to ambulate or not, that is the question....

hey all,
so last week on my neuro prac was very exhausting . I have been working with this left hemi pt ((R) MCA stroke)I have been working alot on improving vol mvt of LL'S ,STS and weight shift in standing. The pt has been progressing very well . Not so much emphasis has been on ambulation as it was decided that it would be better to try for the best gait pettern by attending to other impairments first rather that reinforce a faulty mvt pattern by mobilising the pt too early with a quad stick and assistance.So the decision was made to only mobilise the pt when he had adequate hip /knee extension and trunk and pelvic control. The pt was doing very well and his LL control was improving immensely but mid week the pt became very depressed and anxious and down in himself. Because he has expressive aphasiA it is very hard to understand what really is bothering hin apart from the obvious. On wednesday afternoon the pt was found by his family on the ground in the bathroon on his buttocks. He had attempted to walk to the toilet on his own and fallen. He was unhurt but it just brought home to me that it is a hard call to delay mobilisation in the sake of having the better gait pattern when it is so important to the individual themselves. We decided the next day that we would begin to mobilise (x 2 assist)and the pt has been in much better spirits and I am glad to say is doing really well with his moibility.

Update

Hi everyone,

Just thought I would update you on the progress of my irritated nerve patient that I spoke about last week. I am happy to say that she is making progress. At the end of last week I tried taping her shoulder to unload it and she came back tuesday morning to say that she had the best night's sleep since Christmas over the weekend and didn't wake up in pain at all but then went on to say that Sunday, because she had to lift her son's wheel chair she was in pain yet again. So Tuesday's treatment only consisted of some STM of her UT's and LS that were quite tight and we taped her shoudler again. she seemed quite pleased with the treatment and was to return again on Friday. Friday I decided to reassess her NTPT's again to see if the irritation had decreased at all, and it did, I was able to get her arm into further abduction (for the radial nerve testing) then during the initial assessment. So based on these findings I decided it was time to get into her neck and do some lateral glides and open up that joint space. After the frist set she still complained of pain radiating down her arm but after the 3 sets were done the pain was gone!! So slowly but surely she is making improvements. Too bad I only get to see her one more time, I would really like to see how she progresses.

Cultural Issues

Hello all,
So this week on my cardio prac I treated an older women from a country somewhere in the sub-continent. Reading over the notes prior, I discovered she spoke nil english. I wanted to get a complete chest review done on initial consult and was concerned how I would go about it in light of not only the language barrier but the different cultural/ religious background. I thought momentarily, and fondly, of the lab way back when -where a certain Canadian red-headed gentleman tried to teach another student something in Spanish...golden.
So I was having pretty good luck ascertaining the bulk of my chest questioning... via some creative hand gestures. I was then needing to auscultate. Seeing how she was almost entirely covered with scarfs and clothing, I thought this was gonna be tricky. But she was actually super cool and, while preserving all modesty, we ventured to complete a comprehensive chest Ax.
When I realised her ++SOB and audible expiratory wheeze was limiting any ACBT's that I had in mind (to ensure she had effective airway clearance), it was decieded to give her a neb first. Again all I had to do was show her the neb mask and she understaood exactly what was to happen.
I guess that one good thing, in terms of physio, with pts. that have COPD, is that they are often old pros at the Ax and Rx that happens in hospital. And also our assumptions about how much of a impact cultural differences will have on physio interventions is ultimalety more up to that individual. Thanks for your attention and best of luck in all your final assessments. Matt

Small but effective

Hi all

I am on my musculo placement and thought I would share the background on one of my patients. She has had a history of low back pain for 30-odd years, and has suffered from leg pain for 20-odd years. She was referred to the clinic by her new GP. The leg pain affects her sleep, to the point where she wakes hourly when it is severe, and she needs to get up and walk to relieve the symptoms.

Her presenting back pain was 5/10, which is her pain on a good day, and when severe is 9/10. Her leg pain comes on when her back pain is 7/10. Objective findings showed positive slump test bilaterally, and absent reflexes in the S2 distribution bilaterally. CT findings showed degeneration around L4/5 and L5/S1 facet joints and stenosis of the L5/S1 intervertebral foramen. There was some hypomobility in lumbar unilateral PAIVMs, although the patient was very TOP. PAIVM Ax reproduced her leg pain.

My initial treatment consisted of STM to the Lx erector spinae musculature, and unilateral PAIVMs to the L2-5 segments. It didn't feel like much treatment, but at her next session the patient said she slept for 9 hours that night without waking, and the leg pain had disappeared for 2 days. Re-Ax of her * signs showed that S2 reflexes had returned bilaterally.

Just thought I would share that, as a reminder that perhaps sometimes we don't need to provide too much treatment.

Dale.

Patient non-compliance

I am currently on my Cardio placement and am treating (or lack of) 63 year old woman who was admitted due to feeling unwell on a background of idiopathic thrombocytopenic purpure (low platelets and bruises easy for no known reason). My issue is that she refuses all physio treatment. At home she ambulates independently with a WZF but in the hospital most of the time she refuses to get out of bed. Her excuses range from, not feeling up to it, she might fall over, will do so when she is ready. The more I try to educate her on the benefits of ambulating the more aggravated she gets, in fact she screamed at me last week. Her chest at the moment is clear, however I still think it is an important prophylactic to get her up to ensure she doesn’t get any chest infections. I have tried a number of strategies such as education, idle threats (“the Doctors will get really mad at you”), tried to make compromises and even taken an interest in her scrap booking, however all to no avail. I am now tempted to use a cattle prod to put this woman in motion. If anyone should have any ideas of how I can get this woman up and ambulating with her WZF I would love to hear.

Turned away

Hi,
So this week presented an interesting case…a patient on our Cardio placement has a thoracic aortic aneurysm but after having been in hospital for a few days to prepare for surgery, this patient’s blood pressure was a bit high on the day before her planned surgery. I can’t remember the exact size of the aneurysm but I think it was about 5cm. The patient is quite an overweight/maybe obese individual and would therefore present other risk factors for undergoing a general anaesthetic, but the outcome was that the anaesthetist did not want to anesthetize the patient and therefore she could not have the surgery. She instead was given some medications to assist in controlling the blood pressure issue before she was discharged a few days later to a rural hospital and told to lose some weight before she could have the surgery.

So my problem with this is two-fold. One, if that was me, I would be very anxious about trying to exercise knowing that I had an aneurysm that could potentially rupture at any unknown time-therefore how should I then loose enough weight to be able to have the surgery without risking my life in the meantime? And my second issue is that if this patient had previously tried to loose weight and had been unsuccessful, she would possibly present for lap-band surgery in which an anaesthetist would put her under to do that surgery so how is this any different?

So I suppose there are a few things that puzzle me with this case and who knows if we’ll find out the answers!!

Aphasia frustration

On my inpatient neuro prac I have been dealing with a 65 year old person who has had a L TACI and this has left her with expressive aphasia. anosognosia, gowland 2/7 in R arm and leg. She has been very pleasant to work with and has a good sense of humour and the only real words she says is "NO" and "DONT" which obviously are important for physios wishing to gain consent to treat. Anyway she has recently become agitated and due to her anosognosia has tried to stand and get out of bed which has led to some falls and she now is strapped into her w/c. This has increased her frustration and being unable to verbalise anything but NO and DONT she became very aggressive during a Rx session and would not allow us to transfer her back to her w/c.

This was an interesting situation as she wanted to get back into her w/c chair but would not let us assist and she was a falls risk if she attempted it herself. Fortunately we had some excellent guidance from the supervisor who had to take over and allow the patient to do their own transfer and our job was then to catch her as she fell and help her in her own way back to the w/c. This transfer would have been a fail any day in an OSPE and Ann Furness would have ripped some heads off but it was the only way to get her back without assaulting her. She now shows more respect to us as we did not force her to do it our way but her way and is now more cooperative with us. She still does her own transfer which is unsafe but for now we are just there to catch her.

Involuntary Laughter

Dear all, how's it going?

This week has been quite an unbearable week for me. Apparently my wisdom tooth decided to pronounce its presence. Can't laugh, talk and eat properly. Looks like there's a price to pay for wisdom huh.

Anyway, I've been reading through some of our posts again and realized that for those of us doing or who had been doing clinics at Neuro OPD, our patients more or less remain on the list for sometime. So they get passed down from student to student. Don't know if you remember your patients but can you recall any of your patients who are super giggly and high-strung on laughter?

Those patients who laugh at inappropriate times, un-funny situations or in response to pain or discomfort. Or just at anything. And when they laugh they really go into laughing fits and find it hard to suppress the laughter. Which really affects us during treatment as laughter brings up the tone, makes them lose concentration and really tires them out. Sometimes I find it difficult suppressing my own laughter cos their guffaws are really infectious(and lately because of my throbbing wisdom tooth, it makes it painful for me to laugh).

So, despite it being a really far out topic, I decided to do a little research on the cause of involuntary laughter. Just to satisfy my curiosity.




How Do We Produce Laughter: A Suggested Neuroanatomic Circuitry

First, the anterior cingulate gyrus endows experiences with emotional consciousness and is partially under frontal cortical control. The anterior cingulate is also involved in the expression of emotion, particularly emotional vocalizations such as laughter.

Second, the amygdalae in the temporal lobes feed back to the anterior cingulate for the emotional coloring of perceptions, and the temporal (parahippocampal and fusiform) cortex integrates perceptions with prior experiences.

Third, the caudal hypothalamus, the central coordination center for internal emotional changes, is an effector of laughter.

Fourth, the ventral pontomedullary center for laughter coordinates emotional vocalization, facial expression, and expirations.

Finally, bilateral corticobulbar tracts tonically suppress laughter and oppose extrapyramidal connections for emotional expression. In addition, unilateral capsular lesions may produce temporary synkinetic laughter from crossover of activated but damaged voluntary motor pathways to these extrapyramidal pathways for laughter.

Causes of Pathological Laughter (in relation to infarction and tumours)

• Pseudobulbar Palsy: Bilateral cerebrovascular disease, multiple sclerosis, head trauma, amyotrophic lateral sclerosis, progressive supranuclear palsy


• Unilateral striatocapsular region infarction


• Focal strokes and tumours affecting ventral pons and pontomesencephalic region


• Other tumour locations: tentorial edge, right prerolandic cortex


• Gelastic(Laughing) seizures(fits): hypothalamic hamartomas or mass, temporolimbic lobe, frontal(anterior cingulate) lobe

(Adapted from Mendez et al, 1999)

The pathology sounds familiar when you look at these patients case notes. Ie pontine stroke, PSR, striatocapsular infarction due to occlusion of carotid arteries. Correlates well with the clinical presentation. Really interesting. In fact, laughter is a very little researched topic and its still quite an enigma.

Hope you find this piece of information interesting too.

The end is nigh

Greetings and salutations

Well not long to go now my young padwans i hope you are all feeling as unprepared as me for the pcr's looming on the not to distant on the horizon.

My blog this week is based more on concept than one particular pt, although it was a specific pt who triggered this chain of thought. I find it pretty easy to remain professionally disconnected from my pt's, i like to be empathetic but not to feel to emotional about it. However, when it comes to young people with neurological problems i really struggle to do this. In particular there are two young fellas in my clinic, one had a stroke after playing footy aged 19 and the other is a 14 yr old who has a progressive terminal condition affecting his brainstem who constantly ends up in hospital because his body temp drops down to low 30's. Both of these youngsters are top blokes and you cant help but like them. I find it really frustrating because you want to do more for them than you can. One is going to die and the other has aphasia and sig R sided deficits which are'nt really improving. I guess the reality of PT is that you cant cure everyone.

Anyway it is what it is and thats my thought for the week.

See you all wed week


The Manipulator x

In Uni, very often, we were taught about importance of patient modesty with appropriate draping of towels over limbs. How abt physios?
Had a challenging case over last week. The patient is a 55 year old male, with post-kidney transplant and idiopathic demyelinating encephalopathy. Throughout his inpatient stay, he had behavioral/ impulsive issues. Hence it’s quite common to read in the notes that patient had many outbursts of aggression, falling down, requiring sedation (such as midazalem) It had been a challenging time rehabilitating him because he had short attention span, and did not respond well to non-functional treatment. Hence both gareth and me had been engaging him with functional activities, and varying the activities to catch his attention.

What happened one day was we were walking this patient down the hallway when the patient suddenly grabbed the bottom of my shirt, pulling it, started staring at my (L) chest (or boob). At that point in time, I was dumbfounded for a few min with many thought processes going through in my mind. With his history of aggression in mind, I was caught between allowing him to continue with what’s he’s doing or immediate reaction of pulling his hand away with risk of being punched in the face. In the end I did neither, and decided to be firm with him, yet politely asked him to put his hand down and continue the walk quickly to distract him. Gareth also helped by gaining his attention with other activities. Amazingly it worked quite well. He was compliant and did not resist us.

Something new learnt during inpt neuro placement… not sure whether any of you (females) had such similar experience before?

Bobath principles...

I had the opportunity to be taught some upper limb techniques this week which I applied to a pt who suffered a Left TACI FIVE WEEKS AGO.He is stage 3 upper limb and has quite a significant subluxation and severe left shoulder and hand pain. He is hypersensitive in left hand and has lots of tone. His GHJ adductors are also very tight and is therefore restricted into external rotation. His Prom is 90 degrees flxn/abd before pain inhibits further mvt. I put the patient in long sitting with a large cushion behind him. I started on his unaffected hand/forearm and shoulder and performed SIMMS/transverse soft tissue mobilisation . This lasted abouttwenty minutes. I then moved onto the affected side and performed the same techniques. Because I had started on the good side the affected side was more relaxed although still very tight. Howevere I was able to get the GHJ further into abd and ext rotation than everbefore and the pt was more relaxed and in less pain. It also translated into better responses later in the session when I began to get the pt to weight bear trough the upper limb.

Challenges all round

Hi,
Hope everyone is managing to get through their placements ok. This past week has been interesting at my Cardio placement as we have had a change over in supervisors-we have one for a few days and then another person for the other days. The challenging aspect of this has been adapting yourself to suit each supervisor as they are both quite different. One supervisor had us for the first week and was therefore more confident in letting us go and treat patients independently while the newer supervisor is much more regimented and wanted us to consult back to them much more frequently. While I understand this helps them to understand if we are capable, it takes up more of your available time. It highlights how when constantly dealing with people, we are going to have to change our approach to situations quite regularly!!

Also, just another thought to consider-had a patient come in to have a valve replacement but their co-morbidities were almost as much of a concern as the heart surgery!! This patient has type 2 diabetes, haemachromotosis, below knee amputation AND Parkinsons!! So the dilemma…how to ambulate to clear his lungs with BKA plus prosthesis but with Parkinsons-needless to say, a challenge!!
Have a good week.

Doctors Notes

Currently on my Cardio placement and am really enjoying the many challenges. This week I was going to reflect on a specific treatment session, however I have a more pressing issue....Doctors notes. I don't know about the rest of you but I am having an ongoing frustration trying to read Doctors handwriting. It is a frustration because it takes a lot longer when documenting, and I feel I am continually asking other staff to help decifer their writing. My supervisor assures me that I will get to become more accustomed to styles of writing and in time be better at reading. Irrespective of this explanation I cannot fathom how every allied health personnel that documents an entry in the patients notes are always legible, and yet the vast majority of doctors writing is nothing short of appalling. I have even heard anecdotal stories from nurses about adminisistering wrong medication due to poor notation. I reckon I might be better off taking a crash course in hieroglyphics so I can decifer their scribble. When talking to some of my other colleagues about it during the week, a number of suggestions were raised to help counter this problem, eg there is technology out there like voice recognition which converts to type, and programs that when wrting on a screen converts it into a type font. Now that would be fantastic if this could be applied somehow. If anyone else shares this same frustration or moreover has any input into how I can tackle this issue then I would really like to hear.

Tone

Hello to all again.

I have finally seen the results of foot mobilizations on some of my patients and they really do stand better, walk better as they have improved foot placement and contact with the ground hence a willingness to weight bear more on the affected side. And they put on their socks and shoes quicker on the affected side.

Problem is, every time they start putting effort or really focus their attention on the task(especially walking), the tone sets in and the ankle goes into plantarflexion, the toes curl up into knobs and the whole foot inverts like crazy. And the whole foot becomes "solidified" and moves in a chunk without any dissociation. Guess we have to look at the whole lower limb when it comes to the increase in tone but then realizing the fact that 10 minutes of foot mobs and SIMMS gives you 3 minutes of standing/walking with proper foot contact and when the tone comes on, it negates the effort of the mobs. The equation doesn't seem right.

So, I'm currently trying ways and means to decrease the tone in the ankle and foot so that the effects of the foot mobs stay as long as it can during the functional activity.

Things I've done so far(some may seem really silly):

• Doing lots of weight bearing on the affected side in standing
• Distracting them by talking about topics they like(including how to make a pizza from scratch)
• Stroking the extensor surface of the foot
• Firm pressure/contact on the lateral border of the foot to encourage eversion and prevent inversion
• Putting on an AFO for that foot so they can equal weight bear on the whole foot instead of focussing it on certain spots such as the ball of the foot which will cause a positive support reaction

They all do help to buy me spare time to do a little bit more walking before the full blast of the extensor tone sets in or sometimes help to continue walking after reducing the tone slightly. Ultimately, the foot tends to end up like a chunk at the end of the session.

If you have any ideas/techniques/tips to help with prolonging the effects of mobs/SIMMS or other alternatives to help decrease tone do add in your two cents worth. Or maybe I have missed out other components.

Small gains

I would like to reflect back to my first placement in neuro and one of the patients that I was treating. He had suffered a (L) TACS stroke 2 years previously, and receiving the treatment information from my supervisor indicated that treatment was mostly maintenance. The patient was able to ambulate short distances with a quad-stick, but for greater distances he used an electric WC. He had no use of his right arm, and had significantly increased tone in his right leg. He also had expressive aphasia, and often got very frustrated when trying to talk.

I continued to practice gait with the patient during the placement. At the end of the 4 weeks, my supervisor suggested that we discharge the patient and refer him to community services. The patient’s wife came in and I showed her through exercises that would help her husband. They were both very grateful.

During the placement, despite the “maintenance” of the patient’s condition, I noticed improvement in his gait, which was very rewarding. To see how grateful the patient was when he was discharged was really inspiring. The other physios in the department also mentioned how much he had improved since he was admitted to the outpatient program, and were equally happy to see him discharged.

It just goes to show that despite a patient’s condition, some small improvements may occur that will help the patient in everyday function.

Sorry, not today

Ok so this week on my Medical ward saw another rather skinny turnout at my super awesome exercise class. I am not sure how to get an improved turnout. I know the pt. is ultimately responsible for their own choices and I do my best to educate them on the benefits of this group activity but still so many decline or come up with elaborate excuses. Am I not approaching it correctly?
I generally walk in and say that they have been chosen to attend because it is important for improving/ maintaining their health. Then let them decide. My supervisor, however, has the ability to turn "no" into "sure I suppose". Makes me crazy.
The one cool thing I suppose is I have a pt. who is consistently quite difficult to persuade but usually does, begrudgingly, head on down to the gym with me each day. Did I mention that he has amnesia? Yes indeed he does and thusly, not only does he not recall who I am each day but I get to practice changing my approach subtly each visit!! Perfect for me- although a doubt he sees it that way.
Anyway it is all a wonderful challenge I suppose and I will continue to accumulate successful strategies to gain compliance. However if anyone has some some insight into this skill. pass it along. Cheers,

Pusher Syndrome

On my neuro placement I am currently treating a patient who has had a L TACI and presents with R sided hemiparesis, hemisensory loss, Aphasia and is also a mild pusher. Treatments have consisted of UL and LL facilitation of nornal movement, SIMMS and foot mobs, reaching activities to the L and standing with the tilt table as well as supported standing with 2 assist. The recent two treatments have been similar but had very different results when standing. The first Rx concentrated on reaching to improve her alignment and SIMMS and foot mobs. We only stood her twice with assistance x 2 and she performed the stand reasonably well with some slight lean to the R and Pushing to the right. The more recent Rx consisted mainly of sit to stand practice with 2 x max assist and the outcome was severe pushing to the right with very poor alignment in standing. So why the difference from one day to the next. On reflection it was the preparation that occurred prior to the standing that made the difference. The longer period spend preparing the foot for standing and working on alignment paid off and the end result was a better sit to stand than the last Rx when not much time was spent on the foot or on alignment. We must remember that we need to do the hard work in preparingt he patient before you attempt at training the functional task.

hello Everyone,

this week in my musculo outpatients placement i saw a patient for the first time who, after assessing her i found out had a C5 nerve irritation so she had decreased ROM in her arm. She is only able to lift her arm 60 degrees in abduction and flexion before bringing on extreme pain. This was an incidious onset and she is very concerned as to why this has happened. She has a long history (20+years) of neck problems and therefore does not like anyone touching her neck. ( which makes it difficult to do an objective assessment). After my initial assessment i told her that the likely cause of her pain was her nerve, so I gave her some suggestions on ways not to irritate the nerve (avoiding overhand activities, supporting her arm with a pillow at night to unload it). She seemed fine with the suggestions and went on her way. i say her again at the end of the week only to have her come back worse then before!! She said she tried the pillow and woke up with so much pain that she couldn't go back to sleep. She seemed quite annoyed at the fact that she had not seen any change in her symptoms in four days. I explained to her again that her nerve was irritated and that it takes a while for the pain to go away. She then asked me what was the point in coming to physio then. Well, I was a bit stumped becuase I really had no idea how to treat nerve irritation. She would not let me work on her neck to open up the joint space so I was out of ideas. My supervisor suggested taping the shoulder to unload it. We tried that and it seemed to relieve her pain a bit. She is due back into the clinic on tuesday. Any suggestions on treatment ideas I can try with her??

a silver lining to every cloud

Well hallo my fellow physios to very soon be

My experience this week relates to a 29yr old lady with a 14yr Hx of MS. She is a delightful pt to work with and constantly amazes me with her positive attitude towards life. In the last 18/12 her ms has progressed significantly and she is now mobilising with a MWC. Her primary impairments are very low tone in her trunk, high tone in her LL's bilaterally (esp in the plantarflexors) and she has very poor activation of glutes, lower abs and LL muscles which makes gait very difficult; and to top it all off she is very ataxic. I approached working her with the attitude that i would just try and slow the inevitable but making improvements would be impossible. However, in collaboration with her we came up with several Rx strategies that have actually made several significant improvements in her Fx. Firstly i sent her down to Actimed to buy a duradisk, which she has been sitting on ~ 4-6hr daily whilst doing balance exercises. Secondly we decided to break her gait practice right down and work on basics in stride stance and only move to whole practice once she had mastered each component part. As a result of this, and most importantly her committment to her HEP, she is now able to amb into the toilet independantly and take care of all her basic hygiene needs, something she feels very excited and proud of. I have learnt so much from working with this young lady, i will never approach people with progressive diseases with such a negative attitude again. The other thing i learnt is that by listening to the pt you can learn alot about how best to approach their Rx.

The Manipulator

First impressions

I would like to comment on a patient that I saw today for an initial assessment. I am on my musculo placement, and my new patient is known to the staff on placement, and she had to cancel her appointment yesterday. I was going through the subjective questioning, which took quite a while because she had significant issues with pain. Eventually I asked about her SHx, and she became very defensive and thought that I was invading her privacy. She became very loud at this time too, because most of the other students heard what she was saying.

I explained to her that I needed to find out what her ADLs were like at home, to get an understanding of her physical demands and how these might impact on her pain. She understood and slowly warmed to me during the session. By the end of the treatment I was able to diagnose SIJ instability, and gave her a STM to her Lx region (which I think was all she really wanted in the first place). She seemed very happy with this and was happy to book in for further treatment next week.

I was worried that she would want another physio for her treatment when she became defensive, but in the end this patient was very co-operative. Its important not to judge patients too quickly, otherwise they will get to you, and as a result your treatment will be impaired.

Don't underestimate the power of healing

Hi,
Sorry for the delayed entry but have been tracking a patient who I was lucky enough to see having his surgery and then his treatment when he came up onto the ward!!
I was fortunate enough to see pulmonary valve replacement surgery-watching most of the operation from a stool above the patient’s head!! The surgery took almost 3 hours and for me, the most amazing bits were starting the heart on bypass pump, stopping the heart and then re-starting it again!! All while watching the heart in full view amongst an open chest!! This surgery was performed on Thursday of last wk and the patient was out of ICU and up on the ward by Friday afternoon when we stood them up out of bed! He then continued to progress over the weekend and was discharged late yesterday afternoon after we had left. What has amazed me is that this person had their chest cut and sawed open and then retracted and then had their heart cut open and re-stitched back up and was then well enough to go home 5 days later!! This just goes to show that you should never underestimate the power of the body to heal itself. It did help that they had very minimal complications from the surgery but I was still amazed at how well this patient was doing on Monday when I arrived at prac. So from now on I suppose I will have a better appreciation for getting the patient up and about to reduce any chances of complications but also for how quickly the patient recovers and therefore treatment needs to be efficient from the very beginning!!

Last week was spent adjusting into a new setting… from treating patients who were fully independent (Musculoskeletal outpatient) to patients who require min-max (A) (Neuro Inpatient).

Saw a few cases. One which left a deep impression was a patient with ?GBS. It was interesting, though sad for the patient, to witness how the patient’s functional status changed over a course of period within such a short time:

Tue: Prox UL, LL weakness Grade 3/5, (I) bed mobility & transfer, (I) STS, X2 Max (A) amb; tingling sensation in hands and feet

Wed: Prox UL, LL weakness Grade 2+/5, (I) bed mobility with effort, x1 min-mod (A) transfer, x1 min (A) STS, unable to amb; tingling sensation in hands and feet

Thurs: Prox UL, LL weakness Grade 2/5, x1 min (A) supine to SOEOB, x1 mod (A) transfer, x1 (A) STS; tingling sensation in hands and feet

Fri: Prox UL, LL weakness Grade 2/5, x1 mod (A) supine to SOEOB – poor movement pattern, x2 mod (A) transfer; tingling sensation in hands and feet. Tingling in feet worse than before.

Over the 4 days, he also complained of increasing weakness on (R) side of face and difficulty chewing on that side.

From this case, I realized:
- the importance of knowing the pathophysiology of the condition. It is essential for patient education and for consideration during treatment planning.
- the importance of reassessment S/E and O/E, modifying our treatment goals and plans due to the clinical course
- importance of including patient in rehab. Initially I was planning treatment based on impairments and forgot to include patient in goal setting. Later with prompting from the clin tutor, I asked the patient his goals. His goal was to gain (I) in bed mobility. Based on his goal, we retrained the functional activity. The patient improved with practice and was very pleased with the outcome. He was also more motivated with rehab. This made me realize we should always consider patient’s goals in our treatment planning.

how wrong our presumptions can be!!!

hey all,

Well I am on my neuro prac. I had an outpt appointment this week and it was a 35yo male who suffered a R lat medullary stroke 4 weeks ago. Before I met the pt I had a mental picture of how I thought this pt would present. Major vestibular disturbances, verticality issues ,nystagmus.dizziness etc etc. I just saw the words lat medullary stroke and thought, ok this pt is going to need alot of work given it was only 4 weeks ago. How wrong could I be?

The pt presented with decreased sensation-sharp blunt and hot cold on left side upper and lower limbs. JPS/JMS all fine. Negative VOR/GAZE STABILISATION/NYSTAGMUS/.Sitting balance was perfect with pt able to tolerate ext displacement in all directions.Standing balance -static standing balance was normal,dynamic standng balance was impaired along with SLB on both legs. Fx reach test was above average and the pt performed v well on the Berg Balance.AROM AND mmT WERE ALL R=L AND WNL.Slight alteration of gait pattern was noted.No other objective findings were recorded.The pt's main cmplaints were his dizziness and blurred vision.From the above objective Ax it was clear that the pt's main problems were balance( high level balance) and he was doing rather well. I was astounded about how wrong my picture of this pt would be.Just goes to show, you can never tell how a pt will present.

Getting Footy

Hi all, hope the first week of the new rotation is going well for you all.

Currently doing Neuro OP where some of you folks have been and my brain seems to be still on Cardio. Guess it is slowly adjusting to think Neuro now.

Don't know why, but I have been doing lots of foot mobilizations lately on most of my patients and it has become a routine with them as such. They actually tell you they need foot mobs and don't feel right if they stand/walk without doing it. Its really kind of mundane mobbing feet you know, till the point I felt erm... a little bored.

But I guess that are always good and sound reasons why we do certain techniques and decided to delve deeper into the purpose of foot mobs to motivate myself to do them.

Got this off a website(Foot and Leg Centre) that gives a comprehensive list of why we do foot mobs:

"History:

Foot Mobilisation has its roots in manipulative therapy, which is a long established technique widely used by the physiotherapy, chiropractic and osteopathic professions. The first foot and ankle manipulative techniques were developed in the 1920s by American Dr John Martin Hiss, a student of manipulative therapy.

Purpose:

The primary purpose of FMT is to improve mobility of a hypomobile joint due to connective tissue adaptation caused by immobilisation or dysfunction as supported by Mennell (1964) and Michaud (1993).

Other purposes have been given for the role of FMT including dysfunctional neurological feedback (Charrette 2000, 2002). The neurology of mechanoreceptors and their role in proprioception and pain suppression is comprehensively described in the literature (Wyke 1985, Slosberg 1988, Maitland 1991, Michaud 1993, Logan 1995).

FMT will gently & painlessly restore joint mobility, flexibility & fluidity. When combined with corrective exercises, FMT will stretch, strengthen & stabilise the body’s foundation.

Physiology:

Woo et al (1975) demonstrates that joint hypomobility results from collagen cross-linkages which occur in response to immobilisation or disuse. The biomechanical and biochemical physiological effects of connective tissue to immobilisation are well described in the literature. Factors such as intra-articular adhesions, contracture of the joint capsule, or muscle shortening are also responsible for gross joint stiffness (Binkles & Peat, Woo et al.). Akeson (1980) documented that a sequel to joint immobilisation is joint stiffness.

So (1986) argues that manipulative procedures play a major part in regaining the range of movement or function of the joint. Exercises help to maintain the range of movement gained from mobilisation. ‘The importance of passive mobilisation and manipulation lies in the restoration of gross movements and accessory movements, which cannot be gained by patients through exercises alone, and certainly not by rest.’"

Guess a building always needs a strong foundation/base before we can do anything to it.

Will do foot mobs with this in mind.

Putting lifes problems into perspective

Greetings all from the manipulator

Well my little padwans here we are 3 weeks from pcr's with still so much to learn. My blog this week relates to a 24yr old male i encountered on my neuro placement. Whilst playing AFL footy (as if there is any other type of footy) as a 19yr old he broke his jaw and subsequently had a massive left MCA CVA. Due to his expressive aphasia it is hard to determine the exact mechanism of the stroke, but presumably it was either a fat embolis or mechanical obstruction of ICA by the displaced mandible.

This young man has full cognitive capabilities and can understand everything spoken to him but his has severe difficulty formulating a sentence. He finds this extremely frustrating as he knows exactly what he wants to say to people he just cant say it. He has very poor motor control of the R side of his body and ambulates poorly even with AFO's in-situ. I have found that meeting this young man has put my problems in perspective. I might feel unlucky having to do another 3 weeks of neuro, but this fantastic young man will spend the rest of his life as a R hemi with expressive dysphasia. It really makes me appreciate my health and it makes me determined to help improve his QOL as much as possible in my time there.

Peace

The Manipulator

Believe it or not

Hey guys

I have an interesting patient at the moment on my neuro placement. The patient is a male with MS and has presented with a flare up of the condition. The main issue is that he reportedly collapsed and is unable to ambulate with a WZF due to L lower limb weakness. The other main issue is social and he does not have a home to be D/C to. On examination he is very inconsistent with strength testing 2/5 and sensation (no light touch or proprioception). He is however able to transfer to w/c I and ambulate in parrallel bars. I automatically thought that he was attempting to give false objective measures so that he would be able to stay in hospital longer. He continually had collapsing episodes while transferring or ambulating but never actually collapsed as he always caught himself ( definitely 5/5 strength to do that). The more support I provided the more he "collapsed". On discussion with my supervisor I was told that as a physio you are required to provide treatment to patients that have impairments so this patient had no sensation in the L leg apparently and 2/5 strength in quads but is was not functional so we decided to provide Rx but not to focus on impairment but play his own game on him and provide functional tasks like ambulation and never to pay attention to the L leg as this caused so called collapsing. This seemed to work very well as on initial Ax he was 2x max assist to transfer but 2 days later is amb indep with a w/s. Its a miracle!!!
So I guess the lesson learned is to listen to the patient but be aware of the full picture and be aware of patients who try pull the wool over students eyes. They are to be treated all with some empathy but not to play into the trap but to rather challenge them functionally and not focus on the aparrent impaiments.

The air we breathe

I'm on my Cardio placement and am treating a lady who was initially admitted into hospital feeling unwell and SOB on a background of metastatic lung cancer. She also initially presented with HTN, tachycardia, diarrhoea, sepsis and acute neutopaenia, furthermore she just recently completed her 5th cycle of chemo. Long time smoker. Last Tuesday she was requiring 4l O2 saturating at about 93% via a HM at rest, we are constantly trying to wean her down. During any type of transfer or global mvt her sats plummet. She is basically really unwell. I have been treating her since last Tuesday and RX has consisted of positioning, ACBT's, UL/LL ex's and trying to get her mobile (SOOB and basic transfers from SOEB to commode). She finds it extremely tiring and exhasuting just standing so ambulating has been a challenge.

So on Thursday I had big plans to try and take a few steps with her WZF or at least trying for a SOEB and transfer. However no go, pt refused Rx because too exhausted. About 30 mins later I see her on her commode returning from her shower with her nurse, so I thought I will quickly perform a treatment and at least transfer her from her commode to bed. Mission accomplished but was quickly kicked out by the nurse who still had to clean her up, so Rx half complete.

20 mins later I returned to complete my Rx, then after putting the sat monitor on I was shocked to see her sats hovering around 50%, and tacycradic. I quickly changed fingers to make sure, and it still read the same. I then asked the pt how she felt and said she felt exhausted. I then went into automatic pilot and put the Hudson Mask straight on, pumped up the O2 to approx 4l vis HM, re-positioned her so she was sitting upright in bed and monitored her sats, they thankfully started climbing steadily back up to towards 70%. I then grabbed her nurse to monitor, she said she would look after her. I then promptly relayed the story to my supervisor.

In retrospect and after talking to my supervisor it is so important to relay important information to other health staff, eg to ensure they give O2 for my pt when transferring, and keep on monitoring her vital signs. I also need to make sure I complete all my treatments there and then. In reflection communication is so important with all health personnel for best pt focussed outcomes. If anyone should have any other input in how they might have done things differently then I would like to hear. By the way the pt is now doing fine, currently on RA at rest and saturating above 90%.

The importance of a good subjective

Hello all,

I am currently doing my musculo OP placement and have had a situation this week that made me realise how important it is to get a good subjective and that things are not always as they seem. Ok so here's the situation: I had a patient who came into the clinic who's main concern was tightness around the posterior neck and shoulders. I thought great..this seems simply enough, check her range, do some postrual correction and then we are good to go. But little did I know all was not as it seemed. As i continued my subjective she stated that she never really gets a good night's sleep (maybe only 4 hours) and on these days she feels very lethargic and it seems that her symptoms are worse. However if she gets a good nights sleep then she feels "like she's 20 again" and full of energy. So i asked her why she wakes up at night and it's becuase she has to void her bladder, up to 10x per night!! And with even further questioning she also told me that she was incontinent on one occassion. I asked her how long this has been happening and she said years but she has never done anythign about it. She asked me why i was asking her all these questions so i explained to her the importance of the pelvic floor muscles, where they were, their function (i even brought in the model of the pelvis!!). After my little women's health tut i suggested she should see a women's health physio. I explained the role of the women's health physio and how they could help her with her problem. She seemed very happy and relieved at the suggestion. So what i thought would be a nice, simple case of poor posture turned out to be a whole lot more!! So moral of the story is...it is important to get a thorough subjective or you can be missing out on important information.

Equiptment reliance

Hi all,
Always an eager poster, I hope this makes it into the correct weeks post. Ok so I am on a cardio prac at a large inner city hospital. My pt. has been admitted to my ward shortly following a decrease in BP and increase in SOB. The pt. is a "frequent flyer" as they say and has a long Hx of COPD with secretions. I flowed thru the S and O and was going great on my walk with her. The O2 levels were acceptable (89%) and she had no serious complaints of SOB but half way down the hallway her I noted her HR was dropping quickly (44 BPM!!). I had not done a BP check in supine and then in standing and had only gone on the nursing obs...being stable. Anyway I had also thought it best to ditch my watch so as to not risk scratching her skin. I was silently in a panic as there was ten meters to the nearest chair, no clock on the wall and no way to know if it was a misreading from the, often troublesome, sats meter. Anyway we calmly motored along and she was none the worst for it- with a quick return in HR once seated, but it made me conscious of the limitations of equipment, the need to palpate the pulse and to get a good idea yourself of the pts. orthostatic intolerance and general response to positional changes and exercise. Next time I will address all these. Cheers, Matt

More than one way to skin a cat

I would like to describe one of the situations I encountered on my Neuro outpatient placement. The patient I was treating suffered from a right LACS stroke, and suffered from an abnormal increase in tone on his left side, which presented very similar to rigidity, however it was not velocity dependent, feeling much the same whether the arm was passively moved rapidly or slowly.

Much of the treatment on this patient focussed on dissociating his left scapula from the trunk. The use of SIMMS on lat dorsi was very effective in improving shoulder ROM. Hand stereognosia was enhanced to improve hand placement in functional reaching tasks. One thing that became apparent through treating this patient was keeping him focussed solely on the task of reaching.

If he yawned during the treatment, his left arm returned to its flexor synergy with significant strength. At one time he literally pulled his arm out of my hands. Another time one of the physios came rushing into the treatment gym and spoke loudly with one of the other patients, which surprised my patient, and resulted in this increased tone and the increased flexor synergy once again.

The increased tone in his left leg also led to an altered gait pattern. I attempted some facilitated walking with him, holding his left arm abducted from his body in an effort to decrease upper limb tone and to facilitate weight transfer. I did this after advice from my supervisor. Another physio in the gym made suggestions on my positioning, which I found difficult as I was probably 8 inches taller than the patient. I also tried facilitating from his unaffected side, which proved more effective.

I was trying to do the best for the patient and was receiving different information from two very experienced and excellent physios. It was frustrating as I didn't want to play one physio against the other, so I tried what they both suggested. In the end, all of their suggestions were equally effective, although one was more comfortable for me. What I want to get across is that there may be many ways to obtain the required outcome, and it is as much about the outcome of the treatment as it is about what is most comfortable for the physio performing the treatment. I also found out today that the patient has recently been discharged from physio, so it is encouraging to hear that he has progressed even further.

Accurate Documentation

During my last week in Neurology I treated a lady with a diagnosis of slowly worsening secondary progressive MS. Reason for admission was for a Baclofen trial pump to aid in reducing the spasticity in both her legs. She was initially scheduled for the trial pump approximately two years ago but decided to postpone it in order to try for another child. Since the birth of her last child her MS has significantly worsened. Of the many Objective assessments completed, the Modified Ashworth Scale (MAS) revealed severe spasticity of both LL (all major joints were a 5/5).

After speaking to the pt she was under the impression she was admitted into hospital to not only have a trial but with a view of implanting a permanent subcutaneous Baclofen pump. When told by the doctors that this was probably not going to be the case and she would need to come back in a few months she was very upset. Later on that day I treated her one hour after her initial Baclofen dose and was incredibly surprised to reveal that the MAS showed significant improvement in all major LL joints (0/5 spasticity, apart from her plantarflexors 3/5), this had a huge impact on her functional ability and effectiveness of our treatment session. My clinical supervisor was also a bit angry when hearing what the doctors planned on doing, primarly bc of poor communication and encouraged me to duly document these findings (Baclofen). The next day when assessing the pt prior to treatment the doctors arrived at the pts bed only to reveal they had changed their mind and would now insert a permanent pump due to significant improved functional mobility. The pt was very happy!

On reflection it made me realize to never be complacent with my notes, to be objective at all times and always document clinically important findings (eg Baclofen). This is not only for my benefit but other health personnel will be reading my notes and in fact important decisions are made regarding my notes. If any one else can relate or has any other input I would like to hear.

Simple and effective treatment.

On my last week on my cardio placement I went down to ICU to treat a pt. He was 78 yo who was admitted with a AAA which was surgically treated. His past medical history was that of Bronchiectasis,IHD,RA and occular melanoma. He had had a NSTEMI a few days previously in ICU. Objective Ax determined.Spo2 levels-86% on 12L NRBM,RR 20,BP was 126/60 and pulse was 98. He stated that he was normally productive but was especially productive at the moment and was bringing up alot of thick tenacious sputum M2P3. Cxr- revealed bibasal lower lobe atelectasis with a query of (L) ll pneumonia. He was afebrile at the time but was finding it hard to breathe and stated that he badly needed to get some phlegm up.ABG's revealed reduced O2 levels with slight increase in Pco2 levels.

For my treatment I administered a neb to reduce the viscosity of the secretions and assist further treatment. I then repositioned the pt as he was slumped in bed. I educated the pt on ACBT and put the pt in (R) sly and added percs and vibes during TEE's. I made sure that the pt was comfortable the whole time as he was after abdo Sx few days previously. He was very productive on this side. Obs were monitored throughout and at the end of the treatment the pt 's stas were 92% he was breathing at a steady rate and was more comfortable. He commented on how he "really needed that". So just goes to show, simple treatments can have a massive influence on the pt and the condition...

Patient with Post-Polio Syndrome (PPS)

It had been a rewarding 4 weeks of musculoskeletal outpatient placement – filled with different kinds of learning experiences and fun!

Saw a variety of cases. One particular case which I found quite challenging at first was a lady with history of post-polio syndrome. She presented with 4/12 history of persistent medial ankle pain and swelling. On objective examination, she had significant asymmetrical LL atrophy (L), and leg length discrepancy (L< R). It was challenging because besides treating her (L) ankle, I had to take into consideration:

1) a holistic approach – not just looking at the ankle as 1 entity,
2) type and dosage of strengthening exercises, without resulting in overuse and fatigue of the weakened muscle,
3) psychosocial issues (recall: neuro exam question in last yr’s neuro written paper? >.<)

As such, I decided to use this case as my in-service presentation as I had no idea how much strengthening is “too much” or “too little”. Initially I was prescribing exercise based on “not to the point of fatigue”, and observing closely that she did not do any trick movements after a certain no. of reps (= a sign of fatigue), and not prescribing too many exercises at 1 time.

From my readings, most studies involved training programmes consisting of isokinetic and isometric exercises. Endurance and/or aerobic training were also equally important in maintaining/ improving cardiovascular sufficiency. Below are a few key points I’ve learnt:

- Mild to moderate weakness can be improved with nonfatiguing exercises

- Specific exercise prescription is dependent on several factors such as current level of function, other presenting symptoms, client’s interest *Individualized therapy program!*

- Encourage short periods of activity, adequate rest between bouts of activity, rotate between different muscle groups

- Exercise every other day, and the perceived rate of exertion should be less than "very hard." Loads should be held for only 4-5 seconds, and there should be a 5-minute rest between sets. The patient should perform about 3 sets of 5-10 repetitions.

- Body alignment during exercise and functional activities, incorporate postural exercises and correction to address malalignments and unnecessary use of muscles and joints

- Do not exercise to point of fatigue or pain

Most PPS patients also have the philosophy of “not giving in”. Hence, when prescribed with orthotics, they seldom use the orthotics. Some of them believed that by using the orthotics, they’re accepting defeat. Not sure whether this was the case for my patient coz she had a pair of closed-in built up shoe to correct her leg length discrepancy. She had not been wearing it for 3-4 yrs because she felt peculiar wearing them and felt that they did not fit well. Initially, it took me a while to convince her to wear the shoes for gait re-education. I realized.. getting her to stand in front of the mirror, show her that the shoes were of correct height by showing that the hips are level.. helped in convincing her to wear the shoes. In addition, also explaining the rationale behind wearing the shoes helped: preventing malalignment, unnecessary use of muscles. Aim: maintain/improve strength => improve quality of life.

Hopefully, the above information is useful to anyone who, by any chance, has a patient with PPS =)

Safety first

Hello everyone,

This week concluded pretty well except for with one client on my neuro prac. I have found it very tricky to motivate and have safe treatment sessions with this individual who suffered a (L) MCA stroke and who has a 2 Gowland of the leg and foot...some year and a bit down the track.
He/she had a very big (and in my humble opinion completely unrealistic) goal of walking without assistance this past weekend for a special occasion. None the less the plan, according to my super, was to give it a go. So we had worked on it for the whole month exclusively.
Part of the reason he is unmotivated is due to the meds he/she which make him/her very drowsy. His/her partner is very caring and also does alot of transfers for him/her and thus with his/her impairments and his/her reduced need to self transfer he/she is unable to get out of bed without assistance (moderate...sometimes near max!!). The picture just didn't make sense or safe to focus strictly upon gait in the light of his other activity limitations. But I can understand that having a real tangible goal can give someone a great deal of determination.
The problem is/ was two fold. First, the supervisors incredible manual handling skills were so developed that he could manage to actually get this person to walk quite well..moving quick enough to tap into some auto pilot mode. But I just am no where near there as a neuro PT yet and I felt much more comfortable and SAFE in the // bars- doing a part practice type approach. Second, the pt. really had no interest in my unrewarding style of gait retraining and simply would delay effort for those types of exercise until the super would show up to perform his seemingly magical work. This pt would literally take 5 minutes to sit to stand when I was alone with him/her and when the super was there he/she would nearly pop up. Grrrr.
So anyway, to me, the deal is that we are nearly PTs in the real world and I just feel that I have to be honest with myself about my current skill set and if I make the call that someone is, say at risk of a fall or some other dreadful outcome because there is too many variables for me to control then that is the way it is. For this reason I wrote up my transfer summary to reflect this. After all these clients attend these clinics knowing it is a student run show. The last thing we need is someone to fall because we are working outside of our abilities. Hope that all makes sense. I am enjoying all your posts and best of luck in the next prac. Matt

Remember the patient not just the treatment

Hi everyone,
I am finding it a little tough to write a blog this week as nothing really stands out from my last wk of neuro placement. From a review perspective, I suppose I have walked away from this placement thinking that while we have patients that have serious injuries to their brain, many of them are still the same person that now just has the frustration of not being able to do or say want they want. One person who comes to mind is a patient I treated who suffered a pontine stroke resulting in locked in syndrome. This patient was in their late 20’s when this occurred and it just is impossible to imagine what she must go through not being able to move or speak, yet having full cognitive function. This patient is very lucky as she has an unbelievably supportive network of family and carers that ensure she is still able to do things like going to the movies but also have access to lots of treatment. Seeing patients like this not only makes you want to be there to help them as best you can but also reminds you how lucky you are to be healthy and able to put your shoes on or lift your arm or even speak when you want to.

So sorry for getting all sentimental but I think I have learnt to have an even greater understanding of some of what our patients may go through and the frustrations that they constantly deal with many days of the week.

Take Time To Explain

WARMEST greetings to all of you.

Time passes so quickly. Cardio placements are over(for me). I have really learnt a lot from my placement and don't think I'll ever stop learning. There's always something new to pick up, something new to explore and ask.

During this placement, I've got the opportunity to see many respiratory cases. And it seems that for every respiratory case seen, its almost always a different treatment and management to be done/taught tailored to the individual's needs/signs/symptoms.

Guess I'll just do a comparison of treatment/management for two cases with similar medical diagnosis ie. Asthma, Bronchiectasis. Both had previous hospital admissions for the same problem.

Both of them were 30 year old females and had been admitted for unresolved infection of the lungs and were both super productive and with sputum of similar properties(thick, greenish-yellow).

For Miss A, she was independent in clearing her airway but found the sputum production too much for her to cope due to the long running infection. She is educated by her physio to perform ACBT and postural drainage positions with percussion on the lower lobes which is effective but because of "laziness" she seldom does it.

So treatment/management for her was very much hands-off approach, just reviewed her ACBT technique(some mistakes there: her huff was wrong), corrected her huff and her postural drainage positions. Gave her an Acapella(something like a Flutter) which worked wonders for her as she could expectorate effectively with less effort. Also educated her on long term management of her problems - to exercise regularly such as jogging, hiking and swimming as well as regular application of her ACBT/Acapella to get rid of any secretions. All done in one session.

Miss B's management was quite different as even though she had an almost similar presentation with Miss A, she was not as well educated as Miss A so it was a more hands-on approach with her. She didn't know much of her condition too.

Had to do manual techniques on her in postural drainage positions(left side lying). Taught her the ACBT cycle(which she didn't really understand and kept going into coughing fits). And because she kept wanting to stay in bed, I had to ambulate long distances with her. Couldn't give her an Acapella cos she didn't really know how to use it(incorporate the use of an Acapella in a ACBT cycle). At the end of it all, I was just glad she managed to do an effective full ACBT cycle on her own after 3 sessions and she was quite thankful for that.

Anyway, this 2 case scenarios have made me realize how important patient education is as it was clear that Miss A was well taught by the previous physio who attended to her and could manage independently quickly while Miss B was not well educated properly and slowed down the process of her getting better.

So, I guess, no matter how long it takes you to explain/demo to a patient who maybe less educated than the other, always do it properly as it will in the time to come affect them and the next physiotherapist who may be seeing them again.

So this is why I became a physio...

Hi All,

Ok, so remember how one of my first blogs was about how I was getting frustrated during my neuro outpatient prac because I felt like I was not making a difference only seeing people for 3 hours a week? Well, low and behold, I had a break through with a patient this week that made me realise that we actually can make a difference in such a short time! Like me paint you a brief picture about the patient: 59 y.o male who suffered a (R) MCA (TACS) stroke in 2004 and who presents with Pusher Syndrome. At the beginning of our sessions he was not responding to anything that I was trying to do with him...he was so apprehensive and did not trust me at all. But once I started to be more firm and aggressive with him, he started to slowly respond to me. Now this is a man who has been walking with a walking stick for 4 years and will not go anywhere without it as he does not trust his (L) leg to do anything..he holds onto that stick (or anything within close reach) for dear life!! But this last wednesday I finally got him to walk without his stick or holding onto anything!! Mind you it took A LOT of convincing on my part but I was so proud of him...I even got a little misty eyed becuase I realsied that I can actually make a difference in these patients lives and that's the reason I became a physio. When the patients wife came to pick him up, we showed her the progress we made with him and she started to cry because she was so happy for him. Not only that but the patient himself was very pleased and he said "I have two good legs" which is a pretty big deal as before he only thought that his (R) leg could work. So after this exerience I've realsied that even though you may think that sometimes what you are doing seems so minisual it actually does make a difference...i have seen the light and will never make that mistake again!!

Impaired Airway Clearance

It again has been a pretty uneventful week in the cardio placement and I will dig deep for this blog so do bear with me guys on this one. I would like to discuss when Impaired Airway clearance is actually a problem with the surgical patient. I have seen a few patients with either a sternotomy for CABG or valve replacement or a thoracotomy for a lung resection or a laparotomy for numerous reasons. Now the criteria on Ax for impaired airway clearance is :
1. The presence of sputm either found out subjectively or on auscultation or a moist cough
2. The inability of the patient to clear the sputum independently which could be due to pain, weak cough, thick secretions, conscious state.

The ones that I question is even if a patient has thick sputum but they can cough it up they then do not have impaired airway clearance and also if a patient has sputum and a weak cough that is limited by pain the problem is not impaired airway clearance but pain. Control, the pain and they can clear it themselves. I would like to hear some thoughts from those cardio purists out there (Tam) and so do we really need to see these patients if they can clear secretions and impaired airway clearance is their main problem?

ok so Yes Im extremely late for last weeks blog. But to be honst I had absolutely nothing to write about until yesterday. Not meaning to rant on about the blogging but sometimes it is extremely pressurizing to have to come up with something to share with a group when nothing much has happened during the week. So therefore I left it go because I could not bear to have to make up a blog enrty so as just the tick a box. Anyhow rant over with...

I had my final assessment on my cardio placement during the week. It was 72 yo male who was admitted with an unstable AAA which could not be managed surgically as the risks of such a procedure were too great. He was in ICU for 2 weeks . His medical hx was complicated and his stay in ICU was very complicated with him going into multi organ failure and being on the brink of death. He pulled through and then was sent down to the vascular ward when he was more stable. On reading through his notes and in light of his very unstable aortic disecton I was extremely nervous about what I could/should do with him. Plus the idea of having a pt bleed out on your final placement is not ideal situation.My supervisor reassured me that this pt would eventually be d/c with this condition and would have to partake in all normal ADL'S and that this should guide my tx session. So I went in a little bit more reassured. I was half way through my subjective and the orderly came to take the pt for a Cxr. Damn I thought after all my prep for final Ax. Anyhow I went onto another pt and did my Ax.

That evening when I went back to treat him, he was in a disorientated state, he was in alot of pain even as he was resting in bed. His sats were very low and he complained of feeling very off. I let the medical and nursing staff know about this. Hw was a reviewed and wisked off the ward to HDA that evening. Anyway to cut a long story not so short I guess what I am trying to say is sometimes you just never know how things will go even with a sound theoretical knowledge. This man only transferred from bed to wc to go to xray and 2 hours later he was extremely unstable. So if I had treated him and mobilised him would it of made things worse??? Oh and another moral of the story..thanks for impecable timing from the orderlies.