Week 5.1 Entry

The patient we saw today was progressing very well since we had seen 2/52 ago. She had had a TKR and we were dealing with her return to normal function and reporting back to her surgeon when the time came. She did not believe that she was moving along well at all but we reassured her that she is going very well and on track to having a great recovery from such an invasive operation. In the first week we may not have been able to make this call but with treating 6 patients and dealing with another 10 people in a class designed for those people who have undergone TKRs we felt we were in a good position to offer our opinion on how she was progressing. The patient had also been ill the last few weeks and showed some concern for possible complications such as infection. Our supervisor was able to offer his thoughts on the situation and suggested that the patient mention this to her doctor when she visited him in the next couple of days.

This made me think about all the questions we ask that are designed to clear the possibility of more severe conditions such as infection, cauda equina issues and vertebral artery insufficiencies. At what point does an answer warrant more investigation. For instance we have had many patients who have mentioned losing 5kgs in 2 weeks, dizziness with certain movements or increased frequency of urination. Ultimately most people will lose some weight following surgery thru decreased exercise and food intake, many people get small dizzy spells when moving suddenly etc. Since most of the time the question can appear odd in the context of a musculoskeletal examination, (as we discovered when we asked a 16yo girl about her bowel/bladder function) a patient may begin to worry that there may be something more severe wrong with them. Therefore having a thorough knowledge of the specifics of the question is vital so the patient can be assured that it is simply a routine question. The prevalence of such circumstances may be very low but I’m guessing that at some point in all of our careers we will be faced with dealing with such a situation and it is not something we should disregard at this stage.

At this point in the placement I am feeling very comfortable and confident with treating patients, more so the communication side of things and just making the patient feel comfortable to discuss and trust the treatments which we are applying. I have found that I have developed my ability to explain to patients clearly what is occurring and make them understand what my intention is and how they will progress with time. Also I see that it is very important to build a complete and smooth assessment and treatment process so that the patient can have total confidence in the physiotherapist, as I increase my knowledge base about all the different conditions I imagine this will become second nature to me.

If possible the best option is to plan the process ahead of time and anticipate numerous different scenarios and then deal with the situation as it presents itself. We have learnt this many times with expecting simple situations but been suprised when a patient has many more complicating factors than we could have imagined.

Week 4.3 Entry

Today we saw the disappointment that can occur when a patient’s return is not as quick as they would have hoped or that they were promised.

I have spoken about the patient with bilateral calcaneal fractures after falling from a height several weeks ago. His progress has been steady but as expected slow which he understands to a certain extent but is very keen to get back to work since he is not receiving any workers compensation and is self employed. His work involves him working at height and at some points he needs to jump down from scaffolding that is up to 1m off the ground. He thought that this may be possible sooner rather than later but with an injury such as a fracture and particularly on a constantly weight bearing structure as the calcaneus this is not going to be happening in a hurry. As well the soft tissue damage may not be sufficiently strong and stable enough to allow him to land from such a height. He controls his emotions very well and but it was obvious that he was annoyed that his return would be delayed. To make the matter even worse we made a comment that he should stop drinking everyday….well before midday anyway. This seemed ridiculous to him but when we told him that alcohol is not helpful for improving his injury he seemed to realize that he may need to make the change.

Another patient of ours was recovering from a TKR approximately 8/52 ago and was doing really well when we first saw him and had only improved from there. He could walk well and was affected more by pain in his other knee. Last week we had progressed him to low grade WB ex’s which he was managing very well and was expecting to move him onto some higher grade ex’s and include some more functional ex’s. This session was to be after his visit to the surgeon to see how his knee was going and also decide if he was able to return to work (just gardening and maintenance at a primary school). All 3 of us had expected for him to be able to return to work and were anticipating this by organizing a more extensive exercise list for him to leave us with. Unfortunately the surgeon rejected his request to return to work! This was after the surgeon said originally that he should be able to return to work. His reasoning was….wait for it….the prothesis he had put in was not designed for work such as his!! Bec and I were as amazed as the patient (our supervisor couldn’t believe it as well) and decided that we would keep seeing him but 2/52 apart from now on. The patient is needing to get the other knee done in the near future so was not as forceful with getting an explanation out of him but we expect him to get pretty fired up after the second operation. It was important that we assured him that he was doing really well and to look on the brightside that he gets a permanent holiday on retirement but he really wanted to keep busy.

I realized that it is important to not promise too much to patients and give them false hope on where they will end up by the end of their rehabilitation. Giving a conservative opinion is the best option and possibly avoiding giving a stead fast answer is even better. Everything health professionals say is often taken as gospel by patients and people will base their life around the predictions we have made.

Week 4.1 Entry

At this stage of our placement we are predominantly seeing patients who we have seen before and their treatment revolves mainly around applying similar treatment techniques as previously or modifying them if the desired results aren’t being achieved. Assessing the benefits of the exercises prescribed and progressing these is also important since we will hopefully be discharging a lot of our patients and we need them to be able to continue improving/maintaining their situation.

All of our patients today were making headway with their recovery and the decision had to be made whether we were to progress with treatment/exercises dependent on our latest assessment. With some of them it had gotten to a point where they were coming along great but they simply had to increase their strength and the only way to do this was to keep the same exercise but increase the resistance. Not very exciting for the patient but therabands can only take you so far. This is problem for those that find trouble weight bearing for example but need a high resistance for their HEP. Very few patients will have any kind of exercise equipment at home. We have needed to become a bit inventive on occasion to keep the patient interested and also progress the exercise.

One of our patients is working through a VMO/ leg strengthening exercise program and is almost pain free and able to walk up stairs which he had trouble with before. We moved his exercises to weight bearing and far more functional than the previously used theraband. He enquired about possibly being given the all clear and sent on his way. Since this was the first week which we had seen a significant improvement in his condition and we were only getting onto some tougher exercises today we decided that we needed to see the results from this latest exercise prescription and then reassess. Of course we want to see him head off in a better state but not too soon since we think that it is vital he is aware that his situation needs to be maintained and exercises need to continue well after we have stopped seeing him. Otherwise he will simply be back in a few months complaining of the same problem.

This made me aware of how important it is to have a discharge plan even in an outpatients setting. The proposal at the start of our placement was to formulate a plan to discharge the majority of our patients by the end of our 5 week stint. Some of them will be fine to discharge with exercises to continue their improvements whilst others will need to be handed over to the other physiotherapists which will require detailed handover notes and short & long term goals. This will be an important part of life in the physio world so the sooner I get the hang of it the easier it will be when the real world is reached in 2yrs.

Week 3.4 Entry

Today we learnt just how long some people can be waiting for a physiotherapy appointment within the public hospital system. Our first patient of the day was suffering from anterior knee pain according to the referral for the last 2/52….this was in May. Therefore by the time he was passed onto us he was now at 24/52 and unsurprisingly did not turn up. This made me aware that by the time some patients see us they can be quite frustrated at how long it has taken and possibly also in a worse state than when the referring doctor saw them, therefore it is wise to take this into consideration when assessing a patient.

One of our patients today was returning following a conservatively managed partially ruptured Achilles tendon and a HEP we had prescribed to her. The last time we saw her she had only just had her plaster removed and we were a bit cautious with our treatment and exercises we gave her since she had not seen her doctor as yet and did not want to cause her any additional harm or damage. Our aim this time was to progress her exercises to eccentric movements and begin the realignment of the collagen fibres to make the tendon structurally stronger. This would need to be a balancing act between too much and too little progression. We made the patient aware that despite her not feeling too much pain there was still the chance that damage could be done and she’d be put back a few places in terms of recovery. She appeared to understand the situation.

We searched the depths of our knowledge from PHTY111 days and applied Deep Transverse Frictions to realign the fibres and effleurage to redistribute the swelling. The treatments appeared to be effective and the patient commented that the foot felt better. This treatment regime would be used again next time. Her HEP was progressed to involve some PWB exercises but we emphasized that she should not push it into pain and just a slight stretch should be felt.

Overall the patient appeared very pleased with her progress which showed to us that we had selected the correct treatment program and our clinical reasoning in terms of the speed of progressions was justified. We questioned her about more than the current Achilles problem and looked at her lifestyle and how she is modifying it to benefit her overall health & well being. She suffers from COPD and still smokes so we ensured that she was endeavouring to quit but obviously for a life long smoker this is going to be a long and hard road. She had modified her medication to decrease her reliance on them and begin a more “natural form of recovery”.

I look forward to seeing this patient again next week and discharging her with a continuing HEP to maintain her current recovery progress.

Week 3.2 Entry

Almost half way and still getting along with my sidekick…who would have thought.

Once again even though we were referred this patient we weren’t completely sure of what was going on due to the ineligible nature of the doctors hand writing. We were aware of the patient’s presenting condition but beyond that we were clueless. Turned out the patient had 2 x THR approximately 2yrs ago which greatly affected our initial thoughts on what direction to take the assessment in. For example we wanted to determine if glut med was tight and playing a part in the discomfort the patient was feeling but the stretch required had the patient in F, and Add…big C/I for people with THRs. Another complication was that the patient experienced pain very easily which made assessment and subsequent treatment very difficult. The subjective part of the assessment was also long and time consuming but covered all major aspects. We were able to pin point where the Rx and HEP should be directed based on the patient’s concerns and the objective findings. The patient was revisiting the surgeon in 2/52 so we held back on progressing her too fast until the surgeon had an opportunity to assess her progress and complications.

We found difficulty working with the patient due to her sensitivity to mvts. We did not want to push her too far beyond her pain threshold since we could see that she was very apprehensive about troubling her hip. I suspect there may have been some exaggeration with regards to pain so that we did not test her too much. As to be expected during an initial consultation where everything is being assessed the patient’s primary issue becomes quite irritable making all further assessment and treatment at the time a bit more difficult. This was the case today and hopefully our next session will be a lot more targeted and streamlined towards the main problems. We have seen a quite a few THR and TKR patient’s and have started to build up a list of assessment objectives and exercises for the different stages of recovery. To make this knowledge second nature would make prescribing and progressing treatment more effective.

As I mentioned being able to target the session more next time will give me more confidence in what we have found out and that our intervention is progressing in the correct direction. A lack of information leaves holes in the findings and possible problems with the intervention. The patient needs to know throughout the whole process what is happening and be assured that they will be able to return to what they are limited in doing…..I need to make an extra special point of attempting to find out about the patient’s social history and showing an interest in helping them return.
I can imagine from a patient’s point of view they have already been to see Drs, surgeons, other physios and been through the whole assessment process many times before so that, to certain extent, expect all follow up professionals to know exactly where they are at and what the main issues are and how things should progress. This is very much not the case! For this reason the subjective questioning needs to be targeted and succinct but still be able to gain a clear picture of what we are dealing with. I feel that I have developed this over time by not spending excessive amounts of effort on enquiring about information that will in effect not be a major factor in the intervention thus making the entire process as simple and straight forward as possible for the patient.

Week 2.3 Entry

After our last experience of someone with “just knee pain” we were a bit more prepared for a few more possible scenarios. Would be great if the referring doctors could put down a bit more detail on the patients they are sending our way but I’m sure I’ll be waiting along time for that miracle to happen. The patient had injured her L knee from overuse approximately 9/52 ago without a single specific incident causing the pain. She had surgery 10/12 ago on the same knee to clean out debris and lose cartilage but had suffered no further pain after this which was interesting considering the period between that and her current pain. From the outset we could sense that this patient was impressed with her own ability to withstand pain and exaggerate the pain experience. This made it somewhat difficult at times to decipher exactly what the extent of pain was and how it was actually limiting her and what it meant in the scheme of things. Once again I learnt that even though you may ask about every possible joint and issue the patient will still miss fairly significant pieces of information. In this case she had dislocated her right patella twice with no further complications but this then lead to us learning that there is a family history of unstable patellas and this could be contributing to the current problem in her left leg. Maybe we should make an extra special point of clearing all possible problems with the contralateral side.

The patients sensitivity to movements meant she had only approximately 20° of mvt (could not be moved passively). Strength could not be measured as a result and no other special tests were possible. Despite all this we agreed that the most important course of action was improve the ROM. We were not to sure as to whether we should be pushing her beyond her pain limits (10/10 at EOR) but our supervisor realised that no further damage was going to be done and increasing her ROM was paramount. I have realised that there is a certain amount of bullying of patients that needs to be done to get results but only when it’s safe and within limits. This requires a great amount of trust in the PT by the patient.

It was important to make it very clear to the patient that the sooner we can get her to full function the sooner she could return to work and this means a lot of hard work and most likely an amount of pain. We need to make her aware that pushing beyond the pain will be required sometimes but this will still need to be monitored closely as it could get to a point where additional damage is being caused. With other patients I will push them a bit more beyond their initial pain to enable a better assessment and treatment result.

Week 2.2 Entry

Myself and Bec experienced what will probably happen many more times in our careers as physios….we doubled booked. This worked out well for us though given that both were returning patients and the assessment aspect wasn’t as in depth as the first time and it also gave both of us an opportunity to run through the whole assessment process individually. My patient was returning after a bilateral calcaneal fracture 9/52 ago. He was progressing well, the swelling and pain had decreased and his ankle ROM (esp. DF) had increased. He had been completing his daily exercises which was great to hear considering his past history of not following physiotherapist prescribed exercises. He was very happy with his progression and still showed eagerness to get back to work asap. I was a bit unsure as to how I should progress his treatment and exercises given that the injury was a fracture and did not want to have him weight bearing excessively even though he progressed well and he was managing the original exercises easily. The main factor still was to improve his ROM within pain limits which was fairly easy given that he was very tolerant to pain. I carried out passive physiological DF with a slightly increased amount of force to EOR, this marginally improved the ROM and will possibly progress this to a Gr4 pass phys mobilization next time. I maintained the same exercise program but increased the resistance of the theraband which he managed very well.

The patient was revisiting the surgeon (ORIF on R calcaneus) in 3 weeks so I was a bit cautious about progressing treatment and exercises too soon before we had confirmation that the fractures had healed sufficiently enough. I will need to look into acceptable progressions for his current situation (PTs. Internet etc). The assessment process is very relaxed with this individual and I felt I clearly explained everything and if he had any questions he would be happy to ask. Forward planning for all possible outcomes is important and as we develop our skills this will come more and more easily but at the moment every possibility needs to be thought through. I was very pleased with how everything progressed and I look forward to seeing him next time.