Situation
40 yr old male presented to the physiotherapy clinic with insidious onset of LBP that started 2/52 ago and has remained consistent throughout that period of time. The pain is localized to his left lower back and was described as an aching pain that becomes tight with certain movements and positions. The pain is worst when waking in the morning when it feels stiff and loosens up as the day progresses. The pain is aggravated by sustained standing and with walking for long distances (~20mins). It is eased with sitting or lying down. All special questions were negative and no other issues were present.
The patient has a history of LBP. 6/12 earlier he presented with LBP under the same conditions and was forced to take 3/52 off his work as a fitter working at a minesite (no time has been taken off work on this occasion). He received physiotherapy on this occasion which treated him for decreased mobility within the lumbar spine and prescription of exercises to improve lumbar muscle control.
Task
I was to conduct a thorough objective assessment to explore if this occasion was similar to previous and then treat as required to decrease his impairment and prescribe exercises to minimise the chance of this problem occurring again.
Action
The examination was begun by explaining to the patient how the session would be progressing and that with information we gained from the examination a treatment would be determined & delivered to solve his problem.
I began by assessing all active movements of the lumber spine; flexion, extension, left & right side flexion. From this it was found that flexion and RSF were restricted and thus were the asterisk movements. SLR was then tested in supine which found that L was less than R, with pain at the end of range for left SLR. This could be used as a baseline measure to be re-tested at the end of the treatment. PAIVMs were then applied to the lumber spine with the patient in prone to determine an asterisk level. It was found that L4-5 on the R, L4 central & L3-4 on the L were all stiff with L4-5 painful on the R.
Treatment was then decided to be PPIVMs to promote RSF by treating in R rotation & slight flexion of the lumbar spine. Also unilateral PAs on L3-5 on the L in lumbar spine flexion & central PAs on the same levels in the same position. Soft tissue massage was performed on the quadratus lumborum on the L to loosen the muscle that may be restricting RSF.
Result
The patient responded well to the PPIVMS and PAVIMs with increases in flexion & RSF with the patient also commenting that it felt less restricted. At the end of treatment the massage was used and this actually worked against us and returned the patient to his previous level of restriction. The previous mobilizations were repeated which gave the patient back the freedom he initially had.
Evaluation
The initial mobilizations were very effective and noticeable changes occurred in the patient’s ROM. When treating on a couple of occasions I neglected to re-measure the patients ROM after each set as I assumed they would still be having the same effect. I also didn’t re-assess the patient’s SLR which although not crucial could have been a good way of assessing the success of the treatment. I didn’t perform any clearing tests to assess the involvement of the hip or thoracic spine. It turned out that there was no involvement but I was too focused on the lumbar spine as the source of pain which it was but deficiencies in the other areas could be contributing to this issue.
Strategies
Next I will behave more systematically and work through the process in stages. Re-assessment after every single treatment is critical as may mean the treatment isn’t right or that the treatment wasn’t applied correctly. LBP is a very common occurrence (approximately 40% of cases I’ve seen are LBP related) so I need to be clear on the progression of assessment and treatment for the sake of efficiency of the session.
Friday, March 26, 2010
Saturday, March 20, 2010
Initial Entry - Rotation 2: Kalgoorlie
For a while I have been looking forward to completing a rural placement and being in Kalgoorlie where I have lived before makes the transition all the more easier. I’ve always enjoyed getting away from Perth and getting a chance to take a break and in this case more time to spend studying & revising (since there isn’t a whole lot else to do in this town). From a clinical point of view I am excited about the chance to experience a musculoskeletal private practice setting and utilise the knowledge I have been accumulating since first year. For many years I have been treated in private practice settings so on this occasion I think I’ll find it interesting & rewarding to experience the profession from the other side of the plinth.
The catch is that from the other side of the plinth you are running the show. For all the other placements I’ve been on there has been patient notes, some more detailed than others, that essentially provided me with a picture of each patient before setting eyes on them. In private practice this luxury is not always available and this does provide a bit of uncertainty about what to expect with each patient. Even though I am still a student I would like to be at a level where I can efficiently & effectively diagnose patients by the end of the 5 week period which at the moment seems slightly daunting.
Another reason why I selected Kalgoorlie private practice as a placement is that I had heard good reports from other physiotherapy students that it was a great learning experience. This has been combined with reports of my supervisor being a hard task master & very challenging. Since I am very interested in private practice physiotherapy I hope that I am able to benefit as well as other people have in the past and learn a lot about physiotherapy in this environment.
Information I have gathered concerning my role has me observing for a couple of days then gradually increasing my involvement in the process to the point of treating the patients independently with consultation from the head physiotherapist. I believe this would involve me carrying out a subjective assessment, objective assessment and then treatment with input from my supervisor after each part. At this stage having my supervisor oversea all my actions would be beneficial but I hope to be able to accurately run a session with minimal supervisor input and importantly gain the trust of the patients since I see this as a potential major hurdle to furthering my involvement with patients. I hope to be able to develop a strong rapport with the patients that then transfers to them having confidence in my ability to treat them effectively.
There will also be a component of offsite work with visiting minesites to assess and treat people in their work environment. I am not sure what to expect from this at this stage but it will be an interesting experience to assess people at work and analyse first hand if factors at their workplace are impacting upon their health status as opposed to relying on second hand information.
Although daunting at this stage I am looking forward to experiencing a private practice environment and the broad range of conditions that should present themselves with being a first contact health practice. I hope to develop my professional and clinical skills to graduate levels and also enjoy the experience of potentially being the only health profession to treat and help individuals.
The catch is that from the other side of the plinth you are running the show. For all the other placements I’ve been on there has been patient notes, some more detailed than others, that essentially provided me with a picture of each patient before setting eyes on them. In private practice this luxury is not always available and this does provide a bit of uncertainty about what to expect with each patient. Even though I am still a student I would like to be at a level where I can efficiently & effectively diagnose patients by the end of the 5 week period which at the moment seems slightly daunting.
Another reason why I selected Kalgoorlie private practice as a placement is that I had heard good reports from other physiotherapy students that it was a great learning experience. This has been combined with reports of my supervisor being a hard task master & very challenging. Since I am very interested in private practice physiotherapy I hope that I am able to benefit as well as other people have in the past and learn a lot about physiotherapy in this environment.
Information I have gathered concerning my role has me observing for a couple of days then gradually increasing my involvement in the process to the point of treating the patients independently with consultation from the head physiotherapist. I believe this would involve me carrying out a subjective assessment, objective assessment and then treatment with input from my supervisor after each part. At this stage having my supervisor oversea all my actions would be beneficial but I hope to be able to accurately run a session with minimal supervisor input and importantly gain the trust of the patients since I see this as a potential major hurdle to furthering my involvement with patients. I hope to be able to develop a strong rapport with the patients that then transfers to them having confidence in my ability to treat them effectively.
There will also be a component of offsite work with visiting minesites to assess and treat people in their work environment. I am not sure what to expect from this at this stage but it will be an interesting experience to assess people at work and analyse first hand if factors at their workplace are impacting upon their health status as opposed to relying on second hand information.
Although daunting at this stage I am looking forward to experiencing a private practice environment and the broad range of conditions that should present themselves with being a first contact health practice. I hope to develop my professional and clinical skills to graduate levels and also enjoy the experience of potentially being the only health profession to treat and help individuals.
Friday, March 12, 2010
Final Entry - Rotation 1
Now that I have completed the first of my placements for the year I am much more prepared for the year ahead. On the first day I was thrown in the deep end to assess and treat a patient, which although being tough/daunting at the time put me in good stead for the remainder of the placement. This was shown by all 3 of my supervisors (everyone was taking holidays) feeling comfortable to leave me to my own devices & operate independently on a daily basis, with regular catch-ups through out the day. As I mentioned in my Initial Entry having just completed the cardio unit last semester I didn’t have to delve to far in the memory bank to find out what I needed to know. This made reading up on assessments and treatments far easier and consequently more effective in the hospital setting.
Before starting my placement I was anxious about getting treatments right given a patient may have multiple co-morbidities that complicate their cardiorespiratory problem. As I found almost all patients had a co-morbidity of some description but it was simply a matter of just scaling back the treat intensity and progressing as the patient improved. Surgical patient’s for example are regularly treated for respiratory complications following surgery under GA but their may concern obviously is their wound & main medical problem. I encountered this many times but it’s just a matter of working out what the patient can managed within pain limits without adversely impacting on the wound or the goal of the surgery itself. Thorough reading of the notes and effective communication with the patient are crucial to deciding what direction the intervention needs to head in.
My supervisor/s and I developed a great rapport over the period of the placement which translated into effective learning and confidence in me to conduct sessions independently. This meant that I spent the majority of the time working alone and running sessions and my case load to my own time schedule. This enabled me maximum time to develop the skills needed to treat patients in the hospital environment. Parts of those skills are liaising with other health professionals which was necessary on a daily basis. I developed a good relationship with the OTs and nursing staff and consulted with the medical team when necessary. This enabled more effective development of treatment options for each patient since it used the skills and knowledge of many instead of operating in my own little physio bubble. It also allowed effective planning of patient goals and ultimately discharge into the appropriate living environment
In my Initial Entry I mentioned that wanted to develop my communication and documentation skills. I believe that I improved markedly in both areas through developing strong rapports with patients and constantly working on time management and being concise with documentation. Both made it easier to decide on the treatment required and progression as well as patient compliance with ongoing exercise programs prescribed.
Before starting my placement I was anxious about getting treatments right given a patient may have multiple co-morbidities that complicate their cardiorespiratory problem. As I found almost all patients had a co-morbidity of some description but it was simply a matter of just scaling back the treat intensity and progressing as the patient improved. Surgical patient’s for example are regularly treated for respiratory complications following surgery under GA but their may concern obviously is their wound & main medical problem. I encountered this many times but it’s just a matter of working out what the patient can managed within pain limits without adversely impacting on the wound or the goal of the surgery itself. Thorough reading of the notes and effective communication with the patient are crucial to deciding what direction the intervention needs to head in.
My supervisor/s and I developed a great rapport over the period of the placement which translated into effective learning and confidence in me to conduct sessions independently. This meant that I spent the majority of the time working alone and running sessions and my case load to my own time schedule. This enabled me maximum time to develop the skills needed to treat patients in the hospital environment. Parts of those skills are liaising with other health professionals which was necessary on a daily basis. I developed a good relationship with the OTs and nursing staff and consulted with the medical team when necessary. This enabled more effective development of treatment options for each patient since it used the skills and knowledge of many instead of operating in my own little physio bubble. It also allowed effective planning of patient goals and ultimately discharge into the appropriate living environment
In my Initial Entry I mentioned that wanted to develop my communication and documentation skills. I believe that I improved markedly in both areas through developing strong rapports with patients and constantly working on time management and being concise with documentation. Both made it easier to decide on the treatment required and progression as well as patient compliance with ongoing exercise programs prescribed.
Week 5 STARES - Joondalup Cardio
Situation
I had been treating a 58 yr old man who had been admitted for acute exacerbation of COPD with ↑SOB occurring of the previous 1/7. He had a history of bronchiectatsis & had been admitted 4 times previously in the last year for the same condition (“frequent flyer”). The patient appeared very fatigued & anxious and was regularly productive of thick grey sputum which was evident due to widespread crackles & wheezes on auscultation as well as audible moisture when breathing & coughing. He was normally on home O2 @ 4L but was gradually put on increasing amounts as the days passed & eventually steadied at 35L O2 via high flow nasal prongs with humidification. In the time while I had been treating him he had had 2 MET calls (Medical Emergency Team) for increasing SOB at rest.
Task
From a physio point of view the main goals of treatment were to assist the patient with expectorating secretions, improve his SOB and improve his exercise tolerance. To assess the success of treatments I had to use auscultation and measures of exercise tolerance before & after treatment. Analysis of the patient’s sputum was also necessary.
Action
Subjective questioning was very difficult since the patients SpO2 regularly dropped from 97% to 90% just with talking, so clear concise questioning was a must. I asked questions about his previous levels of activity, what assistance he receives at home & who from, how his condition has progressed over time and what he has done at home in the past in terms of exercise & maintaining his health. Essentially to determine what his goals might be and if he is doing anything at home to prevent having more exacerbations.
Objectively I ausculatated and found that all areas of his lungs contained infiltrates (which was confirmed by CXR). Prior to the auscultation I asked the patient to cough which was strong, moist & productive of thick brown sputum (~1tspn). I then got the patient to walk which he could only manage for ~5m before his SpO2 dropped significantly and he became v. SOB+++. After the patient was allowed to recover for ~10mins I began to educate him on UL & LL ex’s which he responded to well and agreed to carry out when I wasn’t there seeing him. On the next occasion I carried out some percussions & vibrations after nebulisers had been administered but as time went by his tolerance for ambulation and percussion & vibes diminished as he was very anxious at how SOB he became with these interventions
Result
The percussion & vibes enabled the patient to expectorate some more sputum but since his lungs were very consolidated this did not show up in changes during auscultation. The patient reported that he had been completing the UL & LL ex’s in my absence but had suspicions about this fact since he could never accurately reproduce the exercises given to him.
The patient’s level of SOB and SpO2 were severely affected by my intervention which as mentioned made him very anxious and in numerous sessions refused to take part due to not feeling well or not being prepared to be involved. This was despite being explained what the benefits of physio treatment were.
Evaluation
The patient’s response to the treatments was very hard to tell as he was so negatively affected after each session yet expectorated large quantities of sputum. His anxiety contributed to me not being able to reassess what improvements had been made in this regard but I strongly suspected that no improvements had been made.
On one occasion a MET call was initiated which resulted in the Dr requesting more regular physio. It was explained to the patient by the Dr that he had to have physio. On reflection I should have been a bit more of a bully and pushed him in the earlier stages since a small bit of discomfort during physio could lead to big improvements later on.
Strategies
I think closer liaison with the medical team to explain the patient’s constant refusal for treatment may have alerted them to the fact that he was receiving little physio and action being taken sooner. As mentioned explaining even clearer & honestly to the patient the benefits of regular physio and that his state will deteriorate with constant refusal.
I had been treating a 58 yr old man who had been admitted for acute exacerbation of COPD with ↑SOB occurring of the previous 1/7. He had a history of bronchiectatsis & had been admitted 4 times previously in the last year for the same condition (“frequent flyer”). The patient appeared very fatigued & anxious and was regularly productive of thick grey sputum which was evident due to widespread crackles & wheezes on auscultation as well as audible moisture when breathing & coughing. He was normally on home O2 @ 4L but was gradually put on increasing amounts as the days passed & eventually steadied at 35L O2 via high flow nasal prongs with humidification. In the time while I had been treating him he had had 2 MET calls (Medical Emergency Team) for increasing SOB at rest.
Task
From a physio point of view the main goals of treatment were to assist the patient with expectorating secretions, improve his SOB and improve his exercise tolerance. To assess the success of treatments I had to use auscultation and measures of exercise tolerance before & after treatment. Analysis of the patient’s sputum was also necessary.
Action
Subjective questioning was very difficult since the patients SpO2 regularly dropped from 97% to 90% just with talking, so clear concise questioning was a must. I asked questions about his previous levels of activity, what assistance he receives at home & who from, how his condition has progressed over time and what he has done at home in the past in terms of exercise & maintaining his health. Essentially to determine what his goals might be and if he is doing anything at home to prevent having more exacerbations.
Objectively I ausculatated and found that all areas of his lungs contained infiltrates (which was confirmed by CXR). Prior to the auscultation I asked the patient to cough which was strong, moist & productive of thick brown sputum (~1tspn). I then got the patient to walk which he could only manage for ~5m before his SpO2 dropped significantly and he became v. SOB+++. After the patient was allowed to recover for ~10mins I began to educate him on UL & LL ex’s which he responded to well and agreed to carry out when I wasn’t there seeing him. On the next occasion I carried out some percussions & vibrations after nebulisers had been administered but as time went by his tolerance for ambulation and percussion & vibes diminished as he was very anxious at how SOB he became with these interventions
Result
The percussion & vibes enabled the patient to expectorate some more sputum but since his lungs were very consolidated this did not show up in changes during auscultation. The patient reported that he had been completing the UL & LL ex’s in my absence but had suspicions about this fact since he could never accurately reproduce the exercises given to him.
The patient’s level of SOB and SpO2 were severely affected by my intervention which as mentioned made him very anxious and in numerous sessions refused to take part due to not feeling well or not being prepared to be involved. This was despite being explained what the benefits of physio treatment were.
Evaluation
The patient’s response to the treatments was very hard to tell as he was so negatively affected after each session yet expectorated large quantities of sputum. His anxiety contributed to me not being able to reassess what improvements had been made in this regard but I strongly suspected that no improvements had been made.
On one occasion a MET call was initiated which resulted in the Dr requesting more regular physio. It was explained to the patient by the Dr that he had to have physio. On reflection I should have been a bit more of a bully and pushed him in the earlier stages since a small bit of discomfort during physio could lead to big improvements later on.
Strategies
I think closer liaison with the medical team to explain the patient’s constant refusal for treatment may have alerted them to the fact that he was receiving little physio and action being taken sooner. As mentioned explaining even clearer & honestly to the patient the benefits of regular physio and that his state will deteriorate with constant refusal.
Monday, March 1, 2010
STARES - Week 3
Situation
Every day the first port of call for the physiotherapist on each ward is to check the list of patients to see if new patients have been admitted, the status of all patients and if physiotherapy is indicated according to the medical team. There are usually 4 or 5 new patients every day but not all are for the physio to see. On one particular day a 62yr old gentleman had been admitted to the ward after a mechanical fall that morning which had resulted in him hitting his forearm and causing a distal fracture to the ulnar. This had been treated by the medical team with a plaster cast and pain relief….his stay in hospital was not expected to be long. Since it was a simple broken bone physiotherapy was not requested by the medical team
Task
On the ward I am currently on it is normal practice to check up quickly on each new patient no matter what the recommendation and then re-assess the situation from there. This is not intended to undermine the medical team but is simply put in place so that no at risk patients miss out on physio intervention that they may need.
Action
As with all patients the medical notes are analysed to determine the patient’s situation and if any important factors need to be taken into account when treating. This is usually a quick process but with patients that have a complex medical history it can take sometime to fit all the pieces together and determine the overall picture for the patient. As mentioned the notes of all new people are quickly scanned just to be sure that nothing had been missed by other health professionals.
Result
Following the analysis of the notes of the individual in question (62yr old man) my supervisor and I realised that the man had been admitted previously for exacerbation of COPD on 2 separate occasions. Even though this patient was not in hospital for any respiratory compromise we delved a bit further and discovered he was a smoker of some 40+ yrs. We then consulted the medcial team to see if we could see him with reference to managing his COPD, which they had no issue with at all. After speaking with the gentleman we discovered his exercise tolerance was very low secondary to SOB, he lived alone, didn’t leave his home very often and importantly had had 2 recent near miss falls as a result of SOB and fatigue (nearby furniture was used to support himself)
Evaluation
As a result we decided that physiotherapy intervention from a cardio-respiratory point of view was warranted even though it did not appear to be the underlying cause of this current hospitalization. The patient had clearly not had sufficient help regarding maintenance of a healthy lifestyle and no opportunities to regularly check up on his status. In terms of assessing whether this patient was appropriate for physio the correct and standard process was used whereby the notes were analysed, the medical team was consulted and the patient himself was spoken to with regards to the management of his COPD. My supervisor and I then determined that it was necessary to assess and treat this patient to post-pone but hopefully prevent another very likely admission for exacerbation of COPD as well as improving his lifestyle through education and increasing his independence once he got back home.
Strategies
In a hospital a physio is positioned to listen to doctors orders and take them at face value, either treat or don’t treat. As physio students most of time we would follow this protocol strictly but as I learnt from my supervisor we have to be proactive and assess things for ourselves since we shouldn’t let the orders of a medical team restrict us from seeing a patient since the patient’s health is always the main consideration. I learnt that spending a little extra time looking through the notes of a patient to see if physio should really be indicated can pay huge dividends in the future.
Every day the first port of call for the physiotherapist on each ward is to check the list of patients to see if new patients have been admitted, the status of all patients and if physiotherapy is indicated according to the medical team. There are usually 4 or 5 new patients every day but not all are for the physio to see. On one particular day a 62yr old gentleman had been admitted to the ward after a mechanical fall that morning which had resulted in him hitting his forearm and causing a distal fracture to the ulnar. This had been treated by the medical team with a plaster cast and pain relief….his stay in hospital was not expected to be long. Since it was a simple broken bone physiotherapy was not requested by the medical team
Task
On the ward I am currently on it is normal practice to check up quickly on each new patient no matter what the recommendation and then re-assess the situation from there. This is not intended to undermine the medical team but is simply put in place so that no at risk patients miss out on physio intervention that they may need.
Action
As with all patients the medical notes are analysed to determine the patient’s situation and if any important factors need to be taken into account when treating. This is usually a quick process but with patients that have a complex medical history it can take sometime to fit all the pieces together and determine the overall picture for the patient. As mentioned the notes of all new people are quickly scanned just to be sure that nothing had been missed by other health professionals.
Result
Following the analysis of the notes of the individual in question (62yr old man) my supervisor and I realised that the man had been admitted previously for exacerbation of COPD on 2 separate occasions. Even though this patient was not in hospital for any respiratory compromise we delved a bit further and discovered he was a smoker of some 40+ yrs. We then consulted the medcial team to see if we could see him with reference to managing his COPD, which they had no issue with at all. After speaking with the gentleman we discovered his exercise tolerance was very low secondary to SOB, he lived alone, didn’t leave his home very often and importantly had had 2 recent near miss falls as a result of SOB and fatigue (nearby furniture was used to support himself)
Evaluation
As a result we decided that physiotherapy intervention from a cardio-respiratory point of view was warranted even though it did not appear to be the underlying cause of this current hospitalization. The patient had clearly not had sufficient help regarding maintenance of a healthy lifestyle and no opportunities to regularly check up on his status. In terms of assessing whether this patient was appropriate for physio the correct and standard process was used whereby the notes were analysed, the medical team was consulted and the patient himself was spoken to with regards to the management of his COPD. My supervisor and I then determined that it was necessary to assess and treat this patient to post-pone but hopefully prevent another very likely admission for exacerbation of COPD as well as improving his lifestyle through education and increasing his independence once he got back home.
Strategies
In a hospital a physio is positioned to listen to doctors orders and take them at face value, either treat or don’t treat. As physio students most of time we would follow this protocol strictly but as I learnt from my supervisor we have to be proactive and assess things for ourselves since we shouldn’t let the orders of a medical team restrict us from seeing a patient since the patient’s health is always the main consideration. I learnt that spending a little extra time looking through the notes of a patient to see if physio should really be indicated can pay huge dividends in the future.
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