Communication and head injuries

A patient of mine suffered a head injury recently. As a result, he has developed severe dyspraxia, and only as the ability to understand one stage commands. During treatment, it makes it hard to get him to understand concepts such as pelvic tilt and lateral tilt, correction of which involves commands which even a person of normal cognition can find difficult.  After many attempts at trying to simplify my instructions with not much success, I decided do a more hands-on and less talk approach, with telling the pt to "move with me" and not say much more than that other than giving cues such as "straighten up" and "grow long". I found that this approach worked a lot better than giving mainly verbal cues (even though I was trying to make my initial instructions a lot more concise). Therefore I found my treatment a lot more effective, and saved me the effort from talking more than I needed. 

Friends vs Patients

A long time friend whom i play football with came to see me at the beginning of the season complaining of shin pain (shin splints). Without hesitation I agreed to treat him.
Breifly, on assessment his left leg was worse than right, we had both significantly increased our training workload, most of which was running. He also over pronated on both feet.
I explained that i thought it was only shin splints at this stage and that if we address his compounding factors we could manage the issue. I also explained some red flags that he needs to be aware of and what could happen should he fail to manage the simple shin splints.
So i advised him to start wearing his orthotics again and strapped his feet for training and games also asked him to reduce his workload or switch to swimming to avoid running. His left leg responded well whilst his right actually deteriorated, I continually asked him how he was doing and he always responded i'm doing alright.
It wasn't till he had to come off half way through a game that he revealed he had been having significant pain with ambulation, hadn't reduced his training load and had pain at night. I immediatley sent him to our team physio who sent him straight to a sports doctor who had him scanned and diagnosed him with a stess fracture in his right tibia.
Well, I felt like an idiot because I was looking after him and his condition deteriorated. It sidelined him for 6 weeks and I felt really guilty. It was when he decided to play against doctors recommendations that i realised it wasn't my management it was just the way my freind was.
I have realised that dealing with freinds just isn't appropriate, they can't dissociate between freindship and professional relationship. Now i'll give advise but ultimately freinds should see an impartial professional for treatment and on going management.
anyone else expeiranced this with friends and family?

BP issues

I’m on my neuro placement at the moment and treating a pt that had a stroke about 5 weeks ago, his PMHx also includes parkinsons disease. This pt was doing really well for the first few weeks post stroke and managing to walk back to his room after the physio session with the assistance of the PT students there at that time. Over the past 2-3 weeks this pt’s BP has been up and down. At 8.30 in the morning it can be up to 190/100 and then an hour later 80/40 just when we want to start our PT session with him. On this placement we are expected to try see our pts twice a day, but more often than not recently this pt who is normally hypertensive has a BP around 80/40. I’m working with another PT student with this pt and a few times now we have taken this pt to the gym when his BP has looked good, done some foot mobilizations, checked his BP again just before standing or transferring to the plinth and it’s plummeted again and we have to get him straight to bed again. It’s quite a frustrating thing for the pt, his family and us pt students because he has now gone backwards with his rehab because he is not getting the gym sessions he needs.
Unfortunately there is nothing we can do about his BP, the Dr’s are trying to work it out. To deal with this issue we have had to do a lot more sessions in his room when his BP is not great but this often only includes some UL and LL exercises to maintain ROM and strength and foot mobilizations as his feet have a lot of tone and this is not an ideal situation. We have managed to get him to the gym almost once a day in the past 1.5 weeks but as it is not as frequent as we would like, he is not making the same gains as he was when first admitted. We do all we can for the pt and have to modify our treatments to suit their situation. When his BP is stable we do as much as we can in the gym to prepare him to try get him up into standing and with his added PMHx of parkinsons it adds more challenges, so as yet we have struggled to get him to stand with his COG over his BOS but we are hoping to have some good BP days so the gym sessions can start to progress from one to another

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How are you expected to treat patients in a country where the local language has no translation for the word "Physiotherapist" Their title literally means "Person who treats with movement".
Working in Phnom Penh, no body in the general population understood what a physiotherapist actually does. The only way people would attend our rehabilitation centre is if they were referred from a neighbouring hospital or if they heard via word of mouth from a patient of the centre. Subsequently the centre we worked at was under patronised, they provided FREE physiotherapy and there were not fully booked. At first it was hard to believe but the more i thought about it, the more it made perfect sense. It might sound far fetched but I believe that it correlates back to Australia.
I realised that as physiotherapists we have a responsibility to each other, to ensure people envisage physiotherapists as important and valuable members of the allied health team. APA and as individuals we will advertise the profession. However we must work hard not just to better ourselves but ensure we leave a positive impression on our patients so that they will talk about physiotherapist favourably in general discussion.

Education

Recently I completed a placement in Phnom Penh, Cambodia, my first contact with a completely different country and culture. I thought I had prepared myself for the placement, Three and a half years of studying and i thought i was more than qualified to treat and teach. I couldn't have been more wrong. to give some context Cambodia has been at war since the thirteen hundreds and the latest travesty was dealt by the hand of fellow Khmer, A political regime named the Khmer rouge murdered greater than a million people of the educated and intellectual Khmer population, essentially devastating their intellectual infrastructure across the board.

We started at our rehabilitation centre and I had trouble treating patients, the language barrier compounded by my ignorance served to hamstring my treatment sessions. I spoke to patients and facility staff assuming they had some level of knowledge of health. I mean we get taught basic health and anatomy at primary school, every Australian has a basic level of understanding about their body. It wasn't till i grasped the extent of devastation caused by the rouge that i could fully comprehend how illiterate the Khmer people are.
I quickly changed my approach and made my whole education a lot simpler. Sacrificing specific details and options to ensure that the essential information was delivered and understood. After this i found my rapport with patients improved and the staff we were working with understood what we were doing.
It guess my take home message is don't assume that every patient you treat will understand even the very basics and its important to identify this in order to be effective.

Retrospect

Sorry fellow bloggers but I will have to write my reports in retrospect because I have deferred my current placement. Also please excuse any small mistakes in spelling and gramma, I am typing one handed.
Thanks for the understanding.
Dave Kelly

Communication skills

I have been on my international prac for 1 week now and I have already learnt so much when it comes to communicating with people who speak very little, if any English. It is a private hospital and therefore only the wealthier people can afford to receive treatment there which means that most people speak some English however it is still so different. When I would normally babble on and give a patient a few instructions at once intermixed with a bit of conversation, ive now learnt that I just cant do this with some of these patients. Instructions and questioning often needs to be kept to the bare minimum and hand gestures have never been more helpful. It’s also forcing my facilitation to improve as this is often the easiest way to get a patient into a position without confusing them with too much English. This means that conversation to fill the silences can sometimes be difficult which is something I suppose I will just have to get use to with some people as all you can really do is smile or facial expressions to convey meaning or just rely on the tone of your voice to let them know if theyre doing it right or not. Its been really helpful in developing my non verbal communication skills and has also showed me that I often rely on talking too much to explains things and need to improve my neuro facilitation.

Language Barriers

I am currently on my musculoskeletal placement and was treating a patient who only spoke and understood limited English. He was an outpatient being treated for subacromial impingement. When he came to his appointments his wife was always with him to help with translating. At first I wasn’t sure if I should speak directly to him or if I should be speaking to his wife as she was the one that was translating to him and telling me his answers. However I also thought he could be offended if I was speaking more to his wife then him as he was my patient and therefore I was assessing and treating him. I decided it would be best to speak directly to him as he did understand and speak some English and if I needed anything his wife said to me clarified then I would speak more directly to her. When I used this strategy in my assessment and treatment of this patient he seemed to appreciate that I was talking to him rather then just about him to his wife. In the future with other patients with language barriers I will try to speak directly to them rather then talking about them through the translator as it is important that even though they may not be able to understand me fully they are still the patient and therefore should be spoken to directly.

Behavioural issues

I am currently treating a teenage patient who suffered a traumatic brain injury about 5 months ago. She was diagnosed with ADHD pre-morbidly and had a poor track record at school, with 25 suspensions in the 2 or so years she has been at high school. Many of these related to assault of other students in which the police have been involved.

Not surprisingly, if you add a brain injury on top of a history of ADHD, it makes patient compliance and successful treatment outcomes a challenge! She has regained normal 3 joint movement in all limbs, ambulates without any aids, and can run. Her high level balance and trunk stability remain a problem. I try to make our treatment sessions as functional and fun as I can, involving kicking and catching balls as well as using a variety of tasks, although I find it hard to stay enthusiastic about treating this patient as she can be verbally abusive and very difficult to manage. Has anyone else experienced a patient like this?

Family physio

I am currently on my international placement in the neuro ward of a private hospital in Malaysia. Treatment here is very different to in Australia because it is expected that the family take care of the patient as soon as they are medically stable. This means that pts are discharged from hospital straight away even though they have not had any physio and are still acute. After they are discharged the family will look after them and hopefully bring them back for outpt raheb. If the family decides not to come back for physio then the pt receives no treatment. Before discharge the physios are expected to teach the family the best way to transfer the pt and do as much physio as they can fit in, in the few wks the pts are in hospital. However teaching family that have no idea about correct manual handling or any physio techniques often takes up a lot of time and results in the patient having less actual treatment time. Having the pts at home also means that often the physios spend most of the treatment time undoing all the bad habits the pt has developed whilst at home. This normally includes poor posture and inparticular a very poor gait pattern and compensatory techniques, as family members often try to walk the pt before the are even close to being ready.
This has shown me how different the culture is here and how lucky we are that in Australia it is expected that we stay in hospital until we are able to be discharged from the multi- disciplinary team.

Child vs Family

My supervisor and I were discussing about one of our paediatric clients who was bed-ridden, severely contracted and cachexic due to her congenital degenerative condition. As a PT, we do our best to provide the best services for our clients. We act prophylactically to prevent deterioration of the musculoskeletal system eg contractures, scoliosis, deformities etc. We provide advice to the parents and explain the best options for their child. We provide referral to orthotics, orthopaedics, OT etc to ensure their best comfort.

During the discussion, my supervisor said she’d given all the options, and had done all she could within the limits of her profession and duty of care for the best of the client. Nonetheless, the parents chose not to have any wheelchair adjustments, not to take the child to school, and not to have any surgery done on their child. Their rationale was that their child is not going to live very long, so there was no reason for her to go through the ordeal of having a surgery or getting expensive equipment. Despite that, they would do stretches and passive movements regularly, and ensure their child receive love and care from them.

That made me realise that what I (from a physiotherapist point of view) think is best for the child, may not necessarily be so. It is about what the family desires, and what the family thinks is best since they are the child’s primary care-givers. It is vital that I take into consideration the family’s needs and concerns, and be able to adjust my intervention and goals accordingly in order to obtain their trust and co-operation. After all, it is a family-centred practice.

KISS

keep it simple stupid.
i found myself trying to address too many impairments in one session with my patients at a neuro outpatient clinic. Trunk work, reaching, muscle length, gait, balance, HEP...that was a common treatment plan for one of my sessions. To me, it sounds great if i could help the patient with all of those things, but the fact is i cant. the choice is, do 10things poorly or 1-2 things really well. My supervisor mentioned to me that one of the really experienced PT's will work on a shoulder for a whole session. THis got me thinking and i decided i would do the same thing. just work on the one area and give it a full sessions worth of attention. It worked really well, i was able to see things i couldnt see before in my observations and i had more ideas about treatment. I cant speak for other areas, however I think in the outpatient setting and with the appropriate patients it is important to reduce the complexity of ones treatment and treat a few things really well.

learning more stuff...

At an outpatient clinic i saw an older gentleman who had suffered a stroke. He had recovered really well, his major impairment was reduced with fine motor control in his right hand. I had big plans for his rehab, high level balance exercises, improving the fine control of his hand and UL etc. but he discharged himself from physiotherapy before he had started the exercises. I had to realise that the functional level that he leaves the clinic with will always be what he thinks he needs and not what i think he needs. I was thinking i could get him walking regularly and getting out of the house to play golf etc. but this was not realistic as he was content with where he was at functionally.

This was a good lesson for me to learn. I need to remember in the future that its not ok to impose your own expectations on a patients rehab, always focus on what the patient wants. However i still believe it is important for PT's to suggest lifestyle modifications where necessary, just not make them strive for something they feel they dont need.

Telling the parents...

Placement: Paediatrics
My supervisor and I had concerns about one of our clients who was severely overweight (9 y.o. female). So we conducted a 6MWT to determine the condition of her cardiovascular system. The results were alarming as it showed that her CV system had deteriorated significantly since the previous assessment. Further investigation was hence required.

So I typed up a report illustrating the results and our cause for concern for the parents and relevant health professionals. A meeting with the parents was also organised. While I was doing the report, I realised the difficulty of trying to present the results tactfully. It was important that I provide the essential information and facts, yet it was also important that I do not cause the parents to be overly fearful or worrisome. It was already such a challenge doing the report, let alone holding a discussion with the parents.

When the report was done, I noticed that my supervisor had sent it to a fellow colleague (also a physiotherapist) for proof reading, and unnecessary information was omitted. She had also consulted the colleague for second opinion with regards to this issue.

I felt that the actions my supervisor had taken were wise and vital, so I intend to follow her steps should a similar situation re-occur.

One of my patients almost hit the floor.

I had seen this patient once before on this neuro placement. So I knew that she could be a little impulsive and that she had sitting balance but was unable to control her COM if her balance was challenged.

I was getting her ready to stand and walk. The patient was sitting on the edge of the bed with her feet on the floor. I was kneeling in front of her getting her footwear ready. I asked her to help me put on her shoes. She put her socks on ok, but she had some trouble with the shoes. In a flash she had tried to cross her legs over (to bring her feet closer to her) and had lost balance falling forwards. This required me to push her back onto the bed.

Apart from almost soiling my pants I think I handled this situation well. I was on the floor in front of her keeping a close eye on the patients’ movements and I was aware that this patient could act impulsively. I learnt from this situation that you can always be sure that patients will be unpredictable at times and that we need to be ready for anything when treating them and that we must always be in a position to control these unpredictable situations when they arise.

Flexibility

Paediatrics placement.
I had in mind that I was going to see a child with high needs (i.e. required assistance for all self-care tasks, wheelchair dependent, and with intellectual disability). This was my second treatment session with the child, so I had a rough idea of the kinds of things/ activities he liked and disliked. With a specific treatment plan written out prior to that session, I intended to carry it out accordingly.
Little did I expect, the child had a new toy that he did not (for the world) want to let go. When my supervisor and I took him to another room without his toy, just for the session, he became highly unco-operative. One of the activities was to get him into 2pt high-kneeling position, but he kept resisting every movement and insisted to head out the door. He attempted many times to crawl out the door (I was not sure if he could or if he was safe to do so at that moment), I had to use all my strength to restrain him.
I became frustrated at his unwillingness to co-operate, and was slightly disappointed that my plan could not be carried out smoothly.
Then, he tried to stand up to walk towards the door. I reasoned that since he was not co-operative, and walking was a functional activity, I might as well get the most out of the session with that few steps of walking. So I gave him assistance and we walked out the door towards his new toy. After that, to my surprise, I managed to get the child to happily walk for at least another 10m along the corridor successfully.
From this experience, I learned that, especially with this group of clients, situations often do not work out as planned. In order to get optimal co-operation, it is important to be flexible, and modify my treatment activities to suit the child.