In my first week of musculo out pts i had a pt referred from a regional hospital for chronic LBP. On subjective Ax, this was only a piece of the puzzle with pain down the (R) leg to her foot, severe cervical/thoracic pain and a recent shoulder reconstruction causing pain and AROM limitations. Most of the subjective questioning was open and the pt reported that most of the pain was from the cervical/throacic region. These were the most prominent symptoms so activities that brought these on were detailed, while she seemed to dismiss her LBP. On checking with my tutor, due to the LBP referral, this must be the focus of Ax and Rx, and if the other areas need Rx a further referral is needed.
When i returned to my pt and informed her that her LBP must be the focus of this Rx, she accepted this and gave me more details on her low back pain. During the objective Ax and Rx there was no further mention of any Cx or Tx pain, and her shoulder was holding up well. It seemed that as I put my focus on the LBP, so did she and any other pain seemed insignificant. As Rx was on the lumbar spine, post Rx she had greater range and less pain in this area.
This was interesting as the lumbar pain was insignificant at initial Ax, then was the main complaint when she was told it had to be. She also reported that her pain had been worse since she had time off work to recover. I believe as she was not at work she spent most of the day concerned with her pain, while at work she would be pre occupied. Prior to this encounter i didnt realise the effect of focussing on pain and the reinforcing effect it can have. I think for future encounters it will be worthwhile even encorporating some distracting activites in the home exercise programme.
Monday, June 30, 2008
Sunday, June 29, 2008
Appropriateness of expletives
Recently on muscuko outpatients prac I treated an elderly lady with low back pain which was moderately irritable. This was the first time I had seen this patient as she was a transfer from another physio. She's quite a lovely lady and I don't think she meant anything by what she said, it was just her way of dealing with the situation.
I began my objective assessment as usual; observing gait, AROM, palpation, trigger points, PPIVMS/PAIVMS and checked for pain and/or stiffness as I went through. Initially she was fine but when we got to palpation, PPIVMS and PAIVMs that's when the drama started. At first the swearing was just muttered quietly under her breath but then every time she felt a little bit of pain she'd scream out and then add in a few expletives for good measure. This was particularly the case with trigger point release, as you can imagine. It wasn't necessarily what she said either but it was the fact that it was quite loud. We aren't in treatment rooms either, the cubicles are only separated by curtins so all the other patients and treating physios were subject to her verbal display. It was when she got louder that I began to feel a bit awkward so I asked her if she wanted me to stop because I didn't want to make her pain worse but she told me to keep going and it didn't hurt that much.
I was actually a little confused as to what to do? Do I keep going with Rx and allow her to swear or do I change tact and try something different even after the patient asked me to keep going with my original Rx? I was concernend about what other patients would think after listening to this patient?
I decided to change Rx and go through her HEP which hopefully would be less provocative (thankfully it was!!). Then I went back to mob's and TP's and she had settled down little bit as well.
This experience was quite awkward to deal with and if she had started yelling when I returned to mob's and TP's the second time I would have had to tell her discreetly to keep her voice down. I probably would have said something implying that although I didn't mind we have to consider the fact that other patients may find it offensive.
I began my objective assessment as usual; observing gait, AROM, palpation, trigger points, PPIVMS/PAIVMS and checked for pain and/or stiffness as I went through. Initially she was fine but when we got to palpation, PPIVMS and PAIVMs that's when the drama started. At first the swearing was just muttered quietly under her breath but then every time she felt a little bit of pain she'd scream out and then add in a few expletives for good measure. This was particularly the case with trigger point release, as you can imagine. It wasn't necessarily what she said either but it was the fact that it was quite loud. We aren't in treatment rooms either, the cubicles are only separated by curtins so all the other patients and treating physios were subject to her verbal display. It was when she got louder that I began to feel a bit awkward so I asked her if she wanted me to stop because I didn't want to make her pain worse but she told me to keep going and it didn't hurt that much.
I was actually a little confused as to what to do? Do I keep going with Rx and allow her to swear or do I change tact and try something different even after the patient asked me to keep going with my original Rx? I was concernend about what other patients would think after listening to this patient?
I decided to change Rx and go through her HEP which hopefully would be less provocative (thankfully it was!!). Then I went back to mob's and TP's and she had settled down little bit as well.
This experience was quite awkward to deal with and if she had started yelling when I returned to mob's and TP's the second time I would have had to tell her discreetly to keep her voice down. I probably would have said something implying that although I didn't mind we have to consider the fact that other patients may find it offensive.
Tuesday, June 24, 2008
T8 neural tissue provocation
On a recent outpatient musculo clinic I encountered a 50 yo male who presented to with L shoulder pain, with concurrent elbow and axilla pain and pins and needles down his arm. 16 months before he was on a canoeing holiday where he travelled 90 km in three days. Since then he had developed a twinge in his shoulder which became progressively worse. In the last 3 months the pain in his elbow had developed. He has no previous history of L shoulder pain. Pain in the shoulder would occur first and if it was bad enough it would be followed by pain in the axilla which is a sharp pain occurring with elevation of the arm. Pain in the axilla is followed by pain in the elbow, this was a sharp pain that usually came on with lifting. The pins and needles were intermittent and came on 1% of the timelasting for a few seconds, there were located to follow the ulna distribution of the hand.
Main agg and easing factors in the subjective were elevating the left arm, particularly up and back, this brought an immediate onset of pain which would ease quickly when the arm was put down. Main easing factors were medication and keeping arm by side. There was no noticeable 24hr pattern other than it was slightly better in the morning.
Relevant findings of the physical examination were decreased AROM in shoulder flexion, abduction and external rotaton, limited by pain. Isometric mm tests were clear ( flexion, abduction, IR) except for ER which brought on 2/10 Pain in the shoulder and elbow. Empty can and full can were also mildly provocative bringing on shoulder pain. The Cx spine was also assessed which was clear for AROM. Flexion with L rotation brought on 3/10 L sided neck pain which did not travel down to the shoulder. Central PAIVMs were tender at C2, C7 and T1 again not referring to the shoulder. NTPT of the ulna nerve was positive for reproduction of shoulder pain symptoms were increased with CL cx lat flexion and decreased with neutral or wrist flexion.
The interpretation of these findings was that there was mechanical pain of the shoulder brought on with active movement of the shoulder joint. The pattern of pain presentation involving subsequent axilla then elbow pain pins and needles suggests some neural involvement. As the ulna nerve NTPT was positive and was more provocative than impingment test this indicates that C8 neural tissue sensitivity was the main cause of symptoms, due to the positive response of the impingement the initial diagnosis also included the possibility of a supraspinatus tendinopathy.
Initial intervention by the first therapist was lateral glides of C7 and T1 in an attempt to mobilise the nerve root of C8, which was moderately successful. Subsequent treatment focussed on neural mechanosensitivity including lateral glides and manual traction initially and the patient showed good increases in ROM and reduction in pain however progress appeared to slow a little over the next few sessions. As a result further techniques were attempted to treat the mechanosensitivity more specifically and correct any muscle inbalance that may be contributing to nerve sensitivity hence soft tissue release of rhomboids, pec major, levator scap, postural retraining, PAM of the GHJ and the first rib were used. The most effective treatments being Pec minor release, PA PAM of first rib, GIII with the patients symptoms now being mild pain and near full ROM, however there is still Neural symptoms in the provocating position so to further decrease neural sensitivity slide/glides of the ulna nerve were tried and given as a home exercise. The main difficulty in treating this patient was to think about finding ways to treat the problem specifically- such as mobilising the first rib in an attempt to affect C8 neural tissue, rather than just the Cx spine. I found this was an important lession in thinking of all areas that may be affecting the patient and not just sticking to the most obvious treatment
Main agg and easing factors in the subjective were elevating the left arm, particularly up and back, this brought an immediate onset of pain which would ease quickly when the arm was put down. Main easing factors were medication and keeping arm by side. There was no noticeable 24hr pattern other than it was slightly better in the morning.
Relevant findings of the physical examination were decreased AROM in shoulder flexion, abduction and external rotaton, limited by pain. Isometric mm tests were clear ( flexion, abduction, IR) except for ER which brought on 2/10 Pain in the shoulder and elbow. Empty can and full can were also mildly provocative bringing on shoulder pain. The Cx spine was also assessed which was clear for AROM. Flexion with L rotation brought on 3/10 L sided neck pain which did not travel down to the shoulder. Central PAIVMs were tender at C2, C7 and T1 again not referring to the shoulder. NTPT of the ulna nerve was positive for reproduction of shoulder pain symptoms were increased with CL cx lat flexion and decreased with neutral or wrist flexion.
The interpretation of these findings was that there was mechanical pain of the shoulder brought on with active movement of the shoulder joint. The pattern of pain presentation involving subsequent axilla then elbow pain pins and needles suggests some neural involvement. As the ulna nerve NTPT was positive and was more provocative than impingment test this indicates that C8 neural tissue sensitivity was the main cause of symptoms, due to the positive response of the impingement the initial diagnosis also included the possibility of a supraspinatus tendinopathy.
Initial intervention by the first therapist was lateral glides of C7 and T1 in an attempt to mobilise the nerve root of C8, which was moderately successful. Subsequent treatment focussed on neural mechanosensitivity including lateral glides and manual traction initially and the patient showed good increases in ROM and reduction in pain however progress appeared to slow a little over the next few sessions. As a result further techniques were attempted to treat the mechanosensitivity more specifically and correct any muscle inbalance that may be contributing to nerve sensitivity hence soft tissue release of rhomboids, pec major, levator scap, postural retraining, PAM of the GHJ and the first rib were used. The most effective treatments being Pec minor release, PA PAM of first rib, GIII with the patients symptoms now being mild pain and near full ROM, however there is still Neural symptoms in the provocating position so to further decrease neural sensitivity slide/glides of the ulna nerve were tried and given as a home exercise. The main difficulty in treating this patient was to think about finding ways to treat the problem specifically- such as mobilising the first rib in an attempt to affect C8 neural tissue, rather than just the Cx spine. I found this was an important lession in thinking of all areas that may be affecting the patient and not just sticking to the most obvious treatment
Thursday, June 19, 2008
Weight Limit
This happened sometime ago now.
Patient who had recently had a fall, as a result fractured his tibial shaft. He had an ORIF and the fracture was stabilised and was able to weightbear. He had been ambulating with a pulpit frame on a couple of occasion with 2xassist and managed about 5m with the ward physio. The patient normally uses a wheelchair and uses a zimmer frame for transfers. My supervisor had told me to go see this man and get him to ambulate about 5m. So i got everything ready; a pulpit frame and a nurse to help. We managed to get him into standing without any hassels and onto the pulpit frame. He walked a few steps and was doing really well. My supervisor walks past and stops and asks the patient to be seated. She then waved me over away from the patient and told me that the patient was 110kg and the weight limit on the pulpit frame is 100kg!! We eventually got a pulpit frame that had a higher limit and the patient managed fine.
Looking back at it, if something happened, it could of been really nasty. Pulpit frame breaking and as a result, patient falling and possibly other fractures. Then the patient would lose confidence in himself and in the physio. There are so many things that could happen. Luckily, it did, phew.
The thing is, weight limit on a pulpit frame didn't ever cross my mind and i wasn't aware there were other frames that took more weight than others. I did realise the patient was heavy.
There is only one solution to this. Next time check the weight limits of equipment (not just pulpit frames, but tilt tables, zimmer frames ...etc) and have a good idea of what your patient weighs, normally in the obs chart or notes. Now that this has happened, its a quick check i would with all my patients.
Patient who had recently had a fall, as a result fractured his tibial shaft. He had an ORIF and the fracture was stabilised and was able to weightbear. He had been ambulating with a pulpit frame on a couple of occasion with 2xassist and managed about 5m with the ward physio. The patient normally uses a wheelchair and uses a zimmer frame for transfers. My supervisor had told me to go see this man and get him to ambulate about 5m. So i got everything ready; a pulpit frame and a nurse to help. We managed to get him into standing without any hassels and onto the pulpit frame. He walked a few steps and was doing really well. My supervisor walks past and stops and asks the patient to be seated. She then waved me over away from the patient and told me that the patient was 110kg and the weight limit on the pulpit frame is 100kg!! We eventually got a pulpit frame that had a higher limit and the patient managed fine.
Looking back at it, if something happened, it could of been really nasty. Pulpit frame breaking and as a result, patient falling and possibly other fractures. Then the patient would lose confidence in himself and in the physio. There are so many things that could happen. Luckily, it did, phew.
The thing is, weight limit on a pulpit frame didn't ever cross my mind and i wasn't aware there were other frames that took more weight than others. I did realise the patient was heavy.
There is only one solution to this. Next time check the weight limits of equipment (not just pulpit frames, but tilt tables, zimmer frames ...etc) and have a good idea of what your patient weighs, normally in the obs chart or notes. Now that this has happened, its a quick check i would with all my patients.
met call
A few days ago on the geriatric ward one of the pt's i had been treating had a sudden episode of VF (ventricular fibrillation) and the met call button was pressed. The pt was eventually shocked back into regular rhythm and by the evening the pt was conscious and responsive. The pt had a Hx of SVT and AF and was awaiting the all clear before being transferred to a rehab hospital, which has now been posponed.
The interesting part of this story is that i saw this pt the afternoon before these events, and she was the best i had ever seen her. She was motivated, cheerful and went from 1x assist amb and t/f's to standby assist. She managed about double the length of mobilization and also tolerated a series of bed exercises. I thought she had really turned a corner.
When my supervisor and i were discussing this, my supervisor said that this is often the case and regretted not picking up on it earler. She reported that many pts are able to perform better, look better and are more up beat soon before they 'crash'. This came as an absolute shock to me as it really is the opposite to what you would expect. I would have thought that in a place like gero's unwell pt's would gradually decline, or in a step down process, until eventually 'crashing' or dying. I just found this fascinating and will definately be on the lookout for uncharacteristic cheerfulness and performance and hope that it is not a indicator that the pt is about to 'crash'.
The interesting part of this story is that i saw this pt the afternoon before these events, and she was the best i had ever seen her. She was motivated, cheerful and went from 1x assist amb and t/f's to standby assist. She managed about double the length of mobilization and also tolerated a series of bed exercises. I thought she had really turned a corner.
When my supervisor and i were discussing this, my supervisor said that this is often the case and regretted not picking up on it earler. She reported that many pts are able to perform better, look better and are more up beat soon before they 'crash'. This came as an absolute shock to me as it really is the opposite to what you would expect. I would have thought that in a place like gero's unwell pt's would gradually decline, or in a step down process, until eventually 'crashing' or dying. I just found this fascinating and will definately be on the lookout for uncharacteristic cheerfulness and performance and hope that it is not a indicator that the pt is about to 'crash'.
Tuesday, June 17, 2008
An unsuspecting patient
My two week placement in 2nd year was rather interesting as it was basicaly a gerontology clinic which was very similar to a rehabilitation unit. Many of the patients on the ward were fortunate enough to have many friends and family to come and visit.
On one particular visit, I was walking a patient who was 2 weeks post THR of her (L) hip and just before taking her for a walk on the wards, a close friend of patient, who she had known for over 30 years, had come and visited her. I explained to the visitor that we were going for a ten minute walk and that she could join us for a walk outside, of which she accepted.
A few minutes into the walk, the visitor had started to slow down a little bit and was falling behind us and really started to look unwell. I asked her about her condition and explained to her about having a sit down on a nearby chair, but she said she was ok. The condition had gotten worse and her face went bright red and looked very sick. Little did i know she was a diabetic and that she was low on sugar, she hadn't eaten for 5 hours since driving from the country to visit her friend.
The situation ended up ok with the help of some food and a nearby nurse. bu the thing that i couldn't believe was how quickly the situation got out of hand. If a similar situation was to happen again, as soon as the visitor started to show signs, you must immediately start to ask questions as it could be something very simple from her PMH that could causing the symptoms. Although this particular situation couldn't have been avoided, it could have been stopped in the early stages had the simple questions such as " Do you know whats going on?" or "Have you got a condition that provides these symptoms?" etc. These few simple questions could have saved me from being in a stressful situation
On one particular visit, I was walking a patient who was 2 weeks post THR of her (L) hip and just before taking her for a walk on the wards, a close friend of patient, who she had known for over 30 years, had come and visited her. I explained to the visitor that we were going for a ten minute walk and that she could join us for a walk outside, of which she accepted.
A few minutes into the walk, the visitor had started to slow down a little bit and was falling behind us and really started to look unwell. I asked her about her condition and explained to her about having a sit down on a nearby chair, but she said she was ok. The condition had gotten worse and her face went bright red and looked very sick. Little did i know she was a diabetic and that she was low on sugar, she hadn't eaten for 5 hours since driving from the country to visit her friend.
The situation ended up ok with the help of some food and a nearby nurse. bu the thing that i couldn't believe was how quickly the situation got out of hand. If a similar situation was to happen again, as soon as the visitor started to show signs, you must immediately start to ask questions as it could be something very simple from her PMH that could causing the symptoms. Although this particular situation couldn't have been avoided, it could have been stopped in the early stages had the simple questions such as " Do you know whats going on?" or "Have you got a condition that provides these symptoms?" etc. These few simple questions could have saved me from being in a stressful situation
Monday, June 16, 2008
Blue button/yellow button
Today at 4.30pm an orderly came up to myself and another Physio to let us know that a man in room ? needed to go to the toilet and can we walk him to the toilet. I had only seen this man once before and the Physio i was with was brand new on the ward that afternoon so didn't know how the ward operated let alone who this patient was and his mobility. We called the nurse but aparantly he had had his call bell on for about 30 mins and was now busting.
I knew he could shuffle with a wheeled zimmer frame with 2 x assist so the new physio tracked down the older physio (the normal one on the ward who is also my supercisor) and together, my supervisor and i walked with him a few metres to the toilet. We both noticed his profuse sweating on the way to the bathroom.
Once we got there he had difficulty turning around, eventually he was lined up okay and could take a seat on the commode. Both my supervisor and i noticed the man's colour and increased sweating and i ran to get a sats machine. I took all of 30 secs but by the time i returned my supervisor told me i should press the met button.
I couldn't see the met button so pressed the yellow one (the semi serious one but not the met one...) until i finally located the met button but he had reagined consciousness so it wasn't necessary bu this stage. I went and tracked down his nurse and the head nurse while my supervisor stayed with him in the bathroom.
I've never really had anything serious happen to me at a clinic so this would have to be the most serious thing i've come accross. I was a bit panicky when i couldn't locate the met button and also a little angry at myself cos i should know where it is (but it was located near the door entrance near the light switch which i found a bit odd instead of behind the bed-oh well).
It just makes me think that i should never take any situation too lightly and while this seemed like a bit of a hassle, almos,t to start with, just to walk him to the toilet it turned into a situation very quickly. Im glad i had someone else there at the time cos i don't think i could have handled the situation myself.
In the future i'm going to try and act faster on my observations (when i noticed him sweating a lot i probably should have sat him down straight away) and i will look at where that blue met button is in future!
I knew he could shuffle with a wheeled zimmer frame with 2 x assist so the new physio tracked down the older physio (the normal one on the ward who is also my supercisor) and together, my supervisor and i walked with him a few metres to the toilet. We both noticed his profuse sweating on the way to the bathroom.
Once we got there he had difficulty turning around, eventually he was lined up okay and could take a seat on the commode. Both my supervisor and i noticed the man's colour and increased sweating and i ran to get a sats machine. I took all of 30 secs but by the time i returned my supervisor told me i should press the met button.
I couldn't see the met button so pressed the yellow one (the semi serious one but not the met one...) until i finally located the met button but he had reagined consciousness so it wasn't necessary bu this stage. I went and tracked down his nurse and the head nurse while my supervisor stayed with him in the bathroom.
I've never really had anything serious happen to me at a clinic so this would have to be the most serious thing i've come accross. I was a bit panicky when i couldn't locate the met button and also a little angry at myself cos i should know where it is (but it was located near the door entrance near the light switch which i found a bit odd instead of behind the bed-oh well).
It just makes me think that i should never take any situation too lightly and while this seemed like a bit of a hassle, almos,t to start with, just to walk him to the toilet it turned into a situation very quickly. Im glad i had someone else there at the time cos i don't think i could have handled the situation myself.
In the future i'm going to try and act faster on my observations (when i noticed him sweating a lot i probably should have sat him down straight away) and i will look at where that blue met button is in future!
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