Whilst at my musculoskeletal outpatients clinic I treated a man in his early 40s for lchronic low back pain. I was the eighth student he was seeing at the clinic and his progress had plateaued for approximately six weeks when I first saw him. He was still unable to work due to the pain and was very compliant with the advice and exercises he was given, even when he wasn't seeing progress. I became frustrated as his asterisk signs and pain were very inconsistent from session to session, and for example mobilisations one day would work quite well, whilst the next he would be in severe pain for three days, despite the same mobilisation parameters.
Whilst I did not expect a miracle recovery, nor a return to completely pain-free function due to the chronicity of his condition, I became increasingly frustrated and confused by his presentation. Each week my objective findings would indicate a different mode of treatment and management, and these would inconsistently be beneficial or detrimental to his condition.
After discussing the patient with my supervisor, he suggested trying a very general strengthening program, rather than targeting core stability muscle retraining, soft tissue work to reduce spasm and mobilisation for his hypomobility. I gave him some exercises and a gym program (he had been to the gym before but was not given a tailored program and felt it exacerbated his LBP) for general strengthening around the trunk, pelvis and lower limbs in particular.
Although he only performed these exercises for two weeks before I left, he felt that he was having less "bad days" and generally his pain was improving, as well as becoming more consistent. This was very satisfying as he was the most difficult patient I had and whenever he had an appointment I never knew what to expect or where to go with my intervention.
I learnt from this experience that, as reflected by limited and often conflicting evidence for the treatment and management of chronic LBP, there are times when your objective findings do not necessarily indicate which treatment methods will be the most effective. Patience is important for both the physio and patient (hence the term!), and a willingness/awareness to try a very general approach when specific things just aren't working. Next time I would still persist with different interventions targeting specific impairments, however I will be more patient and remember that I have the general approach to try if other methods fail.
Monday, July 28, 2008
Sunday, July 27, 2008
To say or not to say
I've realised that patients are often unaware of their condition. I will read in patient notes that they have a certain condition yet from conversations with patients they are totally clueless. When it comes to times like these, I wonder if I should explain their condition to them. However, I know that at some places, doctors do not like to be told by patients that the physio told them this and that. Yet, when faced with patients asking me what is wrong with them, I can't help but have the urge to explain it to them. This is especially so when I can see that it has been messing with their minds and thus extremely difficult to achieve compliance.
The best solution I have managed with these situations is to try to explain their symptoms instead of telling them exactly the condition that they have been diagnosed with. This was picked up from what one of my supervisors did. Patient could not understand why she was feeling breathless even though her saturation was good (97%). Supervior then explained to her that breathless does not always correlate to saturations and it is perfectly normal for her to feel breathless because she is unwell. To my amazement, patient accepted that and although did not get an exact answer to what is wrong with her, she was consoled just by thatsimple explaination.
Sometimes I feel that I tend to complicate matters and what my patient needs can just be a simple explaination and assurance. Also, body language and confidence when you are speaking to patients does a lot in calming them and getting their trust.
The best solution I have managed with these situations is to try to explain their symptoms instead of telling them exactly the condition that they have been diagnosed with. This was picked up from what one of my supervisors did. Patient could not understand why she was feeling breathless even though her saturation was good (97%). Supervior then explained to her that breathless does not always correlate to saturations and it is perfectly normal for her to feel breathless because she is unwell. To my amazement, patient accepted that and although did not get an exact answer to what is wrong with her, she was consoled just by thatsimple explaination.
Sometimes I feel that I tend to complicate matters and what my patient needs can just be a simple explaination and assurance. Also, body language and confidence when you are speaking to patients does a lot in calming them and getting their trust.
Patience
I had a patient who was producing a lot of secretions but unable to get them out. When I first saw her, she was extremely short of breath. She could barely finish three words before she needed to gasp for breath. All I was able to do the first day was to teach her supported deep breathing exercise and positioning. Those were also limited due to plueritic pain that she was experiencing both sides. She was given the nebuliser but was just unable to generate sufficient energy for an effective cough. The next day, I got her out of bed and ambulated her. She was only able to ambulate from one side of her bed to the foot of the other. Her colour was alright, saturation was good, respiratory rate did not change to much but was just feeling "funny" due to her low blood pressure. However, she was still very short of breath. The following day however, she was much better and able to generate a strong effective cough. Still, nothing was coming out. All these time, the doctors were waiting on sputum specimen for tests.
It was fortunate that I had lots more time that day and I spent almost one and a half hours with her doing acbts combined with percusion, positioning and the huff and ambulation. Patient was also very motivated and it definitely helped that I planned my session just after the analgesics. Finally, we managed to get 2 teaspoons of M3 sputum out. My first sputum!! I was equally excited as the patient and not to mention exhausted.
Prior to this, I discussed this patient with my supervior and I felt that she would definitely benefit from short bouts of treatment when she was really sick. However, that was not possible due to the heavy caseload we had. That got me thinking. There would be times where you are able to prioritise or get help from colleagues. However, if that was not possible, some patient would not be able to get as much benefits as they had potential for. For instance, the first two days although she had been good in terms of sitting out of bed and working on her deep breathing exercises and cough, there was not enough manpower to ambulate her. Also, if we had given up after 1 hour of manual chest therapy, we would not have got that sputum out for testing.
I believe that this will be a dillema that will always exist but this experience has made me aware that if I have time, to persist with treatment depending on how much patient is tolerating.
It was fortunate that I had lots more time that day and I spent almost one and a half hours with her doing acbts combined with percusion, positioning and the huff and ambulation. Patient was also very motivated and it definitely helped that I planned my session just after the analgesics. Finally, we managed to get 2 teaspoons of M3 sputum out. My first sputum!! I was equally excited as the patient and not to mention exhausted.
Prior to this, I discussed this patient with my supervior and I felt that she would definitely benefit from short bouts of treatment when she was really sick. However, that was not possible due to the heavy caseload we had. That got me thinking. There would be times where you are able to prioritise or get help from colleagues. However, if that was not possible, some patient would not be able to get as much benefits as they had potential for. For instance, the first two days although she had been good in terms of sitting out of bed and working on her deep breathing exercises and cough, there was not enough manpower to ambulate her. Also, if we had given up after 1 hour of manual chest therapy, we would not have got that sputum out for testing.
I believe that this will be a dillema that will always exist but this experience has made me aware that if I have time, to persist with treatment depending on how much patient is tolerating.
Wednesday, July 16, 2008
slack PT sessions
Whilst on my neuro placement, I found that I became somewhat lazy when planning a particular patients treatment sessions. This patient sustained a head injury from a car accident and as a result had severe short term memory loss. His treatment included gym based excercises and also hydrotherapy, however his memory loss was so pronounced that he could not ever remember having been in the pool, even though he had been going twice weekly for several weeks.
His memory loss also meant that he could not remember what exercises he had done with me between sessions and also within the same session. His physical impairments were quite limited and we were mainly focusing on core stability, very high level balance work and gait retraining. Initially I tried new and different things with him but soon ran out of new ideas. This is where I felt i became lazy, as instead of seeking out new ideas or techniques as I would have with any other patient, I was able to keep doing the same things as he could not remember what we had done. Whilst they were still effective exercises for him, I just feel as if i was somewhat taking advantage of his memory loss and not trying out different things as much as I probably should have done. Obviously I didnt need to change his treatment to motivate him or keep him interested however other things could have worked better for him, however I never knew because I didnt try them.
This has made me realise that I shouldnt take advantage of any patients situation just to make the work easier for me. There may not have been anything hugely different I could have tried, however I now realise that I should have looked for these harder and not just taken the easy way out.
His memory loss also meant that he could not remember what exercises he had done with me between sessions and also within the same session. His physical impairments were quite limited and we were mainly focusing on core stability, very high level balance work and gait retraining. Initially I tried new and different things with him but soon ran out of new ideas. This is where I felt i became lazy, as instead of seeking out new ideas or techniques as I would have with any other patient, I was able to keep doing the same things as he could not remember what we had done. Whilst they were still effective exercises for him, I just feel as if i was somewhat taking advantage of his memory loss and not trying out different things as much as I probably should have done. Obviously I didnt need to change his treatment to motivate him or keep him interested however other things could have worked better for him, however I never knew because I didnt try them.
This has made me realise that I shouldnt take advantage of any patients situation just to make the work easier for me. There may not have been anything hugely different I could have tried, however I now realise that I should have looked for these harder and not just taken the easy way out.
Difficult terminal patient
On my cardiopulmonary prac I was treating an elderly man post AP resection. I was donated this patients as he was a larger man who was difficult to motivate. Through-out the time I treated this man, he received some bad new, the cancer he was originally treated for had in fact spread to his liver and was now terminal.
It was difficult to continue treating this man as he was originally unmotivated and uncompliant in his treatment. The bad new made it more difficult and treatment aims had to change post news.
Before a lot of the motivating factors included the normal cardio spill, ie walking helps lungs re-inflated ect ect. But with the news that he only had months to live the normal motivating factors were inadequate to get this man out of bed. Before I was very persistent to get this man out of bed, and didn’t stop until he in fact had. I didn’t feel that nagging him to get up was appropriate after the doctors had told him about the spread of his cancer.
Discussing this case with my supervisor we decided to spent more time educating the importance of maintaining active and functional independence and to give him more of a choice to what treatment he wanted to participate in.
The aims of treatment were chosen to maintaining maximal functional independence, and discourage lying around in bed (which he was quite accustomed to) By the end of the prac we were only able to continue bed exercises as he was unwilling to sit out of bed or ambulate. I feel I didn’t help this man as much as I could have, and exhausted so many options to motivate him.
By the end, I treating him day by day, some days he wanted to participate more that others and some days he just wanted to lie in bed. I found it difficult to treat this man but learnt you can only do so much when the patient is willing.
It was difficult to continue treating this man as he was originally unmotivated and uncompliant in his treatment. The bad new made it more difficult and treatment aims had to change post news.
Before a lot of the motivating factors included the normal cardio spill, ie walking helps lungs re-inflated ect ect. But with the news that he only had months to live the normal motivating factors were inadequate to get this man out of bed. Before I was very persistent to get this man out of bed, and didn’t stop until he in fact had. I didn’t feel that nagging him to get up was appropriate after the doctors had told him about the spread of his cancer.
Discussing this case with my supervisor we decided to spent more time educating the importance of maintaining active and functional independence and to give him more of a choice to what treatment he wanted to participate in.
The aims of treatment were chosen to maintaining maximal functional independence, and discourage lying around in bed (which he was quite accustomed to) By the end of the prac we were only able to continue bed exercises as he was unwilling to sit out of bed or ambulate. I feel I didn’t help this man as much as I could have, and exhausted so many options to motivate him.
By the end, I treating him day by day, some days he wanted to participate more that others and some days he just wanted to lie in bed. I found it difficult to treat this man but learnt you can only do so much when the patient is willing.
Learning with peers on prac
Recently on my musculoskeletal prac I was lucky enough to practice and learn with another student, I found teaming up with this particular student quite useful. The arrangement we formed turned out equally beneficial to us, we were able to efficiently sift through the vast knowledge required to competently complete our musculo prac.
Teaming up with another student is less intimidating than asking stupid questions to supervisors, although also useful at clarifying previous knowledge. Whilst practicing different treatment techniques honest feedback can be given directed at the efficiency of the technique. This together with my superivors feedback helped me greatly improve my confidence and effectiveness in the musculoskeletal field.
Here is an example of how learning with another student helped me on prac:
I was treating one lady for upper cervical hypomobility and went through an extensive subjective and objective assessment. After completing this I was moderately confident that I had localised the patients affected segments, after discussing my finding with my peer, I then invited him to complete an abbreviated objective assessment with my current patient. His findings also confirmed my earlier findings. This increased both our confidence in localising affected segments, and once confirmed with our supervisor left us believing we were some sort of musculoskeletal gods sent down from heaven to rid the world of neck pain!
As the prac went on, peer checking continued, we tested each others asterixised objective findings and either agreed or further checked with our supervisor. This approach provided doubly beneficial as it gave feedback from an honest peer and increased the client exposure giving us more chance to learn.
Reflecting on my prac I found teaming up with a peer was the most beneficial aspect; this helped me learn in a non threatening and fun way. I would recommend this to all.
Teaming up with another student is less intimidating than asking stupid questions to supervisors, although also useful at clarifying previous knowledge. Whilst practicing different treatment techniques honest feedback can be given directed at the efficiency of the technique. This together with my superivors feedback helped me greatly improve my confidence and effectiveness in the musculoskeletal field.
Here is an example of how learning with another student helped me on prac:
I was treating one lady for upper cervical hypomobility and went through an extensive subjective and objective assessment. After completing this I was moderately confident that I had localised the patients affected segments, after discussing my finding with my peer, I then invited him to complete an abbreviated objective assessment with my current patient. His findings also confirmed my earlier findings. This increased both our confidence in localising affected segments, and once confirmed with our supervisor left us believing we were some sort of musculoskeletal gods sent down from heaven to rid the world of neck pain!
As the prac went on, peer checking continued, we tested each others asterixised objective findings and either agreed or further checked with our supervisor. This approach provided doubly beneficial as it gave feedback from an honest peer and increased the client exposure giving us more chance to learn.
Reflecting on my prac I found teaming up with a peer was the most beneficial aspect; this helped me learn in a non threatening and fun way. I would recommend this to all.
Wednesday, July 2, 2008
Oxygen indicated... or not?
For Cardiopulmonary placement, i was allocated to an outpatient COPD linkage program. Whereby the service provided additional pulmonary rehabilitation and maintenance classes. The program consisted of clinics whereby the clients were initially assessed to see if they are appropriate for enrollment into the exercise class; then the actual ex classes followed by 6 weekly reassessments.
During a clinic session, a patient will usually have 30 minutes with the COPD nurse, the physio and the respiratory physician in no particular order. between each session there is a quick hand over between us so there is no crossing over. For one patient that i handed over to the doctar, he asked me many questions about the patient's performance in the 6 minute walk test. Noting that he desaturated to 89% from 95% during the test. The doctar then asked me if i think he needed oxygen supplement during exercise. I replied "I don't think so", but i wasn't sure on oxygen prescription requirements and i thought it was the respiratory physician who prescribs the oxygen. It became clear to me then, that as a physio we can have more input, as ultimately we are the ones exercising these people and need to be aware, even if the docs do the official prescription.
That day i was informed of the indications for oxygen prescription for exercise. If the patient desaturates below 90% during the 6MWT on RA, 2L of oxygen via NP is trialled (that is what i preceeded to do for this patient) while performing the 6MWT. Prescription is then dependent on their exercise capacity, not their saturations. If the patient is able to walk significantly further (i.e. extra 30m) with oxygen, then it is prescribed. There is poor evidence regarding oxygen therapy and exercise, so even if the sats improve greatly but there is no improvement in exercise capacity, oxygen isn't prescribed as no benefits have been proven.
I now feel confident in my ability to give an informed opinion on a patient with regards to oxygen use in addition to assessing their exercise capacity. I have also learnt the importance of communicating with other health professions and the benefits of multiple input to get the best solution for each patient. i thought this information would be helpful for everyone as not everyone would get to experience the outpatient setting for their cardio placement.
During a clinic session, a patient will usually have 30 minutes with the COPD nurse, the physio and the respiratory physician in no particular order. between each session there is a quick hand over between us so there is no crossing over. For one patient that i handed over to the doctar, he asked me many questions about the patient's performance in the 6 minute walk test. Noting that he desaturated to 89% from 95% during the test. The doctar then asked me if i think he needed oxygen supplement during exercise. I replied "I don't think so", but i wasn't sure on oxygen prescription requirements and i thought it was the respiratory physician who prescribs the oxygen. It became clear to me then, that as a physio we can have more input, as ultimately we are the ones exercising these people and need to be aware, even if the docs do the official prescription.
That day i was informed of the indications for oxygen prescription for exercise. If the patient desaturates below 90% during the 6MWT on RA, 2L of oxygen via NP is trialled (that is what i preceeded to do for this patient) while performing the 6MWT. Prescription is then dependent on their exercise capacity, not their saturations. If the patient is able to walk significantly further (i.e. extra 30m) with oxygen, then it is prescribed. There is poor evidence regarding oxygen therapy and exercise, so even if the sats improve greatly but there is no improvement in exercise capacity, oxygen isn't prescribed as no benefits have been proven.
I now feel confident in my ability to give an informed opinion on a patient with regards to oxygen use in addition to assessing their exercise capacity. I have also learnt the importance of communicating with other health professions and the benefits of multiple input to get the best solution for each patient. i thought this information would be helpful for everyone as not everyone would get to experience the outpatient setting for their cardio placement.
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