Throughout my last prac in the outpatient setting i saw various examples of how different people and demographics respond to pain and how this can both positively and negatively influence their prognosis.
One example is a middle-aged male patient i saw following a lower limb muscle excision. This patient arrived in the outpatient clinic pushed in a wheelchair by his wife (the car being parked approx 50m away). This immediately drew my attention as the patient's inpatient notes stated that he was WBAT and should be progressed as quickly as possible (and was now 2 weeks out of surgery). Throughout the entire subjective and objective examination it was clear that the patient was not comfortable with the notion of pain and was doing everything in his power to avoid it. He refused to roll up his pants by himself or take his shoes and socks off because he "couldnt" and any his range of movement of initial examination was a total of 5degrees and was 10/10 pain in both directions which increased above 10/10 when i did it passively. These pain scores were very surprising to me as he pulled very few faces and didnt make any painful noise whilst moving, just casually stated it was maximum pain. Also, since the surgery he had not touched to foot down on the floor and spent the last week at home sitting down and keeping the leg as still as possible.
Getting to the point though, his unwillingness to comply with the movement program supplied by myself or the surgeon, because they were painful, were negatively affecting his progrosis as he had started to develop marked ankle joint stiffness. Also with this type or surgery, movement is required very quickly to avoid the fascial structures and scar tissue from adhering to each other and preventing movement long-term. So instead of a 4-6week complete healing period with minimal strength loses, he was looking at a significantly greater rehab period.
Following the initial treatment, i spoke in depth with various other members of staff about possible treatment strategies for this patient. We all came to the agreement that a very upfront and abrupt manner was needed when dealing with this patient. He needed to understand the consequences of his unwillingness to comply with our advice and that regaining movement needs to happen regardless of 1/10 pain or 10/10 pain.
I am unable to comment on the outcome of this patient since it was my last week on placement but i have heard that various different staff members have attempted to treat and educate this patient with varying degrees success.
So in conclusion, a patients response to pain can greatly affect the outcome of their rehabilitation program. Compared to the other post about the elderly generation doing too much activity with pain and hence causing detriment to their condition, there are some who cannot cope with pain and see it as BAD BAD BAD. Our manner and styles of education need to be changed dramatically in relation to the type of patient being dealt with.
Thursday, May 29, 2008
Wednesday, May 28, 2008
Patient Confrontation
Whilst on my neuro placement at Sir Charles Gairdner hospital I was assigned a male patient, 83 years old, who had had a left posterior cerebral artery infarct. On first meeting the patient he seemed very chatty and friendly and we got on very well throughout the assessments that I performed. He was a well educated man who had worked as an engineer for most of his life and fought in the Australian army. This patient was very happy with the assessments performed and was keen to begin treatment to help improve his high level balance.
The next day I went to treat the same patient and began to work through a few high level balance tasks such as getting him to stand with his feet together, these tasks were aimed so as to challenge his balance but not so that he could not perform the tasks assigned. He began to complain that this was too hard and that no one stands with their legs right next to each other in every day life. I reasoned with him and explained the importance of the exercises and why we were doing them. He became extremely agitated and then began to claim that I was a spy sent to Australia from Zimbabwe. He appeared to have a problem with the fact that I had come from Zimbabwe and refused to continue with any treatment. I then found my supervisor and asked her to talk to the patient on my behalf and asked about any strategies that I could use with this particular patient.
My supervisor had no luck with gaining compliance with my patient. We were then informed by some of the nurses that he did not seem to respond well to female nurses or staff and was extremely rude towards them. My supervisor suggested leaving the patient and having another attempt the next day. The next day proved no better and the patient refused to let me see him. My supervisor suggested allowing one of the Australian students to work with this patient.
This was the first conflict that I have encountered with a patient and I did not know how to handle it at first. I learned that there will be times when a patient will have their own prejudices against you and there will be nothing you can do. I cannot change who I am and where I come from but in these cases you can persevere and attempt to reason with the patient but need to know when to stop. I think that with more experience with patients we will all know how better to deal with any conflicts we may come up against with patients. The key is to keep a level head and not take it personally.
The next day I went to treat the same patient and began to work through a few high level balance tasks such as getting him to stand with his feet together, these tasks were aimed so as to challenge his balance but not so that he could not perform the tasks assigned. He began to complain that this was too hard and that no one stands with their legs right next to each other in every day life. I reasoned with him and explained the importance of the exercises and why we were doing them. He became extremely agitated and then began to claim that I was a spy sent to Australia from Zimbabwe. He appeared to have a problem with the fact that I had come from Zimbabwe and refused to continue with any treatment. I then found my supervisor and asked her to talk to the patient on my behalf and asked about any strategies that I could use with this particular patient.
My supervisor had no luck with gaining compliance with my patient. We were then informed by some of the nurses that he did not seem to respond well to female nurses or staff and was extremely rude towards them. My supervisor suggested leaving the patient and having another attempt the next day. The next day proved no better and the patient refused to let me see him. My supervisor suggested allowing one of the Australian students to work with this patient.
This was the first conflict that I have encountered with a patient and I did not know how to handle it at first. I learned that there will be times when a patient will have their own prejudices against you and there will be nothing you can do. I cannot change who I am and where I come from but in these cases you can persevere and attempt to reason with the patient but need to know when to stop. I think that with more experience with patients we will all know how better to deal with any conflicts we may come up against with patients. The key is to keep a level head and not take it personally.
Tuesday, May 27, 2008
Inappropriate Patient Behaviour
Similarly to other students within this blog, I too have come across inappropriate patient behaviour which placed me in an uncomfortable position. This occured on my musculoskeletal outpatients placement in which I was assigned to the ongoing treatment of a male patient with lower back pain, aged early thirties. His treatment consisted initially of rotation PPIVMs, and following this it appeared he had devloped a state of arousal (there is no 'nice' way to put this!!) which was clealy evident.
At the time of treatment I found it fairly easy to ignore, and both the patient and myself pretended not to notice and the session was continued without pause. I did however find it uncomfortable and awkward to complete the rest of the PPIVMs sets, at the time I didn't hesitate long enough to realise that the close-body contact involved in this technique to stabilise the upper trunk may be influencing him. I did follow a hands-off approach for the rest of the treatment however, and following the session thought not much of it and wrote my notes as planned. I did however mention it over lunch to one of my friends, who in the following class jokingly said that she was going to inform our supervisor, and then actually did. Our supervisor was mortified and told me that this patient had expressed similar behaviour with the last female physiotherapy student he had, and that he was supposed to be assigned to a male student from now on but that she had forgotten. She apoligised to me immediately and assigned him to someone else, ensuring me that I had acted appropriately but that I should've told her straight away myself.
Although my behaviour was certainly professional in this situation, we must remember that we do not have to deal with situations such as this independently and that our desire to display professionalism should in no way put us in uncomfortable positions such as these. Our supervisors are their to assist us and I should've thought to tell mine rather than putting up with the problem myself, as in this case there was a much simpler solution - to transfer the patient to a male physiotherapist. Furthermore if ever placed in a similar situation I would think to leave the room immediately to allow the patient to compose himself and consider bringing someone else into the room, whether it be my supervisor or a fellow student (preferably male).
At the time of treatment I found it fairly easy to ignore, and both the patient and myself pretended not to notice and the session was continued without pause. I did however find it uncomfortable and awkward to complete the rest of the PPIVMs sets, at the time I didn't hesitate long enough to realise that the close-body contact involved in this technique to stabilise the upper trunk may be influencing him. I did follow a hands-off approach for the rest of the treatment however, and following the session thought not much of it and wrote my notes as planned. I did however mention it over lunch to one of my friends, who in the following class jokingly said that she was going to inform our supervisor, and then actually did. Our supervisor was mortified and told me that this patient had expressed similar behaviour with the last female physiotherapy student he had, and that he was supposed to be assigned to a male student from now on but that she had forgotten. She apoligised to me immediately and assigned him to someone else, ensuring me that I had acted appropriately but that I should've told her straight away myself.
Although my behaviour was certainly professional in this situation, we must remember that we do not have to deal with situations such as this independently and that our desire to display professionalism should in no way put us in uncomfortable positions such as these. Our supervisors are their to assist us and I should've thought to tell mine rather than putting up with the problem myself, as in this case there was a much simpler solution - to transfer the patient to a male physiotherapist. Furthermore if ever placed in a similar situation I would think to leave the room immediately to allow the patient to compose himself and consider bringing someone else into the room, whether it be my supervisor or a fellow student (preferably male).
Monday, May 26, 2008
notion of pain
Whilst working in the gerontology field for this placement the notion of pain has presented itself quite differently. Normally within the other areas of physio, pain is one of our patients’ main complaints and is a limiting factor to their range, strength and overall function. My patients seen this week have experienced pain unlike anything imaginable; many have been injured at war, given birth rurally without any help, have audible crepitus and degenerative joints. Pain to them is a normal daily occurrence and not a problem that will be mentioned upon subjective and objective questioning.
When observing patients normal movement and during exercises my supervisor questioned me on the underlying reason behind her ideology of conservative treatment for this population group. To me, the antalgic movement patterns could be pinned to their reduced muscle strength and poor balance or some patient’s history of CVAs; and a prescription of five repetitions of an exercise once a day or three times a week even, would not be beneficial for a strengthening program. The supervisor then brought to my attention that many of these patients live with pain during all their day-to-day activities and did not feel that it was a problem worth mentioning. She gave me an example of where she too had to “read between the lines” when a patient who was once able to walk to 100m to the shop with a 4WW had recently bought a gopher to take her instead. It wasn’t due to poor exercise tolerance, a fear of falling or poor balance, but instead my supervisor suspected that it was an increase in pain that led her to buy the gopher. At no time had pain been mentioned to her as a problem, or the reason behind the gopher. Similarly with the prescription of exercises, for this population group, pain would not be something that would hinder them from performing their exercises. This could potentially heighten their underlying problem and make them worse; unlikely to listen to their bodies signals a very conservative approach is necessary.
With this in mind, I have found that although my patient’s may not complain of pain, whilst doing activities during individual treatment and during their HEP, I need to be aware of not overdoing things. In some cases, if I allow them to continue during the treatment this may limit their ability to carry on the rest of their day safely and may lead to further problems. Subtle changes to the performance of exercises during my treatment may indicate an increase in baseline pain levels or some discomfort that will not be mentioned by my patient. It is my responsibility to decide when the patient has done enough and not take their appearance on face-value.
When observing patients normal movement and during exercises my supervisor questioned me on the underlying reason behind her ideology of conservative treatment for this population group. To me, the antalgic movement patterns could be pinned to their reduced muscle strength and poor balance or some patient’s history of CVAs; and a prescription of five repetitions of an exercise once a day or three times a week even, would not be beneficial for a strengthening program. The supervisor then brought to my attention that many of these patients live with pain during all their day-to-day activities and did not feel that it was a problem worth mentioning. She gave me an example of where she too had to “read between the lines” when a patient who was once able to walk to 100m to the shop with a 4WW had recently bought a gopher to take her instead. It wasn’t due to poor exercise tolerance, a fear of falling or poor balance, but instead my supervisor suspected that it was an increase in pain that led her to buy the gopher. At no time had pain been mentioned to her as a problem, or the reason behind the gopher. Similarly with the prescription of exercises, for this population group, pain would not be something that would hinder them from performing their exercises. This could potentially heighten their underlying problem and make them worse; unlikely to listen to their bodies signals a very conservative approach is necessary.
With this in mind, I have found that although my patient’s may not complain of pain, whilst doing activities during individual treatment and during their HEP, I need to be aware of not overdoing things. In some cases, if I allow them to continue during the treatment this may limit their ability to carry on the rest of their day safely and may lead to further problems. Subtle changes to the performance of exercises during my treatment may indicate an increase in baseline pain levels or some discomfort that will not be mentioned by my patient. It is my responsibility to decide when the patient has done enough and not take their appearance on face-value.
Patience with Patients
My first prac this semester was in Neurosurgery. I had a really lovely patient who had been in a motor cycle accident and had severe dyspraxia and dysphasia. He had voluntary control of his upper and lower limbs, head and trunk spontaneously but not on command and was very irratic with movement when given instructions (eg rolling over, would roll away from you right to the edge of the bed). The first time I saw this patient I became really inpatient because he wasn't following what I wanted him to do and wouldn't stay in positions that I new he was capable of. I had a chat to my supervisor about my patient and that I wasn't getting alot done in the session because of his dysphasia and dyspraxia. She gave me a few hints about what to do, but generally made me go away and think about it and change the structure of my treatment sessions for this patient.
The second time I saw him was for my final placement assessment. I decided that the session would rely on what the patient was willing to do, so I went into the treatment with an open mind of what to do. I didn't plan my session rather had ideas of what I could do during the treatment (position patient in upright position to work on his core stability, strengthening work of his glutes and quads, bed mobility and posture).
Firstly I started in supine and facilitated his lower limbs so that he was in a bridging position. He didn't last to long in this position and returned to supine. I then facilitated him into sidelying which he was capable of but again got tired of it and moved himself into prone. I thought this would be a good position to work on his posture and give his back extensor a stretch. He sustained this position well. From here I facilitated him into 4 pt by getting him on his elbows and tucking is leg underneath him, which I was very suprised of doing! I treated him in this position, but really wanted to get him up into 2 pt to stretch his hip extensors and calves as well as strengthening his quads. I got him into 2 pt from 4pt by crawling his hands up the vertical cage at the top of the bed (he also got down in this way also). In 2 pt I facilitated the pt to do some squats by using simple words and physical prompts.
In the end the treatment went really well purely because I did not have any expectations of how the treatment would pan out. I treated the patient in positions that he wanted to go in, so the session was more interesting for him. I also adjusted my handling and improvised how to get the patient into positions rather than using the usual steps (eg to get into 4pt, 2pt etc)
I always thought I had a lot of patience with most things, but this patient made me realise how important patience is when dealing with people and sometimes you need more with certain patients. It also made me realise how much improvisation you need when dealing with different patients. This was such a good experience and really challenged my handling and communication skills.
The second time I saw him was for my final placement assessment. I decided that the session would rely on what the patient was willing to do, so I went into the treatment with an open mind of what to do. I didn't plan my session rather had ideas of what I could do during the treatment (position patient in upright position to work on his core stability, strengthening work of his glutes and quads, bed mobility and posture).
Firstly I started in supine and facilitated his lower limbs so that he was in a bridging position. He didn't last to long in this position and returned to supine. I then facilitated him into sidelying which he was capable of but again got tired of it and moved himself into prone. I thought this would be a good position to work on his posture and give his back extensor a stretch. He sustained this position well. From here I facilitated him into 4 pt by getting him on his elbows and tucking is leg underneath him, which I was very suprised of doing! I treated him in this position, but really wanted to get him up into 2 pt to stretch his hip extensors and calves as well as strengthening his quads. I got him into 2 pt from 4pt by crawling his hands up the vertical cage at the top of the bed (he also got down in this way also). In 2 pt I facilitated the pt to do some squats by using simple words and physical prompts.
In the end the treatment went really well purely because I did not have any expectations of how the treatment would pan out. I treated the patient in positions that he wanted to go in, so the session was more interesting for him. I also adjusted my handling and improvised how to get the patient into positions rather than using the usual steps (eg to get into 4pt, 2pt etc)
I always thought I had a lot of patience with most things, but this patient made me realise how important patience is when dealing with people and sometimes you need more with certain patients. It also made me realise how much improvisation you need when dealing with different patients. This was such a good experience and really challenged my handling and communication skills.
Sunday, May 25, 2008
inappropriate behaviour
My first prac this semester was a Musculo outpatient prac, and whilst there I encountered a difficult situation with a male patient which made me feel very uncomfortable and embarrassed. The situation occurred whilst I was performing the subjective examination, and from the very start of the treatment session I had an uneasy feeling about this particular patient, who was in his early thirties. He was making inappropriate comments right from the start, just not the sort of thing you say to someone you have just met, let alone a young female. Anyway, I had come to part of the questioning which involved asking about morning pain and stiffness, and to this question I got the most inappropriate and embarrassing sexual comment I could have imagined. I realise I may have worded the question entirely wrong, but I still thought it was highly inappropriate for him to react the way he did. It took me a few moments to compose myself, but then he just carried on making smart comments.
So eventually I just excused myself and went to my supervisor and told him what had happened. And although we both then saw a funny side to the situation, he also reassured me that I had done nothing wrong and that this man was acting in an unacceptable way. He made me realise that I should never turn the blame on myself and make excuses for people who act this way, and that even if I had worded things wrong, that was no excuse for him to react like that.
I had to continue seeing this patient for another few sessions. My supervisor did ask if I wanted to hand him over, but I felt like I would just be running away from the situation instead of learning to stick up for myself. So on the next session, my supervisor got one of my classmates to come in the cubicle with me, and he also sat outside the curtain the whole time. This gave me a huge amount of confidence and I was able to be firm with the patient and he soon realised I would not stand for any more jokes.
So I guess what I have learned from this is that communication is such a huge part of physio, and we get so used to just asking all the questions we ask in parrot fashion, that sometimes we don’t pay attention to what comes out our mouths. Also, he could probably tell from my initial reaction that I was not going to put him in his place straight away. In future, and especially with male patients, I will be very careful how I word such questions. But saying that, I will also have more confidence in telling any inappropriate patients that their behaviour is not acceptable, now that I know it is well within my rights to say this straight away. And also knowing that hospitals have such strict laws on sexual harassment is a help, and that you have the right to pass such patients on to someone else.
So eventually I just excused myself and went to my supervisor and told him what had happened. And although we both then saw a funny side to the situation, he also reassured me that I had done nothing wrong and that this man was acting in an unacceptable way. He made me realise that I should never turn the blame on myself and make excuses for people who act this way, and that even if I had worded things wrong, that was no excuse for him to react like that.
I had to continue seeing this patient for another few sessions. My supervisor did ask if I wanted to hand him over, but I felt like I would just be running away from the situation instead of learning to stick up for myself. So on the next session, my supervisor got one of my classmates to come in the cubicle with me, and he also sat outside the curtain the whole time. This gave me a huge amount of confidence and I was able to be firm with the patient and he soon realised I would not stand for any more jokes.
So I guess what I have learned from this is that communication is such a huge part of physio, and we get so used to just asking all the questions we ask in parrot fashion, that sometimes we don’t pay attention to what comes out our mouths. Also, he could probably tell from my initial reaction that I was not going to put him in his place straight away. In future, and especially with male patients, I will be very careful how I word such questions. But saying that, I will also have more confidence in telling any inappropriate patients that their behaviour is not acceptable, now that I know it is well within my rights to say this straight away. And also knowing that hospitals have such strict laws on sexual harassment is a help, and that you have the right to pass such patients on to someone else.
Patient reliance on Physio
I recently completed my Neurology placement in an outpatient setting. While there, I treated a patient over the 5 weeks (twice per week for 90 minutes per session), who was being discharged after having attended the Outpatient Clinic for over a year and a half. She was quite a young stroke patient, with a young family and an extremely supportive husband (who attended every session with her and assisted her with her home exercise program (HEP) which she diligently performed daily.)
On her second last session I started some discharge measurements, at which time she started to become quite upset. She revealed that she felt she was being discharged from the Clinic because she was no longer making any improvements. Her discharge measures actually showed that she had made significant improvements in her gait and balance throughout her admission.
I reassured her that her improvements were continuing because of her commitment to her HEP, not purely due to the 90 minutes, twice a week physiotherapy she was receiving- and that if she continues with her program, there was no reason she shouldn’t continue on this path. We also discussed that although her stroke would leave her with some residual, irreversible deficits, that her commitment to her rehabilitation would ensure she would be able to optimize her function.
On her last session, the patient again became upset about her discharge. I reassured her that in 3 months time she would have a review at the Clinic, and that in the mean time she was more than welcome to call with any concerns or queries she had.
It seemed that the patient had become dependent on Physiotherapy sessions almost as a way of life, and as an absolutely essential part of her week. This situation made me think that patients need to be reminded that their neurological illness (in this case her stroke) shouldn’t be the thing that defines them- that they still have a life to live above and beyond their condition, and above and beyond Physiotherapy.
While we are able to provide some extremely valuable “hands on” physical treatment techniques, I think we need to put more of an emphasis on the patient’s self management and independence with their home program, so they don’t build a reliance on clinical services (especially towards a patient’s discharge within a long term setting, when their condition is lifelong.)
Renae
On her second last session I started some discharge measurements, at which time she started to become quite upset. She revealed that she felt she was being discharged from the Clinic because she was no longer making any improvements. Her discharge measures actually showed that she had made significant improvements in her gait and balance throughout her admission.
I reassured her that her improvements were continuing because of her commitment to her HEP, not purely due to the 90 minutes, twice a week physiotherapy she was receiving- and that if she continues with her program, there was no reason she shouldn’t continue on this path. We also discussed that although her stroke would leave her with some residual, irreversible deficits, that her commitment to her rehabilitation would ensure she would be able to optimize her function.
On her last session, the patient again became upset about her discharge. I reassured her that in 3 months time she would have a review at the Clinic, and that in the mean time she was more than welcome to call with any concerns or queries she had.
It seemed that the patient had become dependent on Physiotherapy sessions almost as a way of life, and as an absolutely essential part of her week. This situation made me think that patients need to be reminded that their neurological illness (in this case her stroke) shouldn’t be the thing that defines them- that they still have a life to live above and beyond their condition, and above and beyond Physiotherapy.
While we are able to provide some extremely valuable “hands on” physical treatment techniques, I think we need to put more of an emphasis on the patient’s self management and independence with their home program, so they don’t build a reliance on clinical services (especially towards a patient’s discharge within a long term setting, when their condition is lifelong.)
Renae
Friday, May 23, 2008
Tone Inhibiting Positions
My first placement was paediatrics, therefore consisting of all areas of physiotherapy but applied to children (0-18yrs). The most difficult area i found was any neurological condition which caused multiple functional problems to the children. At first all i could see was their horrible conditions and how much it had ruined their lives but i soon learnt that children are children and if you can make them comfortable for even an hour, effect their lives just a little you can make them smile and see the child underneath.
On a particular child with Cerebral Palsy i had no idea what i could do after the assessment to help him, his tone was very high and i was having a lot of difficulty moving his arms for assessment let alone any treatment. Luckily for me, my supervisor was with me and reminded me (as im sure weve been told this somewhere along the way) that when it comes to tone, if you find the childs inhibitory position, the tone lessens and the assessment and treatment is so much easier and being in that position is more comfortable for the child. As my supervisor used to be the little boys physio she knew this 'magical' position which happened to be simply sidelying... Simple as that, rolled him over and gained 40 degrees in each shoulder movement as well as full elbow extension from 50 degrees flexion, the child simply relaxed and sighed with a big grin on his face. This position in most children is usually sidelying or curled up into a ball but it can be different depending on the child. I learnt that once you find the tone inhibiting position, you treatment that day and any following days is easier and more effective than struggling against high tone. I'm pretty sure this applies for all high tone but i have not had the chance to see it in an adult yet therefore look forward to my neurology placement.
CW
On a particular child with Cerebral Palsy i had no idea what i could do after the assessment to help him, his tone was very high and i was having a lot of difficulty moving his arms for assessment let alone any treatment. Luckily for me, my supervisor was with me and reminded me (as im sure weve been told this somewhere along the way) that when it comes to tone, if you find the childs inhibitory position, the tone lessens and the assessment and treatment is so much easier and being in that position is more comfortable for the child. As my supervisor used to be the little boys physio she knew this 'magical' position which happened to be simply sidelying... Simple as that, rolled him over and gained 40 degrees in each shoulder movement as well as full elbow extension from 50 degrees flexion, the child simply relaxed and sighed with a big grin on his face. This position in most children is usually sidelying or curled up into a ball but it can be different depending on the child. I learnt that once you find the tone inhibiting position, you treatment that day and any following days is easier and more effective than struggling against high tone. I'm pretty sure this applies for all high tone but i have not had the chance to see it in an adult yet therefore look forward to my neurology placement.
CW
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