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!
Sunday, October 5, 2008
Tuesday, September 30, 2008
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.
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!
Sunday, September 28, 2008
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!
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.
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.
Friday, September 26, 2008
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?
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?
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