Muscle-Stim Heel Switch

Hi everyone,

This week i had the opportunity to use e-stim which i thought i'd never touch this whole year haha but it was great to revist the parameters etc...Anyhow, I have applied it to a patient with an incomplete tranverse myelitis at C5/6 and as a result, his main problems during gait are hip hitching of the (L) leg during swing due to mainly inadequate DF and KF. I firstly got the patient to stand on a wedge to prolong stretch (L) gastrocs before applying the e-stim. My aim was to stimulate the DF but not just the strengthen them while in sitting, but to apply it during gait...

The heel switch component of it was placed in the patient's shoe, and everytime there is pressure through the heel i.e. stance phase, the e-stim is off....however as soon as the pressure is off the heel switch (during pre-swing) the e-stim turns on and it activates the (L) DFs...to the patient's amazement he began walking with a near-normal gait pattern...his hip hitching dramatically reduced and his balance improved significantly.

The treatment obviously proved interseting, but to what extent will it have in terms of effect on the recovery of the strength of DF in a pt with tranverse myelitis, I am unsure of.. Anyone have any experience with the same?

Blogging about blogs

Hi guys,
I apologise for the lateness of my last blog and just wanted to actually blog about blogs! haha. I was wondering what everyone's thoughts were on how useful they have been and what they have got out of them? I feel they are extremely helpful to get other peoples perspective on how to handle difficult patients, supervisors and placements in general. I also find it really helpful when people share the positive stuff about what has worked for them. I do feel however that there are probably too many blogs that we are required to do and often find the quality of my posts dropping a little as I struggle to find things to talk about. All in all I feel the blogs are very helpful and perhaps with a little refinement in future years will be extremely effective in helping students to make the most of their placements!

Major Issues

Hi everyone. I have had a very difficult past few days of prac which is looking like it will result in an extra placement after the PCR. The placement has been quite messy with my supervisor often away but I felt it was going okay and I was at least passable. Things kind of exploded on Tuesday, and I discovered that there had been conversations going on about things occurring that they were not happy with. Had they bothered to ask me or anyone else involved in some of these issues it could have been explained and handled with next to no fuss. Instead it's suddenly a massive problem brought up half way through my last week.

An example included that one morning when my supervisor was not at work, she had organised for me to attend a few speech sessions. That morning the speechie came and spoke to me and said that because of the sensitive nature of two of the sessions it would be better if I didn't attend. I said that was fine, and went on with some reading and preparation (this was in the 2nd week). It was then brought to me by my CCT this Tuesday (still no one at the facility spoke to me about it) that they thought it was unprofessional that I had not turned up to scheduled speech sessions as arranged.

The other situations were similar to this involving miscommunication. In hind sight I acknowledge that some issues could have been prevented by extra communication on my part, but others couldn't.

I had the OT come and yell at me in a rather unprofessional manner, for things that hadn't been classified as requirements to me, stating she didn't "give a rats" what I had been doing that morning. This was in front of my supervisor. Had I been unsure I have have clarified myself, but as far as I was concerned I knew what was expected.

My main frustration with this situation is that on the Tuesday of my final week, this all came to the surface, when it had been being discussed behind my back the entire placement. It was not brought up at mid-placement Ax. As far as I was concerned they were "reasonably happy".

I recognise what my responsibilities were, but without the feedback..?

I am still attending my final two days, despite being told I will fail the FCT assessment, and am hoping to pass my final CCT one. If I have to do another placement I will do one, but without the appropriate feedback and support I'm not sure passing this one was ever a possibility.

If anyone has been in even a slightly similar situation I would really appreciate your input.
Thanks

Non english speaking...

Hi all,
Over the duration of my last placement, I have encountered numerous clients who are non english speaking/reading. There are a few ways to tackle this situation, although generally i feel that not all of the information i need to give them gets through correctly. The ward coordinator attempts to get an interpreter for one session, where all the medical staff are able to attend (midwife, physio, doctor) to discuss and explain things to the client. this doesnt always work out though, as often you are busy at the time the interpreter is available, or it is simply too busy with everyone wanting a turn to speak to the client. I have found that family members (mother or husband) are generally quite helpful if they are fluent in english, though you cant be sure everthing is being passed on accurately. The biggest help i have found is the information sheets/brochures which are written up in all different languages (ie. postnatal advice/pelvic floor exercises/bowel and bladder information), so long as there is the language you are looking for! i think these are a great idea, and i feel they should be available in all public and private hospitals. So always ask the physios/ward coordinator if these exist, as they will help you greatly! Does anyone else have any thoughts or experiences?

Change of approach

Just wanted to share something related to one of my previous posts about trying to get compliance out of a 5 year old. My last session with this client was really successful and I came up with a few reasons for this.
Firstly my supervisor was not in the room so I felt my confidence in myself and my abilities without looking over my shoulder.
Secondly, it was mainly a treatment whereas previous sessions had involved compulsory parts of assessment that I really had to push through to get a baseline.
Thirdly, I changed my style with her. Together we constructed an obstacle course, and I think this made her feel involved and allowed her to include things that she enjoyed and found easier. Consequently I could slip parts in that were more difficult and challenging for her. I had a lot of different ideas to work with that I could bounce back and forth to if she refused one activity. Due to her compliance the session was shorter and more effective and I ended up feeling quite good about it.
I know that there were a few factors that contributed to this session, but I choose to believe my adjustments and ideas were part of it!

Activating Dorsiflexors

We have just learnt a technique from one of the senior neuro physios to activate dorsiflexors where dorsiflexion activation is a deficit. It involves applying pressure/compression between the fourth and fifth metatarsal space of the foot and this would elicit toes extension and some dorsiflexion. I've put this to the test to two of my patients (MS and BG-stroke) and they were amazed at the reflex that was elicited from the pressure applied. However the effect on the actual active-dorsiflexion in gait is yet to be observed but I am positive that this technique would prove helpful!

Final prac...

Hi everyone,
Hope the last placement of the year is going ok, not too long to go now! i just wanted to write about the differences i have found between my first placement of the year and this one...
I have found that all of the physiotherapists i am working with treat me as one of them rather than as a student, and they often make comments 'well your more a real physio now than a student' (it may just be a good placement with nice people!) and i feel that this is because we are so close to finishing. i definately have been given more responsibilities, and am left to do a couple of wards a day on my own, and even take outpatient appointments on my own (womens health). i find this really enjoyable (others hate the sink or swim scenario) as it definately makes me work harder, manage my time more efficiently and learn a lot more.
has anyone else found this on with the last few placements, or do you still feel as though a lot of the supervisors still treat you as though you are on your first placement ever?!!

personal experiences

I was seeing an elderly patient on my last prac and had just positioned her out of bed and were going though some deep exercises etc. A relatively new doctor to the area came over and began to look at her nursing notes sitting on the table at the end of the bed. The patient starting to get very agitated and scared saying she didn't like that doctor and he was not to come near her etc. The doctor hadn't even said anything to the patient before she was begging me not to leave her alone with the doctor and was crying/shaking etc. I had to reassure the patient over and over with help of the nurse, that the doctor was here to help her and he would do no harm. It took around half an hour to settle the patient before she would allow the doctor to see her. The patient revealed later it was the doctor's appearance/nationality that had caused her outbursts, which i found strange and a bit difficult to comphrehend but it did alert me to the that a lot of elderly people have had personal experiences in the past that affect how they interact with people today.

students and health professionals

Hi all,
just wanted to share an experience i had with a nurse during my last prac. I had gone into the room where the nurse was and began my assessment. I was auscultating and making sure i respected the privacy of the patient (she was female). The nurse suddenly interrupted me and began to lecture me on how i was being inappropriate and rude as i hadn't shut the blinds whilst examining. I had made sure the patient was covered the entire time throughout my assessment and explained this to the nurse but she continued to disagree and lecture me in a quite condescending manner. In the end, I did what she said. I felt as a student, she was very intolerant to me. I mentioned what happened to my supervisor and she agreed with me, but did think it was just easier to comply with the nurse. I'm sure everyone has had a similar experience with some other health professional but any suggestions on how we can change this 'student' status? and how others perceive students?

Tough one!

Hi guys,
sorry for the late post. Just with regards to a patient I saw on my cardio placement. He was post aortic valve replacement and was progressing along fine the first few days post op. After the first few days though, he started to plateau, his main problem was dyspnoea, but he was also having dizzy spells and getting sort of a tingly feeling in his hand when he was really short of breath. His ex tol was decreased and Sp02 was dropping when amb'ing. The doctors t/f'd him to Bentley for more rehab before he went home and myself and my supervisor told them several time that there was something not right about his presentation and we couldn't quite figure it out. In the end he came back to the ward and after many more tests they discovered a phrenic nerve palsy! Obviously as a student it is not my role so much to be pushing my point to the doctors but i was just wondering as a professional how much would you make your point to the doctors before giving up? Especially if your not sure what the actual problem is??

Communication with parents

I have found it difficult on my paediatric placement sometimes, to be taken seriously by the parents of the clients I see. Particularly with infants I occasionally get the impression that they think I am too young and inexperienced to know what I'm talking about (which isn't too far from the truth sometimes). Some are quite happy to be seen by a student but then speak directly to the supervisor rather than me. I try to sound confident and talk to them about ideas to help their child at home, but my supervisor will always jump in with something more relevant or effective. I'm trying to power through but I feel because of the set up I'm not being given a chance to show what I know.

Positive Support Reaction and Sit to Stand

Hi Everyone...half way there!!

Although my prac is outpatient neuro, a couple of us have had the opportunity to go down to Ward 2 which is a ward dedicated to intensive neuro rehab for inpatients. A common presentation for some stroke patients is the positive support reaction where the unaffected side is over-active and when weight is transfered to the unaffected side (e.g. in standing) the unaffected lower limb would push away towards the affected side. As part of the sit to stand retraining, the physios make the patient follow a specific pattern that causes the patient to transfer the weight to the affected side and stand through the affected side.

This technique seemed very effective to ensure patients are able to sit to stand and not have a positive support reaction from the unaffected side, however my question is, does this technique not lead to a poor pattern of movement down the line?

thanks for any input

Lumbar Rotation

Prior to my country placment i found the most challenging technique to be lumbar rotation- i found it so hard on my body. So I thought that I would like to alert everyone to a way of doing a lumbar rotation technique which I found to be far easier on my body than the one we have previously been taught at uni. Apparently this is the original Maitland way of doing lumber rotations:

Grade 1: patient side lying with both knees bent up (bend up more for low lumber or less for high lumbar), no rotation through trunk, therapist stands behind the patient in stride stance with both hands hooked over the iliac crest, line of push is down the femur, Grade 1= gentle movement, really good for acute disc/facet injuries!

Grade 2: same as above except the top hand is placed on the patients belly button (some trunk rotation) and the amplitude of movement is greater as it’s a grade 2. If done correctly the top shoulder and the pelvis should be moving in opposite directions with the oscillations.

Grade 3: same as above except the bottom leg is straightened and the therapist supports the top arm at the shoulder (fixates it)

Grade 4: same as grade 3 except the movement is just at the end of range

I found it to be a really useful technique from really acute injuries to chronic conditions. And if the patient find the technique too uncomfortable you can just drop down a grade or likewise you can go up a grade if the technique isn’t forceful enough.

Different ideas...

On my last placement at a private practice I had a ‘clash’ of ideas with my supervisor. At this particular clinic 4 of the clinicians had over 35 years of experience each- so I found that with a few different principles and clinical reasoning we had very different ideas. I know that they had a lot more experience than me but they were totally unaware of some of the various principles/tests that I had learnt at university. For example = the differentiation between the diagnosis of a lumbar facet sprain and a lumbar disc protrusion. Many of the key sings that would have alerted me to a disc problem i.e. mechanism of injury, presence of neuro symptoms, they said would indicate a facet joint problem. I obviously wasn’t going to argue but I did state the typical signs that we had learnt at uni and they said that they all could indicate either. I know that essentially both conditions are treated in the same way anyway but it was just interesting to see their provisional diagnosis compared to mine.

Hand sensory stimulation

Hi everyone

I've just finished one week of my new prac at shents neuro outpt and it has been one hell of an experience so far. Our supervisor is very experienced and has taught us several new techniques, which is starting to get difficult to remember all!

One of the techniques that we've been taught is hand sensory stimulation ( there is another word for it but i've forgotten for now...will keep you posted) It is used for stroke patients who have reduced voluntary control of the upper limb. It involves getting a rigid pencil and having the patient sit over the edge of the bed with a table in front of them to support their affected arm in front of them with the palm facing up. With the pencil, you roll it around the hyperthenar surface of the palm and then you draw lines with the non-lead side, then you colour it in again with the non lead side. After this, the hand is "grounded" which involves other techniques (then practice the Fx task such as picking up a ball). The outcome is quite effective with greater mm activation of the UL. More to come i am sure.

Apologies for the poor explaination!

theatre

hi everyone,
i have had the opportunity to view a couple of procedures in theatre this prac, and as gross as it sounds i thought it was a great experience.
whether you have the opportunity to see a cesarean, hip or knee surgery, or any other kind, i definately recommend it if you have the stomach for it.
by observing exactly what goes on in surgery, you definately find it easier to treat the patients on the ward - and with a lot more understanding/sympathy!
the surgeons are helpful also (in my small experience) and they took the time to explain things to me and teach me something interesting.
i hope most of you have had this opportunity as well, and if not then definately ask your supervisors!

Non-compliant kids

Greetings.
I have just commenced a placement of the paediatric variety, which has been both fun and challenging in the first week. I would like some assistance with the well established problem of getting kids to do what you want them to do. I had a young client (almost 5 years old), who was less than co-operative, especially when asked to do activities that she was well aware she would find difficult. Some of these things (when we finally got her to do them) she could perform quite well. My supervisor was able to get her to do things without her realising that she was doing them, but my strategy really came down to bribery with stickers. I realise that this may not always be effective, so with a child like this, with self esteem issues, how could I get her to attempt difficults tasks?

combining techniques

Hi all,
just wanted to share an treatment session where i combined a number of techniques to produce an effective treatment. We had a patient with infective pneumonia (and on Xray- a very prominent right upper lobe consolidation). The patient was intubated at the time. We decided we would position the patient in high sitting (with the help of nurses and orderlies) to provide some postural drainage, and adjust the ventilator settings to hyperinflate (hence get some increases in collateral ventilation and shear secretions etc etc) At the same time as we hyperinflated, I also provided some rib springing at end of expiration to increase lung volumes and some expiratory vibrations focused on the right upper lung zone to loosen secretions. After a few cycles lasting a minute or so each, we suctioned very large amounts of sputum via his ETT, and on auscultation there was a significant decrease of the amount of coarse crackles which were heard prior to treatment. Overall, it was very useful combining all three techniques for treatment.

mothers and babies...

Hi all,
have just started an interesting but rather emotional prac this week doing womens health. i am dealing with mothers who have just given birth (anywhere from 12 hrs to 6/7 days post so far), and therefore have some very emotional patients!
i have found that this placement, more than any others i have been on, requires a LOT of communication and how well you do your job nearly depends more on your manner/personality than skill and knowledge. there are so many different patients with differing circumstances that there is no set routine to your vistits and sessions - you just have to judge it once you get in there. some i have found quite challenging include mothers who have lost their baby during birth, and those who have very fragile family (husband) situations and no support.
it is much harder to plan your day/patients as often your timing is not the best and so you have to go and treat someone else or find something else to do. often the only 'treatment' you are able to carry out for the patient is leaving them with some pamphlets and checking up on them again later to see if they have any questions, which often isnt ideal.
however, it is great doing such a different prac and apart from the challenges i am really enjoying it, and just thought i would share some of the things i have learnt so far!

ICU patients

I have just completed my last prac in ICU. Over the four weeks, i saw a huge variety of patients-all very sick and most of the time, difficult to see. I found myself sometimes getting quite upset seeing these type of patients, especially the young head injured/spinal injured patients who are essentially the same age as you. It was hard not to get upset as from all our studies at uni of anatomy/neuro, we have the knowledge of what is happening to them and have some idea of their prognosis, which a lot of the time, was not good. From having a particular couple of patients the whole time throughout my placement, it was hard not to somehow get attached to them and their families. The patients left ICU as soon as they were medically stable but it was hard not being able to follow them through and see their progress, seeing as you have formed somewhat of a relationship with them over time. From completing this placement, I realised it gave me good perspective of what a patient looks like/deals with within an acute stage and how they are when heading into rehab (though i would have liked to see some of my patients within the rehab stage) Anyone have any thoughts about this?

Positioning really does work!

Hey all,
At the moment I'm on prac in ICU. We have a patient who is a recent C4 complete quadriplegic. His Chest Xray shows left middle zone consolidation (though it is improving with comparison to previous Xrays). We were called to see him as his oxygen saturation had dropped to 86% after being turned. He was lying on his right side and on auscultation his right lung had widespread crackles and exp wheezes. We did some ventilator hyperinflation, combined with some exp vibes and numerous suctions but to no avail. We needed to reposition him as the secretions had appeared to drain into his "good " lung (right) and since this was preferentially perfused, it was compromising his gas exchange. Even though it required 5 of us to reposition him onto his left side (halo traction and cervical spinal precautions), it was defiantly worth it! His oxygen saturation instantly rose back up to 98%. The now drained left lung became the dependent lung and was therefore better perfused, therefore maximising his gas exchange. It was really good to see an effect occur almost immediately and was valuable to see how simple, yet effective positioning is.

Golf Tips

Hi all,

I really have run out stuff to write, so this week, I will share some knowledge (related to physiotherapy) which I’ve learnt from golf.

During golf swing, momentum comes from your wrist, elbow, shoulder, torso and pelvic. Technically, if you have a greater ROM of these joints, you should be able to hit the ball further.

Few years ago, when Tiger Wood lost the US Open, he employed a physiotherapist to enhance his performance. The physio had developed some thoracic rotation AROM and stability exercise for Wood and he claimed Wood’s thoracic ROM has improved by 15% after treatment. Interestingly, Wood had won the US title for the next 2 years (Believe it or not?)

I was talking to one of the pros in Wembley golf course; he told me many novices tend to grip the golf club too hard and a small proportion of them will develop trigger fingers. His advice to prevent trigger finger is to educate novices to release grip after 10-15 swings when they are practising at the driving range (since learner always tends to grip harder and harder to hit the ball further)

Osteoporosis

Hi all,

Last week, I read an article, published by Osteoporosis Australia, on osteoporotic prevention. It contains some useful information and I will share some of them with you guys this week.

1)Approximate every 8 minutes, someone is admitted to an Australian hospital with an osteoporotic fracture

2)A 10% loss of bone mass in the vertebrae can double the risk of vertebrae fracture, and a 10% loss of bone mass in hip can result in a 2.5 times greater risk of hip fracture

3)A Medicare rebate is now available (from April 1,2007) for BMD testing(DXA Scan) for all women and men aged 70 or above

4)From April 1,2007, people who aged 70 or above with a BMD T-score equal or lesser and -3 can receive treatment for osteoporosis on the PBS( w/o having sustained a fracture)

5)Protos and Bon Viva are the two new first-line medication for fighting osteoporosis

chronic pain

I would like to share with you the experience i had during my last week of prac in musculo outpatients. My final Ax pt was a 19 yo female who presented with bilateral non-specific hip pain. as i couldnt access the medical records, all i had to go on was a dr's referral saying hip pain / bursitis / tendonitis - which wasn't particularly helpful!! turns out we couldnt diagnose it any better, as every joint, muscle and stability test i did came back positive - even palpating in regions unrelated to her hips had her almost in tears. i had a long discussion with my supervisor about her as we couldnt identify a specific problem to treat - alot of our findings contradicted each other.
My supervisor explained how even very young pts can have a chronic pain presentation and the resulting widespread sensitivity throughout the body. We shouldnt expect that those with chronic pain are generally middle aged with LBP... it can occur in anyone with a varying range of pathologies, and is something to always be aware of.
With our pt we ended up starting her in hydro for a few sessions to try and get her trusting us and reduce her acute pain, with the goal of getting her to walk for at least 5 mins pain-free.

Cervicogenic Headache

Hi all,

I had a patient with cervicogenic (CG) headache during my country placement, her clinical presentation was classic and since PCR exam is just around the corner (CG headache has been in the exam for the last few years), I am going to share some information with all of you on this topic.

What is CG headache?
It is a headache caused by abnormalities of the joints, muscles, fascia and neural structures of the cervical region.

Clinical Features:
1)Usually described as a constant, steady, dull ache, often unilateral but sometimes bilateral.
2)Pt may describe a tight band around the head and headaches are usually in the suboccipital region and commonly referred to the frontal, retro-orbital or temporal regions.
3)Usually gradual onset
4)Pt often wakes with a headache that may improve in the day
5)May be present for days, weeks or even months
6)May be a Hx of acute trauma ie whiplash injury, MVA or repetitive trauma ie work or sporting activity
7)Often associated with neck pain or stiffness and us. Agg by neck or head mvmts such as repetitive jolting (travelling on car/bus)
8)Can also be assoc with light-headedness, dizziness, tinnitus
9)Pt also us. presents with poor posture: rounded shoulders, poked chin resulting in weakness of DNF’s
10)Stress is often also assoc

Note: Different types of headache can co-exist

I have gathered the above information from a few different sources and I am aware of some clinical features mentioned do not match with what we’ve learnt in Uni, feel free to give me some comments, I will pay a penny for your thought.

$$$

I am currently on my rural placement at a private practice. The placement has been excellent and it is such a great opportunity to practice musculoskeletal assessment and treatment. My days are pretty booked up with 8-13 patients a day which is great. The patients are however paying full price to see me- so the same price as the other physios (some have been practicing physio for 40+ years). At the start I was quite uncomfortable about this. However as the prac has gone on I have realized a few things:
- lots of my patients are veterans affairs so they don’t pay any way
- lots have workers comp so they don’t pay either
- most have private health so they only pay a small amount
- and finally, that people come to physio expecting to pay for the service they are receiving
After realizing the above I now don’t feel so bad!

Lymphodema

Ethical Dilemma

When I was on my country placement, one of my patients was a 70 years old male who had a head injury (subdural haematoma) secondary to a fall in the community.

When I took over his case (in a restorative ward), he was already 38 weeks down the track. From his previous medical entries, this patient had been documented as ‘unfriendly’, ‘uncooperative’, ‘stubborn’ and ‘verbally expressive’.

In his first physiotherapy session with me, he was unwilling to participate and the only thing he wanted was to kick or punch me. I wasn’t quite sure what to do so I went back to consult my supervisor.

My supervisor went to see the patient with me and she suggested since patient was not doing anything apart from kicking or punching, I might have to integrate these two movements into his session. For example: If I want him to do active knee extension in sitting, I have to ask him to ‘kick my hand’.

To be honest, this method worked for that patient yet I was thinking: Would this encourage patient to develop an aggressive manner towards other medical staff? Is it an appropriate method to treat your patient while hospital has emphasized on the importance of ‘zero-tolerance’ policy.

Working Hours

Hey everyone,
Currently I am on my rural placement which I am really enjoying- except that I am doing 8-5 everyday with only a half hour lunch break (8.5 hours a day). I normally don’t mind if I have to do extra hours to catch up on extra notes or what ever but I often finish my work early but my supervisor makes me stay until 5. I read the unit outline and it states that we do 37.5 hours a week normally on a rural placement which should be 7.5 hours a day and I am doing 8.5 hours a day- which adds up over a week! My supervisor is not the easiest person to approach so should I let her know or just stick it out for the next 3 weeks?

Ward round

During my current placement, I have been warned by one of the physios that certain consultant doesn't like physio to stay with the patient if he was doing a ward round and the physio is in the middle of the treatment session.
I understand that the consultant and the team want to have an uninterrupted ward round. But I could not see how I could disrupt the ward round if i was just standing on the side listening quietly, as I feel it is quite important for me to know the most up-to-date plan from the medical team.
I have a brief discussion about this with my supervisor and she suggested that sometimes the pt can be overwhelmed by the number of wardround team members. So it may be considerate for us to stand behind the curtain / door and have a listen.
My supervisor's advice has made me to think from the pt's perspective, rather than disliking the consultant's "rule".

when physio is not indicated

Hi all,
Currently im on prac in an intensive care unit. We have a patient who is a 22 y.o male with a closed head injury and multiple fractures. At the scene of the accident, he had no pulse, required CPR for 20 mins and had a GCS of 5/15. As a result he has a sub arachnoid hemorrhage. He is currently ventilated and sedated but the medical staff are having difficulty controlling his rising ICP ( he sits at about 23, normal being under 10!) After suctioning him via his ETT, his ICP rose to 28.This is an example of a patient were physio may not be indicated. Even though the suction was productive of a moderate amount of yellow/green sputum and being intubated/sedated etc, it is a possibility that this patient could (or may already has) developed chest complications. However, this is where we need to be able to look at the overall presentation of the patient, and not treat them purely as a 'cardio' pt as for him, the number one thing on his problem list is his neurological status. We need to recognise that our treatment already indicated that it may have a detrimental effect on his number one problem (raising ICP) and even though the condition of his chest is important, his neuro status is of greater concern. Physio at the present is not indicated however the pt will be monitored and when more neurologically stable, we will intervene.

consultants v physio

recently two of my pts in a hospital outpt setting were discharged by their consultants with the plan to 'continue with physio management'. The problem for my supervisor and i was that we were not achieving gains with physio (the pts had platued for a number of reasons) and we were considering sending them back to the consultant for review of their condition as it was becoming apparent that interventions other than physio might be needed. The consultants, however, seemed to 'get in first' and handball / discharge them to physio for continued management, stating that there was nothing further they were able to do for the pt.
What happens in this situation when both parties decide they are unable to appropriately manage the pt and feel other involvement is needed?? with one pt i wrote a letter to the consultant (with the guidance of my supervisor) stating the reasons we thought he needed a follow up and why discharging him to physio was inappropriate. My supervisor dealt with the other pt as it was an ongoing issue. Has anyone else come across this situation in a hospital setting where different departments refer pts back and forth? Is there a 'higher power' in this type of situation that decide whats best for the pt? or do the departments need to compromise and come to an agreement on a course of treatment?

distracting visitors

Has anyone needed to ask family or visitors to leave a treatment session? i was treating a 22yo pt who presented with knee instability and occasional sharp pain. She was fitting her physio sessions in amongst uni lectures and one time arrived with 2 friends. They walked into the treatment rooms with her and in doing so said 'oh its ok that my friends come in isnt it??' to which i said that was fine so long as they allowed us to focus on the physio session. During assessment they were all talking and i politely asked if they could leave the chat till later as we had limited treatment time. During HLB Ax they were laughing and distracting the pt and thus affecting the outcome, and again i asked that they please sit quietly while the session continued. This happened a couple more times throughout the session and whilst i found it easy to ask them to be quiet and not distract the pt i felt unable to ask them to leave, seeing as id already said they could come in. Has anyone else asked people to leave? What is the best way to go about it?

Conversion disorders

While on my neurology placement I came across approx 4 patients with a ‘conversion disorder’ otherwise known as Hysterical neurosis. Apparently that it is post grad stuff but I found it very interesting. For those of you who are unsure here are some facts:
- essentially a conversion disorder is when psychological symptoms manifest as physical symptoms (although there is no evidence of organic cause of the symptoms)
- It is a psychiatric condition
- Common signs and symptoms may include paralysis in an arm or leg, difficulties swallowing, sudden blindness/deafness, or nonepileptic seizures
- Symptoms usually appear suddenly and may follow a stressful experience
- Conversion disorder is rare
- affects women more than men
- most commonly people between age 10 and 35 years of age

Case study: One of my patients who was only young had been assaulted and had presented to the hospital with L sided weakness. The doctors did all the CT/MRI scans and found no organic cause of his weakness and so gave him the dx of a conversion disorder secondary to the stress of the assault. Initially I found it really hard to get my head around this diagnosis as his symptoms were very real i.e. he was unable to stand on his L leg with out it collapsing and shaking like mad. But then when my CCT saw him, the first thing she said was that he had a conversion disorder- just by looking at him. I guess looking back, that his presentation didn’t really fit. He would
- hop on his right leg to get around- which is very strange as it takes a lot of strength in both legs to hop
- he had 2-3 falls (which apparently is a sign of conversion)
- he had pain the whole way down his (L) side which was not dermatomal and had no apparent cause
- when testing sensation and proprioception his results were inconsistent and it appeared as though he was trying to get them wrong

I guess essentially we need to be mindful of this condition and that it exists. Even though it is rare (I saw 4 patients on 4 weeks with it…)

Hi all,

My second post of this week:

Subarachnoid Haemorrhage (SAH)

1) Diagnosis:
- Full Neurological examination
- Ongoing neurological observation (E.g. GCS)
- CT Scan
i. Confirm the diagnosis in 95% of causes
ii. Blood may be widely distributed or more localized
iii. Can also identify other conditions such as hydrocephalus and ICH
- Cerebral Angiogram
i. Undertake by all patients
ii. Four vessel angiography
- Lumbar Puncture
i. Presence of blood in CSF is a positive result
ii. Patient has LP done needs to RIB at least 6 hours
- TCD’s
i. Measure the velocity of blood flow in intracranial vessels
ii. A reading of 120cm/s is significant

2) Things need to consider when seeing patients who has SDH on ward
i. Make sure you know what type of surgery the patient had done, E.g.) If
patient had a craniectomy, they are not allowed to sit up without a helmet
ii. No driving or RTW for at least 6 weeks (For discharge planning)
iii. Fatigue can be a problem for some months post bleed (Impact on your clinical
decision)
iv. Always ask your patient whether they have any dizziness; you need to know
whether the dizziness is position related or movement related. From my 4
weeks experience, it is not uncommon for patient to have some forms of
vestibular impairments.

Base of Skull Fracture

Hi All,

I am going to share with you some knowledge which I have learnt for the last four weeks in neurosurgery ward. They are as follows:

Base of Skull (BOS) Fracture

1) Most common clinical features are blood or CSF from ear or nose

2) Those patient with CSF leakage may complain of a salty tasting fluid running down the back of throat

3) Patient has BOS fracture with CSF leak is far more severe and potentially life threatening when compare to patient who only has BOS fracture

4) Two main complications for BOS fracture with CSF leak are:
- Cerebral Infection ( Particular bacterial meningitis)
- Pneumocephalus( Accumulation of air in cranium)

5) Medical Management:
- BOS fracture with not CSF leak is managed conservatively
- If a feeding tube is required, an orogastirc tube is used instead of nasogastric tube.Nasogastric tube is not used due to the risk of increased trauma to the region
- For surgical repair, it involves a frontal lobe craniotomy with repair of the dural defect using a fascia lata graft

6) Physiotherapy Management:
- Consult neurosurgical registrar before mobilizing
- Many of these patients will have vestibular problem due to the proximity of the BOS fracture to the VIII cranial nerve.
- If patient has vertigo on ambulation, he/she may need stemetil (medication) regularly

7) Respiratory Care
- All suction should be performed via the guedels airway or via an endotracheal tube or trachyeostomy. This will avoid further trauma to the region and minimise the risk of infection

relaxation : not just for the hippies

Hi All,

I had been working with patients who suffers from dypsnea the last 4 weeks. I have used relaxation techniques on many occassions. Some patients are a little bit uncomfortable with this 'new age' thing, some are willing to try anything that works.

One of my patients was an anxious lady who was diagnosed with Type 2 Resp. Failure (recovering) with a past medical history of Breast Cancer (in remission), she also suffered hip and groin pain when actively flexing her hip. I taught her breathing control combined with relaxation technique because of her dyspnoea. No one could figure out or dwell into too much why she's anxious. I guess after we all have been working in the medical respiratory ward for a while, we just assume the dypsnoea's to do with respiratory diseases. The day before her discharge, she revealed to me that she's been worrying about the cancer cells might have spread to her hip as that's what happened to her sister who died to similar cause. She then told me that she used the relaxation breathing technique to help coping with her anxiety related dyspnoea when she was in the scanning machine and that it will be her daily practice from now on. (She's been cleared from cancer, by the way. It was a false alarm.)

I have learned two things from this:
1. it takes time to piece together the cause of dyspnoea sometimes, it's not always so straight forward, anxiety may be the cause, but what is the cause of the anxiety, that's the part we need to have some patience to figure it out.
2. relaxation technique works on ppl who are receptive to it.

Global overview

I had a pt this week who presented with no pain but the last three years after an annual sports carnival she gets quad pain. So she came to me to see what she could do to prevent it from happening again and the carnival was the next day. How do you treat no pain? In this situation PMH is important she had a hx of sprained ankles and knee ligament damage on the same side. This suggested that she had instability problem on that side which also is the side of her quad injuries. So i tested her SIJ which showed massive instability and subsequently had lead to her ankle, knee and quad problems. So when stumped take a step back and view the whole picture.

Neuro exposure

Hello all,
Coming to the end of my neuro prac, just thought I'd share some things that I learnt. I struggled throughout this prac, stemming partially from my poor/undeveloped observation skills. Subtle things like muscle activation I found difficulty to see, and hence decipher the problems, and what to do to fix this. I thought that my skills would improve over time, and they did a little but not enough to be effective or entirey accurate.

I feel in this situation I would have benefitted from specific guidance and examples from senior staff, rather than being asked continuously what i could seeand to "think about it". I take responsibility for not requesting help in this way, and I feel that it could have been offered more by the supervisors when they saw me having troubles.

As well as this I think there needs to be a lot more exposure to real patients and neurological problems at university, rather than getting thrown in the deep end, having only 4 weeks to start learning and developing these skills. I'm not sure any of our opinions make a difference to course changes but was curious if anyone else had experienced similar issues, or has any suggestions on how I could handle this situation in the future.

Aboriginal communities

Hi all,
sorry for the lateness of this blog...its a delayed one from whilst i was on rural prac. I was in Port Hedland which has quite a large indigenous population. Near to town and on the outskirts are numerous aboriginal communities. I was lucky enough to visit one, which i thought was definately one of my highlights there. It was about 2 hours outside Port Hedland, in the bush. Now a lot of these communities have major issues with drugs, alcohol and domestic violence, however this particular one was supposed to be a 'dry' community. Still when i turned up there I would still have to say I was in a little bit of shock. The community was very small with run down houses with smashed windows, wrecked cars everywhere and no one to be seen. It looked like a deserted ghost town. There was a small nursing post along with a few portable classrooms as a school and a small shack as the local shop and that was it. The physiotherapist and myself treated people as outpatients in the small nursing post which was definately different from the usual location of treatment. It was amazing to see how small the community was and the limited resources available. I'm glad i got to witness this whilst on my prac because a lot of the residents living here were often patients on the ward in the local hospital where i was based, and it definately helped me with discharge planning by knowing what they patients were returning to and what resources were available to them. Anyone else had any similar experiences?

Quality of Life

We have been reading and talking about quality of life and how it is one of the most important issues to consider when it comes to treating a patient. However, the reality does not always match with the ideal.

I was doing a discharge planning/review for my COPD patient today and she is requiring 24 hrs home O2. The hospital which I am having my placement at does not issue patients with Home O2 with 4 wheeled walker. It's not much of a big problem if the patient can afford it. For those who are on pension, they will be forced to be housebound and not being able to enjoy outdoors with their partner/family.

I believe this is only one small example on how patient's quality of life is affected due to funding issues. I feel quite frustrated by such situations but at the same time feeling helpless. Does anyone here know of similar situations or ideas on how to problem solve?

Chin.

p.s. sorry for the late posting, was not able to think of an issue to post up until today!

CCT's- not just those nasty ppl who do your final Ax

Hey Guys,
just a word of advice i've sort of realised somewhat late into my pracs! I'm currently on my last prac and my CCT has started asking me about where i want to apply, who i'm going to use as referees, what I'm going to include in my resume, etc. She has given me some really sound advice with regards to all of this stuff which has been so helpful. I guess what I'm trying to say is that CCT's really are a good resource as we don't have much contact with our lecturers this year to ask all those burning q's. I'm lucky that my CCT has offered to help me in this area but if you find you have a bit of extra time with them, don't hesitate to ask them for help in this area, i've found it really useful!

Multidisciplinary Rehab

Hey everyone, just a quick thought this time about how important it is to appreciate other allied health professionals. We all throw the terms "multidisciplinary" and "health care team" around a bit, and I'm sure everyone will mention something to this effect in their PCR's. But it's quite different when you actually get to see speech therapists (ST's) and OT's doing their thing for yourself. I have always quite enjoyed the hospital environment for the opportunities to work with other health professionals, but I have occasionally lost sight of the importance of other professions. On my current placement pts will spend 3 hours per day in physio sessions, whilst only half an hour with the ST or OT, so it's easy to rank PT as having more relevance and importance.

I was allowed to sit in on a ST session with a young stroke pt who had trouble forming the words for what she wanted to say. I was quite fascinated by the different techniques the therapist used and the relationship she had with the pt. I learned what a wide field health care in rehabilitation can be, and have a much better appreciation for what ST's do. Anyone who has an opportunity like this, I highly recommend it.

Children

Hi guys,
On my current placement, i am finding that a lot of the clients bring their children along to appointments with them. This is mainly the ladies who have little children and whose husbands work full time, and also those that have appointments after school (as they work too) and have to bring the kids along as they have nobody else to mind them.
When the children are occupied and are behaving (or are tiny and sleeping in the pram!) this is no problem. However, when the children are misbehaving or need attention so they dont cry, the mothers are always having to lift their heads (majority are in for back pain) and are not relaxed at all during the session. This really stops the treatment from being totally effective and often means that the sessions run over time as the kids are often interrupting.
I suppose this situation probably cant be helped a lot of the time, and physios in private practice may find the same thing.
But i just thought i would put it out there - some children have frustrated me this week and i usually love kids! :)

psychological problems

hey guys- two for me today too!
I have an interesting patient at the moment that has what appears to be an ascending paralysis. On admission to hospital 3 months ago they were walking and now they are unable to even maintain static sitting as the paralysis has ascended up to their trunk. The doctors have tried every known test to try and determine the cause and they have absolutely no clue what is going on. The patient is obviously and understandably becoming more and more distressed, upset and frustrated and is now convinced that she has gone mad. And the patient is constantly asking me wether they will walk again or be able to look after their two young children again! I am finding it hard to answer- I mean I have just been saying that I don’t know because I don’t know the diagnosis! I just find it hard to treat a patient with such a prominent psychological element- because you just have to be so careful about what you say!

NEURO AND BACK PAIN

Hi everyone
I just wanted to talk a little bit about Neuro placements and back pain. I don’t know about any one else but I am finding that no matter how hard I try to protect my back and get my supervisors to help me I still get a sore back at the end of the day. I try my hardest to always bend my knees and use my body weight and contract my TA’s. Especially when we are transferring people that are 3 times my body weight. I would really just love to use the hoist for all my patients! I just don’t know wether it is something that I have to accept! Any thoughts????

Time

One major thing i find hard about private practice is sticking to time. My appointment times were 1hr initial and 30min follow-up, but are now 40min and 20min for the last two weeks of prac. The first couple of days i was running behind time by about 10mins but through the week i have managed to get close to finishing on time. I have found that the section which takes the longest for me is the S and O. Rx can be completed fairly efficiently because by then you have your head wrapped around what you are doing. Some pointers i have been given to get through S quickly are, if your pt starts to ramble, say you need to get something and leave the cubicle, as soon as you get back ask your next question. Remember though you need to be polite because if you are rude they wont come back no matter how good a physio you are. If people are rambling use leading questions to get them back on track, but begin with open questions so as not to limit the info they give. Get your head around the current history (ie: mechanism of injury, time frame etc) because this gives you the best idea of what may be going on. Then you can really focus in on asking appropriate questions for the remainder of the form. After S you should go into O with options of what is going on and one of those should be you "gut" feeling. This i find really speeds up your Ax because you have in your head exactly what structures are possibly affect and you can test and knock them of the list untill you get a +ve which you can run with. Anyone else got handy hints? From what i have been taught S is by far the most important section of your initial Ax and get that right and you can see pt in 40mins and 20mins.

personal details

We are taught throughout our course that building rapport and trust with our patients is essential, and i certainly agree. As we see some of out pts on a very regular basis this trust can build naturally, however last week i found that some people were so comfortable that they confided in me more as a friend rather than their health professional.
2 pts i saw last week highlighted this; during a subjective with a 65yo man, simple questioning of hand numbness (as he previously had thoracic outlet syndrome) led him to tell me about his impotence problem and his current treatment to rectify this. He seemed to feel it was necessary to tell me even after i tried to move the conversation along. Another lady confided in me how she was a victim of domestic voiolence with her ex husband and started telling me all the horrible things that he had done to her in great detail. In both these cases i managed to change the conversation eventually, but in doing so felt like i might appear rude and uncaring.
I know i can change the subjective to more yes/no questions but thats not always appropriate. I guess i need to either learn to not be affected by patients' emotional problems, or not allow those conversations to happen in the first place. Has anyone else found it difficult in that fine line of being genuinely compassionate and caring and becoming someone patients' feel they can confide in?

Safety and dischardge

Hi guys,
2 posts from me this week because I'm running a bit behind schedule!!I'm currently treating a lady who has been admitted for a blood clot in her right lower leg, but has a previous left hemiplegia. Medically she is ready for d/c but when the physio r/v'd her this morning they didn't think she was safe walking independently and needed close standby assistance. When I reviewed her later in the day she still needed standby assistance but on 1 occasion when she almost lost her balance, she stopped herself, had a short rest and then started walking again. Myself and one of the other physios were discussing that perhaps she may have been this unsteady on her feet before she came into hospital but it was difficult to tell and to make things more complicated she only speaks limited english!! We'll keep reviewing her until we think she is "safe" but how long can you do that for before you decide that she may have been like that before she came in? I think it would be a good idea to talk to the family but haven't seen any of them present as yet. Any thoughts?

Not enough patients

Hey guys!
I'm finding on the prac I'm currently at, my supervisors are struggling to find enough patients for me. As it's my cardio prac treatment sessions don't take that long. I feel like the days that I don't have many patients, I generally feel i do "worse" because I'm not being pushed to be efficient. On the days I have lots of pts I work efficiently and my supervisor is really happy with what I do. I've asked my supervisor for a bigger caseload and she is doing the best that she can to give me lots of patients. How can I show my supervisor my strengths if I don't feel like i'm getting the chance to?

Handovers...

I just wanted to talk about patient handovers from physio's in perth hospitals to country physio's when a patient is discharged. being on my country placement, i just had a 20yr old guy come in 1 week post tibia fracture and stabilisation. he had been in hospital in perth (not mentioning any names!) for his op and we recieved a faxed referral from the physio that was treating him in hospital. all the referral said was his name, age, the actual injury and what surgery he underwent. i think that either the physio was very slack, or she just assumed that the patient would be able to pass on all the necessary info to me himself. when he came into see me with his mother, neither of them could tell me if he was supposed to be non or partial weight bearing, and also they had no other instructions as far as exercises went. he had been partial weight bearing as he had not been told otherwise (turned out he was non weightbearing for 6 wks!). The physio i am working with had to call this physio and ask her all the details, and basically told her how useless her handover was and that she expected better.
So i think the lesson learnt is for us all to make an effort with handover and referral summaries, as we cant expect the patients to remember (or be honest) about their instructions. I think it is also just curtesy to include as much info as we can so that we dont leave other physios with no understanding of our patient, or make more work for them.

Knowledge Gap

It seems like on some placements we are expected to know or to find out more in-depth knowledge than what we have learnt from the course. And often we have been told by lecturer/tutors/future employers that critical thinking is an essential skill.
Critical thinking is quite difficult to be assessed in the traditional written exam. As anyone who is good at memorising literature is, in someway, able to spit out what's memorised.

I feel that by giving more score weightings on assignment type (i.e. to eloborate about a disease in-depth) to encourage to explore knowledge based on our curiosity (rather than what's dictated strictly by the marking criteria) would be more beneficial for the student. By giving more score weighting on this type assessment will also give the students the message that the university values our learning based on curiosity and critical thinking, but not route-learning or just about passing the exams.

What do you all think about this? or about current written assessment method and whether it help us to do well in 4th year placements?

Supervisor impressions

Hello friends.
I would just like to share some difficulties that I am having with my neuro prac (surprise!). I have two patients, one a rather complex MCA stroke, and one with more cerebellar based problems. Every time my supervisor comes, I am treating the complex patient, and tend to get grilled about my observations, treatments, rationales etc. (The facility supervisor also mainly observes me with this pt.) My other patient, however, I am managing quite well with. I understand his problems, and all of my treatment sessions are going well. I think both my supervisors have an impression of me that is based solely on this patient which I struggle with, without seeing my more competent side.

Because a lot of this prac is quite new, and not covered in any depth at uni, I feel quite lost, especially with only four weeks to get my head around it and demonstrate competence. I've been doing a lot of study (but it's very different from practical observation and treatment skills) and have redone a SOAPIER that I am hoping will get a better reception on Monday than my last one.

Does anyone have any other suggestions to help me drag myself out the other end of this prac?

Experience

I am currently treating a pt who has a sore and stiff back which is constantly flairing up. He usually gets it cracked either by a physio or one of his mates on the mines. He is very worried that he will lose his job if they find out about his back so he asked that the treatment session be confidential. He is also very worried about missing work due to post treatment soreness which has happened with another physio. Due to this he asked if my supervisor could do the "cracking" rather than me. This is the first time this year that someone has asked if the supervisor could do it, which this time she could. If next time she is too busy to help how can i convince this pt that i am capable of doing it? I will try explaining to him what and how much time we spent covering this topic at uni and tell him that i have performed it on other pts and students countless times. What i would like from you guys is a back up plan if this doesn't work.

Dumb student and impatient supervisor

Hi All,

I am experiencing some difficulties in my placement and I am really frustrated at the moment:

My Curtin Supervisor came for mid-placement yesterday and it was the worst two hours I have so far. My supervisor has high expectation on student, for example: She expects student to know the effect and mechanism of every single drug on patient’s medicine chart.

I could only answer some of her questions and she was very impatient after a while. I was threatened and not motivated after the first hour. I confess my knowledge in neurology is limited but I do look up things which I don’t know. I tried hard to revise my neuro every night after clinic, but some skills (e.g. Observation) really come with experience.

I am planning to get some extra supervision next week and do you guys have some strategies to deal with this? I would love to hear your advice,thanks!

Stroke rehab path

I have just started my neuro placement, which is in a rehab setting, and thought I would share an issue that I have been introduced to. The focus at my facility is on a Bobath approach to treatment which is about encouraging normal movement as much as possible.
However, before patients are admitted they are treated in a more acute area, who often take a different approach. In these settings patients may be allowed to use whatever pattern or muscles possible to achieve a task e.g. rolling. This can hamper the rehabilitation process, as the brain relearns the wrong movement patterns, and can also result in increased overactivity in the "unaffected" side.
I believe it would be in the patients best interests to communicate between facilities in order to acheive the optimum outcome, although I'm sure I am not aware of all the issues involved, or the evidence behind it (but I'll save that for another post). Anyone?

rural prac...

Hi everyone, i just wanted to say a little bit about our rural placement...
i am on mine at the moment and really enjoying it. I am finding that the patient load is a mixture, and even though its not a specialist area i am enjoying practicing a range of treatments - from womens health to cardio, neuro and musculo. i think that working in the country as a physio would be very rewarding, and as long as you have a good support network with other physios, your skills in all areas are maintained.
Occasionally it would be quite challenging as you have nobody to gain a second opinion from, but it would definately make you attend as many continuing ed sessions as possible and keep up to date with the latest treatments available.
i hope everyone else has enjoyed their country placements also, and has found the mixture of patients great practice also!

FINISHING!

I just wanted to talk about how much I am looking forward to finishing prac this year and starting work next year. I have enjoyed prac so much this year and it feels like I have learnt more in this year then the three years we spent learning at uni! But I must say I am looking forward to not being asked questions every two seconds and just concentrating on my treatment sessions. I know that learning never stops and that you can never know enough but it will be good to be a bit more independent next year. It will also be good to finally earn some money- I’m sure that everyone feels that way after being poor for 4 years. Even though initially he pay isn’t that brilliant- but I suppose as long as you enjoy your job then the money doesn’t matter so much. I just wanted to say that I think that the physiotherapy course has been really great and will set us up for a solid career with exciting prospects!

Purchasing a gopher?

I sometimes have been told that patients will teach you more valuable things than what you would have learnt from the books.

Part of my prac consists of pulmonary rehab program. It's not the exercise part that is interesting. It's the 'health topics open discussion' which I find rather valuable not only for the patients, but also for me. During this session, the patients can either ask the physio about issues of their concerns or share their own experience.

One of the topics which came up from last week's session was the motorised gopher. One of those topics which you didn't expect to know or matters. And I thought I would share some of the things I learnt.

Here are some practical gopher-related facts:
1. max speed of a gopher is 40km/hr.
2. battery power duration depends on how often you go up a slope and the steepness of a slope.
3. patient gets only 1/2 price rebate (can't remember which type of rebate) if they are taking normal taxi, whereas they only need to pay 1/4 of the cost to call a maxi taxi so that they can bring along their gopher.
4. sunroof for a gopher costs extra.
5. sheep skin cover makes the seat more comfortable.
6. patient can also fit customised foam cushion on the seat via an OT if the seat is not suitable.

I hope that at some point these facts will assist you when your future patients do ask you about a gopher.

Head Injury Patient

Hi All,

At the moment, I am on a neurosurgical ward in RPH. I have come across a few difficult situations and would like to share some of my experience with all of you.

On the first day, my facility supervisor had clearly stated she was a big fan of Bobath technique and she wanted me to treat patients with this technique. As a student, this was a really good learning opportunity and I was more than happy to learn this new technique from my supervisor. I had used the Bobath technique to treat my patient and things went pretty well until I met my Curtin tutor.

When I first met my Curtin tutor, she asked me what I had done for the last few days. I gave her a quick handover on patient’s condition and reported what sort of treatment I had given to my patient. She was not really impressed on my choice my technique and she gave me a big lecture on Bobath technique and said this technique was not appropriate for most patients (Head Injury) on this ward.

During the three hours with my Curtin tutor, I had treated all my patients with ‘Carr and Shepherd’ approach and when she was not there, I had to use the Bobath technique to treat my patients.

I understand every clinician will have his/her own way to treat a patient but I just wonder will this inconsistency of treatment affect patient’s recovery. Is it better to stick to one approach than using different techniques on head injury patient?

Private Practice

Working in a private practice is at times very challenging. It is a constant balance between physiotherapy and business. What makes effective physio does not make effective business. For ethical reasons effective physio always comes first, but to be successful business has to come a close second. Ways to make good business include having a variety of equipment such as fit balls and orthotics to sell. Investing in good gym equipment, this is handy for treatment and during after hours you can run a public gym. Good, effective physio treatment will always bring the clients back. However, if you offer not only symptom relief physio but exercise prescription/training and add pilates in to the mix you can establish a large clientele which will continue to return over long periods of time. Private practice is a challenging place to work but I find it very rewarding. If anyone else has any other ideas of how to balance physio and business please share.
Dickie

PPIVMs and PAIVMs

Hi everyone,
I have just recently had my musculo placement and am now on my rural. I have been lucky to have had a pretty broad selection of patients, however i have been treating quite a few Cx, Tx and Lx problems. I was just wondering if everyone else finds that it takes a lot of practice to get PPIVM (and also PAIVM) findings completely accurate?! I found at first that although i was fairly accurate it was difficult to work out what levels had the worst restriction... all of us on the same prac had the same difficulty, so just seeing if anyone else has had their musculo and agrees! i think that it definately just takes practice with 'feeling' different necks and backs, and am now finding it easier on this placment as i have already had 5 weeks practice. When speaking to other physios, they say that unless you try and get your hands on as many necks as possible you may be second/third year out of uni and still be unsure with your assesment!
So we had all better get PPIVMing if wanting to work in musculo!

Stace

Good supervisors and tutors

Hi All

I have just finished a placement at SCGH - musculoskeletal outpatient (curtin clinic) and I must say, I agree with everyone else who have said it is by far the best placement ever. It made me stop to think why exactly everyone was thinking the same thing about the placement and it was quite clear that it was because of the supervisor/tutor who made the placement a fantastic experience.

No matter how easy or hard the placement is, the supervisor/tutor can turn the tables right around. Even if you struggle with the area of expertese, having a very supportive and encouraging as well as an understanding supervisor/tutor, the placement becomes highly enjoyable and the learning experience is phenomenal. Whereas, having a supervisor who puts a lot of pressure on you and expects the entire world from you, makes the placement very "unlikeable".

I have indeed come across placements and have heard from others of difficult supervisors/tutors who are very inconsistent and don't give the best support...if only they could be like the supervisor/tutor we had at SCGH musculooutpt, fourth year would perhaps not be so stressful in the end.

patience & education

I have just finished neuro prac in an outpatient setting where many pts arrive via voluntary transport. These drivers are generally very accomodating to different peoples needs, and many pts get along well with them. Ive noticed, however, that some (newer) drivers show strong frustration and a lack of patience with people who ambulate very slowly. I understand that the drivers are working to a schedule and always allow time for my pts to walk to the car at the end of the session. Several times ive had drivers try and force a pt into being wheelchaired out to the car (about 30m away) as its faster than waiting for them to walk the distance.
I explained that its really important the patients get the benefits of a longer walk, and how trying to rush someone with reduced mobility may be unsafe (and will just make them more anxious and slower). Two of the newer drivers said they thought it was better for the pt to be wheelchaired and werent aware that a longer walk was indeed a good thing.
I've since realised that often its simply a lask of understanding by people in the community that leads them to appear impatient towards people with disabilities. The driver i spoke to said he was greatful for my explanations and hoped he would learn more and be more understanding in his job. I think that if we take a little extra time to explain goals, limitations and treatments to family / friends / carers (where appropriate) it can be of great benefit to the patients.

Smokers

My supervisor made a very good point about smokers. Our first thought, even though a bad one, when we read in the notes smoker for 40+ years diagnosed with COPD is that, this is thier fault. My supervisor said that when these pts started smoking they had no idea of the consequences so you do feel sympathetic and this really changes your perspective of the pt. It is the young people who started smoking when the consequences were well known who have no excuse. These are the respiratory pts that we are going to see, so is our attitude going to change (less sympathetic) and will this affect our approach to treating them. I myself think that this is the case and our approach will change. The thought of them doing this damage to themselves will stay at the back of your mind and it will be harder to treat these pts to the best of your ability.

Androgen-deprievation therapy's side effects

Not too long ago, I had a patient who was being referred to me by a gerontology doctor for a Balance Assessment. This is patient has a PMHx of Depression, Prostate cancer and Breast Liposarcoma. He complained that he doesn't feel that his walking is as steady as pre-cancer. The initial assessment results showed that his manual muscle testing of lower limb as well as Berg was almost full score. So I assumed perhaps it has to do with depression and did not think too much about other possibilities.

During a follow-up session, he brought an article about the type of cnacer treatment which he received -- "androgen-deprievation therapy for prostate cancer patient." The article explained that this testosterone reducing therapy can cause side effects such as reduced muscle strength, reduced bone mass and increased body fat. This then made me becoming more aware of the side effects of this type of therapy.

I am glad that he brought my attention to the article. This has taught me to always investigate further with the type of co-mordity treatment which the patient is receiving and whether it has side effects towards physio related problems.

Bilat wrist pain

Hi all

another late post...had a patient with bilateral wrist pain due to prolonged typing/writing as she is a TEE student. On physical assessment, she was TOP over the anterior surfaces of the radiocarpal joint, no restriction in range, positive NTPT (median nerve test), no restriction on PPIVM assessment and on PAIVMs she was TOP as she couldn't quite take the pressure from the PAs of central and unilaterals so no real objective measure was taken from the PAIVMs. Her mom likes to join in the session as she doesn't quite pay attention during the physio session.

is this a case of the patient making an excuse to not clean her room or something or is it really an issue as I couldn't quite seem to gauge where the problem was coming from, taking into consideration that she was quite hypersensitive to the objective assessments and so the accuracy of the measures is questoinable.

Sexual Harrassment?

Hi all,

Sorry for the late entry.

I have a question mark in the title because I am not too sure if it was being considered as a sexual harrassment or not.

Situation 1 - I walked past a regular-visiting outpatient the other day. He was not my patient but we would bump into each other weekly, and would say "Hi" only. He commented: "Hm you smell very nice today". That comment stunned me a little. I was a bit slow at responding to that comment, but came up with "oh, i have just got back from the hydro pool". I am normally not very conservative but I feel he was being a "tad" too flirtatious. That comment was unneccesary and too personal/intimate (even if it's true that I smelt nice).

Situation 2 - I was treating an elderly lady, his son accompanied her to the session. I was trying to explain what she could wear to attend the hydro class. And he jokingly said "in birthday suit, and everyone goes there in birthday suit." "jennifer hawkins has a new bikini range coming out, maybe mom can wear that". I failed to get the joke, so I responded with a cold smirk and hoping he would get the hint and stop the 'joke' right there. I am not too sure if it is his usual way of conversation with his mother or with others.

I normally take the approach of not responding/reacting to those sort of comments on the first occassion and hopefully that will discourage such comments, so that if there is a follow-up appointment, at least the atmosphere will not be awkward. But I would either tell the person directly that I don't find it acceptable or inform my supervisor if that person is re-offending.

Am I being too sensitive towards the situations above?

Chin.

Patient Confidentiality

Hey guys,
just a quick question on patient confidentiality. Aside from the obvious, if you don't mention names do you think its appropriate to discuss other patients in front of patients? For example, i find it sometimes helpful with kids to say, "this other boy I'm treating blow's 20 lots of bubbles, i wonder if you could do that". That is one example but basically i find it helpful to use other kids as motivators or to let the pt know what they can work towards which is particularly helpful when two kids have the same condition. In such a small hospital I'm wondering whether this is appropriate and am a little unsure about whether I am breaching confidentiality or not? Any thoughts?

Impingement

Hi Everyone, this is a very late post sorry

I've been having difficulty thinking of things to add so I thought I'd add something useful I learnt. When classifying shoulder impingments, (primary or secondary) most of us kept getting it wrong when confirming it with the clinical tutor before treating the patient. Initially we thought primary impingment was due to the structure of the acromium process compromising the subacromium space i.e. osteophyte or congenital bony formation. Rather, a primary impingment is any pathology that is compromises the subacroumium space which includes inflammation from the bursa, or torn supraspinatus etc as well as the bony formations. Secondary impingment is due to an impairment in thiei motor control of the GHJ e.g. weak supraspinatus or external rotators etc.

So for instance, a person with a torn supraspinatus tendon would be both primary and secondary shoudler impingment as there is swelling from the tear and poor motor control due to pain/weakness.

Seeing as though most of us had thought the other classification, it appeared that it wasn't very well explained when taught the shoulder. Just thought this may be useful for those who weren't as sure as I was.

Late patients

In an outpatient setting how late is too late? On my prac i have had numerous late pts which has meant i am working over time. I am constantly working till 5 pm where i should only be working till 4:30. I find it tough to turn pts away so i attempt to modify my session to at least give them some sort of intervention but with a prescribed outline of the session already in place its tough to cut it down to fit in to a shorter session. On top of that there is the paper work. I mentioned to one pt that for the next appoinment can they get here on time which they responded positively to so will now just have to wait and see. Does anyone have any other ideas on how to approach a late pt?

Motivation

Hi all! Im currently treating a 62yo lady who suffered a L MCA stroke in nov 06 and is attending outpt rehab to improve mobility. She is motivated to attend the physio twice weekly and participates in all activities well, but is very reluctant to commence a home exercise program. She says its because she is afraid of falling while doing exercises, but with further questioning (and suggestions of exercises done in bed or sitting in a chair) she seems reluctant to even attempt one. She seems to be quite strong in her viewpoint that she will work hard "with me" and that will make her better. I feel that she is relying on me as her cure, and that its entirely my responsibility to fix her. I would like to find ways to help her realise she has to take ownership of her rehab and whilst im there to guide and assist her, ultimately she must take the responsibility. If anyone has suggestions of how to help patients realise they need to take control of their rehab i'd love to hear them, as i feel without daily maintenance stretches/exercises done at home my ability to progress this lady will be limited. Thanks!

different cultures

hi guys,
at the moment I'm on my rural prac in port hedland. Very different place with a very different patient caseload. My first patient was a young aboriginal man who lived in a nearby aboriginal community. He had been stabbed by his partner under his left clavicle and consequently developed a pneumothorax in his left upper lobe. He was also a heavy smoker and had had multiple previous admissions for intoxication, domestic violence and psych issues. Well, this was definitely something new to see. I treated him with the usual chest management i.e subjective, objective assessment and ambulation, deep breathing+ supported cough, but i found myself altering my assessment as the patient wasn't very receptive (focusing on the absolute necessities i.e pain, sputum, smoker history and leaving other questions ie. ex tol, previous chest conditions until the next day). I found the patient prefered he experiment himself with getting out of bed and the supported cough, rather than i showing him (though guiding him through it). Has anyone found similarities when working with the indigenous population?

Difficult Parents

Hi guys,
currently on an inpatients paeds prac and finding the hardest part about it is dealing with the families! One of the kids i'm treating has an extremely controlling mother who is constantly asking millions of questions! I try to answer as much of them as i can but once i answer one, she asks another and i find myself stuck trying to answer questions i don't know the answer to! I have tried to tell her when i don't know the answer to her question but then she just repeats it in another way and i find myself repeating myself over and over again!! and over! I'm finding it a really difficult situation to be in and me and my supervisor are constantly talking about different ways i can deal with things, which is really good because I feel really supported. I just feel i'm not gaining as much respect because I can't answer half of her questions! There's a lot more to it but it'll take too long to explain, just wonder if anyone has some tips from a past paed pracs on how to deal with anxious parents!!

shifty issues...

hi all! my shifty issue that id love some advice on is good old weight shift - something that almost every student will come across at some time on neuro prac! Im currently treating a pt who suffered a R thalamic stroke about 2 years ago who is currently recieving outpt rehab to improve his mobility.
At the time of his stroke he was visiting family in a 3rd world country, thus the first 4 months of acute medical treatment involved little (if any) physio. He currently ambulates with the assistance of a walking stick and whilst his gait is functional he displays many compensations.

One of his biggest issues is a reluctance to weight shift to the left, and he actively resists any kind of hands-on facilitation with any task(resisting and fixing to such a degree that even the supervisor was suprised!). I believe some cultural issues are also affecting our ability to have close contact with him. So far ive tried to limit hands-on contact as he dislikes this so much, and opted for verbal cues which sometimes work (he also has limited english).
To assist with weight shifting activities ive tried giving him a target to reach for so he uses internal displacement over my external facilitation, and also prone standing over a plinth to allow him to get some selective control of the L leg and also get him used to some weightbearing on the L whilst feeling safe and supported.
I'd love to hear if anyone else has had pts who really dislike you coming into their personal space and who activily fix throughout the trunk and upper limb when you try to displace them, and any suggestions as to how i might get my much-desired weight shift to the left side!! thanks

Mood Swings

I have this pt who goes from happy go lucky and willing to do what ever you ask, to swearing, stubborn and non co-operative. The nurse's have told me he is like that with everyone and just to ignore it, but, i find it hard to ignore because i am unwilling to get him up and walking on oxygen if he is going to become abusive halfway down the corridor. He is too unpredictable to be considered safe to walk on oxygen and it wouldn't be safe for me because you have to be close to him when walking. On the other hand this is pretty much the only treatment i can do for him so if i don't do it he gets no physio intervention at all, which he badly needs. What i would like to hear from you guys is would you walk him or not?

Real World 101

Hi all,

I have been discussing about fitting in workplace during the placements with one of my friends lately. I am from Malaysia and finding it difficult to fit in, however I wasn’t aware of the cultural difference at work until my friend pointed it out for me.

From where I come, the ‘students’, ‘newbies’ or ‘lower level employees’ would see the seniors as superior. We may show either respect or feel intimidated depending on the attitude displayed by the superior, and the superior rarely speaks to the rest of the employee as a friend. Over there, we’re expected to do exactly as told, whereas the superior here will guide you towards the direction or indirectly hint what they expect of you and they expect you to be proactive or even take initiative to do more than as told. Of course, not all Asian employees are like what I have just described (or maybe it's just me).

So initially when I have been marked down in assessment form on those areas, I could not comprehend why I have been marked down when I have done my job. I am being told that I’m not proactive enough in seeking feedback etc. Only after my friend has advised me about how to behave in the ‘western’ workplace, then I had that ‘oh my god I have been so silly’, there I was, been feeling like an alien, and not knowing the most basic thing about how to behave at a workplace.

It would have very helpful if someone has told me about what to do and what not to do before I got thrown into the deep end from a completely naïve, unrealistic university environment to a big intimidating real hospital with a huge team to work with. It has been too often that most people take it for granted that it’s common sense or it’s something that ‘u should have it built-in’. If the school can include that into health communication 101 or other similar units, I feel that a lot of students who are not familiar with the workplace culture will be thankful for that.

Complicated

Hey everyone,

Got a patient who has had a long history (> 3 years) of neck pain referred to the shoulders and arms/hands (bilat). Occasionally he would get pins and needles down the left arm and rarely in the right arm. His pain is greater on the left than the right.

On physical examination, he was hypomobile and TOP/pain on PAIVM @ C3,4 and C4,5. He had a limitation in Cx rotation to the left but he has now acheived full rotation (R=L) He is a heavy built, tall, fit male and doesn't have the best posture. It was concluded from this and other physical examinations that it was a postural/loading disorder. The patient has attended several sessions thus far, and has improved greatly but pain still persists with the occassional P+Ns senseation. He benefits mostly from STM of UT and LS and taping of his shoulders to improve posture. I've done PAIVMs @ the aformentioned levels and now has full rotation.

In the previous session I PPIVMed him at C3,4 4,5 to off-load the joint after a discussion with the supervisor. 2 minutes after Rx, the patient experienced P+Ns on the left arm. 5 minutes later he experienced P+Ns on the right arm.

We advised the patient to come back next week (which is this week) to be re-assessed as we're unsure of what is happening. I was hoping to get some ideas of whats going on, what have I done or what have I not done.

Cheers

Yellow flags...

Hi all,

Sorry for my late entry as i have totally got the blogging timing all confused. Luckily our fellow colleague Mark has clarified it for me today and hence i got this blog submitted the first thing i arrive home.
Now that i have got the apology out of the way.. i'll go right into the discussion.

I am currently having a placement at Gerontology outpatient of a tertiary hospital. Most of the patients are there for fall assessments/rehab. However there are a few odd cases where the patients are being referred due to social reasons (i.e. depression due to death of spouse).

I have a lady who was being referred to our department due to multifactorial falls. some sounds almost trivial. I was not aware of her social history at the time as i did not have the referral letter at the time. but only later i found out from the letter that she has been drinking sherry every night with prescribed sleeping pills since her husband's death, which now make sense to me why her 'trivial' falls occured between 11pm and 2am. Her case is also being reviewed by the social worker concurrently.

I feel that all i can do is to focus on physiotherapy problems of hers, which was to improve standing/walking balance, and i feel that there's not much else i can do. I am not entirely frustrated by me not being able to do much else as i know she is in good hands of social worker's plus i'm not an expert in social issues/psychology, but it made me feel a little bit sad somehow.

Has any of you had similar type patient? And how did you deal with the situation or how would you tackle it if you were in similar situation? And do u know of any not-for-profit organisation/services that is doing a reach-out for this type of patients?

Chin.

Final Frustrations

Hi guys
just wanted to open the discussion for how everyone is coping in second semester. I've just returned from rural prac where I was treating every single patient without hesitance. I loved it and felt like I was finally ready to enter the workforce! But now I've come back to perth and started my latest prac and gone back to not being really able to treat the patients but just having to observe! I understand why things are this way but I'm finding it kind of frustrating becuase I feel like i've taken a backwards step!! Just wondering if anyone else is feeling the same now that we're coming to the end of the road!

communication issues

Hi all, id love your advice on some communication suggestions for a 73yo patient who has global aphasia following L ACA/MCA stroke 2 years ago. From doing a few tests i think he has a more significant impairment of expressive aphasia but not so much receptive, as often he appears to understand clearly what im asking him to do. He can use a picture book when prompted to assist with communication, and verbally can only say "right" and "ok" however these are inconsistent. He is a lovely man who at times gets so frustrated with people not understanding him. So far ive tried to restrict my questions to yes/no answers which seems to work, and give him alot of time to answer me. He requires prompting to use the communication book but it doesnt have alot of options for him. If anyone has other suggestions as to how i can approach a 'standard' subjective/objective assessment i would love to hear them! thanks, Em

Difficult Patients

Last week i had a pt who was deaf, semi blind and suffered from dementia. What i am asking of you is if you have had a difficult pt to communicate with, how have you got around this issue. What me and my supervisor tried was a lot of hands on techniques, all we need to do with the pt was to get him up and walking. The pt was very impulsive so we had to place a hand on his chest to notify him when we needed him to stay still and not move forwards. To stop him from standing up we had to place a hand on his shoulder. We stood right in front of the pt and used a lot of eye contact when we were explaining what we wanted the pt to do. Even with all this we still found it extremely difficult and more time consuming. We managed to get the pt to the shower and had to call it a day. So for next time i was hoping for some more ideas to try and make the session more effective and less time consuming.

Dickie

references??

Hi all, apologies for the late posting! I thought id discuss a situation that almost every student will find themselves in at some point this year. As we were approaching the last few days of our last prac one of my fellow students asked me if i was going to ask my supervisors for a reference upon completion of the prac. I think many students will be divided on this issue, but i feel that as one of a large number of students that file through each facility its not our place to request a reference. I dont like the idea of a supervisor feeling obliged to say yes and I think that if you have stood out enough to the supervisor then they will offer to be a referee without you having to ask. I explained my thoughts to the student who agreed, but also suggested i should take a more proactive role in getting good references which is a very good point. I think theres no right or wrong answer to this issue and its always a very individual situation, but id love to hear other peoples opinions!