I really enjoyed my time at Bentley and learnt a lot!! Some of my expectations were correct (which was to be expected as I had an orientation prior to starting placement).
I expected to do hydrotherapy every week, however we only had to do it 3 out of the 5 weeks. It was a good experience but not the best weather for hydro! The hydro was individual programs for patients, not one big group exercise class like I thought it might be.
I expected to see 3 patient a day to start with (which is what happened) but originally thought I’d build up to 8 or 9. I saw a maximum of 6 patients, although I probably could have squeezed in more on some days.
My supervisor was great in that he really helped develop my clinical reasoning. He questioned why I was doing a specific treatment and tried to guide me without just giving me the answers. It really helped my lateral thinking.
While we had access to the referrals and handovers the day before seeing the patient, by the end of the placement I wasn’t so worried about studying up for each patient the night before. I started off by doing this but as I got more confident I knew I could tackle it the morning of seeing the patient. We had planning sessions with out supervisor each morning to discuss the patients we were seeing that day. This was great for developing clinical reasoning but also made me feel more comfortable in that I would know what to do with my patients.
There is a PD session for all the staff once a week and everyone takes it in turns to do a presentation. The students are also included in this and I did my presentation on the link between depression and back pain. I had expected to do a presentation but I didn’t realize how much I would learn from doing it. A lot of the physios in the department also commented it was such a relevant topic.
I had some concerns coming into this placement, but none of them turned out to be a problem! I was concerned I might get a patient who I could not diagnose or work out a treatment plan for, but our supervisor explained how we should treat what we see instead of trying to come up with a diagnosis. In time it would be worked out. The fact we were given so much support also made this less of a worry because I knew I would be able to get help from other physios with my patients if I needed. I was also concerned I wouldn’t remember everything from the past 3 years at university, but I found this wasn’t a problem. If there was anything I forgot I could look it up or try a different technique. We were shown a lot of new techniques while on this placement and I found they gelled really well with what we already knew.
The most important lesson I learned at Bentley was to treat what I see. Just because a person is referred with a specific diagnosis doesn’t mean your assessment findings will match that diagnosis. When this happens trust in your assessment and treat the problems that you actually found. Don’t try and fit you assessment to the referral’s diagnosis.
Thursday, July 22, 2010
STARES 3 – Treatment for patient with knee pain
SITUATION
I had been referred a patient suffering from knee pain. The referral mentioned “patello-femoral syndrome” and through my subjective and objective assessment I found she had lateral mal-tracking of the patella. I also found she had very pronated feet when walking with low arches. Her lateral thigh structures were very tight and her vastus medialis oblique (VMO) was barely activating. Her quadriceps were weak with an obvious quads lag. Her pain was at the worst when she had to go up and down stairs. When a medial glide was applied to the patella it was not as painful to go up and down stairs. There were a number of factors contributing to this knee pain.
TASK
My task was to provide a treatment session for this patient, targeting the knee pain and lateral tracking of the patella.
ACTION
My first part of the treatment was education. It is important for the patient to understand what is going on and what the treatment plan is. I explained that the knee pain would be a result of the mal-tracking patella, which is sitting too far to one side (and therefore not sitting in the groove). I explained it could be mal-tracking as a result of the tight lateral structures pulling it one way and the weak medial structures (particularly VMO) could not pull it back to midline.
The second part of my treatment was aimed at decreasing the tension of the lateral structures. I used massage and advised her on the use of heat and stretches at home.
My final part of the treatment was exercises aimed at increasing the quadriceps and VMO strength. I prescribed step exercises which are very good for quad strength and can be modified slightly to target VMO. I used strapping tape to put a medial glide on the patella to relieve pain temporarily. The aim was to reduce pain to allow the patient to make a start on the exercises at home.
I also sent a referral to the podiatrist regarding the pronated feet to see if orthotics to raise the arches were possible. I feel it would take some of the pressure off the knee (which could be a contributing facto in the knee pain).
RESULT
I completed this treatment session in the allocated time and the patient understood how each treatment component could help to decrease her knee pain. The treatment had an immediate effect on the pain, and strapping provided temporary relief from the pain completely.
EVALUATION
I feel this was a god treatment session as it had an immediate effect on decreasing the knee pain and the patient knew what to do at home to continue this pain relief. I think a good treatment session gives the patient something to do at home to self-manage their pain, rather than waiting until their next physio appointment. It also encourages them to actively participate in the treatment, rather than having it purely passive (which has been shown to have a poor outcome). By prescribing exercises for this patient to do at home it will be a lot more effective than only being seen by a physio once a week. The fact there was an immediate decrease in the pain will encourage the patient to be compliant with the home exercise program as she knows this treatment really can help.
By referring her to the podiatrist I was taking a multidisciplinary approach, which will benefit the patient. Overall I feel it was a well-rounded approach that decreased the pain during the session but also focussed on how we would decrease the pain permanently.
There were a few improvements I would have made in this session. When demonstrating the step exercises I tried to explain too much first when I should have just shown her. Actions speak louder than words! I think I may have temporarily confused the patient with the exercise.
Also, I chose to use a plastic massage device over her clothes, rather than using cream directly on the skin. I feel massaging with cream may have been more effective (I can put more pressure through my forearm than the plastic device in my hand). The patient was wearing long pants that could not be rolled high enough to reveal the thigh. I did not think she would be comfortable taking her trousers off and being covered with a towel, however I should have given her the option instead of assuming what she would prefer.
STRATEGIES
1. Save time trying to explain a complicated exercise to a patient and just demonstrate it instead.
2. Don’t assume what the patient is comfortable with or not, always ask them what they would prefer.
I had been referred a patient suffering from knee pain. The referral mentioned “patello-femoral syndrome” and through my subjective and objective assessment I found she had lateral mal-tracking of the patella. I also found she had very pronated feet when walking with low arches. Her lateral thigh structures were very tight and her vastus medialis oblique (VMO) was barely activating. Her quadriceps were weak with an obvious quads lag. Her pain was at the worst when she had to go up and down stairs. When a medial glide was applied to the patella it was not as painful to go up and down stairs. There were a number of factors contributing to this knee pain.
TASK
My task was to provide a treatment session for this patient, targeting the knee pain and lateral tracking of the patella.
ACTION
My first part of the treatment was education. It is important for the patient to understand what is going on and what the treatment plan is. I explained that the knee pain would be a result of the mal-tracking patella, which is sitting too far to one side (and therefore not sitting in the groove). I explained it could be mal-tracking as a result of the tight lateral structures pulling it one way and the weak medial structures (particularly VMO) could not pull it back to midline.
The second part of my treatment was aimed at decreasing the tension of the lateral structures. I used massage and advised her on the use of heat and stretches at home.
My final part of the treatment was exercises aimed at increasing the quadriceps and VMO strength. I prescribed step exercises which are very good for quad strength and can be modified slightly to target VMO. I used strapping tape to put a medial glide on the patella to relieve pain temporarily. The aim was to reduce pain to allow the patient to make a start on the exercises at home.
I also sent a referral to the podiatrist regarding the pronated feet to see if orthotics to raise the arches were possible. I feel it would take some of the pressure off the knee (which could be a contributing facto in the knee pain).
RESULT
I completed this treatment session in the allocated time and the patient understood how each treatment component could help to decrease her knee pain. The treatment had an immediate effect on the pain, and strapping provided temporary relief from the pain completely.
EVALUATION
I feel this was a god treatment session as it had an immediate effect on decreasing the knee pain and the patient knew what to do at home to continue this pain relief. I think a good treatment session gives the patient something to do at home to self-manage their pain, rather than waiting until their next physio appointment. It also encourages them to actively participate in the treatment, rather than having it purely passive (which has been shown to have a poor outcome). By prescribing exercises for this patient to do at home it will be a lot more effective than only being seen by a physio once a week. The fact there was an immediate decrease in the pain will encourage the patient to be compliant with the home exercise program as she knows this treatment really can help.
By referring her to the podiatrist I was taking a multidisciplinary approach, which will benefit the patient. Overall I feel it was a well-rounded approach that decreased the pain during the session but also focussed on how we would decrease the pain permanently.
There were a few improvements I would have made in this session. When demonstrating the step exercises I tried to explain too much first when I should have just shown her. Actions speak louder than words! I think I may have temporarily confused the patient with the exercise.
Also, I chose to use a plastic massage device over her clothes, rather than using cream directly on the skin. I feel massaging with cream may have been more effective (I can put more pressure through my forearm than the plastic device in my hand). The patient was wearing long pants that could not be rolled high enough to reveal the thigh. I did not think she would be comfortable taking her trousers off and being covered with a towel, however I should have given her the option instead of assuming what she would prefer.
STRATEGIES
1. Save time trying to explain a complicated exercise to a patient and just demonstrate it instead.
2. Don’t assume what the patient is comfortable with or not, always ask them what they would prefer.
Saturday, July 10, 2010
STARES 2 – Communication
SITUATION
I had a patient transfer to me from a previous student. I read in the notes that she had been suffering from headaches caused by increased tension in the cervical spine (primarily due to increased muscle tension through trapezius, rhomboids and levator scapulae). Her headaches were better when the muscles were relaxed, however she had not been very compliant with her home program and her headaches gradually got worse again following each treatment session (after her feeling really good at the end of each session). As a result of her not doing her home exercise program (HEP) the muscles would tighten up after treatment and she would not do anything to help it until the next time she came in for physio.
TASK
My task was to perform a follow-up assessment for this patient and a treatment session. I had the job of telling this patient that is she wasn’t complying with the HEP then we couldn’t do much else for her.
ACTION
I began the subjective assessment by asking how her headaches had been. When she said they were good after the last treatment session but got worse again as time went on I asked her if she had been doing her HEP. She replied that she hadn’t been doing it every day, only occasionally as she had been busy. I took this opportunity to remind her that I could do a treatment for her but she needed to continue it at home to have a long-lasting effect from it. I didn’t want to have a go at her but I needed to make my point. I then performed my objective assessment and started my treatment by working on the muscles around the shoulders and neck. As I massaged I explained again how she could prolong the benefits of this treatment session at home. I thought that if I explained this to her while I was performing a hands-on treatment, she would realize I was still going to treat her and not just send her away to deal with it at home by herself. I tried to make her understand it was a two-way street. I could only help her if she was going to help herself. After I had finished my treatment and was winding up the session I explained to her that we knew what her problem was and we know how to get rid of the pain and headaches, it was just a matter of her actually doing her exercises at home. I put it back on her, saying SHE had to do the hard work to get rid of the pain, rather than expecting our physio session to be a miracle cure.
RESULTS
My patient seemed to understand the point I was trying to make without me having to be too blunt about it. I have given her the idea that if she doesn’t do her HEP then we will not continue with her treatment at the hospital as it was just wasting everyone’s time. The patient agreed to do her program and admitted she needed to lift her game a little. I think she now understands the consequences if she does not actively participate in her treatment. I was able to get this point across to her without ruining my rapport (or the rapport developed with the patient by the previous student). If I had been blunt about it she may have felt that I was blaming her and decided she didn’t want to attend physio. This would have been a shame as physio is definitely something that can help her problem if she complies with her exercises.
STRATEGIES
It can be difficult to have to tell a patient off for not doing their exercises and that if they don’t do them then there is nothing else we can do. Some ways of dealing with this are:
1. Say you don’t want to waste THEIR time coming into hospital when it’s not a very effective treatment by itself. This is better than you saying it’s wasting YOUR time.
2. Be sensitive and sympathetic – find out if there is a reason they haven’t been doing their exercises before you assume they are just non-compliant.
3. Be strong and as forceful as necessary to make your point but avoid being tactless or overly blunt.
4. Compromise – see how many exercises they think they can commit to doing if they think the whole lot you prescribed is too much. This is better than them doing none at all.
I had a patient transfer to me from a previous student. I read in the notes that she had been suffering from headaches caused by increased tension in the cervical spine (primarily due to increased muscle tension through trapezius, rhomboids and levator scapulae). Her headaches were better when the muscles were relaxed, however she had not been very compliant with her home program and her headaches gradually got worse again following each treatment session (after her feeling really good at the end of each session). As a result of her not doing her home exercise program (HEP) the muscles would tighten up after treatment and she would not do anything to help it until the next time she came in for physio.
TASK
My task was to perform a follow-up assessment for this patient and a treatment session. I had the job of telling this patient that is she wasn’t complying with the HEP then we couldn’t do much else for her.
ACTION
I began the subjective assessment by asking how her headaches had been. When she said they were good after the last treatment session but got worse again as time went on I asked her if she had been doing her HEP. She replied that she hadn’t been doing it every day, only occasionally as she had been busy. I took this opportunity to remind her that I could do a treatment for her but she needed to continue it at home to have a long-lasting effect from it. I didn’t want to have a go at her but I needed to make my point. I then performed my objective assessment and started my treatment by working on the muscles around the shoulders and neck. As I massaged I explained again how she could prolong the benefits of this treatment session at home. I thought that if I explained this to her while I was performing a hands-on treatment, she would realize I was still going to treat her and not just send her away to deal with it at home by herself. I tried to make her understand it was a two-way street. I could only help her if she was going to help herself. After I had finished my treatment and was winding up the session I explained to her that we knew what her problem was and we know how to get rid of the pain and headaches, it was just a matter of her actually doing her exercises at home. I put it back on her, saying SHE had to do the hard work to get rid of the pain, rather than expecting our physio session to be a miracle cure.
RESULTS
My patient seemed to understand the point I was trying to make without me having to be too blunt about it. I have given her the idea that if she doesn’t do her HEP then we will not continue with her treatment at the hospital as it was just wasting everyone’s time. The patient agreed to do her program and admitted she needed to lift her game a little. I think she now understands the consequences if she does not actively participate in her treatment. I was able to get this point across to her without ruining my rapport (or the rapport developed with the patient by the previous student). If I had been blunt about it she may have felt that I was blaming her and decided she didn’t want to attend physio. This would have been a shame as physio is definitely something that can help her problem if she complies with her exercises.
STRATEGIES
It can be difficult to have to tell a patient off for not doing their exercises and that if they don’t do them then there is nothing else we can do. Some ways of dealing with this are:
1. Say you don’t want to waste THEIR time coming into hospital when it’s not a very effective treatment by itself. This is better than you saying it’s wasting YOUR time.
2. Be sensitive and sympathetic – find out if there is a reason they haven’t been doing their exercises before you assume they are just non-compliant.
3. Be strong and as forceful as necessary to make your point but avoid being tactless or overly blunt.
4. Compromise – see how many exercises they think they can commit to doing if they think the whole lot you prescribed is too much. This is better than them doing none at all.
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