Splish Splash

I was treating a girl as an outpatient who was starting to lose motivation and become sad, after attending physio sessions 3 times a week for over 6 months. I thought it would be beneficial and more exciting to integrate a hydrotherapy session into her program once a week. This idea went down very well with the child. During the first session of hydro, the girl was very excited because she hadn’t been swimming for over 9 months due to medical treatment. The child got a little carried away during the hydro session, constantly swimming away, doing tumble turns, putting her head under water etc. I found it hard to keep her under control and to get her to follow exercises.

I felt like my patient wasn’t getting a ‘true’ physio session as any exercise I tried to do with her she would do only a few reps then do her own thing. I let her get away with more than I usually would have because I knew the child was having so much fun in the water and I didn’t want to spoil it for her. How much should I let a child (who’s usually emotionally down) get her own way if she’s having so much fun? On reflection after the session, it felt that although she wasn’t following the exercises as well as planned, she enjoyed herself. This may just be enough to regain her enjoyment of physio. In future hydro sessions with this pt I will discuss a plan for the session and negotiate exercises/games. Hopefully, a good combination of effective treatment and fun will be achieved.

From the initial hydro session I have learnt it is not a waste of a treatment session if exercises do not go to plan when treating children. The benefits of the child being happy and feeling like a child again can benefit future physio sessions.

IN FUTURE, I WILL UNDERSTAND THAT INITIAL TREATMENT SESSIONS WITH A CHILD MAY NOT FEEL LIKE AN EFFECTIVE TREATMENT. ALLOWING AN INITIAL TREATMENT SESSION TO BE MORE ABOUT FUN AND LESS STRUCTURED IS APPROPRIATE AS IT ALLOWS RAPPORT TO BE BUILT AND THE CHILDS CONFIDENCE TO BE BOOSTED. HOWEVER, FUTURE SESSIONS WITH A CHILD SHOULD AIM FOR EFFECTIVE EXERCISES THROUGH NEGOTIATION AND EXPECTATIONS MET WITH THE CHILD PRIOR TO THE SESSION.

Discussing goals with your patient

During my ortho inpatients placement I treated a 60 year old female patient that had been in and out of hospital for the past 3 months because of rare complications from what should of been a simple operation for a NOF fracture. On first impressions this patient was very compliant with physio treatment and was constantly sitting out of bed. The doctors had allowed her to start weight bearing on her affected leg, so the patient had started ambulating with a frame. However one week after getting the patient up out of bed and ambulating the doctors changed her to a non-weight bearing status.

At my next session with the patient, the doctor had just been in and told her that she was not to weight bear on her affected leg. I knew that this would severely affect how well she would progress as she was already very de-conditioned from being in hospital for such a long period of time. Over the next week the patient’s enthusiasm towards physio decreased significantly, whenever she got tired or couldn’t do one of the activities I asked her to try she would cry and give up. At first I felt like it was my fault that she was crying and would tell her that I would be back in the afternoon for another physio session. But as I took this approach the patient would do less and less treatment with me and sometimes refused to get out of bed. At this stage I felt I had failed with the patient and didn’t know how to motivate them to get out of bed.

After much thought I decided to go in and see the patient and for one whole treatment session just sit down and talk to them and find out exactly what they were feeling and what they thought they would be able to achieve. The patient was quite depressed and felt that they would never get out of hospital. After discussing the patient’s issues, I explained to her that if we strengthened her non affected leg, I believed she could hop with a frame. She agreed on the goal and for the next 2 weeks we focused on getting her to hop. By the time I left that placement the patient was back to her original cheerful self and was compliant with physio treatment

AFTER TREATING THIS PATIENT I HAVE LEARNT THAT IT IS VERY IMPORTANT TO WATCH YOUR PATIENTS MOTIVATION TOWARDS PHYSIO AND IF THEIR MOTIVATION DOES CHANGE START ASKING QUESTIONS. I HAVE LEARNT THERE ARE MANY WAYS TO FIND OUT HOW A PATIENT Is COPING ASKING THE NURSE, FAMILY AND THE PATIENT THEMSELVES ARE ALL GOOD WAYS TO FIND OUT HOW A PATIENT IS COPING. NEVER AVOID ISSUES BECAUSE IT DOESN’T BENEFIT YOU OR THE PATIENT!

It's for their benefit not ours

The sense of gratification that comes with helping people can be fairly addictive. Sometimes I forget that the patient can benefit even if I don't feel good by the end of the session. When taking a post-natal class recently, my fellow student reminded prior to starting that some of the women will be distracted by their babies and some babies will no doubt cry. This reminder helped me to continue with the session for those who were attentive at various times, and to continue talking when babies were crying. If I had become insecure or distracted when a participant stopped paying attention, the session would never have flowed or finished... then no one would have benefited. The achievement of keeping the class flowing despite so many distractions, in itself was satisfying. 

This has reinforced to me that the patient comes first, and a professional approach rather than following your own emotions is very important. It shows the patient that you are rationale and in control of the situation, but they are ultimately in control of their own outcome. Empowering them would be more motivating than enforcing something on them and making them feel inferior or bossed around.

patients who don't really want to do anything however if they do it would help with their d/c planning

Whilst on a placement recently in cardiopulmonary area there was a patient who had come in from a nursing home with shortness of breath and chest pain. On reading the patients notes I found out that the patient usually uses a stick and requires minimal assistance at the nursing home. It turned out the pt had empyema this was dealt with and the pt's lung function improved. When it came closer to the time when the pt was to be discharged i was to do a mobility review to determine what the patients previous level of function was and also what he was capable of now. The patient was very agitated and seemed like he wanted very much to leave the hospital, he refused to do anything and even with trying to motivate the patient to get up and moving he still wouldn't budge or comply with any request. I was not the only one to experience this either as the OT also had the same issues the patient was becoming quite the problem and was getting a reputation on the ward.
This lasted for a few sessions and after trying various things to get the patient motivated with no result i was beginning to become frustrated myself and thought if the patient wasn't going to move then how could i help.
On discussion with my supervisor we tried to think of ways in which we could get the patient to comply with our requests, i told the supervisor that the pt was just becomming more and more frustrated with his stay in hospital and then it clicked, we could use him going home as his motivation for completing the mobility review. On implementing this with the patient it worked and the patient although still agitated performed the review and could be dischared from a physio point of view.
For me this outlined how sometimes you must use anything you can in your disposal to get a patient motivated and i think by showing the patient that there was light at the end of the tunnel so to speak or by dangling a carrot in front of them (not saying that patients are donkeys) you can sometimes get a better outcome than with normal methods of trying to get a patient to comply to your requests. In future I think I will now be aware of this more and with the more stubborn patients i encounter i have a few more methods up my sleeve which i can use.

Knowing Ones Culture Makes A Difference

One of my previous placements was in the Women’s Health area, whereby a big part of it involved educating patients that had undergone gynae surgeries involving prolapse repairs amongst others. A huge part of the subjective questioning involved quite personal issues about their pre-op status including bowel and bladder symptoms and reasons why they developed a prolapse. Detailed questioning were carried out to determine patient’s risk factors so that the education given could be tailored to target individual cases. It can be a straightforward process if the patient is comfortable with the questioning. The majority of them were quite happy with the session even when they had family or friends around. Therefore, at some point I got use to the idea that people are generally quite unconcerned about having family or friends around for the education session that I sometimes overlook asking prior to the session.

I then came across one patient, a Moroccan lady who had just undergone a gynae surgery for repair of her bladder and bowel prolapse. Upon walking into the room, she had family there with her and I just assumed that it would be all right for me to start the session. I gave her a brief run of what the session was going to consist off and she appeared consenting at the start. She spoke very simple English and I checked regularly that she understood what I had meant. Midway through the questioning she appeared very uncomfortable and her answers was muffled and barely audible. Still, I just passed it as she did not quite understand me and I continued reiterating the question about her prolapse. Few moments later, her family started walking out one at a time. That is when I realized that I had generalized every patient and assumed that patients are generally comfortable around their family when issues concerning women’s health were discussed. I felt bad about my assumptions and apologized for being so insensitive. I then decided to just do part of the session that day and continue the other part the next so that she is not too overwhelmed with information that she is not used to taking in. The next day when I went to see her, she had no one with her. The difference in response and compliance was amazing. She even asked clarifying question, which surprised me, as she was quiet the day before when I saw her. I’m happy that I broke the session up into two parts as she appeared to be the type that needs a bit more time to open up on personal issues possibly due to her cultural background.

WHEN I LOOK BACK ON THIS INCIDENT, I HAVE LEARNT THAT NOT EVERY CULTURE IS READILY OPEN TO DISCUSSION ABOUT THEIR PERSONAL HEALTH ESPECIALLY IF THEY HAVE FAMILY MEMBERS OR FRIENDS IN THE ROOM. IT IS IMPORTANT FOR US TO REALISE THIS SO THAT WE DO NOT COMPROMISE ON PATIENTS COMPLIANCE TOWARDS OUR TREATMENT OR EDUCATION. WE MUST LEARN TO ACCOMMODATE FOR DIFFERENT CULTURAL NEEDS SO THAT WE HAVE SUCCESS IN OUR TREATMENT GOALS OF INDIVIDUALS.

lucky to get a one-word response

A young postnatal Aboriginal inpatient was referred for physio for assessment/treatment of engorged breasts. Reading her notes revealed complicated social issues, and the likelihood of a difficult subjective examination. When I knocked and asked to enter, there was no reply. I entered to check if it was empty but she was standing quite close to the door expressing milk (for those unfamiliar... its like a gentle human milking machine). Despite a stranger entering with an apology and an introduction (and she was exposed), she didn't look up. Initially I thought this might be due to cultural differences we learnt about in previous years: that eye contact is disrespectful. However, it became clear that this wasn't the main contributing factor when answers were often with-held. My presence wasn't acknowledged. It required 3 repetitions (not impatiently) of request for consent before I could asses the breasts. They were severely engorged and lumpy... ultrasound treatment was indicated, but is most effective just prior to breast-feeding or expressing. I treated the breast she hadn't yet expressed, and attempted to develop some rapport to encourage trust and avoid awkwardness. (10 minutes of treatment in silence can seem to last for eternity). After some silences and one word answers, I thought she might feel I'm prying into her personal life (eg whether she is from Perth), so I tried going through some of the post-natal education routinely offered. A mixture of uncooperativeness and inattentiveness eventually lead me to give up or risk angering her. I left the room feeling very dispondent and pessimistic about my chances of alleviating the atmosphere when I returned later to treat the other breast. 

When I returned, something inspired me to keep trying my best. After some less successful attempts, I brought up the topic of a certain colleague of ours who was from her home town of Geraldton who now plays AFL. She piped up after this, and we started having normal conversations. Whether she's a footy fanatic or was simply in better spirits after a visit from her family, I'm not sure. In any case, she came out of her shell, which wouldn't have occurred without persistence. This lead to her asking questions and learning about important postnatal information.

I'm not saying we should harass every patient into constant chatter. If she had given the impression verbally or with body language that she preferred silence, that would be a different matter, but the patient appeared purely uncomfortable. Had I followed my initial desire to give up, I never would have known such a change in 'personality' could occur. This experience has taught me that I should always strive for rapport or at least trust, no matter how impossible it seems. It has also taught me that attitude problems on a first impression may not be an issue at all, its just that the invasion of privacy might be more intimidating for one particular patient than another.  

Increasing patients motivation

A 56yo male presented to my neuro inpatients ward with a stroke to the basal ganglia. This patient had the stroke 2 months ago and was still in hospital receiving physiotherapy rehab. He had improved significantly in the first month according to the notes but now any improvements in gait were minimal.

During my time treating this patient, he told me that his major goal was to walk his daughter down the aisle of her wedding which was one month away. The patient’s present physical status warned me that this would be a huge deadline to meet as he required one assist to walk plus the aid of a 4 point walking stick. I explained to the patient that what he was asking was quite a huge challenge and that at best he should expected to walk down the aisle with his daughter helping him.

During the next week we focused mainly on improving the patients gait, this included 2 hourly sessions morning and afternoon to try to retrain the patients movement pattern. After one week of treating the patient this way I was aware that they were quiet and seemed to be withdrawn from the treatment session. I constantly asked the patient if they were ‘ok’ and they continually told me they were ‘fine’, yet their actions didn’t match what they were saying. After much thought on the inconsistencies of my patients behaviour I decided to talk to my supervisor and ask what they realistically thought this patient would achieve in terms of gait.

I then went to the patient and sat them down and explained how I noticed their attitude towards rehab had changed and how I wanted to reassure them that they were progressing. I had made a list of goals which he had achieved and ones which I thought were realistic with timeframes attached. He then told me that he didn’t feel he was progressing as much as other patients in the hospital. So I then explained how depending on the severity and the type of stroke people will improve at different rates. For this patient educating him on what was realistic and that all patients will progress differently, gave him the help he needed to continue with the rehab and not to give up.

AFTER THIS PLACEMENT I HAVE DECIDED THAT IT IS VERY IMPORTANT TO MATCH THE PHYSIOTHERAPISTS GOALS WITH THE PATIENTS GOALS, AS THIS INCREASES THEIR MOTIVATION TOWARDS REHAB. ALSO CONSTANTLY REMINDING THE PATIENT OF THEIR ACCOMPLISHMENTS DECREASES THE RISK OF THEM GETTING DEPRESSED FROM NOT IMPROVING.