Accepting Help

Currently I am experiencing and enjoying a RITH placement. Working with clients in their homes has presented numerous learning experiences and opportunities to enhance interpersonal communication skills.

As an (almost) physiotherapist we have gained a wealth of knowledge with respect to areas such as falls risks assessment and management, rehabilitation exercises, assistance/care packages available for home help and potential aids available to name just a few.

Having eagerly presented the opportunities available to clients I have at times been surprised by the level of resistance to accepting additional help in the home, making modifications that will ease access, removing rugs that present a falls risk as typical examples.

Two issues stand out to me:
Firstly it is important to recognise the reasons behind the decisions taken by the client - for example older people are often more resistant to any type of change, too proud to accept what can be perceived as charity, denial of the existence of a problem, a want to be fixed by someone else with no recognition of the need for self involvement in the recovery process.

And secondly it has become clearer to me that the way the physiotherapist (or indeed anyone) presents this information to the client has some bearing on the outcome. However, having determined the reasons behind the decision taken by the client this can then influences when and how you re-present the information.

For me this has involved trying to further develop wide reaching communication skills (I have seen some truly high level communication skills modelled by clinic supervisors in somewhat delicate situations)

-to ascertain why or what they do not like about the proposed change
-to attempt to make the client think that the idea was theirs. For example, having given a client a booklet to read about the risk floor mats present , asking the client if they can see anything in their home that may present a risk and letting them suggest the change.
- and finally and possibly most importantly RESPECTING the right of the client to make that decision even if you believe it to be the wrong decision.

Nursing Staff vs. Physio Student

I had a 70 year old lady presented with acute exacerb. of COPD & PMH of Parkinson, AMST score (mental test) 10/10 and with good continence. She transferred to gerontology ward to do some rehab before going back to low-level care hostel. It was in PM when I first saw Mrs P who was still on O2 therapy. Before I could introduce myself, Mrs P asked if I could walk her to the toilet as she had not been taken to the toilet since this AM after breakfast. I checked that her O2 sats was 96% on RA so I took off the O2; however, I still had the O2 bottle with me. As Mrs P needed one assistance with ambulation + wheel walker (from the handover from PT in previous ward), I managed to borrow the only wheel walker in the ward, which however was being used by Mrs P’s neighbour, Mrs C. I also asked a HSA staff for stand-by assistance & to carry the oxygen bottle. When Mrs P stood up, her neighbour, Mrs C asked if she could use the wheel walker as she needed to go to the toilet too. Given that Mrs C was mobile & independent with ambulation + aids, I felt that she could wait longer than Mrs P who had been holding her bladder for the whole day. Before I could tell Mrs C to wait, a registered nurse who was doing regular check up with other patients in the ward interfered & told me to let Mrs C to go to the toilet first & that Mrs P could wait. It was a command rather than a suggestion & being a PT student, I actually gave in. 10 minutes later when Mrs C came back, I stood Mrs P up again, Mrs P could not hold longer & ended up wetting her pants and the floor in front of me, the male HSA staff & other 3 pts who were in the room. She obviously felt humiliated & became really despondent. I reassured her & promised that it will never happen again, and that it was not her fault at all. I felt very sorry & I knew I could have done something. If I was a little bit more decisive & in charge of the situation, I could have prevented it from happening.

On other occasions, I had a blind & deaf 80 year old patient who was literally dragged out from his room by a nurse, not knowing what was happening, he was weeping & cursing when I saw him. I also had a nurse who refused to offer help to stand a patient who needed 2 assistance, saying “I am not going to lift her, I have back pain” in an obviously cold & unfriendly manner in front of the pt. I felt that nursing staff who displayed no empathy to patients greatly affected my treatment as patients were easily discouraged, lost motivation & therefore compliance. I consulted my supervisor & even though I was told to speak to the nursing coordinator regarding nursing staff’s negative behaviours, but I did not do so. Simply being a physio student, I did not want to cause more problems. Although these experiences have greatly reduced my confidence in liaising with nursing staff, I am still working hard to improve my communication skills with them at my current placement. I also learnt that I should be more confident & not let others to affect my treatment decision.

Multiple Facets

Earlier this year I completed my Neuro placement at a hospital that required that I see patients on a variety of different wards as the Hospital did not have a designated neuro ward. One of the areas I worked was a rehab ward for elderly patients, which incorporated functional and balance retraining, as well as inpatient rehab for elderly neuro patients/
On the rehab ward one of my patients was an elderly man who had suffered from a brainstem lesion 3 weeks prior to me seeing him. He had previously been fully independent living at home with his partner, but now as a result of his stroke he had significantly impaired function down one side and as a result his mobility and function was impaired considerably.

As I stated above, this patient was 3 weeks post CVA when I first saw him, and he had recovered to the point that he was able to get from lying in bed to standing with some assistance, and ambulate short distances using a pulpit frame. From talking to the patient he was very impressed with his recovery so far as it was the first time he had been able to stand since admitting to hospital, and as a result was very compliant to future physiotherapy.
However, as my time at the hospital came to an end (he was still an inpatient when my rotation at the facility had ceased) his enthusiasm for treatment began to wane despite what I and the other team members considered to be significant improvement (he had become Independent in most self care, bed mobility and ambulating with a WZF). He repeatedly complained of tiredness or feeling unwell during treatment sessions and chose to cease treatment early, and this was reported by other team members (OT, speech, nursing staff). When asked if anything was wrong, or if he was happy with the treatment he was receiving he always stated he was. However at the next family meeting, his partner reported that the patient had stated to her he was unhappy because he had not recovered enough to be able to eat a normal diet and instead was still on thickened fluids. This in turn was causing the patient to become distressed as he felt embarrassed that his diet was regulated and that for him, thickened fluids 'reminded him of how sick he was'.

Towards the end of my final week there the patient was cleared by Speech Pathology to start on a normal diet, and changes in the patients demeanor were noticed with the return of his enthusiasm. While he would still have a large amount of therapy ahead of him, his prospect for recovery would be a lot higher if he applied himself to all aspects of therapy, especially as he was only 8 weeks post CVA.
This patients changes in behavior showed to me the multi faceted nature of patients. This may be due to a lack of clinical experience on my part, but I would not have immediately made a connection between a patients recovery with Speech Path and their behavior while in Physio rehab. While it is easy to understand and assume that a patients mood will have a huge effect on their response to treatment, I needed to think a step further to see why there are these changes in behavior.
I thought this was a good lesson to be taught and at only a few weeks into 4th year I think the timing was perfect. While in theory I was aware of the many different factors in a patients rehab, to actually see this and how important it is on an actual patient has put me in good stead for my upcoming placements. As a result I now liaise more closely with other allied health members to determine what stage patients are at , so I can have somewhat of an understanding of factors that may be affecting patient behavior.

The uncooperative patient

I have just finished my neuro placement in the neurosurgery ward which is a locked ward with head injured pts. We were assigned 3 patients to see for 1 hour every day. One of my patients decided she didn’t need physio anymore and was very incompliant with physio. She would pretend she was asleep before I came around to get her each morning for physio and sometimes pretended to fall asleep during our treatment session. Initially I thought it was part of her condition but after liaising with the OT staff that performed a cognitive assessment on her I found out that she would deliberately do this to avoid things she didn’t like doing.

It was my job to get her to physio and give her 1 hr of treatment so I had to come up with ways to persuade her to come to physio. Initially I was frightened to try to make her do something she didn’t want to do, as she was unpredictable and had frontal lobe behaviours. I found out that she used to look after 40 horses at her riding school back home and that she was very keen to return to this lifestyle. In order to persuade her to come to physio I told her that she would need to do a lot of work with physio in order to be strong enough and have enough balance in order for her to be able to return to looking after that many horses. She responded to this well and came to physio.

During out physio treatment sessions she would get bored and distracted very quickly and would regularly walk off towards the door in the middle of an exercise or assessment. In order to overcome this problem I had to ensure she had a large variety of exercises to do in order to prevent her from getting bored and terminating her physio session prematurely.

I now feel much more confident in dealing with pts with frontal lobe behaviours and that I have developed my persuasion skills and that in the future when I am presented with an incompliant pt I will be able to apply the same principles to motivate them. In conclusion I have found it to be effective to use functional goals as motivation for non-compliant patients.

Developing Clinical Judgement

I am currently on a neuro inpatient placement where a majority of the patients are in varying stages of recovery post CVA. A patient I am currently treating is a 51 y.o woman who suffered a (L) parietal lobe haemorrhage 1 month ago. She now presents with expressive dysphasia and ® sided weakness UL>LL. Although her static and dynamic balance in sitting has progressively improved with daily physio sessions, over the past week it has been difficult to progress her functional mobility to include sit to stand and static standing balance. Her physical impairments contributing to these AL’s include (R) sided weakness, decreased activation of R hip and knee extensors and poor trunk stability, although over the past week it has been evident that her psychological and language impairments are the primary barrier to treatment progressions.

During the first treatment session for the week, I observed the senior physio’s perform balance exercises in sitting to improve her dynamic balance and passive Rom and stretches of her R UL. The patient was fairly compliant though became increasingly teary and frustrated throughout the session, especially when trying to communicate verbally. When the physio’s suggested sit to stand practice, she began to cry and refused to participate. The physio tried to comfort her at first, then chose to use quick prompts in an effort to encourage the patient to stand. Neither technique was effective and the patient was returned to her room. The following day, with supervision from the senior physio, myself and another student brought the patient to the gym, though she was not overly keen. Again she became frustrated through out the ex’s in sitting so we immediately progressed to sit to stand practice before her emotions limited her physical treatment. With a lot of prompting- both verbal and physical, we managed to get her into standing with 2 max assist. Once in standing she began to cry and curse, and when verbal comforting and prompting to take deep breaths failed, we sat her back down. She was emotionally stressed and crying, and on refusal to participate further, we took her back to her room. The following day she refused treatment, despite outlining the benefits of physio treatment and the other student and I abandoned further attempts to encourage her to consent.

As this was the fist time I have encountered an emotional patient with a language impairment, I was taken aback and confused as to how much persistence was appropriate. My initial reaction was to cease the treatment session immediately with concerns that if we pushed her too hard now, she would not want to participate in future physio, which is imperative to her rehabilitation.

Due to concern of future treatment of the patient, I liaised with the other health professionals treating her including the OT and speech therapist and both revealed that she behaves the same with them. So I enquired as to the strategies they employ to over come this challenge and they said persistence is appropriate if you give her time to recover through out the session and if you slowly talk her through the treatment with constant verbal encouragement.
In the future I will explain to the patient the importance her participation in physiotherapy sessions and the benefits of performing exercises such as sit to stand in her overall rehabilitation. If and when she does become emotional I will verbally encourage her and give her frequent breaks instead of ceasing the session other wise her functional mobility will not progress. I will hopefully develop my clinical judgement skills in determining the appropriate level of persistence as I don’t want to discourage the patient from participating in future physio. Any suggestions on approaches to treatment would be much appreciated.

Patient Cancellations

My last practicum was the musculoskeletal outpatients. I was on my 1st week of this prac and I had a new LBP patient cancel approximately 15 minutes before his appointment. About 5 minutes later, another new patient booked in for the same time slot. Being in my 1st week of prac, this made me a little anxious, even though the replacement patient’s condition was an Achilles tendinopathy (not too difficult), I still had little experience with assessing the ankle and this made me a little nervous. The patient also had to leave early because he was a lecturer and had a lecture he needed to get to. This left me with less time to do the full assessment.
Therefore the two main problems were, having to assess a joint I had not done before with short notice. And also, having less than usually allocated time to do this.

A question that may be raised, could be , if there are time restraints, are there elements of assessment which may be excluded to increase efficiency, or is the only option to cut down on treatment if there are time restraints?

There is value in this experience, since physiotherapists will have to at some point come across conditions which they are unfamiliar with (as simple as they may initially seem), which physiotherapists will also be faced with patients running late, or having to leave early and will have to accommodate due to time factors.

My new understanding or the situation is that, if a patient cannot stay for the full time, it is not the physiotherapist’s fault and so if reduced treatment time is required, this cannot be avoided. Also, even if you are unfamiliar with a condition, confidence, needs to be displayed, to give the patient confidence in the therapist’s ability.

Next time I will not waste time repeating assessments, when not necessary. I will act with more confidence and conviction with findings and treatment rationale. I will also do the necessary assessments, and explain to the patient that it is the treatment that will have to be reduced if time restraints are the issue.

neuro prac

I was on a neuro placement earlier on this year, and had to treat this patient 2x daily (once in am, once in pm), this patient also had a OT Reassessment in the morning from 10-11am. I was aware of this and had organised the day before with the nurse to have him ready earlier the next morning (eg to have shower done). The nurse that was looking after the patient the previous afternoon said it was alright and that she will pass the message onto the nurse on duty for the next morning.

So I turned up the next day and was expecting the patient to be getting ready but he was still in bed. I went to the nurse on duty that morning and the nurse appeared to be quite “stressed out”. I asked her nicely if she could get the patient showered to go for PT and I explained the situation – he had to go to OT and visitors will be coming later and if he went to PT now he won’t be showered until really late in the day. The nurse told me to come back later because she was too busy and there was no way she can shower the patient anytime soon. So I went to the OT that will be working with the patient that day and explained the situation. I told her I would like to get Physio done in the morning but the nurse hasn’t got him ready yet. By then, if i started physio it would be too rushed if I had to have it done by 10am for OT.

We negotiated so that OT started earlier, nurse showered him after OT and I went to get him for physio later in the morning, and still managing to get another session done later that day. So in the end, we were all able to get our work done. I think the situation ended pretty well and if this was to happen again, I will hope the nurse is more cooperative, and I will go and check with the nurse coordinator in the morning to double check/triple check if they can get the patient ready. I will also be more assertive and should have told the nurse we HAVE to do pt that morning and explain to the nurse that physio is better for this patient in the morning.

6 MWT

I am currently on my cardio placement. This week, I had the chance to perform a 6MWT on a patient for the first time. The patient was an 80 y/o male, who was admitted due to an exacerbation of his COPD.

I read up on the 6MWT and came well prepared. After discussion with my supervisor, I was ready to go! The patient was ambulating independently, and was breathing on room air. So, the equipment I needed was an oximeter, chairs stationed along the corridor, a stop watch, a pen and the 6MWT recording sheet.

As with any first time attempts, there is bound to be some hiccups along the way. Which was true in this case.

First, the usual corridor used for the 6MWT could not be utilized. The reason being, that the distance markers were removed, as the walls were painted in the morning. So, I was allowed to use the main corridor on the ward, which has a lot of traffic.

After going through the standard instructions, the test began. I did the usual measurements (heart rate, SpO2, dyspnoea), and the patient commenced walking. During the first few minutes, the patient became distracted by the surroundings/people. Once, he stopped a few meters prior to the end of the corridor, turned around and walked back. The patient then told me that he did not want to go to the end of the corridor as the consultant was there talking to another doctor. The patient felt that he might get me into trouble with the consultant, if we were to walk to where the consultant was standing. At that time, I was puzzled as to why the patient did that, as I was focused on performing the 6 MWT well. I then reminded the pt that he was doing a test, and needed to walk to the end of the corridor, which he did after some prompting.

In addition, the patient and I also had to dodge other patients, staff and family members walking along the corridor. Towards the end of the test, a bed was pushed down the corridor. As such, we had to move out of the way so the bed could pass. The patient took a seat on the chair nearby, while the bed passed by. Throughout the 6MWT, I felt that it was difficult to handle the extra traffic, while trying to cope with giving instructions to the patient at the appropriate times, reading off the oximeter, looking at the stop watch and writing notes.

Due to the above described incidents, it made the results of the test unreliable. The results did not show the true measure of the distance the patient could have covered.

On reflection, I realized that I should have done the 6MWT in a quiet corridor, as suggested in uni! Or could have done the 6MWT at a quieter time, eg: at the start of the day. Additionally, a clear explanation should be provided to the patient prior to commencing the test. Emphasize should be placed on the fact that the 6MWT is a test of the distance he could cover in 6 minutes (therefore, he has to try his best), and to stop only when a rest in required. I have definitely learnt a lot from this experience and will apply it onto the next 6MWT I perform either on this patient or other patients.

Gero's Placement

I have just completed the first week of my Geriatrics placement at SCGH (Day Hospital). The placement requires us to see elderly patients in an outpatient setting, with the goal of keeping them safe and as independent as possible. I (aswel as the other students) have found it very surprising how little you actually need to do for them to achieve that goal. Specifically, I was surprised at the minimal amount of repetitions that our supervisor wants us to prescribe for a strengthening program.

I was treating an elderly lady, who has had some recent falls, for her weak knee & hip extensors and hip abductors, and decreased walking endurance. Part of my treatment involved me assessing how many sit to stands and clams she was able to do before becoming fatigued. She could do 8 and 10 respectively, so based on this I was going to prescribe her glut strengthening program. At uni we were taught the classic exercise physiology principles (60%-80% 1RM, 8-10 x, 3x sets...). I am quite aware that these are subject to modification, obviously depending on your patients ability, physical condition, PMHx ect. For this lady I would have given her 8-10 reps to do 3 x throughout the day (due to her age and co-morbidity's, I did not want her to do the 3 sets consecutively, so as not to over fatigue her, and would instruct her that she did not have to do all of them if she felt too tired or unwell). However, my supervisor said I must give her only 5 reps to be done 1x daily.

I did as my supervisor said and I pondered how this could possibly have any physiological effect on her muscles, as she did not seem that severely deconditioned, and she was very cognitvely there, and eager. I eventually mentioned this to my supervisor and she explained that in the elderly population you must always start conservatively, so as to prevent them from 'over doing it'. She gave me the example that if I did give the theoretical prescription, I could flare up a patient's underlying back pain, or they may actually do more than prescribed due to poor memory, therefore its best to give them less. Also, this patient, like most of all the other patients, function at very low fitness levels, and a seemingly minor increase in physical activity for us, could be enough to fatigue a patient enough to stop them being able to complete their ADLs. The key is to start small and then you have somewhere to progress to, rather then over working them, causing possible pain or more fatigue, which will just prolong their rehab.

I feel this was probably a case of theory vs. experience, but I am still not 100% convinced so I look forward to the rest of my placement,to see how my patients progress. In any case, it has definitely made me more aware of how important it is to tailor your treatment to your patient, and that your text book will not tell you everything!