General comments

Congratulations again on some excellent entries and inciteful observations. I encourage you to empathise with your colleagues, but to also provide possible solutions to difficulties encountered. Enjoy your final week of this placement.

Regards
John

Late blog/blogs

Well finally the manipulator strikes again, everytime i have been trying to log in it keeps telling me my invite has expired, seems like the story of my life. Anyhow, i will describe a few scenarios in this blog and hopefully that will fulfil my blogging obligations.

Case 1.
A 26 yr old lady was referred to the clinic with SA bursitis, however on presentation she listed neck pain as her main complaint. This threw me off a little as i had just been preparing myself for a shoulder examination. On AROM examination i was unable to detect a consistent pattern, almost all directions were painful. Similarly PAIVMS/PPIVMS at all levels were too provocative to get any diagnostic info. By this point i was completely thrown and had no real idea of how to effectively Rx this lady. I ended up doing some light STM of the sub occipitals, caudad traction and taught stretching for the related muscle and educated re use of heat and stretching. I felt pretty bad afterwards as i had'nt made a diagnosis and didnt feel like i had implemented an effective Rx; although the pt felt much better afterwards. Upon speaking to my clinical supervisor later i was told that how i managed the session was appropriate and that when people are acutely sensitised it is almost impossible to diagnose them. On the whole very unrewarding to the aspiring musculo physio :(

Case 2
83yr old female referred to the clinical with a 40+ yr Hx of LBP which had been unsuccessfully treated with an L5 laminectomy and nerve sleeve injections. Luckily however, when she presented she also complained of a 2/52 Hx of cervicogenic headaches and neck pain. Unselfishly i decided to Rx the neck pain and leave the 40 yr LBP for Ed to manage when he arrives at the clinic next week.
On AROM examination extension and R rot was almost non-existant. PAIVMS revealed global hypomobility in the Cx region, as one might expect from a women of her advanced years, but sig more pain in the upper Cx segments on the R hand side. Rx consisted of unilaterals to the R upper Cx segments + education re heat and stretching. Following Rx extension and rot had improved dramatically and her neck and head pain had reduced dramatically. Overall i very rewarding experience, and one that restored my faith in Cx Rx after the debacle described in case study 1.

The Manipulator

Keep it Simple

Hi everyone, hope you have enjoyed the three day weekend!

I am going to reflect back on my previous placement which was musculo at Charlies. My first patient of the placement was a very important doctor within the medical profession. Needless to say I was very nervous, on top of already being nervous about starting a new placement!! After subjective and objective assessment it was apparent he was presenting with shoulder impingement signs. My initial treatment involved releasing tight pecs, release of the posterior capsule, thoracic extension exercise and posture correction and advice. My patient had improved beyond belief by the time I saw him the following week from what seemed like a simple treatment session. He continued to improve and made fantastic progress throughout my placement. So my point here is to always look at the big picture and don’t try and complicate it any more than you need to-sometimes posture correction can alleviate a significant proportion of the symptoms!!!

Enjoy the last week of this placement,
Lauren

6 Minute Walk Test

Dear all, Happy Australia Day and hope you all had a good weekend.

For the past week, I have been performing quite a number of 6 minute walk tests with patients in the wards. Think about 4 or 5 times already. The reason for doing the test was to determine whether they needed ambulatory oxygen and they had their ABGs taken prior to it without oxygen(off for 2 hours) and then the next day I would do the test at around the same time but with 2L/minute oxygen via nasal prongs.

Remember the time our tutors at Curtin demonstrated the 6MWT to us with a student "patient"? We were all standing along the corridor at random points and observing them do the test in a conducive environment. It looked kind of easy.

Not until I had to do it all by myself up in the noisy wards with grumpy dyspneic patients. There were so many things to do at one time. Holding the file with the instructions on one arm, around my neck was the stopwatch, slipping the Borg Scale underneath the file for easy sliding in and out to allow the patient to read, the other hand juggling between the pulse oximeter and pen for recording on a piece of paper on the file. Fully decked out. Sometimes, if the patient walked with a zimmer frame, the situation got worse as I also had to push the oxygen trolley along. Never done so much multi-tasking before.

And then before that, the environment had to be prepared. Clearing the route, chairs along the way, blood pressure machine at the start point and measuring the distance(not too bad for distance as the corridor walls were actually marked off at certain points).

The thing is, it takes so much effort to set up the environment, and every time I get the patient over, the chairs disappear mysteriously(which disrupts the distance I have already measured), and the BP machine rolls away on its own to some visible but far away location. Mind you, I informed the nurses that I was going to carry out the test and needed to route and equipment to stay the way it is.

During the test itself, despite obvious markers that the patient is doing a 6MWT, staff stroll by in front of the patient, stop and talk along the marked route and this really affects the performance of the test and results cos the patient stops to and wait and are unable to hear my instructions clearly.

Currently, I've tried sticking signs on the back of the chairs "6 Minute Walk Test in Progress, Do Not Remove. Thanks." which help occasionally and shifted to the quietest corridor corner I can find. Also got a PCA to help to push the oxygen trolley if the patient used a ZF. Guess it has helped quite a lot.

Wonder if you all encountered such problems along the way? Cos if you think about it, if you can't do a repeat test on the same day itself(patient gets too dyspneic and unwilling to perform it again due to that fear), with all that environmental distractions along the way and a planned discharge in less than 2 days(meaning you have exactly 2 days to do 2 6MWTs), is it a fair and accurate estimate on their exercise tolerance and oxygen demand?

Can 6MWT be an accurate guide under such conditions or is it accurate only under perfect conditions(which can be quite difficult to set up especially in the wards)? How much can these factors affect the results to render it completely inaccurate?

A feeling of helplessness

This week was a mixed bag in my cardio placement. The gen-med ward I am on ATM is pretty quiet for cardio-resp patients, and the one that I do have has really responded to ACBT with vibes and huff. I am still not used to seeing cups full of various shades of green sputum, however.

Anyway, one patient that I have been seeing with my supervisor on the ward had a (L) TACS stroke, so we have been sitting him up and leaning him to his unaffected side, and then hoisting him out of bed. I didn’t have the opportunity to see him this week. He developed severe pain in his right knee, which lead to him screaming in pain on the slightest movement. My supervisor had therefore been unable to move the patient, and as a result he developed a chest infection.

On Friday we were going to attempt to see him, and possibly perform some chest physio and suction the patient. The doctors were concerned about his condition, and had ordered a CXR for him. His bed was visible from the nurses station, and some of the nurses were concerned about his condition. This grabbed my attention, and when I had a look at him, it was pretty confronting.

He was in acute respiratory failure, and was on a rebreather mask on 10 l/min, and was literally gasping for air. They placed him on portable oxygen and began wheeling his bed down to radiology. However, within 20 mins he was back in his room, with his family present. He unfortunately didn’t make it down to radiology.

Seeing a patient suffering like that was extremely confronting, and is something I had only seen as a teenager the evening before my grandfather passed away. It was distressing, knowing that the patient was struggling and not being able to do anything about it. I haven’t had the opportunity to talk about it with anyone, and I thought you might benefit from my experience.

We lost 2 patients on that ward on Friday afternoon. It was interesting to observe what is usually an upbeat group of people drop very quickly into a sombre and restrained mood. However, as the saying goes, life must go on and there were other sick people to take care of.

Dale

Pain - A physio's friend

This week has been rather quiet and so I will reflect on a patient who had some pain issues. He is a 30 yo male who underwent heart surgery for an aortic valve replacement. He had a congenital bicuspid valve instead of a tricuspid valve. The surgery was uncomplicated and on initial Ax following the operation the pt reported 8/10 pain at rest. The patient was young and understood the role we have as physios to assist with their recovery and although he was anxious to move because of the pain he was happy to attempt to SOOB. My supervisor however looked through the med charts and noticed that he had come off morphine and not had adequate pain cover since then. She said that we could use this to our advantage and get the patient on our side especially because younger patients report higher pain scores and would be an issue throughout his recovery.

So we informed the patient that we would discuss pain relief with the doctors and then return later to SOOB. The patient was happy with this decision too. The doctors prescribed further paim meds and 45 mins later his pain was 4/10 and he SOOB and completed all DB ex's nand supported cough with good pain control.

We could have attempted Rx initially but the Rx would have been ineffective due to the pain and it also would have turned the patient against us as he would percieve pain and physio related. This was a good move by the supervisor as we now had a very compliant patient who was more comfortable during our Rx and the Rx was more effective as we got more out of the patient. So the small things can make a difference and we can also use pain to win over pt respect and trust.

Complacency

Currently on my Neuro placement and am treating a pt with a Left TACS, rather than specific lobes damaged this pt unfortunately has wiped out the entire left hemisphere, cortically and subcortically as revealed by CT scans. Dx is still being investigated however it is believed the stroke may have been due to a vasculitis. Some of my treatment to date has consisted of respiratory care, passive movements, muscles stretches, positioning, perceptual anchoring and attentional strategies, sensory facilitation, bed mobility exercises, balance and postural strategies in sitting. During the time spent with the pt they have made some really good progress, however recently the more literature I have read and listening to doctors and specialist neuro nurses, I have almost become resigned to the fact that the pt will more than likely never be able to function independently again. To be honest my treatment has reflected these views, so I guess I have become complacent. However that was until last week when one of my supervisors joined in in one of my sessions and could actually feel voluntary muscle activation on their hemiplegic side! I am not sure it was Lorenzo's oil she poured on the pt but I actually felt something too. Since the last few days my complacency has been replaced by a renewed hope. On Friday I sat in with one of the Speech Therapists and the pt literally fed themself for the first time since the stroke! Very exciting. I will keep you all updated with their progress.

Oxygen Therapy

Oxygen Therapy

Hi everyone. This week I am reflecting back on my Cardio placement and a reoccurring problem that I encountered. My placement was on the general surgery ward so I saw a lot of abdominal surgeries. I learned thorough my placement that it was protocol that any one on a PCA was required to be on min 2L of O2 until they were taken off the PCA. Now what I found was that patients were not compliant with this, but what I found more surprising was that neither were the nurses!! My supervisor had very strong feelings abut this issue and insistent that we were not allowed to get anyone out of bed (with a PCA) unless they had their O2 on. I would consistently walk into a patient’s room and their O2 would be off. I would then have to proceed and give them the explanation about why it was important to have O2 (lung infection, air to bottom of lungs…etc) and what I found was their common response was “the nurse said I didn’t have to have it on”. What is a physio student to do?? Obviously the patient is going to listen to what the nurse says instead of me, even though you explain all the risks to them. They would put the O2 on to make you happy but when you walked in there later on in the day, it was off again!! I approached several nurses and told them that it was protocol and the patient required O2 while on PCA but they just seemed to disregard this fact. So tell me this, what is the point of having protocols in place if staff are not going to follow them? Even if you look at it from the patient’s point of view, it would be frustrating to have one person come in and tell you that you needed to have O2 and then someone else tell you you didn’t. I feel that it reflects badly on the hospital and makes its staff look unorganised and incompetent. Has anyone else encountered this problem on their cardio prac?

Communication

Left 1 week to end of placement!

The past 1 week had been slightly challenging, esp in the areas of communication. Few examples:

1. Patient (41/female) from Somalia
Was asked to see a patient with (R) lateral malleolus #. Patient is a 41 year old lady from Somalia. Although she could speak simple English, it was slightly challenging doing my subjective assessment and patient education. It was difficult getting her to describe her pain. During the treatment, I also had to rephrase various of my sentences so that it is simple for her to understand. Seemingly easy, quite effortful actually -- to think quickly and talk at the same time…asking specific questions that will elicit the info I want.

2. Patient (45/male) with Down’s Syndrome and (R) ear deafness

Usually, we get to know who our patients are for the next day, so that we can prepare in advance. Reading the referral letter (patient referred for rehab for post-ORIF (R) patellar #) and checking the x-ray, I did not think that the patient would be someone with Down’s Syndrome. While checking the x-ray, I was appalled to find that he had a previous patellar # before in his (L) knee. Hence, I was curious to find out what had happened to have resulted him in having both patellar #.

I must admit I had a ‘tiny’ shock when I saw the patient arrived with his carer.

Due to poor memory, the patient was not able to account for his injuries. Hence, my initial-planned-detailed S/E became a short concise one. Compared to the lady from Somalia, my questions became even simpler, shorter and close-ended ones:

“Does it hurt?” “tight?”

I wanted to ask how much on a scale. Then he gave me a blank look. Even getting him to grade “mild, mod, severe” was difficult for him. I then realize my mistake. So it became “a little hurt? Or a lot?”

I wanted to ask what movements/ activities bring on the pain/ worsen the pain? Again, I got a blank look. So I had to give examples to help him along.

Could not get any related past history as well due to his poor memory. As his carer just started work 1/52 ago, I could not get any info on patient’s WB status, history of injuries (both patellar #) and any other related medical history.

During the treatment, I was spending more time talking to his carer, educating his carer on how to guide patient with his HEP. During the process, I realized I had the tendency to talk more to the carer, and forgot to interact/educate the patient too. I noticed that the patient kept looking at me and it dawned on me that the patient needs to know what’s my plan too.

Due to his ® ear deafness, I also realized that I need to take into consideration where I should position myself and him for treatment.

Due to his med condition (DS, poor memory), I need to make my explanation very simple. It was actually quite challenging explaining what the ultrasound machine was and wat the ultrasound gel was for when he asked at first :P The exercises taught also had to be simple at first, with lots of guidance, facilitation, visual/verbal/tactile feedback.

And… throughout the whole session, I had to make a lot of observation – looking at his facial expressions for any signs of pain, observing his walking closely to see how much weight he’s putting through his foot.

So in conclusion? … it was a week of meeting the “unexpected” and (more) modification of S/E, patient education, type and complexity of exercises taught to each individual.Despite similar conditions, every individual is unique!

Expressive dysphasia

Hello everyone,
Week three nearly done. So this week at my neuro outpatient's clinic I had a pt. who has pronounced expressive dysphasia. His vocabulary is around six words. Unfortunately he hasn't warmed to the idea of using a communication book and his writing hand is the affected side from a MCA stroke...so he doesn't like to write. Anyway, I have been liaising with orthotics to try and fit him with a new AFO. The orthotist wishes him to buy a new pair of more supportive shoes. He has become very aggravated by this demand and I have tried to determine where, precisely, his concerns lay. I have had limited success except to determine that the whole process is becoming very frustrating for him. His difficulty in expressing his concerns is understandable.

Unfortunately one impact of this frustration is to increase his tone. Thus my higher level Rx must now take a back seat to the freeing up of his rock solid UL. Today's session I SIMMed his lats and pecs for ages and there was only moderate response.

The lesson for me in this case is slightly complicated because firstly: it has become evident from both speaking with the orthotist as well as my PT supervisor that the communication lines between these two departments are a little bit disconnected ATM - and so I feel it important to step in and help all parties communicate their concerns. Secondly: as a direct result, the pt. views me as being more responsible for any outcome that may occur. The result is a blurred line of responsibility on one hand and being part of a functional MDT on the other. I can see now why such boundaries are so important to understand and respect...it affects the pt!!!

So anyway the goal now is to maintain the communication between departments but also to bring the pt back to the stage where his precious little outpatient PT time is focused on matters that I can directly have an affect on as a therapist and to hopefully provide him the comfort and focus to let his other concerns pass for the moment.

Have a GREAT Australia Day to all you good folks, MJFJ

Maintaining Professional Practice

I am currently seeing a male patient who has previously had a right sided stroke resulting in left sided hemiplegia. He has also had some trouble with continence and is documented as double incontinent. I have previously treated him with wet pants but on this particular day I am sure he had not only wet his pants (adult nappy type underwear) but also let out some faecal matter. Needless to say it was a difficult hour and a half of treatment in which I needed to turn away and take a few deep breaths of fresh air but called on all my professionalism to get through it. It is unfortunate that this patient is aware of his troubles as he previously apologized for spilling his drink bottle in his lap when there was no drink bottle present. It just highlights that even though patients may have physical deficits from neural injuries, they are often cognitively still aware and you need to treat them accordingly. Professionalism must be maintained with all patients no matter how annoying, physically or mentally demanding they are, most of them want to get better and need your help!!

Well I had the opportunity of seeing an open heart surgery last week. It was a CABG x4 procedure on a 70 year old male with PMH of IHD,COPD HTN and current smoker. I had the opportunity to do a pre operative assessment on the pt the previous day not knowing I would be seeing his surgery. He was a very pleasant lively male who was eager to be informed about all aspects of the procedure and of the rehabilitation that would follow. The surgery itself was unreal to watch. It was uncomplicated and lasted a total of 3 1/2 hours with 1 1/2 hours on pump. The surgeons made a reference to who they wished they were all as simple and straight forward as this procedure.
The next evening the pt came down from ICU to and was admitted to the ward. He was awake but in extreme pain and very uncomfortable. He was coughing continuously but was unable to bring anything up even though harsh upper airway sounds were easily recognised on auscultation. Day 1 he was only able to SOOB for a very short period of time. Day 2 was much the same with the patient still in alot of pain and very sick from the pain meds.In the bed next door was a day 2 post same procedure whom I had a hard time trying to get to relax and sit down and take it easy.. It just goes to show no matter how easy or straight forward the procedure it is impossible to judge how a pt will cope post Sx.It will be interesting to see how this pt progressed over the weekend....

Pneumonia Galore

Hi all, apparently all of us have reached the halfway mark of our respective placements. Phew! Don't know about you guys/gals but the very tedious mid-assessment has been a reminder to me that there is always so much to read and learn, so much to experience and so much to ponder.

Questions abound and one that was asked which I recall quite clearly was : "Pneumonia is such a common diagnosis, so how do you make the decision of seeing or not seeing the patient?"

The picture of patients coughing madly, sneezing, feverish and drowning in their own thick greenish sputum came to my mind.

To play safe, I gave a very all encompassing answer: "Erm... Think I would see ALL of them first."

It was to be my doomed answer.

"As a healthcare professional in future, you should learn how to prioritize your patient list for proper time management and by knowing and understanding the conditions clearly, it will help you do so. Please read up. It's a good starting point."

How true.

Anyway, I decided to really read up on pneumonia and realized that its a horrendously big topic. And I thought my glasses couldn't get any thicker.

Here's what I found up so far and tried to condense some points together:

Signs and Symptoms:
Bacterial Pneumonia

• High fever
• Shaking chills
• Shortness of breath
• Chest pain
• Sweating
• Cough that produces thick green/yellow phelgm

Viral Pneumonia

• Flu-like symptoms
• Starts with dry/non-productive cough, fever, headache, muscle pain, fatigue
• Progresses to a cough that produces small quantities of phelgm(clear/white), SOB

Mycoplasma Pneumonia

• Very mild flu-like symptoms
• Dry, persistent cough
• Weakness

Fungal Pneumonia

• Uncommon
• Varies from no symptoms to chronic pneumonia

We typically need to see the first two groups and the most productive ones are the bacterial infected ones. But it does not rule out seeing the rest of them. They may have ventilation issues too.

Check the notes/PACS first to confirm diagnoses and investigations.

• Medical history
• Doctor's physical examination(especially auscultation eg coarse crackles)
• Chest X-rays(localize area)
• Blood tests: WCC, any bacteria, viruses or any organisms in blood(so we can classify and determine a brief picture of the patient)
• Sample of Sputum: micro-organisms etc.

Of course, the list is inexhaustible and not fool-proof. There are always special cases.

I have just started to read about the different names/families of the microbes cos its a mouthful and just too much. But I will persevere on.

Dear all, do help with the list and add on(if you have time and are interested). Or just anything about pneumonia. Guess it'll be a little something new to read everyday. Sounds crazy though. Till the next post, hang in there!

Patient Education II

Pertaining to the lady i shared about last week, she did turn up for follow-up. She reported improved pain which is only significant "a couple of times per week". She has started engaging in regular exercises and is now more aware of her posture. After discussion with the clin tutor, we decided to d/c her as she is coping with her condition well.

From the past 2 weeks in MSOPD, I realized most patients often come for physio initially with expectation of a quick remedy for their problem. A lot of effort is put into patient education to educate them so we can empower them to “take charge” of their own condition. To quote a fellow-physio friend, “changing the locus of control from external to internal”. This is often easier said than done. I realised building a rapport with them 1st is very important. In addition, help them understand where their problems are, and discuss with them the "effects" of different treatment plan.

The power of observation

This week I would like to relate to a patient I have beeen seeing on a cardio-thoracic surgery ward. The 67 yo patient has had a CABG X 3 and on initial Ax in the am on Day 1 post-op in ICU he had minimal pain but was very drowsy and was unable to concentrate for more than 10 seconds as to what I was saying. I however followed the suggested protocol and was able to march him on the spot for 2 min and SOOB for SMI' s and a supported cough.



Later on he was tranferred to the ward where we were to see him in the pm and ambulate him with the support of a trolley for the attachments. On checking the obs charts he seemed stable and afebrile with the last entry but on observing the patient he seemed restless and had a short shallow breathing pattern. He was also tachycardic and had no BS in the R lower zones . He was not drowsy and able to converse as normally expected. He was very keen to go for a walk with me and could transfer independently which was very good for this stage in his recovery. I reported back to the senior physio as to my findings and she was immediately certain that some thing was just not right. We reported to the Dr who immediately called for a X ray which revealed a pneumothorax. We did not go for a walk that pm.



Reflecting back the patient did not seem to have CI to ambulating as other patients have been ambulated with tachycardia and SOB and he seemed very mobile at the time. On subjective examination and the most recent nursing obs the patient was clear to be treated but with a thorough objective examination some factors put together showed that something was wrong.



I guess while we are on a learning curve it is very important not to cut corners with any S or O examinations and always seek advice if not sure of something or just to be sure that it is safe to progress with your intended Rx.

Thinking outside the square

Hi all, hope prac is going well.

I would like to relate the story of one patient I was treating this week, who was admitted with severe shortness of breath, due to an infective exacerbation of COPD. This patient had lung volume reduction surgery 6 years ago, and had developed increasing symptoms since Christmas.

This patient uses oxygen 24 hours per day, on 2l/min during the day, 1 l/min at night and up to 3 l/min on activity. Ambulation is with the aid of a 4WW. When I first saw the patient, his SpO2 was 94% on 31% FiO2. He had an upper chest breathing pattern and was using pursed lip breathing. He had just returned from the bathroom and sat down in a supported upper limb posture. His chest was clear on auscultation, but he was exhausted and was not keen to do anything.

The next day the doctors were trying to wean him off the oxygen, and when I went into see him he was lying down, and his sats were 85% on 24% FiO2. Again he had recently returned from the bathroom. In an attempt to make things easier for him I got him SOEB with his arm supported on the table, and spent the next 10 mins talking to him and trying to get him to relax. His sats climbed to 88%. I came back 90 mins later and he was still in this position, and his sats were at 94%. He felt much better.

I knew that the best thing for him to do was to get up and about in an attempt to improve his exercise tolerance, but he was desaturating when lying down. I thought about the best way to do this, and as he was comfortable with his upper limbs supported, I tried a pulpit frame. He had never used one before, but he was willing to give it a try. This also enabled him to rest leaning into the frame as required. He was on 28% FiO2.

When he got up and out of the room he desaturated to 83%, but leant into the frame and this quickly returned to 89%. After that he rested whenever he needed to, and didn’t desaturate beyond 87%. He managed to ambulate approx 50 metres, and felt better for it.

I was not hopeful of being able to do anything other than positioning this patient due to his severe dyspnoea. Thinking outside the square enabled him to be more comfortable walking, and he also managed to walk further than he thought was possible.

Dale.

Sticky Situations

I am currently on my Neuro placement, and thoroughly enjoying it's many challenges. During the week I had a very interesting encounter, one that I am a little embarrassed and reluctant to share. The situation in question arose when a physio on the ward asked if I could quickly help transfer one of his patients from the chair to bed. The only background information I was given was that "they had psychological issues". Always willing to help I said "yes" right away. So as I proceeded to enter the room I was confronted immediately by a confronting question, which was "Are you straight?". To which I replied, "Well the last time I looked in the mirror I was". The patient then kept on probing about my sexual orientation and that he didn't want any Gay men touching him. Finally I had to reassure him by flashing my wedding band and tell him I was a happily married man and that he was safe with me. Happy to report the transfer went smoothly without a hitch.

Reflecting on this clinical experience, it didn't bother me at all about the patient's behaviour. In fact after the session I quickly found the patient's notes and found that they had suffered a TBI when they were younger, in particular to their frontal lobe. From my previous knowledge I am well aware that these patients may exhibit pseudo-physchopathic behaviours, in particular lack of sexual and social inhibitions. The patient's behaviour then made complete sense.

In future I think it may be prudent to obtain a more detailed handover so that I can be fully prepared, and to not make any wise cracks. Furthermore, it made me realize that during my professional career I will be faced with many confronting patients, but at the end of the day I need to be professional in my behaviour but also empathetic and understanding.

If any of you guys have any other suggestions as to how I could have done things differently or changes for future clinical practice, then I would like to hear.

Motivation

Hello there, hope every one's pracs are going well, can't believe it's the end of the second week already, we're half way there!! This week my neuro outpatient placement has been a bit frustrating. I am mainly working with patients who have suffered strokes, many of them have had the stroke many years ago so they have been dealing with their symptoms for a while now. I am finding it very hard to motivate my patients during our treatment sessions. As I mentioned, most of the patients have been dealing with their impairments for many years, so they are very set in their ways, especially in their gait pattern. During the treatment session, we seem to make gains and improvements can be seen in their gait patterns, however as soon as the treatment is over they resort back to their old ways. Now I know it is not realistic to think that I can cure them by just seeing them for 3 hours a week, but I feel that they are not benefiting from the treatment. Even though I am encouraging and am providing education about why the things we are doing are beneficial for them, most of the patients are not compliant with their HEP. That is the frustrating part; a large part of a patients recovery comes from self management, and if they are not doing any sort of exercise at home then how can I possibly make any gains with them if I only see them 3 hours a week?

Any one have any suggestions on how to motivate the patients and make sure they are compliant with their exercises?

appropriate actions

Hello all,

I have had a good week on prac as I hope you all have. This blog entry is, once again, regarding my pt w the degenerative disorder I had originally described as Progressive Supra-nuclear Palsy...he instead has been Dx w Multi- Systems Atrophy (which presents in similar ways to Parkinsons...reduced initiation of mvmt and forward flexed posture for starters). The pt attended just once this week and had, in the time since last week, noticeably reduced saving responses and balance difficulties. He stated at the commencement of our session that he had really noticed a change this week.
I largely worked on bed mobility, getting off the floor, gait and anything Fx that I could think of to be pro-active. He was significantly more stressed and exhausted with this exercises. I also got some TUG tests going as they appear to be a staple in patients who are on trials of L-dopa...which he is now maxed out on.
Half way thru our 1.5 hr session he quickly moved from our obstacle course back onto the plinth. He said he was very tired. I noticed he had urinary incontinence, his shorts were soiled. He was trying to hide his embarrassment and stated that he was too tired to carry on with the session. I initially pretended not to notice the issue and said that would of course be fine but first I would like to chat with my supervisor quickly before the pt was to leave.
I wanted to know if I should, in confidence, ask the pt if he would let me assist him in finding a solution to this incident and thereby not have to walk thru the hospital ashamed. Perhaps I thought if we got to the change room he might be able to dab them dry while we waited for his transport to arrive?? The supervisor and I agreed that the most important thing was for him to leave w some sense control over his situation and not flee the session with a really bad experience.
When I tried to gently tried to bridge this option with the pt he clearly was is such a state of distress that he didn't even acknowledge my suggestion and practically ran out of the gym. On the way out he quickly blurted that he would not likely be back next week due to a holiday planned down south. Then I tried to stay with him and ensure he was safe and his transport would know where he was. He insisted he was fine and essentially was just not accepting my help. I verbally directed him the men's room. He has a mobile phone and said that he was ok to connect with his ride.
Sorry for the long story here but it was just a rough moment for all parties. Anyway I spoke again w the supervisor and suggested that we follow up w the pt next week via the phone but perhaps re-evaluate how his case will be managed...namely the pt being seen primarily by a staff PT (because I felt that this pt responded better to my senior with all his experience and that way any extra embarrassment I had caused the pt he would not have to re-visit). So yeah lots of lessons learned of which the greatest might be to know when to ask for your senior to step in....That is all. MFJ

Week One Feedback

Hi all

Congratulations on your entries this week. I am delighted that many of you have commented on communication issues including confidentiality, dealing with progressive disorders, aphasia, patient rapport, etc. Clearly, there are unique circumstances for each patient, and many of you have been perceptive to these challenges.

As Dale correctly implemented, do not disclose information (even if the patient is bargaining for it) that is the domain of others (eg. Consultant). If in doubt, it is probably best to be conservative with you disclosure. However, once the information is “public”, you may have an excellent role in further education. You will often have significant time with the patient.

I am pleased that some of you are thinking where appropriate, beyond physical problems and considering issues like potential central sensitisation and appropriate communication strategies for patient’s apparent psychological position. Remember that their mood can be quite fluid, and you may need to adapt quickly. Try to reinforce positive coping strategies and neutralise negative behaviours. Sometimes your role may to be to try and facilitate a persons readiness to change, rather than to achieve change.

I am fascinated by the “miracle” SNAGS and the number of comments clearly indicates successful experiences. I may have to try them more myself!! You are also learning additional techniques from experienced physios which is encouraged. Over time, you can select techniques that work best for you and your patients.

With your responses to original postings, please continue to offer empathetic experiences and suggested solutions.

Well done. Enjoy your week.

Regards
John

A Different Culture

Dear all, how's it going?

Currently doing cardiopulmonary clinics in the medical discipline and this first week has been quite calm. Apparently, it is the "quiet" period, so no dramas at the moment(not that I want any). But there is still quite an array of cases, mainly in the respiratory area and patients with tonnes of co-morbidities.

As this is afterall the first week, my supervisor decided that mastery of a proper subjective and objective examination would be of utmost importance and then work up from there. So, she gave me a new patient, with a rather ordinary name and after reading his case notes(suspected bronchogenic right lung carcinoma with lymphadenopathy admitted for a lung biopsy), we went off to see him. So, we both stepped into the room and looked around expecting a Caucasian patient(the name was misleading), and lo and behold, we saw an Aboriginal sitting on the bed.

So, I just went about formally doing the subjective assessment. I mean, what can be different about this subjective assessment to others right? Well. It was different. Half of the time I was trying to interpret what he was saying(very strong accent), and the questions posed wasn't being answered the way I wanted it to be. Had to keep using different terms, analogies and very simple examples to ask and explain. Think the hardest was asking him chronological questions ie. "Do you know how long ago you started coughing up blood?" and he would name a whole list of places(Derby, Kimberlies, Karratha etc.) he went and where he got it. Not when he got it. He looked absolutely uninterested in answering the questions. He didn't know his doctor's name, what medication he took and his medical history. But he did get a little choked up on talking about his current condition as the doctors suspected that he has right lung cancer.

Anyway, I managed to pry enough information out with the help of my supervisor. 40 minutes!

After objective Ax, we got back into the doctors' room and my supervisor told me to sit down and explained to me that it takes a different approach to do a subjective on Aboriginals.

So here's what she told me:

1) Sit down or bring yourself down to their eye level while talking to them. I was standing up when talking to him. They feel intimidated by that.

2) If they don't make or avoid eye contact with you, it's ok. It just means they respect you as a healthcare professional, or they are just really shy people. So don't think they are uninterested in your questions.

3) If they can't give you a timeline in terms of exact dates, its because they don't know the time we know. My patient doesn't wear a watch and on asking, he says he doesn't need to. Their time is determined by how long they stay in a place. Ie. When I was in Derby I started coughing up blood and about 3 months I went to the Kimberlies I got short-winded etc. So best is you just let them tell their story and ask less questions.

4) Use extremely simple terms with them and give examples they can relate to. If its a body part, just point to it(unless its really obscene.).

5) Don't be suprised if their family members are scattered everywhere in the small townships. They live a nomadic lifestyle. Most live on their own in very small communities with few services.

6) Smile.

Really an experience for me. Hope this helps and if you have anything to share. Please do.
Oh yes, the towns he names were all North. They like the weather hot.

Managing aspects of progressive conditions

Hello all,

I am on the neuro prac in an outpatients setting and I have an older gentleman who has Progressive Supranuclear Palsy (PSP), my supervisor said it goes under a newer name but I forgot exactly what it is called now (will report back soon). To quote wikipedia PSP is: " frequently misdiagnosed as Parkinson's disease because of the slowed movements and gait difficulty, or as Alzheimer's Disease because of the behavioral changes. It is one of a number of diseases collectively referred to as Parkinson plus syndromes. "

This is a rare and truly tragic condition and unfortunately I have now seen two such patients on two different pracs.

The first patient and their immediate family had just been explained the condition when my first prac had commenced and they were in a great deal of denial about the disease. They where constantly asking me to address the patients RC dysfunction.... despite her history of recent falls (resulting in her torn RC) and her increasing difficulty with transfers. These more important issues were clearly to be the focus of my attention but it was difficult to, sensitively, bridge that chasm of understanding and acceptance as to why these matters were to be addressed in light of the impending deterioration.

Now, on my new prac, I am encountering a yet another, different, stage towards that of acceptance which is fear and anxiety about their condition. This patient is keenly aware of his increasing reduction of voluntary movement...and this loss appears to be moving swiftly. In his case, I find it awkward to tactfully introduce such treatment strategies as bed-mobility because right now he can still move reasonably well. We both know why it must occur but there is an air of silence surrounding the rationale. It is tricky when we are students that waltz in for a month and then leave again to establish the kind of rapport needed to build that kind of honest relationship.

I remember reading about these stages of acceptance in our Umphred text and wondering just how regimented such progressions are. All I know is that each stage requires a different type of communication between PT , pt and care-givers. I am certain we have all been in such positions on prac before and would like to open dialogue on how some of you have managed this side of physiotherapy. Cheers, M

Dealing with Confidential Information

I am doing my cardio-respiratory placement on a general medical ward, and during the first week of this placement, there was a dearth of cardio patients on the ward. There were only two patients this week on the ward for cardio-pulmonary related diagnoses, so understandably I was keen to get started.

On the Tuesday of the placement my supervisor encouraged me and the other student to practice our subjective and objective questioning. Reading through one patient’s notes revealed that the patient had developed metastases throughout the lungs, which was a relapse of a previous cancer that the patient had survived. It said in the notes that the patient had not yet been made aware of the condition, and was to be told the following day by the treating consultant.

I felt very awkward knowing this information, yet being required to perform subjective and objective assessments on the patient who wasn’t aware of the diagnosis. I wasn’t sure how I would react. On the Wednesday the other student and I went in to see the patient with our supervisor, and were about to begin the initial assessment. We introduced ourselves to the patient, who was willing to participate in the treatment. This was prior to the patient being told by the consultant.

Unfortunately, as we were about to begin, the consultant came in to see the patient, and we left to treat other patients on the ward. We came back later, however the nurse told us that the patient was in the process of telling their partner, and was very upset. The consultant also told our supervisor that the patient was not for physio at this stage.

This incident made me reflect on how I coped with confidential information, and also on how patients cope with critical illness. It was unfortunate that we were unable to treat this patient, however, when we introduced ourselves to the patient I felt comfortable with the knowledge that I had and knew that I would keep that information confidential. We still haven’t had an opportunity to treat the patient.

Shoulder: Tight Posterior Capsule

Hi Guys,

Hope your placements are all going well.

During my first placement (Musculoskeletal), I assessed and treated a number of patients who presented with shoulder impingement. To help identify the likely culprit as to why my patient's were experiencing shoulder pain and loss of ROM (in particular ER) detailed investigations were conducted. Some of these included PAM's, GHJ Stability Tests, Muscle Dynamic Stability Tests,
GHJ Impingement Tests, Muscle Length Tests, Muscle Strength Test, Motor Control Examination etc.

Apart form the usual impingement suspects (eg bursa, sup joint capsule, supraspinatus and LH biceps tendon), palpation further revealed a number of clues. In particular many of my patients had anteriorly translated HOH's (normally should be 1/3 of HOH). I know from my studies that if the HOH is excessively anteriorly translated this may contribute to shoulder instability and impingement. My supervisor advised me to check for posterior joint capsule tightness as this often a major cause. I accepted this and researched this topic myself and found that the literature supports this view. However on reflection I don't completely understand how a tight posterior capsule can anteriorly translate the humeral head, visualizing this structure if anything I thought it may posteriorly translate the humeral head.

If anyone can clearly the explain the correlation between a tight post capsule and an anteriorly translated HOH I would like to hear.

Christian.

To mob or not to mob, that is the question

I recently saw a 69 yr old lady wh0 presented with a 3 wk Hx of Lx & left buttock pain which radiated down her left LL in an L5 distribution. My immediate thought was that i was looking at some sort of radiculopathy. However, Lx examination only provoked local pain. On palpation her piriformis was like a steel band. After discussion with my supervisor i released piriformis which brought the pt symptomatic relief from her severe (10/10) buttock and leg pain, however i still didnt feel like i was dealing with her real prob. A more detailed examination the following day with the infamous JW confirmed my original suspicions of discal involvement. I applied some G3- L rot mobs in R S/L to which the pt responded well. We then taped her back to prevent excess flexion, educated her, and sent her on her merry way. I am seeing her on tuesday and will keep you all appraised of her progress.

Jez

On Patient Education

How’s everyone going with their 1^st week of placement?

I’m currently doing musculoskeletal outpatient placement. During the past 1 week, I saw a few knee, ankle, shoulder and lumbar cases.

One case which I would like to share is a lady who was referred for low back pain. She complained of I/T LBP, dull ache, unilateral on the (R) side. Agg factors included prolonged sitting and standing, relieved by rest. Nil neuro-related symptoms. On initial examination, flexion, extension ROM was reduced. L3-5 region was hypomobile. Motor Control functional test revealed that she was unable to activate TrAb and pelvic floor without bracing the whole abdominal wall and holding her breath.

During the treatment session, I explained to her my plan and the possible causes for her problem. One of the treatment included teaching activation of TrAb in crook-lying. During the exercise, she found the activation difficult and “tedious”, and wanted to give up. She said “Oh no, I’m not coming for Physio anymore.” She started commenting on how age makes a difference – “you are young, when you reach my age, with the weight put on around the tummy, it will be difficult.” And she even apologized for not being able to do the exercise, n how she is a “nuisance”, and that she’s “wasting my time”, how she did not “understand why the doctor did not refer (me) earlier on, why wait until now?”

I had to spend the whole session on educating her, explaining to her that she’s not a “nuisance” and she is referred for a reason. The doc probably thought that her I/T LBP is a recurrent issue for her and physio may help to alleviate the problem. At the end, I taught her how to do pelvic tiltings in sitting and good sitting and standing posture.

From this case, I felt the impact of psychological factors on the compliance of treatment. I also realized a treatment session may not necessarily consist of hands-on therapy or exercise prescription, (loads of ) patient education is equally important. N also, sometimes from patient’s point of view, she may not see the use of “activation of TrAb” and starting off with something functional may be more useful.

Communication

I am also currently doing my Neuro placement in an outpatient setting. My case load consists of a few patients who are both expressive and receptive aphasic, to differing degrees (some can only respond with yes and no, while others have more words to their vocab and can adopt and repeat your cues), as a result of their strokes. It has been very interesting to consider your own communication you have with your patients and a great way to develop your communication to ensure you can ask the same thing in a number of ways so that your patient understands what you are asking them and that you are getting an accurate response from the patient. I have found that it does however limit the personal relationship you can have with some of your patients as it is quite difficult to answer family etc questions with yes/no. Yet, these people all have families including children and even grandchildren and to see their eyes light up when you mention them but not being able to chat with you about them must be so frustrating for them. To me, this aspect has been a big reminder that a lot of patient’s are often still cognitively alert yet must get so frustrated at not being able to express themselves all the time.

A note on SNAGs

I am relating back to my first placement which was musculo at the curtin clinic. We did not spend much time on SNAGs during the spinal units but in this placement we were fortunate enough to have a clinical supervisor who had recently completed her masters in manipulative physio and had specialised in the mulligan's technique in the cervical spine as her thesis. One of the tutes that she gave was on SNAGs to assist restrictions into rotation. I found it very interesting as she recommended that a reasonable amount of force be provided through the contact and in an upward direction. It is important to warn the patient that the first 3-4 reps will be painful but then will improve dramatically. She recommended 8 reps with a brief hold at the end af rotation before returning to start position. We were fortunate enough to have cervical patients at the time and although the patients reported the technique to be painful is was very effective and provided immediate subjective and objective results. A further note to add is that those patients with very tight sub-occipitals would benefit from muscle release prior to applying the SNAGs. Just remember Ax determines Rx!

Listen to your patient.

I am doing my Cardio thoracic placement at the moment. I was treating a 78yo old lady during the week and she was 7 days post CABG. She had a rather tough time post op and had stayed longer in ICU than most. She was beginning to do well and was amb short distances (15-20m) although it was hard to get her motivated to do so.She was not keen on ambulating or doing anything herself according to the nurse staff. On day 8 I went to treat her and she said she was too tired and fatigued to do anything. Based on past documentation and objective analysis-Obs-sats/hr/bp/RR and general obs there was nothing evident to suggest that this lady should not get OOB and amb other than she not wanting to get up. With alot of persuasion she got up and went for a walk however after a rest break on a chair she was unable to get up out of the chair. All sats were stable and there was no reason for her to require more than x1 assist.I got a nurse to help me with the patient and we brought the pt back to the room. The patient was very frustrated and could not understand why she could now not get up.

Next day when I went to see this patient for a tx session, she was afebrile and tachycardic.She was sent for ECG and Cxr. This just highlights the fact that yes we have learned alot over the last 2 years but sometimes criteria or regimens have to take a back seat to what the patient is telling you. This lady was obviously not feeling well and although no harm was done it shows that sometimes you just have to listen.

Michelle

Continuing Education

I am currently doing my Neurological placement working mostly with stroke patients in an outpatient setting. Our supervisor is really great and has been showing us heaps of techniques that we can use for facilitation. What I was surprised to find was how much mobilisation (especially of the foot and shoulder) as well as SIMMS is used in neurological physiotherapy. SIMMS is a great way to mobilise specific muscles and gain proper alignment, and the effects can be seen immediately. Since we only briefly touched upon this technique in school, I was not aware of the effect it can have on a neurological patient.

This just goes to show how clinics are an excellent learning process and how as a physiotherapist, you never stop learning. There is a strong emphasis in this profession on continuing education. I find this refreshing because you are constantly learning new treatment techniques that will make you a better physiotherapist and better your patient in the long run because you will always have a wide variety of treatments you can fall back on if you find that a certain technique is not working.

I just thought I would share my thoughts on this and ask if anyone else has had a similar experience where they found a new technique beneficial or your comments on continuing education.