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.

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.

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.

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.

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.

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.

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!