STARES WEEK THREE: Communication

Situation: I received a referral for a patient with chronic low back pain. The patient is in his 50's. On presentation he complained of pain in his lumbar spine and a broad pain in the lateral aspect of the thigh. The onset was insidious dating back 2 years ago. He has been working as a gardener three times a week for 5 hours a day in that time and was frustrated that he has been unable work more due to his back pain. Aggravating factors at work include lifting loads and bending. Pain is eased my sitting. After half an hour of work he needs to sit down as the pain is too severe and it takes 5-10 minutes for the pain to ease. The difficulty in communication was due to the fact that his primary language is Cantonese and although he does speak some English he tended to repeat himself and focus on how work has been so frustrating.

Task: To perform a subjective and objective assessment that was not only effective but safe.

Action: I had to make sure that I spoke clearly and precisely. I established early that it was going to be difficulty getting as much information as possible from the subjective so I decided to focus getting the basics first. Finding out where his pain was, what aggravated it, what eased it, how long its been going on for and making sure that an objective assessment was going to be safe to perform. Where I could I tried to use gestures to help. I overall had to spend more time on the assessment part of the session to get an understanding of the problem that I would normally.

Result: It was difficult to even get a basic understanding of the problem from the subjective. The body chart and aggravating factors were the two areas of the subjective that were most difficult. Even though I knew the general area of pain in both his leg and back he had difficulty understanding the concept of specifically mapping out the area of pain and couldn't really describe his pain. Nor did he have an understanding of what I meant by how bad the pain was. I was able to determine the aggravating factors to the pain but trying to get more information about them was hard. I didn't really know what part of lifting was hurting him and what the duties at work were the worst for his back. When performing an objective in the musculoskeletal setting it is important when finding the source of symptoms that we ask the patient "is that the pain you've come to see me about". Many people have pains that are not those they are complaining of but could be a contributing factor or a different problem completely. The barrier in communication meant that although I was finding structures that were painful but I didn't know if this was his main pain. Nor was I able to find a true asterisk motion segment in the lumbar spine because multiple levels were sore and he was unable to tell me which one was truly worst. Generally getting him to perform different movements was also difficult.

Evaluation: Overall I don't think I did all that well in this situation. As much as he was repeating himself I was probably repeating myself. I found it really difficult to get my messages across which meant I didn't have all the information I wanted from the subjective. I was able to get a basic understanding of the problem from the objective and eventually was able to determine which direction of movement caused his pain and what level seemed to be the worst from the way he reacted to my palpation. In saying that it meant that I had to spent a lot of time with this particular patient.

Strategies: I think next time rather then asking opened ended questions I should delve more into the aggravating factors about questioning him about certain things. Whats it like walking uphill? Downhill? Gardening above your head? and other questions of the like. Using visual cues and the reactions of the patient is also beneficial. Bentley Health Service also have the option of the interpreter so I think that if it is still too difficult next session I may have to go down that path. My hesitation to do so is that I think it makes it difficult to build rapport with the patient but I guess at the end of the day getting a true understanding of the problem is in the best interest of the patient and if communication is a barrier then it should be addressed. Hopefully my second session with the patient will be more successful.

STARES WEEK ONE: Assessment

SITUATION: Working in a musculoskeletal outpatient setting I received a referral from a local GP for a patient that suffered from neck pain and migraines. The lady was middle aged and had suffered from this neck pain and "migraines" for 25 years. The pain that she described was an ache that starts in the neck, usually on the right, and expands into the head unilaterally to behind the eye. She highlighted that the headaches were mainly on the right but occasionally shifted to the left in a separate episode. She had only described an aura on one occasion but most headaches were not associated with such a symptom. Occasionally she experienced nausea but had never vomited as a result of the headaches. Aggravating factors for the headaches included lack of sleep and stress. The only easing factor identified was the use of Imigran, a prescribed pain medication. By the end of the subjective there was significant evidence to support that this patient suffered from cervicogenic headache, so an appropriate and thorough objective examination would be able to confirm or deny the diagnosis.

TASK: Perform an objective examination for this patient to rule in or rule out cervicogenic headache.

ACTION: The objective examination included observation, palpation, active movements of the upper cervical spine, overpressures and combined movements in an attempt to reproduce these ladies symptoms. It was also important to highlight to the patient the reason for wanting to reproduce her pain and that as soon as she felt her pain to let me know as to not create fear and unnecessary discomfort.

RESULT: The patient had a classic "chin poked" posture. The asterisk sign from her active movement examination was right rotation which was limited to half range. There was no pain reproduced with active movements or overpressures. I decided to perform a combined movement exam but unfortunately the symptoms could not be reproduced. It was at this stage that I was starting question the suspected diagnosis aswell quality of my objective examination. Having still not found where the patient's pain was stemming from I performed sustained movements of the upper cervical spine. Again this offered no answers. I moved on to the muscles around the neck. The patient had a decreased ability to recruit her deep neck flexors so I thought that this could be a contributing factor to the problem but without the ability to reproduce her symptoms I didn't have a distinct answer. I decided that I would go to my supervisor and explain the situation. He suggested that I try a more aggressive palpation of the musculature around the cervical spine. Palpation of sternocleidomastoid turned out to be the asterisk sign with pain reproduced with palpation of the muscle's origin.

EVALUATION: Even though it took me a while to find the patients symptoms, I felt like my examination wasn't too bad. Each test that I performed stemmed from the result of the previous test and I progressed examination with each test. One aspect that was done poorly was that I tended to focus on the joints of the cervical spine, disregarding the musculature. When the patient performed deep neck flexor recruitment it was evident that sternocleidomastoid was working overtime. I thought that this could be a contributing factor but never really considered that it could be a direct source of symptoms. Reflecting back on the situation the fact that right rotation was limited further supports tightness in the right sternocleidomastoid so one group of tests that could have been beneficial in this case and which were not performed were muscle length tests. I learned from the situation to consider more that just joints as a source of symptoms but consider muscle and all other relevant anatomical structures that could produce pain when performing an objective.

STRATEGIES: Consider all anatomical structures when performing an objective examination and make sure that palpation is specific and directed towards those structures that are likely to be the source of symptoms.

Initial Entry Ist Placement 2010

I'm thoroughly looking forward to my placement at Bentley hospital. Although I had a musculoskeletal based placement in my second year of studies, this rotation allows me to integrate all that I have learnt about the periphery and in particular the spine, and apply the principles to real patients. I feel that by the end of this placement I should be ready to step out into the workforce and work in a musculoskeletal setting. I think this would be the expectation that my supervisors will have and what we will be working towards.

As I am working in a public hospital I think the patients presenting to the clinic will be quite complex. I'm expecting many will have comorbidities such as diabetes and obesity as the demographic will generally be from a lower socioeconomic profile. This will challenge my clinical reasoning skills but I am excited at the prospect of developing this aspect of my profession.

The structure of the placement will probably change as the weeks progress. I think that as I get more practice and improve with my assessment, treatment and clinical skills the amount of supervision that I have will reduce. Initially I may have to consult my supervisor after each the subjective and objective so that they can make sure that I am covering all that I need to to make an educated diagnosis. I suspect that if they feel I can conduct a safe and appropriate assessment and produce an effective treatment plan they will wean their supervision and allow me to work more independently.

The thing that I am a little concerned with is time management. If conducted properly there is a lot of information to gain from a subjective and objective assessment and the more complex a patient the more information there is to get. The ability to get the right information, clinically reason through it and treat the patient in a limited period of time is definitely a skill in itself and one that I think comes with experience. Therefore I am hoping that by the end of this placement I have improved on this skill and am able to conduct an assessment and treatment in a similar timeframe to a more experienced physiotherapist.

Overall I'm looking forward to being able to manage my own caseload and improve on my clinical skills so that I am best equipped to step out into the workforce at the end of 2010 if i were to choose to go down a musculoskeletal path.

Final Review

Looking back at my initial entry for the placement it seems that my expectations were reasonably accurate. The majority of the time I was in the gym working with patients, helping them with exercises that were going to facilitate their recovery and get them walking again. Having a knowledge of a persons comorbidities proved to be vitally important as a persons pre-existing conditions were often the factors that limited recovery and guided our clinical reasoning as to what exercises were appropriate. For example, the implications for a pt with a blister on their residual limb were different depending on whether they had diabetes/PVD or not. The former pt would have to rest whereas with the latter you could consider other possibilities such as dressing the wound to continue with their gaitj retraining.

The one thing that I found that I had missed in my initial expectations observational gait analysis. It was a major focus of our placement, especially in the last two weeks, to be able to look at a persons gait with prosthesis in situ and be able to analyse the reasons as to why a person walked in a particualr way. It was probably the area where I learnt the most because having an external factor such as a prosthesis just added another reason as to why a persons gait might be altered.

As I got more involved with pts care management plans and goal setting meetings I found that my treatment improved as it seemed to give me more direction as to what was in the best interest of the pt and what Rx would best facilitate their recovery. I think this just reiterated to me the importance of finding out a pts goals and client centred practice.

Oveall I think the ability to clinically reason and perform observational gait analysis were the areas that I most improved in and realise that I will need to continue to work on these areas throughout my career.

Topic 3: Analysis annd Planning

Situation: Was working with a pt whom had undergone a left transtibial amputation and had previously been fitted with a supracondylar suspended patella tendon bearing prosthesis. As a result of ongoing issues withk suture line healing the pt had been having trouble with the fit of prosthesis causing compromise to skin integrity. It was therefore decided that the pt was going to be fitted with a prosthesis with thigh suspension to decrease the load through the distal residual limb.

Task: Get pt walking in new prosthesis and perform observational gait analysis on her pattern.

Action: As the pt had already undergone gait retraining exercsises on her original prosthesis and her residual limb had become accustomed to bearing weight, we started with some simple walking in the parallel bars.

Result: Pt was able to walk independently in the parallel bars with minimal support from the upper limbs. Stance phase was decreased on the prosthetic limb and the pt walked with an antalgic gait pattern, flexing the trunk laterally towards the prosthetic limb in stance phase. Increased lateral trunk flexion and overall antalgic gait pattern was attributed to decreased strength and control of hip abductors of the residdual limb and pain that was reported over femoral condyles on weight bearing. As a result we aimed to optimise the number of socks to reduce pain and but allow the best fit in the socket and also give the pt exercises to improve hip control.

Evaluation: Overall I think I performed well in the gait analysis part of the task. Where I could have improved was with the exercise prescription and planning part. I thought I'd give my pt exercises to improve hip abduction control and so prescribed her with standing hip abduction when standing in her contralateral limb. As one of the physios correctly advised me, it would probably be more appropriate to get the pt to stand on the prosthetic limb and maintain hip control when abducting and hitching the contralateral limb. This exercise is more specific to the situation where the pt is experiencing her decreased pelvic control i.e. when standing on her prosthetic throughout the gait cycle.

Strategies: Think about the situation when the pt experiences an impairment and prescribe exercises to be as specific to that situation and context.

Topic Two: Communication

Situation: Spent an afternoon gym session treating one of my patients with my notre dame supervisor. The pt was a 72 yr old male had a L trans-tibial amputation as a result of an infection that he contracted after surgery for ongoing circulatory compromise in the limb. His gym programme consisted of upper and lower limb strengthening exercises. mobility training and compression therapy to manage his oedema.

Task: To give a verbal handover of the pt to my notre dame supervisor.

Action: Reviewed the pts physio and medical notes and prioritised what information would be important for a verbal handover, then deliver the information in an effective and professional manner.

Result: Focused on the pts relevant past medical history, social history, current mobility status, wound healing, pt goals and current treatment strategies.

Evaluation: Overall I gave an effective handover however probably needed to find out some more information from the pt on his social history. A persons level of independant mobility depends not only on their physical capability but also their environment hence I needed to find out more about the pts home and daily regime. Information such as whether a person has stairs or rough terrain helps guide our treatment plan so that a person can gain independance and a safe discharge.

Strategies: When giving a handover, think about the pieces of the pts history that would benefit a physios treatment plan.

Entry Topic Week One : Analysis and Planning

Situtation: I was working with a pt that had undergone a trans tibial amputation (TTA) due to a complication of his Type One diabetes. He had been fitted with his prothesis and was progressing with his gait retraining exercises and was at a stage where he was competent in walking with two elbow crutches on slopes, grass and up and down stairs. The pt had a small blood blister just superior to the suture line on his residual limb that was healing well.

Task: As I felt the pt was quite capable with walking with two elbow crutches I decided that I might progress his gait retraining by having him walk along the outside of the parallel bars with only one hand support.

Action: I consulted my supervisor to check and confirm whether my plan was appropriate.

Result: Supervisor agreed that the pt was at a stage where he would be quite capable to progress with his gait retraining however asked me if I thought it was appropriate because of the small blood blister on his residual limb. It was decided not to progress the pt as losing an elbow crutch would increase the load on the residual limb and further delay healing which is a priority.

Evaluation: I am glad that I discussed the plan with the supervisor first as it opened my eyes to how I needed to look at the pt as a whole and made me realise that rehabilitation for amputees is not just about progressing them back to function but also preventing further complications.

Strategies: Look for all the limiting factors that can slow a pts recovery.