Pain

I have recently begun my Musculo Outpatient placement, and have received patients who present with a number of complaints. The majority of the new admissions appear to be post op follow ups, or referred from orthopaedic clinics, which has allowed me to see some variety in diagnosis and presentation. However, many of the current patients at the practice are chronic pain patients who have been presenting for an extended period of time. While I personally have not been assigned any of these chronic pain patients, I have assisted or observed the assessments of the supervisors. Some of these patients have presented with pain that has lasted for over 20 years, and in some cases the patient has had the pain longer then they haven't. The majority of patients appear to have acquired the pains through work related accidents or injuries, with some as a result of trauma. What I have noticed through the observation of the senior physiotherapists is that the treatment for the pain patients appears to involve very little intervention. For the most part advice and education on self management play a far more significant role then any sort of manipulation. I was informed that the reason for this is due to the psycho-social yellow flags that we observe for during an assessment. The supervisor informed me the applying an intervention such as mobilisations or manipulations for a chronic pain patient is much less effective then self management and education in terms of patient outcomes. Promoting self management decreases the chance of the patient becoming dependant on intervention to function, and also is more likely to allow the patient to remain independant. I have also learnt that with chronic pain patients their response to treatment is as dependant on their physical state as their psychological state. The supervisors have told me that the patients who manage their pain the best are the realists, who acknowledge they will always have pain regardless of treatment. It is the patients who expect a miracle cure who then cease treatment when they don't get the results they expected, which in turn directly impacts their quality of life. Even though I am only a week into my current placement, I feel that I have a greater appreciation of the impact of a clients outlook on their condition, as well as the psychological state, especially when dealing with an issue such as chronic pain.

Discussing Discharge

Over the past four weeks on rural placement I found it difficult to discuss the option of discharge with a few patients, as they where not willing to cease treatment despite being relatively asymptomatic. One patient in particular, a 68 year old male with right low back pain and right lower limb pain/weakness with the medical diagnosis of L3/4 facet joint degeneration and mild disk extrusion, received treatment for the discussed twice weekly, for four weeks. This time period was discussed at the commencement of treatment and agreed upon if he was relatively asymptomatic after this period.
At this rural placement, like a majority of rural facilities, there is quite a large waiting list so it is important that if the patients have progressed to discharge then they no longer receive weekly treatment. But over the period of the four weeks I came to know the patient quite well, and he would bring me wooden pens he made at his wood work shop and express his appreciation at having some one to talk to because he was quite lonely. His treatment included PAIVMS, trigger point therapy of glut’s and Q.L, heat pack application and HEP. After the four weeks his pain was significantly decreased to WNL and he no longer experienced the radiating leg pain.
On the conclusion of the final treatment, he refused to accept discharge and expressed interest in ongoing treatment. So I discussed with him his underlying pathology, and how we have progressed as far as I can help, which he said he understood, but he wanted to keep coming in because it gave him something to look forward to.
After much discussion, he agreed that discharge was necessary, though I did find it quite difficult to be forceful in this situation. My supervisor confirmed that my actions were correct, though I still feel a little bad having to discharge him on that note.If any one has experienced similar patients and can share how they dealt with their refusal for discharge I would appreciate it.

CVA on TIA

On my last placement I was treating a man coming in for a mild TIA which only affected his Right LL (weakness and sensory disturbances) and balance due to R LL weakness. I was treating him for around 4 days for his balance (high level) and some strengthening exercises for his R LL and also weight shifting exercises onto Right to increase WB on R and knee control in R. All was going well and he was ambulating independently around the ward on his WZF. One morning when I went in I couldn’t find the notes for this patient, apparently he was admitted for ED for having another stroke. The physiotherapist was comforting me and told me the patient may be alright – its just that the ward does not have a doctor present all the time, at least when he’s in ED a doctor can attend to him in case something happens. So 2 days after ED, the patient returned to the ward, I had to do his assessment again from the start because he has a new condition now (pt was diagnosed with bilateral cerebellar CVA). It was really interesting to see this - he had severe ballistic movements which frustrates him. It was quite sad to see this to happen especially when you already built rapport with the patient and they are progressing really well. The next few days, I was one of the 2 therapists treating this patient ( we had to have 2 full assist to help him from supine to SOEB otherwise his UL and LL will start to ‘fling’). From there rehab continues…the patient gets quite anxious and frustrated with his uncontrollable flinging movements and our job was to reassure him and get him to relax. From this experience, I believe I can handle emotions better in future if this is to happen again, we must understand the aetiology behind conditions (in this case – previous stroke is a cause for subsequent strokes) and since we can’t stop strokes from happening again, we must be professional and treat as necessary. We can also talk to our supervisors about the experience and I’m sure they will give us some ‘counselling’ of some sort if needed.

difficult patient

On my musculoskeletal placement, I had a patient who came in with knee pain. However, due to an intellectual disability, she was not able to specifically tell me about her pain or its history. All I got out from the subjective exam, was that there was pain all over the knee. When I asked a question to clarify, she always said “yes it hurts” or “yes that makes the knee hurt” etc. Basically, everything I suggested seemed to make her pain worse…

During the objective exam, everything I did made the pain worse and she did seem to like the idea that I was touching her knee. I was getting quite frustrated as I had no idea how I could help her, especially if the patient was not giving any hints!! Her carer started talking to the patient about what they would do after physio, that seemed to make the patient less interested about her knee. I was then able to do PAM’s on the knee, and palpate! Following the example of the carer, I started chatting to the patient about her interest and at the same time getting her to do some of the objective exam (AROM, fx tasks etc). She was more cooperative with physio and did not seem too caught up with her knee pain.

In future, if I do get a similar patient, I am able to handle the situation better. I will not focus the patient’s attention on their pain. Instead, I will use distraction while performing the objective exam. In these situations, an objective exam would give me more information than a subjective exam.

Ongoing education

Finishing my paediatric placement, I found that paediatric physiotherapy despite being given a focus over the years of study, does not receive the same amount of teaching time or content as the other streams of physiotherapy (Musculo, cardio etc). Whilst on my paediatric placement I found that the education I have received has made me competent, but it is still extremely limited in the face of actual patient loads. There were conditions that I saw that admittedly are quite rare, yet I had not even heard them mentioned in the context of physiotherapy, and as a result I have spent time looking into the conditions and appropriate treatment or management techniques. It was not expected of me to be aware of these conditions, and the placement provided me with the resources that they had available in order to gain a better understanding. However the facility I was attending had fantastic resources which benefitted me greatly. I was lucky enough to be on placement while a general meeting for all of the departments physiotherapist's was being held, and as a result I attended. The meeting involved information about continuing ed being held independently, as well as some workshops such as basic Makaton (a sign language). In addition to this, equipment was discussed as well as treatment techniques such as serial casting and dynamic taping. This proved to be a great opportunity for me, as I could practice the techniques and also receive input from the physiotherapists who had applied these techniques in the past. Some of the physiotherapists were new grads on their first year out, and their opinions reinforced mine. They both had felt competent when leaving uni, but due to the education provided at the facility they believed they were much more effective in treating patients, and a lot more comfortable with their knowledge base.
While all of the placements I have been on have provided some sort of education program, I believe that my Paediatric and ICU placement have provided the most input. Admittedly I felt less confident before both of these placements, which may have been a factor in my appreciation of the education. These placements both helped me to appreciate the importance of utilising the facilities at any new work environment, and also to keep an active interest in professional development and education. Given that some of the staff I have met have worked in the same Field since graduation, the content they were taught at uni would be vastly different to what is current literature now.

Dementia 3

Two other clients have also increased my knowledge and understanding of working with clients with dementia. The clients I have referred to in previous blogs were both unaware of where they were. However two clients did know they were in hospital and both were desperate to get out.
The first client had a superior pubic rami fracture but was mobilising with WZF. She had declined physio on a number of occasions but as I walked past her room she called out to me and implored me to help her out of bed. As I wanted her to walk I agreed and assisted her out of bed and she indicated that she wanted to go for a walk. As her gait became more unsteady I asked her to turn around and head back to her room but all she wanted to do was find the exit. I told her we had to go back the other way and when we got to her room she was very upset with me and not easily pacified even with the information that the plan was for her to go home the following day. I found out after that she had previously absconded off the ward and got lost on a locked ward!!
The second client also repeatedly refused physio until I advised her that the doctors had asked me to assess her and would not allow her to go home until that had been done. She then did everything I asked but I felt like I had forced her into consenting and she was merely going through the motions.
When working with patients with dementia I think you need to be quite direct. I have found that asking them to do something usually resulted in them saying no; but telling them that this is what they were going to do usually resulted in compliance - as if they needed instructions to be given to initiate anything.
I think it is also necessary for the physio to be mindful and aware of the fluctuating moods and functional abilities of these clients and be very flexible in their approach and treatments.
I feel more confident of dealing with patients with dementia following these experiences.

Dementia 2

Continuing my learning experiences with patients with dementia.
The physio and I were asked to assess the mobility of a 78 year old lady described as "pleasantly confused".
She was resting in bed and we assessed her ability to move in the bed, go from supine to SOEOB, STS - all achieved independently with supervision including verbal prompts and reminders. Ambulation was with a WZF + 1 min assist with frame + verbal prompts - to take a larger step with her left foot (previous CVA). The physio recorded all this in the notes and included a comment - mobility may fluctuate secondary to dementia.
The next day the physio asked me to take this patient for a walk. On this day the patient needed 2 mod assist to stand from chair, 1 max assist in standing, 2 mod assist with ambulation with WZF + verbal prompts every three to four steps as the patient would just stop and needed to be told to take a step and we just had to wait ( the physio described this as being just like a Parkinson's patient).
This experience enable me to understand very quickly the physio's comment about fluctuating mobility. I will now be aware of this possibility with future clients I assess , particularly when noting mobility recommendations for nursing and other staff.

Dementia 1

Prior to my current placement I have had very little to do with patients with dementia. It has been quite an eventful learning experience.
Obtaining consent can present a challenge with these patients.
After introducing myself and my role as a physio I asked the patient if she would be happy to come for a walk with me. To which she replied - Thank you so much but I can't as I'm going out for tea. Still trying to coax her into walking and with the sun pouring in through the window she responded with "don't be ridiculous, I'm not going for a walk at this time of the night". Then she asked me "what are you going to do?" to which I replied "I'm going to go for a walk with you". The patient stood up and said "thank you , how lovely of you" and proceeded to walk with me.
Can/should I assume implied consent because she chose to walk after I told her too?
I think it would be very easy (due to time pressure/frustration/ lack of patience/ having a bad day) just to walk away and record patient declined to walk but considerable care/attention needs to be taken to make sure that a client with dementia does not miss out on necessary treatment because of issues of consent.

Suprising Age

This week, at my gerontology placement, I conducted a initial assessment of a patient who had been diagnosed with parkinsons disease earlier in the year. She was about 10 years younger than the youngest person I had treated with parkinsons up to this point. I had read in her notes that she was in her 60's, however when I met her, she presented as being still rather youthful. The reason why this was a little more challenging for me was that up to now, my patients with parkinson's disease all had the disease for at least 5 years, and were also considerably older. Therefore with this patient, I was unsure as to how she was feeling about having the disease at a stage in her life, when she was still very active, going for long walks, going to the gym, and very keen on watching sports etc.

Many of the tests we do for initial assessment and annual review, appear to be designed for patients, who are further down the track with the disease, and are struggling with functiona and transfers. So I did feel like the tests might be a little patronising for her. However, she suprised me by being enthusiastic about the assessments, even though she excelled at them, and even remarked on enjoying doing the 6 MWT, as she loves going for walks.

The lesson I learnt from this, was that even though patients seem youthful, and maybe early on in their disease process, they would still like to be thoroughly looked after, as they would not like to have anything go under the radar and not be picked up, with later consequences. It is still important to be tactful however.

Infection Control

Currently on my rural placement, I have been fortunate to experience a situation in which infection control was enforced. On the Monday, a patient presented with constant diahoriah through out the day, and the next day half the ward had loose stools and occasional vomiting. By Wednesday 14 out of the 26 beds on the ward where determined to be positive noro virus.
Through out the week I witness a very efficient display of infection control by the nursing staff and infection control team, with patients being isolated and rooms rearranged to decrease the opportunity of transmission. All staff had a meeting to educate them on appropriate infection control precautions to exercise while on ward including gown, gloves, mask and hand wash between all patients.
As a staff member who had been on ward and exposed to positive patients, I was unable to work on surgical ward to prevent transmission. Although the infection precautions were quite intense, I was very impressed with how the whole situation was handled. By the next week the ward was clear and back to normal, and none of the staff caught the virus.
This experience taught me how important it is to follow precautions and it was a credit to the nursing staff how controlled this episode was. As I have never experienced a similar event, I am now aware of hospital protocols with regards to infectious disease.
If anyone would like to comment on similar previous experiences that was not handled as well that would be appreciated.

Involving patient and family

On my gerontology placement, one of my patients was a 88 y/o male who was referred for falls. He is relatively dependent on his wife for assistance with ADLs. Therefore, usually attends the appointments with his wife. During the treatment sessions, I have noticed that he usually takes ownership of the treatments when his wife is not around. He responds to the exercises when I explain it to him, he also asks questions and seem more responsive. However, when his wife is with him, he seemed to switch off, leaving the wife to learn from the session/clarify things. One instance was when he attended physio, and reported that he had a fall a few days ago. He was rushing to the toilet and had forgotten to take his WZF, so he slipped while turning the corner. His wife had difficulty assisting the patient to get off the floor. The patient also reported difficulty getting off the floor. So, my treatment session for that day, was to teach them how to get the patient up from the floor in case of another fall. Before I did that education, I was giving the patient new exercises for his HEP. During that, his wife was not in the room. The patient was responding well to instructions and seemed genuinely interested. But during the education, I needed to speak to both the patient and his wife. In that time, the patient was just staring into space and did not participate in the session. (I was just demonstrating the procedure with my supervisor, so the patient did not have to get onto the floor).

In future treatment session, I will direct my questions/education to the patient, so that he feels that he is able to take ownership of his treatments. I also felt that the “get off the floor” education was brought across in such a way that it was mainly the wife’s responsibility. In future, I will tailor it in a way that both the wife/partner and the patient play a part in the patient’s treatment/education. Another thing I can do in future sessions, is to ask the wife to wait in the waiting room during sessions. But, involve the wife, if the patient requires a HEP, or education.

Monitoring Symptoms

On my current musculoskeletal outpatient placement, I have been treating a 43 y.o. male patient post right shoulder arthroscopy 3/12 who was previously treated well for his right shoulder ROM and strength which are close to normal now. However no improvements were shown over his last few treatment sessions with me as he reports increased weakness in his right upper limb and worsening symptoms of P&Ns and numbness in his right 5th digit & ulnar border of his forearm. On neurological examinations, he was found to have weak right hand intrinsic muscles, reduced sensation on right upper limb and mild hyporeflexia in his triceps, brachioradialis & pronatus quadratus tendons. NTPT via ulnar nerve was negative and other tests for all possible diagnoses including thoracic outlet syndrome were performed, and no significant findings were detected. I have seen this patient 3 times over the last few weeks and I felt that I have not been helping this patient to improve at all as he continued to complain of worsening of his symptoms each time he came in. After consulting my supervisor, my supervisor re-performed all the tests and results were same. The patient’s symptoms were flared up after double assessments done by me and my supervisor in the last session. After discussing with my supervisor, I was told to only do soft tissue massage on his tender shoulder area to help release pain. In terms of medical referral, my supervisor explained that his symptoms and the results from the neurological exams were not serious enough to get a medical referral. There is not much that we can do in terms of treatment but it is very important to keep monitoring his symptoms and therefore the best management for this patient is to educate him to monitor his symptoms at home and to keep track of his symptoms by re-performing the neurological examinations every time he comes in.

Patient Education

Through out this year, across a majority of the clinical settings, in particular the musculoskeletal environment, I have come across numerous patients frustrated with the lack of explanation they have received from their doctor/source of referral as to their condition. The most recent patient to express their frustration is a 34 year old woman that has been referred for outpatient physiotherapy treatment post excision of the (L) radial head.
This patient was diagnosed with RA two years ago, affecting only her right wrist (which is to be fused when she recovers from this surgery in 6 months) and her left elbow. She reported that the only education received from the surgeon was pre-op, regarding the actual procedure and only briefly addressed the reasons for the op. She received very limited education concerning functional outcome post surgery and the likely prognosis of the surgery. She has presented to the physiotherapy outpatient department, now two weeks on, quite devastated as to her lack of strength and functional use of her L elbow and wrist. She has only just stopped wearing the sling recommended by the surgeon, but with not explanation as to how long it is necessary to wear.
The initial assessment findings included no active ROM of elbow flexors, severely restricted pronation > supination and wrist extension. Finger mobility is also limited due to strength and it feels chronically swollen. Following the physical examination, she simply asked- why can I not lift my L hand to my mouth, brush my hair or write with my left, because I am usually left hand dominated and it is quite hard to cope at the moment. This was the final piece of information I needed to realise this patient has been mistreated in the hospital system, in particular by the medical team. How can she have a piece of bone removed from her dominate hand without any explanation as to the repercussions?
So the initial treatment session was based very heavily on education regarding the operation, why she is experiencing these symptoms and the likely outcome/functional recovery of her L upper limb. I then provided a HEP addressing not only her elbow, but preventative exercises for upper limb mobility following two weeks in a sling and hand exercises. At the conclusion of this session she was quite emotional and expressed her gratitude for the time spent explaining this whole situation. As she is a mother with three children, it made a huge impact on her goal setting and future preparations. From this experience, and the many other similar ones throughout this year, I am beginning to question the patient care pre- and post op within the hospital system. If anyone has an opinion as to who is responsible for this almost negligent case, it would be appreciated.

Disruptions to the prac

Last week our facility supervisor resigned due to wanting to change jobs, and so we were transferred over to another physiotherapist to be our supervisor. At some stage, everyone in the office, was off sick for days at a time, and so the 1st 2 weeks of this prac were very disrupted. This meant being organised and getting bac into the swing of things was made a little more difficult. During my mid -placement assessment, my facility supervisor, who was about to resign, stated that it would help for me to be more organised with notes, to have a clearer picture of my patients in my head.

I found being organised at this stage pretty challenging, as I had just come off 2 days of being very sick, and was still a little confused with the filing system. Having all elderly patients, with similar problems, and similar physical appearance, made it harder to be clear in my head my different patients.

I feel, as mentioned in an earlier post, that taking more responsibility to learn the filing system would have helped to be more organised.
Distinguishing similar patients, may be achieved by rememebering more unusual characteristics about them , that separate them from others.
I would be open to any other's ideas as to how to recall geriatric patients who have very similar presentations.

Client cancellations

On my most recent placement I was situated at a Government paediatric service and was part of a multi disciplinary allied health team that provided services to both the clients and their families. The client load were all from the same catchment area, but barring that each was quite unique in regards to the reason for referral, family structure, support and. On numerous occasions during the four weeks, clients were unable to make the scheduled appointment and had to reschedule, to the point that the week I had planned for never ended up being like the week I experienced. The cancellations could appear out of the blue, and in some cases we were only aware of the cancellation after driving to the clients residence or school, only to be told they were unable. This could then cause problems with the family when booking new appointments, as the wait list was over 3 weeks, and some of the newer admissions grew extremely frustrated at this. While these cancellations proved an inconvenience to all parties involved, it did help me to further appreciate the complex nature of managing a paediatric patient, as well as some of the difficulties that the families and clients face. The cancellations were often related to illness, whether it be an acquired illness, a flare up of a chronic condition, or in some cases hospitalisation. I asked my supervisor if this was common, and was told that it was over the winter months, due to exposure to colds and illnesses from other children at school. My supervisor reported that at times there are whole weeks of cancellations. This in turn becomes a problem, as due to the number of clients it can take over a month to book another appointment. Due to the facility I was placed at being multi disciplinary in nature, any sort of incident that causes a client to miss appointments will in turn affect their progress in all therapy areas, and this can lead to further complications on top of their original diagnosis.
Once I began to appreciate the incredible difficulties faced by some families, in which the client's family had to juggle appointments at numerous facilities, as well as any other commitments made by other family members, I gained an appreciation for the why there was occasional conflict at rescheduling appointments.
While I could in no way relate to the stress that some if not all of the families were under, I did gain an appreciation for what had caused the stress, and realised that all of the staff at the facility were excellent at this. Admittedly they had much greater experience then I, but they were exceptional at communicating with the families and placing the clients' needs as a top priority. Every effort was made to help the families reschedule at the best time, but in some cases the client unfortunately still faced a long wait period.

No PT Rx indicated

This week, a 88y/o patient was referred to the clinic due to hip pain and a history of falls. Her initial referral was for her to attend the hydro sessions. She attended the clinic for an initial session, which included the subjective and parts of the objective Ax. I then booked her in for a hydrotherapy session the following week.
The next day, I found out that my patient’s xray of her hip showed an avulsion and severe degenerative OA. After much discussion with my supervisor, we decided to call the patient and ask if the patient’s pain was worse that am.
I called the patient and it turned out that the patient’s pain was indeed worse. I then had to tell her that at that point, hydrotherapy was not suitable for her. The reason being, that the disadvantages of getting her to the hydro pool outweighed the benefits of the hydro session. The patient used hospital transport to attend appointments at the hospital, she then needed use a step to get off the bus, then walk about 10-15m to the pool. After the session, she needed to repeat that process.
To prevent worsening of her hip pain, we did not advise her to attend the hydro session. Instead, she was to stick with her daily routine at home for now, and have plenty of rest.
The patient is currently being referred to an orthopaedic surgeon for a further review.
From this, I learnt that sometimes no physiotherapy treatment is actually the best PT treatment you could give a patient. It took a while for me to understand that, as I always try to help my patient as best as I can (more exercise, different ways of doing rehab, different types of pain relief that we learnt, etc). But for this patient, the best treatment was no physiotherapy for now.

HEP & Education

On my current musculoskeletal prac, time management has been the main issue as I often spend extra 10-20 mins on each treatment to make sure the patients are happy, especially private patients who need to pay for their treatments. I recently had feedback from my supervisor regarding this issue and he made some good points that I like to share with you guys here. Firstly, the patients should know that they will be treated by students in the first place plus they are paying a lot less than seeing a qualified physio, I therefore should not feel guilty as students often provide more thorough assessments on patients. Secondly, a good treatment is not about quantity but quality, I should not underestimate the quality of the treatment that I am giving to my patients, especially not underestimating the value of home exercise program and education. For example when seeing a new patient, I should focus on one intervention to treat the main problem (e.g. either soft tissue massage or PPIVMS or PAIVMS etc), and then focus on HEP and education (e.g. postural re-education), rather than providing 3 interventions to treat all the problems. After discussing with my supervisor, I became more confident when treating my next new private patient who suffered an acute shoulder pain. I spent 8 mins on ultrasound, 7 mins on her HEP (active-assisted shoulder ex etc), and 5 mins on educating her about the mechanism of injury, use of ice, importance of exercise etc. The patient was actually very pleased with the outcome of the treatment eventhough I did not do much manual therapy.