagine, having to think of a way to modify assessment for muscle strength and endurance of the UL, LL and trunk turning it into something outstandingly “fun”? So I started using cartoon characters like superman and spiderman then doing some animal walks to test trunk strength and endurance. Just I was getting somewhere with the assessment, a sudden machinery noise started coming from the construction site nearby. The mother looked like she had given up not knowing what to do as well. I remembered reading somewhere that some autistic kids are affected terribly by unfamiliar noises. I quickly went and found some headphones to try and filter the noise out for him. It worked but only for a short time, enough for me to at least finish the last part of my assessment so that I could device a program to address the delay in his gross motor skills.
Form this experience I’ve learnt that things do not always go according to plan and that I have to be flexible with whatever challenges I face during a session with a client. I must be able to think and act promptly in difficult situations so that I am able to maximise the limited time I have with clients to gain sufficient information through an assessment. In this case, perserverance did pay off as I was able to gain enough information to provide a treatment strategy.
Can you imagine, having to think of a way to modify assessment for muscle strength and endurance of the UL, LL and trunk turning it into something outstandingly “fun”? So I started using cartoon characters like superman and spiderman then doing some animal walks to test trunk strength and endurance. Just I was getting somewhere with the assessment, a sudden machinery noise started coming from the construction site nearby. The mother looked like she had given up not knowing what to do as well. I remembered reading somewhere that some autistic kids are affected terribly by unfamiliar noises. I quickly went and found some headphones to try and filter the noise out for him. It worked but only for a short time, enough for me to at least finish the last part of my assessment so that I could device a program to address the delay in his gross motor skills.
Form this experience I’ve learnt that things do not always go according to plan and that I have to be flexible with whatever challenges I face during a session with a client. I must be able to think and act promptly in difficult situations so that I am able to maximise the limited time I have with clients to gain sufficient information through an assessment. In this case, perserverance did pay off as I was able to gain enough information to provide a treatment strategy.
Monday, November 24, 2008
"I don't feel I am improving"
On my musculoskeletal outpatients placement, I had a patient who presented with lower back pain, with the main aggravating factor being prolonged sitting (approximately 30 minutes). My treatment and management with this patient involved mobilisations and postural retraining.
About 3 weeks from her initial visit, I began with my subjective assessment to see how she is progressing. She stated that she did not feel that she was improving, as the intensity of her pain was at a similar level as when she first started physiotherapy. I thought to myself that she must have had some improvement, as she has been having treatment for the past 3 weeks. I then decided to focus on the aggravating factors, and asked her how long can she stay in sitting until the pain increases. She then stated that she was able to sit comfortably for longer than that of the initial session (approximately 1 hr), making her realise that she has made some improvement.
I FEEL THAT MONITORING THE PATIENTS RESPONSE TO TREATMENT FROM THE PATIENT'S PERSPECTIVE AND GOAL SETTING WILL HELP GIVE THE PATIENT AN IDEA ON HOW MUCH THEY ARE IMPROVING, THEREFORE MAINTAINING THEIR FAITH IN PHYSIOTHERAPY TREATMENT. IN THE FUTURE, I WILL CONTINUE TO THINK ABOUT PATIENT'S GOALS AND THEIR FUNCTIONAL LIMITATIONS IN TERMS OF MONITORING RESPONSE TO TREATMENT, THUS, HOPEFULLY INCREASING PATIENT SATISFACTION.
About 3 weeks from her initial visit, I began with my subjective assessment to see how she is progressing. She stated that she did not feel that she was improving, as the intensity of her pain was at a similar level as when she first started physiotherapy. I thought to myself that she must have had some improvement, as she has been having treatment for the past 3 weeks. I then decided to focus on the aggravating factors, and asked her how long can she stay in sitting until the pain increases. She then stated that she was able to sit comfortably for longer than that of the initial session (approximately 1 hr), making her realise that she has made some improvement.
I FEEL THAT MONITORING THE PATIENTS RESPONSE TO TREATMENT FROM THE PATIENT'S PERSPECTIVE AND GOAL SETTING WILL HELP GIVE THE PATIENT AN IDEA ON HOW MUCH THEY ARE IMPROVING, THEREFORE MAINTAINING THEIR FAITH IN PHYSIOTHERAPY TREATMENT. IN THE FUTURE, I WILL CONTINUE TO THINK ABOUT PATIENT'S GOALS AND THEIR FUNCTIONAL LIMITATIONS IN TERMS OF MONITORING RESPONSE TO TREATMENT, THUS, HOPEFULLY INCREASING PATIENT SATISFACTION.
Telling the patient the purpose of your treatment
On one of my placements, I encountered a patient with cerebellar atrophy who was quite anxious. Consequently, his major problem was impaired balance. Therefore my treatment was based around improving his balance. To progress the patient, I would challenge his balance by reducing the base of support, adding a soft surface, eyes closed etc.
As the tasks increased in difficulty, the patient would be less compliant, and say comments like "I can't do that, I'll be too wobbly", I woud then reassure him and tell him that I wasn't going to let him fall. As I would try new positions, he required more convincing to try and get him to comply. I then decided to explain to him that the purpose of these exercises were to use positions which will challenge his balance, and will make him feel somewhat unsteady, as there is no point in practicing balance in a position where he can maintain his balance quite easily. I felt that once he understood the purpose of my treatment, he became more compliant.
THIS SITUATION HIGHLIGHTED THE IMPORTANCE OF THE PATIENT KNOWING THE PURPOSE OF TREATMENTS. I FEEL THAT IF THE PATIENT KNOWS WHY A CERTAIN EXERCISE MAKES HIM/HER FEEL UNSTEADY, OR CERTAIN TREATMENT TECHNIQUES CAN BE SLIGHTLY PAINFULL, HE/SHE WILL BE MORE COMPLIANT WITH PHYSIOTHERAPY, THUS MAXIMISING THE TREATMENT OUTCOME.
As the tasks increased in difficulty, the patient would be less compliant, and say comments like "I can't do that, I'll be too wobbly", I woud then reassure him and tell him that I wasn't going to let him fall. As I would try new positions, he required more convincing to try and get him to comply. I then decided to explain to him that the purpose of these exercises were to use positions which will challenge his balance, and will make him feel somewhat unsteady, as there is no point in practicing balance in a position where he can maintain his balance quite easily. I felt that once he understood the purpose of my treatment, he became more compliant.
THIS SITUATION HIGHLIGHTED THE IMPORTANCE OF THE PATIENT KNOWING THE PURPOSE OF TREATMENTS. I FEEL THAT IF THE PATIENT KNOWS WHY A CERTAIN EXERCISE MAKES HIM/HER FEEL UNSTEADY, OR CERTAIN TREATMENT TECHNIQUES CAN BE SLIGHTLY PAINFULL, HE/SHE WILL BE MORE COMPLIANT WITH PHYSIOTHERAPY, THUS MAXIMISING THE TREATMENT OUTCOME.
Friday, November 21, 2008
Discharge planning
On my rural placement, I had an eldery patient who presented with an exacerbation of COPD. Considering discharge planning, I came to the conclusion that if she were to go home, she would have to be fully independent, as she does not always have someone with her at home. Throughout her stay in hospital, she was often non compliant with physiotherapy, and refused walks several times.
When she was for discharge from a medical point of view, I was unsure how well she was able to ambulate, thus, I was not sure if she was safe for discharge from a physiotherapy point of view. The patient refused a mobility assessment, and I was not surprised, as she had refused to ambulate prior to this. I decided to use her going home as motivation to ambulate, and explained to her that she can only go home once she is deemed safe from a physiotherapy point of view. In doing so, she agreed on a mobility assessment.
NOT ONLY DOES THIS HIGHLIGHT THE NEED FOR EXPLANATIONS ON CERTAIN INTERVENTIONS, BUT ALSO THE IMPACT MOTIVATION CAN HAVE ON A PATIENT. IN THE FUTURE, I WILL SET GOALS FOR THE PATIENT, AND USE MOTIVATIONAL TOOLS TO IMPROVE PATIENT COMPLIANCE AND SATISFACTION FROM TREATMENTS.
When she was for discharge from a medical point of view, I was unsure how well she was able to ambulate, thus, I was not sure if she was safe for discharge from a physiotherapy point of view. The patient refused a mobility assessment, and I was not surprised, as she had refused to ambulate prior to this. I decided to use her going home as motivation to ambulate, and explained to her that she can only go home once she is deemed safe from a physiotherapy point of view. In doing so, she agreed on a mobility assessment.
NOT ONLY DOES THIS HIGHLIGHT THE NEED FOR EXPLANATIONS ON CERTAIN INTERVENTIONS, BUT ALSO THE IMPACT MOTIVATION CAN HAVE ON A PATIENT. IN THE FUTURE, I WILL SET GOALS FOR THE PATIENT, AND USE MOTIVATIONAL TOOLS TO IMPROVE PATIENT COMPLIANCE AND SATISFACTION FROM TREATMENTS.
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