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.
Tuesday, September 2, 2008
Monday, September 1, 2008
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.
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.
Tuesday, August 26, 2008
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.
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.
Monday, August 25, 2008
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.
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.
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.
Sunday, August 24, 2008
Claustrophobia
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.
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.
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.
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