The 5 weeks I spent in Kalgoorlie proved to be easily the most challenging clinical placement thus far. I was aware that it wasn’t going to be an easy placement but being put into the environment of a private practice opened my eyes to the difficulty involved with not only being a good clinician but also aware of physiotherapy from a business point of view. I found that being able to put all the musculoskeletal learning and knowledge into practice very rewarding since for years we have been assessing and treating each other which 99% of the time means not finding any issues. So to actually assess someone, find an issue, treat the issue and improve their movement or reduce their pain was very rewarding and made it a lot easier to understand the nature of conditions and how they can be improved.
As I mentioned prior to commencing this placement one of the main difficulties I thought I would face would be diagnosis and not having access to a clear and thorough medical history as is provided at hospitals. Initially I found this particularly overwhelming with not only having to diagnose the problem but make it quick and then figure out a treatment and plan all while questioning the patient and thinking about the situation on the go. As I saw more patients this process became more effcicient and I was able to quickly diagnose but I understand that there is still a lot of work to do and this process will be refined more and more after finishing study.
I could not have anticipated the intensity of the placement and the amount of information being thrown at me. As mentioned there is always more to learn both for the rest of the year but also beyond graduation but I believe that I made some very strong and solid in roads into developing my skills and also made me aware of just how much there is to know. I also refined the process of knowledge acquisition to make learning much more efficient and enable me to accurately learn of the many different clinical conditions and how they may present to the physiotherapist.
As I gathered I began the placement from more of an observer point of view but was regularly quizzed on what was happening in the room to ensure I was clear on the session’s situation. As time went on and I began developing my skills I was able to treat patients with more and more independence. By the end I was confident with conducting an efficient and effective treatment session.
Kalgoorlie really did open my eyes as to how far physiotherapy students really have to go before they become completely proficient. The learning never stops and we need to be open to continuing this development and also strive to add more skills every time we are exposed to the clinical environment.
Sunday, April 25, 2010
Sunday, April 18, 2010
Week 5 STARES - Kalgoorlie MSk
Situation
On the 16th of April a 25 yr old man presented with LBP and hamstring tightness following a soccer game 3 days earlier. The hamstring tightness occurred immediately following the game and the LBP presented the next morning. Since this time the pain/tightness has gotten gradually worse and he presented looking very stiff with slow movements. He felt that his left hamstring was tighter but overall the pain in his lower back, gluteals and hamstring is bilateral. This same situation has occurred on 3 other occasions but none as bad as this and all had resolved with no intervention. His pain was aggravated by activity especially with twisting and when standing or sitting for an extended period of time. The pain would ease off with rest and lying down. The patient had not had any time off work but had ceased playing sport since the incident. Prior to visiting the physiotherapist he had consulted a chiropractor who had manipulated the patient with only moderate immediate pain relief but the pain had returned worse the next day. No official diagnosis had been reported to the patient during these visits.
Task
To determine the nature of the patient’s injury by performing the required musculoskeletal examination and generate a working diagnosis to then treat the patient and reduce his symptoms to allow him operate with less pain.
Action
Initially I had the patient perform Active ROM movements to determine into what directions he is mainly deficient. He was restricted into all directions with flexion being the asterisk direction. His pain was increased when returning from any given direction to neutral position. His straight leg raise was 40° on left and 50° on the right, both very low for someone so young and active. Due to the bilateral nature of his symptoms it was necessary to perform some neural integrity testing to ascertain what neural involvement might be present. His patella tendon reflex on the right was noticeably reduced relative to the left, but all myotomes and sensation testing was negative. A slump test was then performed which produced a positive result, especially on the right where knee extension was stopped as a result of pain 5° short of full extension with the neck extended and 20° short with passive neck flexion added. After this neural testing the patient reported slight tingling in his right foot.
Result
The most important diagnosis to be made was that there were some definite neural issues which with the bilateral nature of the symptoms suggest a discal pathology impacting upon the spinal nerves, mainly on the right. As a result there is also some facet and muscle restrictions possibly as a reaction to the dysfunction being caused by the problem disc. The exact level was not clear but it is likely to be at either the L3/4 or L4/5 level.
Evaluation
Since I had never come across a patient who had diminished reflexes this was something new for me and hence had to think differently to what I had previously. I was fairly comfortable with the diagnosis but in terms of a treatment for the disc dysfunction I was not clear on which direction things had to head. Techniques to reduce the load on the disc such as traction were an option but after discussions with my supervisor we did not know the exact nature of the disc so improving the patient’s movement was the primary goal for this first session by using mobilizations techniques.
Probably the main difficulty I had with this patient was explaining to him the nature of the issue but also making him understand that having a disc problem is very common and not as debilitating as most people believe. His anxiety increased after receiving this news so limiting this became a very important factor. My supervisor was able to assist me with explaining to the patient in the best possible way the situation and that referral to a specialist could be an option.
Strategies
The most important thing I should take away from this scenario is that I need to keep the patient’s needs and limitations in mind and not hope to cure them in one session, especially with a more complex case as presented here. But in saying that some progress should be achieved to improve the patient’s function and maintain as normal as possible their ADLs. Explaining the situation to the patient and what the possible progression will be is something I need to work on and this involves me learning a lot more about the condition and what the options are for treatment.
On the 16th of April a 25 yr old man presented with LBP and hamstring tightness following a soccer game 3 days earlier. The hamstring tightness occurred immediately following the game and the LBP presented the next morning. Since this time the pain/tightness has gotten gradually worse and he presented looking very stiff with slow movements. He felt that his left hamstring was tighter but overall the pain in his lower back, gluteals and hamstring is bilateral. This same situation has occurred on 3 other occasions but none as bad as this and all had resolved with no intervention. His pain was aggravated by activity especially with twisting and when standing or sitting for an extended period of time. The pain would ease off with rest and lying down. The patient had not had any time off work but had ceased playing sport since the incident. Prior to visiting the physiotherapist he had consulted a chiropractor who had manipulated the patient with only moderate immediate pain relief but the pain had returned worse the next day. No official diagnosis had been reported to the patient during these visits.
Task
To determine the nature of the patient’s injury by performing the required musculoskeletal examination and generate a working diagnosis to then treat the patient and reduce his symptoms to allow him operate with less pain.
Action
Initially I had the patient perform Active ROM movements to determine into what directions he is mainly deficient. He was restricted into all directions with flexion being the asterisk direction. His pain was increased when returning from any given direction to neutral position. His straight leg raise was 40° on left and 50° on the right, both very low for someone so young and active. Due to the bilateral nature of his symptoms it was necessary to perform some neural integrity testing to ascertain what neural involvement might be present. His patella tendon reflex on the right was noticeably reduced relative to the left, but all myotomes and sensation testing was negative. A slump test was then performed which produced a positive result, especially on the right where knee extension was stopped as a result of pain 5° short of full extension with the neck extended and 20° short with passive neck flexion added. After this neural testing the patient reported slight tingling in his right foot.
Result
The most important diagnosis to be made was that there were some definite neural issues which with the bilateral nature of the symptoms suggest a discal pathology impacting upon the spinal nerves, mainly on the right. As a result there is also some facet and muscle restrictions possibly as a reaction to the dysfunction being caused by the problem disc. The exact level was not clear but it is likely to be at either the L3/4 or L4/5 level.
Evaluation
Since I had never come across a patient who had diminished reflexes this was something new for me and hence had to think differently to what I had previously. I was fairly comfortable with the diagnosis but in terms of a treatment for the disc dysfunction I was not clear on which direction things had to head. Techniques to reduce the load on the disc such as traction were an option but after discussions with my supervisor we did not know the exact nature of the disc so improving the patient’s movement was the primary goal for this first session by using mobilizations techniques.
Probably the main difficulty I had with this patient was explaining to him the nature of the issue but also making him understand that having a disc problem is very common and not as debilitating as most people believe. His anxiety increased after receiving this news so limiting this became a very important factor. My supervisor was able to assist me with explaining to the patient in the best possible way the situation and that referral to a specialist could be an option.
Strategies
The most important thing I should take away from this scenario is that I need to keep the patient’s needs and limitations in mind and not hope to cure them in one session, especially with a more complex case as presented here. But in saying that some progress should be achieved to improve the patient’s function and maintain as normal as possible their ADLs. Explaining the situation to the patient and what the possible progression will be is something I need to work on and this involves me learning a lot more about the condition and what the options are for treatment.
Saturday, April 10, 2010
Week 3 STARES - Kalgoorlie MSk
Situation
On the 6th of April a 45yo lady presented to me with right calf pain following a traumatic incident at a netball game 2 days prior. She had been running when she suddenly felt pain in her calf and was unable to continue playing. There was no previous history of calf injury or issues and up till consulting a physio she had been icing 2x/day and only walking on crutches due to significant pain when walking especially just prior to push off and with push of itself. From the history of incident the most likely diagnosis was likely to be a strained or torn calf muscle.
Task
To confirm the nature of the injury and rule out other possible issues by completing a thorough objective assessment. Then I was to conduct a treatment and advise the patient on home maintenance and exercises to manage & treat the injury.
Action
The examination initially involved seeing what active movements the patient could achieve. She could only dorsiflex to ~2° before pain was produced during a bilateral squat and couldn’t perform a heel raise on her right leg due to pain. Her single leg balance on her right was less than the left but she could still maintain her balance with more postural sway for 30 seconds. Passively her dorsiflexion with her leg straight was far more painful than with the knee bent. There was some bruising in the medial head of her right gastroc and her achilles tendon was slightly decreased in width relative to the left. She was very tender on palpation in her medial gastroc and a noticeable depression was felt within the medial gastroc head. She was also very tender around the medial border of the right Achilles close to the musculo-tendon junction.
From this assessment and the patient’s history it was determined that the patient had suffered a Grade 2 right medial head gastroc strain and also a strain on the structures at the musculo-tendon junction on the medial side of her achilles tendon.
The treatment in this early stage was very conservative with only ultrasound and some gentle soft tissue massage used. The main emphasis at this early stage was patient education and home exercises. She was encouraged to use her crutches when having the walk long distances, avoid use around the home and wear shoes to limit dysfunction due to an aberrant gait pattern. Some very low grade stretching using a towel and the use of hot/cold therapy to decrease swelling and pain was also prescribed.
Result
The patient seemed aware of the situation and was happy to take heed of my instructions and not cause herself anymore damage. The treatment in the practice was not designed to improve her status there and then but simply but her tissue into a better position to begin the healing process.
Evaluation
The patient was eager to follow the instructions given to her but when she returned two days later I found that she had not followed them as I had desired. Her pain had increased and she was limping noticeably. I had given her simple instructions to follow but I believe that the way I explained it to her was what caused the misunderstanding. The only exercises I gave her had been conducted correctly but she had been experiencing pain after each session but this did not deter her from repeating when the next set was required. Once again I should have explained to her to use pain as her guide and only continue if there is not pain or it is at a manageable level.
Strategies
I need to ensure that I explain clearly to the patient that pain should be used as a guide to limit her with the exercises and with ambulation. Because everyone’s ideas of pain differ I need to use more a measureable guide to limit her activity levels. In these early stages a hard and fast rule of use crutches every time you go outside would have been better than letting the patient decide when and where to use them. Using partial weight bearing and trying to imitate the movement the foot should be doing would have also been useful otherwise the patient would probably think they could walk on it normally with just some balance support from the crutches. Essentially clear and concise explanation of what the patient should be doing and exactly how much of it throughout the course of the day is required to maintain improvements in tissue structure and also limit dysfunction.
On the 6th of April a 45yo lady presented to me with right calf pain following a traumatic incident at a netball game 2 days prior. She had been running when she suddenly felt pain in her calf and was unable to continue playing. There was no previous history of calf injury or issues and up till consulting a physio she had been icing 2x/day and only walking on crutches due to significant pain when walking especially just prior to push off and with push of itself. From the history of incident the most likely diagnosis was likely to be a strained or torn calf muscle.
Task
To confirm the nature of the injury and rule out other possible issues by completing a thorough objective assessment. Then I was to conduct a treatment and advise the patient on home maintenance and exercises to manage & treat the injury.
Action
The examination initially involved seeing what active movements the patient could achieve. She could only dorsiflex to ~2° before pain was produced during a bilateral squat and couldn’t perform a heel raise on her right leg due to pain. Her single leg balance on her right was less than the left but she could still maintain her balance with more postural sway for 30 seconds. Passively her dorsiflexion with her leg straight was far more painful than with the knee bent. There was some bruising in the medial head of her right gastroc and her achilles tendon was slightly decreased in width relative to the left. She was very tender on palpation in her medial gastroc and a noticeable depression was felt within the medial gastroc head. She was also very tender around the medial border of the right Achilles close to the musculo-tendon junction.
From this assessment and the patient’s history it was determined that the patient had suffered a Grade 2 right medial head gastroc strain and also a strain on the structures at the musculo-tendon junction on the medial side of her achilles tendon.
The treatment in this early stage was very conservative with only ultrasound and some gentle soft tissue massage used. The main emphasis at this early stage was patient education and home exercises. She was encouraged to use her crutches when having the walk long distances, avoid use around the home and wear shoes to limit dysfunction due to an aberrant gait pattern. Some very low grade stretching using a towel and the use of hot/cold therapy to decrease swelling and pain was also prescribed.
Result
The patient seemed aware of the situation and was happy to take heed of my instructions and not cause herself anymore damage. The treatment in the practice was not designed to improve her status there and then but simply but her tissue into a better position to begin the healing process.
Evaluation
The patient was eager to follow the instructions given to her but when she returned two days later I found that she had not followed them as I had desired. Her pain had increased and she was limping noticeably. I had given her simple instructions to follow but I believe that the way I explained it to her was what caused the misunderstanding. The only exercises I gave her had been conducted correctly but she had been experiencing pain after each session but this did not deter her from repeating when the next set was required. Once again I should have explained to her to use pain as her guide and only continue if there is not pain or it is at a manageable level.
Strategies
I need to ensure that I explain clearly to the patient that pain should be used as a guide to limit her with the exercises and with ambulation. Because everyone’s ideas of pain differ I need to use more a measureable guide to limit her activity levels. In these early stages a hard and fast rule of use crutches every time you go outside would have been better than letting the patient decide when and where to use them. Using partial weight bearing and trying to imitate the movement the foot should be doing would have also been useful otherwise the patient would probably think they could walk on it normally with just some balance support from the crutches. Essentially clear and concise explanation of what the patient should be doing and exactly how much of it throughout the course of the day is required to maintain improvements in tissue structure and also limit dysfunction.
Subscribe to:
Posts (Atom)