Last One

Well 2nd placement down and PCR on the way. What I learned on the last week of last placement is that now that we are at a basic level we can relax and just learn. What I mean is, there so much pressure to meet that level required that is almost not enjoyable. Now that we are at a basic level we can know that our treatment is good enough to be independent but we can work on improving the little things. When discussing with my supervisor on the last week about my final Ax patient she said relax, just go and do it and then learn from the feedback. She also said there is always going to be something to learn whatever level we are at. It was comforting to put it in perspective and realise we don't have to know it all now. So I hope this is helpful. My thoughts are that we shouldn't expect to be able to know and do everything fantastic straight away. Do your best and learn from those who have been doing it longer. Good luck for the PCR.

Interesting Case

Hi guys,
Well, here we are on our last blog, and our last clinic.

My last week was an interesting one, where I was given one more new patient to see.

He is middle aged aboringinal man who sufferred a bilateral cerebellar infarct 3/12 ago, and has just been admitted with a R MCA. He is dysarthric, and is not accustomed to our lifestyle and therefore feels very apprehensive regarding what we want to do with him.

The learning experience for me is that, at uni, we learn the treatment for different infarcts, not a combination of them.

this man is extremely ataxic in his R UL, R LL, and trunk. To add to this he has L hemiparesis, with very little movement in his L UL and L LL (gowland 2 and 3 respectively).

His sitting balance requires close S/V when he uses his R UL for support, and a 1 mod A with no UL support, as he is very ataxic through his trunk.

Now, this is where your comments/ideas will help. I have decided to address his ataxia issues (trunk and R UL) prior to addressing his hemiparesis primarily. My reasoning is this: I feel that without a decent stable base to move from, he will not be able to move properly. I have given him some bed exercises regarding his L limbs to assist in rehab, but have focused primarily on his sitting balance and ataxic imparments.

I could go on and on about this patient, as i did find his case and culture background very interesting, and unfortunately I will not get to continue with his rehab.

He was progressing well, and we had started standing balance ex with him.

Good luck for the PCR's guys, we all will be FINE!

Last Blog!

Well another prac over ...and I almost forgot to do my last blog! In looking over the last few weeks I can't believe how much I have learnt in Musculo...although I wouldn't have minded another 4 weeks to consolidate further with our brilliant supervisor dropping pearls of wisdom at our feet!

Anyway, something I wanted to comment on was how attempts at motivating a few of my patients I mentioned previously did actually work... as they all were reviewed last week. It was exciting to see that 3/4 patients had really taken on board what I had told them and had clearly being doing their exercises etc by the progress they had made. This was very encouraging to me and emphasized the point that if you do take the time and energy to clearly explain the anatomy/healing process/strengthening process/advantages from sticking to the rehab programme (a good lecture!) it does make a difference, and patients do improve. Using models etc and the "worst and best case"scenario is very useful! Something I shall definitely take into my clinical practice in the future.
So good luck to all of you in the PCR and it has been a pleasure blogging with all of you!!!

Good Guidance with a Full-Time Curtin Clinical Supervisor

For the past four weeks, I was having my musculoskeletal clinics and in a facility with a full-time Curtin clinical tutor,

For the first three weeks, I had to consult my supervisor after both subjective and objective assessment and to work out my treatment plan verbally with her. I found it very tedious and time consuming. This was especially so when I had to join the queue together with five other students. I started to appreciate this form of teaching when I assessed and treated my own patients.

During the last week (where the final assessments were held), I was allowed to assess and treat my own patients (seeking guidance only if I would put my patient in ‘danger’). I found it so much easier to consolidate all the asterisks findings and coming up with the correct diagnosis and classification. I think this was partly due to having more hands on experience with patients and also due to the teaching process in the facility. Having to verbalise my subjective findings, objective assessment plan and findings for every new patient had allowed me to consolidate all the asterisks findings mentally and treat the patient there and then.

It was definitely frustrating in the beginning but I hope future batches of students will appreciate it eventually and enjoy the clinics!!!

Just taking that few more minutes

Sometimes we are get familiar with certain things that we do that we become complacent. Anybody feel the same way too?

One morning, I had a day 1 post radical prostatectomy patient to see. I have seen a couple of those pts, so I had the mindset of the same routine things that I usually do. So as usual, I did the relevant subjective & objective Ax, then went on to treatment. I educated him on importance of early mobilization, upright positioning, DB ex’s & supported cough. The pt was well enough to get out of bed, and ambulated a short distance. Thereafter, I got him to SOOB for a while. He then started to feel cold & clammy, and got a bit sick. Then after a min or so, he said he was better & he could manage SOOB. So, I thought..good, he is feeling a bit better & he says he wants to try SOOB..and I decided to let him stay in the chair. As I was walking out of the room, I felt uneasy about the while thing, decided to take his BP to see for sure if I had made the right decision. Gosh, his BP was 80/55, far from his usual of 110/60. Back to bed it was for him and I also explained the reason to him. Though SOOB was important for him, compromising with his low BP was not exactly what I wanted. I am so glad I took his BP to justify my decision and not have it based only on the pt subjectively, especially on the last week of placement.

Congrats everyone for completing this placement! Good luck for the coming PCR!

Final blog - Musculo

Well, so that's that then! This musculo placement was fantastic. I only wish we had more time to sponge off our supervisor who was an absolute fountain of knowledge and who was able to make things so simplistic and easy to understand! While my experience with the vertebral column remains limited, I sure did see a range of post-surgical pts - some with fantastic results and some the result of surgery gone wrong or poor self-management.

An interesting pt for my final Ax - young boy #tib/fib and metatarsals 1-4. 3/12 later foot barely moving and resting in an extremely disfigured inverted position. Was managed by 3 diff medical teams. Has been told that is a "normal" resting posture for the foot. Somebody might want to clarify with that individual his understanding of normal foot posture. So this brought about a bit of noise with the rest of the physios in the area...... Do you a) slightly overlook the fact that the resting position of the left foot looks nothing like the right b) see how Rx goes for sometime to see if muscle activation and ROM can restore some normal positioning or c) tell the parents to go to a private hospital and try and have the foot reconfigured. Well, we went with b) but with the intention of suggesting c) after a bit of intensive Rx showing limited success. Anyone with any other suggestions?

Anyway, thought I would give a pt example as I hadn't done so in some time. All in all I do feel much more comfortable in Ax and Rx in these 3 domains now. I am able to realize much more now the areas I really do need to expand my knowledge base (and boy is it extensive!!....yikes) in some more and those areas I really am interested in expanding it to! I think that all three pracs have been so very useful in consolidating the knowledge we have acquired at Uni. And not just consolidating, I guess I mean fitting all the pieces together so that it actually makes sense - not just trying to memorize it verbatum for exams! I am also quite excited to get out there and get working and be able to take more courses that I am interested in! So, with that in mind, fingers crossed - PCR be gentle! Good luck all.

The chronic pain patient

Hi everyone,
congrats on getting through another placement. I Just wanted to briefly discuss a patient who presented in the clinic with LBP. She was diagnosed with a chronic hypomobility disorder L4/5 5/S1 and had been receiving physio treatment for several weeks. On the day I treated her, she reported pain scores of 9&10/10 for all Lx ROM. Paivms were even worse… every segment I touched whether it be central or unilateral appeared to reproduce the pain. I quickly realised that pain was not going to be a very useful outcome measure, but what was I to do for treatment? Objectively there appeared to be reasonable segmental movement occurring at Lx segmental levels with mild hypomobility bilaterally at L4/5 5/S1. After discussion with my supervisor it was decided that the most effective treatment for this patient at this stage did not include manual techniques, rather education and a graduated exercise program focused on improving functional tasks. I am told that in recent studies of chronic pain patients, providing education about the chronic pain cycle alone has been shown on MRI to have an effect in reducing pain. I thought that was pretty interesting….I am yet to read the literature myself, but I thought i may as well give it a go. In this case, the education combined with a low intensity gym program of 3 minutes on the bike and treadmill and some core stability work in functional positions had a better effect than the previous sessions of manual treatments. There is still a long way to go in completely resolving her pain, but she appears to be content with the knowledge of what has caused this pain response and what SHE needs to do to improve it.

Good luck everyone for the PCR and thanks for all the comments and suggestions over the past few weeks.

Another placement done - well done

I write this with one day of neuro to go. A little too tired to be outwardly excited but I feel a weight lifting as the number of assessments and tasks is lessened by 1.
It has been a great placement overall, seeing Friedriech's ataxia, transverse myelitis, strokes of varying types and severity and some other conditions across the room, I now have a greater appreciation off tone, what we daily take for granted as 'normal' movement and how independent some are and the lack of independence of others.
I thought I would have decided if I liked neuro after the first couple of weeks however I am still unsure. I see it is challenging, facinating and sometimes hugely rewarding but can be really hard and emotionally draining as the reality of people living normally to then be faced with such disability and loss of function and witnessing and imagining the toll on them and their support network could become overwhelming.
I have met some great characters over this placement in particular, it is the patients regardless of the prac which have kept me going and make me glad I have persisted on the path to one day very soon becoming a physio. Ah and my peers too as without you all it would have been a very tough journey, Thank you!

Physio works 2!!

Yes another exciting discovery that physio works for musculo patients as well as cardio! I thought I'd fill you in on my elderly lady with the chronic rotator cuff tear of a few weeks ago. Having had the tear for 2 mnths and been in a pretty bad way thus far, she has come to PT for 3 weeks now and is now pain free most of the time, has gained 20 degrees more active flxn and abduction, 60 more a/assist, altogether is much more able to carry out functional tasks and besides which is much happier and pleased with her progress. All of which, although sounding not too exciting to the casual observer, did make me very pleased and I have found this to be very catchy with patients, and she was truly excited by the time she left!! Possibly my genuine surprise that anything I did helped added to the general happiness! I suppose often we think we have to do something very clever to gain progress, but often it is just back to a good assessment and planning, ROM exs, strengthening, correcting faulty movement patterns and some good patient education. To quote an infamous lecturer, although at times it does seem to be more difficult than....it actually isn't rocket science!! On that oversimplified note enjoy your last week !
And thankyou all for the various comments and suggestions - it's great to get your input!

Things are coming together nicely!

Yep, fourth and final week on my neuro prac, and really enjoying it.

I feel as though I am at a level where I could work on a ward and treat a range of different neuro patients. However, I feel that things will still be a little scary when working with these patients once employed.

Things are starting to all 'link' together, and I have seen some great results with my patients. Aspects of treatment that once (at uni) seemed to take a lot of thinking, are now happening 'automatic'.

My interest has always been with Musculoskeletal, however there is a huge cross over with neuro. This is really only something i have seen while on clinic, as we are finally with 'real' patients. Certain Bobath techniques are all concepts that could (should) be used within musculoskeletal.

What are your thoughts on your current and previous clinics, and have you thought about where you would like to end up, work wise??

enjoy the last week

Week 3 Musculo

Hi all,

Welcome to your last week of placement! This past week brought more of the same...and by that I mean rehab for #'s. The only problem is that it is much more of a 'set' protocol for this group. While each individual may obviously develop different complications as a result of the injury/surgery you still have to maintain awareness of compensations/tight, short or weak musculature,for examples, but there just isn't as much problem solving involved! I guess I am a little concerned with the lack of spine-associated conditions I have seen. Well one, to be exact, on this placement. I know that in private practice many of these patients can make up a large percentage of your caseload. Thus, if I am so private practice inclined, I am feeling a wee bit apprehensive.... I really do feel that we should have had much more training in the spine. I do not feel that we have been adequately prepared. I know that one will get more competent with time and with experience and maybe I am being too hasty in wanting to be able to successfully 'fix' everyone right away - first visit and wham all better!! :). However I do stand by my opinion that if conditions relating to the spine are a large part of practice, then in reality we should spend more time on it at uni as there are so many techniques - types of mobs for example, that are actually out there - yet we know so few. Yes yes, the time, in what possible hours could we have done that. I guess maybe that is left for post-grad... So, here is hoping that I get a little more comfortable in my rural placement in Mandurah. As for know, orthopedics its you and me baby.

You know more than you think!

Well last blog i spoke about trying to break the habit of a subjective recipe, this week my supervisor really challenged me to ask myself what do I really need to know objectively and why. I'm on my last week of cardio. Often the patients we get are COPD plus other co-mordities. These patients often come in with SOB etc. It's easy just to think straight away "this pt has exacerbation of COPD with either viral or bacterial chest infection". This is because most of them are. Mostly but not always the case. My supervisor challenged me to always exclude all of the other possibilities that may cause SOB. These include PTx, PE and LVF/CCF. Its easy just to assume exac of COPD. So I previously assumed, "well the doctor's should know that" I'll just bang on their chest and get them walking. The reality is it sometimes takes the team a little while to figure it out. A number of times pt's come in and they start treatment for infective exac and realise its CCF. The point my supervisor was making is that you can play a bigger role than you think in the Dx of a pt and ensure they are receiving appropriate treatment. Use all of the Obj Ax you have, particularly observation for example changes in ankle swelling or how sweaty and clammy a pt is, not just the standard recipe objective Ax.

I think this idea is relevant for all areas, don't make assumptions was my lesson. Use the vast knowledge that you have.

Hope this helps you improve in your chosen area, whatever it may be.

The Worst Thing to Get is a Fracture

Today, I saw a patient who sustained a fracture and I was shocked by how she had been coping with the fracture.

Mrs X is a 50y.o female, sustained a fracture of the L humerus 8/52 ago. Since the injury, she had been on a cast for 6 weeks and then a sling for the last 2 weeks. Mrs X was referred to physiotherapy for passive and active assisted ROM exercises. As usual, after subjective assessment, I went on to do objective assessment. The position that I chose to measure PROM was supine. However, Mrs X commented that she cannot lie supine. She commented that the doctor’s instruction to her was that she cannot lie supine due to the fracture. This kept me thinking how she coped with her sleep. Amazing, Mrs X had not been sleeping supine for 8 weeks!! She had been sleeping in a long sitting position. Mrs X was also told not to do any exercises without the brace (she had not move the shoulder for 8 weeks!!)

Due to the doctor’s order, I did my assessment in sitting and also with the brace on. The shoulder PROM was largely limited by pain and elbow movements limited by the brace and there was massive swelling of the UL (which I thought would have resolved after 8 weeks). My treatments for Mrs X were to teach her pendulum and active assisted exercises and swelling management. To further facilitate the rehabilitation process, the plan was to contact the doctor in charge to check if the patient could lie supine and do exercises without the brace. Lying supine would make some ROM exercises for the patient and treatment without the brace would promote more range at the UL joints. It is amazing how some patients cope with their fracture and I think education about the dos and don’ts is very important and fracture is definitely the worst thing to get.

Locked in neuro

Neuro placement. We went to a consultant meeting on Friday morning at Shenton Park, where they were presenting a patient who had suffered from 'locked in' syndrome - a pons stroke. This, in case you are like me and couldn't quite remember what this means is - when the cortex remains unchanged however the pons has been compromised so the person cannot move while retaining cognition. Some can only blink to communicate as with the presenting patient. This same patient 8 months later was sitting independently, was able to speak and be understood, uses an electric wheelchair, can type using index finger is able to stand for a few seconds without support and has started facilitated gait training - she is still progressing well.

There are two other cases of locked in syndrome that I have seen (not treated) over the last few weeks. Both went at least a year without physio intervention after their strokes. They now receive weekly physio treatments however it appears to be more for maintenance - one has passive stretches, tilt table and airsplints, is able to sit independently in a wheelchair, is dysarthric however can be understood as with the previous patient.
The second also is in a wheelchair but with greater head and trunk support, is unable to speak and uses a communication board to speak. More stability exercises are used with this patient in attempt to gain independent trunk and head control, passive stretches and tilt table again are used.

The point that was made on Friday to the consultants was that early physio intervention for these patients is imperative to their functional outcome. In return note that 'locked in' syndrome is now a blanket statement, not all will have the same recovery available due to the extent of damage to the pons.

EPA and other clinical experiences

Hi everyone,
Last week of clinic coming up! I feel like I have seen a good mix of conditions and learnt a lot. I guess I have two brief comments this week…Firstly, from what I can gather from reading blogs and speaking to other students, there is quite a varied approach to supervision.

It is now getting into the final week of placement and we all still have to come out to speak with our supervisor between the subjective, objective and treatment for all patients including follow ups. Some of which I have seen 4 or 5 times before. Now time management is obviously paramount, but when you have to line up with your 4 other colleagues three times per hour, it makes finishing on time very difficult.

On the flip side, there are advantages to such close scrutiny of your skills, such as having your supervisor reax your Pivm and Paivm findings to see if they correlate with what you think you are feeling as far as mobility goes. I have found this really helpful in developing this integral musculo skill.

Finally, just to touch on ultrasound and other EPA modalities, there have been several instances in previous weeks where I have suggested the use of ultrasound for conditions which I considered appropriate. However, it never seems to be a worthy treatment choice. So much so that it is locked in a separate store. I wonder if it has ever been used? My question to you all is did you find EPA modalities to be useful clinically? And if so for which conditions?

Proper explanation helps with time management!

In the 3rd wk, my supervisor decided to challenge us in terms of time management. Prioritising the order of patients to be seen, the no. of treatment sessions required by patients a day etc.

There’s this pt of mine, 80 y.o. male, post pacemaker implant, with a hx of recurrent pneumonia, requiring physio twice a day. For the first 2 days post op, he was in a rather confused, drowsy state, sounding rather chesty but not expectorating anything although he claims he is not in pain. He was being hoisted to SOOB for the first 2 days as his HR was in AF although with paced rhythm. On the 3rd day, he was more alert & cooperative, and his Obs were stable, so we decided to try to stand him up to do a step transfer to SOOB. His LL strength was not fantastic, he managed a step transfer but ambulation was not an option. By the 4th day, we saw more improvements with him and he was keen to try to have a walk, so we assisted him to stand & walk with a WZF. However the limiting factor was his oxygen sats. He was SpO2 95% on 3L oxygen when he began amb, but desat to 86% within 2mins of walking ~6m. Then I increased it to 4L O2 and his sats was barely 90% after ~2mins. With all the preparation work of getting amb O2, drip stand, WZF and oximeter, he was rather frustrated by the time we got ready to stand him up. He was quite annoyed with the fact that he had to keep the oximeter on, had to stop to let his sats come up and we did not allow him to walk further than 10m due to his very low sats although he claimed nil symptoms. So I had to explain to him the significance of what I was doing; why he had to have his oxygen level monitored, why low sats was not good for him to continue walking. All the preparation, frustration, and explanation took up a lot of time, but it paid off as they all made more sense to him. He acknowledged the fact that I knew what I was doing and the next day when I saw him, he was not frustrated and the treatment was more efficient! And my day was definitely more efficient that day.

One more week to go! Hang in there guys!

Week 2 - Musculo

Howdy,

All's well over in musculoland. I have yet to lay a hand on someone with Lx, Cx or come-on!, even a Thx problem. It's all knee related things for me baby. Anyway on the subject of knees, I don't know if any of you know much about autologous chondrocyte implantation? As it is not a really common proceedure I thought I would just share a bit of info about it. The actual Rx of the patient is relatively standard (and by this phase she has well progressed and we are looking at very functional positions for VMO, general LL strengthening, balance/proprioception). Anyway, the protocols that come with these patients are very long and relatively regimented and will be varied according to surgeon. It is a very long recovery process lasting up to 1.5yrs+. So here's a little info in brief (well, definitions of brief may vary....) for those interested:

➢ ACI - Generally indicated for the repair of symptomatic, cartilaginous defects of the femoral condyle (medial, lateral, trochlear) caused by acute or repetitive trauma or failed previous procedures.
➢ May also be performed on patellar and tibial defects


HOW?

• 2 step surgical procedure:
1. Arthroscopic biopsy (day surgery)
➢ A small piece of healthy articular cartilage is harvested.
➢ Over the next 4wks these chondrocytes are cultivated
2. Chondrocyte implantation (arthrotomy – open knee surgery)
➢ Cartilage defect is debrided down to subchondral bone
➢ The defect area is covered with a tissue-engineered bi-layer collagen membrane which is stitched in place and sealed with fibrin adhesive
➢ The cultivated chondrocyte suspension is then injected into this ‘chamber’
➢ Over time these cells will proliferate and regenerate their specific cartilage matrix thus repairing the defect.

PATIENT POPULATION?

• Predominantly for lesions >2cm
• Indicated as a secondary treatment after 1 or more failed alternative cartilage repair procedures
• Suitable if cause of defect is trauma (acute or repetitive) or osteochondritis (Inflammation of both bone and cartilage - several examples of this condition include: Kohler's disease, Osgood Schlatter's, Perthes' , Scheuermann's disease
• Age limits 15-55 (>55, the chondrocytes do not grow as well and at this age the articular cartilage is often too damaged for the procedure to be beneficial)
• Patients must be able and compliant with a lengthy rehabilitation
• Not suitable if the knee is unstable or malaligned. No varus or valgus deformities, intact cruciate ligaments required (these must be addressed first)
• Not for individuals with body weight > than 1.5 times the ideal body weight for height
• Not for any progressive inflammatory, osteoarthritis or rhematoid arthritides (they will simply continue to erode the area)

REHABILITATION

• As with all protocols………variation in rehab time/weight bearing status/exercises……..

• Broad timeline for maturation of the ACI graft:
➢ Proliferative stage: 0-6wks. Tissue fills the defect.
➢ Transition stage: Changes in tissue consistency. At the beginning of this stage it is a liquid. By 3-6months is has a gelatin-like consistency and is now well integrated to underlying bone and adjacent cartilage. At 6-9months this ‘neo-cartilage’ is like putty.
→ After 1 week like WATER
→ After 3 months like YOGURT
→ After 6 months like DOUGH
→ After 9 months like CHEESE
→ After 12 months like RUBBER
➢ Remodelling and maturation stage: lasts as long as 2 yrs as the matrix proteins continue to form cross-links and the collagen framework integrates into the subchondral bone

• The maturation process cannot be accelerated through rehab! Rehab is guided towards protecting the repaired surface to allow natural maturation while mobility, stability, strength and function are gradually progressed.

Motivational tactics and men!!!

Well a couple of weeks in and perhaps I’m able to see some of the trees and not just a blurry forest! Terrible analogy…but all the same!

This week something that struck me in working with patients in musculo is how difficult it is to motivate your patients sometimes, and frustrating when they chose to ignore your advice. I’ve had 2 men in their 20s one with recurrent ankle sprains and another 8mnths post ACL recon…..both with whom I have found it difficult firstly to gauge exactly what they have been doing in terms of exercise etc, why then they are not progressing as they should and then what to do to try and get the best outcome. With both they say they’ve being doing more than it looks like they have given their presentation….so do I think they’re exaggerating or is there something else underlying which means they’re not improving. And one guy clearly was going to go back to sport even though he wasn't ready despite what I said. I’m sure this gets easier to work out the more experience one has, but just in general if anyone has any suggestions, psychological tactics to use to motivate people to take responsibility, stick to regimes, etc, that would be great!!!

Have a great week…halfway there!

Subjective Recipe

Half way through cardio. I feel like with all the placements so far it’s the subjective that is so much more difficult. Most of the time you find yourself particularly in the beginning of the placement asking certain questions because that was what we were taught to ask. Then later you figure out what it all means. Well by halfway through this placement it is slowly starting to become easier to ask what I need to know and know why I am asking it. It makes the S so much more efficient as well as the whole session because you aren’t asking about things that are irrelevant. It really helped after my tutor suggested that when I am going through the notes work out exactly, even write some notes on what I still need to know about and what I need to confirm/expand. It takes a bit more time planning wise but it gets quicker. I found this so much more efficient and found I gained a better overall understanding of the plan needed for the patient both short term and D/C planning. With practice if I think about what I really need to know before I see a patient I can make the transition from recipe to reasoning.

Less is more.......

Hi all,

Thanks for the comments last week regarding how to improve my time management, I have taken on board the suggestions and feel like I am getting into the swing of things a lot better this week. This prac has been the most challenging so far but perhaps the most enjoyable and satisfying. I did learn a valuable lesson this week from one of my follow up appointments.

This particular patient had attended the clinic for LBP and was found to have a hypomobility disorder at L3/4 4/5 5/S1 causing pain into LF and flexion. Well being the conscientious student, I assessed all AROM and comb movements then proceeded to treat each problem with several different techniques. Problem was that in an effort to decrease pain and increase ROM all the treatment techniques and reassessments had left her quite irritable the next day, not the desired outcome.

The next session I discussed the situation with my supervisor who suggested I go back to the original treatment which happened to be only a rotation mobilisation technique at the affected levels which had good effect. I guess what I figured was that the patient would not think a 3x30sec rotation mobilisation was worth the money or would do anything to help with the back pain. I did the treatment as suggested and was surprised to find that she responded well to it and seemed happy enough. I guess I was expecting “I’m not paying for you to take 1hr of my time and wiggle my back for 30 seconds as they treatment”. I have realised this week that especially in the irritable patient, less really can be more.

The Wonders of Taping

Today I saw my first ‘hand’ patient. Mrs X is a 50y.o/F. She fractured the (R) distal radius 6 months ago when she fell and landed on an outstretched hand. The fracture was treated conservatively.

Mrs X presented to the clinic complaining of pain and burning sensation over the medial and lateral aspect of the (R) forearm. The aggravating factors were lifting and any activity that involved wrist extension. On examination, the significant findings were:
1. All carpal bones were tender on palpation
2. Decreased wrist flex and ext AROM due to pain
Surprisingly, all neurological assessments were negative. With only two significant findings, I did not know the patient’s diagnosis, what bought on the pain and let alone the treatment. I was frustrated and disappointed in myself.

Not knowing what to do, I sought my supervisor’s advice. On further examination, the brachioradialis was tender on palpation and had some tight knots. My supervisor also did some taping on the carpal bones (such that the distal row was pulled laterally and the proximal row of carpal bones was pulled medially). The aim of this taping was to off load the carpal joints. The patient responded very well to taping. After taping, there was no pain on all wrist movements. Thus, the treatment for the session consisted of STM to brachioradialis and taping.

I had never come across the taping technique mentioned above was amazed by the immediate effect it had on my patient. After knowing about the wonders of taping, I will definitely read more about this technique and apply it on my patients.

physio's & pt's goals

Hi guys, hope clinics is going well for everyone.

At the CP attachment, I realized that I’m not just dealing with the patient’s lungs but with geriatric issues as well. Most of the patients I see are elderly chaps & ladies, so balance such that the risk of falls is essential to assess for. Thus, all the geriatrics stuff as well.

I’ve been seeing an elderly chap this week, who initially came across to me as quite a stubborn person. He came into hospital with the use of a walking stick and he has been the sole carer for his wife whose health condition is not very well. He has been admitted to hospital for a femoral aneurysm repair, with a Hx of COPD, and has been staying in hospital for nearly 3weeks. The family feels he has not quite as ready to return home as yet. They would like him to regain his independence first as he would be the sole carer for his wife when he returns home.

He is currently ambulating with his WZF, though independently with that, I thought that training him with his W/S would be a good idea of training up his balance, progressing his ex tolerance as well as gaining back his level if independence in terms of a W/A. However, when I talked to him about it, he was not keen on trialing his W/S and he refused to do so as he feels he already knows how to use it. Luckily, his nurse overheard me talking to him, and so tried to help me convince him. I realized that caring for his wife was a great motivating factor for him so I used that as a means to get him to mobilize and do some LL strengthening ex’s and he cooperated.

However, a couple of days later when I saw him, he was deemed on walking with his WZF and not at all with his W/S. He claimed he was fine not using his W/S and he doesn’t think he needs physio treatment as he feels he is ambulating fine with his WZF. I tried offering home physio for him when he gets d/c, but he refused. Despite all the persuasion, with no consent, there was nothing I could do about. Ultimately, it’s the patient’s choice, its not what we want for them, it’s actually what they want for themselves given the options made available for them. Thus, I realize that sometimes you have to compromise with your own goals and the pt’s.

Neuro from a student

I had imagined the neuro clinic to be by far the most challenging however I have found it challenging in respect to the impact of stroke rather than the content required - I found musculo the most challenging for this as all pts were at different stages and different injuries. My neuro pts are at least 6 months post stroke and progress is slow. I see each twice a week, four people a day for 1.5hrs each. A good amount of time to establish how they are feeling, some stretches and back into functional retraining.

I see the frustration on their faces as they try with all their might to will a muscle to work or to relax a grip. I also see the excitment when for the first time they independently pick up and release something. I wish I was more effective, I try and I want to help them. When my supervisor comes over does a fancy technique with such fluidity then says try that and walks off - my poor pt is left with me trying to remember where the hand holds went and the movement of facilitation, force, direction, rotation? - surely 1.5hrs with him would get this person along much faster than I can do at this stage.

I know it is the point and we are students and it is a great to be able to work with 'real' pts however are they getting the best treatment possible?? I guess I just need to ask more questions make him watch me, I'm tired....

I Hate RUDENESS!!

Hey guys! Hope your clinics are going well.

One thing that I don't tolerate is RUDENESS. This blog, I hope will encourage us all to, when qualified, not to treat students with disrespect!

This is the situation that I (and I am sure all of us have had recently) had to deal with on Thursday.

I have been treating a patient with a left cerebellar ischemic stroke for the last two weeks, and have been seeing some great progress with her. On Thursday she was being discharged to another hospital, and I had to give a telephone handover to the physio at this facility.

I won't go into the absolute details as to what information I gave to this physio regarding this patient and what was said to me, but this particular physio (after I introduced myself as a student) was absolutely inappropriate and rude! It was not what this person said, but rather the way it was said.

I ended up 'copping it on the chin' and continued with this in the back of my mind all day, not good for a student to carry around. I/we are all mature aged students and have had a career in a related field, however, we are also all the first to admit that we are no where near these physio's level, hence 'student'.

I worked very hard with this patient, assessing and treating, and was getting some great results, which I and the patient are proud of.

This may sound like a moan, but I feel that if I had not mentioned that I was a student, things would have been different. I am all for constructive criticism, but rudeness will not be tolerated, and if another handover is needed again, this physio will be very diplomatically told.

So, the lesson I feel is this. We have ALL been students and have been through the related stress. We all know what it is like to be a student, grasping for all the confidence you can, and to have someone do this, is NOT a learning experience. Show some respect for students as people, and guide in the appropriate manner, with some constructive criticism.

Enjoy the last two weeks.

'oh wow im fixed'....... Are you kidding???

i seem to have suffered the same condition of a mental relapse as Donelle and didnt post last week..... ill try and make it up to you guys if i have anything interesting to report over this week. I am at the same placement as Jess (I wish she would stop following me around from clinic to clinic :P).

My post this week will consist of patients improvements in musculo out patients. in particular patients who seem to improve a lot in range, quality of movement and a decrease in pain from what Darren would call little wiggles of Cx vertebrae. When the patients say this I feel like saying to them 'are you kidding..... you feel better???', when all Ive done is 'wiggle'. We have had numerous talks with our supervisor about this and she seems to believe that the physiological aspect of mobilisation may or may not be the factor leading to the increased in range and pain decrements but the majority of the benefits come from the pain inhibition cycle (aka Max the pain guru system).

Then when I'm thinking about this I get a little voice in my head from Steve 'Physio isn't that hard...just move the bit that doesn't move.... have a barbecue and play golf with Max'. i think im still at the stage of moving the bit that doesnt move...... maybe with better time management I can fit in the barbecue and golf......(anyone wanna round???)

Ryan

Week 1 of Musculo

In all the excitment of it all I seem to have forgotten to blog my l'il heart out last week. I guess the thing is that I do not have any particularly interesting or challenging patients to share with you. I have a caseload that seems to consist of a fair # of DNA's and the rest with a focus around the knee (PFJ) and ankle (#'s). While it is good to get experience with these problems I do hope that I get some more challenging individuals as now is the time to "learn using them" with our great supervisor! I guess the biggest challenge so far is the time management side of things. I have not had a problem sticking to the alloted time slots so far (new pts up to 1.5hrs, repeats 1hr) - however, the thought of going to private practice 20-30min/pt! Scares the life outta me! I am just unsure how one progresses to that stage, in well,... such a short time from now until we graduate and still manage to be thorough and effective. Obviously exposure to all sorts of conditions/disorders/etc prepares you for similar cases - so experience is key. I think my goals for this week are: 1) to cut out a little of the chitchat of the beginning - more direct and to the point 2) tighten up on my objective - be more efficient between the various assessements 3) remember to REASSESS after all interventions - I seem to be focussing on the overall picture/assessment at the end of all Rx and not each intervention. Okay, until later this week.....

Time management?

Hi everyone,

Just completed my first week of Musculo and to be honest it is not what I expected at all. Perhaps it’s just getting my head around all the first week routine, but I feel extremely time poor. I have decided to discuss time management this week rather than a specific patient as it seems to be the most clinically relevant problem which I am facing. Generally i consider myself to have reasonable time management skills but this week I have had to take notes home to finish most nights. It’s not just me either; all of us are hidden under increasing piles of paper work. As far as the patients go, I am enjoying the assessment and treatment side although I feel we could have been eased into the patient load a little better.

I guess what my question to those of you who have completed this rotation especially at the Curtin Bently clinic; aside from frantically trying to scroll down notes during the Ax and Rx can you give me any suggestions on how to be more efficient? Does it get easier as the weeks go by? or is this what I can expect should I work in private practice?

A Chronic Patient

Dear all,

I am currently having my musculoskeletal placement. Hope all of you had a great first week....

First week of placement and I had this interesting chronic patient. Mr X is a 50y.o/Male, was referred for physiotherapy for bilateral ankle stiffness. Mr X had bilateral ankle stiffness due to his condition of vasculitis. He was diagnosed with this condition about 2 years ago and had gradually developed ankle stiffness since then. He had no previous treatment.

Upon assessment, there was decreased AROM in all ankle ranges especially dorsiflexion, decreased proprioception and strength. The treatment for Mr X thus far had been AP glide of the talus to improve dorsiflexion range, proprioceptive training and muscle strengthening exercises program.

Due to the long-standing condition, I am expecting very slow progress with Mr X musculoskeletal problem. On my first session with Mr X, I spent half the treatment time explaining to Mr X the reason behind his slow progress. It was really FRUSTRATING as I still can’t get the point across to him after 30mins. Whenever I get him to do any exercises, he kept emphasizing that he had been doing the exercises and exercises were not going to help him. (But I taught him new exercises!! And this is only his second physio session!!).

My supervisor had ‘warned’ me beforehand regarding Mr X’s attitude towards physiotherapy and that he was a challenging patient. Do any of you have any similar experience and able to provide me with some ideas on how to handle the patient? Thanks!!

back to basics

Wk 1 at cardiopulmonary placement.
First week at cardiopulmonary placement, I saw a 60y.o. patien, day one post open cholecystectomy with epigastric hernia repair. It was via a midline incision, upper abdomen. He had quite severe pain level and had gotten a intercostals nerve block earlier in the morning to deal with the pain. When I saw him, he only had pain with movement, around 4-5/10. I did all the subjective and objective pretty alright. As he tolerated well enough with SOEOB, sats was 93-94% with 3L oxygen, all other obs were stable as well, I decided to have him SOOB (of course with help of my supervisor). When it came to environment planning, with all the drains, IV drips, PCA, I felt really disorganize & clumsy. Has been some time since I practiced transfer with an actual patient, really need to do more practice of that.

Anyway, back to this patient, we managed to sit him out of bed, he seemed quite uncomfortable due to the pain but he claimed he could manage and try sitting out for a while. As he seemed really exhausted at that point in time and we did not think he could concentrate any more, we decided that we would come back to him in the afternoon to teach him the DB ex’s & supported cough.

In the afternoon, I found out that the patient did not tolerate SOOB very long, about 15mins. Initially I was afraid that patient would be unwilling to be seen by me again as he may think that I’ve made him feel worse. So I had to brace myself to convince him the importance of getting him up early and what he is experiencing is absolutely normal post op. At the beginning he did seem unwilling to have physio again, but thankfully he did listen to me and understood where I was coming from. So I went on with the DB ex’s. Though not fantastic, he still managed to do fairly well with those ex’s. As he seemed exhausted, I thought I would do the supported cough tomorrow morning. Luckily I did not do that, as my supervisor pointed out to me that he has had an upper abdominal incision, and he was at risk of sputum rentention, if any present.

I would always remember now that it is really important to do all the basics—breathing ex’s and supported cough on day one post op, even if mobilization is not possible. If mobilization is not possible, at least sitting up in bed would be helpful. It is also very relevant to ensure that patients understand the importance of doing all those things, which may seemingly look easy or unnecessary. Besides, it would be a good way to gain compliance as well as rappot.

Have a good 2nd week!

Cutting corners

One week into cardio on respiratory ward RPH. I guess I am the first to admit I like to scan over the notes, get a reasonable idea of whats going on with the patient and then just get on with it. I'm realising with cardio it's not quite that simple. Last session with my supervisor meant a deeper look at the notes and analysing the pt's past medical history looking at the implications for treatment. When she quizzed me on the relevance of some of his conditions I didn't manage to come up with a very convincing argument for their relevance. After some discussion I realised that this man with COPD who had previously had GB had very weak respiratory muscles as well as UL and LL muscles. It was very important to know this because he could benefit greatly from continued reconditioning program. I realised that the little things you scan over and think they bear no relevance sometimes need to be included in developing the big picture. It takes a bit more time, but as students on placement we have that. I am continuing to work on making sure I don't miss what could potentially be an avenue for effective outcome for the pt.

Dem bones dem bones....dem dry bones!!!

This blog has nothing to do with bones, just to warn you! Well here we all are again and another week has flown by..!

This week I began my musculo placement, and found the transition a bit difficult. To be thinking cardio and then all of a sudden joints, necks, backs etc, without a bit of a break in which to prepare, revise etc is hard and frustrating! Hard to be trying to revise on the spot with a patient in front of you, and frustrating because I think one could get a lot more out of it, and learn a lot more from great experienced supervisors if time wasn’t being spent trying to remember the basics, which in reality in a day or two of ‘free time’ could easily be achieved.

With my complaint out of the way I’ll now reflect on one of my patients who presented a bit of a challenge to me…..the challenge being where do I start??!!

She is a 74 yr old lady who fell 2mnths ago and sustained a full thickness tear of her R RC tendons, and partial of her L RC. She wasn’t referred onto PT then (..gggrrrrrr!!!) and so 2 mnths later can’t move her R shlder more than 20deg flxn or abdn; her L arm is better but severely limited in ROM too….and both are extremely painful etc. Having done her assessment for about an hour I then did soft tissue massage, release etc, and then as part of her HEP gave her pendular exs for her R arm as she couldn’t even do A/Assist. In thinking about her I found it difficult to know how long it would take for a patient like this to improve, what sort of function can she realistically expect to get back etc. And good ol’ Max did come to mind thinking about all the chronic pain pathways that have been set off and how to try and tackle that area of treatment. So that’s it for now…I’ll fill you in as to how she goes!!!

Have a great week all!

Running

Neuro

A blog a blog, I just used my best material in reply to Troy’s post! I guess the next best would be the running group at Neuro Outpatients Shenton Park.
My patient is not up to running as we are still working on the hyperextension of his knee in the stance phase, in writing that I have just remembered Steph’s hip positioning demonstration and have an idea for the next session. (By the way this pt is a result of a Cx vertebral manipulation gone wrong!)

I digress, others, bounded, skipped, high knee walked, jumped and ran around the gym. The end of the class is a race, my patient has to walk 5 laps and everyone else runs until my patient finishes. The positive for my patient is they all offer lots of encouragement for him to keep going and not to slow down!

The running styles vary so much, their normal gait is still abnormal however increase the speed and its pretty confronting. The ages range from 20’s to 50’s so of course they want to return to be able to run, play with their kids, cross the road in a hurry, run for the bus or just exercise.

I think I was so focused on the basic functional tasks I have seen in NOP this week that when a high level activity was introduced I was a little blown away. There is so much to consider and think about. What mechanisms are required for running, what does being able to run mean to these patients, why was I so taken aback by the severely abnormal gait patterns, what is the EBP behind introducing these activities at this level??

I am so impressed by these patients their commitment to their rehabilitation and tolerance of students!
Happy Clinic

Rewarding!

Here I am, at the completion of my first week in Neuro!

To be honest I was feeling a little anxious about this placement, and I really don’t know why. I have only had one week, and already I am seeing how rewarding neuro really is.

I am seeing a pt who has suffered a left superior cerebellum stroke. She is ataxic with gait, and her STS (one min assist) is not quite what we would want due to in her internal displacement (forward).

I have been treating her STS, with some 4pt kneel exercises, AI's, extensor strength exs, and of course retraining the functional task. After 30 minutes we both (the pt and I) saw a huge improvement in her STS, where only a SBA was needed, UNREAL!

I have just started training her gait, where she is responding well to the side to side weight shift, adding a step. And I am looking forward to seeing her on Monday to cont with this.

I guess my reasoning for this post, is that, we are very capable when leaving uni to treat these pts, and as much as the uni staff know this, I sometimes think that it takes something like this to occur for students to see it! To see the look on a 'usually' independent pt, when they can do an every day task, really does make all that hard study worth it.

This may sound stupid, but I have been buzzing for days, and she was just one pt! Enjoy the rest of your clinic

Well done so far

Hi Physio 07 Bloggers,
I wanted to put up a post to let you know how well you have been doing in engaging in this process. I have had a brief scan through the posts and there has been a wide range of topics that you have explored as a group with some good reflection on difficult issues encountered on the placement. Many of the posts share some fairly in depth observations from clinics. Where an issue has been raised and opened for discussion it would be great for you to consider putting up some follow up reflections later in the placement as to how the scenario may have changed through the clinical placement and what you feel you have learnt or changed through the process of reflecting on that issue.

A reminder that you might want to consider writing your post in a word document, saving it and then cutting and pasting into the Blog. It will save you time if you have technical difficulties in posting your message.

Keep up the good work
PG

Signs of Syncope

Have been thinking all week of something good to write for blog….. I have been seeing much the same patients but I did have one experience that is worth sharing. One of my day 1 CABG patients post –operatively had some unexplained bleeding and was readmitted to theatre to look for the cause, nothing was found and he was back on pathway the following day.

He tolerated SOOB the next AM in the ICU well and was T/F to the ward in the arvo with no complaints. When I went to see him in the Pm he looked quite unwell, very pale and sweaty. He insisted that he was fine and wanted to get up for a walk as planned.

After speaking to my supervisor and the nurse it was decided that he needed to get up to be weighed anyway so we would go ahead and “see how he felt”. Usual observations were checked and the telemetry was hooked up, nothing out of the ordinary. SOEOB patient begins to feel nauseated, as this is common after anaesthesia we precede, other obs stable.

On standing things really start to look wrong. The patient begins to shake and is sweating so much my glove is wet, he looks very pale/ grey, but says he is feeling fine but is very quite.

We cancelled the walk and T/F him to the weighing chair. He is up 11kg on his pre-op weight, he has drained 1.5l into his subcoastal drain and his sats were down to 80% on 4l of o2. We get him back to bed and onto the venturi FIo2 o.5%, then speak to the cardiothoracic surgeon regarding the patient’s condition. CXR are then taken with two large pleural effusions evident, pulmonary oedema is added to his current status. Although we have learnt the textbook signs of what to look for in syncope and desating, it was quite a different experience for me to see it first hand. Just something to keep in the back of your mind.

I hope you all enjoyed you’re last week of clinic, and are feeling ready for the next!!

This last week on clinic I have seen mainly the same patients as I have seen for the last few weeks, in addition to completing a few other mobility assessments and seeing new COPD patients. So having had this Blog in mind for the week I have been trying hard to think of something of interest to write and reflect on. The fact that I have had mostly the same patients for the past few weeks, upon consideration, actually was an issue of importance, if not of interest!

We have all heard a great deal about chronic diseases, rehabilitation and the management of, etc. For a physio in the inpatient setting these issues are of great importance in clinical practice. Not only does the input of physios make an enormous difference, but also how well we rehab, educate, and generally manage patients makes an enormous difference to the lives of these patients. As a very common everyday example I had to do a mobility and respiratory assessment on a patient with COPD who was then to be placed in care, or return home with services after some rehab. For this elderly gentleman in question the difference in options was clearly significant. Although it would be great if we were magicians and could wave away all problems, clearly we aren’t and there are some problems/situations we cannot have an impact on. But there is a huge grey area where PT input can and does make a palpable difference to many patients’ lives. I think we can all empathise with wanting to remain in one owns home for as long as possible, not spending half the year in hospital awaiting placement, or recovering from an exacerbation of COPD which may have been able to be prevented if the infection had been caught earlier. In all these situations our ability to help physically strengthen patients, educate patients, refer appropriately, assist patients to develop daily and long term management strategies and action plans, can make a lifetime of difference. I think if anything could motivate me more to ensure my physiotherapy treatments are effective, efficient and specific this would have to be it…that because of physiotherapy intervention a person will be able to remain at home in their community, with their pets, memories etc rather than be placed in a (lets face it) miserable nursing home. That’s a good days work!!!

Enjoy you’re next placements!!

ICU pt Follow up

Hi guys,

I would like to fill all of you guys in on a patient who i referred to a couple of posts back. He was the IVDU in ICU who was unresponsive and not taking spontaneous breaths. after a couple of more treatments in ICU he was finally weaned off the sedatives and we extubated him. He remained in ICU for a total of 14 days of which 11 he was sedated and intubated. Our role of PT in the ICU aside from his chest work and suctioning was to maintain FROM in all joints etc. when he was D/C from ICU he had great range but as you can imagine his strength from RIB for 14 days was so poor. he had G2/5 quads, gluts and PF's, G1/5 DF HF. sitting balance was like holding up a jellyfish and a 2x Max assist stand (for transfer) was rather interesting.

over then next couple of days he was being treated on the ward and his strength improvement was phenomenal, he was able to walk 1x A with WZF after 24 hours and I after 48. we discharged him from the hospital in RITH program and his determination to be rehabbed was amazing.....

just goes to show how 1st impressions of people and circumstance can change

Ryan

The team approach

In the last couple of weeks I have been treating a pt who was 1/52 post suspected L CVA. He was presenting with R UL weakness and expressive aphasia. He was 85 years old and had a previous history of decreased dynamic balance in standing and c/o feeling shaky on his feet [able to walk <60m (I)]. The pt was improving rapidly from the very mild CVA (R UL went from Gowland 3 to 5, able to pour glass of water and brush hair, Aphasia improving) and was more concerned with his balance. Very well, there in lies the plan for treatment. Over the next week he improved until one day I came in and he c/o feeling unwell. His arm had decreased in function, speech the same. Over the next week he gradually deteriorated to Gowland 2 and was so shaky on his feet he couldn’t get to the bathroom (I).Recent scans showed full thickness SS tear and partial IS tear in the affected shoulder. However, pt reported shoulder pain for 3 years. The doctors were discussing with the pt the possibility of joint injection for the shoulder function. I told them that subjectively he had shoulder pain for 3 yrs and his Gowland had dropped from 5 to 2/3. Voluntary control loss indicated that the pt was having another infarct and was not related to long term shoulder dysfunction as 3 days before he was brushing his hair. The doctor agreed but did very little about it, this was very frustrating and beside my point. My point from all of this is don’t be shy, we know a lot of information from our course it’s important we communicate what we find to the doctor’s to make sure the pt gets the best treatment. It’s a team not a hierarchy.

My First Suctioning Experience

Mr X is 88y.o/M admitted to hospital for decreasing consciousness and dehydration. He lives at home with his sister who is the main carer and is able to ambulate with a ZF with x1 assist from the bed to the toilet. He has no relevant respiratory history.

After admission to the hospital, Mr X is diagnosed with ?aspiration pneumonia and hence referred for physiotherapy management. On objective assessment, Mr X’s Cough: very delayed and ineffective, very moist and non-productive; Ausc: quiet BS throughout lungs, no added sounds and his SpO2 is 92 % RA.

After assessment, I determined that his cardiorespiratory problem is impaired airway clearance. Due to unable to produce an effective cough, other treatment ideas will be tracheal rub, catheter tickle and UL movements. However, all of the above failed and the last resort was suctioning. After advice from my supervisor, we decided to have suctioning via a Guedel as it is an easier method. The first suction was done by my supervisor and the process seems easy. Next was my turn. The first suction had triggered a very good cough and it was just the right time for me to do a second suction.

My first suctioning experience was horrible. I forgot to turn on the suction, the catheter was at the other end of the bed and I just can’t get the catheter down the patient’s AW! It must have been a very uncomfortable experience as the patient started to tear and struggle. Before I could do an effective suctioning, the patient had swallowed all the secretions.

My second session with Mr X: things are better the second time round. I got all the suctioning equipment prepared and now ready to go. Everything went on smoothly and amazingly, the SpO2 increase from 92 to 100% RA. This shows that patient also had impaired gas exchange which was not reflected in the ABGs.

On the first suction, I was very excited and too focus on just wanting to do suctioning. And forgot the importance of the preparation prior to that. On the second session, I learnt from my mistake, I got everything prepared (prepared equipment not only for one but two suctions-just in case). Mr X later commented that he felt more at ease the second time as I was more confident and prepared. That gave him the impression that I would ‘take good care of him’.

I was really glad that I had such a feedback. It is not all about giving the treatment but also giving the patient confidence and that will definitely help to relax the patient during the horrible suctioning treatment.

Importance of PT in d/c planning

In the final week of the placement, I was involved in the discharge planning for a patient.
I have been seeing this patient, Mr P an 80 y.o man, since the week before. There have been talks by the Drs to discharge him that week, but the date was not confirmed. I realized that I should start looking into d/c planning for the pt when the social worker approached me to enquire about the mobility status of the pt.

With Mr P, his premorbid status was independent with all his ADLs, walks more than an hr a day with a W/S or WZF. He has a history of falls. Currently, Mr P has been walking around his room with his WZF independently, and he is able to perform self care tasks in the bathroom independently. However, as his physio I wouldn’t reckon him safe when he returns to the home environment. Firstly, from my O/E, he has got delayed righting response in standing, delayed stepping response, decrease ability to weight transfer to his left, bilateral LL weakness (L> R due to residual weakness from his R CVA), and very tight bilateral gastroc & soleus (bt 0-5deg ankle DF ROM). Although he seems safe walking around with the WZF, and the nurses are very happy to let me do his self-care alone, he does have a high risk of falling if he is allowed to go back home to live alone without further rehab. Besides, Mr P had a Hx of falls and that was also the reason he was admitted to hospital, as he suffered a subdural haematoma due to a fall.

During his stay in hospital, he did made progress with PT input. From requiring assistance to STS & in standing (Normal stance, EO=3s), to independent STS & standing (normal stance, EO>30s). Thus he would definitely benefit from further rehab to make him safer.

With d/c planning, I realized that a PT has a very important say as to where the pt should go next after being d/c from the hospital. PT’s are responsible in determining if the patient is safe to go back home, in terms of mobility wise. We play an important role in caring for the future well-being of the pt and not just pure Ax & Rx during the stay in the ward. It was then that I discovered that d/c planning is actually quite a tedious process. There is a lot of contacting work that you have to go through, speaking to relevant staff of appropriate hospitals/ services to be referred to. A lot of responsibilities come with that!

Week 4 - Last week of cardio and placement reflections.

Truthfully, I came into this cardio placement just hoping for the days to whizz by so I would never have to deal with the topic of sputum again. This placement surpassed my expectations and for that I am thankful!!! Even though I never had much difficulty with the learning of cardio, it always made me a bit nervous - I think due to the fact that I didn't have any experience with anyone with much of a respiratory problem. Thus, even though I could rattle off the lecture notes, I don't believe I ever truly understood them. This placement and exposure to such patients that we have talked about the last 2yrs, really did help me to consolidate and actually learn what Kate/Sue/Nola have been teaching us. The staff on the ward and my supervisors were fantastic in helping me become competent in this area and to appreciate it. I can actually say that sputum no longer scares me and I no longer have the overwhelming urge to race away from a patient's bed the moment they even start to say the 's' word, let alone expectorate!

This last week I have had some interesting patients - all with a neurological twist for good measure! Post-polio syndrome, hydrocephalus and several with motor neurone disease. I have definately learned something about the art of the so called 'quad cough' in these MND pts. I have learned varied ways to go about it. For the one pt, it was only effective if done on her sternum with a wide open hand. For another, it was best to do with both forearms/elbows across the stomach.

In speaking of the MND pts and with reference to a previous posting, one of my MND patients passed away this week. When I was first called for some chest physio I was a little terrified as no nursing staff wanted to do anything due to the fear of putting him into brochospasm and him passing away under your arms. In his end-stage condition, in all reality he wasn't likely to ever leave the hospital. He was not for resuscitation and therefore I was just told to quietly close the door during treatment in the event he did pass away. You can imagine this is a bit overwhelming. He didn't pass away on that occasion, nor on any of the following 5+ treatments. He did slip away quietly later on Friday.

In such situations there is a fine balance between caring too much and trying not to care at all. I know that many who work in such situations all the time cannot afford to care too much because they won't be able to do their job and it may impact too much on their life. I have a tendency to care too much. Whatever one's strategy is for dealing with loss of life, I think it is especially important for those primary health care practionners who will be dealing with terminal cases to show those patients the respect for life that they deserve. I guess that in my mind it means obviously being compassionate and caring, but also taking those extra few moments to consider that person, those that care about them and the life that they have led on this planet - before letting them slip quietly out of your mind so that you can carry on with your job and your own life.

See y'all next week same time, same place, but different placement!

Reflection of Musc OP

So another clinic completed. Outpatients for me was a mixture of straight forward and challenging patients combined with rapid revision and comprehension of the courses musculo topics. I am feeling more confident although wish I had just one more week to get a better handle on it all as things only started to fall into place in the closing stages - some are quicker than others!!
Anyway my point is although some patients caused me dispair it was these particular patients I am most glad I had as the experience means I have a better understanding of how to approach similar cases in the future both for treating and diagnostically. Mostly it was a chronic patient that, unlike Troy's, was not so easy to convice to exercise, I did a lot of listening and empathising however had to be careful as he was quite manipulative and had an agenda which I was slow to pick up on but here it is:
He presented with shoulder pain and was convinced it needed surgery, scans and xrays were clear. He was extremely neurally sensitised and guarded every movement. On completion of the 3rd treatment session, when no progress, he stated that he had only agreed to come to PT as he believed we would then see that his pain was mechanical and tell the surgeon he needed Sx to fix it and that would be that!! So there I was sending him back to his GP with a suggestion to send him to the pain clinic (which I might add as an aside has a 12month waiting list!) where he will hopefully be treated for his pain.
I asked all the questions that might indicate a chronic pain disorder however he was reading into my questions and any discussion of sensitisation of pain by the CNS was scoffed at and I was told that his pain was real and he knows other people play on their pain but not him - ah he was a good challenge!

The Chronic Pain Patient!

That’s it for one more placement, and one that I thoroughly enjoyed and gained a lot from.

During the last 3/52 of my musculoskeletal placement I have been treating a chronic pain patient, who has responded very well to treatment (communicative based)

This pt has been attending the clinic for approx 6/12, with her major complaint being R Lx pain and a painful R hip (not referred).

When I first saw her 3/52 ago, her irritability was very high, and manual therapy was limited to GII left rot PPIVMS, and recently some SNAGS on the hip, which worked very well to improve the limited Lx/hip ROM, and decrease pain levels.

I last treated this pt on 2/7 ago, and the affects of the last couple of weeks have been incredible, and I put it down to different communicative strategies. I have spent most of the treatment time with her in the fitness room, basically getting her moving and letting her see what she CAN do. By increasing the positive talk, and generally being interested in her wellbeing, she has responded very well, and even stated that she feels the best she has for a long while, and is moving a hell of a lot better!

I guess my main point is that manual Rx has not really differed a lot, however, by addressing other issues, such as a pts negative thoughts can help in the recovery of pts, especially chronic pain pts.

Hope all your placements have gone well.

Reflection

Today i decided to reflect on reflections, as we all know we are required to reflect formally on our work as physio's not only for our self benifit but also so that the university can prove that we are all able to professionally self evaluate. So.... how many of you go home after a day of work or clinic sit down to your partners/ family/ pets/ plants or whatever and say nothing. Myself personally I reflect on my day with both my partner and my family, lucky for me i have a mix of professionals between these groups of being medical and non medical so that i am able to get a multi-perspective reflection on whether my apporach with patients was justified, what i could do in order to improve my interaction / Rx (I dont suppose that this would happen if you just had to chat with a plant).

Nevertheless, i find it quite frustrating to then come up with 1 blog that sums up my whole week when all my interesting stories/ grieviences/ concerns have all been aired prior. As well as finding to for researching clinical presentations, assignments for research and PCR review i seem to have run out of time to scratch my self or catch up on my beloved sleep.... I guess this blog could be retitled Ryan is tired and grumpy.. why cant we just do clinic???

Ryan

Life is so Unexpected

Mr X is a 56y.o. and was admitted to hospital for urinary tract infection (UTI).

A few days after admission, Mr X was referred for physiotherapy for administration of BiPAP. According to the doctors, he had sustained a stroke during the stay in the hospital and the stroke resulted in him having difficulty in breathing. BiPAP was to help to decrease his work of breathing and to normalise his ABGs. Mr X tolerated BiPAP well and was weaned off the machine two days later.

However, things didn’t go well and he was back on the BiPAP the next day (Friday). His GCS score had decreased once again and the doctors suspected that he was most likely to have had another stroke. They are not able to come up with a definite diagnosis as the CT scan knows no signs of an infarct.

After the weekend, I was back to the hospital again and got to know that Mr X had passed away the night before, due to ?cardiac arrest. It was really shocking. A man who was just admitted for a minor problem of UTI, his status had declined so drastically to the point of death. Life is so unexpected. I spoke to the nurse taking care of Mr X. She told me she had learnt not to get too emotional with patients. It is important to build a good rapport with patients and do our best for them. However, it is also important not to get too emotional. If not, when incidents like this happen, it would affect our work and thus affect other patients.

For our profession, this is definitely an issue we would face in the future. I am glad that I experienced it now and learnt from it so that I know how to deal with it in the future.

Tempting

Almost there in Neuro placement at Bentley. It is very tempting with time constraints to not assess everything in a Neuro Ax. There is obviously so much to do. I have a had a couple of patients where doing a full Ax and getting information I didn’t think I would do that much with has been turned out to be important. Pt presented TIA? No evidence on investigation. Reduced right sided upper limb voluntary control and diminished light touch and possibly proprioception. Expressive aphasia. Receptive ok. Pt was improving on the ward, main issues were balance unrelated to the TIA? and Gowland 4 arm. Over a period of a few days, aphasia was improving and arm improved to Gowland 5 with minimal PT as pt had refused. So all was going smoothly, good recovery was occurring. I had done a full Gowland on the pts arms as well as most of the rest of the Neuro Ax. The next day pt appears and verbalises he is unwell, aphasia is worse/same but arm has reduced obviously back to Gowland 4. The bells start ringing! Had a chat with my supervisor who suggested a chat with the RMO. As it turns out it was useful information for them as they were currently querying the possibility of another TIA. So in short, if I didn’t assess it, I couldn’t have reassessed it and I wouldn’t have had an objective measure telling me the pt was going backwards. In short I learned don’t cut corners, you never know what info you will need.

Agree to disagree

Hello all,
I have seen a lot of very complicated surg patients this week, in the ICU and on the ward. Have had a chance to do some manual hyperinflation and some suctioning, a neuro assessment on my day 2 CABG patient who had a stroke and a look at surgical emphysema.

Following my mid-placement assessment i asked to see some medical (COPD) patients as our CCT said they would be good for the PCR. I was given an end stage COPD patient admitted with a chronic exacerbation who I saw with the CCT. He was a textbook patient with all the usual problems: dyspnoea, airflow limitation, decreased ex tolerance. O/E widespread expiratory polyphonic wheeze, sats 88-90% fixed upper resp breathing pattern... you get the idea. Someone I thought could really have benefited from physio.

Well when i got to the treatment (breathing control, ACBT, amb etc) he let me know in no uncertain terms how useless “huffing and puffing’ was and that every physio in the last 25 years had tried the same treatment to no avail. I persevered, had him go for a walk then asked him to show me how he recovered from his dyspnoea. I suggested some fixed forward lean positions which he declined to try, but I did notice he was already pursed lip breathing and recovering quite well.

Following the treatment his sats were up to 96% and he was reporting less SOB, his wheeze was significantly quieter too. The frustrating part about this session was that by all objective signs my treatment had made a difference, but my patient refused to acknowledge this change, continuing to believe that physio could not help him. I have to admit, at the beginning of the session I was almost in agreeance with him, what could I offer him that someone else had not already tried? I guess just having confidence in your treatment and approaching this patient not claiming to cure or solve all his problems, but maybe just to offer some suggestions on how best to manage can be helpful. any comments on similar experiences would be appreciated!

Vigilance at all times!!

Having thought about a range of topics this week I thought I’d chat about a particular patient who had an interesting, and encouraging story to tell in which a physio played a significant role.

This patient is a 48 year old man who I went to see post an Ivor Lewis procedure (done for cancer of the oesophagus) to perform a respiratory assess and treat accordingly. The second day or so we of course went walking, and in one of his breaks we were chatting and it came out that the only reason his ca had been diagnosed was because of a PT. He had hurt his shoulder at work earlier in the year and was going to a PT for that, who then wanted to start him on a gym/strengthening programme. The PT was concerned about his recent weight loss (10kg in a year) and referred him back to the GP. The GP said “it’s all ok” and carry on with treatment….but the PT referred him onto another GP who did a endoscopy and…yes he had very advanced Ca.

I found this story amazing in that not only did the PT pick it up, but persevered with getting it checked out despite one dct giving the man the all clear, and now this guy will probably live longer etc because of that. I suppose for me it hugely reinforced all we were taught in Musculo regarding special questions, and gave me a bit of a fright in that literally someone’s life can be changed due to our vigilance as physios, even for the supposedly simple shoulder presentation that arrives in our clinic. So vigilance, and confidence in our own assessment of the individual is the thought for the week!!

We are all Magicians!

The magic of hands indeed!

Third week in, and one thing that I and my fellow colleagues am starting to notice when treating patients is something as simple as STM/mobs can decrease symptoms by half. Your probably thinking, yeah DUH!

Here is one example. A patient presents with Lx pain with bilateral buttocks pain (somatic referral), with the main aggravating factors being standing and walking. Pain levels range from 1-7/10, but it is mainly stiffness that is the main complaint.

All movements are restricted, with R SF, L rot, ext, and combined R SF/ext producing the pain in the R Lx area, so a typical ‘closing’ pattern.

My treatment has consisted of left rotation PPIVM in slight R SF (due to low irritability) of L3-S1, STM of bilateral ES, and HEP consisting of ROM exercises and PF/TA/MF act/endurance.

This pt leaves feeling fantastic with less stiffness/pain with walking and standing and is on ‘cloud 9’.

Here are my thoughts, let me know what you think.
Firstly, something as simple as 3 mins STM can decrease the Sx and promote correct movement, the gift of ‘touch’!

Secondly, and maybe a bit out there, BUT, when we mobilize (as in PPIVMS), I am starting to think that, at the symptomatic level, there is a BIGGER part in the spinal gate model, which decreases the pain. I understand that we are also mobilizing the soft tissue and joint, however, I think that the spinal gate model may attribute more to the pain relief than we think, which then promotes correct movement.

Here’s to the healing hands!

Not quite a textbk case scenario

Howdie. Another week has gone by.
I’m going to keep my blog short this week so it will be more appealing to read.

This week I got to see this patient together with my supervisor. This pt, Mrs H, has got a subarachnoid haematoma in the frontal area. The first day we saw her, she was really drowsy and doped from the medications. She had difficulty performing on commands and her initiation to tasks are poor (e.g. rolling on her side). From observation, she seemed to have inattention to the left. We helped to sit her up and it was obvious that she had some perceptual issues. In sitting, she was leaning backwards as well as to the left. She was a “pusher” (i.e. pushing to the left), so the only way to correct her sitting alignment was to facilitate her to reach to the right as well as forward.

On the 2nd day that I saw her, she was more alert and she could follow commands better. She was also more attentive. Her sitting alignment was slightly better but was still leaning to the left and backwards. After a few repetitions of forwards and right lateral reaching, we managed to get an upright sitting posture. Then, my supervisor decided to try to stand her up. To our surprise, while standing, she did not lean to the left like we would have expected her to. She leaned significantly to the right instead. She couldn’t maintain upright due to her poor hip extensors strength as well as Quads strength and they had to be supported. My supervisor also thinks that she maybe weaker on her Right LL, as she was buckling more on the Right, thus probably the reason that she’s leaning to the ®.

On the 3rd day, I actually wanted to have a closer look at Mrs H, in terms of tone, strength and sitting & standing alignment. However, Mrs H was to be transferred to a rehabilitation hospital. Such a pity I couldn’t explore more to this interesting presentation. Has anyone ever come across such case scenarios? To give me some light on this?

Anywaez, hope everyone had a nice long weekend! One more week to go!

Referred pain

This week, a patient with sharp pain behind her left eye. This patient had a history of cervicogenic headaches that had responded well to physio treatments. This presentation was without neck pain or pain on the sides or over the back of the skull, just behind the eye. Slightly limited AROM into R SF and R rotation otherwise NAD. PPIVMS detected hypomobility at C4 on both sides and PAIVMS were P2 limited at C2, C3, C4 some unilaterals as well. Palpation was ++ tight upper traps, LS, scalenes and SCM. No active or passive testing so far had reproduced symptoms. I had a student with me who asked to palpated SCM, doing TPs along the muscle produced intense pain however not until approaching the bottom third did the pain in the eye start. Here we are a trigger point reproducing the exact pain the patient is complaining of.

So off we went to report the objective, soft tissue the main concern, tick, what will we treat, the soft tissue – but not SCM!! The reason being it is in the anterior triangle where all the vessels and nerves are. Indirect treatment by loosening the U.T.s, LS and posterior structures will help? Ahhh but the SCM reproduces the pain! So off I went treated the posterior structures, yes improved ROM, pt felt better, I bid her farewell with some SCM and Cx stretches feeling horrible as I am sure she will again suffer her eye pain.

So here is a dilemma, well not really, I have learnt that SCM can refer to behind the eye, there are indirect ways to treat it, hold relax, stretches, posture repositioning and if I am asked in the PCR to treat the anterior of the neck I will say no that is contraindicated or at least an area of high caution which should be avoided.

You can turn the patient’s head to the side in supine, support their head with one hand and with the other pick up SCM between your thumb and fingers to perform TPs without fear of compromising the neurovascular structures I believe.

Week 3 - Schizophrenia (me or the pt you might ask?)

G'day,

Definately an interesting patient set this week! The patient about whom this blog is about is a 66yr old female with an admit diagnosis of R sided pneumonia. Her very relevant background Hx includes Schizo-Afflictive disorder. I was lucky enough to be given this, oh how shall I say....hmm "charming" lady for an assessment this wk. She was admitted the previous evening, had been refusing any treatment - namely 02 therapy - with Sp02 dropping to 57%. However some marvellous nurse had finally managed to get her to accept sometime before my visit. I was a little anxious reading her notes.....and readied myself a bit like I was preparing for combat. It was a pleasant surprise that she was quite calm and was able to reasonably answer my questions, even have a feel of chest expansion and auscultate a few ant aspects of her chest. Then all of a sudden the storm clouds rolled in. She became very angry and yelling for us to leave (perhaps a few insults thrown in for good measure...). So realizing the time had expired on our meter, I(we) retreated. Returning later on I met with the same resistance. There was no way I could even get her to position herself so a bit of drainage might occur. Patient very febrile and lotsa secretions. Tried later on - no way! The next day I was asked to do an induced sputum. I think the farthest I got was setting it all up. I attempted 5 times that day - obviously going to settle for even clearance from a cough without the induced sputum method.

I will spare you all my different ways of approaching this situation, but it is a little frustrating obviously from a communication point of view but also due to the fact that she could really use some physio! What I have noticed about this lady is that she is generally very calm and compliant (sort of) for the first 3-5 min that you are in the room and then it is like a button is pushed and she goes off. I guess this is the first Schizo disorder I have had to interact with in such a way and therefore do not know if there are any 'tricks' for dealing with these individuals. As I will likely be seeing her again this coming week, if anyone has had experience and could offer me an tips that would be great.

Dizzy patient

Musculo outpatients:

Week 2, I was presented with a young lady in her 20’s who said the world was swaying and she felt unsteady on her feet – this had been the case for the last 2 weeks. Being a scientist herself she had been mapping the symptoms but could not find a pattern at all, it could last for 30-60 min or more with no known aggravating factors. Sometimes when she was walking, sitting, standing, it was not relieved by lying down or being still. The patient had continued to play netball and volleyball and when dizziness came on she continued. After a couple of episodes where she felt she was going to fall over and then not falling, she now continues to walk, or play believing she will not actually fall.

She had been to see a Dr who said it wasn’t anything in her inner ear and was most likely the muscles in her neck – one side tighter than the other giving different proprioceptive feedback to the brain so one side indicates movement and the other not – the confused brain suggests the ground or the person is swaying!

On hearing all this I thought I would check her vestibular system and vertebral artery in addition to a Cx objective and go on from there. All were negative, I couldn’t make the already present mild symptoms worse or better.

AROM – ↓ lateral flexion R>L, flexion and a slight decrease in rotation. Pt reports always had a ↓ in flexion, has AS however managed well and in remission at present.

PPIVMS – nothing unusual, PAIVMS – tender C3 mainly also C2 and C4 centrally and R uni-laterals.

Palpation – tight upper traps, LS, scalenes, occipital insertion – nuchal line.

With such marked muscle tightness I treated with STM for 10-15 min in hope to reduce some of the tension and see if symptoms changed. When I had finished and the patient sat up from prone she felt much worse so suggested the chair with back and arms so she could hang on. After 5 min the symptoms had returned to pre Rx levels. The AROM had improved and the patient reported feeling much better – even though symptoms still present! Supervisor said the symptoms may get worse before getting better.

I am eager to see my patient tomorrow to see if my Rx had a good, bad or no effect on her symptoms.

I was not aware that tight musculature in the Cx region could make someone dizzy, my supervisor says it is possible so we will see if in this case it is true or otherwise have to refer back to the Dr for further investigation.

Analysis and Plan

I’m still on Neuro placement and starting to bring it together. From an early stage I think we all got a little frustrated with the expectation of a long analysis/problem list and plan whatever placement we were on. As we started to go through clinics we saw the time pressures and the amount of time PT’s had to write notes and thought “how could they possibly write a full A and P like we are expected to”. Well they have probably done A and P lists so many times its automatic in their head. This is what my supervisor suggested would be the case for most PT’s. In the last couple of weeks I have realised that after you have written a few A and P lists for one of the particular core areas it does come more planned in your mind. So I have found the continual requests to write full SOAPIER’s initially frustrating but also very helpful. I have found that it makes my treatment sessions more focused and efficient because I have my goals for the session very clear. So hopefully some others can appreciate the inconvenience as I have but are also able to see the benefits.

Communication is the Key to Success

Dear all,
It is now two weeks into my cardiopulmonary placement. I am starting to get the hang of everything but occasionally, I still have difficulty carrying out my treatment with some patients.

Mr X is a 70 year old/Male is having end stage renal failure and COPD and suffering from depression. He was admitted due to chest infection and thus referred for physiotherapy.

He SOOB in chair all day and refuses to do anything except to the shower. For the last two days, I have been trying to get him to do some UL and LL exercises but it just didn’t work. He commented that he knew doing exercises was good for him and he would do it when he is ready. I persisted and tried again to get him to do some exercises. This time round, he got very agitated and chased me out of the room. I was disappointed with myself for not being able to get the patient to do anything.

Today, I tried a different technique and it worked. Instead of telling the patient: “Mr X, I am going to get you to do some exercises”, I told him: “I am not going to get you to do much. I am here to just have a look at how you are sitting to standing, and to see how’s the movement in your arms and legs.” The patient finally got up from the chair, did some shoulder flexion exercises and also some knee extension in sitting. Although the patient did only one STS, it was very encouraging for me. If I had thought about this trick few days’ back, I could have gotten him to do more and definitely able to get more air into his lungs.

It is all about playing with words and changing the way I communicate with the patient. Having good communication is such an important asset in our profession and I will try different ways of talking to my patients till they start to get moving. I will try the trick again tomorrow with Mr X and hope it still works. If not, I just have to keep on trying.

Do any of you having any ideas of how to get my patients off that chair?? Thanks!!

Communication

Hello all, I have had an interesting second week of prac.
A few experiences have stood out above the others.

One such instance was when I went to treat a Croatian lady in her late eighties who was day one post Laparotomy plus small bowel resection. I read her notes which were brief as she did not speak English well and proceeded to plan my treatment. My plan was to ask the usual subjective questions, assess her chest and obs, teach some ACBT and supported cough and if all was going well ambulate.

When I got to the patient however, it was quite a different scenario all together. Luckily an interpreter had been booked as the lady didn’t understand any English and was feeling very frightened and frustrated. This was the first time she had ever been in a hospital and could not understand why after having the surgery she wasn’t completely better? Everything was completely foreign to her, she was terrified at the beeping of the IV or Feed as she thought something was going wrong with her. She also didn’t understand why she couldn’t eat or go to the toilet (IDC). She likened the last 24 hours to being held in an isolation cell.

As it turned out this was the first chance the patient had to properly communicate with the health and medical staff. A lot of my planned treatment was spent explaining and reassuring her that she was doing well and that some pain/dizziness is normal following surgery. I struggled however, to explain through the interpreter the idea of ACBT and a supported cough. The patient argued that it was her stomach that was the problem not her lungs, and she refused to cough as she didn’t feel she needed to.

All this just got me thinking about how I would feel if I was the patient in a foreign country where I didn’t speak the language, all sorts of attachments and someone coming in and telling me to cough and purposely increase my pain? It just made me realise that treatments which seem so normal to us can seem quite unusual to our patients without good communication.

The unusal presentation

Hi guyz,

I’m in my 2nd week of neuro placement. I have a patient that I thought would be interesting to share about. So the information is as follows…

PHx: Was hit by an object in the face. A few days later presented with fluid coming out from the ears and had a salty taste down the back of throat. Saw GP--> CT head= cribriform plate #--> immediately admitted to the hospital. Stayed in hospital for 4 days-->NAD-->flown back home. Suffered severe headache & occ rhinorrhea still and worsening of gait and coordination. Has pre-existing symptoms of ® UL& LL hemiparesis, sensory deficits & ataxic gait.
PMHx: in ’05, first episode of severe headache. Began with fooginess of ® eye-->® cervico-occipital headache which radiated to frontotemporal region, lasted 2hrs. Was diagnosed with migraine. Has nil previous hx of migraine or family hx of migraine. 2nd similar episode in early ’06, but this time was assoc with ® hemiparesis & sensory deficits. Deficits never resolved. In all, had 4 episodes last yr. Nil neuro diagnosis was ever made.
SHx: lives alone. Works underground, was able to continue working despite deficits as was able to "hide" them.
Inx: MRI Cranial/ spinal cord—nad; CT head—nad; Lx puncture—nad, just ↑glucose of CSF; Indium scan: nil CSF leakage

S/E: c/o pre-exisitng weakness & sensory loss & clumsiness with gait got worse when was flown back home. Has increase headache with movements of limbs. Headache =6-8/10
O/E:
· CN III, IV, VI — nad. Eyes tracking√
· Gowlands stage of recovery— ®arm: stage 5; hand: stage4; leg: stage 5; foot: stage 4
· Ms strength— UL: ® Gr 3-4; (L) Gr 4-4+
LL: ® Gr 3-3+; (L) Gr 4-4+
(Had increase in headache with mvts of limbs, ? true strength)
· Sensation—Light touch: UL: ® ↓↓ palmer> dorsum of hand. ↓ lateral aspect> medial aspect of hand/ forearm/ arm (i.e. feels more on C8, T1 dermatomes). (L)↓ palmer surface of hand.
LL: ® plantar surface nil sensation. ↓on dorsum of foot. ↓ant surface> post surface of lower leg/ thigh (i.e. feels more on L5, S1, S2 dermatomes). (L) ↓plantar> dorsum surface of foot.
Sharp/blunt: ® UL& LL: absent. (L) UL/LL: ↓ (5/10)
Joint position/ jt mvt sense: ® big toe/ ankle—able to det mvt but not direction. (L) big toe/ankle—able to det mvt. Direction 6/10. very slow response. Knee & hip jts not tested yet.
· Sitting posture: slightly W.B on (L)> ®
· Sitting Balance: Static √
Dynamic—Int disp: √ ; Ext disp: slight ↑ resistance when disp to the ®. Efficient saving response. Safe in static & dynamic sitting.
· Standing posture: slight W.B (L)> ®. Tunk tone (L)=®
· Standing Balance: Int disp: slight ↓ to ®. AP/PA√. Tend to overestimates ability but able to recognize when told abt safety.
Ext disp: uses a stepping response for slow & fast disp. (i.e. when disp to ®, ® foot steps out to the ® instead of (L) foot crossing over to take a step to the right).
Safe in standing, static & dynamic.
· Balance: feet tog, EO=30s; EC=5s
Sharpened Rhomberg, EO, (L) fwd= 8s, ® fwd= 11s
SLS, EO, (L)=25s, ®=5s
· Gait: -↓ ® heel strike on initial contact
-® knee hypertext during loadingàmid-stance
-↓ hip E during mid stanceàtoe off
-↓wt transfer (pelvis lat shift) during mid-stanceàtoe-off
-↓ knee F when hip in E during swing phase

So far, what I’ve been able to do is part Ax with the patient each session as I did not want to aggravate his headache too much.

With no neuro diagnosis to be made and with a unique presentation of sensory loss deficits (e.g. deficits of L5,S1, S2 more than L1,2,3; deficits on bilateral limbs), I was quite thrown away by that. Besides, the weakness presented does not match the deficits in sensation. According to my supervisor, the presentation of the patient is unusual. The stepping response during external displacement in standing is also not the norm. She suggested for me to keep these unusual presentation at the back of my head and not to worry too much about it. She advised me to just address the problems like I’ve been taught to, and with more experience in future, I would be able to recognise the abnormal from the norm.

So I’ve been trying to put those doubts aside first & deal with the problems that I can address first. I’ve been working (2 sessions) on weight transference in standing, as well as gait re-edu. I’ve also gave pt some ex’s to improve vol. mvts e.g. DF with knee extension fr 90deg flx to 0deg ext. Pt appeared to have better gait (↑ heel strike) after each session. However, my supervisor thinks it is unusual for the pt to have that much of an improvement after each session.

Thoughts for this week: it is a skill to note the subtleness of abnormality from the normality, the unusual fr the usual. How do we know how much can the patient improve and if it is unusual or not?
Anyone has any thoughts with regards to Ax/ analysis/ Rx of this pt?

Sorry about the long blog. Hope I didn’t confuse anyone.
Have a great week ahead!