frontal lobe deficits

With only experience thus far in the main fields of musculo and cardio, my neuro placement specialising in head injury was something very different. Not only were there physical deficits but a variety of frontal lobe injuries. One patient in particular, (i was in charge of for a week while a physio was absent) had predominately behavioural problems. This young man required a companion 24/7 and constant attention.

Physiotherapy sessions with this man, consisted of a 1/2 hour basic exercise program for strength and balance as he had regained most high level function (walking and jogging). I was instructed to supervise and guide this mans exercise program every morning for that week. i can tell you now that i exhausted all of my persuasive powers and was mentally drained after each session. He would never initiate an exercise unless 1. instructed and 2. wanted to do the exercise. On my first day with this patient i took the 'lets be friends first' approach as he was similar to my age. This worked relatively well as the patient was compliant with all exercises, except for him putting his arm around me by the end of the session. I wasn't sure what to do in this situation, so i changed the exercise swiftly to something requiring both his ULs and nothing more was said

This situation didn't make me feel too confident in dealing with the situation if it were to arise again. At uni, we are made aware of frontal lobe issues that can occur however there was not much insight on how to deal with them. I was also unaware of what the patients behaviour variance was like and therefor not sure how he would react to me saying that his behaviour was unacceptable.

I discussed the situation with my supervisor as she said that what i did was perfectly fine and that every patient is different, requiring team consistency and trial and error. I was informed that this patient had lost the ability to determine a level of social appropriateness, for example he will talk about 10cm away from your face and put his arm around you. Together we derived some strategies to try the next day. A Strategy utilised by the other health professionals was consistently reminding the patient to shake hads instead of hugging as a component of re-teaching the patient appropriate social skills. Other strategies that were successfull included myself participating in the exercise and having a rewards system, whereby if he was compliant he got to go outside in the afternoon and play sport.

After this experience, i have learnt that discussing strategies that can be utilised by all staff work the best, as this reinforces consistency. Also that each patient needs an individual approach. The next day i employed these strategies which worked very well. In the future i will endevour to discuss ideas with other staff members and make our treatment meaningful to the patient.

Patient who does not like physios

On my last day at rural prac, I was given an interesting patient to work with. She is a patient who just got transferred from hospital in the city. She required basic physiotherapy services like a mobility assessment and ambulation. She has been in hospital for 6 months now and the nurses have told us that she is sick of physiotherapy, sick of physiotherapist shouting at her demanding her to do stuff.

I approached the patient who had just finished with the nurse and was lying in bed. I started off with introducing myself and giving her an overview of what we would be doing. She consented to the session and I thought to myself that she is not as scary as the nurse made her out to be. I started asking her some questions being very careful not to repeat any questions that she has been asked before by other staff but half way into it the patient stoped short in her replies and stated that she has already answered these questions to someone else who came in before me. I apologised and acknowledged that she is probably tired of repeating the same stuff but because the information has not been put in the notes I would need the information to plan my treatment with her. The patient was very understanding and we continued with the subjective assessment. Later I managed to proceed through my objective assessment without much hiccups except that the patient was not willing to stay standing for longer than 1 min or ambulate. I did however managed to get her doing many incidental sit to stands and completed my objective assessment. However, the patient dictated the end of the session by going straight back to bed when she decided that she’s had enough. I spoke to the nurse regarding what I managed with the patient and suggested that the nurse encourage the patient to ambulate simply because the patient might be more receptive to other health professionals.

I came out of the session wondering why she was portrayed as such an intimidating character for physios. Personally, she felt like a patient who is just not very complaint. However, with patience and true empathy, the patient was quite co operative. I suppose if future similar situations arise I will not go into the session with preconceived idea as it will make me nervous and cloud my judgement about the patient. It is also a good opportunity to practice multidisciplinary team effort by communicating with the other health professionals to incorporate some of our treatment goals into their session. This would be especially helpful for patients who do not work well with certain health professionals and thus time spent with the patient can be more efficiently used by concentrating on the goals that can only be achieved by physio intervention.

Our role with young neuro patients?

I have not been on my neuro prac yet but I’ve had the opportunity to see a patient who suffered from head injury on my rural prac. On reading the handover notes, it seems like walking was an important functional goal for the patient. Although the handover notes did state swimming as a long term goal, my supervisor and I both thought that the patient should be contented if he could walk normally.
However, when we saw the patient, he was more abled than what the handover described him to be. The issue with this patient was that the facility I was at could not afford to offer him ongoing services. Hence, we wondered about the future management of this patient.
I was not sure how much services the patient could access. For instance, for patients who are at falls risks, they would come in for about 6 sessions to get them to a level where they could participate in one of the community groups before eventually doing their exercises on their own. Yet with this patient, he is already at a good functional level but because he is such a young patient, I feel that he has more potential which might go undiscovered should he just continue with maintenance exercises at home. There are no suitable community classes for him and limited resources for his needs. I guess this is the dilemma of people who cannot access the necessary healthcare. At least this patient is functional but he probably will not be able to attain his full potential due to the above mentioned reason. This makes me wonder how many do we actually rehabilitate these young patients who have a neurological deficit which will probably stay with them for the rest of their life? I will probably get a better insight into this when I start my neuro prac.
Coming back to this patient, I started to explore the possibility of him swimming. It so happened that the Paralympics was on at the same time I had these thoughts. It occurred to me that many of the participants in the swimming event could not even walk. Therefore, it would be highly possible that this patient would be able to swim after all. Yet I note with regret our limitations as physios as we are probably not trained enough to help this patient achieve such a goal. As it was my second last day at the facility, I was not able to attend the meeting where his rehab plan is discussed but I would suppose I will be better equipped to answer these questions when it comes round to my neuro prac.

Treatment of possible shoulder dislocation in stroke rehabilitation

On my international placement I treated a left sided stroke patient with severe left shoulder pain. He reported pain on movement in all ranges of shoulder and elbow motion. The condition had increasingly worsened over the period since his stroke. He had not undergone any investigations on the joint, it was unclear whether it was subluxed or dislocated. Upon observation the head of humerus was displaced from the glenoid cavity and his arm was supported in a sling. Shoulder active ROM was 10 degrees abd/Flx P2, elbow F 30 degrees P2. Touch and pain sensation was intact. There were no P&Ns, numbness or reduced blood flow distal to the joint. His functional ability was restricted: he required assistance x 1 to move up/down/side to side in bed, and to roll (of which he did to his affected side!).

I had seen a dislocated shoulder a number of times, and this presentation was very similar. I was almost sure of it. But I was unsure of the role I could play as a physio. I was not qualified to reposition it. And even once repositioned, it was likely to sublux or dislocate again due to increased laxity in joint structures.

My choice of treatment was firstly to reposition his sling so the weight of his upper limb was well supported, and his HOH approximated to his glenoid cavity. I educated him on sling use: to wear it consistently throughout the day, but take it off to complete his stretching program. I recommended he see his GP for an X-ray. I suggested surgery may be an option (however it was unlikely he would financially be able to do this). I taught him how to roll to his unaffected side.

I am unsure whether the course of action I took was the most appropriate, or if there were other treatments I could have performed. I was in a foreign country and did not have adequate supervision. Basically the treatment was discussed and justified between my fellow student and me. I am curious about what course of action to take, as this is a case not covered in our course, and I want to know the best way to treat such a patient in the future. Does anyone have any suggestions? Did I do anything you wouldn’t do? Do you have further suggestions on treatment or management?

Communication with pts who do not speak english

On my international placement I learnt how to communicate with patients who have a verbal communication barrier. This skill will be important when faced with patients whose primary language is other than English. These patients are continually increasing in Perth.

From the first day of the placement, I was expected to conduct exercise classes for patients of Malay and Chinese backgrounds, who spoke various languages including Bahasa Malay, Mandarin, Cantonese and Hokkein, to name a few. This was difficult at first. Initially I spoke in English, using descriptive sentences on what I wanted them to do. I did all the talking, and they listened and attempted to follow. Some patients who understood English comprehended the activities well. However the majority appeared quite lost. By the end of the session was dissatisfied with the results of the class and felt I had confused them. I had failed my role as a health care provider.

Over the next few days I refined my skills. I found with concise, simple word instructions, complimented with body language, effective communication was possible. I used one worded instructions such as ‘up’, ‘down’, ‘left’, ‘right’ etc, along with demonstrating the action. I learnt basic instructions in Bahas Malay, which improved their understanding of each instruction, as well as improved my rapport with them as they realised I embraced their culture. When it was apparent they had not understood an instruction, I repeated it again. Simple things like slowing down the pace of the exercises and repetition were useful. I included them in the instruction process as often as possible by asking them to count (‘kirra’ in Malay), which in turn ensured they were always paying attention.

It is possible to conduct physiotherapy without speaking the same language as your client. Yes, it is more difficult. But the desired results can be achieved.

Professionalism

On my international placement I was confronted with a difficult situation that taught me to control my feelings of frustration and stress in order to remain professional. I learnt that authoritative figures often are not open to compromise and will only do things their way. If challenged they may exert their authority to our detriment. As students, or new graduates, we can only accept their decisions because attempting to change their point of view is impossible.

This is applicable when facing an employer as one single mistake may taint their opinion of you, which may not be reconciled for a long time.

I made the mistake of requesting to compromise leave for a mountain climb. My supervisor thought this very unprofessional. After telling me how she felt, I was taken a back. I continued to defend my action, saying that I thought it was quite professional of me to approach her to make a compromise. She did not agree. Throughout my mid and final placement assessments, this situation haunted me. I left my international placement, not having won her respect back.

It is important for us to make careful calculations of our employers. Even if we don’t agree with them, or think they are too harsh in their judgements. They hold the key to our employment, thus livelihood!

In the future I will ensure I will judge my employer correctly. Then decide what requests are appropriate. I will take much consideration prior to making any form of request that may potentially upset them.

Delayed acceptance

Whilst on my paediatric placement I was assessing children with spastic Cerebral Palsy to determine whether botox injections were likely to improve their function. I was also able to assist the Doctors who gave the injections to ensure the optimal part of the muscle bulk was injected. Generally in this placement I found that the parents of these children were willing to making sacrifices to ensure the best for their child, were very tuned in to what health professionals had to say and seemed to have accepted that the disability was permanent.

During my final week at this placement I witnessed an episode where the parent of a child awaiting injections became very angry. The two year old child had been given the local anaesthetic and was waiting in a room with five other children and their parents for it to take affect before having their injection. I did not see what triggered everything, but my supervisor and I heard her yelling and came into the room to find her slamming a chair on the ground swearing at the nurses and saying that she wished her son had died (I later learnt that he had been in a car accident at 11 months of age).

Some of the nurses were able to settle the woman down eventually and she was asked to leave without her son having the injections. Although I was able to avoid involvement it was still a very important moment for me as a strong reminder that people may not be coping with life-changing issues such as the permanent disability of a loved one. The fact that she was the only person I saw expressing their frustration and anger at what has happened to their child certainly does not mean that she was the only parent who was not coping with their situation.

As a result of this situation I expanded my questioning at all appointments to find out directly or indirectly how the child’s family was coping. Although this seems of obvious importance, it is very easy to focus on the child once you feel that the family is coping and happy with how the management of their child is going. In this situation the child had been disabled for 13 months and yet the mother reacted as if she had just understood the position her and her son were in. This also made me consider that new treatment options or changes to health management or even schools and other aspects of life can trigger responses that may be unexpected. I have become more aware of considering the impact certain terms or procedures can have on a person’s understanding of their condition or that of a loved one, which is very important when dealing with families, palliative care and permanently disabled patients in particular.