Hello all! I appologise for being so late but was having some computer/e-mail issues!
I am currently completing my musculo prac at Curtin and am enjoying my time. An issue that I have had with both this prac as well as my cardio prac was "time management". Now this comment was not always made directly towards me but I feel that it is something that the supervisors and tutors love to tell us to work on. Now, I realise that this is definitely something that we do need to be aware of and that when we graduate and are practicing that we will constantly have to deal with, however, I do not feel that it is the "be all and end all" of being a good physio and that, while we should be aware of it, it should not be one of our main concerns in the first couple weeks of the practicum. I feel that, as students, everything is brand new to us, and while we can't "dilly daddle" and waist people's time that it should be taken into account that we need to get a good grasp on ALL of the information to start. In learning how to establish all of the recently learned new material into clinical practice I feel that it is far mor important to go into greater detail and learn as much as we can about everything. This then allows us to have a good understanding of the issues and what we can and can't miss as a practicing physio (ie; knowing what is the most important assessment, treatment, to do and what can wait till next session due to time constraints).
So, in conclusion, I feel that a student should not be necessarily labeled as "doing well" because they are able to treat more patients and hold to the time contraints, as this may be simply due to them missing out important information! I can definitely say that I, myself, have felt the pressure of time and have most likely missed out on something I probably shouldn't have and have, in fact, being praised for it! If anyone else has anything to add I'd be happy to hear!
Nicole
Monday, January 15, 2007
Postherpetic Neuralgia
At my orthopedic outpatients placement I’ve recently treated a patient who presented with postherpetic neuralgia with pain in her cervical region and associated headache.
As I was not familiar with the syndrome, I’ve sourced some information about it on the internet (www.mayoclinic.com, accessed 14/01/2007):
Postherpetic neuralgia is a painful condition affecting the nerve fibers and skin. It's a complication of shingles, a second outbreak of the varicella-zoster virus, which initially causes chickenpox. A case of shingles usually heals within a month. But some people continue to feel pain long after the rash and blisters heal. This pain is known as postherpetic neuralgia.
The symptoms of postherpetic neuralgia are generally limited to the area of the skin where the shingles outbreak first occurred. They may include: sharp and jabbing, burning, or deep and aching pain; extreme sensitivity to touch and temperature change; itching and numbness; headaches.
In rare cases, patients might also experience muscle weakness or paralysis — if the nerves involved also control muscle movement.
Treatment for postherpetic neuralgia depends on the type of pain experienced. Possible options include: Lidocaine skin patches, antidepressants, certain anticonvulsants, injected steroids, painkillers, transcutaneous electrical nerve stimulation (TENS), spinal cord or peripheral nerve stimulation.
In some cases, treatment of postherpetic neuralgia brings complete pain relief. But most people still experience some pain, and a few don't receive any relief. Although some people must live with postherpetic neuralgia the rest of their lives, most people can expect the condition to gradually disappear during the first three months. For about 10 percent to 20 percent of people with postherpetic neuralgia, the pain may persist for a year or more.
The patient I’ve treated mainly presented with pain on active movement and ↓AROM into SF bilaterally and extension. On assessment her upper trapezius on both sides had trigger points reproducing her pain locally and referred (headache), and the insertion of splenius capitis and semispinalis capitis at the occiput were tender and reproduced her pain. On PPIVM’s I found normal movement. I was unable to assess PAIVM’s due to tissue tenderness.
I therefore decided to treat her muscular symptoms, performing STM and very light trigger point release as the patient was still very tender to touch. My reasoning behind is that due to the hypersensitivity of the nerve, the muscle had reacted into local spasm, creating a trigger point. A contributing factor for her muscle soreness could be pain provoked posture, making her lift her shoulders because her neck had been so sore for a while.
Has any one had a similar case where a patient presented with muscular soreness due to neuralgia and how did you treat it? Any other ideas, suggestions or comments…
Thanks,
Edith
Sunday, January 14, 2007
The first neuro patient
I am currently taking neuro placement at the Royal Perth Hospital Shenton Park Campus.
The first patient I saw was a lady who had LMCA stroke and was attending the neuro outpatient department for ongoing rehabilitation. Reading her transfer summary I have noticed that previous physiotherapist was working mainly on this ladies UL function. When I met the lady for the first time I observed that she had quite and advanced pregnancy and her gait was very compensated to the point that I thought that she is quite unsteady and at risk of falling.
During my subjective examination, I asked her what were her main concerns were.
She pointed out to me to her R UL, as she couldn’t talk due to receptive aphasia. All the questions had to be with answers being yes or no. So my first treatment consisted mainly with the exercises of her R UL as she requested and also I followed what was in her transfer summary of her exercise program. On her second visit I decided to do an assessment to revaluate her impairments and prioritise the problem list for her ongoing rehabilitation.
During the assessment of the ladies gait I noticed that she had inadequate weight shift on the affected side and she looked very unsteady. My instant thought was that I needed to change her program in terms of working more on postural control and improving her gait pattern, rather that just working on her R UL function.
My dilemma was how would I tell this lady to change her program as she was quite determined what she wanted, that is to improve her UL function. Seeing her for the second time I wanted first to gain the patients trust and build a better rapport to gain her compliance of the rehabilitation.
I decided to explain the reason for my decision. First, by doing the Berg Balance reassessment and 10 min walk test would show her and me a good outcome measure, that is results probably indicating that she hasn’t improved since her last assessment. Secondly explaining how balance changes with pregnancy in normal people and that being affected by the stroke balance will be affected even more puts her at risk of losing balance, which may harm her and the babie. This may increase her awareness and therefore compliance.
What do you think colleagues of my plan when dealing with this patient?
The first patient I saw was a lady who had LMCA stroke and was attending the neuro outpatient department for ongoing rehabilitation. Reading her transfer summary I have noticed that previous physiotherapist was working mainly on this ladies UL function. When I met the lady for the first time I observed that she had quite and advanced pregnancy and her gait was very compensated to the point that I thought that she is quite unsteady and at risk of falling.
During my subjective examination, I asked her what were her main concerns were.
She pointed out to me to her R UL, as she couldn’t talk due to receptive aphasia. All the questions had to be with answers being yes or no. So my first treatment consisted mainly with the exercises of her R UL as she requested and also I followed what was in her transfer summary of her exercise program. On her second visit I decided to do an assessment to revaluate her impairments and prioritise the problem list for her ongoing rehabilitation.
During the assessment of the ladies gait I noticed that she had inadequate weight shift on the affected side and she looked very unsteady. My instant thought was that I needed to change her program in terms of working more on postural control and improving her gait pattern, rather that just working on her R UL function.
My dilemma was how would I tell this lady to change her program as she was quite determined what she wanted, that is to improve her UL function. Seeing her for the second time I wanted first to gain the patients trust and build a better rapport to gain her compliance of the rehabilitation.
I decided to explain the reason for my decision. First, by doing the Berg Balance reassessment and 10 min walk test would show her and me a good outcome measure, that is results probably indicating that she hasn’t improved since her last assessment. Secondly explaining how balance changes with pregnancy in normal people and that being affected by the stroke balance will be affected even more puts her at risk of losing balance, which may harm her and the babie. This may increase her awareness and therefore compliance.
What do you think colleagues of my plan when dealing with this patient?
Saturday, January 13, 2007
Angel Transfers
Dear All,
I am currently completeing a neuro inpatient clinic on an acute ward. One thing we've had to learn to do thus far is an 'Angel' transfer. For those of you that are unaware - it is a maximal dependent transfer - with students 1 at the front of the patient and one behind controlling the pelvis. It can go to say that the person at the front has a bit more work to do. Anyway, the idea is that you take the patient's weight with them leaning on you, ensure that you've got their weight, and you kind of rock forwards and to the direction you are going in, then unaware to the patient, you transfer them. Nursing staff do not do this transfer due to the 'no lift' policy and this transfer is classified as a lift.
We have been seeing a patient who had a large L MCA infarct on the 6/1/07, and was allowed up on Wednesday. Thursday we took the pt to the gym and were shown the transfer. Our supervisor wanted us to perform it ourselves getting the pt from the plinth back into her chair, and almost unfortunately I was the student in front. This pt would weigh approx 100kg......my weight: approx 55kg. I was quietly anxious regarding transfering such a large pt in this style, however completed the transfer with minimal difficulty, however I felt as though I put in maximal effort.
Then on Friday, I had to transfer the pt from her bed (complete with Nimbus mattress) to her wheelchair. By the end of the week I also had quite considerable DOMS in both my ULs and LLs, not to mention trunk, abs....ok everywhere - I'm the sorest I've ever been, so I was a little anxious to say the least. The pt's room was full of pepole and I didn't want to have to spend a lot of time doing the transfer, and needless to say - the transfer didn't go as well....I almost overshot the wheelchair and pushed my weight too far backwards....so although the pt ended up in her chair....I nearly ended up on the floor! I was quite embarrassed to say the least, and have learnt my lesson in that - when preparing for the transfer to TAKE YOUR TIME and not go until you are really sure you've got the pt exactly where you need them. I was also really worried that the pt had lost confidence with me.....so when we got down to the gym, despite being asked by my supervisor if I would like her to do the transfer, I did another 2 - with no hiccups. BUT I am still quite sore to say the least. So....I have restored my pt's confidence in me (I hope) and my confidence in myself....however I'm wondering when and how you decide that a pt is either too big for your body size and therefore it's unsafe for you to manually transfer them whilst they are completely dependent? I have also been thinking about the culture of physiotherapists....we seem to have this belief that we can manually transfer anyone, no-one is too big for us if we have the correct technique - but is that really true?? What about all of the 'workplace safety policies' - do they not apply to us? AND, if you do decide NOT to manually transfer a pt - do you look incompetent or like you have a lack of confidence to your supervisors?
Mads
I am currently completeing a neuro inpatient clinic on an acute ward. One thing we've had to learn to do thus far is an 'Angel' transfer. For those of you that are unaware - it is a maximal dependent transfer - with students 1 at the front of the patient and one behind controlling the pelvis. It can go to say that the person at the front has a bit more work to do. Anyway, the idea is that you take the patient's weight with them leaning on you, ensure that you've got their weight, and you kind of rock forwards and to the direction you are going in, then unaware to the patient, you transfer them. Nursing staff do not do this transfer due to the 'no lift' policy and this transfer is classified as a lift.
We have been seeing a patient who had a large L MCA infarct on the 6/1/07, and was allowed up on Wednesday. Thursday we took the pt to the gym and were shown the transfer. Our supervisor wanted us to perform it ourselves getting the pt from the plinth back into her chair, and almost unfortunately I was the student in front. This pt would weigh approx 100kg......my weight: approx 55kg. I was quietly anxious regarding transfering such a large pt in this style, however completed the transfer with minimal difficulty, however I felt as though I put in maximal effort.
Then on Friday, I had to transfer the pt from her bed (complete with Nimbus mattress) to her wheelchair. By the end of the week I also had quite considerable DOMS in both my ULs and LLs, not to mention trunk, abs....ok everywhere - I'm the sorest I've ever been, so I was a little anxious to say the least. The pt's room was full of pepole and I didn't want to have to spend a lot of time doing the transfer, and needless to say - the transfer didn't go as well....I almost overshot the wheelchair and pushed my weight too far backwards....so although the pt ended up in her chair....I nearly ended up on the floor! I was quite embarrassed to say the least, and have learnt my lesson in that - when preparing for the transfer to TAKE YOUR TIME and not go until you are really sure you've got the pt exactly where you need them. I was also really worried that the pt had lost confidence with me.....so when we got down to the gym, despite being asked by my supervisor if I would like her to do the transfer, I did another 2 - with no hiccups. BUT I am still quite sore to say the least. So....I have restored my pt's confidence in me (I hope) and my confidence in myself....however I'm wondering when and how you decide that a pt is either too big for your body size and therefore it's unsafe for you to manually transfer them whilst they are completely dependent? I have also been thinking about the culture of physiotherapists....we seem to have this belief that we can manually transfer anyone, no-one is too big for us if we have the correct technique - but is that really true?? What about all of the 'workplace safety policies' - do they not apply to us? AND, if you do decide NOT to manually transfer a pt - do you look incompetent or like you have a lack of confidence to your supervisors?
Mads
Thursday, January 11, 2007
Mingling
Something that I seem to be having a problem with is mixing the physios in the department other than those who I am in direct contact with. At morning tea and lunch the tendency is to just either speak with the physios that I work with on the ward or with other students. I’m not really looking for advice, just more if anyone else is having the same problem, or if I’m just special.
Dealing with different points of view
Like Jess, I have also just begun my cardiopulmonary placement at a major teaching hospital and have been faced with my first clinical dilemma.
I have noticed in many of the patient notes that the consultants have recommended the use of incentive spirometry (IS) post surgery to prevent postoperative pulmonary complications (PPCs). In lecture, we’ve learned that there has been little evidence to prove that IS has clinical benefit over other physiotherapy techniques in preventing PPCs. Having come home this evening and done a search on the Cochrane Collaboration, and explored a variety of search engines, I have not been able to find firm evidence of IS preventing post-op pulmonary complications.
Our research unit tells us that expert opinion has minimal levels of evidence, and that randomized controlled trials are much higher on the hierarchy of the levels of evidence. My question is then, why do doctors continue to prescribe the use of IS post-op if there is little evidence supporting its use?
IS disposable units cost more than $100 each, which can become quite expensive for the hospital if it is being recommended for most post-op cardiothoracic and abdominal surgery patients. How can this cost be justified if the evidence supporting the use of IS is so conflicting? I spoke with my clinical supervisor about what she does in these situations. She wasn’t able to give me a definitive answer, as most of the time it depends on how firmly the consultant believes IS is necessary. Often, she is able to substitute IS with other physiotherapy breathing techniques and exercises.
This conversation with her made me realize how difficult it must be to provide a treatment even though current evidence states that benefits from it have yet to be proven, however you are part of a hierarchy that demands you do it anyway.
I feel I am becoming more aware now of the struggles that we will be faced with upon graduation when we begin working. Over the remaining 12 weeks of clinical placements, one of my goals will be to develop the skills that are necessary for dealing with conflicting evidence and differing points of view. My question to you as students, is how have you dealt with scenarios such as this and what are your thoughts on how to deal with them?
I have noticed in many of the patient notes that the consultants have recommended the use of incentive spirometry (IS) post surgery to prevent postoperative pulmonary complications (PPCs). In lecture, we’ve learned that there has been little evidence to prove that IS has clinical benefit over other physiotherapy techniques in preventing PPCs. Having come home this evening and done a search on the Cochrane Collaboration, and explored a variety of search engines, I have not been able to find firm evidence of IS preventing post-op pulmonary complications.
Our research unit tells us that expert opinion has minimal levels of evidence, and that randomized controlled trials are much higher on the hierarchy of the levels of evidence. My question is then, why do doctors continue to prescribe the use of IS post-op if there is little evidence supporting its use?
IS disposable units cost more than $100 each, which can become quite expensive for the hospital if it is being recommended for most post-op cardiothoracic and abdominal surgery patients. How can this cost be justified if the evidence supporting the use of IS is so conflicting? I spoke with my clinical supervisor about what she does in these situations. She wasn’t able to give me a definitive answer, as most of the time it depends on how firmly the consultant believes IS is necessary. Often, she is able to substitute IS with other physiotherapy breathing techniques and exercises.
This conversation with her made me realize how difficult it must be to provide a treatment even though current evidence states that benefits from it have yet to be proven, however you are part of a hierarchy that demands you do it anyway.
I feel I am becoming more aware now of the struggles that we will be faced with upon graduation when we begin working. Over the remaining 12 weeks of clinical placements, one of my goals will be to develop the skills that are necessary for dealing with conflicting evidence and differing points of view. My question to you as students, is how have you dealt with scenarios such as this and what are your thoughts on how to deal with them?
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