Weighty Issue

On my Musculo Outpatient placement, I encountered a rather overweight patient who presented with lower back pain. During my assessment of PPIVMs (especially flexion and extension), even after taking all the biomechanical measures I could to protect my back, I still found the assessment extremely challenging on my back.

Although we are constantly reminded and well taught about our biomechanics and protecting our backs, it seems there is sometimes only so much you can do. When faced with an overweight patient in an outpatient setting, there is often little opportunity to have assistance with manual handling (as may occur in a hospital with an extra person/ lifting equipment etc). While in hospitals, there are normally strongly reinforced ‘no lift polices’, it makes me wonder at what point do we have the right to refuse certain manual handling for assessments and treatments in order to protect our backs. While I don’t think it is fair to refuse appropriate assessment or treatment of patients, I can see how important it is for us to be looking after our backs and be constantly aware of our biomechanics. After all without our backs, we don’t have much of a career.

Treatment effectiveness

Whilst on my Musculo Outpatient prac, I have been finding it very rewarding having patients comment on how much better they feel upon leaving their session. It’s much more different than within a hospital setting, where patients often see you as the ‘evil’ one who is making them get out of bed/ move their limb post-surgery, when it is often the last thing they feel like doing.

However having experienced patients leaving their session feeling worse, or much the same as when walking in, is something I hadn’t been prepared for. We are often taught that “this treatment is used to improve this condition”, so it can sometimes come as a surprise when a patient returns with little improvement. This happened to me when I had a new patient, already diagnosed with subacromial bursitis. Although I already knew her diagnosis, I went through a full examination of her shoulder and treated her as appropriate. However, the more assessment I did, the worse her pain would get, and therefore on re-assessment (post-Rx) her pain came on earlier in range although still at the same intensity. My supervisor assured me that some post-treatment soreness was common in this condition (especially since she had hardly been moving her arm for 3 months) and also due to the inflammatory nature of her problem.

After discussing this with my supervisor and feeling reassured my treatment had not caused any harm, I still felt almost guilty that my patient’s pain was seemingly worse. I think it is important to remember we can’t always offer ‘magical cures’ to our patients, especially when there are other processes going on (in this case a strong inflammatory response), although this can still sometimes not seem enough to help your confidence.

Patient confidence

I have always known from our lectures that you sometimes need to push a patient to do things that they often don't want to for their own benefit, but it is important to not let a paitnet work harder than they are able as this will proabably set them back phsychologically as they will be unable to complete the task! It's one thing to know something and another to experience it.

On my cardio placement I had a patient who had been bed ridden for 5-6days and had become quite deconditioned. She got up on the 7th day and walked on the spot for a couple of mins. The next day she walked 10m. On the following day all I had wanted to accomplish was a walk a bit further than the 10m of the previous day. She had other idea's however and pushed herself to around 40m, the last 3m of this were hard going for her and she became extremely SOB and lost her confidence completely. I then spent the next 10-15mins reassuring the patient that she woudl eventually be able to walk that distance and even further again!

In this specific case there was nothing I could have done to prevent this lady's loss of confidence as I had attempted to get her to turn back and return to her room several times but she was determined to walk the further distance. It just made me think about other exs prescriptions we give patients and how important it is to get the prescription just right!

Osbervation

Whilst on my musculoskeletal outpatients prac I realised the value of taking note of every observation, no matter how insignificant it may appear. I also learnt that experience is worth it's weight in gold!

i had a patient come in, an elderly lady who presented with resting pain in both shoulders, her Cx, both elbows and occasionally pain in both legs. She had decreased range of motion bilaterally, limited by pain and it was impossible to make a complete assessment of her due to her pain levels! I treated her quite globally in the first session with STM of UT and LS combined with heat as well as AP mobs of both shoulders, both of these decreased her pain and increased her range slightly. On the second assessment she was back to the same pain levels and decreased range and the effects of the last treatment had only lasted a short period without her overexerting herself or doing anything different then normal. All of these findings tended to lean towards an inflamatory cause. I had noticed that she had quite widespread psoriasis but hadn't really thought enything of it. My supervisor came in to have a look at my patient and straight away noticed the psoriasis. It turned out that this lady had had the psoriasis for a long time and had not seeked any professional assistance with it.

We then referred this lady to her GP who referred her to a rhematologist aswe believed her problem to be psoriatic arthritis!!

I had remembered learning about this condition in our arthridities lectures and had noticed the psoriasis but had not made the connection. This expereice just showed to me the value of linking your observations, no matter how insignificant they appear to you, and your assessment findings. It did help that my supervisior had a few years of experience and had come across this condition before!

Patient education

On my Musculo Outpatient placement, I have come to realize the importance of educating patients on their condition and your treatment rationale. Many of my patients have been educated in health and the human body (nurses, lecturers, teachers etc) and with these patients, I found I was automatically explaining exactly what I was finding on my assessment as well as the rationale for my treatments and home exercise programs. However, I found when I had an elderly patient or someone I thought wouldn’t really understand, I found myself not bothering with going into much detail.

I didn’t actually come to realize this, until I had a patient come in who had been an ongoing patient for around 5 sessions. Throughout the assessment and treatment, I gave her brief explanations of what I was doing. Towards the end of the session however, she asked me if it would be much trouble if I could possibly show her a picture or a skeleton so she could understand fully what was going on (in this case, bilateral patellofemoral syndrome due to poor biomechanics at the hip and foot and muscle imbalances). She seemed much more satisfied and eager for her HEP after I had given her a much more in-depth explanation of her condition.

It made me realize that although you might assume that a person in less educated or knowledgeable about the human body, they still appreciate knowing what is going on with their bodies as well as reasoning behind what you are doing (and what they are paying for). I also think it helps make the patient much more compliant with exercises if they know exactly why they are doing them, as well as making them more confident in your knowledge and expertise.

The Mutli-diciplinary team

Whilst on a ward placement, i came to understand the importance of the whole team approach to treatment. I was quite shocked about how much communication there was between each field. The ward meetings, which previously seemed to be the doctors talking to each other about medications, turned into very detailed discussions about all aspects of treatment and the options available.

Throughout these meetings, each team, from doctors, to consultants, the pain team, physios, speach therapists, OT's, social workers, pharmacists, nurses and psychologists... everyone got a chance to talk through their treatments, how they are progressing and both the physical and mental sides to their health. Everything was discussed including what sports the patient likes, whats foods and their favourite colour. I began to understand how this very detailed discussion about the patient would improve the quality of their stay, their mental state of mind and ultimately their health.

I first attended these meetings in the 3rd of 5 weeks at the placement and from then on, i felt much more comfortable with my treatment plan, i felt i could bond with the patient much more and i was alot more efficient. Also i felt much more confident talking to other team members and asking for advice.

Since then, on my placements i have endevoured to communicate with other members of staff around the ward about how the patients are progressing or to seek advice about the best ways to bond with them. It has made the placements much easier and i have found that even though we are students are there are hundreds of us around the wards, most staff members are willing to take time to speak to us and help us out. All we have to do is smile and ask!

Supervision

Through the pracs completed so far i have experienced a wide range of different techniques used by the physio supervisors to teach and assess. The techniques that are used contribute largly to the enjoyment, the amount learned and also the stress felt whilst on placement. I am not talking here about the supervisors being really friendly or easy, more the way in which they go about their assesment.

Whilst on a prac earlier in the semester i experienced supervision that didnt really suit me and thus caused quite a stressful time. The supervisor was insistant that every aspect of the sessions were completed the way that they wanted and were taught. This came down to the ordering of the questions, the words i used to ask them, the way i wrote my notes and the types of intervention used. For the placement it felt like i was not utilising my clinical reasoning skills but just trying to copy the supervisor and please them. I felt that i didnt really learn much except for how to please them.

Contrary to this, a different placement i went on provided a very flexible supervision process which resulted in me enjoying the prac alot more and learning a great deal. At the beginning of the prac the supervisor sat down and discussed certain things about my learning and style of learning in order to best judge the way to supervise. All through out the placement they asked constantly what things i wanted to improve on, how much supervision they should give. This did not make the placement cushy, i felt it made the prac much more beneficial and i felt more comfortable and hence learnt a great deal more.

As a result of this i will endevour to speak to my supervisors more at the beginning of the placement so we can both get the most out of the 4 weeks!