Finishing the cardio placement tomorrow... and it has been good. For some reason, cardio seems to be lower stress, even though some of the patients have been a lot closer to death's doorstep than any I saw on the neuro prac.
One of the arts that I have learnt by doing is that of getting the patient to 'cough it up': 'harvesting the prairie oyster'. Here are my top tips for harvesting good gob:
1. Adapt the ACBT:
At school, we were taught a standardized version of the ACBT; but in practise, it gets modified quite often. For instance, if a patient goes through the first cycle of TEEs and you can hear the rattle of a good goober in the pipes, why would you go through another set of TEEs, huff and cough? What is the patient going to do, balance the little jewel on his tongue while he goes through the rest of a standard cycle? No, she will swallow it! And what a pity, you lose the chance to see how the lungs are doing (is it like pea soup?... infection! White & frothy?... possible pneumothorax!), to say nothing of that satisfying entry in the notes: "E/ pt produced 14 Tbsp.s thick++ creamy golden" (it is all about volume...).
2. Listen for the loogie:
You can hear when a patient is hiding treasures in the airways (even without a 'scope). Just think back to how L.R. , a 26y.o. female PT student, presented in the first year of the programme: you knew she was packing. So when you hear that rattly, 'chunks-are-coming' tone to a pt.'s exhale, skip the rest of the ACBT and go straight to the cough. (it's funny, thinking back to visiting the Dr. for a sore throat and being asked to cough, you wondered 'Why?' - now it is so obvious).
3. Grease the wheels:
To move anything, you need lube. If a patient has a dry throat, you aren't gunna get anything out of her. Imagine my chagrin when they put A.S., my top producer, on thickened fluids - he went from being an easy Tbsp. per-session-man to "np" (that's 'non-productive' for you musculo-heads). And then the Doc wants three sputum samples! The solution was easy. A.S. is a compliant, reasonable man: he understood that he wasn't safe to swallow water, but given how dry his throat was, he happily promised not to swallow in exchange for a sips of water to wet his whistle and then spit. Sure enough, the Doc. got three specimen jars of premium caramel custard.
4. Watch for the swallow:
Early in the prac, I often found that patients who had a moist++ cough and audible secretions on Ausc. would not produce. After a while, it seemed obvious that they were swallowing the goods. Many patients won't admit it, thinking it is too disgusting. So the trick is to watch their throat after a cough - you can see if they are swallowing.
5. The secret weapon:
Apple juice. For some reason, a sip or two of apple juice and the pt will double their production. The once thing you have to watch for is that it changes the colour of the final product.
Which brings me to my reflective question: more than one pt. reported that they always have more secretions after eating or drinking. What have the rest of you found? Is the after-lunch harvest better?
(dedicated to T.G., GEM 2008's very own sputum queen).
Thursday, January 31, 2008
Tuesday, January 29, 2008
the gap
Hi guys,
when reading ABGs, have you come across the term "anion gap"? well, i've always wondered what it meant and how it relates to our patient so i thought i'd share it with you guys so you guys can get a better picture of our patients status.
The anion gap represents the concentration of all the unmeasured anions in the plasma. It is calculated from the following formula:
either [Na]-[Cl]-[HCO3] or [Na]+[K]-[Cl]-[HCO3]
The optimum value is about 10-12mmol/L. Some of the major clinical uses of the anion gap include signalling the presence of a metabolic acidosis, helping to differentiate between causes of a metabolic acidosis and to assist in the assessment of the biochemical severity of the acidosis and following the response to treatment.
An elevated anion gap is commonly die to ketoacid overproduction due to fat metabolism (diabetes, alcohol, starvation), lactic acid overproduction due to respiratory failure, inability to excrete acids due to renal disease and dehydration.
A decreased anion gap then might be due to hyponatremia, primary hypothyroidism and hypoalbuminemia.
I think this is a pretty useful number as by working backwards from the ABGs then we would be able to detect the associated problems with the patient and thus adjust our treatment and approach accordingly.
Also, i think knowledge of this gap gave me a better understanding of why my patient (whose anion gap is abnormal ) was so lethargic. In fact, i think that the reason could possibly be attributed to insufficiency of the electrolytes which in turn compromises energy production and cellular function.
when reading ABGs, have you come across the term "anion gap"? well, i've always wondered what it meant and how it relates to our patient so i thought i'd share it with you guys so you guys can get a better picture of our patients status.
The anion gap represents the concentration of all the unmeasured anions in the plasma. It is calculated from the following formula:
either [Na]-[Cl]-[HCO3] or [Na]+[K]-[Cl]-[HCO3]
The optimum value is about 10-12mmol/L. Some of the major clinical uses of the anion gap include signalling the presence of a metabolic acidosis, helping to differentiate between causes of a metabolic acidosis and to assist in the assessment of the biochemical severity of the acidosis and following the response to treatment.
An elevated anion gap is commonly die to ketoacid overproduction due to fat metabolism (diabetes, alcohol, starvation), lactic acid overproduction due to respiratory failure, inability to excrete acids due to renal disease and dehydration.
A decreased anion gap then might be due to hyponatremia, primary hypothyroidism and hypoalbuminemia.
I think this is a pretty useful number as by working backwards from the ABGs then we would be able to detect the associated problems with the patient and thus adjust our treatment and approach accordingly.
Also, i think knowledge of this gap gave me a better understanding of why my patient (whose anion gap is abnormal ) was so lethargic. In fact, i think that the reason could possibly be attributed to insufficiency of the electrolytes which in turn compromises energy production and cellular function.
schatzki's ring
hi all, that's a picture of "schatzki's ring"
I used to think that dysphagia largely meant difficulty swallowing liquids, and i never expected the patient to have difficulty swallowing solids and not liquids till i met this old lady.
This lady patient has GORD and intermittent difficulty swallowing solid food which the medical team attributed to the 'schatzki's ring'. As i've never seen that term before, i thought i'd share what i found with you guys to expand our knowledge.
the schatzki's ring is an abnormal ring of tissue in the lower esophagus located at or near the border of the lower esophageal sphincter. It is also known as a lower esophageal ring. The causes for this is unclear and it is hypothesized that it could be a consequence of GORD or be congenital or even pill-induced.
A barium esophagram followed by an esophagogastroduodenoscopy is usually done to diagnose the condition and dilatation with intention to fracture that ring is usually the first course of action. If that does not work, the medical team might resort to surgical excision, all the time keeping in mind aggressively treating any existing reflux diseases.
Although this is not directly physio-related, i hope this piece of information comes in useful for you guys at some point in time, especially if your patient has GORD and has difficulty swallowing things like bread and steak but not water (like my patient).
Monday, January 28, 2008
the 'Blue Tab' & resusc. instructions
During my cardio placement, I have seen a few sets of patient's notes with a blue tab attached to one of the pages.
The blue tab marks the page in a patient's notes where there are instructions about DNR (do not resuscitate) if there are any. Maybe I was asleep when it was discussed, but I don't recall learning about this crucial bit of info at school.... My supervisor told me about it after I had been on prac.s for >5 weeks.
This, and the very poor health of some of the pt.s we see got me thinking about the balance between keeping people alive and minimizing suffering. There is no doubt that, for some patients, there comes a time when the two goals not aligned. One patient we were treating was discussed by one of the health care team as "...just needs to die". Not at all out of callousness; quite the opposite: it seemed plain to these experienced practitioners that there was no point in prolonging the patient's life, as he didn't seem likely to live and was suffering.
Of course, that doesn't make any difference to us: we would never decide not to treat a patient. However, I can't help wondering about the whole thing: when i finish giving some patients chest physio, they are exhausted and look worse that when I started even though they are breathing easier and are perfectly capable of declining treatment. I guess they do feel better and / or they blindly trust that what we do is good for them.
My reflection on the matter is this: how do we take patient suffering / will-to-die into account? All of our treatments are supposed to be evidence based practises, but how do studies take into account the balance between prolonging life and prolonging pain? Has anyone seen any studies that try to incorporate these factors?
The blue tab marks the page in a patient's notes where there are instructions about DNR (do not resuscitate) if there are any. Maybe I was asleep when it was discussed, but I don't recall learning about this crucial bit of info at school.... My supervisor told me about it after I had been on prac.s for >5 weeks.
This, and the very poor health of some of the pt.s we see got me thinking about the balance between keeping people alive and minimizing suffering. There is no doubt that, for some patients, there comes a time when the two goals not aligned. One patient we were treating was discussed by one of the health care team as "...just needs to die". Not at all out of callousness; quite the opposite: it seemed plain to these experienced practitioners that there was no point in prolonging the patient's life, as he didn't seem likely to live and was suffering.
Of course, that doesn't make any difference to us: we would never decide not to treat a patient. However, I can't help wondering about the whole thing: when i finish giving some patients chest physio, they are exhausted and look worse that when I started even though they are breathing easier and are perfectly capable of declining treatment. I guess they do feel better and / or they blindly trust that what we do is good for them.
My reflection on the matter is this: how do we take patient suffering / will-to-die into account? All of our treatments are supposed to be evidence based practises, but how do studies take into account the balance between prolonging life and prolonging pain? Has anyone seen any studies that try to incorporate these factors?
fun therapy
Hi all,
I have been seeing a 24 yo woman with Cerebellar Syndrome (her main impairment is ataxia) in neuro outpatients, twice a week for three weeks now. We have been doing mainly trunk stability, balance and gait work with her and although our sessions were different each time, I felt like the sessions were a bit boring and wanted to make them more interesting for her. I discussed this with my supervisor and he showed me some really good ideas for making core stability work interesting and fun for both me and my patient.
My favorite exercise was ‘the airplane’ which I’ve done with my kids at gymnastics quite a lot but would never have thought to do it with patients. The airplane involves the patient lying on a plinth with their knees bent up to their chest and their feet in the air. I stand on the plinth facing the pt and place the pt’s feet on my ASIS, then lean fwd and hold onto the cage/frame in front. The pt then straightens their legs to lift my feet off the plinth so that it looks like I’m flying (hence the name of the exercise). To make it hard for the pt you can let go of the cage and hold onto their hands, or move slightly form side to side to make their trunk work harder. My patient really liked this exercise as it was something different from what we normally did, and it made her have to work really hard.
Obviously this isn’t the sort of exercise you would do with everyone and you have to choose the pt’s you do it with very carefully. But for those pt’s that it is suitable for I think it is a great thing to do as it works whole body strength, stability and balance all at the same time… and its really good fun!! If anyone ever has a patient like this that is capable of doing this exercise, I really recommend giving it a go.
Tara
I have been seeing a 24 yo woman with Cerebellar Syndrome (her main impairment is ataxia) in neuro outpatients, twice a week for three weeks now. We have been doing mainly trunk stability, balance and gait work with her and although our sessions were different each time, I felt like the sessions were a bit boring and wanted to make them more interesting for her. I discussed this with my supervisor and he showed me some really good ideas for making core stability work interesting and fun for both me and my patient.
My favorite exercise was ‘the airplane’ which I’ve done with my kids at gymnastics quite a lot but would never have thought to do it with patients. The airplane involves the patient lying on a plinth with their knees bent up to their chest and their feet in the air. I stand on the plinth facing the pt and place the pt’s feet on my ASIS, then lean fwd and hold onto the cage/frame in front. The pt then straightens their legs to lift my feet off the plinth so that it looks like I’m flying (hence the name of the exercise). To make it hard for the pt you can let go of the cage and hold onto their hands, or move slightly form side to side to make their trunk work harder. My patient really liked this exercise as it was something different from what we normally did, and it made her have to work really hard.
Obviously this isn’t the sort of exercise you would do with everyone and you have to choose the pt’s you do it with very carefully. But for those pt’s that it is suitable for I think it is a great thing to do as it works whole body strength, stability and balance all at the same time… and its really good fun!! If anyone ever has a patient like this that is capable of doing this exercise, I really recommend giving it a go.
Tara
Sunday, January 27, 2008
Treatment for weakness vs altered muscle activation pattern...(Daria's Post)
Hi all,
I am currently on my neuroplacement at SCGH. One of my patient is 65 year old male who had PCI. Patient's gait is ataxic and his balance vary significantly from day to day or even between morning and afternoon of same day. Patient showing lack of insight and often overestimates his abilities.He is really compliant with physio treatment and wants to work hard to improve his functional level however, he is stubborn personality and very inpatient and attempts to do things before full explaination/demo is finished. It is my third week of placement and last two monday's morning I find very upsetting as patient had 2 falls when he was trying to get to toilet on his own even though his "mobility chart" says "ambulation 1 A - close supervision".I was trying to explain to the patient that he needs to call for help, that he could fracture his leg ect. My clinical supervisor said it is qiute common problem that patient is trying to experience his abilities.Hoverever it does not make me feel better. My treatment first consisted of: balance exercises ( static,dynamic with all possible variables), walk, protective responses training and exercises to decrease ataxia AI's and RS's. I've noticed that balance even vary improved whereas I was not satisfied with patient's gait especially his trunk moving forward and backward with preference for backward (the patient tends to fall backward). So after consultation with my supervisor I added more abdominals exercises and moved toward building endurance in walking by increasing distance. Additionally, I noticed some weakness (not significant) in LL and decrease the ability to produce fractionated movements in LL (L>R). Can anyone give me some suggestions what sort of treatment can be used to improve ability to fractionate movements.
Thanks,
Daria
I am currently on my neuroplacement at SCGH. One of my patient is 65 year old male who had PCI. Patient's gait is ataxic and his balance vary significantly from day to day or even between morning and afternoon of same day. Patient showing lack of insight and often overestimates his abilities.He is really compliant with physio treatment and wants to work hard to improve his functional level however, he is stubborn personality and very inpatient and attempts to do things before full explaination/demo is finished. It is my third week of placement and last two monday's morning I find very upsetting as patient had 2 falls when he was trying to get to toilet on his own even though his "mobility chart" says "ambulation 1 A - close supervision".I was trying to explain to the patient that he needs to call for help, that he could fracture his leg ect. My clinical supervisor said it is qiute common problem that patient is trying to experience his abilities.Hoverever it does not make me feel better. My treatment first consisted of: balance exercises ( static,dynamic with all possible variables), walk, protective responses training and exercises to decrease ataxia AI's and RS's. I've noticed that balance even vary improved whereas I was not satisfied with patient's gait especially his trunk moving forward and backward with preference for backward (the patient tends to fall backward). So after consultation with my supervisor I added more abdominals exercises and moved toward building endurance in walking by increasing distance. Additionally, I noticed some weakness (not significant) in LL and decrease the ability to produce fractionated movements in LL (L>R). Can anyone give me some suggestions what sort of treatment can be used to improve ability to fractionate movements.
Thanks,
Daria
Saturday, January 26, 2008
A lesson learnt in safety procedures
Hey guys, this week my neurological placement was turning out to be pretty similar to the previous two weeks until Thursday morning. Together with my fellow student and clinical supervisor we were scheduled to see a new patient ‘James’.
James is a 28 y.o. male who was in a car accident approximately 7 years ago. James suffered brain damage mainly to his cerebellum and the fronto-parietal lobe resulting in impairments of motor deficits for the muscles that produce speech, and hemiparesis and spasticity to the right side of his body. James biggest impairment though was the ataxia he has in his trunk which means he spends most of his day (waking hours) in an electric W/C which has bilateral supports at the trunk to keep him in his chair. He is a 2 person max assist for transfers (W/C to SOEB) and is a 1 person max assist for SOEB balance.
The aim of this session was to assess James’ static sitting balance and dynamic sitting balance if appropriate, his bed mobility, and the amount of voluntary movement he has in his limbs. Based upon assessment appropriate treatment techniques and exercises were to be implemented to assist James.
James was T/F to bed via a slide board where we assessed his sitting balance and instigated some sitting exercises which he initially had some difficulty with but improved. This lasted approximately 20 minutes before James was T/F to supine. Through out the whole session James was constantly monitored; he responded that he was feeling good with no problems. Then James bed mobility was assessed and he was asked to move from supine to side lying. After 3 rolls to the right then three to the left I noticed that James was starting to look increasingly tired and fatigued. Each time he came back to supine there was an audible rattle in James’ throat that he tried to clear himself via a tracheal rub.
James movement pattern moving into side lying (esp. left) was quite poor with a lot of neck extension and rotation as opposed to flexion and rotation. James was asked to roll to his left again to try and clear his throat as his rattle was still present. In left side lying James appeared to be losing consciousness. The clinical tutor was very concerned for James’ state and decided to hit the alert buzzer. It started to become clear that James was passing out (probably due to hypoxia) or he was having a seizure (less likely as patient has no Hx of seizures and he was not shaking). The medical emergency team responded very promptly and O2 therapy was required as James O2 saturation had decreased. After about 15-20 minutes James condition started to improve and he returned to an alert state of consciousness.
While this was quite distressing for the patient I found it a fantastic learning experience as the speed with which my supervisor responded was fantastic. She picked up on the signs that were indicating that James may have been drifting out of consciousness very quickly. This reinforced to me the importance of continued monitoring of your patient. Her quick reaction made a big difference to the outcome of the patient.
The other important factor highlighted to me through this event was that neither myself nor my fellow student had been given instructions or the protocol on what to do in an emergency. Considering that this was the third week of our placement it should have been done by now. The message I would like to get across to everyone is to make sure they know the protocols in their department in case of emergency. As initially I was asked to get a mask and suctioning equipment and we had not been shown where they were.
Thanks
James is a 28 y.o. male who was in a car accident approximately 7 years ago. James suffered brain damage mainly to his cerebellum and the fronto-parietal lobe resulting in impairments of motor deficits for the muscles that produce speech, and hemiparesis and spasticity to the right side of his body. James biggest impairment though was the ataxia he has in his trunk which means he spends most of his day (waking hours) in an electric W/C which has bilateral supports at the trunk to keep him in his chair. He is a 2 person max assist for transfers (W/C to SOEB) and is a 1 person max assist for SOEB balance.
The aim of this session was to assess James’ static sitting balance and dynamic sitting balance if appropriate, his bed mobility, and the amount of voluntary movement he has in his limbs. Based upon assessment appropriate treatment techniques and exercises were to be implemented to assist James.
James was T/F to bed via a slide board where we assessed his sitting balance and instigated some sitting exercises which he initially had some difficulty with but improved. This lasted approximately 20 minutes before James was T/F to supine. Through out the whole session James was constantly monitored; he responded that he was feeling good with no problems. Then James bed mobility was assessed and he was asked to move from supine to side lying. After 3 rolls to the right then three to the left I noticed that James was starting to look increasingly tired and fatigued. Each time he came back to supine there was an audible rattle in James’ throat that he tried to clear himself via a tracheal rub.
James movement pattern moving into side lying (esp. left) was quite poor with a lot of neck extension and rotation as opposed to flexion and rotation. James was asked to roll to his left again to try and clear his throat as his rattle was still present. In left side lying James appeared to be losing consciousness. The clinical tutor was very concerned for James’ state and decided to hit the alert buzzer. It started to become clear that James was passing out (probably due to hypoxia) or he was having a seizure (less likely as patient has no Hx of seizures and he was not shaking). The medical emergency team responded very promptly and O2 therapy was required as James O2 saturation had decreased. After about 15-20 minutes James condition started to improve and he returned to an alert state of consciousness.
While this was quite distressing for the patient I found it a fantastic learning experience as the speed with which my supervisor responded was fantastic. She picked up on the signs that were indicating that James may have been drifting out of consciousness very quickly. This reinforced to me the importance of continued monitoring of your patient. Her quick reaction made a big difference to the outcome of the patient.
The other important factor highlighted to me through this event was that neither myself nor my fellow student had been given instructions or the protocol on what to do in an emergency. Considering that this was the third week of our placement it should have been done by now. The message I would like to get across to everyone is to make sure they know the protocols in their department in case of emergency. As initially I was asked to get a mask and suctioning equipment and we had not been shown where they were.
Thanks
Patella Tendon Rupture
Hi all,
I am currently completing my musculo placement and I have a new patient next week 3/12 post patella tendon rupture and surgical repair. I have been unable to source any info from the patient's notes as of yet and thus do not have much information about the surgical procedure and subsequent treatment protocol and contraindications.
Just guessing, but at 3 months I would think you would be into the 3rd stage of treatment, so one would be starting to strengthen the quads, hamstrings and gastroc around the knee in weight bearing positions, and begin proprioception work. Stage 1 (the first 6 weeks) would be all about controlling inflammation and mininmising scar tissue, bracing and passive mobilisation. Stage 2 (weeks 6-12) would be about improving ROM and maybe some strengthening in non-weight bearing positions.
Therefore I was wondering if any of the crew have treated such a patient on there musculo placement (or can remember any details from there ortho placement last year) and can shed some light on the subject for me.
Cheers
Nico
I am currently completing my musculo placement and I have a new patient next week 3/12 post patella tendon rupture and surgical repair. I have been unable to source any info from the patient's notes as of yet and thus do not have much information about the surgical procedure and subsequent treatment protocol and contraindications.
Just guessing, but at 3 months I would think you would be into the 3rd stage of treatment, so one would be starting to strengthen the quads, hamstrings and gastroc around the knee in weight bearing positions, and begin proprioception work. Stage 1 (the first 6 weeks) would be all about controlling inflammation and mininmising scar tissue, bracing and passive mobilisation. Stage 2 (weeks 6-12) would be about improving ROM and maybe some strengthening in non-weight bearing positions.
Therefore I was wondering if any of the crew have treated such a patient on there musculo placement (or can remember any details from there ortho placement last year) and can shed some light on the subject for me.
Cheers
Nico
Manual Therapy Techniques Reinforced
Hi crew,
This week I’d like to share with you a summary of one of the patients on my musculoskeletal placement because I think this experience may help reinforce some of the assessment and manual therapy techniques we’ve practiced in labs. This mid twenty year old patient presented with moderate to severe left side mid and low back pain that had been progressively getting worse after feeling the onset of pain following a wrestling incident. In addition to the back pain, the patient reported of intermittent sharp pain down the back of the left leg to the knee and numbness in the toes and sole of the foot. Immediately I’m thinking neurological testing is required here and the patient had a fair amount of pain and irritability so my objective assessment had to be modified. Basically focused on observation, essential active movements, neuro testing, NTPT’s, palpation, PAIVMs and PIIVMs. The findings were no real pattern with AROM, altered sensation in the L5 dermatome in the lower limb, positive SLR with DF, normal PIIVMs. The finding that completed the picture for diagnosis was the hypomobility and reproduction of her low back, leg pain and numbness in her left foot with unilateral AP of the L4-5, L5-S1 passive accessories.
To be able to clinically observe the reproduction of a patient’s symptoms with PAIVMs and correlate those segments to the results from the neurological testing was a first for me and really reinforced the ideas that were presented in the labs.
The initial treatment focused on relieving the patient’s pain so that sitting at work would be manageable. STM for the overactive erector spinae and QL followed by mobilisation of the L4-L5, L5-S1 levels at a grade 2 minus for 30 secs x 3. As subsequent sets of mobs were applied the patient reported of a decrease in leg and back complaints during the 30 secs and reassessment revealed a slight increase in lumbar extension. Home exercises for supine trunk rotation and advice for posture at work finished the session.
The patient reported at the appointment 2 days later that sitting at work and sleeping was more comfortable since treatment. The mid back pain and muscle tension had decreased and the complaints had centralised to the low back region with a decrease in left leg pain and foot numbness.
This experience has definitely shown me the impact we can have with some of our manual techniques and consolidated the ideas on which our treatments are based. It’s important that we practice on each other but we have to continually feel pathological structures and tissues so learning the difference between normal and pathological will becomes more apparent. The outcome of this case has shown me that we just need to keep seeing as many patients as possible. So I hope that if you don’t feel comfortable with your manual skills at the moment, no worries as you’ve been taught the skills you need and you can make a difference for your patients. Have a great long weekend.
Gareth
This week I’d like to share with you a summary of one of the patients on my musculoskeletal placement because I think this experience may help reinforce some of the assessment and manual therapy techniques we’ve practiced in labs. This mid twenty year old patient presented with moderate to severe left side mid and low back pain that had been progressively getting worse after feeling the onset of pain following a wrestling incident. In addition to the back pain, the patient reported of intermittent sharp pain down the back of the left leg to the knee and numbness in the toes and sole of the foot. Immediately I’m thinking neurological testing is required here and the patient had a fair amount of pain and irritability so my objective assessment had to be modified. Basically focused on observation, essential active movements, neuro testing, NTPT’s, palpation, PAIVMs and PIIVMs. The findings were no real pattern with AROM, altered sensation in the L5 dermatome in the lower limb, positive SLR with DF, normal PIIVMs. The finding that completed the picture for diagnosis was the hypomobility and reproduction of her low back, leg pain and numbness in her left foot with unilateral AP of the L4-5, L5-S1 passive accessories.
To be able to clinically observe the reproduction of a patient’s symptoms with PAIVMs and correlate those segments to the results from the neurological testing was a first for me and really reinforced the ideas that were presented in the labs.
The initial treatment focused on relieving the patient’s pain so that sitting at work would be manageable. STM for the overactive erector spinae and QL followed by mobilisation of the L4-L5, L5-S1 levels at a grade 2 minus for 30 secs x 3. As subsequent sets of mobs were applied the patient reported of a decrease in leg and back complaints during the 30 secs and reassessment revealed a slight increase in lumbar extension. Home exercises for supine trunk rotation and advice for posture at work finished the session.
The patient reported at the appointment 2 days later that sitting at work and sleeping was more comfortable since treatment. The mid back pain and muscle tension had decreased and the complaints had centralised to the low back region with a decrease in left leg pain and foot numbness.
This experience has definitely shown me the impact we can have with some of our manual techniques and consolidated the ideas on which our treatments are based. It’s important that we practice on each other but we have to continually feel pathological structures and tissues so learning the difference between normal and pathological will becomes more apparent. The outcome of this case has shown me that we just need to keep seeing as many patients as possible. So I hope that if you don’t feel comfortable with your manual skills at the moment, no worries as you’ve been taught the skills you need and you can make a difference for your patients. Have a great long weekend.
Gareth
Communication between the staff
Hi all,
I’m currently on my neuro placement treating TBI patients.
One of my patients (34yo, female) is (R) hemiplegic since she had bleeding and infarction in (L) frontal and parietal lobe about four months ago. She has been improving well since she was transferred to the ward for her rehab. Her main issues are increased tone and flexor synergy pattern in (R) UL& LL, decreased activation of trunk muscles, gluts and quads, short hip flexors and external rotators, etc. When I saw her three weeks ago, she had very poor her sitting and standing posture and reduced exercise endurance as she was exhausted after 1hr session. Also, she showed dominant (L) arm and leg use, for example she pulls herself forward with her (L) arm rather than by using weight shift and abdominal muscles and she uses (L) leg more than (R) when standing up. So I’ve been working on correcting her sitting posture, sit to stand, standing balance and she seems progressing well in physio.
I had an opportunity to observe her OT session this week. She was practicing independent dressing shirts and pants in W/C when I went down to see her. I was quite disappointed in her doing all things that I told her not to do such as pulling with (L) arm to come forward, lifting leg in a synergy pattern, leaning back in standing, etc.
I realised how important discussion and communication skills between the staff is so that the aim of PT and OT for her is in the same direction. For example, if she practices cooking in OT to improve her endurance in standing, we should focus on good standing posture and standing balance as well as her ability to do them with some distraction such as talking or UL movements. I was also curious about how to apply what she learns from physio session into her real life. She understands what she should do and should not do, however it doesn’t seem to work well in her daily activities. Does anyone have any ideas? It would be a great help, thank you in advanceJ
In Sun
I’m currently on my neuro placement treating TBI patients.
One of my patients (34yo, female) is (R) hemiplegic since she had bleeding and infarction in (L) frontal and parietal lobe about four months ago. She has been improving well since she was transferred to the ward for her rehab. Her main issues are increased tone and flexor synergy pattern in (R) UL& LL, decreased activation of trunk muscles, gluts and quads, short hip flexors and external rotators, etc. When I saw her three weeks ago, she had very poor her sitting and standing posture and reduced exercise endurance as she was exhausted after 1hr session. Also, she showed dominant (L) arm and leg use, for example she pulls herself forward with her (L) arm rather than by using weight shift and abdominal muscles and she uses (L) leg more than (R) when standing up. So I’ve been working on correcting her sitting posture, sit to stand, standing balance and she seems progressing well in physio.
I had an opportunity to observe her OT session this week. She was practicing independent dressing shirts and pants in W/C when I went down to see her. I was quite disappointed in her doing all things that I told her not to do such as pulling with (L) arm to come forward, lifting leg in a synergy pattern, leaning back in standing, etc.
I realised how important discussion and communication skills between the staff is so that the aim of PT and OT for her is in the same direction. For example, if she practices cooking in OT to improve her endurance in standing, we should focus on good standing posture and standing balance as well as her ability to do them with some distraction such as talking or UL movements. I was also curious about how to apply what she learns from physio session into her real life. She understands what she should do and should not do, however it doesn’t seem to work well in her daily activities. Does anyone have any ideas? It would be a great help, thank you in advanceJ
In Sun
Friday, January 25, 2008
Infection control
Hello Everyone,
VRE as with other bugs in the hospital are often caught while people are in hospital. The hospital often screens for VRE when patients are transferred out of ICU. They undergo numerous tests to confirm they are VRE negative. If anyone of the tests come back positive the patient is isolated and flagged. Quite often these bugs are in the hospital and therefore if a person contracts the virus it might not be their fault as little can be done to avoid this transmission. The longer a patient remains in hospital the greater their chance is of acquiring the virus.
Infection control protocol is to isolate them in a single room and anyone that comes in contact with the patient needs to have gloves and a gown on, if you are dealing with fluids a face mask is required. People often become nervous and cautious around these flagged patients.
I was given a new patient. I checked his file and it said VRE positive. My first thought was oh no…time to gown and glove up not my most enjoyable part of my day. Yes I know we have had presentations on how to protect our self and proper application of infection control however I still worry about the transmission and how to avoid it. Everyone who has ever had to glove and gown knows how hot, uncomfortable and worried you become when you are in contact with the patient. It tends to impact on the quality of your treatment. Until today all my thoughts and concerns have been to protect myself, I have failed to think of how the patient feels when they are diagnosed as VRE positive.
As I continue to read through my new patient’s notes it states that he has become very depressed/down from being in this room alone and due to being flagged. The notes report he has asked to leave and not have a single room. But his request was obviously denied as he would put the rest of the ward at risk. Despite this fact he has taken matters into his own hands and now sits out in the hallway and forcefully refuses to return to the room. As you can tell the nurses have a tricky issue on their hands. The patient is making scenes and refusing to return to the room but at the same time he is violating the infection control protocol. Plus his depression and mental state has become a large concern for the nurses as well. “He feels like he is going crazy in this hole”. The nurses are responsible for his well being as well as the ward’s health. This situation has forced the head nurse to contact the infection control to see what the hospitals options are. The infection control people said with him just sitting in the hallway he would not increase the risk of contamination.
My question is then why are all the protocols made when they have decided to allow him to sit out in the hallway all day as it won’t cause the virus to spread?
In the hospital the protocols are often not consistent between members of the ward. This lack of consistency and allowing patients to be walked on the ward seems to send mix messages with regards to the severity of infection control.
Perhaps there should be a ward that is specific to different infection controls? Might this decrease the risk for other patients, allow more consistent delivery of protocols as nurses on that ward would be dealing with cases more often and therefore become more efficient and confident with the infection control protocol. An option like this might reduce the risk of mental state and depression emerging in these patients due to the segregation they experience on other wards.
It’s a tricky one any thoughts?
Thanks have a great weekend everyone :).
dani
VRE as with other bugs in the hospital are often caught while people are in hospital. The hospital often screens for VRE when patients are transferred out of ICU. They undergo numerous tests to confirm they are VRE negative. If anyone of the tests come back positive the patient is isolated and flagged. Quite often these bugs are in the hospital and therefore if a person contracts the virus it might not be their fault as little can be done to avoid this transmission. The longer a patient remains in hospital the greater their chance is of acquiring the virus.
Infection control protocol is to isolate them in a single room and anyone that comes in contact with the patient needs to have gloves and a gown on, if you are dealing with fluids a face mask is required. People often become nervous and cautious around these flagged patients.
I was given a new patient. I checked his file and it said VRE positive. My first thought was oh no…time to gown and glove up not my most enjoyable part of my day. Yes I know we have had presentations on how to protect our self and proper application of infection control however I still worry about the transmission and how to avoid it. Everyone who has ever had to glove and gown knows how hot, uncomfortable and worried you become when you are in contact with the patient. It tends to impact on the quality of your treatment. Until today all my thoughts and concerns have been to protect myself, I have failed to think of how the patient feels when they are diagnosed as VRE positive.
As I continue to read through my new patient’s notes it states that he has become very depressed/down from being in this room alone and due to being flagged. The notes report he has asked to leave and not have a single room. But his request was obviously denied as he would put the rest of the ward at risk. Despite this fact he has taken matters into his own hands and now sits out in the hallway and forcefully refuses to return to the room. As you can tell the nurses have a tricky issue on their hands. The patient is making scenes and refusing to return to the room but at the same time he is violating the infection control protocol. Plus his depression and mental state has become a large concern for the nurses as well. “He feels like he is going crazy in this hole”. The nurses are responsible for his well being as well as the ward’s health. This situation has forced the head nurse to contact the infection control to see what the hospitals options are. The infection control people said with him just sitting in the hallway he would not increase the risk of contamination.
My question is then why are all the protocols made when they have decided to allow him to sit out in the hallway all day as it won’t cause the virus to spread?
In the hospital the protocols are often not consistent between members of the ward. This lack of consistency and allowing patients to be walked on the ward seems to send mix messages with regards to the severity of infection control.
Perhaps there should be a ward that is specific to different infection controls? Might this decrease the risk for other patients, allow more consistent delivery of protocols as nurses on that ward would be dealing with cases more often and therefore become more efficient and confident with the infection control protocol. An option like this might reduce the risk of mental state and depression emerging in these patients due to the segregation they experience on other wards.
It’s a tricky one any thoughts?
Thanks have a great weekend everyone :).
dani
Trusting patients information given to you
Hi all,
I am currently on my Cardiopulmonary placement in which I had an interesting situation occur. I was asked to see a 70 year old male who came in with the following:
PC: 3/7 of palpitations, increased SOB & R neck pain.
PMHx: AF, IHD, MI 84, 95, asthma, COPD, R TIA/CVA, traumatic pneumothorax, (R) lower arm amputee. In addition to this he had pins in his R hip from a previous car accident which prevented him from ambulating very well such that he gets around in the electric wheelchair however he is able to walk short distances.
In doing my subjective Ax on this gentlemen I was getting rather inconsistent information in regards to his smoking history. He said that he had now quit however, he used to smoke 3 packets a day for 15 years and then dropped down to 3 packets a week and then 1 packet a week, and that for the last 6 weeks he had quit. However, he kept on changing how much he had smoked and for how long so I just dealt with the information he gave me. I could also clearly smell that he had a cigarette recently and I had seen him earlier in the morning smoking outside the hospital building. The patient also claimed that he was not on home O2 therapy however since being in hospital he relied on the O2 therapy majority of the time.
The problem arose in that when I confronted my supervisor she told me that this patient already had O2 therapy at home- and smoking whilst on O2 therapy is a big NO NO as the person may start a fire is they happen to leave the O2 on and spark a match.
I was then unsure what to do. I didn’t know whether I should confront the man in regards to his current smoking history again even though he had already denied smoking. For me it became a safety concern in regards to using O2 therapy whilst still smoking. I was thinking I could try calling his next of kin and ask them if they could inform me however, my supervisor said that the best thing to do would be to educate him in regards to smoking and the use of O2 therapy at home.
What would you guys do in this situation?
Thanks,
Debs
I am currently on my Cardiopulmonary placement in which I had an interesting situation occur. I was asked to see a 70 year old male who came in with the following:
PC: 3/7 of palpitations, increased SOB & R neck pain.
PMHx: AF, IHD, MI 84, 95, asthma, COPD, R TIA/CVA, traumatic pneumothorax, (R) lower arm amputee. In addition to this he had pins in his R hip from a previous car accident which prevented him from ambulating very well such that he gets around in the electric wheelchair however he is able to walk short distances.
In doing my subjective Ax on this gentlemen I was getting rather inconsistent information in regards to his smoking history. He said that he had now quit however, he used to smoke 3 packets a day for 15 years and then dropped down to 3 packets a week and then 1 packet a week, and that for the last 6 weeks he had quit. However, he kept on changing how much he had smoked and for how long so I just dealt with the information he gave me. I could also clearly smell that he had a cigarette recently and I had seen him earlier in the morning smoking outside the hospital building. The patient also claimed that he was not on home O2 therapy however since being in hospital he relied on the O2 therapy majority of the time.
The problem arose in that when I confronted my supervisor she told me that this patient already had O2 therapy at home- and smoking whilst on O2 therapy is a big NO NO as the person may start a fire is they happen to leave the O2 on and spark a match.
I was then unsure what to do. I didn’t know whether I should confront the man in regards to his current smoking history again even though he had already denied smoking. For me it became a safety concern in regards to using O2 therapy whilst still smoking. I was thinking I could try calling his next of kin and ask them if they could inform me however, my supervisor said that the best thing to do would be to educate him in regards to smoking and the use of O2 therapy at home.
What would you guys do in this situation?
Thanks,
Debs
Trunk exercises
Howdy Folks
One thing that being on a neuro ward has taught me is that strength and stability of the trunk are key factors in determining the degree of balance and mobility a person has, or could possibly achieve. I have seen patients with a number of different diagnoses and one thing in common with them all is that their balance is affected, usually both sitting and standing, static and dynamic. And the trunk is one area of the body that all of these patients have required rehabilatation on in order for them to improve their balance. While the specifics of their impairments have differed, being either alteration in tone, a decrease in voluntary movement or ataxia, my treatments for these patients have centred on exercises for the trunk, and then translating these into relevant functional tasks. As you know, without a stable trunk, it is considerbaly more difficult for us to move our limbs or our head, and as such we are severely limited in how much of our environment we can independently explore.
What I have been having trouble with is coming up with new and exciting ways to treat the trunk, and progressions for these exercises. To treat altered verticality I have been using techniques we covered in class such as having the patient SOEB and leaning down on their elbow on their unaffected side (for stroke patients) then coming back to the midline. To improve fractionated movement, pelvic tilting exercises in crook lying, SOEB, modified plantar-grade and standing, as well as isolated pelvic then shoulder rotations in side lying. For ataxia, AI's and RS's while the patient is SOEB, in 2pt or 4pt kneeling. To increase strength, moving the knees from side to side while in crook lying, or laterally side flexing while in supine. I have also been shown some low level abdominal exercises for early stroke patients which I have added to my arsenal.
I am slowly coming to understand that if we keep in mind priniciples of rehab, and what our specific aims of treatment are, our background knowledge is sufficient to enabe us to adapt whatever exercises we have to any particular patients. But until then I would love to hear suggestions of other exercises for the trunk that you guys have come across in your travels, or any specific techniques that address trunk-related impairments.
Thanks and enjoy your long weekends!!
Bini
One thing that being on a neuro ward has taught me is that strength and stability of the trunk are key factors in determining the degree of balance and mobility a person has, or could possibly achieve. I have seen patients with a number of different diagnoses and one thing in common with them all is that their balance is affected, usually both sitting and standing, static and dynamic. And the trunk is one area of the body that all of these patients have required rehabilatation on in order for them to improve their balance. While the specifics of their impairments have differed, being either alteration in tone, a decrease in voluntary movement or ataxia, my treatments for these patients have centred on exercises for the trunk, and then translating these into relevant functional tasks. As you know, without a stable trunk, it is considerbaly more difficult for us to move our limbs or our head, and as such we are severely limited in how much of our environment we can independently explore.
What I have been having trouble with is coming up with new and exciting ways to treat the trunk, and progressions for these exercises. To treat altered verticality I have been using techniques we covered in class such as having the patient SOEB and leaning down on their elbow on their unaffected side (for stroke patients) then coming back to the midline. To improve fractionated movement, pelvic tilting exercises in crook lying, SOEB, modified plantar-grade and standing, as well as isolated pelvic then shoulder rotations in side lying. For ataxia, AI's and RS's while the patient is SOEB, in 2pt or 4pt kneeling. To increase strength, moving the knees from side to side while in crook lying, or laterally side flexing while in supine. I have also been shown some low level abdominal exercises for early stroke patients which I have added to my arsenal.
I am slowly coming to understand that if we keep in mind priniciples of rehab, and what our specific aims of treatment are, our background knowledge is sufficient to enabe us to adapt whatever exercises we have to any particular patients. But until then I would love to hear suggestions of other exercises for the trunk that you guys have come across in your travels, or any specific techniques that address trunk-related impairments.
Thanks and enjoy your long weekends!!
Bini
Monday, January 21, 2008
Decompressive craniectomy
Hi all,
I’m currently treating patients with TBI. I’ve seen many patients wearing a helmet to protect their head after craniectomy (removing part of the skull and opening the duramater), so I was wondering what other treatment options are, how it helps to manage increased intracranial pressure and what its outcome would be like.
ICP is the most frequent cause of death and disability after head injury and it’s important to maintain within normal range 15-20mmHg to prevent brain herniation and improve cerebral perfusion. General manoeuvres include head elevation, volume resuscitation, sedation, etc and more aggressive measures include CSF drainage, moderate hypocapnia and mannitol administration. When these therapeutic options are failed, second level therapies like decompressive craniectomy are considered.
This surgical decompression is divided into two types; primary and secondary. Primary decompressive craniectomy is performed to avoid expected postsurgical increases in ICP, whereas secondary decompressive craniectomy is to control high ICP for patients who have undergone surgery to evacuate tumour and who develop brain swelling.
There is no evidence of the routine use of this surgical procedure in adults population and the effectiveness of decompressive craniectomy are quite controversial in adults population as clinical trials have not confirmed although one study showed improved survival and neurological outcomes in pediatric patients with raised ICP. One study by C Woertgen et al stated that age and clinical signs of herniation were significantly associated with an unfavourable outcome regardless of the type of surgery (craniectomy or craniotomy).
I had an apportunity to observe one of the senior physiotherapist treating patient who had a craniectomy previously and now the piece of bone is back in. She told me that patient used to talk and walk around the ward, however now he doesn't have any voluntary movements in his limbs and hardly does visual tracking. She said the compressive force when the bone is put back in as well as dried and contracted dura mater while the bone was not there might be the reason for it and he should be able to regain his functions hopefully. It's very unfortunate that this guy lost what he has achieved in physio after craniectomy procedure and could be frustrating as a physiotherapist as we have to treat this guy from the start again.
Hope you all enjoying the placement
In Sun
I’m currently treating patients with TBI. I’ve seen many patients wearing a helmet to protect their head after craniectomy (removing part of the skull and opening the duramater), so I was wondering what other treatment options are, how it helps to manage increased intracranial pressure and what its outcome would be like.
ICP is the most frequent cause of death and disability after head injury and it’s important to maintain within normal range 15-20mmHg to prevent brain herniation and improve cerebral perfusion. General manoeuvres include head elevation, volume resuscitation, sedation, etc and more aggressive measures include CSF drainage, moderate hypocapnia and mannitol administration. When these therapeutic options are failed, second level therapies like decompressive craniectomy are considered.
This surgical decompression is divided into two types; primary and secondary. Primary decompressive craniectomy is performed to avoid expected postsurgical increases in ICP, whereas secondary decompressive craniectomy is to control high ICP for patients who have undergone surgery to evacuate tumour and who develop brain swelling.
There is no evidence of the routine use of this surgical procedure in adults population and the effectiveness of decompressive craniectomy are quite controversial in adults population as clinical trials have not confirmed although one study showed improved survival and neurological outcomes in pediatric patients with raised ICP. One study by C Woertgen et al stated that age and clinical signs of herniation were significantly associated with an unfavourable outcome regardless of the type of surgery (craniectomy or craniotomy).
I had an apportunity to observe one of the senior physiotherapist treating patient who had a craniectomy previously and now the piece of bone is back in. She told me that patient used to talk and walk around the ward, however now he doesn't have any voluntary movements in his limbs and hardly does visual tracking. She said the compressive force when the bone is put back in as well as dried and contracted dura mater while the bone was not there might be the reason for it and he should be able to regain his functions hopefully. It's very unfortunate that this guy lost what he has achieved in physio after craniectomy procedure and could be frustrating as a physiotherapist as we have to treat this guy from the start again.
Hope you all enjoying the placement
In Sun
Sunday, January 20, 2008
Bed rest and deconditioning
I have been working with a 94 year old lady for two weeks now. Being on my cardio placement ward we see a variety of cases. She was admitted to the hospital for back pain which turned out to be crush fractures. Therefore pain and mobility are her largest issues at the moment. She was living independently prior to her admission. She is a small and frail lady, strength and confidence are areas we are working on as she needs lots of encouragement during our sessions.
Last Friday her daughters and I were very happy with her progress and the plan was for her to return home. I knew she would not receive physiotherapy treatment over the weekend as she did not fit the criteria for weekend physiotherapy therefore I wrote out and drew up an exercise program for her and asked the nurses to take her for walks so she could maintain her current level. Monday afternoon I came to take her for our scheduled walk and checked her medical chart to find she had a temp of 34. It was obvious she was not doing well. I asked her if she was out of bed and doing her exercises over the weekend? She said no. Due to her lack of confidence and motivation she sat in bed or chair all weekend. She did not do her exercises because she forgets them despite my handout. I think she walked with the nurses to toilet couple times but that was it. Everyone on the team became concerned at this rather quick decline. Worse of all she became even less motivated and said she had enough that everything is too hard. Therefore discussion started for placement into high care.
Over the week she stabilized and through lots of convincing by her daughters and I, we got her out of bed again. She had lost so much from being in bed for four days. In class they tell us how bad rest in bed is for the body and how quickly people can de-condition but I have never really experienced it first hand until this week. It was sad and frustrating at the same time because she lost everything we gained the previous week and was so close to heading home. But the good part to the story is that due to the good relationship we developed she agreed to try again. She has improved still not to the level we had previously attained but they are now discussing rehab with her and low level care is the goal. She will be unable to go home which was the original plan but low level is better then high level care.
My supervisor pulled me aside and said she was very happy with what I was doing with this lady and said that I have played a large role in her looking at low level care. With the doctor, nurses and social worker she vocalized she had enough and did not want rehab which would have lead into high level care. But with me she is willing to continue working.
This event reinforced for me, the importance of physiotherapy in the hospitals as well as the importance of building rapport with your clients.
Last Friday her daughters and I were very happy with her progress and the plan was for her to return home. I knew she would not receive physiotherapy treatment over the weekend as she did not fit the criteria for weekend physiotherapy therefore I wrote out and drew up an exercise program for her and asked the nurses to take her for walks so she could maintain her current level. Monday afternoon I came to take her for our scheduled walk and checked her medical chart to find she had a temp of 34. It was obvious she was not doing well. I asked her if she was out of bed and doing her exercises over the weekend? She said no. Due to her lack of confidence and motivation she sat in bed or chair all weekend. She did not do her exercises because she forgets them despite my handout. I think she walked with the nurses to toilet couple times but that was it. Everyone on the team became concerned at this rather quick decline. Worse of all she became even less motivated and said she had enough that everything is too hard. Therefore discussion started for placement into high care.
Over the week she stabilized and through lots of convincing by her daughters and I, we got her out of bed again. She had lost so much from being in bed for four days. In class they tell us how bad rest in bed is for the body and how quickly people can de-condition but I have never really experienced it first hand until this week. It was sad and frustrating at the same time because she lost everything we gained the previous week and was so close to heading home. But the good part to the story is that due to the good relationship we developed she agreed to try again. She has improved still not to the level we had previously attained but they are now discussing rehab with her and low level care is the goal. She will be unable to go home which was the original plan but low level is better then high level care.
My supervisor pulled me aside and said she was very happy with what I was doing with this lady and said that I have played a large role in her looking at low level care. With the doctor, nurses and social worker she vocalized she had enough and did not want rehab which would have lead into high level care. But with me she is willing to continue working.
This event reinforced for me, the importance of physiotherapy in the hospitals as well as the importance of building rapport with your clients.
Plantar Fasciitis Treatment Options?
Hi crew,
Hope the placements are going well. I’m currently on my musculoskeletal placement and the question I have may have no further answers but I wanted to see if there is anything else I can try to help one my patients. This particular patient is an avid runner that is currently unable to even walk long distances due to chronic heel pain. She has been into the clinic prior to X-mas and I’ve had two sessions with the patient. The patient has the common complaints of a constant feeling of discomfort in her heel during the day that increases to 7/10 with impact activities such as running and walking that has continued over the last 3 months. She reports of no acute incident that started her heel pain and that her complaints have not receded even after stopping her walking/running over the holidays. The patient is now very frustrated due to the fact that she is unable to perform the activities that she loves. The diagnosis has changed between a fat pad contusion and plantar fasciitis depending on the response to treatment, but I’m fairly certain that the fascia is the source of the complaints.
The patient complains of pain at the insertion site of the plantar fascia on the medial portion of the calcaneus. Both feet are extremely flat but the affected foot is slightly more pronated and has reduced gastrocnemius and soleus muscle length as well as reduced ankle AROM into dorsiflexion. Also compared with the fascia on other foot, there is a visible and palpable increase in tension in the fascia itself. Interestingly enough there is actually a decrease in muscle length of the flexor hallucis longus on the symptomatic foot, a measure that was determined last session.
Treatment so far has consisted of STM of the gastroc/soleus muscles and the plantar fascia itself in addition to the low dye taping of the foot. The home exercise program consists of stretching of the plantar fascia, gastrocnemius and soleus muscles. She has recently had some orthotics made and is using them regularly. We are also trialling a walking program which she started last week consisting of a 4km walk on grass 3x/week and progressions in her frequency and level of impact will occur according to the response of her heel complaints.
As I don’t have a huge amount of experience with this type of injury, I was wondering if anybody has other treatments options that I could apply to her sessions or is my management of the patient’s heel complaints the area where I’m going to have the most impact in her recovery. Because at the moment, I feel limited in the treatments options that I can provide for the patient. I know that management of a patient’s daily activities is a huge portion of being a physiotherapist but I guess would like to have a larger role in her return to running through actual treatment techniques/options.
Gareth
Hope the placements are going well. I’m currently on my musculoskeletal placement and the question I have may have no further answers but I wanted to see if there is anything else I can try to help one my patients. This particular patient is an avid runner that is currently unable to even walk long distances due to chronic heel pain. She has been into the clinic prior to X-mas and I’ve had two sessions with the patient. The patient has the common complaints of a constant feeling of discomfort in her heel during the day that increases to 7/10 with impact activities such as running and walking that has continued over the last 3 months. She reports of no acute incident that started her heel pain and that her complaints have not receded even after stopping her walking/running over the holidays. The patient is now very frustrated due to the fact that she is unable to perform the activities that she loves. The diagnosis has changed between a fat pad contusion and plantar fasciitis depending on the response to treatment, but I’m fairly certain that the fascia is the source of the complaints.
The patient complains of pain at the insertion site of the plantar fascia on the medial portion of the calcaneus. Both feet are extremely flat but the affected foot is slightly more pronated and has reduced gastrocnemius and soleus muscle length as well as reduced ankle AROM into dorsiflexion. Also compared with the fascia on other foot, there is a visible and palpable increase in tension in the fascia itself. Interestingly enough there is actually a decrease in muscle length of the flexor hallucis longus on the symptomatic foot, a measure that was determined last session.
Treatment so far has consisted of STM of the gastroc/soleus muscles and the plantar fascia itself in addition to the low dye taping of the foot. The home exercise program consists of stretching of the plantar fascia, gastrocnemius and soleus muscles. She has recently had some orthotics made and is using them regularly. We are also trialling a walking program which she started last week consisting of a 4km walk on grass 3x/week and progressions in her frequency and level of impact will occur according to the response of her heel complaints.
As I don’t have a huge amount of experience with this type of injury, I was wondering if anybody has other treatments options that I could apply to her sessions or is my management of the patient’s heel complaints the area where I’m going to have the most impact in her recovery. Because at the moment, I feel limited in the treatments options that I can provide for the patient. I know that management of a patient’s daily activities is a huge portion of being a physiotherapist but I guess would like to have a larger role in her return to running through actual treatment techniques/options.
Gareth
Very rewarding Rx of a neuro patient
Hi guys,
Currently I am doing my Neurological placement in the acquired brain injury ward. I am finding it a very rewarding experience both on a professional level and a personal level as one of the patient’s I am treating is a friend.
My patient ‘Tony’ is a 49 y.o. male who suffered right frontoparietal lesion after a traumatic accident and subsequent subdural and subarachnoid haemorrhage. At the scene Tony had a GCS of 3, with readings “below 6 or 7” (I think, Kate Smith ‘07) being associated with a high mortality rate. The accident occurred whilst at work on a rural property and the patient had to be transferred to Royal Perth Hospital by the Royal Flying Doctor Service. The following day a hemicraniectomy (partial removal of the skull) procedure was performed to relieve ICP. Over the next few weeks the patient remained in a serious but stable condition before having massive bilateral pulmonary emboli resulting in the patient being ventilated on CPAP at Fi 1.0 with SaO2 90%. Since then the patient has been transferred back to the ward and is currently undergoing extensive rehabilitation.
Currently 10/52 post injury the patient is independent for bed mobility, W/C mobility; standby supervision for transfers (WC←→bed) and moderate assistance of 1 for walking.
Tony can sit independently on the bed and can maintain his sitting balance both with internal and external displacement. Tony can stand independently for approximately 30 seconds and can shift his weight within his BOS but cannot stand on one leg. Tony also displays ataxia, dysmetria, dysdiadochokinesia and incoordination with his cerebellar testing. Tony’s impairments contributing to his loss of mobility and function include:
- decreased control of trunk, abdominals, back extensors and pelvic girdle
- decreased strength of the muscles of left side of the body
- diminished sensation of the left leg
- diplopia
- loss of ROM of the left shoulder, wrist and hand
Tony’s goal is to be able to walk again, return to work and home. Treatment so far has been aimed at improving strength of the upper and lower limb muscles, trunk strengthening exercises, sitting balance exercises and recently standing balance exercises have just commenced. Gait retraining has also been implemented with encouraging results thus far. Exercises which I have used include those learnt at uni in our neurological labs. It has been an immense experience implementing these with real patients in a clinical setting as the results gained so far have been very encouraging. When I firstly started treating Tony his limits of stability in sitting were severely reduced and he couldn’t stand independently. Initially he also needed the assistance of 2 to walk, and with assistance of my clinical tutor he can now walk with moderate assistance of 1 (myself). The improvement in Tony’s condition has been great to see from a professional experience and a personal one as well, as he really enjoys his treatments and works very hard in physio with me.
I was hoping if anyone can suggest treatments for Tony’s cerebellar signs and symptoms that can improve function? I know one treatment option is alternating isometrics but if anyone else can give further suggestions that would be fantastic.
Thanks
Currently I am doing my Neurological placement in the acquired brain injury ward. I am finding it a very rewarding experience both on a professional level and a personal level as one of the patient’s I am treating is a friend.
My patient ‘Tony’ is a 49 y.o. male who suffered right frontoparietal lesion after a traumatic accident and subsequent subdural and subarachnoid haemorrhage. At the scene Tony had a GCS of 3, with readings “below 6 or 7” (I think, Kate Smith ‘07) being associated with a high mortality rate. The accident occurred whilst at work on a rural property and the patient had to be transferred to Royal Perth Hospital by the Royal Flying Doctor Service. The following day a hemicraniectomy (partial removal of the skull) procedure was performed to relieve ICP. Over the next few weeks the patient remained in a serious but stable condition before having massive bilateral pulmonary emboli resulting in the patient being ventilated on CPAP at Fi 1.0 with SaO2 90%. Since then the patient has been transferred back to the ward and is currently undergoing extensive rehabilitation.
Currently 10/52 post injury the patient is independent for bed mobility, W/C mobility; standby supervision for transfers (WC←→bed) and moderate assistance of 1 for walking.
Tony can sit independently on the bed and can maintain his sitting balance both with internal and external displacement. Tony can stand independently for approximately 30 seconds and can shift his weight within his BOS but cannot stand on one leg. Tony also displays ataxia, dysmetria, dysdiadochokinesia and incoordination with his cerebellar testing. Tony’s impairments contributing to his loss of mobility and function include:
- decreased control of trunk, abdominals, back extensors and pelvic girdle
- decreased strength of the muscles of left side of the body
- diminished sensation of the left leg
- diplopia
- loss of ROM of the left shoulder, wrist and hand
Tony’s goal is to be able to walk again, return to work and home. Treatment so far has been aimed at improving strength of the upper and lower limb muscles, trunk strengthening exercises, sitting balance exercises and recently standing balance exercises have just commenced. Gait retraining has also been implemented with encouraging results thus far. Exercises which I have used include those learnt at uni in our neurological labs. It has been an immense experience implementing these with real patients in a clinical setting as the results gained so far have been very encouraging. When I firstly started treating Tony his limits of stability in sitting were severely reduced and he couldn’t stand independently. Initially he also needed the assistance of 2 to walk, and with assistance of my clinical tutor he can now walk with moderate assistance of 1 (myself). The improvement in Tony’s condition has been great to see from a professional experience and a personal one as well, as he really enjoys his treatments and works very hard in physio with me.
I was hoping if anyone can suggest treatments for Tony’s cerebellar signs and symptoms that can improve function? I know one treatment option is alternating isometrics but if anyone else can give further suggestions that would be fantastic.
Thanks
Outpatient Rx
Hi all,
I’ve been at a Neuro Physio Outpatients clinic for 2 weeks now and I’m starting to question why we see some of the patients that come in.
I have this one patient in particular who has had a R MCA stroke just under a year ago which has affected both his upper and lower limbs. He has a real problem with high tone, which is made worse upon any sort of effort or even thinking about doing something. He is a lovely guy and I really enjoy working with him but I don’t seem to be getting anywhere. I’ve seen him four times now, and each time he comes in I spend over half an hour with him doing techniques to reduce his tone to maximize the movement in his limbs. We then do half an hour of upper limb retraining, with the last half an hour spent on gait retraining.
This guy does really well when I’m there and he tries really hard to do what I ask him to and make corrections to his movements, especially his walking, but as soon as he leaves he goes back to the old way. I watch him walk out of the gym and he leaves exactly the same way that I saw him walk in.
I’ve raised this issue with my supervisor and he said that ultimately a person will do what is easier for them, and that is to use compensatory strategies. For a person who’s had a stroke, the more they use these strategies, the harder they are to change.
While patients are inpatients on a rehab ward, they are receiving physio for a few hours everyday. Their rehab is quite intensive and good gains are made. As soon as they leave the hospital and become outpatients, we only see them for a max of 3 hours per week, which in my experience with this patient is not enough. Its not like this with all patients I’ve seen, but for him 3 hours isn’t enough to do any good. Most of his problems come from the fact that he has such high tone with any activity and that’s something that a physio can’t do much about in the long term. I just wonder, for someone like this, if the pt is the same every time he comes into the gym, and nothing much changes by the time he walks out, is treatment worthwhile or is it better to spend time with someone else that we can have an effect on?
Tara
I’ve been at a Neuro Physio Outpatients clinic for 2 weeks now and I’m starting to question why we see some of the patients that come in.
I have this one patient in particular who has had a R MCA stroke just under a year ago which has affected both his upper and lower limbs. He has a real problem with high tone, which is made worse upon any sort of effort or even thinking about doing something. He is a lovely guy and I really enjoy working with him but I don’t seem to be getting anywhere. I’ve seen him four times now, and each time he comes in I spend over half an hour with him doing techniques to reduce his tone to maximize the movement in his limbs. We then do half an hour of upper limb retraining, with the last half an hour spent on gait retraining.
This guy does really well when I’m there and he tries really hard to do what I ask him to and make corrections to his movements, especially his walking, but as soon as he leaves he goes back to the old way. I watch him walk out of the gym and he leaves exactly the same way that I saw him walk in.
I’ve raised this issue with my supervisor and he said that ultimately a person will do what is easier for them, and that is to use compensatory strategies. For a person who’s had a stroke, the more they use these strategies, the harder they are to change.
While patients are inpatients on a rehab ward, they are receiving physio for a few hours everyday. Their rehab is quite intensive and good gains are made. As soon as they leave the hospital and become outpatients, we only see them for a max of 3 hours per week, which in my experience with this patient is not enough. Its not like this with all patients I’ve seen, but for him 3 hours isn’t enough to do any good. Most of his problems come from the fact that he has such high tone with any activity and that’s something that a physio can’t do much about in the long term. I just wonder, for someone like this, if the pt is the same every time he comes into the gym, and nothing much changes by the time he walks out, is treatment worthwhile or is it better to spend time with someone else that we can have an effect on?
Tara
Importance of hand therapy
Howdy Folks
One of the first patients I encountered on my current placement in an acute neuro ward was a 80-ish year old man who presented with left-sided weakness, UL>LL and dysarthira following a R sided LACS. The main aim of treatment for him to was to increase the function of his left wrist, hand and fingers. He is L hand dominant. Until then he had been treated with exercises to facilitate wrist extension, finger extension, different grip positions and finger opposition, as well as FES for 30 mins a day to improve his L wrist extensor function. Exercises for him included picking up different sized blocks of foam, using a pincer grip to pick up cone-shaped objects and squeezing putty given to him by the OT. Further examination revealed that grasping and picking up and glass and bringing it to his mouth was a functional task that needed rehabilitating, on top of the manipulation defecits.
As you guys know, the UL was not something we spent a great deal of time on in our studies of neuro rehabiliation, particularly on the practical side of things. As such I felt quite unprepared to treat this man, and particularly how to progress treatment according to his level of recovery. On top of this, a number of physio's at the hospital have pointed out that, as we know, the hand and fingers represent a huge area in out sensory and motor homunculus, and therefore require a lot of cortical activation for there movement and re-training. Thus hand therapy is a tiresome job for patients and should be the priority of treatment if a number of impairments or functional tasks need attention and time is limited. This information has definately changed the way I think about sructuring my treatment sessions (if relevant to the patient).
Of course I made sure to read about treatment options for the hand, including sensory and motor re-training, and felt confident to being treating the man and offer suggestions for progression. This experience, and others, have really opened my eyes to some of the world of knowledge and treatment options that exists beyond our 2 year study at uni so far. With regard to the hand, I would love to hear what others have encountered on their neuro pracs, including occurence of presentation, treatment options and how patients have responded to such therapy. With regard to this man, I went in to treat him the following day, armed with my aresenal of awesome treatment options only to find he had been discharged! Bugger! But at least I feel more confident should I have to provide hand therapy in the future.
One of the first patients I encountered on my current placement in an acute neuro ward was a 80-ish year old man who presented with left-sided weakness, UL>LL and dysarthira following a R sided LACS. The main aim of treatment for him to was to increase the function of his left wrist, hand and fingers. He is L hand dominant. Until then he had been treated with exercises to facilitate wrist extension, finger extension, different grip positions and finger opposition, as well as FES for 30 mins a day to improve his L wrist extensor function. Exercises for him included picking up different sized blocks of foam, using a pincer grip to pick up cone-shaped objects and squeezing putty given to him by the OT. Further examination revealed that grasping and picking up and glass and bringing it to his mouth was a functional task that needed rehabilitating, on top of the manipulation defecits.
As you guys know, the UL was not something we spent a great deal of time on in our studies of neuro rehabiliation, particularly on the practical side of things. As such I felt quite unprepared to treat this man, and particularly how to progress treatment according to his level of recovery. On top of this, a number of physio's at the hospital have pointed out that, as we know, the hand and fingers represent a huge area in out sensory and motor homunculus, and therefore require a lot of cortical activation for there movement and re-training. Thus hand therapy is a tiresome job for patients and should be the priority of treatment if a number of impairments or functional tasks need attention and time is limited. This information has definately changed the way I think about sructuring my treatment sessions (if relevant to the patient).
Of course I made sure to read about treatment options for the hand, including sensory and motor re-training, and felt confident to being treating the man and offer suggestions for progression. This experience, and others, have really opened my eyes to some of the world of knowledge and treatment options that exists beyond our 2 year study at uni so far. With regard to the hand, I would love to hear what others have encountered on their neuro pracs, including occurence of presentation, treatment options and how patients have responded to such therapy. With regard to this man, I went in to treat him the following day, armed with my aresenal of awesome treatment options only to find he had been discharged! Bugger! But at least I feel more confident should I have to provide hand therapy in the future.
difficult patient
Hi guys,
this week of placement was pretty uneventful. I had this patient though who had a huge stoma bag post-laparotomy. He complained his stoma bag was leaking and it was only after a few hours that the nurses decided to change his stoma bag. Instead of going for morning tea, i decided to stick around and help out.
The first step was taking off the existing stoma bag. That was ugly business.. and smelly too. The glue had to be removed with special wipes but because the previous nurse didn't shave him, the glue was adhering to the skin and was really painful to remove. The next step was cleaning the area. I helped to suction out some debris but the rest had to be cleaned out with dailee wipes. All this time the patient kept cursing and swearing as it hurt so badly. Then the last step was just shaving him and then putting the new stoma bag on.
Ever since that incident, the patient seemed to be in a really bad mood all the time and has refused physiotherapy even after 2 days. He declined even getting out of bed and requested to be washed in bed instead of ambulating to the shower which he normally does, stating that he just doesn't need physio? (He reports no pain or discomfort and has declined even after my supervisor and i tried to talk to him) And i was wondering why he suddenly changed his attitude (he was previously pretty motivated to ambulate and was walking well with a WZF), and though it sounds a tad silly, if i did anything wrong by helping or if there was anything else i could do to make him change his mind?
this week of placement was pretty uneventful. I had this patient though who had a huge stoma bag post-laparotomy. He complained his stoma bag was leaking and it was only after a few hours that the nurses decided to change his stoma bag. Instead of going for morning tea, i decided to stick around and help out.
The first step was taking off the existing stoma bag. That was ugly business.. and smelly too. The glue had to be removed with special wipes but because the previous nurse didn't shave him, the glue was adhering to the skin and was really painful to remove. The next step was cleaning the area. I helped to suction out some debris but the rest had to be cleaned out with dailee wipes. All this time the patient kept cursing and swearing as it hurt so badly. Then the last step was just shaving him and then putting the new stoma bag on.
Ever since that incident, the patient seemed to be in a really bad mood all the time and has refused physiotherapy even after 2 days. He declined even getting out of bed and requested to be washed in bed instead of ambulating to the shower which he normally does, stating that he just doesn't need physio? (He reports no pain or discomfort and has declined even after my supervisor and i tried to talk to him) And i was wondering why he suddenly changed his attitude (he was previously pretty motivated to ambulate and was walking well with a WZF), and though it sounds a tad silly, if i did anything wrong by helping or if there was anything else i could do to make him change his mind?
"Likely MS" diagnosis (Daria's Post)
Hi all,
I am currently on my neuro placement in SCGH. Last week I treated a patient with "likely MS" diagnosis.
This patient presented at the beginning of last week with neurological symptoms such as altered sensation (R) face, double vision lasting for more than 1 hour, decreased hearing (R) with tinnitus, numbness (R) arm plus (R) leg. Everything started suddenly in November 2007 with loss of balance.
I found really hard to treat this very nice and cooperative patient and I had to constantly think about wards I am using and how I communicate with this particular patient. During the treatment I was trying not to use the words that would indicate that patient has definite MS even mentioned earlier neuro symptoms plus fatigue, depression, headaches seem to match MS very well.
The patient has asked one of her friends to find out on internet about MS, another friend who is nurse was helping in interpretation. The doctors were doing extra investigations to confirm/exclude MS diagnosis. I knew that it is very hard time for this patient like wanting for a sentence. On the one hand patient wanted to know as much as possible but on the other hand probably wanted to find out that doctors are wrong. To be honest I wanted to believe that it is not MS, too.
In addition, this patient (female) is only 4 years older than me. She has loving husband, beautiful daughter, good job and suddenly everything may have to change. At the end of week this patient sensation, balance have improved a lot, gait has become more stable but still slow on top of this patient finds balance exercises very tirying and has to concenetrate o lot.
To sum up, I think that treating patients with degenerative disease can be very rewarding but depressing,too
Daria
I am currently on my neuro placement in SCGH. Last week I treated a patient with "likely MS" diagnosis.
This patient presented at the beginning of last week with neurological symptoms such as altered sensation (R) face, double vision lasting for more than 1 hour, decreased hearing (R) with tinnitus, numbness (R) arm plus (R) leg. Everything started suddenly in November 2007 with loss of balance.
I found really hard to treat this very nice and cooperative patient and I had to constantly think about wards I am using and how I communicate with this particular patient. During the treatment I was trying not to use the words that would indicate that patient has definite MS even mentioned earlier neuro symptoms plus fatigue, depression, headaches seem to match MS very well.
The patient has asked one of her friends to find out on internet about MS, another friend who is nurse was helping in interpretation. The doctors were doing extra investigations to confirm/exclude MS diagnosis. I knew that it is very hard time for this patient like wanting for a sentence. On the one hand patient wanted to know as much as possible but on the other hand probably wanted to find out that doctors are wrong. To be honest I wanted to believe that it is not MS, too.
In addition, this patient (female) is only 4 years older than me. She has loving husband, beautiful daughter, good job and suddenly everything may have to change. At the end of week this patient sensation, balance have improved a lot, gait has become more stable but still slow on top of this patient finds balance exercises very tirying and has to concenetrate o lot.
To sum up, I think that treating patients with degenerative disease can be very rewarding but depressing,too
Daria
Saturday, January 19, 2008
Suctioning concerns...
Hello fellow colleagues,
I am currently working on my placement in the surgical and medical wards. This past week I have had a few interesting patients in which we were required to suction.
One of these patients was a post laparotomy and the other had come in due to a bad fever.
These patients were in need of suctioning as they had ineffective coughs and you could hear their secretions being transmitted audibly and UATS were heard on auscultation. These patients were not intubated- they were however drowsy. Due to them having ineffective cough my supervisor and I decided to use an oropharyngeal airway (Guedel) and then suction via this. We treated both these patients in the morning and returned in the afternoon for a second treatment session due to the copious amounts of secretions in the lungs. On the 1st visit both patients did not like the experience and found it very uncomfortable as well as tiresome but we still managed to suction a large amount of secretions. On the 2nd visit both these patients refused the Guedel airway. As you can’t force a Guedel in on a conscious patient without their consent we decided to try the nasopharyngeal route instead but the patients nostrils were too small and we were unable to gain entry.
The situation that then arose was that we had two patients who clearly needed suctioning however were both refusing and were unable to clear independently and effectively. I was concerned as to what you would do in this situation because you can not force someone to give their consent however there would be a large likelihood these patients would deteriorate over time due to the large amounts of secretions still present. In the end my supervisor told me that all we could do was leave these patients and try at a later time as the extra stress placed on them via forcing suctioning could be detrimental to their status. I was however concerned that by not treating them that would also be detrimental to their status.
I thought I would just share this incident with you as I found it an interesting situation as I would have thought that it would be a priority to treat someone presenting like these two patients did. Has anyone else had any interesting suctioning issues on their placements??
Debs
I am currently working on my placement in the surgical and medical wards. This past week I have had a few interesting patients in which we were required to suction.
One of these patients was a post laparotomy and the other had come in due to a bad fever.
These patients were in need of suctioning as they had ineffective coughs and you could hear their secretions being transmitted audibly and UATS were heard on auscultation. These patients were not intubated- they were however drowsy. Due to them having ineffective cough my supervisor and I decided to use an oropharyngeal airway (Guedel) and then suction via this. We treated both these patients in the morning and returned in the afternoon for a second treatment session due to the copious amounts of secretions in the lungs. On the 1st visit both patients did not like the experience and found it very uncomfortable as well as tiresome but we still managed to suction a large amount of secretions. On the 2nd visit both these patients refused the Guedel airway. As you can’t force a Guedel in on a conscious patient without their consent we decided to try the nasopharyngeal route instead but the patients nostrils were too small and we were unable to gain entry.
The situation that then arose was that we had two patients who clearly needed suctioning however were both refusing and were unable to clear independently and effectively. I was concerned as to what you would do in this situation because you can not force someone to give their consent however there would be a large likelihood these patients would deteriorate over time due to the large amounts of secretions still present. In the end my supervisor told me that all we could do was leave these patients and try at a later time as the extra stress placed on them via forcing suctioning could be detrimental to their status. I was however concerned that by not treating them that would also be detrimental to their status.
I thought I would just share this incident with you as I found it an interesting situation as I would have thought that it would be a priority to treat someone presenting like these two patients did. Has anyone else had any interesting suctioning issues on their placements??
Debs
A Serial Patient!
Hi all,
I am currently treating a patient with severe muscles tightness and secondary joint hypomobility (leading to limited ROM) in the lower Cx and mid/upper Tx spine. The client has had these episodes (that usually last for a couple of weeks) periodically over the last couple of years and has come to the clinic each time (a few trees have been cut down to build her file!!). They are very much related to her study habits as a med student where she says she often studies up to 14 hours straight with no breaks.
The client maintains that she comes to the physio clinic when these episodes occur, as a preventative measure, because if she doesn't she begins to feel disabling pain in her neck and between the scapulae. The client is always happy with the treatment she receives at the clinic which includes STM, myofascial release, PAIVMS to Tx/Cx spine, stretching and education. As a private paying client the client is obviously very lucrative for the clinic.
So you may ask what is Nico going on about here?!!
It just seems that all the education in the world reguarding her study habits, posture and ergonomics can't seem to change her behaviour. The client knows that if she adopted some of the advice including frequent breaks, getting a better chair etc.. her symptoms would disappear. For instance I mention that she should break from study every 20 min and walk/stretch and she responds with "yeah I know, I've been told all this before". The client is just a very driven person and is so busy in other areas of her life to implement the strategies given to her. The client would rather deal with the symptoms when they occur than deal with the root problem.
Does anyone have experience with a pt/client like this and what strategies did they use to affectively get their point across?
Something to think about too. Is it ok to keep on taking this clients money knowing that you are making her happy but not effectively dealing with her loading/postural disorder? I can imagine this kind of client would be a common occurance in private practice. Anyway something to think about if you want to.
Take it easy.
Nico
I am currently treating a patient with severe muscles tightness and secondary joint hypomobility (leading to limited ROM) in the lower Cx and mid/upper Tx spine. The client has had these episodes (that usually last for a couple of weeks) periodically over the last couple of years and has come to the clinic each time (a few trees have been cut down to build her file!!). They are very much related to her study habits as a med student where she says she often studies up to 14 hours straight with no breaks.
The client maintains that she comes to the physio clinic when these episodes occur, as a preventative measure, because if she doesn't she begins to feel disabling pain in her neck and between the scapulae. The client is always happy with the treatment she receives at the clinic which includes STM, myofascial release, PAIVMS to Tx/Cx spine, stretching and education. As a private paying client the client is obviously very lucrative for the clinic.
So you may ask what is Nico going on about here?!!
It just seems that all the education in the world reguarding her study habits, posture and ergonomics can't seem to change her behaviour. The client knows that if she adopted some of the advice including frequent breaks, getting a better chair etc.. her symptoms would disappear. For instance I mention that she should break from study every 20 min and walk/stretch and she responds with "yeah I know, I've been told all this before". The client is just a very driven person and is so busy in other areas of her life to implement the strategies given to her. The client would rather deal with the symptoms when they occur than deal with the root problem.
Does anyone have experience with a pt/client like this and what strategies did they use to affectively get their point across?
Something to think about too. Is it ok to keep on taking this clients money knowing that you are making her happy but not effectively dealing with her loading/postural disorder? I can imagine this kind of client would be a common occurance in private practice. Anyway something to think about if you want to.
Take it easy.
Nico
Thursday, January 17, 2008
Frustrating communication
Hi all!
I’m currently doing my Neuro Outpatients placement.
This week I saw a patient who was a new admission to the neuro outpatient clinic. The patient had a L MCA infarct approx 7 months ago and was a late addition to my case load and I hadn’t had a chance to read over his medical notes before seeing him. Because of this, I had no idea of his history and what to expect. When I finally met the pt and started chatting, I was faced with a person grunting and gesturing at me in an attempt to tell me that he couldn’t talk. The pt had only mild receptive aphasia and could understand simple instructions, however he had severe expressive aphasia and was unable to communicate other than indicating yes or no through nodding his head. Even then, his yes and no answers seemed all over the place and not at all consistent which made it really hard to get a clear picture of what was really going on. My subjective Ax was pretty much non existent and my objective was very sketchy. Some Ax such as tone and ROM were relatively normal to complete, however the pts physical responses and facial expressions to this had to be monitored closely, rather than relying on a verbal response to stop. Other Ax was seemingly almost impossible.
This whole process had to be done so slowly to be as accurate as possible and was extremely long and yet at the end of it all I felt like I had gotten nowhere and had more questions than answers which left me feeling extremely frustrated and useless…
Later that day I was buying lunch at the cafeteria and saw the same pt eating lunch with his wife, daughter and 3 of his grandchildren. They were all chatting, laughing and looked like a happy family having a nice lunch together. As I watched this family, my patient looked like he was really happy to have so many family members around him and yet I couldn’t help but feel like he was missing out on something. He had so much going on around him and he couldn’t contribute at all… all he could do was sit there and listen.
I thought back to how I had felt at the end of our session that morning and how frustrated I was with the situation… then I thought, how must this guy feel? 7 months ago this guy was a seemingly normal, happy, working man who could interact with his family and environment around him. Now all he could do was nod his head and grunt. At that point my morning didn’t seem so bad after all.
I’m currently doing my Neuro Outpatients placement.
This week I saw a patient who was a new admission to the neuro outpatient clinic. The patient had a L MCA infarct approx 7 months ago and was a late addition to my case load and I hadn’t had a chance to read over his medical notes before seeing him. Because of this, I had no idea of his history and what to expect. When I finally met the pt and started chatting, I was faced with a person grunting and gesturing at me in an attempt to tell me that he couldn’t talk. The pt had only mild receptive aphasia and could understand simple instructions, however he had severe expressive aphasia and was unable to communicate other than indicating yes or no through nodding his head. Even then, his yes and no answers seemed all over the place and not at all consistent which made it really hard to get a clear picture of what was really going on. My subjective Ax was pretty much non existent and my objective was very sketchy. Some Ax such as tone and ROM were relatively normal to complete, however the pts physical responses and facial expressions to this had to be monitored closely, rather than relying on a verbal response to stop. Other Ax was seemingly almost impossible.
This whole process had to be done so slowly to be as accurate as possible and was extremely long and yet at the end of it all I felt like I had gotten nowhere and had more questions than answers which left me feeling extremely frustrated and useless…
Later that day I was buying lunch at the cafeteria and saw the same pt eating lunch with his wife, daughter and 3 of his grandchildren. They were all chatting, laughing and looked like a happy family having a nice lunch together. As I watched this family, my patient looked like he was really happy to have so many family members around him and yet I couldn’t help but feel like he was missing out on something. He had so much going on around him and he couldn’t contribute at all… all he could do was sit there and listen.
I thought back to how I had felt at the end of our session that morning and how frustrated I was with the situation… then I thought, how must this guy feel? 7 months ago this guy was a seemingly normal, happy, working man who could interact with his family and environment around him. Now all he could do was nod his head and grunt. At that point my morning didn’t seem so bad after all.
Wednesday, January 16, 2008
Rib troubles
Does anyone have experience with rib troubles?
This pt presented with pain & TOP ++. Based on the presentation, I thought it was a broken rib... but thinking about it, there was not sufficient trauma to explain this.
PC: pain in back & chest
Hx:
3 week history of sleeping in different bed (travelling).
Possible contribution of connubial activities.
Functional problems:
pain 5/10 sneezing / coughing centred on L post / post-lat rib #4
pain 4/10 deep breath same location
TOP ++ area of L rib #4
AROM:
L SF 5cm < style="font-weight: bold;">PAIVMs:
bilateral (transverse processes):
R2: no noticeable diff. in T1,2,3,4,5
pain 3/10 T2; 4/10 T3; 5/10 T4; 5/10 T5
ribs:
P2: at 1/3 range R & L ribs 3,4,5
pain 8/10 L rib 4
pain 7/10 L rib 3 & 5, R rib 4
pain 6/10 L rib 2, R rib 3, 5
Any ideas about Dx or Rx?
In retrospect, I am thinking I should have checked for trigger points / muscle tightness of the paraspinals, traps and rhomboids to see if they were contributing to the global soreness & TOP around the costovertebral joints - it seems to me more likely that one structure (e.g. rhomboids) would be so sore rather than any separate structures (i.e. 5-6 underlying costovertebral joints). Perhaps the go is to relax overlying muscles before doing PAIVMs?
This pt presented with pain & TOP ++. Based on the presentation, I thought it was a broken rib... but thinking about it, there was not sufficient trauma to explain this.
PC: pain in back & chest
Hx:
3 week history of sleeping in different bed (travelling).
Possible contribution of connubial activities.
Functional problems:
pain 5/10 sneezing / coughing centred on L post / post-lat rib #4
pain 4/10 deep breath same location
TOP ++ area of L rib #4
AROM:
L SF 5cm < style="font-weight: bold;">PAIVMs:
bilateral (transverse processes):
R2: no noticeable diff. in T1,2,3,4,5
pain 3/10 T2; 4/10 T3; 5/10 T4; 5/10 T5
ribs:
P2: at 1/3 range R & L ribs 3,4,5
pain 8/10 L rib 4
pain 7/10 L rib 3 & 5, R rib 4
pain 6/10 L rib 2, R rib 3, 5
Any ideas about Dx or Rx?
In retrospect, I am thinking I should have checked for trigger points / muscle tightness of the paraspinals, traps and rhomboids to see if they were contributing to the global soreness & TOP around the costovertebral joints - it seems to me more likely that one structure (e.g. rhomboids) would be so sore rather than any separate structures (i.e. 5-6 underlying costovertebral joints). Perhaps the go is to relax overlying muscles before doing PAIVMs?
Monday, January 14, 2008
A lesson in patience
Hi guys, i'm currently doing my cardiopulmonary placement. This incident didn't happen to me personally but it definitely taught me alot about taking time to do the right thing.
Last week, there was a patient who came in after surgery (laparotomy) and had a drainage tube connected to him. This tube basically was for the drainage of waste matter and had a little balloon attached to the end of it to prevent it from getting yanked out accidentally.
What happened was that one of the doctors was trying to remove the tube from the patient. However, he didn't want to wait for the nurse to run out to grab a syringe to deflate the cuff first. Instead, he pulled on the tube till the balloon was showing and then stabbed the balloon with his pen, thereby causing all the waste matter to splatter on him, another doctor and everywhere else.
As a result, he had to spend the rest of the day getting tested for the different diseases that could he could be infected with and even had to draw up an accident report. This incident maybe funny as we're not the doctor who made that mistake but it really taught me about how tempting it is to take shortcuts (especially when we're tight for time) yet how important and how much more efficient it is to do the right thing and in the right way.
For example, it might only take us 2 secs to check if our patient is nauseous/dizzy on standing but it'd take us alot more time and effort trying to ambulate someone who is or happened to faint or vomit halfway. Therefore, I'm reminded that it's always worthwhile to take some time to do it right, especially when our patients are involved.
Last week, there was a patient who came in after surgery (laparotomy) and had a drainage tube connected to him. This tube basically was for the drainage of waste matter and had a little balloon attached to the end of it to prevent it from getting yanked out accidentally.
What happened was that one of the doctors was trying to remove the tube from the patient. However, he didn't want to wait for the nurse to run out to grab a syringe to deflate the cuff first. Instead, he pulled on the tube till the balloon was showing and then stabbed the balloon with his pen, thereby causing all the waste matter to splatter on him, another doctor and everywhere else.
As a result, he had to spend the rest of the day getting tested for the different diseases that could he could be infected with and even had to draw up an accident report. This incident maybe funny as we're not the doctor who made that mistake but it really taught me about how tempting it is to take shortcuts (especially when we're tight for time) yet how important and how much more efficient it is to do the right thing and in the right way.
For example, it might only take us 2 secs to check if our patient is nauseous/dizzy on standing but it'd take us alot more time and effort trying to ambulate someone who is or happened to faint or vomit halfway. Therefore, I'm reminded that it's always worthwhile to take some time to do it right, especially when our patients are involved.
Sunday, January 13, 2008
Neuro Clinical Reasoning Problem for you
Had an interesting case during the Neuro placement which brought up an intriguing clinical reasoning problem - you can have a read and see if you would crack the nut yourself.
The patient was a 68 year old gent with transverse myelitis and a PMH of R MCA stroke.
Transverse myelitis (TM) itself is interesting in that it is similar to Guillan Barré, but presents like an incomplete spinal cord injury (SCI). Specifically, TM involves demyelination (like Guillan Barré) of the spinal cord across a specific spinal cord level (so there is partial or complete loss of motor control below a segment, like an SCI).
The clinical course is similar to Guillan Barré in that there is an extremely rapid decline followed by long, slow recovery. However, the prognosis is not as good as Guillan Barré: 1/3 of patients recover with a mild to moderate disability; 1/3 of patients recover with a moderate to severe disability; and 1/3 of patients don't recover appreciably. Thankfully for our patient, people with TM who show early signs of some recovery (as he did) are much less likely to fall into the last group.
Another positive aspect is that, unlike Guillan Barré, TM leaves with patients with wholly intact function above the affected level of the spinal cord. Our patient was a C7 TM case, so he had complete control of triceps, etc. - but not the best finger grip for pens, etc.
This brings up the clinical reasoning question. Our patient was starting to lose ROM for wrist flexion. The questions was: do we stretch out the long finger flexors to retain muscle length & avoid a flexion contracture; or do we leave it alone so that he will still have a tenodesis grip?
What would you do?
We debated the question before asking our clinical supervisor. The answer she came up with was: Consider the likely clinical course... While there is any chance for recovery, we should try to aim for optimal function and not go for compensations - which is what a tenodesis grip is. We therefore instituted a 'HEP' stretching program so that the patient could maintain his wrist ROM.
The patient was a 68 year old gent with transverse myelitis and a PMH of R MCA stroke.
Transverse myelitis (TM) itself is interesting in that it is similar to Guillan Barré, but presents like an incomplete spinal cord injury (SCI). Specifically, TM involves demyelination (like Guillan Barré) of the spinal cord across a specific spinal cord level (so there is partial or complete loss of motor control below a segment, like an SCI).
The clinical course is similar to Guillan Barré in that there is an extremely rapid decline followed by long, slow recovery. However, the prognosis is not as good as Guillan Barré: 1/3 of patients recover with a mild to moderate disability; 1/3 of patients recover with a moderate to severe disability; and 1/3 of patients don't recover appreciably. Thankfully for our patient, people with TM who show early signs of some recovery (as he did) are much less likely to fall into the last group.
Another positive aspect is that, unlike Guillan Barré, TM leaves with patients with wholly intact function above the affected level of the spinal cord. Our patient was a C7 TM case, so he had complete control of triceps, etc. - but not the best finger grip for pens, etc.
This brings up the clinical reasoning question. Our patient was starting to lose ROM for wrist flexion. The questions was: do we stretch out the long finger flexors to retain muscle length & avoid a flexion contracture; or do we leave it alone so that he will still have a tenodesis grip?
What would you do?
We debated the question before asking our clinical supervisor. The answer she came up with was: Consider the likely clinical course... While there is any chance for recovery, we should try to aim for optimal function and not go for compensations - which is what a tenodesis grip is. We therefore instituted a 'HEP' stretching program so that the patient could maintain his wrist ROM.
Gains made in treatment and intensity of rehabilitation
Hey crew,
In December this year I had my Neurology placement. I was working on an acute neurology ward. One of my patients was a 64 year old female who had had a R MCA stroke. Her main impairments were left sided weakness and abnormal motor control patterns of her left arm and left leg. This lady was fairly dependent and initially required 2 x moderate assist to sit to stand and do any transfers. Our main goals for this patient was for her to achieve independence in sit to stand (with the assistance of a rail) as well as independent transfers such as w/c to bed such that she would be able to return home to live with her husband. The doctor gave us 2-3 weeks to try and achieve this goal as after this they wanted to transfer her to Osbourne Park for further rehab and then return home or a nursing home.
Initially in the first week of Rx with her we focused on muscle strength of her legs and core stability. After this week I found out that if she didn’t achieve close to independent status she would have to go to a nursing home. This upset me as you could tell she did not want to go to a nursing home and her husband did not want her to either- however, he would not of been able to cope at home unless she improved her status. This situation really motivated me to assist her in regaining her functional status. From this day, I changed my Rx ideas to focus on transfers from w/c to bed and back as well as sit to stand practice. Everyday I saw her twice and spent 45-60minutes with her- I found her to be a very challenging patient as she was very inconsistent with her progress. One day she would have a great session and do the tasks really well and then the subsequent day it felt like we were back to basics and where we had started. She also had some memory problems which affected the way she performed tasks as she would forget the sequence of movements to achieve the goals. On her bad days I felt very frustrated as I felt my treatment was being ineffective and I wasn’t progressing her- these days really tested my patience and motivation to her Rx. Personally, when I’m treating patients I like to see the patients progress and improve as this shows that I am being effective and helpful in the patients function. I guess with this patient I realized that you’re not always going to get fast results and patients will progress and then regress on their bad and good days. I think I thought that everyday I would see progress and then when this wasn’t the case and she was fairly inconsistent it opened my eyes to the rehabilitation in stroke and how it can take a long time for someone to regain function.
Overall though, in the 2-3 weeks I was treating the patient I learnt a lot from her and she made some good gains although not as significant as I had hoped as she still required lots of cueing for each task she performed. For me, this patient raised 2 issues; the first being that I realized that rehabilitation can take a long time and you’re not always going to get fast results however its still important to prosper on and keep trying to achieve improvements by using various Rx technqiues, the 2nd issue that it raised for me is how much rehab is necessary for patients to improve? As we are students we were able to see this patient 2 x per day however I doubt that we would have this opportunity in the clinical world with a full case load. It concerns me that if this patient had of received less Rx would she of been in an even worse functional status? I worry that when we get into working in the clinical setting we wont always have time to achieve all that we want to achieve with patients and we may have to settle for a reduced functional status of the patients.
Just let me know if any of you feel the same way as me in this situation. Thanks.
In December this year I had my Neurology placement. I was working on an acute neurology ward. One of my patients was a 64 year old female who had had a R MCA stroke. Her main impairments were left sided weakness and abnormal motor control patterns of her left arm and left leg. This lady was fairly dependent and initially required 2 x moderate assist to sit to stand and do any transfers. Our main goals for this patient was for her to achieve independence in sit to stand (with the assistance of a rail) as well as independent transfers such as w/c to bed such that she would be able to return home to live with her husband. The doctor gave us 2-3 weeks to try and achieve this goal as after this they wanted to transfer her to Osbourne Park for further rehab and then return home or a nursing home.
Initially in the first week of Rx with her we focused on muscle strength of her legs and core stability. After this week I found out that if she didn’t achieve close to independent status she would have to go to a nursing home. This upset me as you could tell she did not want to go to a nursing home and her husband did not want her to either- however, he would not of been able to cope at home unless she improved her status. This situation really motivated me to assist her in regaining her functional status. From this day, I changed my Rx ideas to focus on transfers from w/c to bed and back as well as sit to stand practice. Everyday I saw her twice and spent 45-60minutes with her- I found her to be a very challenging patient as she was very inconsistent with her progress. One day she would have a great session and do the tasks really well and then the subsequent day it felt like we were back to basics and where we had started. She also had some memory problems which affected the way she performed tasks as she would forget the sequence of movements to achieve the goals. On her bad days I felt very frustrated as I felt my treatment was being ineffective and I wasn’t progressing her- these days really tested my patience and motivation to her Rx. Personally, when I’m treating patients I like to see the patients progress and improve as this shows that I am being effective and helpful in the patients function. I guess with this patient I realized that you’re not always going to get fast results and patients will progress and then regress on their bad and good days. I think I thought that everyday I would see progress and then when this wasn’t the case and she was fairly inconsistent it opened my eyes to the rehabilitation in stroke and how it can take a long time for someone to regain function.
Overall though, in the 2-3 weeks I was treating the patient I learnt a lot from her and she made some good gains although not as significant as I had hoped as she still required lots of cueing for each task she performed. For me, this patient raised 2 issues; the first being that I realized that rehabilitation can take a long time and you’re not always going to get fast results however its still important to prosper on and keep trying to achieve improvements by using various Rx technqiues, the 2nd issue that it raised for me is how much rehab is necessary for patients to improve? As we are students we were able to see this patient 2 x per day however I doubt that we would have this opportunity in the clinical world with a full case load. It concerns me that if this patient had of received less Rx would she of been in an even worse functional status? I worry that when we get into working in the clinical setting we wont always have time to achieve all that we want to achieve with patients and we may have to settle for a reduced functional status of the patients.
Just let me know if any of you feel the same way as me in this situation. Thanks.
Cognitive Deficits Impacting PT Rx
Hi guys,
During December I completed my musculoskeletal placement in an outpatients department. In the first week of my placement I was presented with the following patient.
A 65 y.o. male, presented with right shoulder pain that had a 10 month history with an insidious onset. He had been treated by numerous physiotherapy students previously. Upon reviewing the patient’s notes it had become quite clear that progress had plateaued in the previous 5 months. Medical imaging investigations (X-ray, U/S) had been conducted and no abnormalities were found in his shoulder (normal acromian, rotator cuff intact).
The first session with this patient I had a lot of difficulties with obtaining accurate information from his subjective assessment with patient being very inconsistent with reporting their aggravating and easing factors. This was further compounded with the objective assessment with the patient having difficulty understanding simple instructions to perform AROMs even though I demonstrated and described how to perform the movement a number of different ways. His pain response to the objective examination also made my findings inconsistent. For example in standing he had markedly different shoulder ROM than in supine. As this was my first week in my musculoskeletal outpatient’s placement it was difficult to determine what was going on and to have confidence in my abilities.
After consultation with my tutor about my subjective and objective findings it was quite difficult to determine what factors were causing his pain. My tutor then informed me that this patient had cognitive deficit’s that had been documented in his notes but not the patient’s notes. After discussing treatment options, scapulothoracic exercises were given and the patient could perform these very well and these were also given for his HEP.
The next Rx the patient’s HEP was reviewed. The exercises he performed did not resemble what he had been prescribed despite the fact that he could perform this extremely well in the clinic in his previous treatment and a handout with pictures given.
This highlighted to me the fact that performing exercises for motor control was quite difficult, and further complicated by the patient having cognitive difficulties.
Ax findings were quite similar to the first session. After consulting with my tutor it was decided that a different approach was necessary but with the same goals in mind of trying to improve and obtain optimal scapulothoarcic movement in order to decrease the shoulder pain being experienced. Once again treatment was implemented and upon re-Ax symptoms were improved (decrease pain) and the patient sent home with a different HEP.
At the patients 3rd PT session, his HEP was reviewed and the patient once again performed exercises that did not remotely resemble what was learned previously.
It was becoming quite clear that the patient’s cognitive deficits were impacting on his ability to rehabilitate his shoulder.
As a PT is was frustrating that the Rx being provided was not having the desired effect and the HEP was unable to be performed appropriately. In this case I was able to implement some different strategies to try and achieve Rx goals. However I do need to develop further strategies to achieve PT Rx goals.
During December I completed my musculoskeletal placement in an outpatients department. In the first week of my placement I was presented with the following patient.
A 65 y.o. male, presented with right shoulder pain that had a 10 month history with an insidious onset. He had been treated by numerous physiotherapy students previously. Upon reviewing the patient’s notes it had become quite clear that progress had plateaued in the previous 5 months. Medical imaging investigations (X-ray, U/S) had been conducted and no abnormalities were found in his shoulder (normal acromian, rotator cuff intact).
The first session with this patient I had a lot of difficulties with obtaining accurate information from his subjective assessment with patient being very inconsistent with reporting their aggravating and easing factors. This was further compounded with the objective assessment with the patient having difficulty understanding simple instructions to perform AROMs even though I demonstrated and described how to perform the movement a number of different ways. His pain response to the objective examination also made my findings inconsistent. For example in standing he had markedly different shoulder ROM than in supine. As this was my first week in my musculoskeletal outpatient’s placement it was difficult to determine what was going on and to have confidence in my abilities.
After consultation with my tutor about my subjective and objective findings it was quite difficult to determine what factors were causing his pain. My tutor then informed me that this patient had cognitive deficit’s that had been documented in his notes but not the patient’s notes. After discussing treatment options, scapulothoracic exercises were given and the patient could perform these very well and these were also given for his HEP.
The next Rx the patient’s HEP was reviewed. The exercises he performed did not resemble what he had been prescribed despite the fact that he could perform this extremely well in the clinic in his previous treatment and a handout with pictures given.
This highlighted to me the fact that performing exercises for motor control was quite difficult, and further complicated by the patient having cognitive difficulties.
Ax findings were quite similar to the first session. After consulting with my tutor it was decided that a different approach was necessary but with the same goals in mind of trying to improve and obtain optimal scapulothoarcic movement in order to decrease the shoulder pain being experienced. Once again treatment was implemented and upon re-Ax symptoms were improved (decrease pain) and the patient sent home with a different HEP.
At the patients 3rd PT session, his HEP was reviewed and the patient once again performed exercises that did not remotely resemble what was learned previously.
It was becoming quite clear that the patient’s cognitive deficits were impacting on his ability to rehabilitate his shoulder.
As a PT is was frustrating that the Rx being provided was not having the desired effect and the HEP was unable to be performed appropriately. In this case I was able to implement some different strategies to try and achieve Rx goals. However I do need to develop further strategies to achieve PT Rx goals.
Communicating
Hey Guys
I am currently completing my neuro placement on an acute neuro ward. Most of the patients here present with an acute stroke, of varying severity. I came into the placement ready to apply the skills we had learnt during the past year, and contribute to the rehabilitation of these patients.
One of the first patients I was assigned was a 60 year old woman who had suffered a (L) TACI affecting her ACA and MCA. Her MRI revealed massive destruction of her (L) hemisphere, with only a small portion of the occipital lobe left intact. She presented with aphasia and dyspraxia, with very limited voluntary movement. So essentially she was not talking, not eating and not moving. She is able to blink, but in no meaningful pattern, move her eyes (only to the left), move her head, primarly to the left, and squeeze a hand placed into her left hand. It was my task to complete a stoke assessment on her and begin treatment.
As you can imagine, this was not an easy task. I was completely unprepared with reagrds to how to communicate with this patient, and how to go about treating her. Upon entering the room, I was met with the patient sitting in her tilt-in-space wheelchair, with her partner in the corner of the room. I began by introducing myslelf, explaining what I wanted to do and then began examining her chest, and asking if she could cough or swallow. The patient was completely unresponsive to this, and continuued with stare into space, barely making eye contact.
While this may not seem like much, this really hit me hard. I had never encountered anybody in this state, and really felt like I had no idea how to effectively communicate with my patient and go about my assessment and treatment. Coupled with this, with her partner in the room, my thoughts immediately went to her family, and how they might be feeling, and I just got completely overwhelemed. I had to leave the room and ask my supervisor for help. I honestly had no idea what to do!
My supervisor came in and took over the assessment. Just watching how she spoke to the paitent for 5 minutes, and how she went about the process was all it took for me to feel cofident that I could manage the situation. I have since seen this patient twice a day for the rest of the week and am very happy to see small improvements in her every day.
So the point of this is that while we are taught some therory about appropriate comminication strategies with different patients, encountering these patients is a much different story. In these cases, I can reccomend observing those more experienced than us, and taking on board effective communications strategies, and thinking how these can be applied to different situations. No mater how good our treatment strategies are, we will get nowhere without appropriate commincation.
I am currently completing my neuro placement on an acute neuro ward. Most of the patients here present with an acute stroke, of varying severity. I came into the placement ready to apply the skills we had learnt during the past year, and contribute to the rehabilitation of these patients.
One of the first patients I was assigned was a 60 year old woman who had suffered a (L) TACI affecting her ACA and MCA. Her MRI revealed massive destruction of her (L) hemisphere, with only a small portion of the occipital lobe left intact. She presented with aphasia and dyspraxia, with very limited voluntary movement. So essentially she was not talking, not eating and not moving. She is able to blink, but in no meaningful pattern, move her eyes (only to the left), move her head, primarly to the left, and squeeze a hand placed into her left hand. It was my task to complete a stoke assessment on her and begin treatment.
As you can imagine, this was not an easy task. I was completely unprepared with reagrds to how to communicate with this patient, and how to go about treating her. Upon entering the room, I was met with the patient sitting in her tilt-in-space wheelchair, with her partner in the corner of the room. I began by introducing myslelf, explaining what I wanted to do and then began examining her chest, and asking if she could cough or swallow. The patient was completely unresponsive to this, and continuued with stare into space, barely making eye contact.
While this may not seem like much, this really hit me hard. I had never encountered anybody in this state, and really felt like I had no idea how to effectively communicate with my patient and go about my assessment and treatment. Coupled with this, with her partner in the room, my thoughts immediately went to her family, and how they might be feeling, and I just got completely overwhelemed. I had to leave the room and ask my supervisor for help. I honestly had no idea what to do!
My supervisor came in and took over the assessment. Just watching how she spoke to the paitent for 5 minutes, and how she went about the process was all it took for me to feel cofident that I could manage the situation. I have since seen this patient twice a day for the rest of the week and am very happy to see small improvements in her every day.
So the point of this is that while we are taught some therory about appropriate comminication strategies with different patients, encountering these patients is a much different story. In these cases, I can reccomend observing those more experienced than us, and taking on board effective communications strategies, and thinking how these can be applied to different situations. No mater how good our treatment strategies are, we will get nowhere without appropriate commincation.
SOB and oxygen therapy
I am now finished my first week of my cardio placement. I am on the general medical ward which is great because we have been exposed to numerous different types of patients.
I have been working with a 97 year old COPD patient. She was admitted with complaints of breathlessness (SOB). She is productive in the morning with about a tablespoon of M3P3 sputum, however her main complaint is of SOB. During our treatment session we go through her ACBT’s and then go for a walk. She walks 20m on RA and requires 2 short rests. Pre ambulation she was 88% on RA and she then de-saturates to 83% when walking. Strategies she uses is pursed lip breathing however she is very adamant that oxygen therapy (2L via NP) gives her the relief she needs. As we have learned from cardio lectures, we know that oxygen therapy is not a treatment for dyspnoea.
I find it very difficult with this patient as she is convinced that she lives with this problem and she knows best what helps her SOB. I have educated her on proper strategies to help manage her SOB such as (forward lean, relaxed breathing, and the fan). However attempts at convincing her that she does not need oxygen as her Sats aren’t that bad have been unsuccessful. I think the nurses find it difficult to manage as well. They often end up just giving her oxygen because she is so persistent and makes a fuss if she does not get it.
The last visit I had with her I entered her room and her oxygen was actually at 2 ¾ L. I adjusted the flow rate back down to 2L. Her SATS were 94 %. On the return from our walk it was perfect timing as the doctor was waiting for us to return and she was able to see how the patient recovered from exercise without oxygen. I was also able to mention the flow rate that she was on when I entered the room. From our discussion and due to the fact she re-saturated within 2 min to 88-90 % without oxygen after exercise the doctor documented in the notes to avoid overuse of oxygen therapy as the patient is very dependent on it however does not require it.
It was a great conversation with the doctors and I feel more confident that this issue will be taken more seriously with a note from the doctor rather than a note from the physiotherapy student.
The plan is to reinforce the education I have already discussed with her. I know that discussing physiological reasoning with a 94 year old is not ideal however I think that will be my next approach to inform her why too much oxygen is not necessary and it interferes with her hypoxic drive to breath. Any thoughts of ways to get my message across?
This situation is a multidisciplinary approach as well. When working in the hospital if all the members of the team are not all consistent with the goal and treatment plan for the patient, managing the patient becomes challenging. Thus when I enter the room and she is sitting at rest with her oxygen on, it becomes that much more difficult to convince her she does not need it. I am hoping with the entry the doctor made the team will be a bit more consistent with not giving in to her request for oxygen.
Dani
I have been working with a 97 year old COPD patient. She was admitted with complaints of breathlessness (SOB). She is productive in the morning with about a tablespoon of M3P3 sputum, however her main complaint is of SOB. During our treatment session we go through her ACBT’s and then go for a walk. She walks 20m on RA and requires 2 short rests. Pre ambulation she was 88% on RA and she then de-saturates to 83% when walking. Strategies she uses is pursed lip breathing however she is very adamant that oxygen therapy (2L via NP) gives her the relief she needs. As we have learned from cardio lectures, we know that oxygen therapy is not a treatment for dyspnoea.
I find it very difficult with this patient as she is convinced that she lives with this problem and she knows best what helps her SOB. I have educated her on proper strategies to help manage her SOB such as (forward lean, relaxed breathing, and the fan). However attempts at convincing her that she does not need oxygen as her Sats aren’t that bad have been unsuccessful. I think the nurses find it difficult to manage as well. They often end up just giving her oxygen because she is so persistent and makes a fuss if she does not get it.
The last visit I had with her I entered her room and her oxygen was actually at 2 ¾ L. I adjusted the flow rate back down to 2L. Her SATS were 94 %. On the return from our walk it was perfect timing as the doctor was waiting for us to return and she was able to see how the patient recovered from exercise without oxygen. I was also able to mention the flow rate that she was on when I entered the room. From our discussion and due to the fact she re-saturated within 2 min to 88-90 % without oxygen after exercise the doctor documented in the notes to avoid overuse of oxygen therapy as the patient is very dependent on it however does not require it.
It was a great conversation with the doctors and I feel more confident that this issue will be taken more seriously with a note from the doctor rather than a note from the physiotherapy student.
The plan is to reinforce the education I have already discussed with her. I know that discussing physiological reasoning with a 94 year old is not ideal however I think that will be my next approach to inform her why too much oxygen is not necessary and it interferes with her hypoxic drive to breath. Any thoughts of ways to get my message across?
This situation is a multidisciplinary approach as well. When working in the hospital if all the members of the team are not all consistent with the goal and treatment plan for the patient, managing the patient becomes challenging. Thus when I enter the room and she is sitting at rest with her oxygen on, it becomes that much more difficult to convince her she does not need it. I am hoping with the entry the doctor made the team will be a bit more consistent with not giving in to her request for oxygen.
Dani
What is patient’s priority? (Daria's Post)
I finished 1st week of my neuro placement at SCGH. One of my patients case seems to be very interesting when I analyzed his social history, past medical history, his attitudes toward his health. The patient had PCI before that he had 2 episodes of vertigo, blurred vision, slurred speech and couple falls. However, he ignored these signs. He is 65-year-old male with history of HTN, CABGx3 who smokes 25g tabbaco per week and drinks 1 L wine per day. As the patient has own business and lives alone his social circumstances absorbing him more than his health state. Patient verbalized couple times he wants go home even after doctor has educated him about his condition which deteriorated, necessity of further investigation and rest in bed ( head flat to 30°) in order to improve blood supply to his brain. At that stage, it was interesting to see how results of investigation match with signs (↓ level of consciousness). Now I understand what Anne meant by person appears to be sleepy.
I find this case difficult as well as challenging. On the one hand, the patient is very compliant/ cooperative during physio treatment on the other hand he shows unawareness of his state and even ignorance and I know that sorting out his social issue ( own business) is his priority.
Daria
I find this case difficult as well as challenging. On the one hand, the patient is very compliant/ cooperative during physio treatment on the other hand he shows unawareness of his state and even ignorance and I know that sorting out his social issue ( own business) is his priority.
Daria
Psychological Issues Post Cardiac Surgery
Hi there physiocrew,
My cardio placement was in December and when I first started working with patients that had just arrived on the ward after having coronary bypass surgery, my biggest concern was with how each patient would react physiologically to transferring out bed and attempting to take a few steps for the first time. Thus my attention was solely focused on organising their attachments, monitoring their chest status and response to ambulation.
However what I failed to monitor or give adequate thought to during my initial two weeks was the patient’s mental or emotional well being since coming out of the operating theatre. Around the end of my second week, I started noticing that patients were fairly upbeat when I was with them providing treatment. But when I was walking by their room I noticed that the majority of the coronary bypass patients were sitting in their chair, not talking to anybody, usually staring off in the room or with their head down, some a bit tearful. There was an obvious pattern emerging and some further investigation was required.
Looking at studies in the some of the databases, a lot of research has been done on the psychological issues that post cardiac surgery patients encounter. The majority of papers stated that upon assessment of pre and post surgery levels of issues such as depression and anxiety, a measurable decrease in emotional and mental status was evident post surgery, and these decreases were seen as much as six months down the track. Further research into the mechanisms responsible for this onset of psychological issues varied from ischemic cerebral events to a disruption in circadian rhythms of certain hormones as a result of going on-pump during surgery.
All this was fairly interesting but the main result from doing a little reading into the topic was that I found myself more aware of these types of issues for patients on the ward during the final two weeks of the placement. My increased awareness resulted in the addition of more education for my patients during the treatment sessions, such as providing more time for reassurance and explaining to the patient what the next 6 weeks would involve for them. By diverting more attention to the potential for psychological issues to arise, I think my treatments session actually became more effective for the patient. However, I also noticed a need to increase and develop the number of strategies in my arsenal to address these types of patient issues as I found myself a little limited in this regard.
If anyone has also seen this pattern with their patients post surgery then please feel free to provide any ideas or strategies that you used to address these issues with this population.
Thanks
Gareth
My cardio placement was in December and when I first started working with patients that had just arrived on the ward after having coronary bypass surgery, my biggest concern was with how each patient would react physiologically to transferring out bed and attempting to take a few steps for the first time. Thus my attention was solely focused on organising their attachments, monitoring their chest status and response to ambulation.
However what I failed to monitor or give adequate thought to during my initial two weeks was the patient’s mental or emotional well being since coming out of the operating theatre. Around the end of my second week, I started noticing that patients were fairly upbeat when I was with them providing treatment. But when I was walking by their room I noticed that the majority of the coronary bypass patients were sitting in their chair, not talking to anybody, usually staring off in the room or with their head down, some a bit tearful. There was an obvious pattern emerging and some further investigation was required.
Looking at studies in the some of the databases, a lot of research has been done on the psychological issues that post cardiac surgery patients encounter. The majority of papers stated that upon assessment of pre and post surgery levels of issues such as depression and anxiety, a measurable decrease in emotional and mental status was evident post surgery, and these decreases were seen as much as six months down the track. Further research into the mechanisms responsible for this onset of psychological issues varied from ischemic cerebral events to a disruption in circadian rhythms of certain hormones as a result of going on-pump during surgery.
All this was fairly interesting but the main result from doing a little reading into the topic was that I found myself more aware of these types of issues for patients on the ward during the final two weeks of the placement. My increased awareness resulted in the addition of more education for my patients during the treatment sessions, such as providing more time for reassurance and explaining to the patient what the next 6 weeks would involve for them. By diverting more attention to the potential for psychological issues to arise, I think my treatments session actually became more effective for the patient. However, I also noticed a need to increase and develop the number of strategies in my arsenal to address these types of patient issues as I found myself a little limited in this regard.
If anyone has also seen this pattern with their patients post surgery then please feel free to provide any ideas or strategies that you used to address these issues with this population.
Thanks
Gareth
Saturday, January 12, 2008
PPIVMS for Tx Spine.
Hi all,
Hope your new placements have begun well! I am presently completing a placement in musculo outpatients.
Last Friday I was doing some preparation for a 67 year old male pt that I have this Tuesday with Tx spinal pain and limited rotation ROM (especially to the right). Going through the Veterbral Assessment Form I came to the PPIVMs box and could not for the life of me remember how to do this. On looking at the 651 manual I realised that we never did PPIVMs for the Tx spine in class.
So what I would like to know is:
(a) do you need to to this in your Ax and is it relevant for the Tx spine (especially if you can't find anything unusual on PAIVMS or other in other areas of the Ax)? and
(b) how do you do this?
(c) can you use PPIVMs to treat in this area and how?
I gather that you would want to do PPIVMS only for rotation (and maybe lateral flexion) as the Tx vertebrae are designed to limit flexion and extension. My guess is that you would do rotation/side flexion for the lower half in side lying like in the Lx spine and the top half in supine like in the Cx spine.
Looking on the internet I found a site that described a PPIVMs Ax in sitting where the physio sits next to the pt then laterally flexes the pt away and then rotates the pt towards themselves (the PT) down to each level palpating with the non rotaing hand looking for movement in the interspinous space. However this sounds very awkward.
So if anyone has any ideas about this your help would be greatly appreciated.
Cheers!!
nico
Hope your new placements have begun well! I am presently completing a placement in musculo outpatients.
Last Friday I was doing some preparation for a 67 year old male pt that I have this Tuesday with Tx spinal pain and limited rotation ROM (especially to the right). Going through the Veterbral Assessment Form I came to the PPIVMs box and could not for the life of me remember how to do this. On looking at the 651 manual I realised that we never did PPIVMs for the Tx spine in class.
So what I would like to know is:
(a) do you need to to this in your Ax and is it relevant for the Tx spine (especially if you can't find anything unusual on PAIVMS or other in other areas of the Ax)? and
(b) how do you do this?
(c) can you use PPIVMs to treat in this area and how?
I gather that you would want to do PPIVMS only for rotation (and maybe lateral flexion) as the Tx vertebrae are designed to limit flexion and extension. My guess is that you would do rotation/side flexion for the lower half in side lying like in the Lx spine and the top half in supine like in the Cx spine.
Looking on the internet I found a site that described a PPIVMs Ax in sitting where the physio sits next to the pt then laterally flexes the pt away and then rotates the pt towards themselves (the PT) down to each level palpating with the non rotaing hand looking for movement in the interspinous space. However this sounds very awkward.
So if anyone has any ideas about this your help would be greatly appreciated.
Cheers!!
nico
Loss of full knee extension after KTR
I was doing Musculoskeletal Outpatients placement in December and was treating a 72 years old patient who had TKR 6/12 ago.
She was transferred to physiotherapy because she has lost full knee extension over time since the operation. On objective assessment, she showed -5 degrees extension of the operated knee, 10 degrees quads lag on both sides, poor gait pattern with dragging her feet and poor standing balance. So I did massage on the popliteal fossa to break down soft tissue contracture, taught her passive stretching in sitting, SQE so as to written HEPs given to her, gait re-education and balance exercises. When I saw her each week, I checked HEPs and reassessed knee ROM and VMO strength, though there was no improvement. I felt I didn’t achieve anything while I was seeing her 4 times during the placement and it was quite frustrating.
While I was focusing on the knee, I didn’t realise her history that she had a car accident years ago which caused her traumatic brain damage as well as her back problems. So even though she told me that she had done HEPs and showed a good compliance, I didn’t necessarily have to believe that and I was not sure whether the reason why she was not improving was because of her memory problem or the time that it takes for knee ROM and VMO strength to improve.
So from this experience I learned that I should look at the whole picture including other joints as well as cognitive aspect when I treat patients. In addition, 5 degrees loss of knee extension sounds subtle though it affects her activities significantly like weak VOM, her standing posture which might aggravate her existing back problem and cause the opposite knee flexed and also her unstable gait pattern. It is important to get the full knee extension and it is not easy to achieve as I thought especially for old patients.
It would be great if anyone has comments on ‘tricky’ HEP compliance and any good idea to improve her problems in this case.
She was transferred to physiotherapy because she has lost full knee extension over time since the operation. On objective assessment, she showed -5 degrees extension of the operated knee, 10 degrees quads lag on both sides, poor gait pattern with dragging her feet and poor standing balance. So I did massage on the popliteal fossa to break down soft tissue contracture, taught her passive stretching in sitting, SQE so as to written HEPs given to her, gait re-education and balance exercises. When I saw her each week, I checked HEPs and reassessed knee ROM and VMO strength, though there was no improvement. I felt I didn’t achieve anything while I was seeing her 4 times during the placement and it was quite frustrating.
While I was focusing on the knee, I didn’t realise her history that she had a car accident years ago which caused her traumatic brain damage as well as her back problems. So even though she told me that she had done HEPs and showed a good compliance, I didn’t necessarily have to believe that and I was not sure whether the reason why she was not improving was because of her memory problem or the time that it takes for knee ROM and VMO strength to improve.
So from this experience I learned that I should look at the whole picture including other joints as well as cognitive aspect when I treat patients. In addition, 5 degrees loss of knee extension sounds subtle though it affects her activities significantly like weak VOM, her standing posture which might aggravate her existing back problem and cause the opposite knee flexed and also her unstable gait pattern. It is important to get the full knee extension and it is not easy to achieve as I thought especially for old patients.
It would be great if anyone has comments on ‘tricky’ HEP compliance and any good idea to improve her problems in this case.
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