On my placement at the moment, I was treating a patient with my supervisor in the gym. We invited his wife to come along to watch so that she became familiar with the activities that she will be doing with him once he is discharged. Throughout the whole session she would speak for her husband and say things like the poor baby can't stand up it will hurt him. She would also interfere during the session by helping her husband with the activities/exercises even though he was perfectly capable of doing them independantly. We decided that the next time we brought the patient to the gym for treatment we would tell the wife that it was now protocol that no family members are allowed in the gym during treatment session. She was compliant with this but still hovered at the door watching. Luckily for us, this patient was very motivated and willing to do anything we asked him so minimal education/motivation was needed for him. Most of the education was directed at the wife to ensure the patient becomes fully independant at home.
This situation made me realise how important family members are to the patient. Sometimes however you have to be strict on visitors because they can impact on treatment sessions and the progression of the patient's function.
Monday, October 27, 2008
Trying different approaches
Whilst on my rural prac i had the oppertunity to explore some different methods of communication and also treatment strategies with patients. A patient that started attending the clinic was a young girl with a history of chronic lower back pain approx 75% of her life sofar. From an early age she was told be her doctor that she had a serious back condition (as seen on CT scan- which was actually just a sacralisation of L5. A condition that has no significant evidence to attribute increased LBP). This developed into a very heavy fear-avoidance cycle where she was not going to school very often, not doing any physical activity and not working.
One of the senior physiotherapists started treating the young girl but with very limited results both emotionally and physically. The young girl then got handed to myself to treat and i got told to try some different approaches.
Being closer to the age of the patient i was able to develop really good rapport and achieved some drastic emotional and physical results. Initially we developed an exercise program that we would both do together. The rules for this program were that we were not allowed to mention her back pain (unless it increased significantly during) and that we would do the program no matter how she was feeling. I was able to use conversation and lots of distraction techniques to stop her focusing on the back pain. One of the biggest break throughs was when she started to understand that even if the back is sore, if exercise doesnt make it worse then its getting better!
This is a very long-winded example of how utilising different treatment approaches can be very beneficial, expecially in chronic conditions. Also, its an example of how we should not be afraid to refer to a different therapist if we are not getting the results/rapport that we need with a patient.
One of the senior physiotherapists started treating the young girl but with very limited results both emotionally and physically. The young girl then got handed to myself to treat and i got told to try some different approaches.
Being closer to the age of the patient i was able to develop really good rapport and achieved some drastic emotional and physical results. Initially we developed an exercise program that we would both do together. The rules for this program were that we were not allowed to mention her back pain (unless it increased significantly during) and that we would do the program no matter how she was feeling. I was able to use conversation and lots of distraction techniques to stop her focusing on the back pain. One of the biggest break throughs was when she started to understand that even if the back is sore, if exercise doesnt make it worse then its getting better!
This is a very long-winded example of how utilising different treatment approaches can be very beneficial, expecially in chronic conditions. Also, its an example of how we should not be afraid to refer to a different therapist if we are not getting the results/rapport that we need with a patient.
Juggling placement and curtin tutors expectations
Whilst on my last prac i had some definate difficulties satisfying the expectations that the placement and the curtin supervisors wanted. This wasnt because i was not competent and was not satifying the workload, it was for a different reason.
Whilst on the placement i was expected to work independantly with my own patient load and treat the patients as the other physiotherapists were. This consisted of quite short and very functional treatment sessions where you go in, address a problem and then leave. This approach worked very well in this scenario as it was a private rehab ward.
The difficulties arose during the 3 hour per week curtin supervisor period. As part of the prerequisite to demonstrate my competence i was required to assess, treat the impairments, treat the functional tasks and write-up goals and show how these goals were progressing. This approach required approx 1.5-2hour session with the patient. This would have been fine if i had the oppertunity to practice this approach during the week.
It turned into the most stressful prac because i was being assessed on things i havent had the oppertunity to practice in full. When i talked to the tutor about this, the solution included full write-ups for each patient. This made it easier but meant that every night i was knee deep in paperwork for each patient.
I got through the placement alright but it just emphasises the difficulties that arise when the placement and clinical tutors are on completely different wavelengths!
Whilst on the placement i was expected to work independantly with my own patient load and treat the patients as the other physiotherapists were. This consisted of quite short and very functional treatment sessions where you go in, address a problem and then leave. This approach worked very well in this scenario as it was a private rehab ward.
The difficulties arose during the 3 hour per week curtin supervisor period. As part of the prerequisite to demonstrate my competence i was required to assess, treat the impairments, treat the functional tasks and write-up goals and show how these goals were progressing. This approach required approx 1.5-2hour session with the patient. This would have been fine if i had the oppertunity to practice this approach during the week.
It turned into the most stressful prac because i was being assessed on things i havent had the oppertunity to practice in full. When i talked to the tutor about this, the solution included full write-ups for each patient. This made it easier but meant that every night i was knee deep in paperwork for each patient.
I got through the placement alright but it just emphasises the difficulties that arise when the placement and clinical tutors are on completely different wavelengths!
Sunday, October 26, 2008
You know more than you think.........
My last clinical placement was with community physiotherapy services and on this placement I had to run several exercise classes. This was fine and I had no problem planning and executing the classes at the right level and achieving what I had set out to schieve.
The most important aspect of the classes I did have to work on....... the education segments........ I got some great advice from one of the physiotherapists that I was working with and it was 'you know more than you think you do'. By this she meant that we as physiotherapists (even us as students) have aquired a large amount of information over the last 4yrs, even though we may not think so. The general public are not as well informed. Her advice to me for my classes was to just throw in various pieces of advice as they came to mind, even if I thought that everyone in the class already knew the information I should just say it as it it would be more than likely that most people did not know and even if they did a reminder is always a good thing. Just as an example posture, everyone knows that they should maintain a good posture but how much do the general public actually know about how and why they should be doing this???
I just thought I would give this advice as I have found it very useful not only for exerise classes but for individual treatment sessions as well.
The most important aspect of the classes I did have to work on....... the education segments........ I got some great advice from one of the physiotherapists that I was working with and it was 'you know more than you think you do'. By this she meant that we as physiotherapists (even us as students) have aquired a large amount of information over the last 4yrs, even though we may not think so. The general public are not as well informed. Her advice to me for my classes was to just throw in various pieces of advice as they came to mind, even if I thought that everyone in the class already knew the information I should just say it as it it would be more than likely that most people did not know and even if they did a reminder is always a good thing. Just as an example posture, everyone knows that they should maintain a good posture but how much do the general public actually know about how and why they should be doing this???
I just thought I would give this advice as I have found it very useful not only for exerise classes but for individual treatment sessions as well.
Clinical Tutors
Through out the year and through all of my previous placements I have not had a problem with anyone of my supervisors and so have never really had to deal with conflict of this sort. Whilst on my last placement I had several supervising physiotherapists which soon began to take it's toll as each of these physiotherapists had thier own preferred method of doing things and ranked the importance of certain tasks very differently. There was one particular physio who I just could not seem to see eye to eye with. I only had a chance to deal with each physio once a week and even though I would implement the changes in my sessions as she had requested but I was getting conflicting advice from other physios and I felt as though I could do no right in her eyes.
This eventually began to stress me out quite badly. My curtin supervisor came to assess me whilst I was with this physiotherapist and commented on the difference between this class that I took and the others that I had taken, she was worried because the class that I had taken was not up to the standard that I had set with other classes. I had not yet spoken to her about my 'conflicts' with the physio as I had only seen my curtin tutor on two occasions previously and did not feel that I could tell her of my problem. Luckily for me she picked up on it and her and I sat down and discussed strategies to manage this. It was just a matter of conflicting personalities, she also encouraged me to just back but the reasons why I was doing what I was doing as the phsyio would respect this more.
From this I realised the value of our curtin tutors, not only for promoting and developing our clinical knowledge but for a range of other problems that we might have. If anyonelse has any difficulties on their placements I really would recommend discussing this with your tutor. They are here to help us through to the end of our physiotherapy degree so just ask for help if you need it!!
This eventually began to stress me out quite badly. My curtin supervisor came to assess me whilst I was with this physiotherapist and commented on the difference between this class that I took and the others that I had taken, she was worried because the class that I had taken was not up to the standard that I had set with other classes. I had not yet spoken to her about my 'conflicts' with the physio as I had only seen my curtin tutor on two occasions previously and did not feel that I could tell her of my problem. Luckily for me she picked up on it and her and I sat down and discussed strategies to manage this. It was just a matter of conflicting personalities, she also encouraged me to just back but the reasons why I was doing what I was doing as the phsyio would respect this more.
From this I realised the value of our curtin tutors, not only for promoting and developing our clinical knowledge but for a range of other problems that we might have. If anyonelse has any difficulties on their placements I really would recommend discussing this with your tutor. They are here to help us through to the end of our physiotherapy degree so just ask for help if you need it!!
Monday, October 20, 2008
chronic pain
While on my rural prac I encountered a chronic pain patient for the very first time. He was a middle aged man who had a 10 year history of lower back pain, which resulted in him quitting work and being on workers compensation for a very long time. When I first assessed him, he was very specific about where his pain was, and on physical examination I was able to establish some problems which I could treat. However, with each visit he made more and more problems became evident, and he kept remembering more things that he couldn’t do. So I became quite confused, even though I realised he was a chronic pain patient, I just wasn’t sure what exactly to do.
So I spoke with both my supervisors and they gave me a lot of education on chronic pain, because I feel this is an area we don’t get to spend a huge amount of time on in class. They educated me on the best management strategies for him, and that hands on treatment would work short term but he needed longer term management. So when my patient came in again, we spent the whole session just talking. He asked me why I wasn’t `treating` him as he always felt 99% better after treatment. I explained that he needed a much broader approach to his pain. I booked him in for hydro sessions, which he absolutely loved and which helped to keep his pain well under control. We also managed to address other issues in his daily life which may have been affecting him. The end result was a very happy patient who I felt happy to discharge from physio as I knew he had taken everything on board and would manage fine. After all the help and information from my supervisors I feel much more able at managing patients with more chronic pain now and will take the same approach as I did this time but modify it for each patient
So I spoke with both my supervisors and they gave me a lot of education on chronic pain, because I feel this is an area we don’t get to spend a huge amount of time on in class. They educated me on the best management strategies for him, and that hands on treatment would work short term but he needed longer term management. So when my patient came in again, we spent the whole session just talking. He asked me why I wasn’t `treating` him as he always felt 99% better after treatment. I explained that he needed a much broader approach to his pain. I booked him in for hydro sessions, which he absolutely loved and which helped to keep his pain well under control. We also managed to address other issues in his daily life which may have been affecting him. The end result was a very happy patient who I felt happy to discharge from physio as I knew he had taken everything on board and would manage fine. After all the help and information from my supervisors I feel much more able at managing patients with more chronic pain now and will take the same approach as I did this time but modify it for each patient
very sick patients
Whilst on my cardio prac, I encountered a very sick 78 year old man who really challenged me. He had been admitted after NSTEMI and had had a CABG surgery. After this he was in intensive care for a few days longer than normal due to lots of complications. When he was finally admitted to the ward he was so badly deconditioned, and adding to this was the fact that he had to be on daily dialysis. So I started treating him and was able to help him clear his chest quite nicely, but I was not able to get him to ambulate. He would just tell me he was far too tired, and sometimes I would convince him to just take a few steps up and down the room with me, but other times he would just refuse. However, when my supervisor came in, he would agree with everything. So over the time he spent in hospital, he developed a pneumonia on top of everything else, and I felt really bad seeing as he was my patient.
This man also became very depressed, and started showing signs of some sort of neurological insult, but we were not quite sure what was going on and he was having head scans the day I left so I wont ever know. But I just felt that he was very untrusting of me because I was a student, and he would always comply with my supervisor. I also had times where I felt so bad going in there and waking him up for physio as he hardly slept during the night so I felt like he really needed any sleep he could get.
I spoke with my supervisor about it and she helped a lot. She said that with time you find out which patients are really really sick and those are the ones you back off on a bit. But you also learn how hard you can push someone within the limits of safety, and that this was a clinical judgement skill that would come with practice. She also said that unfortunately some patients just did not feel safe in students hands, and that was just a personal thing. And she reminded me of how much success I had had with my other patients and said that even for her there are some people she hasn’t had great success with. So in future, I will always talk over difficult patients with my supervisor along the way so that they can give me any handy hints for increasing patient compliance as a student. And I have also realised that in time I will be able to know which patients I can push a little harder than others.
This man also became very depressed, and started showing signs of some sort of neurological insult, but we were not quite sure what was going on and he was having head scans the day I left so I wont ever know. But I just felt that he was very untrusting of me because I was a student, and he would always comply with my supervisor. I also had times where I felt so bad going in there and waking him up for physio as he hardly slept during the night so I felt like he really needed any sleep he could get.
I spoke with my supervisor about it and she helped a lot. She said that with time you find out which patients are really really sick and those are the ones you back off on a bit. But you also learn how hard you can push someone within the limits of safety, and that this was a clinical judgement skill that would come with practice. She also said that unfortunately some patients just did not feel safe in students hands, and that was just a personal thing. And she reminded me of how much success I had had with my other patients and said that even for her there are some people she hasn’t had great success with. So in future, I will always talk over difficult patients with my supervisor along the way so that they can give me any handy hints for increasing patient compliance as a student. And I have also realised that in time I will be able to know which patients I can push a little harder than others.
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