patient with a pre-morbid disability

Whilst on my orthopaedic prac, i treated a patient who was quite disabled. He had been involved in a car accident and had a broken NOF, however was also wheel-chair bound most of the time pre-morbidly. He came across as having a mental disability as well and so when i first saw him, i used very simple language and treated him like someone who had a mental disability. After my first treatment session with him, his mum told me that he was actually fine mentally and quite intelligent. This was rather embarrassing for me as i had been treating a 19 year old like a 5 year old. It was still hard when i treated him later on because i would start using really simple words and then have to remind myself that he actually had near perfect cognition. This taught me just to take extra care when working with people with a disability and to properly check what their disability is before you see them. This would just help this happening again in the future and will help us gauge the best way to interact with them.

Perseverance

The biggest challenge doing prac in a country where they speak a foreign language is developing effective non-verbal skills to get the intended result. There are positives and negatives about working with children over here. Firstly they primarily respond by non-verbal communication anyway but it is the simple commands that hold you back. Secondly, even though you don’t need an extensive vocabulary, these children (especially the ones with Autism and ADHD) have very limited attention spans. 

One child in particular was very reserved, however constantly seeking visual and tactile sensory stimulus. Over a couple of days I noticed that he thrived off repetition and habitual activities, such as walking on the beams in a continuous circle holding your hand. He would go on all day if you didn’t stop him. Having poor core stability and balance this boy needed to progress. Reaching outside his BOS was a foreign idea for this boy. 

I attempted to gradually challenge this boy by taking my hand away. Eventually after much perseverance I was able to get his walking sideways and backwards. This activity required two of us using primarily manual handling to guide his feet. On this placement, I have learnt to pick up on small improvements as things happen a lot slower over here with the language barrier. In addition, my non-verbal communication skills have improved quite a bit.

continuing ed.

I found it very challenging having never worked with Autistic and ADHD children before. One child in particular was excessively hyperactive. He would bounce around and around on those bouncing balls without loosing any energy. Any attempt at a one on one treatment session with this child was a mission. He would follow commands of the Chinese speaking staff but obviously we struggled in that department.

 I had been allocated with two other students in this sensory integration room who are studying Occupational therapy. Sensory being one of the domains of OT, they came up with some sound ideas that I have taken on board and thought I’d let you all know about if you don’t already. 

The first technique is to firmly wrap the child like a sausage in a blanket for ~ 5 minutes. As the child can’t move their limbs, they are calmed down. It worked a treat. The second calming technique I adopted from the centre was the use of a large fitball that had rubber spikes all over it (like those easy grip catching balls). All the children laid down on the mat and for 15 mins the therapist rolled the ball up and down each child in supine and prone. I gave it a go and it almost put me to sleep. This experience has taught me to feed off other health professionals for new techniques and knowledge that may improve the effectiveness of your treatment. 

Thinking outside the square

I am currently on placement in Shanghai, China working at a children’s rehabilitation centre. I have been working with a 16yo child with quadriplegic cerebral palsy. As she is quite dependent, she tends to be left in her wheelchair off of to the side, poorly positioned. Rarely are her footplates ever down for her feet to go on which leaves her in a slouched and abnormal posture. She is not the only child in the centre that I have observed with poor wheelchair positioning and footplates not in use. With the language barrier it is hard to communicate the purpose behind our treatment. I felt very frustrated and helpless in this situation. Some of the staff are unaware of the consequences poor positioning can have on a weak and hypertonic body. With the help of an OT student who spoke fluent Mandarin to translate, we demonstrated and explained correct wheelchair positioning for this child with additional methods for support. Using what we could find we adjusted the foot plates, applied a hip and chest strap, rolled towels either side of the trunk for support and finally a sandbag in between to assist with the adduction/IR contracture. The rationale was clearly translated and the therapist was appreciative. Every day since, effective positioning has been applied for this child. This child is now more alert in this position and will participate in more activities. This experience really made me aware of the mental/emotional effects good positioning can have on someone's confidence. It just shows what you can achieve with limited resources. It is also now our aim to develop a staff handout informing them of the importance and reason behind correct positioning.

Bronchoscopy

This semester I was able to sit in on a bronchoscopy of a patient who had suffered lung cancer and had had previous surgery to implant a stent in her right main bronchus. The consultant who performed the inverstigative procedure was kind enough to explain to us the entire procedure from start to end including the process of anaesthetising the patient and its effect on the respiratory system.

Although I have been able to observe surgery and video assisted procedures before, what made this experience so valuable was that the consultant, medical students and anaesthetists all took the time to treat the procedure as an educational tool. What would of taken 10 minutes to see whether the stent was still in situ and to laser off any scar tissue ended up taking half an hour due to the consultants willingness to explain and allow us to get as much out of the experience as possible. He even ended up quizzing myself and the other physio student in a non threatening way, assuring us that we know more than we think!

I valued this expreience greatly as it was nice to know that there are other professionals out there who insist on sharing their knowledge and time rather than seeing us as annoying students and ignoring us which I'm sure we've all experienced by someone this year. It makes such a difference to our learning when people strive to get the best out of us.

wry neck pain

What is wry neck. How do we treat acute neck pain.

Neck pain as a whole is a major contributor to disability worldwide, with about 70% of the population experiencing an episode of neck pain at some point in their lives. Wry neck is a recognised syndromes causing pain in the neck it occurs as involuntary contractions of the neck muscles, leading to abnormal postures and movements of the head. Fortunately wry neck is a transient and self limiting condition that can usually recover in a few days to a week. There are usually no risks or complicating however neck pain can return. Statistics show that around 10-15% if the population has neck pain at any given time.

What causes wry neck?
The exact cause of wry neck is not know but usually results from unusual movements or prolonged abnormal postures. It is thought that one of the joints in the neck become jammed or locked, resulting in a painful, protective muscle spasm. Any one can get wry neck but is typically occurs in young people between 12– 30 years of ages

Characteristics of Wry Neck
• A sudden onset of sharp neck pain
• Pain can be anywhere in the neck extending the head, shoulder and upper back, usually worse on one side.
• Difficultly turning head in one direction
• Patient is unable to correct posture due to pain and muscle spasm.
• Palpable neck spasms on affected side.

Differential Diagnosis
It may not be Acute torticollis
• Non Specific neck pain
• Cervical postural syndromes
• Cervical spine degeneration
• Acceleration / deceleration injuries
• Cervical spine fracture
• Acute never root pain


Explaining the Symptom
As Wry neck an abnormal contraction of the muscle in one side of the neck, people may appear with their head turned to one side. Their head is rotated due to the attachments of the spasming muscle and the pull of the muscle on the neck whilst contracting. The loss of movement in the neck may be due to pain and tightness of spasming muscle.

Evidence based Treatment

What work and what doesn’t
Multi-modal treatments – stretching/strengthening exercises and mobilisation/manipulation
Proprioceptive and therapeutic exercise—Muscle energy exercise
Massage - release tight affected muscle and reduce pain
Thermotherapy - heat pack applied to painful muscle
Acupuncture—short term pain relief. Can help with muscle tightness.
Temporary use of a soft collar – collar can provide support and comfort for a short period for acutely painful necks. Not generally recommended as the neck is best kept mobile and exercised naturally

Thank you

AGED CARE LOW VS HIGH

Recently on my gerontology prac, I wondered what determined whether a patient that required aged care went into low care or high care.

There was a patient on my prac who was admitted due to hospital from an aged care facility due to functional decline, staff at the low care facility report this particular patient was to not able to return to the facility because they were unable to cope with their needs, and basically admitted the patient to hospital because they believed they required a high care facility to “cope” with this patient.

This patient’s mobility was limited in terms of distance although they were independent with a WZF up to 30 metres. If they were to return to the low care facility they needed to walk independently to the dinning room, which was 80 metres. My aim of treatment was to build to this level so that the patient could return to the low care facility. The patient’s mobility had a big influence on whether or not they went into low or high care. This reflects in the staffing and funding difference between the low and high care facilities.

From this example we see that mobility has an influence in whether a patient requiring aged care goes into low or high care, but not the whole picture.

Assessment of patients going into residential care is done by someone on the Aged care assessment team (ACAT) they ask a number of questions relating to the patients needs and determine what appropriate placement for each individual is. This essential determines the funding paid to the residential care facility.

Funding is based on three domains
Activities of daily living
Behaviours
Complex Health Care

In reflection, it is not the physiotherapist job to determine whether or not a patient goes into aged care, although in the hospital system we are the experts on patients mobility and are uniquely positioned to rehab patient to a level which achieves there maximal level on functionality. I thorough knowledge of discharge options is required to discharge patients to the most appropriate facility to care for there needs.

patella femoral pain

My musculoskeletal prac, included a lot of patients with anterior knee pain. I would say it was one of the most commonly seen area of visits by patients. I effectively treated this condition but I wanted to search the literature to see if my treatment techniques had any evidence base behind them.

Patellofemoral pain (PFP) is used to describe pain in and around the patella. It is an umbrella term used to embrace all peripatellar or retro patella pain in the absence of other pathologies. Other terms of chondromalacia patellae, anterior knee pain, patella malalignment and patellofemoral arthralgia have all been used synonymously with PFP. PFP is often seen in physically active individuals and may account for almost 10% of all visits to a sports injury clinic, reported incidence rates of 7% exist among young active adults. The cause of pains may differ among patients, with the pathologic origin of the disorder not clearly understood. Numerous structures within the patellofemoral joint PFJ are susceptible to overload. A number of these intra and extra articular components can be responsible for the generation on neurosensory signals ultimately responsible for the perceived pain.

PFP is believed to develop when an individual experiences an increase in the magnitude of the PFJ load. The increase in magnitude of load can be considered in two categories intrinsic and extrinsic. Extrinsic load being affected by the bodies contact with the ground therefore moderated by body mass, speed of gait, surface and footwear. Intrinsic factors can influence both the magnitude and the distribution of the PFJ load. Increased femoral internal rotation, knee valgus and subtalar pronation are all intrinsic factors that can contribute to the development of PFP. The overload the PFJ structures may be sufficient to initial a painful response. The increase in PFJ load results in PFP through injury of the musculoskeletal tissue from supra-physiological loads, either single maximal loads or lower repetitive loads. Injury to these tissues initials a cascade of events encompassing inflammation of the peripatella synovium through bone stress. Thus any number of pain sensitive structures can results in the conscious sensation of patella femoral pain.

Differential Diagnosis
• Patellar tendinopathy
• Fat pad impingements
• Osgood-Schlatter lesion
• Referred pain from hip
• Quadriceps tendinopathy
• Patellofemoral instability

Characteristics of Patellofemoral Pain
• Pain in anterior knee may be non-specific or vague. Medial, lateral or infrapatellar
• Pain aggravated by activities that load the patellofemoral joint – eg stairs, running
• Insidious onset unrelated to traumatic incident
• May have small amount of swelling above or below the patella

Functional Anatomy of the patella femoral joint
At full extension, the patella sits lateral to the trochlea. During flexion the patella moves medially and come to lie within the intercondular notch until 130 degrees of flexion, when it starts to move laterally again. The patellas mediolateral excursion is controlled by the quadriceps muscles, particularly vastus medialis oblique (VMO) and vastus lateralis (VL) components. With increasing knee flexion a greater area of patella articular surface comes into contact with the femur, thus offsetting the increased load that occurs with flexion. Loaded knee flexion activities subject the PFJ to loads many times the body weight (eg 7-8 times for climbing stairs) Anatomically the lateral structures of the PFJ are much stronger than the medial structures, so any imbalance in the forces will cause the patella to drift laterally.

Intrinsic contribution factors
These factors may contribute to the development of patellofemoral pain
Remote factors
Increased femoral internal rotation
Increased knee valgus
Increased tibial rotion
Increased subtalar pronation
Inadequate flexibility
Local factors
Patella position
Soft tissue contribution
Neuromuscular control of the vasti

Diagnostic features of PFP
• Display typical clinical features without other pathology on the knee
• Positive McConnell’s Critical
• Pain on palpation of patella facet joints
• Medical Imaging
• X-ray – can show osteoarthritis and an increased likelihood of sinding-larsen-johansson lesion
• MRI- increasing popularity of investigating PFP, due to its capacity to image the patella articular cartilage.
The majority of patients do not require imaging although it may be useful to confirm a clinical impression obtained from the history and examination.

Evidence based Treatment
What work and what doesn’t

Based on summary of Literature found in Brukner and Khan (2006)

Multimodal Intervention – rest from aggravating activities, ice, short course of NSAID’s, electrotherapeutic modalities, mobilisation, acupuncture and taping.
Level 1 evidence
Taping – aim to correct abnormal position of the patella in relation to the femur.
Level 1 evidence
Strengthening exercises – VMO training program, generalised strength training
Level 1 evidence
Stretching—Stretching tight muscles—NA
Hip muscle retraining – retraining hip abductors and external rotators helps to control the lateral pelvis and has been associated with pain reduction in patients with PFP— NA (no available literature)
Foot Orthoses – in shoe orthoses can be an effective management for PFP
Insufficient evidience—Level 1
Surgery – to be avoided. In very resistant cases surgical options may be considered.


Thank you

shin splints

Whilst on my musculosketal prac I treated a patient with anterior shin pain, not having come across shin pain before I had very little treatment ideas and advice for this patient in regards to managing his pain and preventing it in the future. I thought in my blog I could elabourate on what shin splints is and give some evidence based treatment advice If other student s treate a similar patient.

Shin splints are described as pain and discomfort in the leg from repetitive activity on hard surface, or due to forceful, excessive use of foot flexures. The term shin splints have historically been used as an umbrella term for shin pain which is not stress fractures. More recently descriptive terms of Medial tibial traction periostitis MTTP and Medial tibial stress syndrome MTSS have been used to more accurately description the involved anatomy and presumed pathophysiology of this common condition Beck (1998). Published studies report that shin splints accounted for 6-16% of injuries among runners, this been the third most common injury reported among runners. There is still no clear consensus of the pathophysiology in this condition thus naming of this condition may change with further research.

Differential diagnosis
• Medial tibial traction syndrome
• Bone stress reaction or stress fracture
• Chronic exertion compartment syndrome
• Popliteal artery entrapment
• Muscle-tendon injuries, strains and tendinopathy.

Signs and symptoms of Medial tibial traction syndrome
• Dull ache in over the distal one third posterior medial cortex of the tibia.
• Pain may decrease with warm up
• Pain typically worse with loading and resistance
• No focal area of pain present as that may indicate stress fracture

Diagnosis is made through
Hallmark clinical features - tenderness over a 4 to 6 cm area at the posteromedial margin of the middle to distal third of the tibia
Ruling out other pathology - Special test for stress fracture. Using a tuning for over the site of tenderness can provoke pain in the presence of a stress fracture
X-ray - indicated to rule out TSF, infection or neoplasm but findings are generally normal with MTTS
Triple phase Tc bone scan - scan is highly sensitive for tibial stress injuries with the added advantage of being able to distinguish between MTTS and TSF
MRI - has become an increasingly utilized modality for assessing tibial stress injuries.

Patho-anatomy
Neither the exact pathophysiologic mechanism nor the specific pathologic lesions are completely understood in MTP. Traditionally researcher believed the underlying mechanism was repetitive microtrauma to the periosteum and fascial attachments as a result of traction forces from the soleus and the flexor digitorum longus musculature. Although more resent research Beck (1998) is suggesting MTTS like TSF is a bone stress reaction caused by chronic repetitive loads that induce tibial bending forces. It is believed MTP is merely a symptomatic expression of normal periosteal modelling at the site of maximal tibial strain whilst under load.

Evidence based Treatment
The foundation of treatment is based on symptomatic relief, identification of risk factors and treating underlying pathology.
• Activity modification - relative rest and activity modification
Level 2 evidence
• Cushioned orthoses with a semi rigid medial arch support to assist with shock absorption and support pronated foot – can significantly reduce the overall incidence of and specifically prevent medial tibial periostitis
• Level 1 evidence
• Appropriate footwear
• Resolve acute inflammation and promote analgesia - Non-steroidal anti-inflammatory, ice, massage, ultra sound whirlpool baths and acupuncture.
Level 2 evidence
• Soft tissue therapy – digital ischemic pressure, sustained myofacial tension and transverse frictions.
Insufficient literature
• Vacuum cupping
Insufficient literature
• Surgical release – in very resistant cases, has a projected success rate of 70% improvement in high-performace elite athletes

Returning to Sport
The return to activity for athletes after treatment for MTTS must be gradual and individualized. Cross training (eg cycling, swimming, deep water/pool running) and altered training is essential to resolve with conditijavascript:void(0)on. Athletes must adhere to the “start low and go slow” mantra. Once athletes are asymptomatic, it is recommended to start at 50 percent of their baseline training load and increase the frequency/intensity/duration by 10 to 15 percent per week. They should avoid back-to-back days of repetitive impact activity for the first two to four weeks, depending on the severity of the case. If symptoms recur, two additional weeks of rest are recommended and should be followed by a “downgraded” training regimen. Patients can often achieve a return to full, unrestricted activity in three to six weeks. However, a delayed return is not uncommon for this often refractory condition.

I hope this information helps any other students if they treat anterior shin pain.

Abuse on the ward

Recently on my cardio placement, myself and another student happened to encounter a patient with an extremely violent history with unresolved severe mental illness, drug abuse and was Hep C +ive. He was admitted to the ward with a severe chest infection and subsequently stayed for most of the duration of our 4 week placement.
Although we did not directly have to treat the patient as he was deemed too aggressive, we did on occasion have to talk past him and talk to him when he confronted you. The patient hadd 14 code blacks (personal threat) called against him and required 4 point restraint on the bed and sedation on multiple occasions. He also required security guards to follow him whenever he left his room.
The patient became increasingly aggitated and restless as the weeks progressed and his behaviour more unpredictable to the point where he lashed out at a nurse who was not even looking after him and proceded to assault her. Knowing this it made it made me feel anxious and nervous around this patient when I passed him in the ward as he had a tenedency to talk to anyone he wanted to very unexpectably and would demand you reply. I found myself not acting like I usually would and becoming quite reserved around this patient.
Unfortuntely the patient picked up on this and and the change in behaviour toward him and not other patients was enough to set him off into a spat of abusive insults to all staff on the ward.
I learned as the days went on that the best way to deal with this patient was to be alert and on your toes at all times due to his unpredictability but also to treat him like anyone else and ask him how he was and try to relate things to his life even though I was not treating him in any way. The patient responded well to this and would often initiate harmless conversation with me knowing that I wouldn't judge him for his past.

Unprofessionalism

Recently I went to a neuroloigical consultation and multidisciplinary team meeting with my senior to discuss the progress and future care plan for one of my patients. What utterly shocked me the most was the extreme unprofessionalism of the meeting particularly on the neurological consultants behalf. I had been preparing myslef thoroughly for the meeting so that I could provide all the health professionals with the best handover I could so that the team looking after my patient and the consultant knew his progress (and also so I didn't look like a really unintelligent student and make a fool of myself). I had always looked up to consultants, respecting them completely for the amount of hard work, effort and years of dedication that they had given to their field of expertise.
The meeting opened with jokes and comments regarding flatulence, with the consultant proceeding to ask all 15 people in the room their preferred way of using toilet paper (folding/scrunching). I thought that this was highly inappropriate especially for someone like me who was new to the meeting and had never met many of the health professionals before.
It took over 45 minutes to begin the actual discussion on each patient and even then the consultant continued to make bizarre and inappropriate comments about patients and other topics.
On leaving the meeting over 1 hour and 45 minutes later, my senior proceeded to tell me that she also felt that the situation was very unprofessional however I would have to draw my own conculsions on the matter. Was it purely just a bit of fun and humour? I feel not, I felt like all the staff there also thought that the behaviour was unaccebtable but laughed along anyway because it was the consultant, a senior staff member. However to me he will not be so respected in regards to his communication with other staff.

Helping those that do not help themselves

How do we assist someone who does not want to or have the desire to help themselves? On a recent placement one of my patients who was morbidly obese with severe arthritis of most of her large peripheral joints which in conjunction with each other and her lack of motivation had resulted in a severe loss of function.
On the second time that I visited her I found that she would rather blame her lack of mobility on everything else other than her weakness, escessive weight and lack of motivation. In the public health sector, resources and staff are stretched to full capacity as it is, there simply is not the time or manpower to do everything for these patients and treat them on an ongoing basis.
I know that this particular patient may have thought I was a little cruel but I refused to be lenient as I knew she had the ability just not the motivation or the determination. When pushed this patient could get up and walk to the physio gym from her ward rather than be wheelchaired. On one particular session I managed to push her to walk 250m after she had previously been to or from the gym. On subsequent session, the patient displayed utter disgust and shock when I arrived to her room without the wheelchair in tow. She complained the whole way but I didn't care, she was safe and stable which was the most important thing. The only reason she was still in hospital was becuase of her weight and her instistance that she was not ready to go home.
She could abuse me or any other physio all she liked but we are only trying to ensure that she receives the best health outcome. Sometimes shock tactics is what is required to motivate people or to get them to take ownership of their own health. No one else is responsible for their lifestyle and health choices. She may like the nursing staff that come round to see her rather than physio but it is not their respoonsibility to know what specific areas this particular patient needed addressing in.
At some stage treatment and care for these patients has to cease, but when? However it is a fine line between ceasing treatment completely and maintaining treatment to prevent readmittance to hospital. In such an instance what do you do?
In the end the patient was discharged much to her disapproval and was provided with rehab in the home to focus on functional goals within a contextual setting. Quite frankly I was glad she had left because I felt that there were so many other patients that could of benefitted from my help, I really didn't see the point in wasting my time, her time and resources on someone who was draining the system.

Protection

Over the course of this year, we have been exposed to the depressing and sometimes unfair reality of the hospital system. Personally I have experienced two patients who have died overnight and a number more with terminal illnesses. If I have encountered this number of morbid situations in my relatively short time working in hospitals, I give full respect to those that have worked for much longer than me. Especially the professions that are exposed to death and dying on a much greater scale than a physiotherapy student can imagine.

At the beginning of the year I was shocked at the amount of humour that was related to death, dying, injury and the general disease process and its effects. I could appreciate the humour from a comical standpoint but was nonetheless disturbed by the prevalence of it. And it wasn't young, uneducated laymen who were making these jokes, it was educated, experienced, professional medical, nursing and allied health staff that had the largest comedic repertoire.

It bought up a memory from high school where a good friend of mine was telling me about his older brother who had recently graduated from medicine. My friend and the rest of his family had intensely strong christian beliefs and values and the older brother especially was a role model in his faith. So I was shocked to be told about how only a year into his medical profession he was having major doubts about his faith and the place it had in situations he was seeing in his career. Fortunately these doubts were dispelled and this doctor was able to use his religion to protect himself from the deeply affective nature that a working in a hospital has on you.

For those of us who do not share similar beliefs or embrace religion, humour seems to be the most effective way to protect ourselves from the emotionally jarring circumstances that we encounter in hospitals. This isn't humour that insults, patronizes or belittles a patient but humour that allows us to sometimes detach ourselves from terminally ill patients that we have undoubtedly formed an emotional connection with. Some strategy of coping, whether it is humour, physical activity or an ideal home environment is essential in our line of work.

reputation

Earlier this semester I completed my rural prac in Kalgoorlie. In an overall sense Kalgoorlie is quite a large town, but the portion of the town that is permanently based there is significantly lower. As such it falls prey to the usual country town syndrome of gossiping. From what other students have told me, they too have experienced this, whether it be another WA rural town or an international placement in a small community. Coupled with this is the fact that the majority of students are still in their early to mid 20's, a well known stage in life in which we are still prone to do silly and even stupid things.

During our rural pracs most of us would have worked longer hours than our metropolitan placements and had no days off. Therefore it is logical to assume that over the weekend we had quite a lot of steam to blow off. The country pubs and international nightspots in south east asia are great places to let your hair down and have a bit of a party. What I only realised after I had done my rural placement, was the potential for anything we had done over the weekend to trickle back to our places of work.

Luckily for me I had an established group of friends in Kalgoorlie and did not get up to any real mischief over the weekends. The real danger is the affect an event over the weekend, in a non-professional setting, can have on your professional reputation during the working week. Not only can you lose respect in the eyes of your fellow health professionals, but you could lose the respect and necessary authority that is needed to be an effective professional in the eyes of your patients. Especially the local ones who would know anything that happened to occur over the weekend. This affect may not even be obvious but it could be sneaky and insidious and undermine your reputation.

So although those that choose to work in a rural and remoter communities over the following years would be aware of this more than I could be, I thought it was important to re-iterate this point. Remember you can have plenty of fun, but be prepared for the consequences to your professional reputation if something you do is considered great gossip material.

bouncing around ideas

In my last blog I mentioned my feelings towards my musculoskeletal outpatient prac. One other aspect of this prac that I thought really appealed to me was the number of students that were in the placement at the same time. Even though it meant less face-to-face time with our tutor, it facilitated a social environment which I believe improved our skills as physiotherapists. Maybe as a result of the decreased time we could spend with the tutor, there were many times when we bounced treatment and management ideas of each other. Although most of the time we didn't drastically change our approach according to any person's advice, it did guide our decision making and clinical reasoning process for the better. By receiving input from other students with differing ways of thinking, ideas that we might have missed were made clear to us. All in all it was a highly effective way in which to provide the most comprehensive management for our clients.

Once we begin working in the following years, those of us working in a hospital or large group setting will still have the advantage of being able to confer with a multitude of other physio's. Not just physio's though, every other health professional we are associated with can assist us in some way or another, which leads me to my final and illuminating point.

I believe it is absolutely necessary for those beginning their careers in a private practice, to establish a network of professional health workers that are able to assist in clinical reasoning and decision making skills. I know there are some freakishly smart students among us, but even they can not possibly know enough (as new graduates) to provide the most effective treatment possible to each of their patients. Even a close group of new graduates that are working in private practices throughout Perth, can be utilised to share ideas on how to best treat their patients. Remember we do have facebook...

job direction

Before I completed by musculoskeletal placement earlier this semester, I was in no way planning to work in private practice physiotherapy. So I was pleasantly surprised to find out how enjoyable physiotherapy in a musculoskeletal outpatient setting really was. This was because it gave you the opportunity in most cases to completely manage a patients care based on our own knowledge and clinical reasoning skills. We were still guided in our decisions by doctor's referral letters, but the final decision on the patients diagnosis and subsequent treatment was mostly up to us.

In an in-patient setting the patient, in most cases, already has a diagnosis made by the medical team and we are asked to apply our skills to complement their plans and ideas on how the patient should be treated. Now in no way do I disagree with this process, in my limited experience it seems like this way works the best. What I am trying to emphasize is the greater opportunity to clinically reason and make decisions in an outpatient or private practice setting.

I still believe the direction of my career will lead me to a hospital setting, but in this situation I really appreciated this full year of clinical placements and how it exposes to work settings that we never even considered just a year or two ago.

Coming to grips with mortality

Working in hospitals makes us become so much more aware of our own mortality. It's difficult not to empathise too much with patients, or want to become too involved in their lives.

A patient I saw on the ward was an example of this. She was a 59 yo woman presented to hospital after a dizzy and fainting spell. I was asked to review her due to her unsteady gait, and decreased equilibrium responses. During my initial assessemnt, I felt a real connection with this lady- we got on very well, and joked a lot. I recommended she use a zimmer frame, whilst medical testing was being completed to work out the cause of her sudden onset of symptoms. She shared her history with me, she just left her job to start her own business from home. She had put down her dizziness to overwork from the amount of work she had put in to setting up her business, working up to 18 hour days some days.

However, her symptoms continued, and she did not appear to be making any improvements. However, I built a stronger and stronger rapport with this patient, and looked forward to my daily treatment sessions with her.

Then at the ward meeting, the medicos told me news that shocked me. This woman had lung cancer, which has metastasised to her brain, and was given maximun of three months left to live.

I felt really uncomfortable with seeing her after I knew this. What do I say to someone is such a situation? Our friendly comraderie had gone, we lost rapport.

Looking back, I feel we lost rapport on both sides of the therapist- patient relationship. I couldn't believe such a diagnosis could be given to such a young and active person, and this lady was coming to grips with her prognosis. I don't know how to prevent this in the future, but this was my initiation to the unexplainable events of life and death that are an everyday occurence in hospitals.

Patient perspective...

In the final week of my final prac for this year I managed to badly injure my knee and end up in a knee splint and on crutches. I was able to see first hand the emergency department of the hospital I was working in, and was instructed to take the week off. Scared of failing my prac, I didn't take time off, and persevered through the week.

What I learnt during this week as a patient/therapist was invaluable. When we are able bodied, we take for granted our mobility, freedom and ability to do the tasks we are required to do with little or no effort. Day to day we see patients either in outpatients or on the wards who are on crutches, have a cast on, are in pain, post-op or in a great many other conditions. Its so easy for us to instruct people to use crutches, or to say 'use this brace for a few weeks', often without realising how hard that will be for the patient in their day to day lives. On doctors orders, I was only allowed to talk to patients, verbally give exercises, do easy hands on tasks and have an assistant for my initial assessments. I wasn't aware of how frustrating this would be! I had to totally change my way of looking at things, and the way that I ran my treatment sessions.

Another 'lightbulb moment' I had during this week was the frustration of not having a diagnosis or prognosis for my injury. Patients often come to us searching for answers, and we are not always able to give them what they want. Due to cirumstances, I was left not knowing what damage I had done to my knee, whether I would require surgery or whether I would simply wake up the next morning and it would be better! This is a scary situation to be in, and we need to be aware of this with all of our patients - be aware of the psychological impact of the injury, as well as the physical marking such as swelling and pain. Mental state can have huge repercussions for recovery and good outcome. Tell them as much as you can - don't assume they won't understand, or shouldn't know. Communicate!!!

Last but not least, I learnt that when you walk with crutches, or limp, or can't do things due to pain, people stare. They just can't seem to help themselves. Don't stare at someone on crutches!!! Help them out if they look like they're struggeling with a heavy door, or simply offer them a seat if you can see they have a brace on and are hurting (I know, as physio students I'm probably preaching to the converted, but I had a surgeon at the hospital take a chair that I was about to sit on, and then say 'that looks painful'. Duh.)

Although injuring myself whilst on prac was not a good thing to have happened, it gave me an invaluable insight into how life is for so many of our patients. One of my patients has been on crutches for 5 years, and will be using some sort of walking aid for the rest of her life. She didn't have a lot of sympathy for my sore wrists from hopping around the hospital on crutches!! Put yourself in the patient's shoes (hopefully not literally like I did...) and then rethink what you want to tell them, or prescribe them to do.

ignorance about PT

I have just realised how little some other health professionals think some physios do. Last week there was a meeting held mainly between orthopaedic surgeons and the anaesthetists to try and establish what the best form of anesthetic was to enable early mobilisation and post-op recovery. Members of the allied health team were also there to provide input when appropriate.

In a nut shell, the surgeons were asking if there was any evidence-based literature to support a form of surgery where patients didnt need to have an epidural or regional anaesthetic and therefore had less chance of a motor block preventing standing on day 1.

What shocked me was that several anaesthetists boldly said they thought mobilising day 1 post -op had little benefit. When the physios and surgeons promptly told them that yes it was infact beneficial, they asked why a few orderlys couldnt just stand them up and support the quads if a motor block was in place. Most people were shocked by this statement as it showed just how little these anaesethetists knew about physio and patient treatment. This therefore highlighted to me the need to be able to rationalise our treatment choices and have a strong justification for what we do as there will be many people out there who try and challenge our choices.

staff communication

Since this last prac has been the first one for me on an inpatients ward, it has really helped me to work as a team with the other staff. I have learnt how much easier everyone gets along if people help out even when a task isn’t really in their particular field. For example just little things like taking the time to help a nurse roll a comatose patient over so they could change them meant that the next day that same nurse helped me walk a day 1 post-op patient that needed x2 assist, when really it should have been the other physio student.

It has also shown me how important it is to coordinate tasks with other staff. Since walking is so tiresome for some older people, they can often walk only a few metres before being tired for the next few hours. This means that its really essential to time it so that when we get a patient OOB, it fits in with the nursing staffs plan of when to shower them, sit on the commode etc. It has just really opened my eyes to the benefits of talking with the other staff so that everyone knows exactly what’s happening and can work together to a job done the most effective way for us and the patient.

Treating a physio

During the last week of my cardio prac, I had a post-laparotomy patient who also happened to be a practicing physio. It was a great opportunity to talk to someone who understood all the different facets of our treatment and I took the opportunity to get some extra feedback on my skills. The patient was quite fit and healthy before the procedure and had little complication afterwards.

A situation did arise where the patient disagreed with one aspect of my management. They requested to be discharged with a pair of elbow crutches, something that I would not normally do in my usual management of this type of patient. I had sent home patients much older and in worse shape home with nil gait aids and was quite justified in doing so. Why prescribe a gait aid which could negatively affect the patients posture and the quality of their gait? Isn't it optimal to get the patient walking as "normally" as possible as earliest as we can?

These are the reasons I used to justify my choice to the patient. Conversely, the patient had reasons of their own, based on past medical history, the complicated situation surrounding their surgery ( x4 misdiagnosis in ED before the procedure was undertaken) and differing views on how to best undergoe their rehab.

Now usually I am quite happy to recieve a few little negative responses from patients if I know without doubt my management strategy is the right one. If it was any other patient I would have discharged them with nil aids. With this particualr patient I had no real problems prescribing elbow crutches because they had justified why they needed them. I was confident that the patient understood the impairments that could arise from relying to heavily on them because of their education and experience as a physiotherapist.

dishonest?

On my last prac I was looking after a older lady (90+) who was initially admitted for a laparotomy. In most cases the patient is discharged anywhere between 4-10 days. This patient had her operation at the beginning of my second week and was still not discharged by the time I finished the prac. She had no chest issues that were keeping her in hospital and after consultation with her surgical team I found no medical reason to keep her in hospital.

The reason she was still at hospital was because her carer had informed the social worker that the patient was not coping at home. This was revealed to us at a team meeting. The patient lived at home pre-admission and had services for cleaning and cooking and family help for shopping. She was still home alone for large amounts of time with no help. It was reported that her mobility was impaired to such a level that there were hygiene and toileting issue beginning to emerge. She was also found many times asleep in her lounge chair because she was not able to make it to her bedroom.

Consequently the patient's main physiotherapy concern was mobility. This patient was a typical candidate for low-level care and a request for the DCGM (Department of Community and Geriatric Medicine) team to review her was promptly sent with the aim of an ACAT (Aged Care Assessment Team) assessment.

When I discussed this with the patient I recieved quite a negative response from her and was promptly told that the only place she was going to would be back home. The treatment session I had planned was refused and the patient would not talk to me. Even though the medical and allied health team, together with the family, decided that the patient was not coping at home, the patient was still adamant that she was going home.

Now I don't believe I was being dishonest, but to be able to perform any rehab with this patient it was necessary for me to not mention low-level care again. The patient repeatedely commented during the rest of our treatment sessions how she was going home. I didn't say anything contrary but neither did I agree with her. In the end I believed that the best course of action was to maintain a rehab program while she was still on the surgical ward. Maybe later on in her rehab process the issue could be raised again but in order to provide the most effective rehab while she was still on my ward I chose to not disucss low-level care again.

Rapport building

Whilst treating a patient this week I learnt the benefit of being polite but firm with patients. I was seeing an older lady who was day 4 post routine TKR. She was only getting about 20 degrees of active knee flexion but should have had around 50 or 60 by then. She was complaining of severe pain however refused pain medication as she preferred more natural remedies. My supervisor had warned me that she was difficult and very particular about her treatment and not to bring up some of her PMHx as she would argue that none of it was true. If things weren’t done her way then they weren’t done at all – hence the lacking ROM.

So the first time I went to take her down to the gym, I tried extra hard to be nice and build some rapport with her so that she would be compliant. Which meant that I let her brush her hair, put on some hand cream, helped her walk very slowly to the toilet etc. However this meant that I had already spent 25 minutes with her by the time she got into the wheel chair to go down to the gym. She was extremely friendly with me and did as I asked and increased her AROM, albeit very slowly. By the time I got her back to her room, a treatment that should have taken a maximum of 30 minutes had taken just over 1 hour. I still had so many patients to see and therefore was rushed the rest of the day.
From this I learnt that whilst building rapport with the patient is essential, we still have to be in control of the treatment session because our time is very precious, especially next year when it would have been just me on the ward. The next time I went to see her I popped in 15 minutes earlier to say she had to be completely ready by a certain time and we had to be back to the room in 20 minutes. This worked effectively and taught me that yes you need to build rapport with the patient but this should not mean using up all our time just to keep ‘fussy’ patients happy.

Diagnosis and treatment

On my current prac I work on the wards each morning, mainly with post-op and respiratory patients. Last week I was asked to see a young girl with 'left lower lobe pneumonia'. She had quite frank haemoptasis, and was in a great deal of pain, which was localised to the left side of her chest. She was short of breath, fluctuated between febrile and afebrile an back to febrile in the blink of an eye. For the first few days of her stay, she was quite uncooperative with breathing exercises ue to pain, and was refusing to get out of bed. Wary of her pain and blood stained sputum, I approached her with caution. Her sats were VERY low and she was in serious need of some treatment. The first treatment conisisted of teaching thoracic expansion exercises within pain limits, and bed exercises (ankle pumps, static quads and gluts), and instructing the patient to perform these at least every hour. I documented each treatment in great detail, and saw her everyday. Gradually she was able to get out of bed, and walk on the ward, but she was not getting better no matter what we tried. Each chest xray came back the same. After 10 days, the doctor finally ordered a CT scan and other investigations that had not yet been done. These picked up that my pneumonia patient actually had a PE and a DVT!!! No wonder she wasn't improving. On reviewing the notes, it was evident that we had done all we could to treat her, and had done our best to prevent the subsequently developing DVT. After being treated for the actual problem, the patient was back to health in just a few days. If I have taken anything away from this experience, it is to be conservative and cautious, and never underestimate simple bed exercises and good documentation. Even if you think a word of advice or basic exercises are not that important to document thoroughly, you never know when your documentation will be reviewed. My documentation in this case is evidence that we did everything within our power to offer the patient the best possible treatment.

Age Care Assessments

I was on my rural prac doing aged care assessment for permanent residents at the hospital. This assessment is done by a physio either six monthly or yearly and involves an in depth look at the patient mobility, balance, ROM, strength and coordination. It is documented in the patient notes and can be reference to monitor the patient through out there residency at the hospital.

This particular patient I was required to assess had been admitted due to dementia and varies co morbidities. More recently her mental status had declined and the nursing staff where finding her more and more difficult.

I had been warned that she was most likely going to be uncooperative, but I thought I could lay down a bit of the physio student charm and get her onside and happily participating in the assessment.

I strolled into her room confident as can be, quickly built some rapport with her, then wrongly asked her if she would like to participate in the assessment. She quickly changed tunes from being a nice old lady to promptly telling to where to stick it. I was shocked; I had been bitterly shut down by an old lady giving the nurse looking after her quiet chuckle and slightly denting my ego.

I walked away with my head down preparing for round two. It was extra important for me to win round two as she and her stubborn ways was the only thing stopping me from going home nice and early.

I thought I would change tacts a little and instead of asking participation in the assessment I would DEMAND it. I went in for round two, not mentioning the word assessment but rather asking the patient to do various tasks involved in the assessment. This change in communication strategy work quite well and left the nursing staff amazed I had got so much out of the patient. In the end I finished the assessment thoroughly completing the assessment. What I learnt from this was don’t give up when a patient is difficult go in for round two changing communication strategies.

Staying motivated for Self directed placement

Looking back on the 4 years of my physiotherapy degree it seems that I have been subjected to an amazing amount of work. Why now with less than 10 weeks to go do I find it ever so hard to stay motivated with this ridiculous self directed placement?

I know this blog is not under the typical contents of reflections, but I think is fits nicely within the professional practice and ethics theme of blogs.

The self directed practicum may be as challenging as any other pracs undertaken in the 4th year clinical experience. For some like me it seems to be extremely challenging in regards to motivating my self.

I believe the self directed prac is included in the 4th year clinical experience as it duelly reflects a task that may be required whilst working as a physiotherapist. It is beneficial to now realise the troubles of motivating ones self when completing a teadious (at time seemly pointless) task.

In terms of overcoming my limited self motivation, I have no magic answer. Personally I have found treating it like a job useful. (If you can trick yourself and not sleep in) I have found the most benefit by going into Uni finding a computer and pretending I’m getting paid to complete my self directed assignment (I wish). The deadline also helps, breaking up the big tasks into smaller tasks and putting achievable deadline on them may also prove useful for some.

Well best of luck for anyone else going through this similar conundrum.

Patient not managing at home

Recently on my Neurological outpatient’s prac, I was treating this gentleman with degenerative neurological condition. He had been diagnosed with this condition for 10 year but was still able to live at home independently. He presented to outpatients, this time been the first time I had seen him reporting a severe pain in his left hip. He reported having this pain for a number of weeks with it becoming unbearable in the last few days.

With further questioning he reported that he wasn’t managing at home due to the severe pain. The pain was made worse when he suffered a spasm in his left leg. It was a negative support reaction or flexor withdraw response associated with his neurological condition.

Straight away I realised it was my duty to organise further referral to get to the bottom of this patients pain. Collaborating with my supervisor we had a medical team reviewed this patient within 30 mins and offer him an inpatient bed for further investigation.

The patient ended up on a rehabilitation ward for 2 weeks and had his pain thoroughly investigated and treated. It improved vastly and the patient was heading towards pre hospitalisation function. My prac ended, but it was assumed the patient was adequately rehabilitated to again function independently at home.

The time physiotherapists spend with patients in the rehabilitation setting, places them in a good position to understand there needs and basic requirements. The time spent with a client often reveals information that otherwise wouldn’t have been revealed if time was rushed. The example above highlights this; the physiotherapist initiated other services which benefited the patient. If this information wasn’t obtained the patient may have continued living at home not coping well.

observe

I am currently doing my cardio placement on a surgical ward. As most of you would know this involves mainly chest physiotherapy and mobilising the patient (amb, SOOB in chair etc). When it comes to getting the patient up from a bed for the first time post surgery, it is imperative that we monitor their SpO2 and make sure it does not drop dramatically. We should also check the pt's charts prior to any treatment to make sure their blood pressure is stable.

Even though monitoring the patient is quite important, I have been made aware of the fact that I seem to rely too heavily on a SATS monitor and not enough on my observational skills. This was pointed out to me a number of times by my CCT, who is encouraging me not to underestimate the reliability of these observational skills. It seems that I have been using the monitor as a security blanket. As a result I am not questioning the pt throughout the treatment about any changes in their symptoms.

The two pt's I have seen with my CCT have both displayed low SpO2's of below 94% but have been consistently asymptomatic. If this is the case what is the point of me fumbling constantly with a monitor when I know the patient is not suffering from any ill effects. In fact, there have been some instances where the added piece of equipment may potentially compromise the pt's safety.

After all this was pointed out to me I realised that a major area of improvement within my skill set was my observational skills. It is just as important if not more to monitor the pt's appearance and note any signs that they are not coping with ambulating or moving out of bed. In order to effectively learn this, we sometimes have to go easy on the SATS monitors and develop our observational skills, especially while we are still students for only 2 more weeks.

Postural Hypotension or something else?

I am on my neuro prac and this has happened just recently. One of the patients who was recently admitted to the ward following a stroke was taken to the physio gym to progress with rehabilitation and treatment. The patient proves to be a VERY strong "pusher" and is unable to maintain the vertical postition in standing as he pushes his COG over to the affected side, however due to his hemiplegia he requires the assistance of 3 people to sit to stand and remain in standing. The decision was made to attempt to provide some treatment for the patient on realignment using the tilt table with the senior physio.

At the start of the treatment session the patient displayed exceptionally high tone in the right biceps, internal rotators, adductors and wrist flexors - your typical flexor synergy of the upper limb. He is also very overactive on the unaffective side and has impulsive behaviour. The patient was incrementally raised on the tilt table, and signs for postural hypotension noted. While the physio was providing some mobilisations on the affected foot and positioning the feet the patient suddenly lost all tone in the right upper limb and his head became fixed in a side flexed position. The situation did not follow a typical lack of oxygen to the brain as in postural hypotension as the expected signs would be sudden loss of postural and voluntary control. We found it odd that the patient had fixed his head and we were unable to move it - it looked more like the patient was having a fit, or another stroke.

The patient was rapidly taken back to a horizontal position and his vitals taken - all of which returned normal values. The situation was discussed with the doctors who diagnosed the event as 'poor perfusion'. Subsequent events have since occurred, however it seems the medical staff are not taking the situation seriously as they insist that we promote standing ASAP yet disregard these incidences which would seemingly be a contraindication to stand. In this situation I think it is necessary to go with your instinct and if you don't feel comfortable continuing with the treatment session due to patient saftey then don't!

When it all becomes too much...

I am currently on my neuro prac on a stroke/rehab ward. On my first day I was writing notes at the nurses desk when a nurse hurried past calling for a doctor and some assistance. One of the patients on the small ward had tried to end his life by jumping off the balcony before the nurse had managed to get him back inside. The patient who had suffered a stroke was hemiplegic and had communication problems and was clearly frustrated and angry at the attempts made to prevent him hurting himself. The patient continued to scream on the ward, swearing and saying that the staff should of just let him die before a doctor calmed him down by sedating him.

This is not the first time this year that I have dealt with patients who have attempted to end their life however I have never been experienced to the situation actually taking place. I cannot even begin to imagine the emotional turmoil that some of these patients are going through, having to depend on others for all their basic needs when previously they were completely independent. Today I had one of my patients tell me that he wanted to die. He has been an inpatient for over 10 weeks and his progress has started to stagnate in terms of functional gain. What do you say to someone who shares that with you? Encouragement throughout treatment sessions is crucial but as Andrew said it is so important to be careful of what you say, so that you don't give people false hope.

I think it is important to be aware and very conscious of the fact that people who have had an acute neurological insult are more prone to having negative thoughts and feelings of hopelessness. This can carry over to you and be quite a burden yet you can't pretend to know how the person feels. At the end of the day, referral to psychologists may be required but patients are still going to reveal their darkest feelings on occasion and it is necessary to know how to handle these situations with tact and not disregard them.

Child Health referrals

On my current prac we receive many referrals from child health and school nurses, often for minor things that turn out to be not a problem. However, being on this prac has made me aware of the immense importance of these nurses in the development of many children in the area. Last week we received a referral regarding a little boy who walked on his toes and his feet slightly turned in. At the start of the assessment, it seemed that the boy was simply toe walking, and there turned out to be a family history of this. However, as the time with the child went on, it became obvious that something was not quite right. He didn't make eye contact, was easily distracted, and his movement patterns were not what we would have expected. Rather than starting to form words, he made very primitive noises to get what he wanted, and the more the mother told us, the more we worried. He also had some minor abnormal tone findings. As a result of our assessment, he has been further referred to see the paediatrician, with a possible diagnosis of CP or autism.

This expereince has made me realise that although many referrals come through from child health nurses, and some are just precautionary, some of the precautionary ones tend to be lifechanging for the child involved. A thorough assessment is paramount, and if possible, 2 sets of eyes are better than one. Child health nurses are an invaluable part of our healthcare system, and we should never underestimate the power of a referral. The mother in this scenario simply thought her first child was restless and was reaching all his milestones, when in reality he was not. Hopefully the intervention of the nurse, physiotherapy department and finally paediatrician will allow the child to lead as normal a life as possible.

protect your backs

A few days ago my supervisor and I went to see a patient who was day 2 post TKR. She is on a clinical pathway and therefore the aim for day 2 is to walk a few steps and start her knee exercises. However she was in too much pain on day 1 to stand so this was her first time getting OOB. This patient however is quite stubborn and impulsive and also weighs 170kg. After getting the doctors in to convince her to at least try standing up, she did so very reluctantly. However after a few seconds standing up she tried to sit back on the bed without telling us. As a result she nearly missed the bed and we had to really try hard to stop her falling. She's quite a short lady with little legs and therefore couldnt push off the ground to get back on the bed so we had to sort of 'pull/lift' her back on the bed. I was behind her and in charge of her trunk and as a result got quite a sore back. I think it's a tricky situation because obviously you cant let a patient fall and she was in severe pain and trying to get back into bed straight away, however you always have to make sure you protect yourself as well, especially your back. In hindsight we probably should have anticipated her having difficulty getting back into bed and asked the nurse to be around in case we needed a third pair of hands to help just to make sure everyone involved stayed safe.

A conservative approach

It has taken several occasions with similar circumstances for me to realise the importance of being on the conservative end of the realistic spectrum when it comes to patient outcomes.

There have been many musculoskeletal outpatients that I have treated this year who are very motivated and have very high expectations, for example chronic low back pain that will completely resolve if they do all the exercises and follow the advice I have given them. In a case such as this it may be clear that an important part of managing the patients problem is just that - educating them that managing the problem is likely to be the best outcome due to an element of irreversible damage. There have been other times however where patients have been unrealistic about their prognosis in terms of function and time taken to reach the function, and it is much easier to reflect their optimism than to "bring them down" to the most likely outcomes, trying not to reduce their enthusiasm and compliance.

It has been in my current neuro prac working on a rehab ward with stroke patients that the importance of being realistic, and even conservative with the way I influence a patients expectations. I have found that being overly optimistic and even saying "The way you are progressing at the moment you should have more movement in your hand by next week" - the type of statement several patients are clearly looking to hear can have a detrimental effect. Although in the short term it may help with compliance and motivation, I have found that when I am wrong about these types of prediction the patient loses confidence in me as a therapist and/or themself in terms of recovery.

From these many experiences I have learnt to keep certain goals for patients to myself and when I do give them my opinion on likely outcomes (which is still important), I think longer before answering to stop myself being caught in that desire to reflect their optimism and give a more cautious, considered response, erring on the conservative timeframe or level of recovery expected for their condition.

Reassessing a patients situation

Although the patient involved in this situation was not in my care it drew to my attention a situation which is not uncommon in the public health sector that is likely to result in poor patient outcome.

A patient who had a stroke was admitted to the hospital I was on prac at and acute care provided, however the initial plan was for transfer to a rehabilitation ward at a different hospital. The patient was seen by a physiotherapist who performed an assessment, some basic ROM exercises and repositioning of the patient. At this point it was assumed that the patient would receive the necessary rehab elsewhere in the next day or so and was effectively discharged from physio services on that ward. There were complications (not related to the patients status) which prevented immediate transfer to the rehab unit for more than a week, during which time the patient was hoisted on the ward and not given any form of rehabilitation from allied health.

This situation can easily occur if patients are not re-referred from the coordinating staff when discharged from a particular service such as physio, or if the judgement that it has been too long to continue waiting on a future service is not made. In most cases allied health professionals will review the ward lists and enquire as to why a patient has not been discharged after the intended period, however this needs to be common practice to ensure that a patient receives rehab as soon as feasibly possible to maximise outcomes.

adverse neural tension

Whilst on rural placement I saw a lady who had fallen off a trailer, landing on her shoulder and forearm who was diagnosed with and treated for a distal radial fracture. She had been seeing the OT at the hospital who then referred her to physio due to shooting pain down her upper limb originating in the shoulder.

On assessment I found that she was extremely sensitive to neural tension provocation tests and palpation of the median nerve, with symptoms in this distribution. Her presentation was difficult in that she had a history of bilateral carpal tunnel syndrome from her work in embroidery as well as persistent oedema and pain around the fractured wrist.

Initially I felt overwhelmed by her problems and symptoms, which presented in a very irregular fashion - changing every couple of days when I saw her. I wasn't sure where to start as she was quite irritable and had many likely contributing factors which were difficult to differentiate. I needed to do some reading to find out more about the problem of adverse neural tension, however after doing this I became aware that these fluctuating and highly variable symptoms are quite typical of this problem. Although the evidence is not very specific in terms of treatment parameters, I learnt more about gliding versus tension in the peripheral nervous system and their roles as treatment techniques based on the irritability of the problem.

Having the knowledge of the evidence that is available (much of which has been conducted in the last couple of years, after we covered it) the patient and I were able to make fairly rapid progress with what initially presented as a highly irritable and functionally limiting condition.

This really highlighted for me that even now, before we have graduated, the importance of finding suitable ways to continue learning about the ever-changing best practices to deliver the most effective treatment to our patients. This will virtually always extend beyond PD courses and journal clubs etc as they might not cover the conditions or treatment areas that are specifically required for our clients.

Rural

On my current placement (rural) I am working with a lot of patients who live in remote communities, or in home situations that are not the same as what we'd experience in Perth. For me, the hardest thing about this is knowing when to change my plans or treatment sessions and goals to suit the patient and hospital better. For example, last week I saw a lady who was admitted with hip pain and was unable to walk, post MVA. She lived quite a way out of town, and appeared to live quite roughly. After assessing her strength and range, and determining that she did not require the oxygen therapy she was receiving at the time we got her out of bed and went for a walk. I would ideally have sent her home with a frame to assist her ambulation and decrease her pain, but after talking to my supervisor, this would likely not have been appopriate. A falls prevention group, regular checkups and provision of an aid would have been by discharge plan, but in this case was not appropriate.

Many walking aids are given to patients from outlying communities, and few are ever returned. Some are returned, but are often burnt or destroyed in some other fashion. My supervisor told me that many patients will use the frame for a day or two, but then discard it due to social situations, uneven or unnegotiable terrain or other factors. THe outlying communities are visited, but it is often hard to track down patients or see everyone on the limited visits.

It is therefore important that we as physios in this situation ensure that the patient recieves optimum care whilst accessible in hospital, and that they are ready to go before they go home, no just becuase the bed is needed. Plans need to be constantly updated and modified as required, and not two patients are ever the same!!!

Treating a Prisoner...

Recently on prac i was allocated 4 patients that i was treat everyday for my placement. When it came to my attention that one of my patients was a prisoner, i didn't know what to think. The usual thoughts went through my head: is he dangerous, do i treat him differently so he can't take advantage of the situation (i.e. use of equipment that could be a potential weapon), are there things i shouldn't say etc etc.

This man was convicted for armed robbery. He sustained his head injury from a gun shot to the head leaving him a hemiplegic and this is why he was in hospital. After seeing him for the first time i immediately knew that i could treat this patient just like any other and i was safe. Even though this patient was a hemiplegic and couldn't stand independently let alone crawl away, he had shackles around his ankles at all times (except physio) and 2 armed guards with him 24/7, which was later reduced to 1. It was intriguing to observe that all prison rules applied to him while in hospital. Visiting hours were scheduled and limited and he was only allowed to wear prison clothing and shoes.

Treatment progressed as normal, the most difficult aspects i found was the communication. What do i talk about with him? Trying to get a subjective history off him was really difficult as it was to do with his criminal history, unlike other patients where they had just a motorbike accident. I asked the standard questions and he gave me very brief answers. I didn't push for the details unless i felt some more information was necessary for the treatment. Over the next couple of weeks, most preconceptions i had of prisoners disappeared as he slowly opened up and were then able to have friendly conversation.

What i'm trying to say (as its not everyday you are treating a prisoner) is don't have preconceptions about individuals because of sterotypes. Everyone has a past and so don't judge a book by its cover. Having said that, never be complacent and treat each case individually as it presents.

If anyone has any insight though on whether there are any guidelines we have to abide by in these situations. i.e. not discussing criminal offences with the patient or if you see them on tv?? i gather that it is just up to the individual's discretion.

The patient in a holistic view

On my current placement I visited a patient post laparotomy on two occasions. He had a complicated previous medical history. His presenting complaint was yet to be diagnosed. The medical staff had changed trialled and changed his medications a number of times. He had lost 30kgs over the last 6 months, and was now 50kg. He had undergone a huge amount of investigations. He had been on a nasogastric feed for a number of days, every time he tried solids diarrhoea would follow. His gut couldn’t hold anything in.

My supervisor had asked me to check on his chest and mobility. On the first occasion his nasogastric tube was in and no diarrhoea was present. He felt confident to comply with physiotherapy treatment, which included a chest review and ambulation. On the second occasion he had trialled solids the night prior and had diarrhoea all morning. He was not confident to leave the bed. He was not compliant with physiotherapy. Initially he told me to ‘go away, I don’t need physiotherapy’. I proceeded to explain that it was only a procedural check-up, he told me ‘physiotherapy is the last thing on my mind’. His wife and I stepped aside for a moment, and she apologised, saying how he usually not like this, and usually very compliant.

At this point I considered him more as a holistic being. In my mind, the best thing for this man would be to review his chest, and maintain his ROM/strength through ambulation and strengthening exercises. But all he wanted was to understand why he had lost a third of his bodyweight in a matter of months, why he can’t eat and why his stomach hurt so much.

My decision was to assess his chest only. He was compliant with this as it did not require him moving from his bed. After this, I educated him on maintaining his breathing exercises, strengthening exercises and walk on the ward when he felt able. I left the treatment there.

In the future, I want to read my patient notes and attempt to picture my patients in a holistic view, prior to approaching them. Physiotherapy may not necessarily be top priority for them, and as much as I would like to assist, I must never force treatment on to them.

The transition from a student to Qualified health professional

My recent international placement was conducted at a community centre for stroke rehabilitation. It was a non-governmental, not for profit organisation, which relied mainly on the assistance of volunteers to function. Our supervisors were local physiotherapists who also volunteered their time.

Within the first 2 hours of arrival I was expected to conduct an exercise class to a group of stroke patients. By the end of my first day I had conducted 2 exercise classes and seen 3 patients. Throughout the initial week I was the primary health professional of which these patients saw for treatment. There was another Malaysian physio present at the centre, but she had her own clients, plus her training varied from Australian physiotherapy and I was reluctant to seek her advice.

I was initially challenged by this. But by the end of the first week I had learnt to trust my observational skills, and my choices of treatment. As there was no one else to double check me, I had to be confident that the skills I’d learnt, during my practical classes and that of my previous neurological placement at SCGH, were effective.

This experience has changed my perspective of physiotherapy from a student point of view, where learning is the main focus, to that of a professional, where treating, informing and educating is the main focus. I think this experience has assisted in bridging me from being a student to a qualified health professional. I know this year is aimed at doing this as well, but I think this placement really threw me out there with no safety nets.

quality of life

During my placement on a head injury unit, i encounted various issues and situations that really made me think about quality of life. One in particular was a 25 yo man post head injury who presented with only high level balance problems. His primary problems were cognitive and he could barely retain any short term memory, lacked simple initiation and struggled to follow more than 1 stage commands. This young man always had a smile on his face and was a pleasure to treat.

I lost sleep just thinking about quality of life. this man would need a carer 24/7, he wouldn't even be able to cross a road by himself. So many thoughts went through my head. Where do you draw the line? what will this person ever achieve? His family will now be consumed by his existence; his g/f is waiting for the old him to come back. I know i would do the same if it were one of my family but is it worth it. Yes my personal views were pessimistic but i couldn't help it.

It seems as though medicine at present is caught inbetween enhancing their ability to save more and more severe head injuries, however we are left with more and more patients that require long term care. I guess it is just time before medicine improves even further.

I have learnt on this placement to put myself in the families position as much as i can and i continue to treat to my capacity in effort to maximise each patient's potential. In this particular case the patient is always happy and would brighten up the day of anyone he sees. Even though he is not the same as before he makes small improvements everyday. If anyone else has a different perspective on similar issues i would love to hear and continue to widen my awareness.

Cross-cultural rapport

I am currently on prac in a rural area with a large proportion of indigenous patients. Whilst treating a 22 year old indigenous woman for her chest symptoms following an acute bout of pancreatitis, I learnt first hand that rapport is often more difficult to establish, and certainly at least as important when treating patients with a different cultural background to my own.

The first time I saw this young lady I did not allow a lot of time to see her as she did not need too much intervention from a physiotherapy perspective. Although I had several communication strategies in my mind for this particular patient to avoid any perceived disrespect, such as being aware that she may prefer to avoid eye contact, I missed the most important element of communication: building rapport.

I felt I was being culturally aware, explained rationale for what I was asking her to do and (I believe) instructed her effectively. Despite this she appeared very disinterested and barely said a word, even when I asked her questions. After some thought, the next day when I saw her again I allowed more time, and for the first 15 minutes I just asked her about what she likes to do and generally made conversation. After this, although she still did not speak a lot, she appeared much more interested in what I was saying, and was able to do her breathing exercises more effectively.

What I learnt from this scenario was that I can’t expect a patient to be interested in what I am telling them if I don’t show interest in them as a person as well. Sometimes patients are eager to understand their condition and how to manage it, whilst others need to be interested in what you have to say in general rather than the specific information you are giving them. I found that I naturally establish good rapport with patients who I can identify with more easily, and so need to be more conscious of doing this when interacting with patients of other cultures or vastly different personalities to my own.

Effective physiotherapy Rx post lobectomy

On my current placement on a cardiothoracic surgery ward, I had a patient who underwent a right middle lobectomy. I saw her from Day 1 to 4 post-op, and saw remarkable results that I believe are largely due to the physiotherapy treatment she received.

Her chest x-ray from Day 1 showed consolidation of pleurae below the area of lung tissue that had been removed. The right hemidiaphragm was superiorly displaced 3 ribs higher than the left. Subjectively she reported pain with coughing and no production or clearance of sputum. Upon observation she had an upper chest breathing pattern. Auscultation showed inspiratory crackles throughout bilateral lower zones, reduced breath sounds in her right lower zones, and absent breath sounds in the area here her right posterior and lateral lower lobe should be. Chest expansion was reduced in bilateral lower zones. Cough was weak, painful (7/10), moist, ineffective, non productive. She was unable to mobilise in and out of bed due to discomfort.

For the following 3 days her treatment program consisted of; education on PCA use and importance of mobilising, deep breathing exercises (breathing control, Sustained maximal inspirations, huffs and supported cough), mobilising out of bed and ambulating on ward and IPPB (Bird).

Chest x-ray on Day 3 showed great results. Her lungs appeared to be re-expanding. The right hemidiaphragm was 1.5 ribs higher than the left. Subjectively she reported little pain with a supported cough and she was not producing or clearing any sputum. Her breathing pattern was almost normal and she consciously corrected herself when she began upper chest breathing. Auscultation showed no inspiratory crackles, and breath sounds in the right lower zone was improving. Cough was moderate, no pain and dry. She could mobilise with stand by assist. Medical staff anticipated discharge over the weekend. She had booked Therapy In The Home (TITH) to assist with her mobility for the initial week or so, and will come to Cardiothoracic rehabilitation classes for the next 4-6 weeks.

I think this is a good example of how a simple physiotherapy regime can be effective. It is nice to have an uncomplicated and rewarding case!

Compliance at first sight

On my rural prac in Kalgoorlie I was introduced to a patient suffering from Parkinson's Disease who had recently undergone cardiac surgery in Perth. He had been transferred back to the rural hospital and was in need of basic post-op physiotherapy that would also take his PD into consideration.
The physio treating him before me was not having much luck, as the patient would often feel depressed, not willing to do exercise and fearful during any treatment. Subsequently he was not achieving his goals as well as was hoped for.

My initial assessment with the patient was with the physio's supervision and we were not able to persuade the patient to partake in our treatment plan. He got tearful and requested to go back to bed. The next time I saw him it was by myself and the treatment session consisted of ambulation and basic bed mobility. Even though it was quite a short session, the patient was performing the tasks set by me with relative ease and was enthusiastic about them. I saw him for a total of 2 weeks for twice a day and was able to observe improvements that would impress even the most disillusioned physio or physio student. I was quite happy with the thought that I had succeeded where working physiotherapists had failed.

During the remaining time I had left in my prac I realised I might have been a little full of myself during that time. I was able to observe my supervisors deal with patients and situations that had left me baffled and frustrated and also see which patient's responded the best to each of us. What I'm trying to highlight is the fact that how well your patient is improving might not always be a direct reflection of the quality of physiotherapy you are providing. Sometimes a patient may not be responding well due to factors out of your control. In this case the patient and myself automatically 'clicked', we had similar senses of humour and were also able to discuss our aims of treatment in ways that we both understood and were happy about. In no way was this a reflection of any superior physiotherapy skills I might have compared to my experienced supervisor but rather an example of two personalities that worked well together.

In conclusion, palming off a patient to a fellow physio might sometimes actually be the right thing to do, as a last resort. Not with the aim to reduce your workload and make life easier for yourself but with the realisation that for reasons out of your control, a different physio with a different personality might be better for the patient and his well being.

viscous cycle

At university we are taught the gold standard. It has come to my attention that this may not always be possible. No matter how hard you try.

While treating a patient with an ABI resulting in dense left hemiplegia, for 2 sessions we attempted to improve this mans standing capacity. I was using the Gold standard technique of no shoes to enhance proprioception and everything. For this particular patient, his ability to stand was limited by immence localised pain and discomfort on the sole of both of his feet (pain meds had been administered). He would easily be able to stand longer if he had no pain. On assessment, dorsiflexion was slightly limited due to pain and a nodule was found on the sole of his left foot, which reproduced this mans pain when palpated. For 20 minutes i mobilised this patients feet with a variety of techniques which improved range but did not eliminate pain.

When standing this patient (x2 assist) post rx, he experienced pain immediately and was able to maintain for no longer than 1 minute.

It seemed that a viscous cycle had formed. this man had painful, tight feet due to prolonged recumbency and tone which prevent him from improving his standing capacity and therefore he remains off his feet.

Clutching at straws, i approached the medical team about re-assessing his pain control and in the mean time brainstormed. We trialed standing with his joggers on as the sole has arch support. This improved his standing capactity to ~5 minutes before limited by pain.

It is in these situations i feel that minor changes need to be made to break the viscious cycle. This prac has definately challenged my problem solving skills in a good way!

A supervisor: it could be you next year!

On my current cardiopulmonary placement I am being supervised by a Physiotherapist who graduated only two years ago. Although she is young and may not necessarily have a wealth of knowledge behind her (considering she has only been working as a physio for a short time) I think she is the best supervisor I have received so far.

There have been a few things that I’ve noticed that makes her supervising style effective. They include:
- Thorough orientation on first day: highlighting our expectations and the format of our placement
- Continually asking us questions (for example interpreting investigations or assessment findings, or giving rationale for treatments) in a non threatening manner
- Using the Sandwich approach of feedback (positive, negative, positive)
- asking us to write draft copies for the initial few extracts in patient notes, of which she edits. Once the standard is high enough we are able to complete them ourselves.

There is a high possibility of us being supervisors within the first few years of graduating. We should take note of the styles the supervisors adopt, and consider if they are effective or ineffective.

Hopefully we can make the students learning experience memorable for all the right reasons!

Prolonged stretch as a HEP for hypertonia

I recently completed a placement in a rehabilitation centre in Malaysia for people who have undergone stroke. Time frames ranged from 3 months to 5 years. Although impairments were various, the majority of patients endured problems with hypertonia (spasticity) in the trunk, upper limb or lower limb. Presentation of the upper limb usually consisted of increased tone in pectoralis major, biceps brachialis, wrist pronators and flexors, and finger flexors. Affected muscles in the lower limb usually included hip adductors, hamstring muscles and muscles of the posterior leg (gastrocsoleus, FHL, FDL and Tibialis Posterior).

There was an apparent difference between those patients who routinely stretched their muscles each day and those who did not. If they came to their treatment session having reduced tone in their muscles, then the majority of the session could be focused on other impairments (muscle strengthening, reduced balance etc) and functional retraining. However if they did not come prepared, the majority of the session was spent conducting prolonged stretches of each muscle until tone was reduced. By the end of the session, fewer outcomes were achieved.

I believe prolonged stretches of muscles with increased tone should be considered as one of the primary home exercises prescribed by the practitioner. They are easy for the patient to administer. And as they take a long time to do, they are inefficient for the practitioner.

I suggest it is a good idea to create a comprehensive muscle stretching program, with written diagrams and explanations, as well as frequent re-assessment to ensure the patient is conducting it effectively.

In an acute setting, this may not be as effective, as the patient is likely to be seen by the physio for up to four hours per day. But it appears effective in the case of long term rehabilitation, where the patient may only see the physio for an hour each week, of which time must be spent wisely.

student overload

In the rehabilitation setting, patients tend to be in hospital for an extended period of time, some even up to 9 months. Consequently over that time, many students come and go. When dealing will ABI patients, there is always a probability of behavioural issues, therefore to get the most out of our neurology experience the supervisors will tend to allocate patients with little behavioural problems and always a good hemi. Unfortunately with low turn over of patients and such a specified patient presentation, it can be the same patients that get allocated students. This means a slow thorough ax and analysis before treatment. By the third student, the patient begins to know more about his presentation than us in addition becoming frustrated and unmotivated.

So being the 6th round of students for this particular patient, it was fairly obvious that he has preconceptions about physio students. I could completely empathise with this patient. For both of us students there, we both felt very unworthy of assessing and treating this patient. The supervisors were already aware of this patients feelings and his motivation to just continue with his usual physio sessions. We were not allocated this patient for our daily sessions.

Over the weeks spent on this placement, gradual rapport was built with this patient and made me realise that even though we are here to learn from the patients, the patients expect the therapist to use their time efficiently and see results. I will now always endevour to prepare for patient sessions and make sure ax, analysis and treatments are explained and related to the patient for a combined goal vision.

Appropriate treatment progression

I am currently on rural prac based in a hospital which treats many indigenous and fly-in/fly-out patients. As well as working on the ward I am seeing many musculoskeletal outpatients, which has presented an issue that I have not come across in metropolitan areas. The frequency of non-attendance is very high for appointments, as patients forget, organised transport is unreliable and appointments are often not a high priority.

I have found it difficult to establish ongoing treatment programs with time-specific goals with most of my patients for one reason or another. The low attendance as mentioned before means that when I see someone, although we can book another appointment in, say one week, there is a good chance I won’t actually see them for two weeks for various reasons. Similarly, it is difficult to book appointments with the patients who fly in and out of town for work as they are often not here yet not based in the metro area either, so referring on doesn’t necessarily work either.

Yesterday I had a specific example of this where a 24 year old female had sprained her MCL one week earlier and I was seeing her for the first time. She was then flying to Perth a couple of days later for two weeks, which I could see would make it difficult to give ongoing advice and intervention that was progressing at the appropriate rate.

My approach to this problem was to recommend that she see a physio back in Perth during her time there, and to give advice for the next two weeks as much as possible. For example I told her she needed to keep trying to improve her knee flexion range guided by pain, however also information about what she would be best doing if the pain resolves within a week in terms of graduated return to activity. I found this difficult with all the “what-ifs” and felt frustrated that she could easily come back from Perth with an aggravated injury or a lack of progress.

I think it is important with these patients to always explain the plan beyond the next week or two as future appointments at the ideal times may not be possible. Does anyone else have any suggestions to provide the best management for patients in these circumstances?