On Friday I had a patient that made me really nervous just from reading his notes. He had fallen off a table at his own 50th birthday party after a few drinks and dislocated his elbow. From looking at his x-ray it was a huge displacement and amazing that he had so little soft tissue damage.
He was delayed in getting into the physiotherapist in the first place due to the long waiting lists, and apparently there is only a small window of opportunity for regaining ROM with dislocation, which he consequently missed. When he presented to the physio department he had 2 treatment sessions which regained some of his ROM but not much. After the 2 treatment sessions he returned to his specialist for his routine check-up, and the specialist was so worried that physio was stretching his ligaments too much that he stopped him from seeing a physio until the specialist decided it was ok to go back.
Luckily, when he went back to the specialist he had to see another doctor instead who promply put him back into physio and couldn't believe he had been taken out in the first place. Once he began treatment again he was 20 degrees off full elbow extension. He had 6 treatments; 3 with a curtin 4th year and 3 with a curtin 3rd year. When I was speaking to my supervisor about seeing this patient I expressed my concern about more experienced students not being successful with the patient and that they had exhausted all of the treatment options I had in mind. We decided that I would give it a go after having done my own assessment and if there was no improvement by the time my placement was up he would have to be discharged.
Earlier I had had another discussion with my supervisor about the use of accessory mobilisations and that he believed that if a joint was stiff it wasn't so important what direction it was moved in, but just that it was moved. So I decided that I would have a try at a different direction than the other students had attempted, even if it was against convention. It so happened that I got 4 degrees improvement. It was one of the best feelings!
Sunday, October 26, 2008
Week 2 Day 2-3
On Tueaday and Wednesday all of my patients except one had fractures or knee conditions such as ACL reconstructions, menisectomy's or TKR's. The other patient I had presented with a typical shoulder impingement, however the reason he had it was so interesting.
He has a condition called Arnold-chiari malformation. It is a condition that causes the brainstem to be elongated and displaced into the opening of the base of the skull and the spinal canal. It occurs in most people with hydrocephaly and spina bifida. It affects not only the brainstem, but also the cranial nerves and the cerebellum. Consequently, anything controlled by the brainstem, cranial nerves or cerebellum can be affected.
Althought he had had surgery 3 years ago to decompress these structures, he still presented with posture control, upper limb weakness and unsteady gait. It was due to his weakness of scapula muscles that he had a secondary impingement.
When I was reading his notes his conditioned was only mentioned twice; in his subjective assessment in the 'past surgery' section, and in his transfer summary from his previous therapist. I therefore didn't consider it a major part of his condition. It wasn't until he walked in that it dawned on that a big part of his therapy would revolve around his condition. I really learnt that co-morbidities should never be ruled out and can always affect your treatment and assessment.
He has a condition called Arnold-chiari malformation. It is a condition that causes the brainstem to be elongated and displaced into the opening of the base of the skull and the spinal canal. It occurs in most people with hydrocephaly and spina bifida. It affects not only the brainstem, but also the cranial nerves and the cerebellum. Consequently, anything controlled by the brainstem, cranial nerves or cerebellum can be affected.
Althought he had had surgery 3 years ago to decompress these structures, he still presented with posture control, upper limb weakness and unsteady gait. It was due to his weakness of scapula muscles that he had a secondary impingement.
When I was reading his notes his conditioned was only mentioned twice; in his subjective assessment in the 'past surgery' section, and in his transfer summary from his previous therapist. I therefore didn't consider it a major part of his condition. It wasn't until he walked in that it dawned on that a big part of his therapy would revolve around his condition. I really learnt that co-morbidities should never be ruled out and can always affect your treatment and assessment.
Monday, October 20, 2008
Week 2 Day 1
Today I had 3 very different patients, a stiff knee, a shoulder impingement and an elbow post joint wash out from a golden staff infection. They were all very interesting but the lady with the shoulder impingement was especially interesting as she really demonstrated to me the importance of posture.
She had a secondary impingement in her right shoulder that caused her RC to tear and therefore required rotator cuff repair sugery. However, due to her poor scapula posture which had caused the impingement in the first place, it failed. The specialist has decided that there is no way he can repair it again so she has a shoulder that remains in neutral. Now, her left shoulder is affected by her poor posture and is causing a secondary impingement. We are trying to correct this poor posture to save this shoulder from surgery and possibly becoming useless aswell! Its really shown me the importance of physios and surgeons working closely together, as good posture, one of the basics of physio could have saved her a lot of problems.
Whilst its generally easy to fix scapula posture, for this lady its another story. her major problem is her abduction and protraction as she is 15cm from her midline!!! She also has bilateral medial rotation, elevation and winging. She showed huge improvement today but she still has so far to go, problems with endurance and over 60 years of bad posture to contend with! I'll be very interested to see how she progresses over the next few weeks, and I'm aiming to have her with full ROM with correct scapula posture by the end of placement.
She had a secondary impingement in her right shoulder that caused her RC to tear and therefore required rotator cuff repair sugery. However, due to her poor scapula posture which had caused the impingement in the first place, it failed. The specialist has decided that there is no way he can repair it again so she has a shoulder that remains in neutral. Now, her left shoulder is affected by her poor posture and is causing a secondary impingement. We are trying to correct this poor posture to save this shoulder from surgery and possibly becoming useless aswell! Its really shown me the importance of physios and surgeons working closely together, as good posture, one of the basics of physio could have saved her a lot of problems.
Whilst its generally easy to fix scapula posture, for this lady its another story. her major problem is her abduction and protraction as she is 15cm from her midline!!! She also has bilateral medial rotation, elevation and winging. She showed huge improvement today but she still has so far to go, problems with endurance and over 60 years of bad posture to contend with! I'll be very interested to see how she progresses over the next few weeks, and I'm aiming to have her with full ROM with correct scapula posture by the end of placement.
Sunday, October 19, 2008
Week 1 Day 4-5
My most interesting patient over these two days was not interesting because of the condition but because of his age, and the changes I had to make to my assessment and treatment because of this. He was a 91 year old that was referred to the physio because of degenerative changes in his knee that were not suitable to be fixed surgically. We were asked to improve his musculature to assist in decreasing the symptoms associated with the degeneration.
I had to speak slowly and loudly as he was hard of hearing and his hearing aid had broken that morning. I also had to ensure that I was in his line of sight when I was speaking as he lip read a lot of the time. The entire assessment took a long time for these reasons and also because he moved very slowly to the positions I needed him and his skin was extremely frail from anticoagulants, so I had to be extra careful. It took a lot of planning to ensure that I didn't have to move him around a lot and completed all the tests in each position and then moved on rather than all of the tests for strength etc.
I found that his gait was very shuffly due to the pain, fear of falling and tight gastroc and hamstrings. He also had very decreased VMO activation. After some VMO strengthening exercises, some stretches and some gait reeducation he walked out of the clinic like a different man. He was also very happy to have been taught to walk properly as he felt ashamed to walk how he was in public, as he thought people would label him as old and senile.
It was nice to have had a postive experience with an older gentleman, as to be honest I wasn't looking forward to working with older people, as I thought it wasn't a strength of mine. After that experience though, I feel a lot more confident. I would have liked to have been a little more consistent with the words I used to cue actions though, as he seemed to get confused with some aspects of the assessment, especially strength testing.
I had to speak slowly and loudly as he was hard of hearing and his hearing aid had broken that morning. I also had to ensure that I was in his line of sight when I was speaking as he lip read a lot of the time. The entire assessment took a long time for these reasons and also because he moved very slowly to the positions I needed him and his skin was extremely frail from anticoagulants, so I had to be extra careful. It took a lot of planning to ensure that I didn't have to move him around a lot and completed all the tests in each position and then moved on rather than all of the tests for strength etc.
I found that his gait was very shuffly due to the pain, fear of falling and tight gastroc and hamstrings. He also had very decreased VMO activation. After some VMO strengthening exercises, some stretches and some gait reeducation he walked out of the clinic like a different man. He was also very happy to have been taught to walk properly as he felt ashamed to walk how he was in public, as he thought people would label him as old and senile.
It was nice to have had a postive experience with an older gentleman, as to be honest I wasn't looking forward to working with older people, as I thought it wasn't a strength of mine. After that experience though, I feel a lot more confident. I would have liked to have been a little more consistent with the words I used to cue actions though, as he seemed to get confused with some aspects of the assessment, especially strength testing.
Friday, October 17, 2008
Week 1 Day 2-3
I had some pretty standard patients on day 2; an 18 year old girl 3 weeks post ACL reconstruction, a 15 year old girl 8 weeks post partial meniscal tear and possible ACL tear seeking conservative treatment and a 43 year old man post meniscal tear repair who was experiencing bilateral patellofemoral pain. While they each presented some small challenges, they were almost as if they came from one of our case studies.
On day 3 however, I had a very interesting patient. She presented with pain on the head of her 5th metatarsal during weight bearing, and had been passed from doctor to podiatrist and back again, each palming her off to the next health professional but never actually diagnosing or helping her. It took me some time to get a really good picture of what was going on and I still wonder whether I really understand the extent of her problem.
She presented very differently, with cortisone and ultrasound both aggrevating her more. My supervisor advised me that if her condition didn't make sense medically, I was better off being honest with her and coming straight out and telling her. It turned out that I not only understood her problem, but she didn't even want to be there, and she didn't believe that physio would help at all. It was amazing the different turn the treatment took at that point, because she then for once felt like there was someone being honest with her. I proposed that we attempt my treatment for a few weeks and at the end if it hasn't been successful we will reassess and take a completely different route.
Although treatment wise I felt like I achieved the least of all of the patients I have had, I believe it was one of my most sucessful patients as she now wants to go ahead with treatment and doesn't feel like she has been palmed off again onto someone that doesn't care. When I see her again next week I plan to really get to the cause of her problem now that she is open to treatment.
On day 3 however, I had a very interesting patient. She presented with pain on the head of her 5th metatarsal during weight bearing, and had been passed from doctor to podiatrist and back again, each palming her off to the next health professional but never actually diagnosing or helping her. It took me some time to get a really good picture of what was going on and I still wonder whether I really understand the extent of her problem.
She presented very differently, with cortisone and ultrasound both aggrevating her more. My supervisor advised me that if her condition didn't make sense medically, I was better off being honest with her and coming straight out and telling her. It turned out that I not only understood her problem, but she didn't even want to be there, and she didn't believe that physio would help at all. It was amazing the different turn the treatment took at that point, because she then for once felt like there was someone being honest with her. I proposed that we attempt my treatment for a few weeks and at the end if it hasn't been successful we will reassess and take a completely different route.
Although treatment wise I felt like I achieved the least of all of the patients I have had, I believe it was one of my most sucessful patients as she now wants to go ahead with treatment and doesn't feel like she has been palmed off again onto someone that doesn't care. When I see her again next week I plan to really get to the cause of her problem now that she is open to treatment.
Thursday, October 16, 2008
Week 1 Day 1
The first day we arrived at placement I wasn't exactly sure what to expect. All we were told was that for the first hour of the day we would be having a general orientation of the hospital and then after that we would go to our respective areas. It just so happened that one of the first places we were taken in the orientation was the reception, and we were shown the patient appointment book. I casually glanced at the book and saw a column with my name on it, and a patients name for 10.30am! I spent the rest of the orientation stressing about having a patient in about an hours time and having absolutely no idea what I was about to be thrown in to.
It ended up being one of the best things I've ever done and an experience I will never forget. Monique and I were each given a patient, mine was in the morning and hers in the afternoon. We were given time to research our patients and plan our treatment and the other person was allowed to come in with us for support, but not to be too involved in the assessment and treatment. I did a full subjective as it was a new patient and then went to find the supervisor where we discussed the findings and decided on an objective assesment that wold be appropriate. After the objective testing I was allowed to speak to my supervisor and discuss an appropriate treatment, and then go through with it.
I really suprised myself. Although my supervisor really cleared up why I was to do what I needed to do, I came up with the skeleton of the assessment and treatment myself. It was amazing to know that I could calmly deal with the situation. I would have liked to have improved the flow of my objective assessment but I feel that the case studies we did in the lectures and the practice clinical reasoning panels from 221 really helped with my subjective assessment.
It ended up being one of the best things I've ever done and an experience I will never forget. Monique and I were each given a patient, mine was in the morning and hers in the afternoon. We were given time to research our patients and plan our treatment and the other person was allowed to come in with us for support, but not to be too involved in the assessment and treatment. I did a full subjective as it was a new patient and then went to find the supervisor where we discussed the findings and decided on an objective assesment that wold be appropriate. After the objective testing I was allowed to speak to my supervisor and discuss an appropriate treatment, and then go through with it.
I really suprised myself. Although my supervisor really cleared up why I was to do what I needed to do, I came up with the skeleton of the assessment and treatment myself. It was amazing to know that I could calmly deal with the situation. I would have liked to have improved the flow of my objective assessment but I feel that the case studies we did in the lectures and the practice clinical reasoning panels from 221 really helped with my subjective assessment.
Saturday, October 11, 2008
Initial Entry
Thoughts and feeling about going on clinical placement:
I'm nervous to go on placement, mainly because I have no idea of the expectations the placement has for me. I'm also nervous about my surperviser and just hope that I get along well with them and that I can make a very good first impression. I'm looking forward to actually getting out there and having a go and seeing what my strengths and weaknesses really are, as in the uni environment its really hard to get a realistic look at your progress. I really just can't wait and start so that I can get into it and stop being so nervous.
How I see the physiotherapist working with other physiotherapists and health care porfessionals in the clinical setting:
I think that the within the environment I am going to be working in (outpatient department) there will be a lot of work between physiotherapists and other health care professionals. I think that it will involve a lot of communication and gathering of information between professionals and working very solosely together to provide the best care possible.
I'm nervous to go on placement, mainly because I have no idea of the expectations the placement has for me. I'm also nervous about my surperviser and just hope that I get along well with them and that I can make a very good first impression. I'm looking forward to actually getting out there and having a go and seeing what my strengths and weaknesses really are, as in the uni environment its really hard to get a realistic look at your progress. I really just can't wait and start so that I can get into it and stop being so nervous.
How I see the physiotherapist working with other physiotherapists and health care porfessionals in the clinical setting:
I think that the within the environment I am going to be working in (outpatient department) there will be a lot of work between physiotherapists and other health care professionals. I think that it will involve a lot of communication and gathering of information between professionals and working very solosely together to provide the best care possible.
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