I am very happy to say that my placement at Hollywood hospital in neurological rehabilitation was exactly as I had hoped it would be in my initial entry. I thoroughly enjoyed working in the area with the wide variety of presentations appearing right in front of me instead of just a description in a lecture or a book. It has definitely confirmed my passion in this area and I would be happy to work in an area like this when I graduate.
Students who had previously been placed at Hollywood hospital told me that the staff were friendly, caring and very involved in the rehabilitation of their patients. This was also my experience. We were given a few days to follow our supervisor and other staff members around where we were able to jump in if we felt comfortable or just stand back and learn from their years of experience. After that the supervision was slowly taken away and we were left with a high level of autonomy. If however, we felt unsure or needed questions answered there was always someone willing to help us out.
Expectations throughout the placement slowly increased, but they were always clearly stated. Completing two SOAPIERS over the five week placement allowed our supervisor to assess our clinical reasoning skills and give us valuable feedback. Also, my first experience with a Notre Dame tutor allowed for greater feedback and more one-on-one teaching. It was a fantastic learning experience to assess and treat patients with someone with such a varied outlook on physiotherapy and a wealth of knowledge and experience. It is something I looked forward to every week.
I was very excited to experience new treatment techniques on this placement as our treatment toolbox from Notre Dame was limited in comparison to the treatment options available, and I was not disappointed. Between my supervisor and my clinical tutor I was taught a myriad of treatment techniques for such a large variety of patient presentations. I now feel that I can come up with some of my own treatments, but that I have a lot of learning to do once I graduate if I want to have the experience and knowledge required for a career ion neurological physiotherapy. The staff were so open to seeing the techniques that we knew, as well as open to teaching us the techniques they thought most suitable. I was very impressed with the fact that everyone here appears to be as eclectic as we are at Notre Dame, as I believe it results in the best treatment for patients.
The placement wasn’t structured exactly as I thought initially. We were given patients both in the acute neurological and neurological rehabilitation wards. Some of our patients were shared while others were given to us separately. Most of our patients had suffered from strokes, Parkinson’s disease or Guillain Barre and the different presentations of the patients allowed us to gain a good clinical picture of the possible stages, types and severity of each of the conditions. I feel that I have gained a lot of confidence in the area of neurological physiotherapy because of the mix of patients we were able to see which I believe is an invaluable tool for when I go out into the workplace.
I feel that my confidence in my observation, assessment, communication and clinical reasoning skills have grown hugely in this placement and I believe this will not just help me move forward in the area of neurological physiotherapy, but will carry over into other areas, other placement and hopefully into my career. I have learnt the importance of continual education, as without learning new skills and treatment tools I will not be able to work successfully as a neurological physiotherapist, or as any type of physiotherapist. I have also learnt the importance of good communication with patients coupled with n understanding of the patient as a person. Without knowing your patient holistically you cannot achieve those goals that they find most important and in neurological conditions these are generally very important skills such as bed mobility, ambulation or balance. Discharge planning is a huge part of neurological physiotherapy and of utmost importance. Sending a patient home without the proper services, skills or knowledge could quite easily see them back in hospital days, weeks or months after discharge in a much worse condition. However, the most important skill I have learnt is to be creative. If you are clear about what deficits a patient has and the goal they would like to reach you can think outside the box in order to reach that goal and it is generally in this way that patients reach their full potential.
Overall I have gained a lot from this rotation and am very glad to have been placed here. I feel that it has consolidated a lot of my skills and I hope that this caries through to my next rotation and into the future.
Saturday, June 12, 2010
Wednesday, June 2, 2010
Rotation 3 Fourth Year - Discharge Planning STARES
Situation
An 89 year old man was admitted to Hollywood Private Hospital on the 17/5/10 after a CVA – a left LACS. We were not introduced to the gentleman until the 20/5/10 where he had been to SCGH ED, and transferred to Hollywood Private Hospital. He already had a physiotherapist looking after him, so he was just an interesting case for us to look at until he was transferred down to the rehab ward. Due to other complications with his heart and multiple falls he was having he was a hard man to get in to see and his physiotherapy care could be described as intermittent at best. Once he was stabilised he was sent to rehab ward and was officially a patient of mine.
Task
My task was to assess and treat this patient accordingly.
Action
I decided to do a full initial assessment on the patient as my knowledge of his impairments and social situation was patchy at best. On initial assessment he appeared to have minor right-sided weakness of the UL and LL and some cognitive and perceptual deficits, namely agnosia and dyspraxia. His Berg Balance score was 49/56 with all of his scores being a 3 or a 4 except for single leg stance where he received a 1. He appeared to lose his balance with functional tasks such as dressing and leaned to the right with ambulation. He ambulated with no aids and only supervision for ~80m. I decided to focus his treatment on improving his balance and his awareness of his impairments, especially during functional tasks. He was progressing very well, with his Berg Balance score increasing to 53/56, he was able to keep his balance during functional tasks, he understood that his balance was not great and not admitted so and he had no more falls.
I had taken a social history initially, finding that the patient lived with his wife and they shared most of the tasks around the house. They lived in a retirement village with services and amenities at their doorstep and no stairs at all. He also has 3 very supportive children to help him out. I was very happy with him going home as long as he was supervised at all times and there were services put in place to assist him where needed. The discharge planning at Hollywood Hospital is a multidisciplinary process – generally. However, every now and again a doctor will decide to discharge a patient without input from the nursing or allied health teams. In this case I was convinced that the doctor and social worker were clear on his limitations however, the doctor decided that the patient would be discharged in two days, didn’t tell the patient or the family and had not organised the social worker to discuss the issues related to discharge planning.
When visiting the patient that day one of the nurses mentioned that he was going to be discharged in two days time thinking that the family was aware of the fact. The family were irate, and quite understandably. They demanded a family meeting to discuss the issues and I was able to put forth my opinion on his status and what he required.
Result
In the end it was decided that the patient would go back to his house with his wife and services for meals, cleaning and outpatient physiotherapy. The family was very happy with the outcome as were the medical and allied health teams.
Evaluation
This situation really highlighted the need for appropriate and timely discharge planning that includes every member of the team involved in the care of the patient. A family meeting should have been organised within 7 days of the stroke to discuss with the patient’s family what has happened, what his impairments are, the prognosis and what the plan is for moving forward. This would keep the family involved and informed and would help them in motivating the patient to reach their goals.
Another family meeting should also occur a week or so prior to discharge to discuss issues such as the patient’s discharge destination, the services they require, the skills they need to function once they have left and any ongoing issues either the family or the medical team have in regards to the patient.
This situation also made me realise the need to be on the ball with patient’s care. It is not good enough for me to assume that the doctor is listening to me in the meetings and leave it at that, but instead I need to be questioning them about their intentions for discharge and what they have in place for the patient. This is the second time that the allied health team has had to put their foot down and not allow a patient to be discharged and both times I believe the patient was much better off because of it.
Strategies
As I said above, I believe that it is important that communication between the patient, family, medical team and allied health team is open and regular and that each issue a party has to bring to the table is discussed fully and resolved appropriately. A formal discharge planning/family meeting timeline for stroke should be put in place as this would ensure that everyone is kept informed and all issues are resolved when they need to be.
An 89 year old man was admitted to Hollywood Private Hospital on the 17/5/10 after a CVA – a left LACS. We were not introduced to the gentleman until the 20/5/10 where he had been to SCGH ED, and transferred to Hollywood Private Hospital. He already had a physiotherapist looking after him, so he was just an interesting case for us to look at until he was transferred down to the rehab ward. Due to other complications with his heart and multiple falls he was having he was a hard man to get in to see and his physiotherapy care could be described as intermittent at best. Once he was stabilised he was sent to rehab ward and was officially a patient of mine.
Task
My task was to assess and treat this patient accordingly.
Action
I decided to do a full initial assessment on the patient as my knowledge of his impairments and social situation was patchy at best. On initial assessment he appeared to have minor right-sided weakness of the UL and LL and some cognitive and perceptual deficits, namely agnosia and dyspraxia. His Berg Balance score was 49/56 with all of his scores being a 3 or a 4 except for single leg stance where he received a 1. He appeared to lose his balance with functional tasks such as dressing and leaned to the right with ambulation. He ambulated with no aids and only supervision for ~80m. I decided to focus his treatment on improving his balance and his awareness of his impairments, especially during functional tasks. He was progressing very well, with his Berg Balance score increasing to 53/56, he was able to keep his balance during functional tasks, he understood that his balance was not great and not admitted so and he had no more falls.
I had taken a social history initially, finding that the patient lived with his wife and they shared most of the tasks around the house. They lived in a retirement village with services and amenities at their doorstep and no stairs at all. He also has 3 very supportive children to help him out. I was very happy with him going home as long as he was supervised at all times and there were services put in place to assist him where needed. The discharge planning at Hollywood Hospital is a multidisciplinary process – generally. However, every now and again a doctor will decide to discharge a patient without input from the nursing or allied health teams. In this case I was convinced that the doctor and social worker were clear on his limitations however, the doctor decided that the patient would be discharged in two days, didn’t tell the patient or the family and had not organised the social worker to discuss the issues related to discharge planning.
When visiting the patient that day one of the nurses mentioned that he was going to be discharged in two days time thinking that the family was aware of the fact. The family were irate, and quite understandably. They demanded a family meeting to discuss the issues and I was able to put forth my opinion on his status and what he required.
Result
In the end it was decided that the patient would go back to his house with his wife and services for meals, cleaning and outpatient physiotherapy. The family was very happy with the outcome as were the medical and allied health teams.
Evaluation
This situation really highlighted the need for appropriate and timely discharge planning that includes every member of the team involved in the care of the patient. A family meeting should have been organised within 7 days of the stroke to discuss with the patient’s family what has happened, what his impairments are, the prognosis and what the plan is for moving forward. This would keep the family involved and informed and would help them in motivating the patient to reach their goals.
Another family meeting should also occur a week or so prior to discharge to discuss issues such as the patient’s discharge destination, the services they require, the skills they need to function once they have left and any ongoing issues either the family or the medical team have in regards to the patient.
This situation also made me realise the need to be on the ball with patient’s care. It is not good enough for me to assume that the doctor is listening to me in the meetings and leave it at that, but instead I need to be questioning them about their intentions for discharge and what they have in place for the patient. This is the second time that the allied health team has had to put their foot down and not allow a patient to be discharged and both times I believe the patient was much better off because of it.
Strategies
As I said above, I believe that it is important that communication between the patient, family, medical team and allied health team is open and regular and that each issue a party has to bring to the table is discussed fully and resolved appropriately. A formal discharge planning/family meeting timeline for stroke should be put in place as this would ensure that everyone is kept informed and all issues are resolved when they need to be.
Monday, May 24, 2010
Rotation 3 Fourth Year - Evidence Based Practice STARES
Situation
A 61 year old man was admitted to Hollywood Private Hospital rehabilitation ward for two weeks elective respite and rehabilitation. He presented with a 21 month history of severe Guillain Barre Syndrome, post-infection in July 2008.
He had spent 7 months in Sir Charles Gardener Hospital initially where he was intubated 6 days post the onset of his symptoms and remained so until January of 2009. He had lost complete use of his upper and lower limbs until September 2008 when he regained a minimal amount of strength. He was completely dependent for all activities of daily living and experienced a number of pulmonary complications during this time including pneumonia and a pulmonary embolism.
In February 2009 he was transferred to Shenton Park where he underwent extensive rehabilitation. It was during this time that he regained a large amount of strength and functional ability. When he was discharged in September 2009 he had independent bed mobility, x2 assist sit-to-stand and step-stand transfer and could operate an electric wheelchair independently. He had very little use of his upper limbs due to decreased strength in his arms and minimal use of his hands due to contractures at the fingers and weakness. He was however able to eat independently and use a modified computer set-up independently.
Currently he is receiving private physiotherapy twice a week (neurological and musculoskeletal) and attending Shenton Park outpatient department physiotherapy twice a week. He also receives private OT and help with showering and toileting twice daily from an outside carer. All other care is provided by his wife.
To give his wife a break he elected to spend 2 weeks at Hollywood Private Hospital where he felt he could also have intensive physiotherapy rehabilitation as well.
Task
My task was to assess and treat this patient accordingly.
Action
This patient had two main goals; to walk independently with an aid ~15m in his home and to regain the use of his upper limb to decrease his dependence on people with his activities of daily living. I therefore focused my treatment towards these goals. Whilst I did do some treatment to assist with his upper limb function, I decided to focus on his goal of ambulation, as he had recently begun to ambulate x2 maximum assistance at Shenton Park outpatient department.
Whilst ambulating the patient with 2 therapists we noticed how cumbersome and dangerous the task was. The patient weighed over 100kg and was very unpredictable in the way in which he moved his weight around. This was due mainly to his lack of core and hip stability. It was therefore important to find a task-specific treatment method for this patient that maintained the safety of the therapists involved. It was important that whilst safety was a high priority, the treatment of the patient was as specific as possible.
In my research I found the article:
Tuckey, J., Greenwood, R. (2004) ‘Rehabilitation after severe Guillain-Barré syndrome: the use of partial body weight support’. Physiotherapy Research International. 9 (2), 96-103.
It is a case report outlining the use of partial body weight support treadmill training in a man with severe chronic Guillain Barre Syndrome. It uses the evidence supporting partial body weight support (PBWS) treadmill training in other clinical populations such as stroke and spinal injury to justify its use in Guillain Barre and then follows the rehabilitation of this man to show its usefulness.
It outlines the fact that PBWS could allow task-specific gait training for patients in which purely therapist assisted ambulation is too cumbersome and poses a manual handling risk. This was especially poignant for our patient as he had decreased core stability which didn’t allow him to focus on the motor sequence of gait and the activation of his lower limb muscles. It also allowed the therapist to facilitate muscle activation instead of focusing on maintaining the patient upright and on balance.
It was then decided after a week of treatment focusing on his core and hip stability that the second week would include daily sessions on the PBWS treadmill system. It did take some trial and error, especially with the timing of the session as the patient was too fatigued for his treatment in the afternoon if he had been on the treadmill in the morning. Different facilitation methods were trialled but eventually it was found that one therapist was required at the trunk to facilitate trunk stability and weight transfer and one therapist was required at each leg to facilitate gluteal activation and knee extension.
Result
By the end of the two weeks, both on and off the treadmill, the patient was walking with improved core and hip stability, less trendelenburg signs in stance, less adduction of the leg in swing phase, larger stride length and a more rhythmical cadence. Whilst his dependence on the therapists during off-treadmill ambulation was still the same his gait pattern was greatly improved.
The patient also felt much more confident and a lot happier with his walking pattern and the psychological benefits of getting closer to his goal was definitely evident.
Evaluation
It is a hard balance to determine if low level evidence is reliable or not, especially in a clinical population as small as Guillain-Barre. However I think that it is important to extrapolate from evidence those benefits they may be useful for your patients and think outside the box. I believe that even if the case report did not exist I still would have chosen the PBWS treadmill training as a treatment due to strong evidence for task-specific training and the added benefits it gave in terms of safety of the patient and therapists and the ability to facilitate gait much more thoroughly than off the treadmill.
My one concern is that it was only one week of training and he may loose those benefits quite quickly. It has been shown that training such as this requires a program of at least six weeks for any long-term benefit, so the improvement may be short lived.
It may however open the door for Shenton Park or one of his private physiotherapists to offer the same treatment to him on a regular basis. I have sent a discharge letter to them to let them know what treatment the patient did receive here during his stay.
Strategies
I think the most important strategy here is to think outside the box and always remember that ‘a lack of evidence is not evidence of lack’ as people commonly say. If you can clinically reason a treatment choice that has been shown to help in another clinical population then there is no harm in trying as long as there is no risk to you or the patient. The evidence out there really did help to guide my treatment choice and made it an informed and reasoned one. It really does enforce the need to stay on top of the evidence once we have graduated and are out in the real world.
A 61 year old man was admitted to Hollywood Private Hospital rehabilitation ward for two weeks elective respite and rehabilitation. He presented with a 21 month history of severe Guillain Barre Syndrome, post-infection in July 2008.
He had spent 7 months in Sir Charles Gardener Hospital initially where he was intubated 6 days post the onset of his symptoms and remained so until January of 2009. He had lost complete use of his upper and lower limbs until September 2008 when he regained a minimal amount of strength. He was completely dependent for all activities of daily living and experienced a number of pulmonary complications during this time including pneumonia and a pulmonary embolism.
In February 2009 he was transferred to Shenton Park where he underwent extensive rehabilitation. It was during this time that he regained a large amount of strength and functional ability. When he was discharged in September 2009 he had independent bed mobility, x2 assist sit-to-stand and step-stand transfer and could operate an electric wheelchair independently. He had very little use of his upper limbs due to decreased strength in his arms and minimal use of his hands due to contractures at the fingers and weakness. He was however able to eat independently and use a modified computer set-up independently.
Currently he is receiving private physiotherapy twice a week (neurological and musculoskeletal) and attending Shenton Park outpatient department physiotherapy twice a week. He also receives private OT and help with showering and toileting twice daily from an outside carer. All other care is provided by his wife.
To give his wife a break he elected to spend 2 weeks at Hollywood Private Hospital where he felt he could also have intensive physiotherapy rehabilitation as well.
Task
My task was to assess and treat this patient accordingly.
Action
This patient had two main goals; to walk independently with an aid ~15m in his home and to regain the use of his upper limb to decrease his dependence on people with his activities of daily living. I therefore focused my treatment towards these goals. Whilst I did do some treatment to assist with his upper limb function, I decided to focus on his goal of ambulation, as he had recently begun to ambulate x2 maximum assistance at Shenton Park outpatient department.
Whilst ambulating the patient with 2 therapists we noticed how cumbersome and dangerous the task was. The patient weighed over 100kg and was very unpredictable in the way in which he moved his weight around. This was due mainly to his lack of core and hip stability. It was therefore important to find a task-specific treatment method for this patient that maintained the safety of the therapists involved. It was important that whilst safety was a high priority, the treatment of the patient was as specific as possible.
In my research I found the article:
Tuckey, J., Greenwood, R. (2004) ‘Rehabilitation after severe Guillain-Barré syndrome: the use of partial body weight support’. Physiotherapy Research International. 9 (2), 96-103.
It is a case report outlining the use of partial body weight support treadmill training in a man with severe chronic Guillain Barre Syndrome. It uses the evidence supporting partial body weight support (PBWS) treadmill training in other clinical populations such as stroke and spinal injury to justify its use in Guillain Barre and then follows the rehabilitation of this man to show its usefulness.
It outlines the fact that PBWS could allow task-specific gait training for patients in which purely therapist assisted ambulation is too cumbersome and poses a manual handling risk. This was especially poignant for our patient as he had decreased core stability which didn’t allow him to focus on the motor sequence of gait and the activation of his lower limb muscles. It also allowed the therapist to facilitate muscle activation instead of focusing on maintaining the patient upright and on balance.
It was then decided after a week of treatment focusing on his core and hip stability that the second week would include daily sessions on the PBWS treadmill system. It did take some trial and error, especially with the timing of the session as the patient was too fatigued for his treatment in the afternoon if he had been on the treadmill in the morning. Different facilitation methods were trialled but eventually it was found that one therapist was required at the trunk to facilitate trunk stability and weight transfer and one therapist was required at each leg to facilitate gluteal activation and knee extension.
Result
By the end of the two weeks, both on and off the treadmill, the patient was walking with improved core and hip stability, less trendelenburg signs in stance, less adduction of the leg in swing phase, larger stride length and a more rhythmical cadence. Whilst his dependence on the therapists during off-treadmill ambulation was still the same his gait pattern was greatly improved.
The patient also felt much more confident and a lot happier with his walking pattern and the psychological benefits of getting closer to his goal was definitely evident.
Evaluation
It is a hard balance to determine if low level evidence is reliable or not, especially in a clinical population as small as Guillain-Barre. However I think that it is important to extrapolate from evidence those benefits they may be useful for your patients and think outside the box. I believe that even if the case report did not exist I still would have chosen the PBWS treadmill training as a treatment due to strong evidence for task-specific training and the added benefits it gave in terms of safety of the patient and therapists and the ability to facilitate gait much more thoroughly than off the treadmill.
My one concern is that it was only one week of training and he may loose those benefits quite quickly. It has been shown that training such as this requires a program of at least six weeks for any long-term benefit, so the improvement may be short lived.
It may however open the door for Shenton Park or one of his private physiotherapists to offer the same treatment to him on a regular basis. I have sent a discharge letter to them to let them know what treatment the patient did receive here during his stay.
Strategies
I think the most important strategy here is to think outside the box and always remember that ‘a lack of evidence is not evidence of lack’ as people commonly say. If you can clinically reason a treatment choice that has been shown to help in another clinical population then there is no harm in trying as long as there is no risk to you or the patient. The evidence out there really did help to guide my treatment choice and made it an informed and reasoned one. It really does enforce the need to stay on top of the evidence once we have graduated and are out in the real world.
Friday, May 14, 2010
Rotation 3 Fourth Year - Assessment STARES
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.
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.
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.
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