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.
Sunday, January 13, 2008
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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