Autism

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.

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?

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.