Situation
A 72 year old man was admitted to the rehabilitation ward at Hollywood Hospital on the 25th of April 2010 with a decrease in mobility, an increasing number of falls and lethargy. According to his wife his memory was starting to fail and he was finding it harder and harder to cope at home. This in turn was putting an increasing amount of pressure on her and she could no longer manage on her own. His past medical history included a diagnosis of Parkinson’s disease in 2006 and ischaemic heart disease.
Task
I was set the task of performing a neurological assessment on this gentleman.
Action
In preparation for the assessment of the patient I read through his medical and bedside notes. There was very little mention of his Parkinson’s disease in the notes and, according to the drug chart, on the 27th of April he was taken off his Parkinson’s medication (Madopar). After this date the notes mentioned the diagnosis of progressive supranuclear palsy (PSP), however there was no clear time or indication that the diagnosis changed. I spoke to the registrar and the consultant but they too didn’t know where the diagnosis had come from, only that the medication was not effective so he was taken off it. I then decided that within the assessment I would include some tests that differentiated between PSP and Parkinson’s disease. These tests included observation of his posture in standing as in PSP the patient will lean backwards but in Parkinson’s disease the patient will have a flexed posture, testing of his eye movements, as vertical tracking and convergence decrease with PSP but remain normal in Parkinson’s disease, and lastly, observation for any resting tremor as this is present in Parkinson’s disease but absent in PSP.
On assessment the patient did show signs of bradykinesia, decreased cognition (MME 16), decreased balance (Berg 33) and a history of falls. These are all signs and symptoms of both Parkinson’s disease and PSP. There was no resting tremor, minor rigidity, no history of freezing or akinesia and he was not responsive to Levadopa, which are all signs of only Parkinson’s disease. Lastly, he had very minimal vertical tracking and convergence of his eyes and leant backwards in standing, all symptoms only present in PSP. Whist I couldn’t definitively say that the patient had PSP, clinically it appeared that it might be a possibility. I spoke to the registrar regarding my findings and she is now in the process of confirming a diagnosis.
As the assessment allowed me to construct a concise problem list, a definitive diagnosis did not affect my treatment of this patient. It does however guide the medical treatment, so it is an important finding from the registrar’s perspective. My problem list included decreased dynamic standing balance, decrease insight and attention and abnormal standing posture. I then treated the patient with exercises that focused on these problems, keeping in mind the patients discharge destination, low level care.
Result
My actions resulted in the patient having further investigations into their condition, therefore leading to a better diagnosis and hopefully better treatment. This however did not affect my treatment much except that with a clear diagnosis I have a better idea of how the disease is predicted to progress, the prognosis, the best treatments and what to look out for in the future.
Evaluation
Whilst I am happy with the outcome of the situation, I am quite aware that without the mention of PSP in the notes by another healthcare practitioner I would not have even considered it. It makes me realise the importance of knowing each condition in detail and the possible options for differential diagnosis. Even a basic knowledge of a condition and its differential diagnoses would allow the options to be known. I will definitely be revising my neurological conditions over this placement and ensuring that I know the other similar conditions out there. In this case it was not detrimental to the patient however in the future a lack of knowledge such as this with another condition could possibly result in a negative outcome.
Strategies
As stated above, knowledge of the various neurological conditions and their differential diagnoses would have ensured that this possible misdiagnosis was picked up. Also, thorough reading of the notes ensured that any miscommunication within the medical notes was picked up and that all health care practitioners are treating the same condition.
Friday, May 14, 2010
Sunday, May 9, 2010
Rotation 3 Fourth Year - Initial Entry
I am really excited about this next placement at Hollywood Hospital in the area of neurological rehabilitation. Neurological physiotherapy has been one of my favourite areas during my studies and I have been looking forward to seeing the patients and their symptoms that that I have only read or heard about. As it is an area I am possibly looking to work in I think it will be good to see if I still feel that way after five weeks immersed in the area.
I have heard only good things about this placement from at least three people, some who have just attended the rotation and some that have been there in other years. Not only have they expressed their enjoyment about the work that they did and the patients that they saw, but also that the staff were friendly, passionate and very helpful. This gives me a feeling of confidence that it I put the effort into this placement I will reap the rewards of a successful and enjoyable learning experience.
Of course I am also feeling the usual nerves of starting at a new rotation and the expectations that they may have of me. It is a constant worry throughout this year as to whether you are meeting the high expectations of clinicians in the workforce to a graduate level by the end of the placement. It usually takes me the first week to feel comfortable in the new surroundings and with the new supervisors, so I will have to be patient. This will also be the first time that I will have a tutor, so this will bring a new dimension to the placement that I have never experienced before. I really have no idea what to expect in terms of the tutor as I have heard that they, like the supervisors, are all very different in their approach. I think I will just have to wait and see!
There is one thing that I am really looking forward to in this placement and that is seeing the various treatment techniques used. We were taught only a small selection of treatments in our neurology unit due to the large amount of treatment options available. I am really hoping that we are taught and shown some new techniques to use and that they can be added to our already eclectic tool box of neurological treatment techniques.
I have heard from past students that I will be working in the rehabilitation area rather than the acute neurology area. Patients will have mainly suffered from strokes and Parkinson’s disease and some other conditions such as multiple sclerosis may also present. I believe that the last two students there worked predominantly together, however they may be splitting us up this time as they would like to see how we work independently. I think that this plan will depend on the staffing availability in terms of supervision so it will be interesting to see what happens. I’m not sure as to the level of supervision there and how much we will be allowed to do independently. I am hoping for a lot more independence in this placement as I was supervised quite heavily in the last placement and I feel I don’t work my best having someone looking over my shoulder at all times.
I believe my role at the hospital will begin as a student therapist, a combination of observation of the clinicians, some observation of my skills and a small amount of independent treatment. I then think that the supervisor will gradually take away supervision until I am working at the level of a new graduate by the end of the placement. I think it is important that I emulate a skilled, independent therapist, but at the same time have respect for those with greater skills than I and treat them accordingly. I also need to remember that I am a guest in their workplace and to respect this fact at all times. Most of all I think my role is to learn and gain experience from this fantastic resource that I am so lucky to be a part of.
Overall I don’t really have any concerns about this placement as I have complete confidence that if I work hard and use the tools I have been taught over the past three and a half years I will be fine. My concern is usually about the supervisor that I get but as I have been told that I will have a great supervisor I feel much better about the rotation. I really can’t wait to get in there and start!
I have heard only good things about this placement from at least three people, some who have just attended the rotation and some that have been there in other years. Not only have they expressed their enjoyment about the work that they did and the patients that they saw, but also that the staff were friendly, passionate and very helpful. This gives me a feeling of confidence that it I put the effort into this placement I will reap the rewards of a successful and enjoyable learning experience.
Of course I am also feeling the usual nerves of starting at a new rotation and the expectations that they may have of me. It is a constant worry throughout this year as to whether you are meeting the high expectations of clinicians in the workforce to a graduate level by the end of the placement. It usually takes me the first week to feel comfortable in the new surroundings and with the new supervisors, so I will have to be patient. This will also be the first time that I will have a tutor, so this will bring a new dimension to the placement that I have never experienced before. I really have no idea what to expect in terms of the tutor as I have heard that they, like the supervisors, are all very different in their approach. I think I will just have to wait and see!
There is one thing that I am really looking forward to in this placement and that is seeing the various treatment techniques used. We were taught only a small selection of treatments in our neurology unit due to the large amount of treatment options available. I am really hoping that we are taught and shown some new techniques to use and that they can be added to our already eclectic tool box of neurological treatment techniques.
I have heard from past students that I will be working in the rehabilitation area rather than the acute neurology area. Patients will have mainly suffered from strokes and Parkinson’s disease and some other conditions such as multiple sclerosis may also present. I believe that the last two students there worked predominantly together, however they may be splitting us up this time as they would like to see how we work independently. I think that this plan will depend on the staffing availability in terms of supervision so it will be interesting to see what happens. I’m not sure as to the level of supervision there and how much we will be allowed to do independently. I am hoping for a lot more independence in this placement as I was supervised quite heavily in the last placement and I feel I don’t work my best having someone looking over my shoulder at all times.
I believe my role at the hospital will begin as a student therapist, a combination of observation of the clinicians, some observation of my skills and a small amount of independent treatment. I then think that the supervisor will gradually take away supervision until I am working at the level of a new graduate by the end of the placement. I think it is important that I emulate a skilled, independent therapist, but at the same time have respect for those with greater skills than I and treat them accordingly. I also need to remember that I am a guest in their workplace and to respect this fact at all times. Most of all I think my role is to learn and gain experience from this fantastic resource that I am so lucky to be a part of.
Overall I don’t really have any concerns about this placement as I have complete confidence that if I work hard and use the tools I have been taught over the past three and a half years I will be fine. My concern is usually about the supervisor that I get but as I have been told that I will have a great supervisor I feel much better about the rotation. I really can’t wait to get in there and start!
Sunday, March 14, 2010
Rotation 1 Fourth Year - Final Entry
I stated in my initial entry that I was both excited and slightly anxious about my upcoming placement at Armadale Hospital Outpatient department and on reflection this was an accurate description of my experience at Armadale. My placement was full of many highs as well as some lows.
I discussed the expectations of us as fourth years rising in comparison to past placements and this was very true. My first day on placement was the toughest of all. My supervisor quizzed me at every opportunity and I had a very hard time understanding the majority of his questions. Initially he was present with all of my patients and asked me questions in front of them. When I was unsure of the answers he offered no solutions, only silence. He also viewed spinal pain in a completely different way and asked that I learn his way and incorporate the Notre Dame way in with his. It was a very intense first day and a lot to handle. I went straight home and spent the night studying to try and keep up with his expectations.
On day two he started to quiz me on pathologies that we had learnt nothing or very little about at Notre Dame and was disappointed at my lack of knowledge. He told me at the end of week one that my knowledge of pathologies of the entire body must be complete by week 2 as well as practicing my hands on techniques as they were lacking confidence. I wasn’t sure if that was a task that could be accomplished over a weekend but I tried my hardest. By the end of the second week the quizzes turned to discussions, the questions in front of patients turned to learning opportunities, the criticism turned to pats on the back and the difference between our terminologies with spinal pain turned into an effective diagnostic algorithm. In the end I learnt more than I ever expected and the hard line he took with me only made me work harder. I believed at the start of the placement that if I left being confident and knowledgeable in the field that I would deem it a successful placement. Whilst it may have been tough, I do feel that I have left with the skills required as a graduate musculoskeletal physiotherapist and I therefore consider it a success. One thing that I did get wrong however is that my marks may drop, this is not true as the supervisors are marking us as new graduates not as experienced clinicians, so they were very fair in the marks and comments given.
I was very correct in my assessment of what was to come in the placement. My supervision did start at a high level and decrease as the placement went on. I was given a lot more room to make my own diagnostic and treatment decisions and these were rarely questioned as I learnt to express my clinical reasoning clearly and succinctly. I started by discussing my patients with my supervisor before seeing them and then going to my supervisor after my subjective assessment and objective assessment discussing each step of the process and then we discussed the patients response to treatment and the plan for them at the end of the day. By the end I went to my supervisor after my assessment to summarise my findings and my treatment plans and then he read my notes and countersigned them at the end of the day.
The second prediction I made was that I would see a variety of patients – from the usual TKR to the not so usual. This prediction was not so correct as I didn’t see any weird or wacky conditions, however I did see a large variety of patients. These included a large group of patients presenting with the same condition but a completely different treatment required and a large group of patients with very confusing presentations that made diagnosis very hard. It was great to see this variety as I learnt to also be on my toes and to never assume that I know what is wrong with a patient or that a recipe treatment will work for them.
One thing that was really driven home was the presence of chronic low back pain! I did predict this however not to the extent that I experienced at Armadale. It was intense, disabling and multifaceted and extremely challenging to treat. I found it extremely important to reinforce that the pain was not in their head and that they were not making it up. I was taught a few different methods of explaining chronic pain and central mediation as well as the effect of emotions on the pain experience. Dealing with living with pain forever and aiming at functioning with it was the hardest concept for patients to comprehend but with more and more education it was a concept they eventually understood.
My final prediction was that my subjective and objective skills would be at an expected level and that my clinical reasoning skills would improve as the placement progressed. My supervisor mentioned on day one that he was impressed with my subjective assessment and the only criticism I had of my objective assessment was that I needed to alter it according to the irritability of the patient, so I would say that my prediction was correct. In terms of clinical reasoning skills, I feel that I improved greatly from day one to my final day and my confidence in my skills also grew with them.
Overall, I have learnt a great deal from this placement. The first important lesson was the importance of a detailed subjective and objective assessment that lead to a clear and accurate diagnosis. If you have not reached a diagnosis by this stage you have not assessed the patient successfully and therefore will not be able to treat the patient successfully. The assessment must not stop until a diagnosis can be reached. With this comes the need to be continually changing your assessment to the patients presentation and not following an assessment recipe as this may lead to a lack of diagnosis.
The second lesson I learnt was to never assume what is wrong with the patient, what their goals are, how to treat them etc, simply never assume anything! It is important to always be on the ball and listening to the patient. One example is a TKR patient I had that was referred for continuation of his rehab post-op. I found out on his initial visit that his goal was to ride his Harley again, which required at least 120° of knee flexion with hip extension. My rehab focused on this above all other issues such as standard ROM and strength which played more of a secondary role in his treatment. On my last day he thanked me for focusing on his goal that he felt was within reach and stated that if I had focused on the other things as they did with his first TKR he would not have returned for treatment. This really drove home the importance of being flexible in all aspects of assessment of treatment or else you may not be successful or you may even lose patients.
My final lesson was to be confident in what you do know and to admit when you are unsure. Patients will only listen to you if you are confident in the treatment and education that you are delivering to them. It is important to be well informed and then confidently pass this information onto your patients. If you are unsure it is important to go away and check, using text books, available evidence or someone more informed than yourself and return back to the patient confident in what you are about to do.
In terms of learning experiences, this rotation has been fantastic and I hope that all of my rotations are as enlightening as this one has been.
I discussed the expectations of us as fourth years rising in comparison to past placements and this was very true. My first day on placement was the toughest of all. My supervisor quizzed me at every opportunity and I had a very hard time understanding the majority of his questions. Initially he was present with all of my patients and asked me questions in front of them. When I was unsure of the answers he offered no solutions, only silence. He also viewed spinal pain in a completely different way and asked that I learn his way and incorporate the Notre Dame way in with his. It was a very intense first day and a lot to handle. I went straight home and spent the night studying to try and keep up with his expectations.
On day two he started to quiz me on pathologies that we had learnt nothing or very little about at Notre Dame and was disappointed at my lack of knowledge. He told me at the end of week one that my knowledge of pathologies of the entire body must be complete by week 2 as well as practicing my hands on techniques as they were lacking confidence. I wasn’t sure if that was a task that could be accomplished over a weekend but I tried my hardest. By the end of the second week the quizzes turned to discussions, the questions in front of patients turned to learning opportunities, the criticism turned to pats on the back and the difference between our terminologies with spinal pain turned into an effective diagnostic algorithm. In the end I learnt more than I ever expected and the hard line he took with me only made me work harder. I believed at the start of the placement that if I left being confident and knowledgeable in the field that I would deem it a successful placement. Whilst it may have been tough, I do feel that I have left with the skills required as a graduate musculoskeletal physiotherapist and I therefore consider it a success. One thing that I did get wrong however is that my marks may drop, this is not true as the supervisors are marking us as new graduates not as experienced clinicians, so they were very fair in the marks and comments given.
I was very correct in my assessment of what was to come in the placement. My supervision did start at a high level and decrease as the placement went on. I was given a lot more room to make my own diagnostic and treatment decisions and these were rarely questioned as I learnt to express my clinical reasoning clearly and succinctly. I started by discussing my patients with my supervisor before seeing them and then going to my supervisor after my subjective assessment and objective assessment discussing each step of the process and then we discussed the patients response to treatment and the plan for them at the end of the day. By the end I went to my supervisor after my assessment to summarise my findings and my treatment plans and then he read my notes and countersigned them at the end of the day.
The second prediction I made was that I would see a variety of patients – from the usual TKR to the not so usual. This prediction was not so correct as I didn’t see any weird or wacky conditions, however I did see a large variety of patients. These included a large group of patients presenting with the same condition but a completely different treatment required and a large group of patients with very confusing presentations that made diagnosis very hard. It was great to see this variety as I learnt to also be on my toes and to never assume that I know what is wrong with a patient or that a recipe treatment will work for them.
One thing that was really driven home was the presence of chronic low back pain! I did predict this however not to the extent that I experienced at Armadale. It was intense, disabling and multifaceted and extremely challenging to treat. I found it extremely important to reinforce that the pain was not in their head and that they were not making it up. I was taught a few different methods of explaining chronic pain and central mediation as well as the effect of emotions on the pain experience. Dealing with living with pain forever and aiming at functioning with it was the hardest concept for patients to comprehend but with more and more education it was a concept they eventually understood.
My final prediction was that my subjective and objective skills would be at an expected level and that my clinical reasoning skills would improve as the placement progressed. My supervisor mentioned on day one that he was impressed with my subjective assessment and the only criticism I had of my objective assessment was that I needed to alter it according to the irritability of the patient, so I would say that my prediction was correct. In terms of clinical reasoning skills, I feel that I improved greatly from day one to my final day and my confidence in my skills also grew with them.
Overall, I have learnt a great deal from this placement. The first important lesson was the importance of a detailed subjective and objective assessment that lead to a clear and accurate diagnosis. If you have not reached a diagnosis by this stage you have not assessed the patient successfully and therefore will not be able to treat the patient successfully. The assessment must not stop until a diagnosis can be reached. With this comes the need to be continually changing your assessment to the patients presentation and not following an assessment recipe as this may lead to a lack of diagnosis.
The second lesson I learnt was to never assume what is wrong with the patient, what their goals are, how to treat them etc, simply never assume anything! It is important to always be on the ball and listening to the patient. One example is a TKR patient I had that was referred for continuation of his rehab post-op. I found out on his initial visit that his goal was to ride his Harley again, which required at least 120° of knee flexion with hip extension. My rehab focused on this above all other issues such as standard ROM and strength which played more of a secondary role in his treatment. On my last day he thanked me for focusing on his goal that he felt was within reach and stated that if I had focused on the other things as they did with his first TKR he would not have returned for treatment. This really drove home the importance of being flexible in all aspects of assessment of treatment or else you may not be successful or you may even lose patients.
My final lesson was to be confident in what you do know and to admit when you are unsure. Patients will only listen to you if you are confident in the treatment and education that you are delivering to them. It is important to be well informed and then confidently pass this information onto your patients. If you are unsure it is important to go away and check, using text books, available evidence or someone more informed than yourself and return back to the patient confident in what you are about to do.
In terms of learning experiences, this rotation has been fantastic and I hope that all of my rotations are as enlightening as this one has been.
Rotation 1 Fourth Year - Communication STARES
Situation
A 47 year old man was referred to outpatient physiotherapy at Armadale Hospital two months post a MVA where he sustained a neck injury. The car in front of him suddenly braked and he went into the back of it. He did not present to his GP for treatment until one month after the accident, he reported this was due to running out of the strong pain medication he had at home after previous surgeries. He didn’t have any insurance claims pending and there appeared to be no red or yellow flags.
Task
I was asked in the referral letter to assess and treat him accordingly.
Action
From the subjective assessment I found that the patient had a very long history of lumbar, thoracic and cervical pain and had cervical surgery two years previously. Whilst the cervical surgery minimally resolved all of the pains (thoracic and lumbar included), it was the MVA that brought all of the pains back again to intense levels. He did not know what would help to relieve his pain or what goals he had for physiotherapy as he believed this was the duty of the doctor and the physiotherapists to decide for him. He also had a very passive attitude to treatment. On objective examination he had widespread pain all over the back and he was unable to distinguish which pain was worse than the other. All movements of each part of the spine caused equal amounts of pain.
I therefore diagnosed the man with centrally dominant chronic back and neck pain and set out to educate him accordingly. I explained central mediation and its relationship to chronic back pain. I explained the impact the brain has on the pain experience. I explained that if it was just the injuries that were causing his pain, the surgery would have completely resolved his pain, however, it didn’t. I also explained that he may never be pain free and that working towards functioning with the pain may be a more realistic goal than being pain free. He said that he understood what I was saying and was happy to start an exercise program working towards functioning with the pain. I gave him some simple exercises staying early in range as he said that these were pain free and asked him to think about what his goals were to tell me when he returned the next week.
When the patient returned I asked him how he was feeling and how his week had been. He spoke about how bad the pain was and how nothing he did seemed to ease the pain. He expressed his frustration at not being pain free and that the exercises were doing nothing to ease the pain. I again reiterated everything from the week before, making sure that at the end of each point he understood what I was saying. I asked him to explain what I had said in his own words to ensure that he understood. He repeated what I had said and that he understood it all. I progressed the exercises and we went to make an appointment for the next week.
After ten minutes in the waiting room whilst waiting for his wife to pick him up he came to find me in the office. He explained that he did not want to return for the same thing the next week. I asked him if he meant that he would like to be discharged, he said no, that he would like ‘proper physiotherapy’. I asked him what he meant by this and he stated that he was in pain and that I should be able to fix the pain. I told him that I had already explained his pain to him and that he had told me he understood. I again asked him if he understood and he said he understood but that the pain was not in his head and he would like to speak to my supervisor. I said that I would be happy to get my supervisor for him and went to find him. My supervisor and I had a discussion away from the patient and he said that he agreed with me 100% and came with me to discuss this with the patient. I had to leave as I had another patient booked in, but my supervisor discussed the issues with the patient and reported back to me afterwards.
Result
My supervisor told me later that the patient would agree with what he said and then come back with the same issue that he had pain and we weren’t helping him get rid of it. My supervisor decided that the conversation was going around in circles and made an appointment with the patient for a week later. A week later it was revealed that the patients GP and surgeon felt the same way as I did and had already referred the patient to pain management, however, they had not explained to the patient why. My supervisor continued the education and eventually the patient understood. It was therefore decided by both the patient and my supervisor that pain management was the best route for him and he would be discharged from physiotherapy.
Evaluation
This situation really taught me about the polite patient effect and the importance of reading body language as well as verbal language. The patient was just agreeing with me to be polite although he really had very little understanding of the situation or what I was trying to tell him. I was also working against the doctors telling him that surgery would help him and then when it didn’t help not explaining why to him. Whilst the patient was saying that he understood something about his eye contact told me that he didn’t understand which is why I kept asking him if he did and to explain it back to me.
In the end there were also cultural issues affecting the situation and I should have had that in mind when I first met the patient. He was Middle Eastern, and culturally they have high respect for doctors, hierarchy and men. I fit none of these categories and so I was in a bad position to begin with. At least my supervisor was male and the head of physiotherapy outpatients so he had something to back him up in the eyes of the patient.
While I feel that I did my best in this situation and there were a lot of factors that I could not change I would definitely read his body language over his verbal language and try to explain the issues in a different way over and over until the patient understands. Chronic pain is a very hard concept to explain to patients - especially centrally mediated chronic pain – but I feel that as I went through the five weeks of rotation my explanation became simpler, clearer and more confident.
Strategies
I feel that if I am faced by this situation again I would book another appointment with the patient, but have my supervisor (or someone else) present to back me up. I think it showed a lack of conviction on my part to pass the patient on to my supervisor. However, cultural issues must be treated with sensitivity, so it was possibly the best solution that the patient ended up with the male head of department. Getting in touch with someone who understands the culture well and could point you in the right direction for successful treatment would definitely be something to consider in the future. Finally, a strategy that was put in by the end of my rotation was a series of information sheets that explain chronic pain and central mediation were put together to aid in the explanation and also for the patient to take home with them.
A 47 year old man was referred to outpatient physiotherapy at Armadale Hospital two months post a MVA where he sustained a neck injury. The car in front of him suddenly braked and he went into the back of it. He did not present to his GP for treatment until one month after the accident, he reported this was due to running out of the strong pain medication he had at home after previous surgeries. He didn’t have any insurance claims pending and there appeared to be no red or yellow flags.
Task
I was asked in the referral letter to assess and treat him accordingly.
Action
From the subjective assessment I found that the patient had a very long history of lumbar, thoracic and cervical pain and had cervical surgery two years previously. Whilst the cervical surgery minimally resolved all of the pains (thoracic and lumbar included), it was the MVA that brought all of the pains back again to intense levels. He did not know what would help to relieve his pain or what goals he had for physiotherapy as he believed this was the duty of the doctor and the physiotherapists to decide for him. He also had a very passive attitude to treatment. On objective examination he had widespread pain all over the back and he was unable to distinguish which pain was worse than the other. All movements of each part of the spine caused equal amounts of pain.
I therefore diagnosed the man with centrally dominant chronic back and neck pain and set out to educate him accordingly. I explained central mediation and its relationship to chronic back pain. I explained the impact the brain has on the pain experience. I explained that if it was just the injuries that were causing his pain, the surgery would have completely resolved his pain, however, it didn’t. I also explained that he may never be pain free and that working towards functioning with the pain may be a more realistic goal than being pain free. He said that he understood what I was saying and was happy to start an exercise program working towards functioning with the pain. I gave him some simple exercises staying early in range as he said that these were pain free and asked him to think about what his goals were to tell me when he returned the next week.
When the patient returned I asked him how he was feeling and how his week had been. He spoke about how bad the pain was and how nothing he did seemed to ease the pain. He expressed his frustration at not being pain free and that the exercises were doing nothing to ease the pain. I again reiterated everything from the week before, making sure that at the end of each point he understood what I was saying. I asked him to explain what I had said in his own words to ensure that he understood. He repeated what I had said and that he understood it all. I progressed the exercises and we went to make an appointment for the next week.
After ten minutes in the waiting room whilst waiting for his wife to pick him up he came to find me in the office. He explained that he did not want to return for the same thing the next week. I asked him if he meant that he would like to be discharged, he said no, that he would like ‘proper physiotherapy’. I asked him what he meant by this and he stated that he was in pain and that I should be able to fix the pain. I told him that I had already explained his pain to him and that he had told me he understood. I again asked him if he understood and he said he understood but that the pain was not in his head and he would like to speak to my supervisor. I said that I would be happy to get my supervisor for him and went to find him. My supervisor and I had a discussion away from the patient and he said that he agreed with me 100% and came with me to discuss this with the patient. I had to leave as I had another patient booked in, but my supervisor discussed the issues with the patient and reported back to me afterwards.
Result
My supervisor told me later that the patient would agree with what he said and then come back with the same issue that he had pain and we weren’t helping him get rid of it. My supervisor decided that the conversation was going around in circles and made an appointment with the patient for a week later. A week later it was revealed that the patients GP and surgeon felt the same way as I did and had already referred the patient to pain management, however, they had not explained to the patient why. My supervisor continued the education and eventually the patient understood. It was therefore decided by both the patient and my supervisor that pain management was the best route for him and he would be discharged from physiotherapy.
Evaluation
This situation really taught me about the polite patient effect and the importance of reading body language as well as verbal language. The patient was just agreeing with me to be polite although he really had very little understanding of the situation or what I was trying to tell him. I was also working against the doctors telling him that surgery would help him and then when it didn’t help not explaining why to him. Whilst the patient was saying that he understood something about his eye contact told me that he didn’t understand which is why I kept asking him if he did and to explain it back to me.
In the end there were also cultural issues affecting the situation and I should have had that in mind when I first met the patient. He was Middle Eastern, and culturally they have high respect for doctors, hierarchy and men. I fit none of these categories and so I was in a bad position to begin with. At least my supervisor was male and the head of physiotherapy outpatients so he had something to back him up in the eyes of the patient.
While I feel that I did my best in this situation and there were a lot of factors that I could not change I would definitely read his body language over his verbal language and try to explain the issues in a different way over and over until the patient understands. Chronic pain is a very hard concept to explain to patients - especially centrally mediated chronic pain – but I feel that as I went through the five weeks of rotation my explanation became simpler, clearer and more confident.
Strategies
I feel that if I am faced by this situation again I would book another appointment with the patient, but have my supervisor (or someone else) present to back me up. I think it showed a lack of conviction on my part to pass the patient on to my supervisor. However, cultural issues must be treated with sensitivity, so it was possibly the best solution that the patient ended up with the male head of department. Getting in touch with someone who understands the culture well and could point you in the right direction for successful treatment would definitely be something to consider in the future. Finally, a strategy that was put in by the end of my rotation was a series of information sheets that explain chronic pain and central mediation were put together to aid in the explanation and also for the patient to take home with them.
Sunday, February 28, 2010
Rotation 1 Fourth Year - Evidence Based Practice STARES
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.
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.
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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