In one of my placements, I met a 53 year old lady, was admitted to the hospital 2/52 after a CVA. She is still employed as a CEO in a very reputable accounting firm. She sustained right (R) sided hemiplegia from the CVA . She has been attending inpatient physio rehab daily. Since then, she has shown some improvement in motor recovery. She was going to be discharged in a few weeks and will be attending outpatient rehab. She is very anxious about her recovery as she is adamant about returning to work as soon as she is able to. She has been one of my difficult, non-compliant patient as her frustration builds up quite easily during treatment sessions. One day however, she asked me about acupuncture and whether it is a good idea to pursue it once she gets out of the hospital. I had done a bit of research into it before so I gave her an answer. I told her that I can’t promise it will be helpful for her as research does show that acupuncture to some extend helps with recovery but not everyone really benefit from them. So my advice was to give it a try and see whether it works for her. Clearly she wasn’t happy with my answer and just looked away. Anyway I went on treating her that day and she appeared really apprehensive about me treating her. I wasn’t sure what was going on then I asked her politely, if everything is alright and then she became rude and used inappropriate words against me. I was so frustrated because I had worked so hard to get her on my side and then suddenly she reacted that way. I had to just leave her that moment. I spoke to my supervisor and she decided to take me off her case.
When I looked back at what had happened, I am still not sure how I would have handled it differently but I have a certain regret that I was taken off the case without a chance to learn a way of dealing with a situation like that so that when faced with a similar situation in the future I will be better at knowing how to handle it. However in the future, if I do come across a situation like that, I probably will give them the space they need for a bit and come back on a different time and attempt finding out what the issue really is. I guess in a lot of patient it important to make them realize that we are there to help them in their recovery and we can only achieve it if they allow us to. Whether this is the way to go, I am still not sure, anyone have any ideas?
Wednesday, October 29, 2008
Tuesday, October 28, 2008
maintaining control during a treatment session for the safety of the patient and physio
Whilst on my neurology placement I encountered a patient who presented with a cerebellar bleed, as well he was displaying frontal lobe behaviours, was highly impulsive and quite a tall man which complicated matters a bit. The patient had also had a trache and as he was improving his trache was removed so he began to be able to communicate a bit more.
The first few occasions of treatment were really based upon transfers and basic functional exercises, this was progressing well but as the patient improved in terms of there function they became more impulsive, and it became harder to complete a full worthwhile treatment session which would address the goals I would set out at the start of each session.
Following a discussion with my supervisor they provided some tips on how to achieve these goals. The first tip was to make sure each time the patient did something for example supine to SOEOB that they would perform it in the correct manner and pattern and if they didn't to make them perform it again. The second was to try and keep the sessions short as the patient would tend to lose interest so perhaps two shorter session in the day would be more effective. A final tip that I was given was to. The final tip was to take a more of a controlled role in the session using verbal and tactile measures to make sure the patient was paying adequate attention and performing the correct task, and even if the patient became impulsive it would be easier to get them back on task.
THROUGH IMPLEMENTING THE ABOVE TIPS ALTHOUGH THE PATIENT WAS STILL DIFFICULT AT TIMES IT ALLOWED FOR THE SESSIONS TO BECOME MORE EFFECTIVE IN ADDRESSING THE IMPAIRMENTS, WHERE AS BEFORE A LOT OF THE TIME WAS SPENT ON JUST TRYING TO GET THE PATIENT TO PERFORM THE CORRECT TASK, NOW THE TREATMENT WAS BECOMING EASIER FOR ME AND ALSO MORE BENEFICIAL FOR THE PATIENT, AND SAFER FOR BOTH OF US.
The first few occasions of treatment were really based upon transfers and basic functional exercises, this was progressing well but as the patient improved in terms of there function they became more impulsive, and it became harder to complete a full worthwhile treatment session which would address the goals I would set out at the start of each session.
Following a discussion with my supervisor they provided some tips on how to achieve these goals. The first tip was to make sure each time the patient did something for example supine to SOEOB that they would perform it in the correct manner and pattern and if they didn't to make them perform it again. The second was to try and keep the sessions short as the patient would tend to lose interest so perhaps two shorter session in the day would be more effective. A final tip that I was given was to. The final tip was to take a more of a controlled role in the session using verbal and tactile measures to make sure the patient was paying adequate attention and performing the correct task, and even if the patient became impulsive it would be easier to get them back on task.
THROUGH IMPLEMENTING THE ABOVE TIPS ALTHOUGH THE PATIENT WAS STILL DIFFICULT AT TIMES IT ALLOWED FOR THE SESSIONS TO BECOME MORE EFFECTIVE IN ADDRESSING THE IMPAIRMENTS, WHERE AS BEFORE A LOT OF THE TIME WAS SPENT ON JUST TRYING TO GET THE PATIENT TO PERFORM THE CORRECT TASK, NOW THE TREATMENT WAS BECOMING EASIER FOR ME AND ALSO MORE BENEFICIAL FOR THE PATIENT, AND SAFER FOR BOTH OF US.
Monday, October 27, 2008
Autism
On paeds placement at a child development centre, my first patient at this setting was a 4yo child with autism who was generally small for his age and had developmental delay. I was to see this patient following initial assessment from another physiotherapist. When reading through his file it was evident that he had problems with jumping, kicking, hoping, climbing and stairs.
I subsequently set up the gym with equipment I thought could be useful having not seen the patient. Having created a curcuit I had to think of strategies for this child to engage him in play. What would I do?
I made a checklist for the child with all the activties drawn on the sheet, which included SLS, trampoline, jumping through series, hopping, strairs with and without railing, basketball and soccer. Next to each activity I put a square so I could either get the child to tick it once he had done it or put a stamp/sticker on completion.
This suprisingly worked well. I allowed the child to do what they would like first rather then trying to have some flow to my session. The child I felt they were more in control of the play session because they could choose what they were doing, but he also knew he had to complete all the tasks on the sheet. This was my first strategy I used to deal with a child with autism and by the end of the session I had achieved the goals I had set out to do.
From this session I learnt that treating children half the battle is motivation and attention. By creating an environment mimicing a fun play session I achieved what I had set out to assess and treat and the child was allowed to play, and I think will be more likely to attend physio again.
Next time I see this child or in fact any other children with motivation and attentional problems I could use this strategy. But also I think its important to have a couple of strategies that you can call upon. Some of these which I have used subsequently with this child are, playing whats the time Mr. wolf with heel-toe walking, and hide and seek at the end of the session.
I subsequently set up the gym with equipment I thought could be useful having not seen the patient. Having created a curcuit I had to think of strategies for this child to engage him in play. What would I do?
I made a checklist for the child with all the activties drawn on the sheet, which included SLS, trampoline, jumping through series, hopping, strairs with and without railing, basketball and soccer. Next to each activity I put a square so I could either get the child to tick it once he had done it or put a stamp/sticker on completion.
This suprisingly worked well. I allowed the child to do what they would like first rather then trying to have some flow to my session. The child I felt they were more in control of the play session because they could choose what they were doing, but he also knew he had to complete all the tasks on the sheet. This was my first strategy I used to deal with a child with autism and by the end of the session I had achieved the goals I had set out to do.
From this session I learnt that treating children half the battle is motivation and attention. By creating an environment mimicing a fun play session I achieved what I had set out to assess and treat and the child was allowed to play, and I think will be more likely to attend physio again.
Next time I see this child or in fact any other children with motivation and attentional problems I could use this strategy. But also I think its important to have a couple of strategies that you can call upon. Some of these which I have used subsequently with this child are, playing whats the time Mr. wolf with heel-toe walking, and hide and seek at the end of the session.
Chronic Pain
While on placement in the country I received a referral for an elderly patient who had multiple problems associated with Polymyalgia rheumatica, which had been present for two years. This patient had multiple sites of pain- the shoulders, neck, temporal area (due to associated giant cell arteritis), low back pain radiating into the left leg and also bilateral hip pain. She mobilises with the aid of a four wheeled walker and was previously completing a home exercise program consisting of walking and LL strengthening exercises. However she ceased these following a fall five weeks previously.
Initially I was unsure of where to start with my assessment, however she stated the wish for her lumbar pain to be treated. I initially felt a bit overwhelmed with all her areas of pain, however as she wished I focused solely on her back during the sessions, with advice to recommence the walking program. After the initial session where I performed PPIVMs (rotations) and piriformis releases and soft tissue massage, she reported a reduction in her pain in the lumbar area. Over a series of treatment this continued.
From this patient I have realised that although a patient may have multiple problems and areas of pain, if you can start by easing just one area, this provides great relief to the patient. Also I have realised patients often don’t expect you to treat everything initially, but gradually work through the problems. In the future I won’t feel pressured to work on multiple areas of pain (unless they are related) and understand that to someone with chronic pain a small reduction in pain (or in one area) may greatly improve their quality of life.
Initially I was unsure of where to start with my assessment, however she stated the wish for her lumbar pain to be treated. I initially felt a bit overwhelmed with all her areas of pain, however as she wished I focused solely on her back during the sessions, with advice to recommence the walking program. After the initial session where I performed PPIVMs (rotations) and piriformis releases and soft tissue massage, she reported a reduction in her pain in the lumbar area. Over a series of treatment this continued.
From this patient I have realised that although a patient may have multiple problems and areas of pain, if you can start by easing just one area, this provides great relief to the patient. Also I have realised patients often don’t expect you to treat everything initially, but gradually work through the problems. In the future I won’t feel pressured to work on multiple areas of pain (unless they are related) and understand that to someone with chronic pain a small reduction in pain (or in one area) may greatly improve their quality of life.
Whiplash
While on my rural placement I encountered a patient who was admitted for pain management following a whiplash injury three months previously. A CT Scan eliminated a fracture. The patient complained of pain in the cervical spine radiating into the head causing headaches, and thoracic spine pain with generalised pain in the surrounding muscles and shoulders. The patient was on very high dosages of pain relieving medications, however still complained of pain ranging from 8-10/10. The patient was discharged with a physio outpatient appointment, however did not attend, then was soon re-admitted for pain relief. This patient had also been seen previously in the outpatient setting by the previous student when the individual was approximately two months post injury, where he received ultrasound, however did not attend follow up appointments. This patient had a few yellow flags such as chronic pain, fear avoidance behaviours and reporting high amounts of pain. He was also receiving input from the Psychologist.
Assessment showed loss of cervical lordosis, significant stiffness throughout the cervical and thoracic spine and “tightness” in rhomboids, upper traps and erector spinae. The patient would not tolerate mobilisations (passive physiological, accessory and distractions) and only allowed us to treat through gentle massage. This situation was particularly frustrating because although we explained the need for mobilisations to decrease the hypomobility, which was contributing to his pain, he refused this treatment each time we attempted it. Although he stated the massage eased the pain during the session, it soon increased the pain. I felt like I was not able to help this patient because he would not allow me to treat him with the optimal treatment strategies. We were also receiving criticism from a doctor who didn’t believe in the value of Physiotherapy.
From this experience I realise the need for early treatment for whiplash injuries to prevent further complications arising. The need for education is also vital to ensure the patient understands the need for treatment. For complicated patients such as this a multi-disciplinary approach is also required. Does anyone know what other techniques we could have used?
Assessment showed loss of cervical lordosis, significant stiffness throughout the cervical and thoracic spine and “tightness” in rhomboids, upper traps and erector spinae. The patient would not tolerate mobilisations (passive physiological, accessory and distractions) and only allowed us to treat through gentle massage. This situation was particularly frustrating because although we explained the need for mobilisations to decrease the hypomobility, which was contributing to his pain, he refused this treatment each time we attempted it. Although he stated the massage eased the pain during the session, it soon increased the pain. I felt like I was not able to help this patient because he would not allow me to treat him with the optimal treatment strategies. We were also receiving criticism from a doctor who didn’t believe in the value of Physiotherapy.
From this experience I realise the need for early treatment for whiplash injuries to prevent further complications arising. The need for education is also vital to ensure the patient understands the need for treatment. For complicated patients such as this a multi-disciplinary approach is also required. Does anyone know what other techniques we could have used?
Education
While on placement at a rural hospital a patient came to see me in the outpatient department regarding pain involving the entire arm and shoulder. On examination the patient showed signs of ulnar nerve sensitization such as positive neural tissue provocation tests and pain in the distribution of the ulnar nerve. I performed lateral glides to the appropriate cervical spinal segments. I briefly explained the pathology behind the pain and explained it would take at least 6 weeks for any improvements.
This lady did not attend her next appointment, which I was disappointed about because my supervisor was going to demonstrate a taping technique that unloads the shoulder which significantly reduces pain.
I decided to ring the patient, she said she didn’t come back because she didn’t notice any improvement in her pain levels. I realized I may not have taken enough time to explain the pathology and give a realistic picture of recovery of function. I explained this over the phone and told her I would try a taping technique to relieve her symptoms.
From this experience I have realized that for complex problems that require an extended recovery period, thorough explanations are required, and you need to ensure the patient understands this. I also think I should have asked my supervisor to demonstrate the taping technique on the initial visit because this would have helped the patient trust that we can actually help relieve the pain.
Next time I have a patient who I think may require extended treatment to reduce pain I will ensure patient education plays more of a role in my session.
This lady did not attend her next appointment, which I was disappointed about because my supervisor was going to demonstrate a taping technique that unloads the shoulder which significantly reduces pain.
I decided to ring the patient, she said she didn’t come back because she didn’t notice any improvement in her pain levels. I realized I may not have taken enough time to explain the pathology and give a realistic picture of recovery of function. I explained this over the phone and told her I would try a taping technique to relieve her symptoms.
From this experience I have realized that for complex problems that require an extended recovery period, thorough explanations are required, and you need to ensure the patient understands this. I also think I should have asked my supervisor to demonstrate the taping technique on the initial visit because this would have helped the patient trust that we can actually help relieve the pain.
Next time I have a patient who I think may require extended treatment to reduce pain I will ensure patient education plays more of a role in my session.
Sunday, October 26, 2008
Severe Dementia
I was treating an elderly lady with a # hip who had severe dementia. I had never had a patient with severe dementia before. This patient was difficult to wake up, and communication was very limited. I was to assess the patient’s hip and mobility status. It was difficult to get a precise assessment of her hip in regards to strength and ROM.I tried different techniques, saying short words, repeating words and allowing plenty of time, to try get her to do the actions I required for assessment.
It was frustrating as it wasn’t going as easy as I thought. Assessing muscle strength seemed to be the most challenging. In the end I found a way that suited this lady. This involved doing repeated passive movements and gradually taking my assistance away with each repetition and saying a couple of prompts. In the end this patient showed general strength to be sufficient to stand and walk. Surprisingly, this lady was quite good at standing and walking and required very little prompting. She responded well to physical guidance rather than verbal.
From this situation I was introduced to some of the challenges faced when treating patients with severe dementia. Although challenging, once I had worked out the best strategy for this patient, it became easier in treating the patient at the end of the session and simple on subsequent sessions. Some of the strategies we learnt at university when dealing with dementia patients included breaking down tasks, gentle physical facilitation, clear slow voice, visual cues, eye contact/facial gestures and limit distractions. When seeing the patient, I also thought it was important to try having the same therapist treat the dementia patient as this would mean the patient and therapist would be familiar with each other.
In future, I would approach a dementia patient using less verbal communication and more physical facilitation, keeping in mind dementia patients may respond differently. It is important to allocate time for these patients especially in the initial session so the therapist can work out the best means of assessing and managing the patient. I also learnt that a patient with dementia can fluctuate throughout a day, so a therapist needs to be able to be relatively flexible in when they can see them. I hope to continue developing the skills to treating patients with dementia, best done by further exposure to such patients.
It was frustrating as it wasn’t going as easy as I thought. Assessing muscle strength seemed to be the most challenging. In the end I found a way that suited this lady. This involved doing repeated passive movements and gradually taking my assistance away with each repetition and saying a couple of prompts. In the end this patient showed general strength to be sufficient to stand and walk. Surprisingly, this lady was quite good at standing and walking and required very little prompting. She responded well to physical guidance rather than verbal.
From this situation I was introduced to some of the challenges faced when treating patients with severe dementia. Although challenging, once I had worked out the best strategy for this patient, it became easier in treating the patient at the end of the session and simple on subsequent sessions. Some of the strategies we learnt at university when dealing with dementia patients included breaking down tasks, gentle physical facilitation, clear slow voice, visual cues, eye contact/facial gestures and limit distractions. When seeing the patient, I also thought it was important to try having the same therapist treat the dementia patient as this would mean the patient and therapist would be familiar with each other.
In future, I would approach a dementia patient using less verbal communication and more physical facilitation, keeping in mind dementia patients may respond differently. It is important to allocate time for these patients especially in the initial session so the therapist can work out the best means of assessing and managing the patient. I also learnt that a patient with dementia can fluctuate throughout a day, so a therapist needs to be able to be relatively flexible in when they can see them. I hope to continue developing the skills to treating patients with dementia, best done by further exposure to such patients.
Tuesday, October 21, 2008
Potential (for) Pool Problems
Whilst on my paediatric placement during the first week of the prac I was thrown into the deep end during a hydro session, not literally the deep end but figuratively. The class for which I was involved on this occasion only consisted of 5 participants with varying conditions including forms of muscular dystrophy, juvenile arthritis and hypotonia and developmental delay, so really each child presented differently so each child warranted a different approach to the session.
Even before the session had a begun I noticed there was a child who seemed a bit older that the others and he was also quite excitable. On entering the pool it was also clear that he was more independent in the pool with regards to keeping afloat and performing the activities, however it became apparent very quickly that it would be necessary someone remain with him due to his excitable nature. As the student i was assigned this task, and I must admit at first i found it quite daunting having a over excited child in the pool who didn't seem to be following instructions too well either.
This presented me with a few issues, firstly the safety of the particular child then also the safety and well being of the other children participating in the class who had more of an issue keeping their head above water, as well as this I had to devise some way that would ensure the child was still getting benefit out of the session.
So the first thing I tried to do was try and develop somewhat of a report with the child and work out a way of communicating with them, bribery goes a long way and i made sure i always made direct eye contact with them as this seemed to make the child listen. Also the child was able to complete the tasks with the other children however a harder aspect was added to challenge this child more. To address the increase in energy I tried to use basic things in between each task like jumping on the spot and swimming out to a point then back to the wall however i had to be careful using these things as every so often it tended to excite the child even more.
All up the strategies worked quite well and as i went to more sessions it became easier to interact with this child. As I became more confident in the situation and also more proficient with communicating at the child's levels I feel my initial concerns were dispelled.
Even before the session had a begun I noticed there was a child who seemed a bit older that the others and he was also quite excitable. On entering the pool it was also clear that he was more independent in the pool with regards to keeping afloat and performing the activities, however it became apparent very quickly that it would be necessary someone remain with him due to his excitable nature. As the student i was assigned this task, and I must admit at first i found it quite daunting having a over excited child in the pool who didn't seem to be following instructions too well either.
This presented me with a few issues, firstly the safety of the particular child then also the safety and well being of the other children participating in the class who had more of an issue keeping their head above water, as well as this I had to devise some way that would ensure the child was still getting benefit out of the session.
So the first thing I tried to do was try and develop somewhat of a report with the child and work out a way of communicating with them, bribery goes a long way and i made sure i always made direct eye contact with them as this seemed to make the child listen. Also the child was able to complete the tasks with the other children however a harder aspect was added to challenge this child more. To address the increase in energy I tried to use basic things in between each task like jumping on the spot and swimming out to a point then back to the wall however i had to be careful using these things as every so often it tended to excite the child even more.
All up the strategies worked quite well and as i went to more sessions it became easier to interact with this child. As I became more confident in the situation and also more proficient with communicating at the child's levels I feel my initial concerns were dispelled.
cultural? language barrier?
On a recent prac I had to give a new mother post-natal information as per protocol. Unfortunately, my Vietnamese isn't quite up to scratch and I was told by the nurses she doesn't speak a word of English. I asked the nurses if she has any regular visitors who might be able to translate and it turned out she did. I came back the next day when they were visiting and found out their English wasn't that great either, but it still helped a lot. I tried my best to used gestures and work with the relatives translating. They were all friendly, however, there was either an awkward atmosphere or they knew less English than I thought. At times it was like one of those movie moments where the subtitles show how ridiculously wrong the translations are.
Upon reflection, I realized that it may have been culturally inappropriate for them to translate the questions about topics like bladder and bowel problems in front of the husband. If anyone happens to know about Vietnamese culture a comment on this would be much appreciated.
I also realized that organizing to see the patient with visitor/translators was not something I would have known to do a year ago... we are learning a lot after all!
Next time in this situation I would ask the translating relative if it is appropriate to ask the wife personal questions in the presence of a male.
Monday, October 20, 2008
You please everyone
Whist on an outpatient’s placement I treated a lady who had neck pain for 14 years and had been coming to Physio for 2 months. The previous treating students ceased trigger point release as that is all the patient said improved her pain and had nil compliance towards HEP. When I Ax her she said there had be no improvement. I decided to do trigger point releases as they were indicated as well as postural re-education and other exercises. Over the course of the 4 weeks her pain improved to nil neck pain. When I told her that I was going to D/C her, the lady got quite defensive and said that her pain was back and she made a mistake. I was taken back by this and spoke to my supervisor. We decided to discharge the lady due to her improvement- Subjectively and objectively.
Initially I felt like I was did the wrong thing by using trigger point release and then felt bad for D/Cing the lady but now I am aware that sometimes some people can lie about their symptoms to either gain their desired treatment ‘massage’ or for social interaction. If faced again with a situation like this I will ensure that I am clear with my objective examination findings so I will have more confidence when deciding that PT Rx is no longer indicated. Further I will investigate her social hx and suggest social groups they could go to. You cannot please everyone.
Initially I felt like I was did the wrong thing by using trigger point release and then felt bad for D/Cing the lady but now I am aware that sometimes some people can lie about their symptoms to either gain their desired treatment ‘massage’ or for social interaction. If faced again with a situation like this I will ensure that I am clear with my objective examination findings so I will have more confidence when deciding that PT Rx is no longer indicated. Further I will investigate her social hx and suggest social groups they could go to. You cannot please everyone.
Sunday, October 19, 2008
On a recent neurology prac I was working with a lovely patient who had a L MCA stroke rendering him expressively aphasic among other things. At first there was some receptive aphasia too, but that quickly resolved so he could understand perfectly well but speech was minimal. Initially he was unable to verbalize at all, but could phonate to command (ie repeat kaka, gaga...) After 2 weeks he was still unable to form sentences but could respond to questions where options were given, and occasionally when they weren't. Having to spend 2hrs a day for 3 weeks with someone who can't speak, I had to employ some strategies to enhance assessment and communication. I thought these might come in handy for anyone who encounters a similar patient.
- Patience, patience, patience. If you get frustrated (or can't hide frustration) the patient would become more frustrated or self conscious. These emotions detract from the task making speech harder... similar to us in an OSPE if an examiner fired questions at you faster than you can respond.
- Open questions are a waste of time. If someone can't form a sentence, closed questions are the only option when an answer is required eg during Ax (as opposed to speech exercises)
- No stroke patient would like being talked to as though they're stupid. It is possible to simplify language &/or talk slower without sounding condescending if you consciously try. In this example, 'dumbed down' speech would have been totally inappropriate and annoying for the patient (once the receptive aphasia disappeared).
- Extra checks can help you determine whether aphasia is influencing the Ax results eg for light touch localisation, practise with eyes open first.
- Non-verbal response options to Ax questions include: thumbs up/down (good for joint position sense); smile/frown (good for sharp blunt or shoulder pain screening)
- Try not to feel awkward with silence. Occasional silent times give the patient a chance to relax and is probably as important for cognitive rest as sitting down after gait retraining.
- Think about what you say before it comes out to ensure that there's an easy way for the patient to answer it
- Ask one question at a time
- Everything requires more concentration post-stroke so don't attempt multi-tasking when both tasks are hard eg UL facilitation + conversation
- Minimize background noise and distraction
- Put in as much effort to develop rapport as you would with any other patient. After 3 weeks I actually felt like I knew this guy quite well. I was surprised at how few words are needed for quality conversation.
- Liaison with the speech therapist equipped me with lots more tactics that I wasn't aware of before, eg
- Practising automatic language like the alphabet, counting, days of the week...
- Finishing doubles eg hot and... (cold), light and... (dark)
- Naming objects nearby
- Giving options in closed questions eg are you from Australia or overseas? rather than 'what country are you from?'
- These were useful to practice during breaks from physical tasks. As the speech therapist was unable to see the patient everyday, our input in this area could be invaluable.
I'm sure lots of these ideas were already common sense to everyone, but hopefully there are some new ones too.
Monday, October 13, 2008
Refer on
In my first week in an out pt setting I received a pt that had been coming to physio for 4 months and had been seen by other physio students. She presented with a neck strain after turning too quickly while driving. Former students had also begun a walking program with her as she had a BMI of 37. When I asked her how her neck was progressing all she could talk about was her sick father who was in a nursing home. She told me some disturbing issues and the conversation was getting very personal. Whenever I asked her a question she always responded about her father and she argued that she was unable to complete any exercise or the walking program as her father would not cope without her there. I responded by discussing with her that her health was very important and that she needed to commence her walking program. I was unsure what I could achieve with this pt and felt like that she needed to discuss her personal issues with someone who was more qualified in that area. After talking to my supervisor, I decided to refer the pt on to the clinical psychologist. I was hesitant on how I was going to tell the pt by being professional as well as not being harsh. I told her that I believed that she could improve her level of physical activity and her neck pain if she tried to off load her personal issues and speak to someone with more experience than myself. The pt begun to cry but took it well and agreed to the referral.
This was an interesting yet new situation for me. Afterwards I started to feel guilty for referring her on simply because the stigma that is related to a psychologist. However I then realized that I was just more overwhelmed by my role and responsibility as PT student. I now understand how someone’s physical ability can be so affected by personal issues. I wouldn’t change how I treated the situation, next time I will have more confidence in myself as a professional. Do not be afraid to refer on!
This was an interesting yet new situation for me. Afterwards I started to feel guilty for referring her on simply because the stigma that is related to a psychologist. However I then realized that I was just more overwhelmed by my role and responsibility as PT student. I now understand how someone’s physical ability can be so affected by personal issues. I wouldn’t change how I treated the situation, next time I will have more confidence in myself as a professional. Do not be afraid to refer on!
Never make assumptions
On my prac in the geriatric area, I had a patient a 78 y/o lady who attended outpatient due to her chronic lower back pain. She is physically independent and mentally alert. She walks with a 4WW due to her LBP and bilateral knee pain. As part of her physiotherapy treatment, I felt that she would benefit from hydrotherapy exercises. I discussed with her about the class and how it will help ease her pains. She seemed happy to participate and so I assumed that she had agreed to attend. I then went on to fill out the papers required for the hydrotherapy classes. The following week she had failed to attend the class and so I rang to find out why. She just said that it wasn’t a good day for her that day so she did not attend. Then the 2nd week came and again, she was absent from the class. I then suspected something is not adding up to her reasons. Initially, I was not sure how to pursue the matter without making her feel like I don’t trust her words. I just felt terrible at the fact that this lady has an ongoing problem with pain and has not received any treatment for the past 2 weeks and the thought of it turning into a vicious cycle and all that really bugged me.
I then organised for her to come for treatment with me, I thought it’ll be better dealing with the issue face to face rather than over the phone. So I rang her and asked f she could come in within the next few days for physio and she agreed. So I saw her two days after that and gave her some education on how a chronic pain can become a huge problem and impact her functional levels. At this stage it is really important that we do whatever it takes to try and preserve whatever function she has in her daily life. And some of the things that can help was hydro, I subtly brought the topic up again and she begin to tell me how she is afraid of the water as she doesn’t like the cold and also she does not own a swim wear. I assured her that the pool is heated and we will be able to loan out a swim wear. She seemed more convinced this time around and I was sure in a way that she will be attending the next hydro session. When the day came, she turned up. I was glad to see her and she seemed to have enjoyed her first hydro session. She then made it again the following week and reported having had a bit of relieve from her pains after the first session.
From this encounter, I have learnt never to assume that we have patient’s compliance just because we have given them a good run down on all the benefits of doing the things we ask them to (just like how I’ve assumed here) .To a certain extend I think we are in an industry that we have to be able to sell and it can be very challenging especially when we do not understand our buyers needs. If I just took a step back and asked a few more questions I would have been more successful the first time around and that would have meant that the patient started hydro 2 weeks earlier rather than later. This was yet another experience for me to take on board and help me be a better advocate of exercise and treatment as a qualified physio one day.
I then organised for her to come for treatment with me, I thought it’ll be better dealing with the issue face to face rather than over the phone. So I rang her and asked f she could come in within the next few days for physio and she agreed. So I saw her two days after that and gave her some education on how a chronic pain can become a huge problem and impact her functional levels. At this stage it is really important that we do whatever it takes to try and preserve whatever function she has in her daily life. And some of the things that can help was hydro, I subtly brought the topic up again and she begin to tell me how she is afraid of the water as she doesn’t like the cold and also she does not own a swim wear. I assured her that the pool is heated and we will be able to loan out a swim wear. She seemed more convinced this time around and I was sure in a way that she will be attending the next hydro session. When the day came, she turned up. I was glad to see her and she seemed to have enjoyed her first hydro session. She then made it again the following week and reported having had a bit of relieve from her pains after the first session.
From this encounter, I have learnt never to assume that we have patient’s compliance just because we have given them a good run down on all the benefits of doing the things we ask them to (just like how I’ve assumed here) .To a certain extend I think we are in an industry that we have to be able to sell and it can be very challenging especially when we do not understand our buyers needs. If I just took a step back and asked a few more questions I would have been more successful the first time around and that would have meant that the patient started hydro 2 weeks earlier rather than later. This was yet another experience for me to take on board and help me be a better advocate of exercise and treatment as a qualified physio one day.
Friday, October 3, 2008
Motivation?
On cardio clinic at a large hospital I treated a young lady in her early 20s following drug overdose and subsequent 2 week coma. Following he stay in ICU the patient was discharge to the ward where I began to see her. The lady was quite obviously markedly obese and had developed bilateral foot drop as a result of prolonged positioning in ICU.
The main aim for this patient was to mobilise her, beginning right back with basic bed mobility. This patient was to be seen 3 times per day for physiotherapy. I subsequently devised her a general exercise program which she could perform 3 times per day and on weekends, and would check on her daily. Through the week the patient was obviously very unmotivated to do anything, constantly becoming emotional around medical staff, however I noticed she was totally the opposite when conversing with friends who came to visit or on the phone.
For this patient to get better and leave hospital I thought this lady needs motivation. I proceed to ask her what she wanted to get out of physiotherapy in hospital. She said she would like to get back to ballet. I subsequently used this as a source of motivation throughout her exercise sessions to good effect. I also suggested to the medical team the patient's problem with her weight and the doctor said the patient would have to loose 40-50kg to be considered for gastric banding surgery. So together with the patient wanting to return to ballet and the need for her to loose 40-50kg this made her more motivated to do physiotherapy. I found that I would just need to pop my head in to progress her exercises rather then having to actually go through 3 sets of exercises per day.
THIS SITUATION IDENTIFIED TO ME THE NEED TO SET GOALS FOR PATIENTS. THE GOALS IN THIS CASE SERVED TO MOTIVATE MY PATIENT AND KEEP HER COMPLIANT WITH THE PROGRAM.
IN THE FUTURE I THINK ITS IMPORTANT TO SET GOALS FOR PATIENTS DURING INTIAL TREATMENTS SO THAT THEY FEEL THEY ARE WORKING TOWARDS SOME BIGGER THEN JUST GETTING OUT OF BED OR AMBULATING WHICH IS MORE IMPORTANT TO PHYSIOTHERAPIST IN A WARD BASED SETTING.
The main aim for this patient was to mobilise her, beginning right back with basic bed mobility. This patient was to be seen 3 times per day for physiotherapy. I subsequently devised her a general exercise program which she could perform 3 times per day and on weekends, and would check on her daily. Through the week the patient was obviously very unmotivated to do anything, constantly becoming emotional around medical staff, however I noticed she was totally the opposite when conversing with friends who came to visit or on the phone.
For this patient to get better and leave hospital I thought this lady needs motivation. I proceed to ask her what she wanted to get out of physiotherapy in hospital. She said she would like to get back to ballet. I subsequently used this as a source of motivation throughout her exercise sessions to good effect. I also suggested to the medical team the patient's problem with her weight and the doctor said the patient would have to loose 40-50kg to be considered for gastric banding surgery. So together with the patient wanting to return to ballet and the need for her to loose 40-50kg this made her more motivated to do physiotherapy. I found that I would just need to pop my head in to progress her exercises rather then having to actually go through 3 sets of exercises per day.
THIS SITUATION IDENTIFIED TO ME THE NEED TO SET GOALS FOR PATIENTS. THE GOALS IN THIS CASE SERVED TO MOTIVATE MY PATIENT AND KEEP HER COMPLIANT WITH THE PROGRAM.
IN THE FUTURE I THINK ITS IMPORTANT TO SET GOALS FOR PATIENTS DURING INTIAL TREATMENTS SO THAT THEY FEEL THEY ARE WORKING TOWARDS SOME BIGGER THEN JUST GETTING OUT OF BED OR AMBULATING WHICH IS MORE IMPORTANT TO PHYSIOTHERAPIST IN A WARD BASED SETTING.
Thursday, October 2, 2008
Sharing ideas
On this particular morning my scheduled pt’s on the acute ward all became either unavailable or physiotherapy Rx was not indicated at that particular time. My supervisor suggested that I assist another student. The other student was mid way through looking through the notes when I told them the plan. I said that I would check the chest X-ray whilst they finished reading the notes and then we can come together and briefly talk about the pt. The student told me that this was one of their favourite pt’s and preferred if I did not look at their X-rays until they did first. I was taken back by that comment and felt like I was not apart of the team treating this pt. We looked at the X-ray together and then went to treat the pt. The student said to me that they know exactly how this pt likes to be treated and they will ask for help if needed. I ended up assisting with transferring the pt and Rx.
THIS SCENARIO HAS TAUGHT ME THAT NOT ONLY DO WE HAVE TO LEARN TO WORK WITH DIFFERENT PERSONALITIES AND WORKING STYLES BUT SOMETIMES IT IS TOO EASY JUST TO AGREE AND ACEPT WHAT THE OTHER PERSON IS SAYING WITHOUT VOICING YOUR POV IF YOU DISAGREE. THIS IS ONE TRAIT THAT I NOW KNOW I NEED TO FURTHER DEVELOP.
IF I WAS IN A SITUTAITON LIKE THIS AGAIN I WOULD BE LESS PASSIVE AND ACTIVELY ASK MORE QUESTIONS UNTIL I TOO AM HAPPY WITH THE PROFILE OF THE PT. I FURTHER WOULD CONSTRUCTIVELY AND PROFESSIONALLY DISCUSS WITH THE PERSON IDEAS ON HOW I BELIEVE THE RX SESSION CAN BE PLANNED.
THIS SCENARIO HAS TAUGHT ME THAT NOT ONLY DO WE HAVE TO LEARN TO WORK WITH DIFFERENT PERSONALITIES AND WORKING STYLES BUT SOMETIMES IT IS TOO EASY JUST TO AGREE AND ACEPT WHAT THE OTHER PERSON IS SAYING WITHOUT VOICING YOUR POV IF YOU DISAGREE. THIS IS ONE TRAIT THAT I NOW KNOW I NEED TO FURTHER DEVELOP.
IF I WAS IN A SITUTAITON LIKE THIS AGAIN I WOULD BE LESS PASSIVE AND ACTIVELY ASK MORE QUESTIONS UNTIL I TOO AM HAPPY WITH THE PROFILE OF THE PT. I FURTHER WOULD CONSTRUCTIVELY AND PROFESSIONALLY DISCUSS WITH THE PERSON IDEAS ON HOW I BELIEVE THE RX SESSION CAN BE PLANNED.
Wednesday, October 1, 2008
Messy
During a placement there was one student who constantly had a messy plinth area during and between patients, and did minimal to help in ‘house keeping’. This made the rest of us students look bad even though the rest of the plinths were tidy. A physio in the department had a word with us, but the messy student wasn’t even there. As ridiculous as this sounds, the mess irritated me.
I think I have become one of those pedantic neat physios. I found myself tidying their plinth because it was irritating. I just thought there was no reason to have a messy area (sheets half on the plinth, pillows randomly placed, towel messed up, US machine in cubicle) since the rest of us are able to keep a tidy area. On a couple of occasions, after waiting 15 minutes or longer to see if the student would tidy their area, I reminded the student that their area needed tidying ( very very very very nicely/subtly of course!). By the end of the placement the student was somewhat neater.
From the situation I have learnt that people do notice messiness/tidiness and that it is important to keep an area tidy. It also highlighted to me memories of 1st 2nd and 3rd year pracs thinking some physios were pedantic about specific ways of having things organized and set out, but now I understand where they were coming from.
I have learnt that people might not realize that their habits/ways of doing things can irritate others, no matter how small the issue. Physios should have their individual style to how they carry out and organize things; however I believe keeping a plinth area tidy should be simple enough no matter what organizational style they have. If in future a similar scenario was raised, it would be worth nicely addressing the issue with the person which could result in a better working environment. Little irritations in the workplace could lead to greater arguments, which is why it would be important to address the issue sooner rather than later.
I think I have become one of those pedantic neat physios. I found myself tidying their plinth because it was irritating. I just thought there was no reason to have a messy area (sheets half on the plinth, pillows randomly placed, towel messed up, US machine in cubicle) since the rest of us are able to keep a tidy area. On a couple of occasions, after waiting 15 minutes or longer to see if the student would tidy their area, I reminded the student that their area needed tidying ( very very very very nicely/subtly of course!). By the end of the placement the student was somewhat neater.
From the situation I have learnt that people do notice messiness/tidiness and that it is important to keep an area tidy. It also highlighted to me memories of 1st 2nd and 3rd year pracs thinking some physios were pedantic about specific ways of having things organized and set out, but now I understand where they were coming from.
I have learnt that people might not realize that their habits/ways of doing things can irritate others, no matter how small the issue. Physios should have their individual style to how they carry out and organize things; however I believe keeping a plinth area tidy should be simple enough no matter what organizational style they have. If in future a similar scenario was raised, it would be worth nicely addressing the issue with the person which could result in a better working environment. Little irritations in the workplace could lead to greater arguments, which is why it would be important to address the issue sooner rather than later.
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