Depressed geriatric pt

This blog concerns a patient I saw whilst on my gerontology placement. I was set to see her with my Curtin supervisor and demonstrate a thorough geriatric assessment. Upon reading the patient notes, I found that this lady had become a widow earlier that year and since then had become less mobile and less motivated and had increased her alcohol consumption significantly. The medical staff had noted that she was suffering from depression and this was very evident in speaking to her. When I entered the room, the patient obviously didn't want to see anyone (commenting "and what are you going to make me do?") and in my initial questioning I was able to gather that she was in quite low spirits. I spent most of the first session talking to her as I felt it was important to develop a good rapport with the patient if I were to get her to do anything and the only intervention we did was a short walk before she needed to sit down due to dizziness and fatigue.

My Supervisor commented afterward that it would have been more effective to do little questioning and get the patient up and going for a more effective session. I felt, however, that had I done this the patient may have found me pushy and, in my opinion, it would have been less likely that i would have gained cooperation in future treatment sessions.

In future sessions, I found myself getting the patient to do a little bit more every day and her making great progress, as well as developing a great rapport. In contrast, most of the other staff found her difficult. 

I learnt from this situation that sometimes it can be effective to allow the patient a little more time to tell you their background and not be too pushy in order to have a good treatment outcome. Having said this, I will keep in mind that not all patients have the luxury of a longer stay in the hospital and sometimes you will need to get them up and going straight away. some patients may also use your not so "pushy" nature to their advantage...a few things to think about I guess.

This blog concerns my cardio placement which was undertaken in ICU. A fellow student and I were to assess a patient who had been in the ward for at least 10 days. We read his History etc and went into his room. He was in his late 20’s and had been the victim of a punch which knocked him out. He was ‘coming around’ every so often lately so we were asked if we could perform a subjective and objective assessment on him.
On entering his room we were met by some members of his family. After introductions and reasons for being here were explained to all they willingly left so we could perform our duties. A nurse was in the room and she was performing her duties but we were ok to commence.
We started our subjective assessment. I was the first to ask him questions. And I was met with silence and a blank stare. After a few more tries I suggested to the other student (who was a female and the patient was a male) that she try the subjective questions. She got a slightly better response so we went with her asking the questions. He wasn’t very willing to engage with us overall. We persisted as best as we could and after 20 minutes the nurse was informed that we were finished. She went out into the waiting room and got the patient’s family to bring them back in. Just before we were going to leave his room he appeared more responsive and happy. I put this down to his family being back there with him. Just before we left he held his hand up to me as if to say thank you. I acknowledged this and told him we would be back to see him again at another time.
This perhaps indicated to me that sometimes it may pay to have someone who the patient is comfortable with in the room. This may help them engage or if required a family member can ask the questions on your behalf. I guess asking the nursing staff prior to seeing a patient like this can give you an indication of what kind of communication strategy you should use and more importantly if anyone should be in attendance to make it easier for all concerned!

Sorry, this isn't working out!

Whilst on my country prac I was treating a patient in the outpatient department who was suffering from a sprained ankle. She had sustained this injury a year ago and she was convinced that she had fractured the medial aspect of it. The x-rays indicated no fracture! She also had a referral for a lower back complaint. Over the coming weeks she would improve at one stage and then come back in 3 days later and report 9/10 pain. Yes I went through the pain scale with her, explained it etc. She didn’t look like she was experiencing 9/10 pain. Anyway amongst her other medical history it was written that she suffered from fibromyalgia. Could this explain her high levels of pain?
The senior physio was a gun and knew her stuff. She came in to the last few appointments I had with this patient because it was getting confusing and not following the script I would have thought it should. The senior suggested one day we look at the patient’s lower back. The assessment I carried out and treatment was performed accordingly. The senior and I would see her in 2 days time. She came back worse off. I had no idea what to do with this lady and the senior was ‘stumped ‘ also. We gave her 2 more appointments before the senior decided to refer this patient on. She explained to the patient that maybe she needed to go back to her GP as PT intervention was not helping her condition. It was actually quite a ‘release’ to hear someone say that especially the senior because I regarded her as a very good physio, she had at least 10 years in the profession and she had taught me quite a lot during my time there. The patient agreed with this course of action.
This act taught me a lot. If PT intervention is not helping a patient then there is no point wasting anyone’s time and more importantly delaying some further investigations which may need to take place.

Don't believe the truth!

This blog concerns my gerontology placement. A patient had come in one afternoon (suffering from a UTI) and I was to see her with my Curtin Clinical Tutor. The patient was from a high level care nursing home. According to the notes the patient ambulated with a WZF. Fine! When the tutor and I went into her room she had nurses working with her and we probably wouldn’t be able to see her today. Ok, I could do my mobility assessment tomorrow I thought, no dramas.
My tutor suggested I ring the nursing home just to clarify some of the information from the admission notes regarding the patient’s current ambulatory status. I obliged but thought why was I doing this. I put it down to the fact she just wanted to hear me communicate to another health care professional over the phone.
I called the nursing home and spoke to a physio there. She explained to me that this patient does not ambulate at all! She gets around in a wheelchair. I told her about the admission form we had. What had happened it was explained to me was this lady in her confusion had got up from her wheel chair in the dining room grabbed someone’s WZF and proceeded to walk with it. Interesting I thought.
I got off the phone and relayed this to my tutor and a nurse who was aware of us following this up. I guess I was the most surprised that that could happen. A valuable lesson was learnt and I know if I ever have any doubts about some information I read regarding a patient I will follow it up. Or if it concerns our job such as mobility status then it doesn’t hurt to clarify a few things!

Scary Injuries

I encountered a very scary injury while I was working as a sports trainer this year, and wanted to share it. I worked with a rugby team this year and the worst injury that could happen on a rugby field nearly did. During an U20's game the scrum collapsed and the hooker injured his neck, a very scary suspected spinal cord injury.

I immediately placed a neck brace on him, log rolled him onto a stretcher and took him off the field. During class, studying spinal cord injuries you always imagine what you would do, but when its in front of you its very different. While on the side of the field I subjectively checked if the patient had any pins and needles, change in sensation, headache or muscle strength changes. Objectively i checked his sensation and when that was all normal I gently and isometrically tested his muscle strength. The results from all the tests above were within normal limits, but he was complaining of a painful neck. I then allowed him to sit up with the neck brace on and continued to monitor him for the next 30min. After this time he had no further symptoms, besides the neck pain. At this stage I removed the neck brace and treated his neck cautiously, but as a musculoskeletal injury.

I was quite freaked out after this incident. So when I was on my musculoskeletal clinic I discussed my treatment of the injury with my supervisor. Our ideas of how we would manage this condition were very similar. The most important thing i learnt from this case was to always communicate with your patient. Let them know what is going on at all times, and let the patient know that they have to keep you informed if they begin to develop any neurological symptoms. I hope none of you have to ever be in this situation, but if you ever are I hope this helps you.

Patient Exposure

While on my neuro placement I treated an Abouriginal patient from a rural community near Broome. I learnt a lot about communication and cultural differences from this patient. I learnt from my own mistakes and from the mistakes of others.

While on the ward he was considered a falls risk and had a permanent male nurses aid in his room. This nurses aid in particular was very forceful man, and often said quite derogatory comments towards my patient. At one stage I was assisting the patient to transfer from his bed and into the wheelchair to go to the physio gym. This nurses aid seemed to take over from me and demand that the patient move. He was very reluctant to move!

I noticed a few moments later that the patient kept on adjusting his pants, he was scared that he might be exposed in front of me. It was at this point that I tactfully told the nurses assistant that his assistance was not neccessary and for him to stop. Just by allowing the patient to regain his composure and give him back his dignity made the rest of the treatment session flow well.

This incident made me quite angry, I couldn't believe that someone could be so disrespectful to another person. I learnt so much from this incident, that when a patient feels volnerable they wont want to partake in any form of therapy and knowing when to intervene in a professional manner to prevent this happening in the future.

Postnatal Depression -Scary reality

On my rural placement I treated a patient with a very confusing musculoskeletal issue. She was referred to the local hospital for abdominal, ?C-section pain. When she arrived, her abdominal pain was not her most serious complaint. When filling in her body diagram, it seemed to nearly be completed coloured in. She complained of headaches, neck pain, lower back pain, thigh pain, knee pain and pain on the soles of her feet when walking.

Not only did she have a complicated pain picture, but her social history raised a few yellow flags too. She lives with her husband and 2 children, one 2 years old and the 3 months. She recently moved to the area and has no family support. She brought her baby in with her, the baby was constantly crying and this seemed to make the patient very distressed.

To be able to perform the objective assessment, my supervisor took the baby out of the room. This seemed to slightly calm the mother, but when the baby returned she needed to be fed. Unfortunately the baby was unable to be settled and the mother decided to leave very quickly without making a follow up appointment. Everything seemed to happen very quickly, I felt out of control in the situation.

My supervisor and I immediately discussed this case. We felt that because she had not made a follow up appointment at the time that we needed to refer her back to her GP immediately. From her presentation we both felt that she could be suffering from postnatal depression and required further help.

Unfortunately I was unable to see this patient again during my placement. If I was able to see her again, I would have liked to book a double appointment and given us more time to spend on each issue and not feel rushed. If she was able to get a babysitter for her daughter during the session that would be great, but in the circumstances I don't think this would have been feasible. In a case like this I feel that building a good rapport with your patient and gaining their trust would be the most important factor in treating their musculoskeletal problems. I wish I had been able to see this patient again, but despite that I feel that I have learnt a lot from this case.

Inspirational patients

It seems to be so easy to blog about patients that we clashed with, had difficult presentations or interesting backgrounds. I wanted to tell everyone about an inspirational patient that just makes our jobs a lot easier.

While on my rural prac at a private practice I saw a man who was referred to the practice for cardiac rehab following a heart attack. He was in his early 50's and a very active man, who swam and surfed most days of the week. He was a smoker with very high cholesterol levels and family history of heart attacks. His heart attack was a very mild one, but was enough to give my patient a fright.

We often see patients with similar conditions, but who don't change their ways. I feel that in many of my placements I have been begging patients to change, with no results. This patient had given up smoking immediately, started on a low cholesterol diet and was determined to get back to surfing. He was one of the patients you have to hold back so that they don't over do it.

It was hard to hold this patient back, because to him and myself he seemed very healthy. I discussed this with my supervisor and we came to the conclusion that thoroughly educating this patient on his condition and rehabilitation was going to be the best way to treat him.

This was a very good approach, by thoroughly educating the patient we gained his trust. This made it a lot easier to prescribe his rehab and for him to be compliant. This was a very good experience, to deal with a highly motivated patient.

Over affectionate patients

While on my paediatric placement I treated a patient from Malaysia. She had quite severe developmental delay and a mental disability. She was visiting Perth for a week long intensive physiotherapy treatment.

After every session her mom would insist that she gave me a kiss and a hug to say thank you. This is a perfectly appropriate practice between friends, but in a proffesional manner I wasn't quite sure. I did not want to hurt my patients feelings by not doing it, but at the same time I began to feel uncomfortable.

I was only treating this patient for a very short time, so I decided to put my feelings aside and give her a hug after every session. In the long run I feel that this was the right decision to make. It created a good bond between myself and the patient and allowed her to trust me. Every situation is different, and in the future I might not allow this again, but in this situation it was the right thing to do.

How much do patients understand.

On my neeuro placemetn I treated many patients suffering from acute, seroius strokes. One patient in particular was 6 weeks post a severe right MCA infarction. At the time of my placement, he had no head control, left sided inattention and was able to comunicate with basic yes/no answers but would often respond inapproprately. Due to his injuries and circumstances he presented very child-like.

While treating this patient I started to think. How much do these patients understand of what were saying to them, will they remember later on in their rehab what we said?? While treating him I found myself babying him. Talking to him and encouraging him as if he was a child. I felt really bad about this, and discussed with my supervisor how you can encourage with out babying.

I came to the conclusion that I have to, no matter what, talk to and treat the patient with regards to their age. I need to then encorporate the encouragement into the feedback to the patient in a proffesional and friendly manner. Ihave started to learn what is more appropriate, butit it is difficult. With more time and experience it will become easier and more natural.

Communicating with patients.

On my Neuro placement I treated many patients that were unable to verbally communicate with. There was one patient in particular who had GB and a cuffed trachy in situ who I found very complicated to treat. He also had no movment in his uper limbs and only dorsiflexion and plantarflexion of his ankles in his lower limbs.

He had a past medical history of depression, and had been in hospital for several months with no real improvment in his symptoms. During my four week placement I only observed a small improvement with his sitting balance. This was very frustrating to the patient and it became apparent to me that his mood was starting to became more and more depressed.

Due to his trachy and inability to communicate verbally it was very difficult to ask him how he was feeling. I did not want to make him feel worse or misread the situation and say something inappropriate. I discussed this with my supervisor and asked her for some advice regarding the situation.

She informed me on how she had previously been handling the situation with the same patient. She encouraged me to be cheerful, talk about what I have been doing and ask him basic yes and no questions which would be easy for him to reply to. I followed her advice an it helped dramatically. I offered up information about myself and found some common interests with the patient which we could communicate about non-verbally. The communication techniques I learnt from my supervisor were very valuable when dealing with my patient.

But you do it this way....

I was on a neurology placement and decided to attend an OT session with my patient to get an idea of perceptual deficit assessment that is conducted for a stroke patient. Whilst at the session the OT team were teaching the patient to use an electric wheel chair and thus had to transfer the patient from his manual wheelchair to the electric. I watched while the two OTs allowed the patient to stand up in a maladaptive and unsafe way aka pull up from a table, they almost forgot to put the breaks on the chair until I reminded them and then struggled to control/facilitate the patient's balance in standing. This was a huge eye opener for me as I assumed that OTs have the same level or instruction and learn similar patient handling and transfer methods as physiotherapists do.

Throughout the treatment session I kept trying to stop myself from interferring with their patient handling as I felt it would be inappropriate for me, a student, to teach experienced OTs safe handling methods for the patient without appearing condescending. However at times I did step in for patient safety, i.e. wheelchair breaks and recorrecting the patient's affected LL alignment to prevent his foot slipping off the electric wheelchair while it was in motion. I also ended up doing a transfer with one of the OTs when the other OT was occupied showing her and stating/hinting that the patient usually transfers this way and it is the easiest for him.

As a qualified PT I think I will feel more comfortable teaching and sharing patient handling techniques to other health professionals. I have also now realised that contrary to my previous opinion not all OTs and maybe nurses etc. will know appropriate patient handling and that the baseline knowledge and safety precautions physiotherapists learn are not commonly known or taught to other health professionals. Thus it has highlighted to me how important and specialised the physiotherapy profession is.

Has anyone been in a position where they have witnessed poor manual handling and felt powerless to change it?

Did you step in or did you just struggle not to intervene and state, "but you should do it this way"?

Oh NO don't lose it!

Whilst on neuro placement I was treating a patient who is severly receptively and expressively dysphasic. After liaison with my supervisor we decided that attending a speech therapy session would help me obtain an idea of his level of understanding and to help me to be able to communicate with the patient and make some sense of his disorganised speech. The other student on the placement with me decided that although she wasn't treating a dysphasic patient, it would be a great experience to attend a speech therapy session. We contacted the speech therapist and organised to attend a session.

During the session the speech therapist was attempting to teach the patient to pronouce and recognise some relevant pictures and words. She initially allowed the patient to look at the picture and corresponding word, then asksed what the picture/word was. If the patient was unsure she then put the word in context to try to get him to guess the word. If this didn't work she said the first sound of the word and if they still didn't get it, the whole word and then got the patient to repeat the word a number of times.

Previously during treatment sessions the patient tended to talk to me about what we were doing, usually not making any logical sense but I was able to understand eventually based on his gestures and expression. Therefore I was somewhat accustomed to his dysphasia yet as I had never attended a speech therapy session or asked the patient to specifically verbalise a certain word I was unprepared for what happened.

The speech therapist was trying to get the patient to say something like drive or shower, and the patient was trying his hardest to find the correct word but instead randomly said onions. At this point the student and I were unable to keep our composure as it was just so unexpected and random that we couldn't help but have a chuckle. We felt aweful as the paient was honestly trying and we apologised to the Speech therapist (who had also had a laugh at one point during the session) and to the patient and explained that we had been unprepared. In the future I will compose myself and try to think more from the patient's perspective and thus try to maintain my professionalism.

Now as students and eventually as physiotherapists we always try to have the utmost respect for our patients and AHT as well as protray a professional standard but has anyone been in a position on a prac where they lost it and couldn't help but burst out laughing?

Pts that are inapproapriate

Whilst on my neuro placement I was having a chat to the other student on the placement with me. Earlier in the day I had heard our supervisor reprimand a patient for a comment he had directed to the student. When I asked the student what exchange had occurred she said the patient had randomly made an inappropriate comment about her and that she was feeling anxious as this patient was planned for her final exam. She had previously read the patients medical notes and discovered that since his stroke he had a history of verbal abuse to the allied health team. This issue was being addressed yet she was nervous that she wouldn't know how to react if it happened during her final exam.

My advice was to notify our curtin supervisor about it prior to the assessment. I said that she could think about it, come up with a way to deal with it and tell the supervisor how she will approach the situation if it arises, then confirm with them if this is an appropriate way to address the problem and also ask their personal opinion. I let her know that as long as she doesn't appear to be intimidated by the patient and she remains in control of the situation regardless of what is said, the patient will be unlikely to be abusive again. I said in the past when it's happened to me I usually humourously turn the tables on the patient to address what they are saying but show them I am not taking offence or if the remark is quite offensive or I can't think on my feet, I simply state that their comment isn't appropriate and re-direct them to the physiotherapy assessment/ intervention.

Is this good advice?

Has anyone come across inappropriate verbal comments from a pt? If so how did you deal or not deal with it?

Is it okay to reprimand a pt for inappropriate behaviour when they have a frontal lobe lesion and can't help what they are saying?

Code Black

In my last placement on a neurosurgery ward, I had an encounter with a patient who was very anxious and impulsive. He suffered from a dense (R) hemiplegia due to a (L) parieto-temporal lesion in his brain that has been excised. Pre-operatively he did not have any deficits in his limbs, and was a carer for his wife who had a stroke last year. He came in for the surgery because of the increase in frequency and severity of his headaches.

This patient was very anxious from day 1 post-op. When we went to see him for the first time to assess his mobility, he said he was able to walk to the toilet on his own and wanted to jump out of the bed to show us. Naturally, he could not do so due to his (R) sided hemi. He struggled in bed and was kicking up a big fuss, hitting his (R) leg and asking it to move for him. We tried to calm him down and explained what happened to him. We told him that after the surgery, due to swelling in the brain, it might take some time and rehab before he could recover function in his limbs. He was angry and said that he was normal. We couldn’t continue to assess him that day but assisted the nursing staff to transfer him into the commode to go to the bathroom.

Over the next few days, his mood seemed to calm down a little and I was able to engage him to perform some bed mobility and transfer retraining by his bedside. I thought he was progressing well when he started to get impatient again.

When his wife came to visit, he asked her to push him in a W/C to the courtyard where he could get some fresh air. The nursing staff were informed and permission was granted. That afternoon when I went back to see him, I heard from the nursing staff that he tried to abscond from the hospital grounds! He threatened and abused his wife and asked her to push him down to the car and drive away from the hospital. He was quickly returned to the ward and brought back to his room. This made him even more furious and he started throwing objects at the nursing staff.

The doctors came around to speak to him and advised a Code Black (Personal Threat) if the patient continues to pose a danger to himself and the people around him. He was under 24-hour surveillance for the next few days and refused Physio treatment. There was no way I could get through to him. I was not able to follow-up with him anymore as I have already finished my placement.

Does anyone have any ideas for a patient like this? Is there a way in which I can get through to the patient to help him understand his condition better?

Orientated to TPP?

Orientation questions are important questions to ask patients before we start any treatment with patients that have neurological problems. These questions will direct my treatment session and will also let me know if the patient’s answers are sane and coherent. These questions are simple questions that asks the patient the following:
1) What is the day today? Date? Month? Or Year?
2) What is your full name? Do you know who I am?
3) Where are you now? Do you know the name of this hospital?

If the patient is not able to answer the above questions, it will lead me to think that whatever the patient says next, may not be true. The patient may also appear to be very confused if they are not sure of the orientation questions.

For example, the patient may be talking to you, but saying illogical things? And when you try to engage in a conversation with them, the responses that you get from them may be something that you would never expect. I had a patient, who after surgery was very confused and disorientated. When I asked him the above questions, he got almost all of them wrong. Firstly, he did not know the day or date. He only managed the correct year. Next, he did not know his full name. He came up with all sorts of other names and said that was his name. Lastly, while he was lying on the hospital bed, he told me that he was in an office in Melbourne and was sitting on a horse!

When I first heard these responses, it made me want to laugh. But I controlled myself, as I knew that this was the effect of a brain lesion. It took time before the swelling in his brain would resolve, and he would slowly be more orientated. So when I was treating this patient, I had to be very careful with what I got him to do, as I was not sure if he could even differentiate sensations of pain. Performing objective assessments had to be tailored also because the patient’s answers may not be relevant all the time. I feel only time would help a patient like this get over his confused state of mind.

Does anyone else have other suggestions or precautions to take when dealing with patients like this?

How Not To Burst the ‘Hope’ Bubble

Whilst treating my patient with pernickety tendencies on my gerontology patient, I was frequently asked to assist one of the physios in treating a man with a dense L MCA. He was originally from the former Republic of Yugoslavia (from an area that is now part of Croatia) and spoke little English. As a result he was impulsive as he couldn’t understand us, and his family frequently came in to translate. This proved difficult too, as he was easily distracted by his loved ones and treatment could be a bit challenging.

One session the physio and the physio assistant were doing gait retraining with him, and he was ambulating with a walking stick. His daughter was watching in absolute amazement, and was almost in tears. She began to explain to me that when he was originally admitted to ED and then ICU, the doctors told them that he was going to die. When he spoke up and was being weaned off the ventilator, the doctors said that he was going to be a vegetable and would need to be in a nursing home. Later during rehab, they were told he’d never walk again. She then told me that back in Croatia the medical staff would never do this, rather they would say that they didn’t know what would happen and that there were multiple outcomes. For her, after being told her father would die, this was a miracle and that we, the physios, were her father’s saviours.

Thinking about this later on, I felt that perhaps the medical staff were being criticised a bit heavily because in Australia doctors tend to prepare families for the worst so that the shock is reduced if the worst does happen. However, I think that as medical and allied health professionals, we should be realistic and not give false hope but never eliminate hope. If you handle it in the most pragmatic and blunt way possible, patients and their families feel they are given no options when that isn't necessarily the case. Issues such as this need to be handled which the utmost care and sensitivity, because you never know when someone may give this news to you.

Frontal Lobe Behaviours

I never knew the extent of Frontal Lobe behaviours until I had a patient who suffered from one. He was a 26-year-old male who got admitted to hospital due to a Motor Vehicle Accident. He had to undergo an emergency craniectory in the frontal lobe region of his skull to relieve the pressure that was building up in his brain due to swelling. This patient already had psychological care before the accident as he was suffering from Bipolar Disorder.

Initially, the patient seemed to be in a coma. He was not responsive to pain, touch or sound. He also had a very low GCS score and was nursed in the high dependency unit on the ward. Over time, when the swelling reduced in his brain, he started to have some response. He was able to open his eyes and listen to one word commands. About 1 week after his surgery, he started to be able to say a few words and recover some upper and lower function. It was a good sign as it showed that he was slowly recovering. We continued to treat him daily and monitor his progress.

After treatment had concluded, we took him back to his room. He suddenly did something very inappropriate that day. We were positioning the wheelchair to perform a transfer back into his chair. To do so, we had to bend down and to the side to put the brakes on and place the chair in a good position. The patient suddenly slapped the physio on her bottom! Both the physio and I were shocked! She asked the patient what he just did, and all he said was spanking and gave us a grin! We did not know what to say or whether to report this as the patient was sick and had no insight. He did not know what he did was socially inappropriate.

It was an experience for the physio and me. She never encountered anything like this before and was taken aback when it happened. From this, I learnt to make sure I do not put myself in a situation where I could be “taken advantage”! I learnt to make sure I have enough space to move around and do not have to bend over to reach for the brakes etc.

I hope no one else was as "lucky" as me to experience something so inappropriate like this situation.

The Pernickety and Self-Deprecating Patient

On my gerontology placement I had taken over the care of an elderly man who had fallen in the bathroom of his home and sustained a serious head injury approximately 2 weeks prior to me seeing him. He had had an evacuation of a large subdural haematoma, and presented with mild weakness of his left side, as well as mild sensory deficits. Personality wise he was a lovely gentle man, but had a tendency to be a perfectionist in his movement and very focussed on the little, relatively unimportant things (very pernickety) and extremely hard on himself and saying how hopeless he was (extremely self deprecating). After speaking to his wife, I discovered that he has always been like this and had a hard upbringing which made him feel as if he wasn’t good enough at anything. This saddened me greatly, as I felt his progress was coming along in leaps and bounds, and I realised that I had to make sure that he knew it.

So, with each session I praised him whenever he was completing an exercise correctly or if I had seen an improvement from the previous session. If he wasn’t performing it correctly, I encouraged him to look at what he was doing and asked if it felt right to him. I thought if I approached it this way he would learn to self critique and use internal feedback instead of me correcting him, and possibly feeding his lack of confidence. On my last day, he told me that finally he felt like he was doing well and he felt more confident. I felt very proud that day.

Anyone else had a patient like this gentleman?

Depressed VS Flat Affect

In my last placement, I was attached to a neurosurgery ward in the hospital. Most of my patients came in for elective or emergency craniectomies because of brain tumour. Some of these patients were completely normal before the surgery. (ie. They had Full ROM, Full muscle strength, nil sensation deficits and normal tone) Post surgery, some of these patients recovered very quickly. These patients recovered full strength by post-op day 2 and were up and walking around the ward.
Majority of these patients suffered from the post-op effects of the surgery (ie. Swelling). Due to the different parts of the brain being compressed by the tumour, it takes time before the return of function in the upper or lower limbs etc. Some of the patients may not have any deficits pre-op, but post surgery, they might result in one-sided weakness or sensory loss.

One of my patients had a (L) parietal craniectomy done to remove her tumour. Preoperatively, she was completely normal. She was a stay-home mum and was able to handle the daily chores at home independently. After the surgery, she was not able to move the (R) side of her body. She had a (R) hemiparesis. On top of that, she was not able to speak due to the expressive aphasia she suffered from post-op. In the integrated notes, I described her as “appeared depressed”. Obviously anyone in that situation would be depressed as they suddenly lost function and control of one side of their body! My supervisor told me that it was not right to say that a patient appears depressed because depression is a medical diagnosis. Instead, they normally describe a patient as have a flat affect.

This was something that was new to me and I would like to share it with all of you. I used to always use the word depressed lightly as I did not think much of it being a medical diagnosis. But currently, my vocabulary of medical descriptions has widened thanks to my supervisor.

Has anyone of you come across other words that were not as appropriate? And learnt a better word to substitute it?

Communicating with the Hearing Impaired

On my neuro placement, I was treating an elderly man who had presented to hospital after falling off a retaining wall in his backyard and hitting his head on a concrete slab. His family explained to me during my first treatment session that he was profoundly deaf due to years of suffering Meniere’s disease, and had had one ear surgically terminated (i.e. his inner ear was burnt out) to stop the crippling vertigo he’d suffered. As a result, communication was a bit difficult (he had trouble lip-reading and didn’t know any sign language) and most long explanations had to be written out on paper.

On my second treatment session however, the family wasn’t there to assist with my explanations, so I decided to sort out a few communication cues with him first. When we were in the gym, I asked him to copy my movements as if he were looking in the mirror and if he needed at rest to put up his hand so I knew he needed to sit down. After a few awkward trials at this, and lots of laughter in doing so, our communication worked well. Ultimately he didn’t need a lot of rehab as he had only minor bruising to the side of his head, so I only saw him for two sessions.

I felt I did reasonably well with this patient as I didn’t have a lot of communication strategies to work with, and I did get my point across in the end. Anyone encountered anything like this before?

Optimal Patient Care?????

In the first week of my neurology placement there was a 35 year old pt was admitted with a R MCA CVA(TACS) rendering only about half his brain function intact. The patient’s hospital stay had been complicated by seizures, pneumonias, cardiomyopathy and a number of urgent and elective cranial surgeries resulting in osteomyelitis etc. Basically the patient was still quite unwell as he was on ABs, had a lung infection/atelectasis and experiencing frequent residual HA/migraines. I was going to take over this patient’s rehab, so for the first few days while treating other patients I observed his treatment sessions.

The patient’s concentration level was only a few seconds at a time and the treating physio tended to scream at him to get his attention. A couple of other stroke patients commented at the time at they disapproved of the way she was handling the patient. The patient on a number of occasions also told the physio that her loud voice was making his HA worse yet this didn’t deter her from yelling at him. I was extremely upset by this as I thought it to be a disrespectful and unethical approach for this patient, especially as her management was aggravating his symptoms. However as a student I didn’t feel that I could broach the subject with her or any other physiotherapists working in the gym. I witnessed other physios treating this patient and they were able to have effective results without yelling. I was actually glad that I was taking over the patient’s rehab, so I could prevent him from being treated by this physiotherapist.

I think in the future if a come across a similar situation as a qualified physio, I will talk to the physio and try to emphasis the detrimental effect their behaviour/ management is having on the patient and suggest other methods that can be employed with the patient to maintain his attention.

Has anyone come across another physiotherapists behaviour during a treatment session that they thought was not respectful to the patient or not optimal patient care?

It's not a TIA!!

This blog concerns an outpatient whom I treated whilst on my country prac. She presented with neck pain. During the subjective she informed me that 3/12 prior she had attended the ED department of the hospital complaining of unilateral facial numbness, weakness down one side of her body and severe headaches.
She went on to tell me that investigations performed at the time and subsequent imaging revealed she had not suffered from a TIA. I spoke to her GP later regarding this information and he confirmed her story and mentioned that she is known to the medical staff in the establishment because of her frequent attendances, many unwarranted!
During my 3rd week of placement and having already seen this patient twice at that stage I received a phone call from her. She told me she was suffering from severe headaches and unilateral facial numbness . I was taken aback initially I must admit. Why did she call me to tell me about this? Isn’t this a serious matter.? Once I composed myself I asked her how long these symptoms had been present. She replied about an hour. I noticed her voice sounded normal (for some reason I would have assumed the voice of a person who is suffering from a stroke would sound different owing to the hemiparesis of the facial muscles).
I asked other screening questions and asked if she had spoken to her doctor. She replied in no uncertain terms that he would not be interested in this and that she was not happy with him treating her. I told her then to report to ED immediately. She asked if I could do something for her symptoms! I explained to her briefly the seriousness of these symptoms, that physio intervention was not appropriate and the need for urgent medical attention was required. She then reported to me that her mother would soon be home and if it worsened she would report to the ED department. I did insist on her calling an ambulance for which she declined. I asked the PT staff if I should call one on her behalf for which they said it was her decision.
The other PT staff were aware of my ongoing dialogue with this patient and were satisfied that I handled the situation appropriately. I guess in hindsight knowing what I did about this patient I still thought it necessary to ask the questions I did and then inform them to report to the ED department. Any patient that complains of symptoms like these regardless of what they have told you previously or how they present need to be taken serious. There is no doubt in my mind that it is always safer to be overly cautious.

Pain of a different kind!

This concerns my country prac and an Outpatient who I saw during my 4 week tenure. She was known to the PT department and I saw her for neck and shoulder pain. She was referred by her GP.
During the Subjective assessment it became apparent to me that she had a few yellow flags and she readily disclosed some psych issues she had(some of which had seen her institutionalised). There were no consistent findings with her reported neck pain with either the subjective or objective. Her initial response to AROM and PROM of the Cx region indicated severe pain though she appeared to have fairly adequate movement prior to the assessment from what I observed in the waiting room. Her shoulder movement was pain free and she informed me it was not an issue.
I discussed all this with my supervisor prior to commencing Rx. She gave me some good advice. I was to highlight to the patient the importance of compliance to the exercises I was about to prescribe. If she performed these exercises her symptoms would reduce and she would be over this ailment within 4/52. The exercises were ROM of the Cx spine, deep Cx flexor strengthening and postural positioning
The patient presented the following week with no pain, no limitation in AROM or PROM and her posture was notably improved with no chin poking and only minor Tx kyphosis evident. The convincing the week before had got across to this patient and whether or not she had performed her exercises I saw for myself pain-free movement and no restriction in all planes.
I believe that the more experience we gain the better we will become at treating patients who present a little differently! This patient was convinced she had a neck complaint. Rx strategies were used which emphasised the importance of self-management. Obviously my Supervisor knew this approach would prove favourable. I learnt alot from this experience and feel I could pick which patients would benefit from this approach.

Dysphasic Patients

I'm currently on my neuro placement and I've been treating a pt who is quite receptively and expressively dysphasic. Initially when I assessed the pt I thought his lack of comprehension and speech would severly hinder our communication and thus affect treatment outcomes and compliance. There were a number of assessments I was unable to conduct due to his inconsistent yes/no and unreliable responces, especially concerning sensation and proprioception tests. With some initial ideas from my curtin supervisor concerning assessment techniques and communication strategies, I started to utilise certain techniques which have helped convey basic instructions to the pt. Some strategies I have employed include using short concise commands rather than speaking in sentences which I usually do, using touch (esp on their affected side to promote sensory input) to get the patients attention, demonstrating on myself and the pts unaffected side, imitation, gestures, repetitive verbal cues and consistent treatment sequence, facilitatory manual handling and using the pts own language to establish important pt feedback like assessment/treatment induced pain and discomfort.

These basic techniques have all worked well with my pt and I have obtained good compliance and treatment progress. Also, as I have got to know the patient and his family, I have developed a better understanding of his objectives and goals. I have found it much easier to read the pt's body language, facial expression and recognise fatigue and occasionally vasovagals. I have also been able to use his gestures, body language and vocal expression to understand what he is actually discussing when his speech is not logical or structured. In the past when I have not had any clue as to what the pt is attempting to say I have asked him simple questions to try to understand him. For example asking "Are you talking about your leg/arm?" and then either continue questioning if I'm on the right track or else simply ask if what he wants to tell me is important or if he can let me know later.

I think in a similar future situation, working with neurological pts I will remember these strategies as well as utilising new ones I will hopefully learn along the way.

Does anyone have any useful communication strategies they have employed with dysphasic pts?

Mobility Ax on a UTI

An interesting incident occurred whilst I was on my Gerontology placement. I was required to complete a mobility assessment for a patient, whom had which was suffering from a UTI. Of course some of the symptoms of such pathology is a confused and sometimes delirious state of mind.

On arriving to her room I found her sitting in her chair. She appeared very distressed. On introducing my self and explaining why I was there she proceeded to retort with responses indicative of ‘giving up on life’ and that ‘no one cares about her’ and ‘wanting to go home to be with her son’. As I knelt down beside her and tried to ease and comfort her and orderly came into the room with a wheelchair for my patient. She was to have imaging performed. On hearing this further request of her she fired up again and refused all intervention. The nurse in the room was now trying to coax the patient into having the imaging performed. The patient was becoming more distressed obvious to all so we all let up and the nurse and orderly left the patient’s bed space.

I couldn’t resist trying once more to talk to the patient. I had not had any previous experience dealing with patients in this mental state. Her confusion and behavior was to prove to overwhelming for me. She just got worked up again continuing with her earlier remarks.

I realized that this state she was in was hindering my chances of gaining her consent for a mobility assessment. We as physio’s have to consider all things in terms of a patient’s presentation, which can be highly variable anyway on a day-to-day basis, including their cognitive function, willingness to engage with us before we can undertake a mobility assessment.

I know now from this experience that the symptoms which can be associated with UTI’s can alter a patient’s behavior and therefore their willingness to engage. It can also disrupt and upset the patient. Mobility assessments as important as they are need to be undertaken when the patient is willing and able.

Social Situation

During my ortho inpatient prac my Curtin supervisor and I had an appointment to see a 21 year old female who had fractured her (R) ankle at the pub skylarking with friends. She was a student and lived with her father. There were some social issues regarding her situation which became apparent as the subjective examination was being conducted. As I asked her some questions regarding ‘home care’ and ‘mobility’ she continually appeared to become upset . My supervisor at this point asked her if she was ok and with this she broke down and cried.
The issues being brought up from my questioning she had not thought about and the uncertainty of not knowing the answers to my questions caused her this distress. I told her I would refer a Social Worker and Occupational Therapist to see her. She calmed down thanks to my Supervisor and I went and paged the SW and OT.
During the second part of my assessment the Supervising Nurse on the Ward called out to my Supervisor who attended to her. I continued my assessment. Later it was explained to me that the SW was not happy regarding my referral to him for this patient. He didn’t consider it necessary to see the aforementioned patient. My supervisor explained to the nurse why it was appropriate and subsequently this was relayed to the SW. He did end up seeing her prior to discharge.
I understand as physio’s we need to ask the questions regarding Social Hx, Mobility etc not only for our benefit but also so we can decide whether we need to refer other allied health care workers to our patient’s.
This experience highlighted to me the importance of conducting a thorough subjective assessment. From this a holistic approach to health care is delivered. The patient in question required the services of a SW and an OT and thankfully they were forthcoming to her. Where we deem it necessary for other allied health care workers to intervene we may need to put out case across as not everyone may agree on why there services are required. At the end of the day it is all about adequate patient care and appropriate discharge.

dominoes

I am currently on my rural placement in the Kimberley and I visited a remote aborigional community today. There is a young boy there who is an above knee amputee after an accident involving a lawnmower. Currently he is ambulating on crutches as he refused to wear the initial prosthesis as it had a white foot. Now having grown out of that prosthesis and needing a new one he has an appointment in two weeks at PMH in Perth.
This is where the logistics of organising his trip to Perth gets complicated! He has a very disfunctional family who do noy have a car and will have to take the bus 250km to the closest airport the day before their flight. He is going with his aunt and they do not have accommodation in this town for the night so that has to be organised along with someone to pick them up and drop them at the airport the next morning. Once they get to Perth, they then need to find their way to their organised accommodation. They need to then find their way to PMH in time for their appointment (which by the way is a very rare thing up here!) Once their commitments in Perth are over they have to then do the same to get back home. This has been organised by myself and my supervisor and I never realised the logistics involved. PMH has all the staff booked and appointments scheduled so the patient must get there... he is also in great need of a new prosthesis and intensive rehab. Although this isn't a clinical example it is an experience I've had that had taken many hours of organisation and many phonecalls. The dominoes have been put in place and I'm hoping they all fall!!! If it doesn't fall into place then I realise a lot of people are going to be put out. Has anyone else had to organise something like this, did it work out in the end?!

"You talk too much!"

I am currently on my rural placement in the Kimberley, and it has been the most rewarding and the most frustrating of all my placements so far. I'm learning so much and am really enjoying it. Recently I've had an elderly inpatient from a rural aborigional community admitted post CVA. She presented with right UL paresis but no problems with her LL. This seemed a bit strange to us and the physio wanted to assess her. She told me that she would take on this patient as she was known to be a 'difficult' patient to the people on the ward. After half an hour, the physio came back to me looking quite annoyed and said that the patient had withdrawn from her during the assessment, sitting huddled on her bed and wouldn't look at her. All she was saying is "you talk too much!" The same day the OT got the same reception half way through her session.
When the next morning came and the physio walked into her room she immediately withdrew... so I was asked as a last resort to go and see the patient. I didn't have a great idea of how to approach her but i did know not to talk too much!
I grabbed a stick and casually walked into her room, I said "G'day X, I'm Sophie, here to make the arm better, lets go for a walk" and then I stood there and waited. She looked me up and down and after a strange silent minute or so she sighed, got up and took the stick out of my hand and off she went. I couldn't believe my luck! Neither could the physio. When she was tired she sat down and I sat next to her. I needed to assess her R UL so I said that she did so well I wanted to give her some high fives...she lifted her arm to my hand. I was also able to test her strength and get her a glass of water so that I could assess her ability to perform this activity and the voluntary movement she had in her wrist and fingers. I gave her exercises too. Most of my treatment was done without saying much, but I found she was happy to talk about fishing and hunting and where she was from.
From this encounter I learnt a few things...a lot about communication, how we tend to do so much explaining and talking when really it's not so necessary. I learnt that you really need to get the trust from your patient and build raport...then you'll be able to do almost anything and I've also learnt up here that you have to be a lot more opportunistic whith assessment and treatment of patients.

When a Gentle Approach Does The trick

On one of my previous placements I had treated a lady who had just undergone a TKR. She had been transferred from the acute Ortho ward to rehab, was ambulating reasonably well and undertaking regular physio without too many complaints. However one morning I went to treat her and found her in tears. She explained to me that it was coming up to the anniversary of her husband’s death, she was far away from home (she was from the South-West) and her daughter was overseas on holiday and she missed her terribly. She also told me that she felt she had been bullied by the physio on the previous ward, because on one occasion she had asked to have her treatment postponed and he said she had refused it altogether.

Instead of focussing on the issue regarding the physio, I decided to talk to her about her family. I consoled her and reassured her that it was alright to feel upset, and that even though I would give her a bit of a push with her physio treatment, I would not make her do anything I didn’t think she was capable of. From then on she was a happy, compliant patient who achieved her knee ranges and mobility within a couple for days.

I’ve found that many patients feel as though their concerns or issues are not listened to, and that they may feel a bit scared about being in hospital. By taking a gentler approach with these patients, they can become more compliant and easier to deal with.

Cruel To Be Kind

On my rural prac I’ve seen a variety of different patients. One lady I saw was in her early sixties and was approximately 10 days post back surgery. She presented to me on the ward, ambulating with a WZF and with a foot drop. She was an extremely difficult lady, continually complaining of pain even when on the highest dose pain killers she could have, and was convinced that if she worked on her muscle strength her foot drop would disappear, and her pain would be cured by a cortisone injection. She was given an AFO for her foot, which she refused to wear (it didn’t look pretty enough and didn’t fit into her shoes), and she continually tried to walk without her WZF.

The solution I came up with at the time was to educate and reinforce to the patient how important it was for her to use the AFO, and incorporated it into our sessions more. I managed to convince her to buy a pair of shoes that would fit the AFO and lo and behold, she realised the AFO worked! The other technique I used was for her to walk in the parallel bars, with me guarding close by, without her hands to see how steady she was without the WZF. On turning in the parallel bars her knee on the side of the foot drop kept collapsing on her and she began to see why she needed the WZF. It may have been a bit harsh, but in order to break through her denial and unrealistic expectations, I felt she needed to be shown her limitations, for her own safety.

Would you guys have done the same?

Family Care

One of my patients on my neuro placement was an extremely young patient who had suffered a stroke and required an emergency craniectomy. Because of her young age I expected to meet a patient who had abused her body with drugs and alcohol and who probably wouldn't have much family support in hospital. It was very refreshing to find a very pleasant woman with the support of her husband, mother and sisters from overseas. The support that she had from her family was something that I had not seen on my placement for anyone else on the ward. They were all very caring and trying to help the patient with her recovery.

Unfortunately that love became an unforeseen problem for me with her physio treatment sessions. As they all wanted to help so desperately, they would all want to come to the physio gym and watch her treatment and help out where they could. I was inexperienced enough to allow them to come for the first few sessions and I quickly became aware that although they were only trying to help, they were becoming more of a nuisance then anything during treatment. They were constantly asking questions and trying to help the patient during transfers and telling her to try harder, etc.

It took me a few sessions to realise that this in fact was not helping at all and I had to muster up the courage to ask the family if they could stop coming to the physio gym during her treatments. They actually took it a lot better then I expected and I just tried my hardest to explain to them that the patient would get a better treatment if it wasn't so crowded in the gym. I still allowed the husband to come as the patient seemed to be more comfortable with him around and he was able to get through to the patient better then me in some situations.

This was a steep learning curve for me as I would previously have had no problem at all allowing family and friends to watch our treatment sessions. Now I know for future that it is really not suitable to have more then one extra person involved in a patient's treatment and even then it can be too much sometimes. I think I will allow 1 person to watch and then decide from there if they should stay or not. Has anyone else had any circumstances like this one?

Bound for a Nursing Home

Recently on my neuro placement I had a patient who had suffered a massive stroke. As I was very inexperienced when I was given the patient, I expected to see significant gains in the patient over the course of the month that I was to treat him. However this was not the case and the patient remained completely dependent. After one month of treatment he still had absolutely no sitting balance and was unable to swallow. We spent countless treatment sessions trying to improve this sitting balance and left sided inattention that he displayed with little luck.

After a couple of weeks of treating the patient my thoughts began to change and I went from being very disappointed in the patient's progress to extremely excited whenever we noticed the slightest improvement. These improvements that we saw would be a tiny flicker of tone, a couple of clearly spoken words or a spontaneous turn of the patient's head to engage in an activity on the left.

It did become very clear that the patient would be eventually discharged to a nursing home as he was simply not showing enough improvement to warrant further rehabilitation. It became quite hard speaking to his family as they were always so excited about the patient's rehab and asking how long it would take for him to walk, etc. All we could do was constantly remind them that the patient was recovering a lot slower then we would expect and it would be a very long road to recovery if he ever got there.

I found it very hard to see the hope in his family's eyes slowly start to disappear over the month as mine had already done. In future I don't think I would approach the situation any differently however I would have the experience of dealing with such a patient and would not be so shocked if a patient didn't progress as I would expect. And I would just be as honest with family as i possibly could be.

Unsafe Patient

On my neuro placement I was treating a patient who had had a stroke. She had not been badly affected however she suffered from diplopia and verticality issues. Therefore my treatment was focused primarily on treating the patient's verticality issues. This improved fairly quickly and soon the patient was able to walk with stand by assistance. However she still very definitely needed that stand by assistance as she would periodically stumble to the right. To add to her problems she also displayed quite marked perceptual deficits.

From the allied health point of view this lady was going to need quite intense rehab over a prolonged period of time as she was very young and still working in management. However, after about a week in hospital I got news that the doctors were looking at discharging her to her home in the coming days. I was completely shocked about this and had multiple conversations with other allied health team members only to find that they were in total aggreance with myself. I was told that all I could do was write clearly in the notes that the patient was not safe for discharge and explain why. So i did this every day in capitals but it did not make a difference. The resident and registrar both noted our inputs but the consultant still wanted to discharge the patient.

I couldn't believe it and asked if I should talk directly to the doctor but my supervisors laughed and said it would not help at all and that I would just get my head bitten off. I don't understand why some doctors are so stubborn and will not take advice from the allied health team. This patient was clearly not safe and would probably be re-admitted with a fall. Not to mention there was no way she could work in management again.

I think if i was a qualified physio I would have approached the doctor but as I was only a student i felt it was not my place to make such calls. What would you have done?

Long Term Patient

Recently I was on a neuro based placement and was asked to continue the care of a patient who was recently admitted to hospital. From reading the notes I realised that the patient had been previously independent in all areas of life and still drove her car. She also seemed to be part of quite a wealthy family. On assessing the patient it became very obvious that she was going to be a 'handful' over the coming month. Although she realised she was no longer independent, she believed she would get better on her own. To add to the situation, this lady lost focus very easily and loved to talk bout anything at all, no matter what relevance it had.

Obviously I did my best to explain the necessity of physio as well as other medical help but this lady still felt she only required rest to get better. Over the month I was treating her we had some very interesting times and I found to get the best outcomes I had to become more of a friend then a physio and barter with her to complete her physio sessions. I often found myself giving her choices and rewarding her if she chose the harder option. It ended up being quite an interesting challenge to gain her compliance twice a day but it was something that i found myself looking forward to.

I approached it almost as a competition and I believe it allowed me to perform some effective form of treatment each day rather then very little if i had let her get her own way. After a few days it became very easy for me to tell whether she was just bluffing to get out of physio or whether she was in fact, not up for it at the time. I don't believe I would have been able to sense this if i had just taken a standard approach to the patient.

This approach would obviously not work for everyone but if I had a similar type of patient in a similar sort of setting again I would use the same techniques.

Beckons the Dragon - Part 4

I worked with a five year old boy suffering from spastic hemiplegic cerebral palsy. He was a boy with a dense left hemiplegia. Both his left upper and lower limbs were in a flexor pattern and had increase tone when I tried to extend them.

He has only been in the Centre for about six months. The staff reported that when he first came in, he did not speak a single word, kept wetting his pants because he did not know how to say he needed the toilet, had no voluntary control of his left upper and lower limbs and even has an incidence of epilepsy and was foaming at his mouth. The staff thought they may have pushed him over his limit and overworked him. This is something that they do with all their children to help them reach their full capabilities.

When I learnt about all this that was happening, I felt worried for the children. The staff at the Centre work the children really hard. When stretching, they tend to stretch past normal range! They sometimes stretch the knee into hyperextension and the elbow into hyperextension. This was a sight that sent shivers down my spine. These poor children, most who could not express themselves, were not able to say if they were in pain. The staff also made the children stand for extended times in wooden standing frames. While in these frames, the children had lower limb splints on. They were then strapped at the ankles and knees, to the standing frame. This promoted knee hyperextension and was again another scene that required change! Finally, the children also had upper limb splints on and were made to remain in a 4-point kneeling position for at least 30mins. Support was given at the shoulders but some of these children did not even have the strength to maintain the weight of their body. If not careful, the children’s shoulders may sublux. Again, these poor children were not able to express themselves. The children sometimes cry and the staff took crying as a form of disobedience, and punished them further by extending the therapy time.

All the children in this room, regardless of their diagnosis, went through the same schedule daily. Even if a child had low tone, the staff would still be stretching them, and stretching pass neutral! This was something that was unacceptable back home. I noted all these down and during our handover session in the final week, told the staff that they should be careful with the exercises that they prescribe to the children. I even demonstrated the different exercises and stretching to show them where they should have their hands placed to give maximum support and how far they should go when stretching (never to go beyond neutral!!!).

These are just a few of the unacceptable practices I saw while on placement in Shanghai, China. What would you have done different to me if you were on the same placement?

Beckons the Dragon - Part 3

The Director of the Centre requested that I perform some therapy with her son. I accepted her request and went to see her son today. The Director told me yesterday that he is a very unmotivated boy. I didn’t think too much of it until I saw him.

The Director's son was a typical 17-year-old teenager. When I asked him to do exercises with us, he came up with lots of excuses. I tried to teach him a more suitable way of coming down to the ground from sitting but he said it was easier for him to do it “his way”. “His way” was reaching out to the ground with both hands while seated on the plinth, and going straight into a 2-point kneel position on the mat. He did not go through the half-kneel position but used upper limb support to get himself down. Even when he got back up onto the plinth, he lifted himself with his upper limb strength. He could be doing this due to the fact that he really did not have the strength to get into a different position because his lower limb muscles were just too weak (MMT grade 1/5). The session did turn out to be good eventually but most of the time was spent talking to him and understanding what he wanted out of therapy.

I guess when interacting with teenagers, they do not always share the same vision as their parents. He kept saying that his Mum does not know what he wants and that he will wait to go to Perth next year to do therapy. He said that his Mum has tried many forms of therapy, including surgery, and all these therapies did not help at all. Instead, he has just gotten worse from the many surgeries that he went for. I tried to talk to him and explain that his Mum is doing the best she can for him, and that he has to help himself if he wants to get better. He cannot be passive and wait for therapy to come, but has to be proactive in doing therapy now so that when he goes to Perth next year, he would be able to get so much more out the therapy session there!

What else could be said to a rebellious teenager to get him to do his exercises? I guess, having lots of patience could be something to start with. Have anyone else experienced something like this before?

Beckons the Dragon - Part 2

I felt I finally managed to make a difference today! I was working with a child suffering from CP in the Conductive Education room today. I felt she was a child that might have skipped a milestone and went straight onto walking. She seemed as though she never learnt to crawl as she was not able to coordinate the reciprocal movement of the upper and lower limbs when in 4-point kneeling position. As such, I decided to set up steps for her to climb up into a ball pit. This encouraged her to move her limbs reciprocally to facilitate crawling and climbing. I also taught her to stand through 2-point kneeling to half-kneeling and finally to standing. It took many attempts before she was able to do it properly.

Towards the end of the treatment, the child got really tired and started to cry! I tried to stop her from crying but to no avail. I had to let her go eventually and she started to crawl towards the center of the room where the other children were playing. She was attracted to the large fitball and wanted to play with it. Without prompting, she moved towards the ball and stood up in the way we taught her to! I was so happy as I felt that the treatment I just had with her was effective.

I was beginning to have more confidence in being able to help both the children and staff at the Centre, be it in terms of treatment, training or just being able to listen to them and offer suggestions to the issues they were facing. The successful therapy session with the child made my day!

Beckons the Dragon - Part 1

Hey everyone, it's been sometime since my last post but here is the 1st part of my 4-part post on my PT Abroad placement in Shanghai! I worked with children suffering from cerebral palsy, autism, ADHD and Down Syndrome while I was there. It has been a wonderful experience and I definitely did not regret making that choice to go.

The Centre I worked at had three different rooms: the “Physical Therapy room”, the “Conductive Education room” and the “Sensory Integration room”. Each had different types of children and different equipment. Of the three room, the one that physio had most in common with was the Physical Therapy room.
In this room, I saw a range of children. Amongst the many children, there was one child that was positioned very poorly in the wheelchair. She had very high tone in both her upper limbs and lower limbs and it was very difficult to even try to extend her arm. Her hands were in the small space between the armrest and her trunk was rotated towards the right. Her hips were also internally rotated and it seemed to me she had windswept hips.
A reason why she was in such a bad position could be due to the size of the wheelchair? The wheelchair was too big for her and thus could not give her adequate support to keep her in an upright posture. The staff did try to put extra towels to support her trunk but I think not enough towels were used.
I also noticed that none of the staff were doing any therapy with her. She was just left to sit in the corner. As it was only my second day at the Centre, I felt I might not have seen the bigger picture. In a sense, I may have missed the parts where the staff did the passive movements and muscle stretches and any other therapy that they have lined up for her.
I had a whole plan drawn up for her. She requires vigorous therapy to prevent deterioration. What else could be done for her if there was not enough staff to carry out therapy for her? Afterall, I will only be there for four weeks, and when I leave who will help her? I feel for the children there and hope that things will start to get better for them.

Serotonin Syndrome

Hi everyone, hope your pracs are going well- one to go til we’re physios!

On my rural prac I’ve had the opportunity to watch my supervisor treat patients in ICU. One patient caught my attention as he had been admitted with a condition I’d never seen before. It’s called Serotonin Syndrome, and I thought it was an interesting condition so I thought I’d share what I’ve learnt.

Serotonin Syndrome is an adverse drug reaction that can happen after therapeutic or recreational drug use, and usually involves an interaction between two or more drugs. It’s not a spontaneous reaction; it’s the result of excessive serotonergic activity in the CNS and peripheral serotonin receptors. The most common kinds of drugs which, if combined or used in excess, cause this are anti-depressants, opioids, CNS stimulants, psychedelic drugs (e.g. LSD) and some herbs (like St John’s Wort and Gingko Biloba). Clinical presentations of serotonin syndrome can range from mild to potentially fatal. Milder symptoms can consist of tachycardia, profuse sweating, myoclonus, hypertension, hyperthermia and hyper-responsive reflexes. Severe symptoms include the previous symptoms as well as agitated delirium, muscle rigidity, metabolic acidosis, rhabdomyolysis (muscle breakdown) and renal failure. Most symptoms tend to resolve within 24-72 hours.

In the patient I’ve seen, he had taken a combination of ecstasy, dexamphetamines, cannabis and alcohol. He was also taking three different prescription anti-depressants and anti-psychotics. He has been sedated and intubated in ICU for 11 days, far longer than the 3 days that it should last. His muscles exhibit leadpipe rigidity on muscle testing and he is constantly sweating, even under sedation. He is 24 years old, and there is a possibility that he has suffered brain damage from this condition.

It is an extremely sad situation. It has made me realise that many people don’t know or understand the consequences of mixing medications, and how dangerous it can be.

Suitability for physio

Recently I was on my musculoskeletal placement and had a 26 yr old female English patient referred to me from her GP for low back pain. On assessment, I found that she had developped this back pain insidiously about a month after the birth of her first baby. Her husband works full time and she is a stay-at-home mum. They have been in Perth for six months. There were no significant findings on objective assessment which could fully explain her LBP. It also did not follow a pattern of conpression or stretch and her posture was reasonable.
On initial session, I educated her about posture and the lasting effects of pregnancy on the body (relaxin, decrease muscle tone) as well as the importance of strengthening TA and pelvic floor to support her lower back. I went through basic TA retraining with her and also good lifting techniques and positions for changing, bathing baby.
After seeing this patient, I spoke to my supervisor as something just didn’t seem to add up. I discussed my findings and session with him as I felt that perhaps there was something else going on as I didn’t have enough assessment findings to explain it. My supervisor suggested that I investigate further at the next session. On the next session she presented with similar low back pain as well as pain up into her thoracic spine. I also found out that she is not coping well at home with her husband working. She doesn’t have family in Perth and doesn’t have many friends here as she moved recently.
I asked if she had sought any help or support to which she replied that she wasn’t aware it was avaliable. (I had talked to my supervisor the previous week about the nature of her chronic pain and the potential for something such as PND to perhaps be contributing or causing her problem. My supervisor agreed it was a possibility and to talk to her about it next time.) I explained that I had recently also been on a womens health placement and that it is not uncommon for women to feel overwhelmed with a new baby, I also explained PND and asked if she had heard of it. She said that her sister had it with her second baby. After talking to my supervisor we decided to refer her back to her doctor for an assessment and I wrote a letter to him explaining the assessment and findings and querying another cause of the chronic pain.Two weeks later, I recieved another letter from her doctor explaining that she had been diagnosed with mild PND and reffered on. This made me realise how important it is to keep in mind that some patients may not be fully appropriate for physiotherapy even though sometimes it seems like they are. I suppose it is always been in the back of my mind, but after this patient, I was certainly more aware!

Stand Up for Your Rights!

Many of our fellow students have told me stories about their dealings with other health care professionals, in particular the arrogance and condescending attitudes of those in the medical profession. Granted, not all doctors are like this (the doctors on my current prac are marvellous), but it reminded me of the dealings I had with one particular doctor a few months ago.

I was on a general surgical ward for my cardio placement and was sent to another ward to see a patient with pneumonia. I had tried to see this lady for 3 days but to no avail as she had gone for dialysis twice and for a biopsy the other day. This time I was determined! I spoke with one of the doctors treating her prior to starting my Rx as they had tried to put a cannula in her foot, and I had planned to ambulate her. The doctor informed me it was fine, and they were finished with her so I could go ahead. About 10 minutes into my treatment, another doctor came in, demanding that I stop my treatment so he could try re-inserting the cannula. I firmly but politely said to him that I was in the middle of treatment and that I would be finished shortly. The doctor persisted, basically saying that his treatment was more important than what I was doing so I had to get out of the way. My reply was that I had been trying to see this lady for 3 days, and that the condition her chest was in was so bad that if I did not intervene, there was a high chance her condition would deteriorate. I also stated that if the doctor would give me 10 more minutes to try some breathing exercises and ambulation, then she was free for his procedure. Much to my surprise, he left me to it, and I was able to complete an effective treatment for my patient. At no point was I rude or condescending to him, I just stated my case.

What I learnt from this experience is that whether as students or new grad physiotherapists, we should not allow ourselves to be intimidated into giving up our treatment time just because someone else is rude enough to barge in and expect us to get out of the way. If the patient is booked for a procedure (e.g. CT scan, dialysis, surgical procedure) then by all means that comes first. However in situations such as these, we have every right to stand up for ourselves.

Treating the Bereaved

I am currently on my rural prac where I’ve been seeing patients on an aged care rehab ward. One of my patients was admitted to the ward with lumbar, sacral and rib fractures following a fall at home. These fractures are stable, and my treatment thus far has been mobilising her around the ward with a WZF. As I have been treating her, she has started to tell me bits and pieces about what happened the night of her fall, but also the weeks leading up to it. To cut a long story short, her husband of 62 years had passed away 8 weeks before her fall, and she had cared for him for 3 years before he died. She also said she hadn’t been taking care of herself and wasn’t eating enough because she felt so lonely and grief stricken. She has cried during several Rx sessions with me, and has stated she wishes she’d ‘died with her husband.’ During the Rx session, I’ve asked her about how she had been coping with her loss and about her husband (only if she felt comfortable with it) because I felt that if she could talk about her loss, then maybe it may alleviate some of her pain, but also assist in her compliance with PT Rx.

My concern now is that she has become reliant on me to talk about what has happened, but also she has been asking me advice on issues that I don’t feel qualified about. Her doctors have asked her about taking antidepressants, which she has refused, but she almost constantly asks me whether or not she can be forced into taking them. My reply is always that she should discuss it with her doctor, but she keeps asking me as she says she isn’t comfortable speaking to him.

My current plan for this situation is to speak to my supervisor to see how I could change my tack with the patient without hurting her feelings, and asking whether a referral to a counsellor/ clinical psychologist would be beneficial (mainly to find someone who is qualified and can give her appropriate advice). I also plan on speaking to her doctor about what the patient has been telling me.

I feel as though I’ve bitten off more than I can chew here, as I didn’t expect that my input to her would mean as much as I thought. Has anyone else dealt with a situation like this before?

This blog concerns my orthopaedic prac. The pt involved had a nail inserted into her femur roughly 12/12. The ORIF caused an infection and progressively her pain increased to the point where she was on the strongest pain control able to be tolerated. Of course her body developed tolerance to the analgesia’s and started having no effect on her pain level (or very minimal). The pt had to undergo a 2nd operation and have a bone graft and the nail removed from her femur.
I saw her day 1 post-op this operation. She was reluctant to mobilise as any movement caused her immense pain from the looks of it. She had pain cover prior to PT but the effects as I had mentioned her minimal. Myself and my supervisor managed to convince her that she needed to move today and she attempted to reluctantly. On starting to move from supine to SOEOB she started sobbing uncontrollably and then preceded to cry.
I was taken aback, my supervisor tried to encourage the pt and make her stand up. I had mixed feelings about the pt’s response. I was questioning whether she was being ‘brave’ or ‘dramatic’. My supervisor and I discussed later what had occurred and she gave me some advice on how to manage this patient.
After that experience i was keen to learn about tolerance to pain medication. I saw her subsequently by myself for the next 4 days sometimes x2 daily, iIam happy to say she improved dramatically though would still be in a lot of obvious pain at time. I educated her alot regarding her pain and tried to enforce what we were doing was not harmful and she would benefit from this intervention in the long term. Her trust in me developed and she made progress with each session. I gained alot by working with her and the experience helped me understand from a pt’s perspective the concepts of pain and pain cover. In addition and equally important I found that we as physio’s can really influence our patient’s through education and developing a good rapport with them. If you do this successfully they will trust your judgement and will feel more empowered with each gain they make per session.

full on family

Recently, while on my musculoskeletal placement, I was treating a woman who had cervicogenic headaches. I met her in the waiting room for the first time and her husband was with her. I hadn't had a family member attend with a patient in the outpatient clinic before but I didn't think it would be an issue, so I didn't object when he accompanied us in to the cubicle.
From the first minute of the subjective assessment I could tellk that he was quite imposing. As I asked questions, his wife would begin to answer and then he would interupt and answer it instead. He would use comments such as 'what she means is...' or 'what she is trying to say is...' His wife was not of another background or spoke another language, she was Australian, understood me perfectly well and was very capable of answering the questions herself, she just didn't get a chance. I got very frustrated and was so surprised that this man was treating his wife in this way and that she was letting him get away with it. During the objective assessement of her Cx AROM, her husband said "you don't need to test that, she can move her neck perfectly fine, that's not her problem". I was frustrated but also felt confronted by him. I explained that I had to do a full assessment of her neck so that I can work out what may be causing the headaches. As I went through the assessment from then on I was very careful in explaining exactly what I was doing and why. Her husband was still quite pushy during the rest of the assessment and treatment but I felt that becuase I had allowed it to become an issue I couldn't just ask him to leave the cubicle.
The next time I saw the patient, her husband was there with her again. I asked him if he would not mind waiting in the waiting room and he didn't look pleased. I explained that it would be a more effective treatment if I was able to treat his wife alone as we would be able to focus solely on her neck problem, and that I would fill him on on how it went after the treatment session.
Whilst in the cubicle, his wife was much more talketive and seemed to 'come out of her shell' - I was able to do a much better session as she was a lot more relaxed and also was able to gain a much clearer picture of her headaches than I had at the previous session.
This taught me that if an issue arises, to deal with it straight away. I've had family attend while I've treated patients before in other settings and it hasn't been a problem but in this case it was. I've also learnt that communication is the key! Her husband was quite happy to sit and wait after I had explained to him why.

Cognitive deficit, part II

This blog refers to the same patient as in "Cognitive Impairment, Part I".

Another issue I faced with the stroke patient with cognitive impariments was managing his wife's attendance and contribution to treatment sessions. I had taken note of the fact that social work had reported in the notes that the patient's wife had been particularly distressed by her husband's current condition. I felt it would be nice for her to feel included in the treatment sessions to see the tasks he was performing well with and also to see the areas in which he was improving. She was appreciative of the invitation to attend the physio sessions and it became part of her daily routine to join us.

This did not pose too much of a problem to begin with. When I started to attempt to get my patient to perform more abstract tasks such as weight shift, however, his wife would want to try to explain the task to her husband when he wasn't responding to my instructions. Although occasionally her instructions did gain a better response than mine, for the most part this became a big distraction for my patient and caused more confusion.

Eventually, during a treatment session with my patient I had to explain to his wife that it was taking all of his concentration to maintain focus on me and what I am asking him to do, and that although sometimes her explanations helped it then took some time to get his concentration back to me. She seemed a little hurt by this to begin with but I spoke to her once I had finished treatment and she said she understood and thought it was very reasonable.

In the future, if such a situation arose I would rectify the issue as soon as it became an issue, rather than waiting until the middle of a treatment session which is already a rather stressful situation. Or otherwise mention it to begin with when inviting the family member to the physio session.

Cognitive deficit, part I

Earlier on this semester I had a patient on my neuro placement who had had a stroke which affected his cognitive function. He displayed ideational apraxia, decreased concentration, (L) side neglect, perseveration with complex tasks and tasks that had been explained in an abstract way and many other behavious that made treatment a bit of a challenge. He was also regularly not orientated to person, place or time, although as the days went by he started to remember that I was a "very well trained physiotherapist"! (His words, not mine!)
The initial sessions with him were a bit of a disaster due to my lack of experience with such a patient. I had no idea how to communicate to him what I wanted him to do without causing him a huge amount of confusion.What seemed a simple idea to me was actually abstract and complicated for him. What would have been perfectly reasonable to expect from any other of my patient's was cognitively too high level for him. Due to this difficulty with communication he appeared to be a 2 moderate to maximum assist for STS, T/Fs and bed mobility and ambulating was out of the question.
After discussing the difficulty I was having with him with my supervisor, it was suggested to me to make every activity with him a functional one with a purpose and all instructions short and concise. For example, when explaining to him I wanted him to move from the wheelchair to the plinth, instead of giving a longwinded explanation about how I wanted him to do so, I would simply tell him to move from the chair to the bed. I would watch to see what he could do and if he started to have difficulty I would break the task down but explain only one part at a time, allow him to perform that, then explain the next part of the task.
To my astonishment, this patientwas actually quite capable to performing most tasks with stand by assistance or 1 minimal assistance. Ambulating was a two person job due to his tendency to push to the left but otherwise he had the strength and (most of) the coordination required to walk about 100m.
The experience with this patient was invaluable to me. I feel like it is something that an explanation can be helpful but nothing helps as much as experiencing it first hand and seeing how changing your communication slightly can make the biggest difference. I feel as though due to this experience I am now more well-equipped to deal with patients with cognitive deficits and it be a more enjoyable and rewarding experience in the future.
This also showed me the importance of not being afraid to ask questions in difficult scenarios!

Angry Oldies

I was recently asked to assess a very old man who had been admitted to the ward with an exacerbation of his COPD. He also had a background of cardiac conditions. When I approached the patient he was resting in bed and was originally quite happy to have a chat with me. However, as the subjective Ax progressed the patient became increasingly frustrated. I finally convinced him to ambulate with me and he managed about 10m with his W.S before he turned around and headed back to his room. When I asked him why he had turned around he snapped at me and said "here, why don't you try walking for me." I know, it didn't really make sense but as the patient was obviously quite angry I decided to leave him alone until the next day.

When I walked into the patients room the next day he said "oh not this bl**** sh** again." As the patient was lying in bed again I decided there was no way I was going to let him push me away so easily. So I asked him why he didn't want me to help him. I think that stumped him and he realised that I was truly only trying to help. He then stated that he felt ill and wanted to rest. When I asked him why he felt ill he calmly replied that he had a crushing central chest pain that he had never had before. I then alerted the NS and the appropriate management was initiated.

This made me realise that you really can't afford to let patients dictate the way they want to be treated and when they want to be treated. Being in hospital is not an enjoyable time and I think they just have to realise that they are there to get better and its our job to do that, no matter how annoying.

In future I won't be easily persuaded to leave a patient and just treat them later. Although this might help build a better rapport, it may not be giving that patient the most optimal treatment.

What do you think?

Fibromyalgia

During my last placement I was referred a ?fibromyalgia patient from a rheumatologist. The referral just asked me provide the patient with a gentle exercise program. I wasn't 100% sure what to expect when the patient walked through the door and to my surprise it was one of the nursing assistants from the hospital. The patient seemed perfectly healthy and it wasn't until I questioned her further that I found she was anything but. She complained of pain and weakness all throughout her lower limbs and stated that she had recently had 3 weeks off work as she just couldn't walk around anymore. She told me that her rheumatolgist had prescribed her with NSAIDS which enabled her to walk again but by the end of her working day she just collapses and finds it too hard to walk around anymore.

On objective exam the patient was found to be TOP all through her LL's and to have reduced muscle strength throughout. Everything else was normal including neural testing. I was unsure of what I could do for the patient because if I gave her a strengthening program I feared it would impede her ability to work. Therefore I suggested some light exercise in a hydrotherapy pool and she agreed that this sounded like a good idea. I told her to try it every 2-3 days and then come and see me again in 2/52 to monitor her progress.

The situation made me feel helpless in a way as there was nothing we learnt at uni that could help this type of patient and I don't even know if there is anything to help.

Does anybody else have any suggestions or experiences with such a patient that they could share with me?

Depending on how she responds to this treatment I think I would take a similar course in future.