Situation
A 26 year old female was referred to the Outpatient Department at Armadale hospital by her GP for ‘tennis elbow’. The injury resulted at a game of ten pin bowling 3 months earlier where the woman bowled on an unusual angle. She played ten pin bowling on a weekly basis and had never experienced an injury such as this before. The patient took two weeks off work initially as her work was manual in nature and the pain was limiting the tasks she was able to complete. She had also stopped ten pin bowling after the initial injury and had not yet returned.
Task
I was asked in the referral letter to assess and treat her accordingly.
Action
When the patient arrived I performed a full subjective and objective assessment, completely disregarding the diagnosis given in the referral, to ensure that I was unbiased in my own diagnosis. The patient did indeed have an extensor tendinopathy which was started to resolve on its own with the patient stopping the aggravating activities of ten pin bowling and work. However, there were still quite marked limitations in terms of elbow, forearm, wrist and grip strength and some pain especially with grip. I remembered from 2nd year the benefits of eccentric strength exercises in tendinopathy and prescribed the patient eccentric wrist flexion, extension, radial deviation and ulnar deviation with weights, education on continuing to avoid the aggravating activities where possible and wearing a tennis elbow brace when doing the tasks she cannot avoid. I also gave her general elbow and grip strengthening exercises and stretches for the wrist.
Before I next saw the patient I decided to look at the evidence on extensor tendinopathy treatment to ensure I was giving her the best treatment I could. I found an article called Lateral epicondylalgia: a musculoskeletal physiotherapy perspective by B.Vicenzino (Manual Therapy 2003, 8 (2), 66-79) which is a masterclass article on tennis elbow. It outlines appropriate treatments depending on the presentation of the patient. I found it especially interesting as my patient fit very nicely into one of the classifications given; pain-free grip strength deficit is much larger than pain elicited on direct palpation of the lateral epicondyle (i.e. the pressure pain threshold). It spoke about the Mulligan’s (1999) MWM and how it is extremely beneficial in the treatment of patients with this presentation, specifically the sustained lateral glide with pain-free grip. This technique can be done manually and then reinforced with taping of the lateral glide to continue improvements once the patient leaves the physiotherapist, as well as self mobilization techniques for home. Due to the strength of the evidence supporting these techniques I decided to try them on my patient when she returned if she still fit into the same clinical picture.
When the patient returned the techniques I had prepared were still relevant, so, I performed a sustained lateral glide while she performed pain-free gripping movements. She felt that the grip she could maintain with the glide was much stronger than without, and this was then confirmed with a handheld dynamometer. The treatment therefore seemed to be a successful one. I taped the patient before she left and she felt this helped the pain substantially. I decided not to teach her self-mobilizations as I was not confident she would be able to perform them correctly at home.
When the patient returned a week later she had significant improvements in pain and functional level and no longer had pain on grip. I was then able to focus more on improving her strength functionally to allow her to return to ten pin bowling.
Result
I believe that the patient recovered much faster with the evidence-based intervention that was chosen due to her specific clinical pattern rather than a recipe treatment for every tennis elbow available. Whilst I was treating her initially with eccentric exercises which are backed by strong exercises, I was able to incorporate even more specific treatments that really targeted her problems.
Evaluation
Whilst I believe that there was little that I could have done in this situation to have prepared or performed any better, it has definitely taught me the importance of evidence-based practice. We are taught over and over again at university the importance of knowing the evidence and using treatments that are backed by evidence, but until you experience it for yourself it is a hard concept to grasp. Just saying that you are doing a treatment because it was what you were taught to do just does not cut it in the real world with real patients, you must be able to back yourself up with hard evidence.
Strategies
I now know that when I graduate I am really only just beginning to learn. University has given me my base knowledge but I must continue the learning by keeping up to date with the literature in order to be the best physiotherapist I can be. I will definitely keep up to date once I graduate, as my supervisor is a great clinician and it is due to his very comprehensive knowledge of the evidence that is available.
Sunday, February 28, 2010
Saturday, February 13, 2010
Rotation 1 Fourth Year - Assessment STARES
Situation
A 71 year old woman was referred to the Outpatient Department at Armadale Hospital by her GP with a diagnosis of tibialis posterior tendonitis and medial malleolar zone pain. This was after an accident at the supermarket where another woman ran into her ankle with a shopping trolley 4 months earlier. An x-ray had ruled out fractures as a possible cause of her pain, and an ultrasound had found some degeneration in both the medial and lateral malleolar zones as well as marked swelling.
Task
I was asked in the referral letter to assess and treat her accordingly.
Action
Wanting to be prepared for the patient and have all of the possible causes of her pain fresh in my mind, I read up on medial ankle pathologies and the possible differential diagnoses of these. I assumed that while the diagnosis may not be correct the GP would have at least correctly described the area of pain. However, when the patient arrived I quickly found that her pain was not in her medial ankle but instead in her lateral ankle. All of the pathologies and tests I had revised were no longer relevant to this patient. I quickly rethought my approach to my objective assessment to include structures in the lateral ankle such as the ATFL, deltoid ligament and CFL and did my best to bring on the patients symptoms. However, no matter what I tried, whether it be a functional test, muscle strength test, muscle length test or ligament integrity test I could not bring on her pain except in weight bearing activities. Even in the weight bearing activities she could not pin point the part of the activity that aggravated it except that it was when her weight went through her ankle. I was becoming thoroughly frustrated and nervous as my supervisor was present and offering no solutions to me. After taking too long to complete my objective assessment the patient announced that she had to return home straight away as she was a carer for her disabled husband. My supervisor spoke up and said that it was ok to rebook and continue the assessment later that week if the patient is happy with that. Luckily the patient was very understanding and was happy to come back a few days later.
Result
My actions eventuated in a patient leaving the department with no diagnosis or understanding of her problem and no treatment was given. If it were another patient they could have been very unsatisfied with the length of time I had spent with them without any resolution to their problem. However, I was lucky enough to have a very understanding patient who did return to the department to continue their treatment.
Evaluation
Of all of the bad experiences I have had on a placement this would have to be the one that I am most ashamed of. I feel I completely let down my patient, offering them no explanation or solution to their problem. I believe that I let myself assume what was wrong with the patient before they even arrived. Not by believing the referral as it was exactly, but by believing the referral at all! She is not the only patient who has arrived with completely different sore body parts than the ones spoken about in the referral. This is not only because of the GPs but also because of the length of waiting time that is unavoidable in the public system and some pain symptoms can change in a matter of months. I also believe that I didn’t take the patient’s chronicity and non irritability into account and was not aggressive enough to bring on the patients symptoms. Whilst part of me does wish that the supervisor had stepped in at the time, I feel that he didn’t want to embarrass or undermine me in front of the patient and we later had a lengthy discussion about the patient regarding what I could have done to avoid the situation and how to approach the patient the next time I saw her. Whilst I believe that the situation was terrible and one I never want to repeat I believe the discussion and therefore the things I have learnt from the situation would not have come about without making the mistakes that I did. I am also glad that I kept my cool in front of the patient and never let her know that I was concerned and frustrated. To her it just appeared I was doing my job and ran out of time.
Strategies
I believe that my objective assessment was not dynamic and flexible enough, as I had already made assumptions about what was wrong with the patient before I had seen them. All areas of assessment and treatment should be always changing depending on each new piece of information the patient presents to me. I should never stop at the end of the objective assessment and start thinking about what is wrong with the patient, I should be already forming ideas as I go so that I can change my assessment if need be. Also, my objective assessment was not aggressive enough for a patient that was non irritable and chronic. A patient like her requires an aggressive assessment to find the source of the symptoms. Through the week I practiced my objective assessment on the ankle and when the patient returned later that week I was a lot more aggressive, dynamic and flexible with my assessment. Unfortunately I still couldn’t find the source of symptoms but my supervisor and I discussed it and decided that there may no longer be an injury, hence no reproduction of symptoms, but that the pain is centrally mediated. Whilst it would have been nice to find a source of symptoms, I can safely say that I performed an effective objective assessment and that my findings were accurate the second time around.
A 71 year old woman was referred to the Outpatient Department at Armadale Hospital by her GP with a diagnosis of tibialis posterior tendonitis and medial malleolar zone pain. This was after an accident at the supermarket where another woman ran into her ankle with a shopping trolley 4 months earlier. An x-ray had ruled out fractures as a possible cause of her pain, and an ultrasound had found some degeneration in both the medial and lateral malleolar zones as well as marked swelling.
Task
I was asked in the referral letter to assess and treat her accordingly.
Action
Wanting to be prepared for the patient and have all of the possible causes of her pain fresh in my mind, I read up on medial ankle pathologies and the possible differential diagnoses of these. I assumed that while the diagnosis may not be correct the GP would have at least correctly described the area of pain. However, when the patient arrived I quickly found that her pain was not in her medial ankle but instead in her lateral ankle. All of the pathologies and tests I had revised were no longer relevant to this patient. I quickly rethought my approach to my objective assessment to include structures in the lateral ankle such as the ATFL, deltoid ligament and CFL and did my best to bring on the patients symptoms. However, no matter what I tried, whether it be a functional test, muscle strength test, muscle length test or ligament integrity test I could not bring on her pain except in weight bearing activities. Even in the weight bearing activities she could not pin point the part of the activity that aggravated it except that it was when her weight went through her ankle. I was becoming thoroughly frustrated and nervous as my supervisor was present and offering no solutions to me. After taking too long to complete my objective assessment the patient announced that she had to return home straight away as she was a carer for her disabled husband. My supervisor spoke up and said that it was ok to rebook and continue the assessment later that week if the patient is happy with that. Luckily the patient was very understanding and was happy to come back a few days later.
Result
My actions eventuated in a patient leaving the department with no diagnosis or understanding of her problem and no treatment was given. If it were another patient they could have been very unsatisfied with the length of time I had spent with them without any resolution to their problem. However, I was lucky enough to have a very understanding patient who did return to the department to continue their treatment.
Evaluation
Of all of the bad experiences I have had on a placement this would have to be the one that I am most ashamed of. I feel I completely let down my patient, offering them no explanation or solution to their problem. I believe that I let myself assume what was wrong with the patient before they even arrived. Not by believing the referral as it was exactly, but by believing the referral at all! She is not the only patient who has arrived with completely different sore body parts than the ones spoken about in the referral. This is not only because of the GPs but also because of the length of waiting time that is unavoidable in the public system and some pain symptoms can change in a matter of months. I also believe that I didn’t take the patient’s chronicity and non irritability into account and was not aggressive enough to bring on the patients symptoms. Whilst part of me does wish that the supervisor had stepped in at the time, I feel that he didn’t want to embarrass or undermine me in front of the patient and we later had a lengthy discussion about the patient regarding what I could have done to avoid the situation and how to approach the patient the next time I saw her. Whilst I believe that the situation was terrible and one I never want to repeat I believe the discussion and therefore the things I have learnt from the situation would not have come about without making the mistakes that I did. I am also glad that I kept my cool in front of the patient and never let her know that I was concerned and frustrated. To her it just appeared I was doing my job and ran out of time.
Strategies
I believe that my objective assessment was not dynamic and flexible enough, as I had already made assumptions about what was wrong with the patient before I had seen them. All areas of assessment and treatment should be always changing depending on each new piece of information the patient presents to me. I should never stop at the end of the objective assessment and start thinking about what is wrong with the patient, I should be already forming ideas as I go so that I can change my assessment if need be. Also, my objective assessment was not aggressive enough for a patient that was non irritable and chronic. A patient like her requires an aggressive assessment to find the source of the symptoms. Through the week I practiced my objective assessment on the ankle and when the patient returned later that week I was a lot more aggressive, dynamic and flexible with my assessment. Unfortunately I still couldn’t find the source of symptoms but my supervisor and I discussed it and decided that there may no longer be an injury, hence no reproduction of symptoms, but that the pain is centrally mediated. Whilst it would have been nice to find a source of symptoms, I can safely say that I performed an effective objective assessment and that my findings were accurate the second time around.
Saturday, February 6, 2010
Rotation 1 Fourth Year - Initial Entry
I am really looking forward to this placement, for a number of reasons, but along with the feelings of excitement come feelings of trepidation and mild anxiety. The excitement is due to the fact that my 2nd year placement at Bentley Hospital Outpatient Department was such a success and really set up my clinical placements for the future to be viewed in a positive light. My placement at Armadale Hospital also taking place in the Outpatient Department fills me with good memories of successful patients, many learning opportunities and 5 weeks of my confidence in myself and love of physiotherapy growing gradually. I hope that my experience at Armadale is a similar one.
My feelings of trepidation are due to the expectations of me growing now that I am a fourth year student. I have heard from past students that expectations of us are high – new graduate level by the 5th week on the placement – and that most people’s marks on placement drop compared to the marks they received in their 2nd and 3rd year placements. It is not the drop in marks that concerns me but that the lack of flexibility with the knowledge we are expected to have will decrease the learning opportunities presented to us. If I leave Armadale Hospital feeling confident to treat patients on my own in the musculoskeletal field, I will consider the placement a success.
I have read from the fourth year presentations given on placements last year that I will start my placement with a considerable amount of supervision, and that this will gradually decrease as the placement continues. I expect that my patients will represent a variety of musculoskeletal disorders/problems, ranging from the usual such as ankle sprains and TKR to the not so usual. I expect to get a considerable amount of patients with back pain as this is a common condition, and one that I am looking forward to treating as I am not overly confident with the condition and have never seen or treated anyone with back pain before. I will be expected to be a professional member of the physiotherapy team, proficient in both subjective and objective assessment and attempt to the best of my ability, experience and knowledge to clinically reason and then perform an effective treatment of the patient. I will be expected to improve significantly from day 1 of placement to my final day, especially in the area of clinical reasoning.
I think that the placement will be structured in one of 2 ways: supervised with supervision gradually decreasing, or leaving the patient to discuss their assessment and treatment with the supervisor. This is based on my past experience at Bentley and from what I’ve heard from other students. I think that both ways are beneficial, however I hope that I will experience the latter at Armadale as I believe my clinical reasoning and patient communication are far better when I am left on my own as I don’t feel as nervous.
I believe my role at the hospital will begin as a combination of an observer and a student therapist, and as the placement goes on will eventually be purely as a therapist. Whilst I believe I will be expected to conduct myself as a confident and proficient therapist I also believe it is important I remember my role as a guest in the hospital and my role as a student, continually learning and observing those with a much greater pool of knowledge and experience than I have.
Overall I am very excited at the prospect of starting my first fourth year placement, and looking forward to the skills and experience I will gain.
My feelings of trepidation are due to the expectations of me growing now that I am a fourth year student. I have heard from past students that expectations of us are high – new graduate level by the 5th week on the placement – and that most people’s marks on placement drop compared to the marks they received in their 2nd and 3rd year placements. It is not the drop in marks that concerns me but that the lack of flexibility with the knowledge we are expected to have will decrease the learning opportunities presented to us. If I leave Armadale Hospital feeling confident to treat patients on my own in the musculoskeletal field, I will consider the placement a success.
I have read from the fourth year presentations given on placements last year that I will start my placement with a considerable amount of supervision, and that this will gradually decrease as the placement continues. I expect that my patients will represent a variety of musculoskeletal disorders/problems, ranging from the usual such as ankle sprains and TKR to the not so usual. I expect to get a considerable amount of patients with back pain as this is a common condition, and one that I am looking forward to treating as I am not overly confident with the condition and have never seen or treated anyone with back pain before. I will be expected to be a professional member of the physiotherapy team, proficient in both subjective and objective assessment and attempt to the best of my ability, experience and knowledge to clinically reason and then perform an effective treatment of the patient. I will be expected to improve significantly from day 1 of placement to my final day, especially in the area of clinical reasoning.
I think that the placement will be structured in one of 2 ways: supervised with supervision gradually decreasing, or leaving the patient to discuss their assessment and treatment with the supervisor. This is based on my past experience at Bentley and from what I’ve heard from other students. I think that both ways are beneficial, however I hope that I will experience the latter at Armadale as I believe my clinical reasoning and patient communication are far better when I am left on my own as I don’t feel as nervous.
I believe my role at the hospital will begin as a combination of an observer and a student therapist, and as the placement goes on will eventually be purely as a therapist. Whilst I believe I will be expected to conduct myself as a confident and proficient therapist I also believe it is important I remember my role as a guest in the hospital and my role as a student, continually learning and observing those with a much greater pool of knowledge and experience than I have.
Overall I am very excited at the prospect of starting my first fourth year placement, and looking forward to the skills and experience I will gain.
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