Proving it works

I am currently on my cardio placement and i have been treating this 77yo italian lady who has been recently diagnosed with mild bronchiectasis. Previous to her admission, she has been fit and healthy without any major complaints. In the last 6months she has had increasing SOB, increase sputum production and decrease ex tolerance (due to SOB). She was admitted due to her increasing SOB and yellow-brown sputum. This lady speaks minimal-moderate english.

On initial assessment and treatment, it was just my luck that her two daughters were there. So they helped me to interpret. I'd asked the patient the relevant questions regarding her SOB, cough and ex tolerance. She indicates she only gets SOB when she goes for long walks (>1hour) and there is minimal sputum pre-admission. She also states that she is able to cope at home well (she lives with her daughter). However, upon speaking to the daughters, this 77yo lady has been struggling with SOB and has had 10 falls in the last year! Her falls are mainly mechnical, either from someone bumping into her or tripping over something.

Her main problems with dyspnea, impaired airway clearance and decrease ex tolerance. My treatment started with teaching her breathing strategies to combat dyspnea. She was hesitant in wanting to perform breathing control as she thought it didn't help (even when the daughters have explained to her several times). I then educated her on the importance of deep breathing exercises (TEEs) in order to get air behind secretions and push them up the respiratory tract. She also had trouble understanding the mechanism/reason behind the exercise. She expressed to her daughters of how such simple exercise can help with sputum clearance. She was not sold on the idea. I still managed to get her to do a few TEEs and to make things worse, she didn't clear any sputum with the exercise (here i was thinking if the TEEs worked and helped her clear secretions, she would be compliant with the exercise). I was certain that once i'd left the room she would not continue with those breathing exercises. At the end of the treatment I had this feeling that she didn't find physiotherapy to be useful.

I have only seen the patient once. I need to find ways to prove to her that physio works. I'm still thinking about it. I thought maybe get her in a dyspneoic situation (ie, long walks) and try get her to do what she normally does and then get her dyspneoic again and use breathing strategies and see whether that makes a difference. And also try TEEs (with ACBT) on a day when she is little bit more productive and maybe she can clear some sputum. I've learnt that you may not see changes/results immediately after your treatment and you can lose patient confidence at that time because of it. Next time i will try a different tactic and maybe put the patient in the situation (ie, dyspneoic or unable to clear secretions) and then apply the physiotherapy techniques. Or just simply persist with the treatment for a couple more sessions and hopefully see an effect. Will discuss with my supervisor tomorrow about strategies that i can use to overcome this problem.

The Aphasic patient

I'm on my neuro placement and dealing frequently with acute stroke patients. I have one patient who has had a (L) MCA and as a result has global aphasia. I didn't anticipate the extent to which it affects communication. I knew that it would be more challenging but there's just no point explaining much at all. I've found that the whole approach to Rx changes because of the patient's response. The scans have also showed some frontal lobe involvement so in addition to the communication difficulties we also have to combat the behavioural changes.

I'm amazed at how much he has improved over the last week in terms of communication. Whe we first saw him all he could say was 'yes' and 'no'. Now he is beginning to form proper sentences and is able to comprehend 2 stage commands. I struggled for the first few Rx sessions to communicate and thus treat this patient because I found we were so used to explaining everything before we did it we ended up confusing the patient. We would go throught he entire plan of what we wanted him to do and he wasn't able to communicate to us that he didn't understand. He would begin doing the right movement but soon got lost and ended up doing something completely different.

It was a challenge to change the approach to Rx but after a few days we worked it out. Now we only give one command at a time and luckily he has adequate motor control and strength to do most tasks. For example, he is able to 'stand up' on command and all the support he needs is minimal assistance to control his weaker knee. We've learnt not to talk so much and let our hands guide his movements. Demonstration of the task is useful and the use of mirrors works quite well. I never realised how challenging it would be to treat someone with global aphasia and the amount you have to adapt the approach to Rx. Through this experience i have become alot better with the use of manual contacts to guide the movement and the ability to communicate with only keywords of the task.

Frontal lobe changes

I have recently started a new prac and i am on a general surgical ward with lots of different patients from TKR/THR to pnuemonia to subdural haematomas to traumatic stab wounds. It is an extremely varied case load and provides me with a lot of different pathologies to study all at the one time so it is always interesting.

Today i went to treat a man who has been on the ward for about a week with a presenting complaint of a subdural haematoma and some queried frontal lobe involvement due to behavioural changes. The Physio i have been working with had not yet performed a specific neuro exam and had stuck to general mobility assessments when seeing him.
I have already completed my neuro placement but had not come accross a subdural haematoma yet and thought it would be interesting to do a general neuro exam on him to find out the extent of his deficits.

When i walked into his room i politely introduced myself and my role and what i would be doing with him today. He was rambling on a bit trying to tell me about a bundle of nerves in his spine that are wound up wrong etc. etc. so i proceeded with what i had planned to do and asked him to extend his knee against my resistance. He then yelled at me and told me im not a doctor and i don't know what im talking about and he has a bundle of nerves wound up wrong in his spine...his wife was sitting beside him and looked at me with a bit of sympathy. I ended up not being able to assess anything (he refused) and also i wasn't really achieving anything due to his lack of understanding of what i was asking him to do.

I didn't realise how much frontal lobe aggressive behaviours could alter a persons willingness to comply with treatment and understand what i was trying to look at. I had never had any first hand experiences with someone who had frontal lobe changes before and i just assumed if i explained everything i was doing and why i was doing it the patient would be reasonable. I did not expect him to disregard any information i was trying to explain to him. I suppose i just thought he might be like an person who gets angry easily but still not without reason.

In hindsight i suppose i will just take away from this situation that i never know how someone will react to any given situation and to never assume anything...especially not about people who have suspected frontal lobe changes.

Stubborn patient

On my previous placement, I was treating an 88yo man who was admitted 2weeks ago as he was not coping at home. 1 month previously to this he had suffered a (R) MCA stroke and had spent 1 week in hospital before discharging himself against medical advice. When he self discharged himself he was not able to ambulate and his (L) arm had no voluntary control. He was then re-admitted as he had had many falls (no injuries) and his wife could no longer look after him. When he was admitted the 2nd time he was ambulating with a walking stick (extremely unsafely) and had voluntary control in his shoulder and elbow (but mainly in synergies) and flaccid wrist and fingers on the (L) hand.

When I assessed him my main findings was he had global muscle weakness especially LL, poor static and dynamic balance, delayed and ineffective saving responses and no voluntary mvt in his (L) wrist and hand. He ambulated with a walking stick x1 mod A. I treated this patient x2/day, the morning session included balance exercises, strengthening and gait retraining and in the arvo we worked on UL and again gait retraining.

Improvements where slow (I did see some good improvements in his (L) UL - he was able to extend his wrist mid-inner range against gravity by 3 weeks) and the patient was not happy to be in hospital. He did enjoy physio session however and worked very hard in each session. By the end of the 3 week the patient hd had enough of hospital and self discharged himself again against medical advice. On discharge he was still a very high falls risk and still requires close S/B assistance when ambulating. His wife agreed to provide this assistance to him when at home but she was 85 yo and bearly 5 foot high!

We all educated the patient on the risk of going home but the patient had made up his mind. It is very hard to get through to a patient that we are really there for their best interest and to keep them safe. However I too would go stir crazy being in hospital for 3weeks +! In the future I am very sure I will come across many more patients like this man nd I believe all I can do is educate them on the risks and try to persude them to reconcider.

wry neck

On the last day of my musculo prac when i felt like i was getting the hang of musculo, I had one new pt that i had not planned for. She called up complaining of extreme neck pain after a bad night sleep and needed to see a physio. She was driven in and 15 minutes later she had arrived. She presented with a posture of nearly full range (L) side flexion, 1/2 (L) range rotation and 1/2 range flexion all to open up her right side. This was a classic acute wry neck presentation that was just as extreme as wat we learnt about it.

When it came to Ax, she was so irritable the only thing that could be done was put on a heat pack and hopefully reduce some of the discomfort and muscle tone. Following this she was very tender on her (R) side and had strong muscle guarding and pain responses resisting a neutral position. On PPIVM Ax there was a clear limitation at C2/3, and she was diagnosed with acute wry neck at (R) C2/3.
Her other Rx consisted of gentle upslope technique for (R) rot'n at C2/3 and a SNAG at C2 (L) for (R) rot'n. She also received postural advice and positioning, as well as AROM rot'n for a HEP.

I found this case fascinating and a great way to finish off my prac as it was a new and confronting experience where i had not seen an acute Cx pt prior to this. She presented in such a textbook way, which i always thought after learning about it was exaggerated. She was also incredibly irratable which we also leant about, making it very difficult to Ax and Rx. I think the message i got from this patient is that everything we learn at uni does exist and the content is from real life experience. I think when i actually work as a physio ill keep all my notes close-by for the next time i see a new presentation that again is likely to fit the profile detailed in out guides and lecture notes.

Ceasing Rx??

I'm on my musculo out-patients prac and i treated a patient 3/52 post elbow dislocation. On intial Ax he was lacking 30 degrees elbow extension, was restricted in supination and pronation and he had increased tightness and trigger points around the elbow and forearm. So folllowing Ax I began to treat him. Treatment was progressing slowly but we continued to improve his range each session and were able to reduce some of the tightness around his elbow and forearm by using STM and trigger point release.

He was an extremely motivated patient who wanted to restore his elbow function as soon as possible. I treated him 3 times a week for 2 weeks. Following these two weeks he informed me that he had an appointment with his orthopaedic team and was to atend mid week the following week. All of a sudden his appointments were cancelled following the orthopaedic consult. I rang him to enquire as to the reason for the sudden cancellations. He told me that the consultant did not believe in PT Rx and that the elbow would get better by itself (as nature takes its course). The pt was told to just "let it be" and do passive type exercises as opposed to doing any active triceps contraction to achieve elbow extension.

I couldn't really argue with this and told him that letting the elbow heal in time was only one view. He then asked whether I thought he should be doing anything else. I advised him that gentle movement would be good for his elbow and a few other passive techniques would also be beneficial, having first discussed it with my supervisor.

This incident reinforced that there are many different views regarding the effect and implication for physiotherapy. Whilst in this case I believe treatment was beneficial for the pt and terminating treatment will not result in a favourable outcome, I appreciate that not all health professionals agree. It's frustrating, though, not being able to express your concern to the rest of the team, as you would in an in-patient hospital setting.

EPA modalities?

I am currently on a musculo prac and have a patient who has chronic back pain. I find treating patients with back pain a complete mystery. Some how the manual techniques we learnt at uni does not seem to produce much relief for chronic conditions. Upon giving up all hope, she is now attending physiotherapy as a last resort based purely on the fact that she has been referred by her doctor. And, she has no expectations for the therapy at all. She had a pain score of a constant 8 out of 10 in her LB. She looked tired, worn out and any slight sense of hope has been removed from her frail body. She also displayed a stressed out mood, was very lethargic and seemed frustrated with her work situation as she is a car detailer which would involve a lot of bending and twisting.

Even though some professionals regard EPA as an alternative treatment, I believe in this situation EPA worked very well for her. Upon consulting my supervisor and clearing any contraindications related to using TENS, we decided to try TENS on her. After the applications of TENS on the patient, her back pain had reduced to 2 out of 10. Since it had produced such good results, we decided to see her 2 days later and did TENS on her again. She was also impressed with the outcome of the treatment and voiced her relief.

This made me feel nervous yet excited at the same time as I had never done TENS on a patient before. This has thought me that as a physio, we encounter various conditions and technique outcomes vary patient to patient. We should not be afraid of venturing into the different modalities and techniques.

It is also important to understand what the patient is going through especially with this patient who has absolutely no hope of recovering. It is essential to have patience with this patient because she might be reluctant to try various therapies especially TENS. The ability to effectively deal with patients will come with time and practice.

Cultural Differences

I am currently on my MS outpatient prac. In my first week of this prac I was assigned a new patient. He was referred into PT after an ortho doctor’s appointment post distal radial fracture, managed conservatively.

On this particular prac we get issued a 90min time frame for each new patient consisting off 30 min subjective assessment, 30 min objective and 30 min for treatment.

My patient was due to arrive in the morning .Upon meeting my patient and introducing myself I came to realize he was unable to converse in fluent English and had limited vocabulary. Nevertheless I took this on as a challenge having the faith that I could overcome this language barrier. Henceforth the commencement of my initial assessment began. Further into the assessment, I had realized that I underestimated this language barrier and was literally left dumbfounded. After about an hour into the subjective assessment I realized that I had still not got vital information with regards to his condition. Upon consultation with my supervisor, it was decided that this patient had to be re-booked for another consultation with an interpreter.

In my opinion of being a physiotherapist, it is essential to have a holistic approach and thus provide services that benefits the patients needs. Even using simple skills such as hand gestures or drawings to express myself and get a likewise feedback goes a long way and enables the patient to feel comfortable with me. With regards to my patient, because of his inability to communicate with me, I was reluctant to express myself in the notion of offending him especially since we both come from very different cultural backgrounds.

From this experience it has given me a broader perspective to my job as a physio whereby it isn’t always going to be smooth sailing and that there are going to be milestones that I have to encounter in order to become a better individual and physio resulting in good patient rapport regardless of their background.

Gaya:)

We can forget about patients...even if they are non-responsive

This is now my last week on my neuro prac. I have mentioned this patient previously but I want to post another blog to update you all. I have been seeing this patient since day 1 at prac. This patient is an 88yo man who was admitted to ED 4weeks ago and was diagnosed with having a (L) CVA. His past medical history included 2 previous CVA ( TIA and R MCA ischaemic stroke) aswell as AF, emphysema, HTN and much more.

I have treated him every day for 4 weeks. His GCS is still only 10/15, he spontaneously opens his eyes, makes incomprehensible sounds, and localises to pain. He does not follow verbal commands (which may be due to many factors such as ideomotor/ideational dyspraxia, global dysphasia, decreased cognition etc etc). Functionally - he is 2x max assist to move up/down bed (with slide sheet), rolling L and R, and Supine to SOEOB. He does not have static or dynamic sitting balance and req a full hoist to transfer from bed to reclined bucket chair. Treatment so far has included passive movements and muscle stretches esp of (R) pect mj, lat dorsi, wrist and long finger flexors, hamstrings and plantarflexors (he has an artificial R elbow and his range pre-admission was 60-90 degrees flexion, thats all so it has been difficult to stretch biceps but I maintain that limited range by passive mvt). Also rolling L and R and position in long sitting for chest management and supine to SOEOB x 2A. I have also been lucky enough to find a physio to help me put him on a tilt table which he tolerated well.

Three weeks ago I assisted the physio to hoist this pt out into a reclined chair which he also tolerated well. We put in the nursing sheet that the patient is able to be hoisted out into the reclined chair and should be hoisted out each day and placed in the chair for at least 30 min. Every day I asked the nursing staff if the pt had been hoisted and I was told they did not have time. So I told the physio and she said it is part of the nursing care plan and that they should be doing it. I checked each day and this poor patient was being left in bed each day. Last week I had had enough so I asked a nurse if she could help me hoist this pt OOB. Her response if that I am a student and not capable of doing such a thing. Politely I reassured her that I was more than capable and that I had hoisted the pt out with the PT the prev week. It took me half and hour to convince 3 nurses! Finally we hoisted him OOB and he was in the reclined chair for 30 min. I politely said to the nurses that would it be possible to check the nursing care plan and see if this was in there for this patient. They said they would check.

The next day I asked if the pt had been hoisted and I was given the same response - We havent had time! I feel like I have failed this patient. Even though he is non responsive he is still a human being! Hopefully next time i am in this situation I will be the physio on the ward and hopefully what I recomment will have more impact then being just a student.

fixated patient

Whilst on an outpatient musculoskeletal placement I followed on treating a patient who had been diagnosed with an MCL sprain to his left knee 6 weeks previously, following a fall playing soccer. At the time I saw him his pain levels were 2-3 and only with very specific movements or after jogging for 15minutes. He also revealed that the pain he experienced post fall had mainly subsided and the pain he was experiencing now he had actually had 3-4 months earlier. With this in mind I did some further tests and found that he had a positive McConnells test and a medial patella glide relieved his pain to zero when squatting. He also had a very tight ITB. I explained what I thought had happened to the patient and that i felt his initial problem had probably healed quite well and this residual pain was probably due to poor patella tracking. He understood this and said it made alot of sense and treatment became focussed on dealing with this.

The next week this patient had an orthopedic review with his surgeon. The surgeon did no tests but told him that he didnt think it was a tracking issue as the pain was too medial. When the patient came in next time, even though he said the taping reduced his pain to nothing during the week, he was very fixated on what the doctor had said and wanted to get an MRI to find the specific source of pain. He also said he had done some research on the internet and he thought it might be cartilage or something, he also had some doctor friends who he was asking for their opinion and they said maybe meniscus tearing. The next week he came in and had pain $250 for and MRI scan to find out what was wrong. The scan revealed that there was a small tear of his posterior medial meniscus and fissuring of the medial patella margins. At this point the patients pain was nil with taping and 1-2 out of 10 without it. He had returned to soccer and was playing for 30 minutes, only feeling slight pain when cooling down. However he continued to remain fixated on his pain and diagnosis and felt that he wasnt improving even though I could show him each week through various objective markers that he was. I had also given him a thorough explanation of how patella tracking involves many factors that may take time to correct.

At our final session he still seemed to feel that his progress was abnormal, even thought he was only complaining of 1-2/10 pain at most and he revealed that another player had suffered the same injury as him at the same game but had not yet returned to sport. He was also questioning wether he should have surgery so the doctor could 'just get in and clean it up'. I found this patient very difficult to deal with as, although he wasnt unpleasant or demanding he was clearly unable to put his condition into perspective and was willing to pay quite alot of money to fix a problem that was causing him 1-2/10 pain 5% of the time and was also improving. I also found it frustrating how my opinion was secondary to his orthopedic surgeon who did a 5 minute assessment, his friend who would have made no assessment and the internet. It was only when imaging backed up my diagnosis that I had any credibility.

What I did learn from treating this patient was that your explanations need to be very clear and confidant as there are so many conflicting information sources for patients. Often to us a diagnosis is not that important if we have found many contributing factors and are treating them successfully, however for some patients they have difficulty letting go of a set diagnosis/cure relationship. It was also difficult to convince this patient that he was getting better, when it was clear to me that he was and had hardly any activity limitations. If I met a patient like this in future I hope I would recognise education as a primary aspect of treatment and establish clear markers to indicate progress and educate the patient on expected/normal recovery.

Rate it!

This is not a particular case study as such........

This is a repeating issue that i have on all placements. The question of rating pain out of 10. There are lots of patients that struggles to understand the scoring system. We often tell them that "10 is the most excruiciating pain you can have, like childbirth" to use as an analogy, but some mothers don't consider childbirth as 10/10 pain. It's confusing for patients and they get rather annoyed when we repeatedly as them to rate their pain again and again. I think in my current musculo placement 50% of my patients don't really understand what it means (i've actually asked them "do you know what the rating means?"). I understand that it becomes an objective measure for us for reassessement and all, but it is really accurate? I think sometimes just asking the patient whether the pain is the same, better or worse is sufficient for reassessment purposes. At the same time i think i tend to focus on pain so much that i sound like a broken record, "where is the pain? how painful is it? Is it the same pain as you were getting? Is the pain deep or superficial? How is it now? What score is it?" It's the way university has taught us, and that's what we use. I understand that the measure is individual to the patient, yet, one day they can be 4/10, and next week is 8/10 even though the pain is exactly the same.

I still use the VAS scoring to all my patients if they get it, that's fine, but if i know they struggle to understand the system, i ask them whether the pain is mild, moderate or strong and that usually fixes the problem, sometimes by using percentage works too 10%, 50%, 90% etc, even though it's exactly the same as the 0 to 10 system. I've learnt that the system is useful for us as an objective measure, though we can't rely on it. You can also look at other objective measures such as ROM, strength, swelling size etc for reassessment too. Some patients will just not get it! Rather than get your patient frustrated and annoyed, it is better just to ask them whether what you just did makes the pain better.

Anyone else have similar problems? What other strategies have you used?

ACL regression

I'm on my musculo out-patient's prac and have a patient who had undergone an ACL reconstruction 10 weeks ago. She is a young netball player with no other complications other than a stiff knee. Her strength is good in the available range. I can't test strength between 0-20 degrees KF because AROM=PROM. My problem is that no matter what I do there is very little improvement in her extension ROM or flexion ROM for that matter.

Following the op she had full knee extension but at about 4 weeks post op suddenly came into physio with a knee extension lag of about 20-25 degrees. She has made no improvement in the way of extension for the last 6 weeks and currently her range is 20-75 degrees knee flexion??? Initially we thought that the restriction of knee extension was due to tightness posteriorly and muscle guarding of hamstrings +++. Since then we have been doing lots of STM and release of H/S, popliteus and gastroc. We have also tried an array of other techniques: med/lat glides of the patella, lots or IRQ stuff (active and act/assist), hold relax techniques, massage, trying to facilitate extension by using gait. She is still managing the swelling with application of ice. She also has an intensive HEP which she appears to be adhering to???

So what are the possible reasons for her lack of progression, or more correctly her regression? 1) Not complying with HEP 2) increased intra-articular swelling 3) increased muscle guarding H/S. I can't think of any other reasons? I've pretty much tried everything I can think of as well as supervisor input and CCT input so if anyone has any sugesstions, please feel free?

It's a very frustrating case for both the pt and the PT. She keeps coming week after week with no improvement and all she wants is for it to get better so she can get back to doing the things she used to. She's not much older than us so it must be pretty demoralising, especially if you are doing your HEP and not getting anywhere. As the treating PT it's hard to know what to do. From talking to other PT's, with more experience, I've learnt that sometimes you can do all the right things during Rx sessions but if the pt doesn't take them on board and put the strategies into practice through gait or everyday activities then there's not much more you can do about it. I think it's one of the harder lessons to learn a PT - sometimes you can't do it all and you don't see much of an improvement.

Did not want a d/c

On my current musculo placement i have a number of on-going pts that have been coming for anywhere up to 2 yrs. One pt in particular has had several complaints and has been coming for about this long with a shoulder complaint, LBP and recently hip pain. His first Rx from me was an initial Ax for his hip and continuation of his LBP Rx. He presented the following week with much improved hip symptoms and pain free AROM for his Lumbar spine. His shoulder gains were also maintained. This was a great outcome, so i decided to suggest him to come back in a fortnight instead of a week, and because he had a good grasp of his HEP this seemed to be logical. Upon my suggestion he quickly replied with "but ive been coming weekly". I then proceeded to explain that he was progressing well and if he continues to do so hopefully we can lead to a d/c. The pt seemed surprised by this and accepted, though appeared nervous and ensured that if he had any symptoms he could be seen next week.

I found this situation interesting as this pt appeared to have gotten into a physio routine, and thought that if he wasnt coming in weekly, he would start deteriorating. He seemed to be settled when i explained he had a good grasp of his exercises and if he kept them up he would continue to improve. Prior to this encounter i thought musculo out pts was not so long term and pt's would be eager to self manage with checkups that became fewer and further in between until d/c. This pt and others i have had that are longer term appear quite dependent on weekly sessions that have been given by many students. I think this has to be kept in mind when considering d/c, and a full explanation with self management and coping is vital. I will try and keep this in mind for future pts.

The Wrong Rx??

Let me just start by saying this wasn't my patient but it got me thinking. If I was in this situation what would I have done? She was an out-patient who was well into her thrid trimester and presented with low back pain. The pain radiated down into the back of her leg. As part of her objecctive examination she was found to have increased muscle tightness in piriformis and her gluts. The treating physio decided to try STM and try and release the muscles which were tight. The following day the patient rang up saying that she could barely walk and the pain was constant all the time when she did walk. She was treeted again the following day and the problem resolved itself.

But it got me thinking. How would I react if I was the treating physio and would it be a simple problem to correct? It would require a good analysis of the initial Rx session and an evaluation as to the posible reasons for the resulting pain. I think it would require a fairly level head when a patient is questioning you on the phone and re-telling the symptoms. I'm still a bit unsure as to how I would react to a situation like this? And it seems to be a very real possibility because you can't be 100% right, 100% of the time!

Any other reactions to a situation like this??

HEP

In musculo outpt's a HEP and self management is strongly enforced and is crucial to injury management. One pt with recurrent LBP came to physio with that aim of easing her pain and maximising function. After an initial Ax and Rx she reported feeling much better, eagerly accepted a HEP, and felt good that she was now armed with exercises/stretches to improve her injury. She was then booked in for the next week for a follow-up appointment.

On the next session, the pt reported that she felt worse later that day after the initial Rx, and was at baseline pain during the week. When i asked if she had been doing her exercises/stretches, she reported she had not attempted any of them, and didnt really want to correct her posture. At this point i was thinking "why are you making the effort to come here and not follow advice, and why am i bothering to give you Rx, the results of which will only be maintained with a HEP". She apologised for not doing the exercises, and assured me the next lot of exercises will be performed as much as i prescribed. When it came to the end of the session, we went through the same exercises that she was unable to remember, and i added in one more for a new problem she presented with. 2-3 additional ex's more would be optimal but i suspected i had more chance of getting compliance with 1 vs 3 ex's.

This situation made me wonder what some people really expect from physio, probably just a quick fix Rx then your on your way. Prior to this encounter i thought that people coming to physio would happily receive a HEP and perform it as instructed to maximise their benefit, after all they are going out of their way for Rx. I dont think this pt in particular realised that a chronic injury requires 'chronic' management, that is usually a change in posture and motor control/muscle length etc. With this experience, appreciating how some pt's may feel about physio, i will aim to emphasise a HEP more to hopefully optimize compliance and results.

Where's the pain? Everywhere....

Words to sum up musculo outpt so far - notes, cancellations, dna's, notes, notes, and notes.....

I saw this patient in the first week. Prior to seeing her, i had a flick through her notes. The first thing i saw was the body chart, the whole back was basically shaded, and the legs too...... this patient has arthritis, disc degeneration, spondylisis of the lumbar spine and some more problems!

She is really a nice lady with an european accent. The first thing i said to her was "How are you?" and i think thats where it went wrong. She spent about 15mins telling me how bad her pain was, and that it was everywhere, and it's sore in the morning, and at night and during the day, and she couldn't take meds for pain because she has stomach ulcers and it sometimes drops her BP. You just couldn't win..... i felt really sorry and helpless.

Anyway, i finally managed to get a word in, though it didn't help, i just asked her specifically where her pain was. She was basically sore everywhere in her back. Any type of movement will bring on her pain, she was just ..........in pain! After chatting to my supervisor he educated me about these types of patients (chronic pain sufferers). There are yellow flags flashing everywhere. I needed to understand i couldn't get rid of her pain, next week her pain will be the same, and unfortunately, it will only get worse with age. He told me that i could only really provide some temporary relief with massage or heat pack and to maintain her mobility with general mobility exercises. And i thought physios were meant to treat people, like if someone had an ankle sprain, you do U/S, massage, PAMs etc and they get better and you fix them. But for chronic pain sufferers like my patient, it was important NOT to focus on pain and maybe even focus on more positive things such as exercises, how much more she could move in the last week and how many repetitions she could complete.

What i learnt was that we can't always "cure" everyone and not everyone will be pain free. Sometimes it's a matter of teaching and educating the patient on how to manage their pain and that's enough! I have seen other patients with similar issues since this episode and have taken the focus off pain and tried to focus on more positive aspects of their life. If you do that, the treatment session will run much more smoothly and you'll finish on time!