It is not always about physio.

On my prac in the geriatric area, one of my patients was a 86 y/o man who had led a very active lifestyle all his life. He lives with his wife who is in her 70’s and is still physically active and independent. He came to see us because he felt that of late, his balance is deteriorating and that he sometimes feels unsteady during ambulation. As a result, he had a couple of falls in the past year. I then commenced assessment to identify his key problems and the reasons he’s been falling. During the subjective assessment, I found out that he had a fall 2 weeks ago which he blamed his wife for. He and his wife were rushing to catch a tram because she didn’t want to miss it. He then tripped over a high kerb and fell landing on his forehead. The patient then started expressing some issues he had been facing with his wife ever since this had happened. He feels as though she doesn’t understand that he is not able to do certain things that he used to be able to do. She thinks that his problems are not real and that he is just trying to avoid having to drive her down to the shopping mall when she wanted to go to the shops. All of these had made him so frustrated and depressed.

Listening to this, I had to take a moment to try and see how I can help with the situation as it was really obvious it is affecting him terribly. They needed to get help before the situation gets too complicated. I then offered to refer him and his wife to a counsellor but he refused. At the same time I felt that if we did not find a way to deal with the issue, it is not going to help his rehabilitation process. I then decided to continue with objectively assessing his condition so that I was able to tailor and exercise program to help facilitate his rehabilitation. At the end I discovered that he had genuine balance issues as well as some weakness in his lower limbs which needed to be addressed promptly. I prescribed a home exercise program to help with his balance and improve his strength after the first session. Then, I realised that I have only addressed half his problems and I disregarded the problems he had with his wife as soon as he refused counselling. I was sceptical of his compliance to the home exercise program because to him, having a wife that does not understand his condition is a “bigger” problem. So I really thought that in order to achieve anything with him I must address his “bigger” problem.

So for the next session, I asked him if he was happy for me to talk to his wife about my assessment findings. He said I could try but he wasn’t sure if that was going to make things any different. I decided anyway to try and explain some of what I found with his balance. She was surprised at what I had commented about her husband’s condition but looked accepting. I also explained that he may improve if he kept to his home exercises and that she should play an active role in reminding him if he forgets. She seemed eager to be a part of his rehab. And after that session, I realised how much difference that had made to his motivation. He seemed a lot more compliant to physiotherapy which resulted in a difference to his balance score.

From this encounter, I’ve learnt the importance of dealing first with the patients primary problems regardless of whether it is physiotherapy related or not as this is one step closer towards achieving patients’ goals. Besides that, addressing patients’ specific concerns will help enhance motivation and compliance towards rehabilitation.

Making mistakes

While on cardiopulmonary placement I encountered a patient who was identified as a intravenous drug user. The patient had experienced a perforated bowel, which was subsequently repaired, however subsequent complications required an ICU admission. During the patient’s stay on the ward it drugs had been discovered in her room and she had crushed painkillers which she tried to insert into her IV. The patient was keen to return home to care for her children.

As the patient had been desaturating on oxygen, this needed to be tested to ensure her oxygen did not drop too low when ambulating. Initially the patient’s oxygen was 94%, but she refused oxygen as she was intent on going home, during ambulation her oxygen dropped to 88% at this stage I tried to apply oxygen to the patient, she refused, so I asked her to stop and take deep breaths prior to recommencing oxygen. However the patient did not listen to me as we were close to her room. During the last few metres to her bed, her oxygen sats dropped to 71%. Once again the patient refused oxygen despite warnings and education. With deep breaths her oxygen recovered to pre ambulation levels within 2-3 minutes. I promptly informed the my supervisor, the nursing coordinator and the medical team. A chest X Ray was performed and she was found to have significant bilateral atelectasis.

I felt I had lost control of the situation with this patient and I should have been more firm. Patient education is even more important with difficult patients to ensure they are aware of your reasoning behind your assessment and treatment to improve compliance.

I have learnt a few things from this experience
· ENSURE I AM IN CONTROL OF ALL TREATMENT SESSIONS
· BE FIRM WITH PATIENTS IF THE SITUATION BECOMES DANGEROUS
· EVEN IF I MAKE A MISTAKE, ENSURE I INFORM THE APPROPRIATE STAFF AS IT MAY INDICATE A SERIOUS PROBLEM THAT REQUIRES FURTHER INVESTIGATION

Sometimes patients don't realise what they can do

On my rural placement, a patient was admitted after having a CVA. On first impression, this patient seemed very unmotivated, and convinced my supervisor and I that she "couldn't do anything". She would continuously compare how she is now with her premorbid status, and was very fixed on the fact that she had movement on her affected side.

For the first few sessions, everytime my supervisor and I would attempt to stand her up and walk her, she would state that she can't, and would just sit straight down. After setting the goal of walking to the toilet, we were able to stand her up and walk her with 2 assist, however, the more steps she took, the more she would actually contribute, needing less assistance.

The next session, she still refused saying that she was unable, until I reminded her of her performance the day before. This seemed to have improved her confidence, and she was able to walk a greater distance with less assistance.

I FEEL THAT SOMETIMES PATIENTS THAT HAVE DISABLING CONDITIONS SUCH AS STROKES, WILL TEND TO COMPARE THERE CURRENT STATE WITH THERE PREMORBID STATE, AND WILL ASSUME THEY ARE UNABLE TO DO CERTAIN TASKS. I THINK THAT A GOOD WAY TO TREAT THESE PATIENTS IS TO SET REALISTIC SHORT TERM GOALS, AND USE THAT GOAL AS MOTIVATION FOR THE NEXT SESSIONS.

I've broken my hip

I am currently on a musculoskeletal outpatient placement in which I am treating a lady diagnosed with traumatic trochanteric bursitis after a fall onto her side of her hip. During the initial session the patient explained that she felt she had pulled some ligaments or broken her hip. She has ideas regarding the basic anatomy of the hip in general saying she felt the “ball and socket isn’t rotating properly”. After doing the physical examination I was confident she hadn’t broken her hip nor pulled any ligaments.

I explained to the patient some of the reasons she was having the pain in the hip and thigh and our plan for treatment. I reassured her she hadn’t broken her hip and that I had tested for ligament problems and found them all good. On the second time seeing this patient she had noticeable improvement in pain, ROM and function. However she still felt she had a broken hip (even though she had nil pain, able to walk/run, all ADL’s). Once again I reassured her hip wasn’t broken and explained to her the healing that takes place and the muscles running over her G.T., bursa etc etc. She felt better and understood. At the very end of the session I showed and explained a picture of the hip, muscles and bones. She sighed of relief.

With this patient I focused a lot of the treatment session on education and getting the patient to understand the problem. But while understanding the problem the patient did not entirely exclude their own conception. This suggests the patient had not entirely understood what I had explained on the initial treatment. The patient finally understood when a picture was used that separated the area of interest (G.T) to the ball and socket joint (in which she thought she had broken/damaged ligaments).

From this patient I have acknowledged the importance of readdressing education regarding the cause of a problem. It also illustrated the benefit of using diagrams/visual aids to help in explaining mechanics and anatomy. In future I will try to use diagrams or visual aids in an initial treatment session. I have learnt the importance of ensuring patients understand the problem, but also reassuring and explaining any misconceptions.

Not enough info

While on placement in the community setting, my supervisor and I encountered a patient who had been referred to physiotherapy upon discharge from hospital. She had been admitted to hospital following a fall caused by her legs shaking and then giving way. No cause was discovered however her referral only stated the diagnosis as “leg weakness”. As her medical notes took a few days to come to our office we were not able to access the investigations carried out. On assessment the patient’s the patient had good muscle strength, however experienced fairly severe shaking when quads were activated against manual resistance or on sit to stand. This was relieved through activation of hamstrings or marching on the spot. Her muscle tone was normal. My supervisor and I queried anxiety or some underlying neurological problem as the cause, however the cause needed to be investigated. This patient was later readmitted to hospital for further investigations. I believe the cause of the shaking legs should have been investigated further in hospital, or information given in the referral as to the outcomes from investigations carried out.

This incident highlighted these issues
1) The need for a thorough assessment to be carried out prior to referral and adequate information should be included in referrals to other physiotherapists.
2) If inadequate information is contained in a referral I should always attempt to call the referring source for a verbal handover.
3) The need to fully investigate abnormal findings and refer onwards is vitally important in the community setting as you may be the only health professional that they speak to about a certain problem.


IN THE FUTURE, PRIOR TO REFERRAL TO ANOTHER PHYSIOTHERAPY SERVICE, I WILL ALWAYS ASSESS A PATIENT ADEQUATELY AND ENSURE MY HANDOVER INVLOVES SUFFICIENT INFORMATION FOR THE NEXT PHYSIO. I WILL ALSO MAKE SURE I CLARIFY ISSUES OR ABNORMAL FINDINGS AND DISCUSS THESE WITH A SENIOR OR REFER ONTO ANOTHER HEALTH PROFESSIONAL IF NECESSARY.

Never run away..

In my neuro prac, I worked with acquired brain injury patients. Most of them have problems communicating as a result of their brain injury. The most challenging part about being able to treat this group of patients is to be able to communicate what we want of them during therapy sessions. One of my patients, a 19 year old male was assaulted and sustained a sub-dural hematoma that had left him with drastic impairments including an inability to verbalise speech. Apart from that, he sustained cranial nerve deficits (minimal eye movement), only able to have a fixed gaze and does not have the control for neck and head movement. He was the most challenging patient that I have had to date. I thought to myself, it’s hard enough to treat someone with brain injury but now I have someone with brain injury and can’t communicate. I was just about to give up as I really felt that it wouldn’t be fair for me to treat him if I was not confident enough. I went to my supervisor and I had a word with her and she told me not to give up so soon without a try, she guided me along for the 1st session with him. That really helped build courage to take him on as a patient.

I then went on to see his speech pathologist and ask for a bit more insight as to how I can communicate more effectively with him. She gave me some really good ways to communicate with him (non-verbally) and also how to judge his way of saying yes or no. Some of which was, yes = one blink, no= two blinks and how much he lifted his leg up in the air correlates with pain levels. Every session was a learning curve for me, I got better each day and that helped me achieve good rehabilitation outcomes with him. Then there came a day when we were partly through therapy, the patient suddenly became very distress, his UL and LL tone started kicking in terribly and it panicked me. I tried to keep things together and calmly verbalised each body part for him to identify which part was giving him the problem. As it turned out he was getting uncomfortable with his secretions in the mouth due to his inability to swallow. I then organised for suctioning. After that, he looked a lot more settled and was able to continue with therapy. I am glad that I took the initiative to learn the language he spoke which has helped me tremendously in his rehabilitation during my four weeks there.

From this experience, I have learnt that I must embrace every challenging patient and treat it as an opportunity to better myself so that it sets me up to become a better physio one day. In the future when I have a challenging patient like that, I will try my best to gain as much insight I can about the patient by liaising with staff that had worked with the patient. This will help me utilise what works best for the patient to help facilitate patients’ rehabilitation more effectively.

Educating the Patient

On a musculoskeletal outpatients placement, one of my patients was a lady who presented with chronic lower back pain, pain around her buttock, hip and thigh, and at times, pain down her leg. The patient's main problem according to her was her buttock, hip and thigh pain. I initially hypothesised that this was referred pain from the lumbar spine, as her history suggested so.

I continued assessing and treating her lumbar spine, and I could start to notice that she was unsatisfied with my choice of treatment, as her primary complaint was the pain on her buttock, hip and thigh. It was at that point when I decided to educate and explain to her why I was focusing around the lumbar spine, and I could sense that she was more satisfied.

I LEARN'T THAT A PATIENT WILL BE MORE SATISFIED AND MORE COMPLIANT WITH PHYSIOTHERAPY TREATMENT IF HE/SHE UNDERSTOOD THE REASON BEHIND THE THERAPIST'S TREATMENT TECHNIQUE. I THINK THAT NOT ALL PATIENTS WOULD UNDERSTAND THE CONCEPT OF SYMPTOMS SUCH AS REFFERED PAIN, THEREFORE EDUCATION IS AN IMPORTANT ASPECT OF PHYSIOTHERAPY. IN THE FUTURE, BEFORE TREATING A PATIENT, I WILL EXPLAIN WHY I'M DOING A PARTICULAR TREATMENT, TO ENSURE THE PATIENT UNDERSTANDS, THUS, MAKING HIM/HER MORE SATISFIED.