On a musculoskeletal outpatient placement I was treating a lovely 70 year old man for his final review session before discharging him to community physiotherapy. It was my first time meeting the pt who was 4 months post NOF#. I showed the pt to a cubicle and closed all the curtains and gestured to have a seat. After a minute of talking to the patient about how he’d been since his last physio session he told me he was feeling a little claustrophobic.
I rearranged the curtains so that we were taking up 2 cubicles (lucky no one was using the cubicle next door).He felt a little better. The pt began to say how he’d been getting claustrophobic recently and has to go outdoors. I asked him if he got SOB, of whether it occurred after a cigarette, the answer was no. We talked about the claustrophobia for a minute trying to work out possible causes and then continued on with the session.
Just as I was about to start an objective on the pt he told me he still was claustrophobic. So we decided together to open up some of the curtains so he could see outside the cubicles. Once again he continued to be claustrophobic so we moved to a different cubicle that was right next to an exit door. I opened the door, opened all the curtains and had him facing so he could see the glass door and outside, with the wind coming in, as well as seeing the openness of the room inside. The patient felt much much better!!!I was relieved something had finally worked so he could feel relaxed and not panic. At the end of the session I recommended he speak to his doctor regarding the claustrophobia.The patient agreed.
I have learnt that it is never a waste of time making a pt feel comfortable and relaxed as it will ultimately influence their treatment sessions, concentration, ability to relax and enjoyment of coming to physio.
This scenario has shown me the need to think on the spot and be somewhat flexible when dealing with clients. It also illustrates the need to think about the pt as a whole and to expect the unexpected. The situation highlighted to me that not all pts feel they need privacy (by closing curtains) and are happy to have their treatment sessions in the ‘open’. If a similar situation came up with a claustrophobic pt I would ask them how they would prefer to have the environment set up and accommodate accordingly.
Sunday, August 24, 2008
Brain Training
On rural prac, I conducted community classes for patients with chronic pain. The group consisted of 4 patients all of whom had some sort of spinal condition and had experienced chronic pain for 2 years or longer. To be eligible to attend this group participants were screened for suitability. 3 of the patients saw the group as a way to change their lifestyle and reduce their pain, however one particular group member saw the group negatively becuase he felt that surgery and medications had not helped him in the passed so how could physio? After all all we do is "massage" according to this lovely patient.
The group commenced, totalling a 3 week full time program, with sessions from pain specialists, psychologists, OTs, dieticians and physios. I conducted the physio part of the program taking the patients for a very light cardiovascular work out as well as light stretching and mobility exercises. During the class the patient would never do anything properly, and when asked to try and change his technique the patient would become upset and tell you that this would put him in a wheelchair and that he wasnt going to do any of it.
3 weeks passed and the post re assessment took place. Other participants in the group genuinely expressed a enhanced QOL and reduction in pain, putting into practice what they had learnt over the passed 3 weeks. This patient however remain skeptical and still scored his pain highly and gave us feedback that the group was a waste of time.
This patient I thought needs "brain training," it was his mind set that was holding him back from getting better, rather then his impairment. This highlighted to me the need to identify such patients early during physiotherapy programs, and provide them with more education based management rather then hands on management as a change in mind set was required for them to benefit from physiotherapy. By encoutering this patient it highlighted the need to identify such patients during your subjective examination and then subsequently tailor your treatment in such a way as to make them understand that mindset plays a huge part in your perception of pain and our injury.
The group commenced, totalling a 3 week full time program, with sessions from pain specialists, psychologists, OTs, dieticians and physios. I conducted the physio part of the program taking the patients for a very light cardiovascular work out as well as light stretching and mobility exercises. During the class the patient would never do anything properly, and when asked to try and change his technique the patient would become upset and tell you that this would put him in a wheelchair and that he wasnt going to do any of it.
3 weeks passed and the post re assessment took place. Other participants in the group genuinely expressed a enhanced QOL and reduction in pain, putting into practice what they had learnt over the passed 3 weeks. This patient however remain skeptical and still scored his pain highly and gave us feedback that the group was a waste of time.
This patient I thought needs "brain training," it was his mind set that was holding him back from getting better, rather then his impairment. This highlighted to me the need to identify such patients early during physiotherapy programs, and provide them with more education based management rather then hands on management as a change in mind set was required for them to benefit from physiotherapy. By encoutering this patient it highlighted the need to identify such patients during your subjective examination and then subsequently tailor your treatment in such a way as to make them understand that mindset plays a huge part in your perception of pain and our injury.
Thursday, August 14, 2008
Differences in treatment options
During my musculoskeletal placement as previously mentioned I have had quite a few different supervisors who all have different options about how to treatment certain conditions and what exercises to prescribe to patients. At the beginning of the placement I found it exceptionally hard when changing supervisors as one tutor would give me an idea of how to treat a patient and then the next week, I would have the same patient with a different supervisor and they would ask me why I chose that particular treatmenta dn tell me a different treatment technique. Which in the beginning of a placement can be difficult when your not very good at rationalising certain treatment techniques.
So how does one deal with this situation ? This is what I have done in this prac to deal with the difference in opinions for physio treatments, which no doubt we will continually have deal with throughout out physiotherapy career.
1)We have been very much taught from an evidence based practice point of view, so at the moment going back and seeing what the lecture notes say is always helpful.
2) Looking up systematic reviews as to what treatments are available for certain conditions and how successful they were, is a good idea.
3) There is no harm in trialing both treatments on the patient (during different sessions to assess which one was more effective). Or if it is a difference in option about how to train particular muscle groups if one cue doesn't work, use another one!
OVERALL THERE WILL ALWAYS BE DIFFERENT SCHOOLS OF THOUGHT, DEPENDING ON WHERE PEOPLE WERE EDUCATED AND WHAT LITERATURE THEY USE. HOWEVER IF YOU CAN RATIONALISE YOUR TREATMENT WITH AN EVIDENCE BASED APPROACH AND THE PATIENT IS IMPROVING THEN WHAT YOUR DOING AS A PHYSIOTHERAPY TREATMENT IS WORKING.
So how does one deal with this situation ? This is what I have done in this prac to deal with the difference in opinions for physio treatments, which no doubt we will continually have deal with throughout out physiotherapy career.
1)We have been very much taught from an evidence based practice point of view, so at the moment going back and seeing what the lecture notes say is always helpful.
2) Looking up systematic reviews as to what treatments are available for certain conditions and how successful they were, is a good idea.
3) There is no harm in trialing both treatments on the patient (during different sessions to assess which one was more effective). Or if it is a difference in option about how to train particular muscle groups if one cue doesn't work, use another one!
OVERALL THERE WILL ALWAYS BE DIFFERENT SCHOOLS OF THOUGHT, DEPENDING ON WHERE PEOPLE WERE EDUCATED AND WHAT LITERATURE THEY USE. HOWEVER IF YOU CAN RATIONALISE YOUR TREATMENT WITH AN EVIDENCE BASED APPROACH AND THE PATIENT IS IMPROVING THEN WHAT YOUR DOING AS A PHYSIOTHERAPY TREATMENT IS WORKING.
Monday, August 11, 2008
When to Discharge??
Over the past 3 weeks during my musculoskeletal placement we have had 4 different supervisors. Having so many different supervisors has been good, as each one teachs differently and has different ideas on what exercises and stretches to give patients. However the other day at prac one aspect of different supervisors that made life challenging was the fact that they all have very different ideas on when to discharge patients.
One particular patient I had been treating for the whole of the 3 weeks, whom had adhesive capusulitis had not been improving at all. I myself felt that maybe the patient would benefit from physio when they were out of stage 1; which is the inflammatory stage. However none of my supervisors discussed discharging her, until this week when as soon as this particular supervisor heard my patients diagnosis and nothing else they said discharge her, we can't do anything for them.
After this comment, I began to question when do we decide to discahrge patients. We have the normal criteria like has the patient improved ? Are they back to pre-injury status ? Or if the patient has fractured something, they get referred somewhere else. But in terms of; if the patient has begun to plataeu when do we say, your not getting better, I think we need to discharge you and refer you back to you GP.
With my patient I introduced the idea of discharge, only to find they became very upset with the idea of having to go back to the doctor, as they were afraid they may require an injection or surgery. To try and relax my patient I said if she hadn't improved by next week, then it would be a month since she had been at physio and had any improvement at all, so discharge from physio would probably be the best option. The supervisor I had at the time said I should of just discharged her that day, but I don't think letting the patient have some ownership of their discharge is such a bad thing to do.
OVERALL IN TERMS OF WHEN DO YOU DISCHARGE PATIENTS IF THEY BEGIN TO PLATEAU, I PERSONALLY WOULD GIVE IT A COUPLE OF WEEKS, DEPENDING ON THE DIAGNOSIS. IF THEY HAVEN'T IMPROVED DURING THIS TIME, I WOULD DO THE SAME AS I DID WITH THE PATIENT ABOVE IF THEY WERE RELUCTANT TO BE DISCHARGED I WOULD INTRODUCE THE IDEA ONE WEEK AND SAY IF THERE IS NO IMPROVEMENT THEN PHYSIO ISN'T REALLY HELPING. THEN DURING THE LAST SESSION GIVE THE PATIENT EXERCISES TO COMPLETE BY THEMSELVES SO THEY DON'T FEEL LIKE YOU HAVE JUST GIVEN UP AND REFER THEM BACK TO THEIR GP OR WHEREVER IT IS THAT THEY COULD GET MORE ASSISTANCE. IF ANYONE ACTUALLY HAS EXACT CRITERIA FOR WHEN TO DISCHARGE PATIENTS LIKE THIS WOULD LOVE TO KNOW THEM?
One particular patient I had been treating for the whole of the 3 weeks, whom had adhesive capusulitis had not been improving at all. I myself felt that maybe the patient would benefit from physio when they were out of stage 1; which is the inflammatory stage. However none of my supervisors discussed discharging her, until this week when as soon as this particular supervisor heard my patients diagnosis and nothing else they said discharge her, we can't do anything for them.
After this comment, I began to question when do we decide to discahrge patients. We have the normal criteria like has the patient improved ? Are they back to pre-injury status ? Or if the patient has fractured something, they get referred somewhere else. But in terms of; if the patient has begun to plataeu when do we say, your not getting better, I think we need to discharge you and refer you back to you GP.
With my patient I introduced the idea of discharge, only to find they became very upset with the idea of having to go back to the doctor, as they were afraid they may require an injection or surgery. To try and relax my patient I said if she hadn't improved by next week, then it would be a month since she had been at physio and had any improvement at all, so discharge from physio would probably be the best option. The supervisor I had at the time said I should of just discharged her that day, but I don't think letting the patient have some ownership of their discharge is such a bad thing to do.
OVERALL IN TERMS OF WHEN DO YOU DISCHARGE PATIENTS IF THEY BEGIN TO PLATEAU, I PERSONALLY WOULD GIVE IT A COUPLE OF WEEKS, DEPENDING ON THE DIAGNOSIS. IF THEY HAVEN'T IMPROVED DURING THIS TIME, I WOULD DO THE SAME AS I DID WITH THE PATIENT ABOVE IF THEY WERE RELUCTANT TO BE DISCHARGED I WOULD INTRODUCE THE IDEA ONE WEEK AND SAY IF THERE IS NO IMPROVEMENT THEN PHYSIO ISN'T REALLY HELPING. THEN DURING THE LAST SESSION GIVE THE PATIENT EXERCISES TO COMPLETE BY THEMSELVES SO THEY DON'T FEEL LIKE YOU HAVE JUST GIVEN UP AND REFER THEM BACK TO THEIR GP OR WHEREVER IT IS THAT THEY COULD GET MORE ASSISTANCE. IF ANYONE ACTUALLY HAS EXACT CRITERIA FOR WHEN TO DISCHARGE PATIENTS LIKE THIS WOULD LOVE TO KNOW THEM?
Tuesday, August 5, 2008
LT activation
I have had numerous patients during my musculoskeletal placement that have decreased activation of their lower traps (LT). Most patients whom I have taught to activate LT normally take approx 5 minutes to understand what action I am actually asking them to do. However the other day after 10 minutes of explaining the concept in different ways and trying PROM > active assisted ROM in side lying, the patient was still unable to activate LT. By the end of the session I was getting annoyed with myself for not being able to explain in a way that the patient could understand what I wanted.
After the session I revised all the possible positions that I could possibly retrain LT in; this included side lying, prone, sitting and standing. I also asked the supervisor what she thought was the best way to activate LT and she thought that pushing your fingers onto the scapula where LT attaches and getting the patient to push against it worked well to activate LT. I also sat in on another student activating LT which was probably the most helpful, as it made me realise that I might have given up too early. This student took 15minutes to get the idea across to their patient, but once they had the patient was able to activate LT without any proprioceptive input.
The next session when my patient came in, I used all the ideas I had found and been told. Plus I took more time during the active-assisted phase of retraining LT. By the end of the session the patient had the idea of LT activation and I was able to give them home exercises as they could do the movement properly.
WHAT I HAVE LEARNT FROM THIS EXPERIENCE IS THAT SOMETIMES IN CERTAIN CASES, YOU WILL HAVE TO SPEND A GREAT DEAL OF TIME GETTING THE PATIENT TO PRACTICE A MOVEMENT OR MUSCLE CONTRACTION BEFORE THEY ARE ABLE TO DO IT INDEPENDENTLY. IF WHAT YOU DO IN THE FIRST SESSION DOESN’T WORK, DON’T TRY THE SAME THING NEXT SESSION, RESEARCH AND FIND AN ALTERNATIVE.
After the session I revised all the possible positions that I could possibly retrain LT in; this included side lying, prone, sitting and standing. I also asked the supervisor what she thought was the best way to activate LT and she thought that pushing your fingers onto the scapula where LT attaches and getting the patient to push against it worked well to activate LT. I also sat in on another student activating LT which was probably the most helpful, as it made me realise that I might have given up too early. This student took 15minutes to get the idea across to their patient, but once they had the patient was able to activate LT without any proprioceptive input.
The next session when my patient came in, I used all the ideas I had found and been told. Plus I took more time during the active-assisted phase of retraining LT. By the end of the session the patient had the idea of LT activation and I was able to give them home exercises as they could do the movement properly.
WHAT I HAVE LEARNT FROM THIS EXPERIENCE IS THAT SOMETIMES IN CERTAIN CASES, YOU WILL HAVE TO SPEND A GREAT DEAL OF TIME GETTING THE PATIENT TO PRACTICE A MOVEMENT OR MUSCLE CONTRACTION BEFORE THEY ARE ABLE TO DO IT INDEPENDENTLY. IF WHAT YOU DO IN THE FIRST SESSION DOESN’T WORK, DON’T TRY THE SAME THING NEXT SESSION, RESEARCH AND FIND AN ALTERNATIVE.
Monday, July 28, 2008
Frozen shoulder!
This week on my musculoskeletal placement I had a patient come in with a diagnosis of Adhesive Capsulitis (frozen shoulder), who had been referred from their GP. Upon reading the previous students notes it became clear that this patient was within the 1st/2nd stage of the pathology. Therefore I knew before even meeting the patient that they would be in a considerable amount of pain.
When I met the patient they said their pain had decreased since the last physio session, so after an brief assessment I decided to do the same treatment as the previous student. Then 3 days later the patient returned for another physio session however after the subjective assessment it was very clear that they were in more pain than the previous session. This didn’t surprise me as I knew that with this certain pathology during the inflammatory stages there is little that physio treatment could do to relieve pain. This particular day I could hardly touch the patient as everything was ‘too painful’. The patient was a little confused as to why they hadn’t improved like the last physio session.
So for the patients benefit I spent half of the treatment session explaining the stages of a frozen shoulder and how the 1st and 2nd stages were focused on relieving pain and that they would have to wait for the pathology to ‘run its course’ before they could start getting better. At the end of the session the patient seemed happy with the session and said they would continue to come to the physio treatment sessions.
FROM THIS EXPERIENCE I HAVE LEARNT THAT YOU CAN’T ASSUME THAT JUST BECAUSE THE DOCTOR HAS WRITTEN A DIAGNOSIS ON A REFERRAL FORM THAT THEY HAVE FULLY EXPLAINED THE PATHOLOGY TO THE PATIENT. PATIENTS REALLY DO APPRECIATE SOMEONE TAKING THE TIME TO EXPLAIN THEIR PATHOLOGY. NOT ONLY DOES THIS HELP COMPLIANCE WITH PHYSIOTHERAPY, BUT IT ALSO PREPARES PATIENTS WHEN A THINGS DON’T GO THE WAY THEY PLANNED.
When I met the patient they said their pain had decreased since the last physio session, so after an brief assessment I decided to do the same treatment as the previous student. Then 3 days later the patient returned for another physio session however after the subjective assessment it was very clear that they were in more pain than the previous session. This didn’t surprise me as I knew that with this certain pathology during the inflammatory stages there is little that physio treatment could do to relieve pain. This particular day I could hardly touch the patient as everything was ‘too painful’. The patient was a little confused as to why they hadn’t improved like the last physio session.
So for the patients benefit I spent half of the treatment session explaining the stages of a frozen shoulder and how the 1st and 2nd stages were focused on relieving pain and that they would have to wait for the pathology to ‘run its course’ before they could start getting better. At the end of the session the patient seemed happy with the session and said they would continue to come to the physio treatment sessions.
FROM THIS EXPERIENCE I HAVE LEARNT THAT YOU CAN’T ASSUME THAT JUST BECAUSE THE DOCTOR HAS WRITTEN A DIAGNOSIS ON A REFERRAL FORM THAT THEY HAVE FULLY EXPLAINED THE PATHOLOGY TO THE PATIENT. PATIENTS REALLY DO APPRECIATE SOMEONE TAKING THE TIME TO EXPLAIN THEIR PATHOLOGY. NOT ONLY DOES THIS HELP COMPLIANCE WITH PHYSIOTHERAPY, BUT IT ALSO PREPARES PATIENTS WHEN A THINGS DON’T GO THE WAY THEY PLANNED.
Wednesday, July 23, 2008
Elbows... aagh!
A new patient I was about to see on a musculo placement had a referral letter with 'my arm hurts when I move it' as the reason for visit. This wasn't ideal in narrowing down my preparation, but I assumed it would be shoulder pain and only briefly skimmed material on the elbow.
It turned out to be elbow pain of course.
Background - elbow pathologies we learnt about were medial/lateral epicondilagia, MCL sprain (little leagure's elbow), olecranon bursitis and radial head dislocation in children.
This patient had posterior/medial pain from 10cm above to 5cm below elbow, exacerbated by elbow extension and driving (hands on top of steering wheel). It began with ballistic extension activities (punches/push-ups) in a martial arts class.
From the beginning it wasn't fitting into the typical presentations we're familiar with from lectures. This was further confirmed with special objective tests, eg for golfer's elbow: medial epicondyle palpation, finger/wrist flexor stretch, resisted wrist flexion and pronation were all negative.
Neural involvement was excluded by pain characteristics, neck screening, NTPTs and ulnar nerve palpation posterior to medial epicondyle.
Not knowing what to look for next I palpated the area and found a very distinct triceps 'knot' that reproduced the pain.
It turned out to be a simple triceps strain. Triceps length, pain levels, and elbow extension ROM all improved significantly with some massage and hold-relax! Also, the 'knot' nearly completely disappeared. (Other advice/HEP/education were also conducted.)
I tend to under-estimate the value of palpation as an assessment tool, probably because it seems so much easier than the specific tests we learn in labs.
This experience has re-affirmed to me its usefulness, especially in situations where the source of pain is difficult to establish.
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