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.
Tuesday, July 29, 2008
Monday, July 28, 2008
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.
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.
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.
Tuesday, July 22, 2008
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.
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.
Monday, July 21, 2008
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.
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.
Saturday, July 19, 2008
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.
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.
Thursday, July 17, 2008
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.
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.
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