I can’t believe prac is completely over! The year has gone by too fast.
Mandurah was a fantastic note to end on, I feel that I really experienced true working life, and I loved it!
NATURE: I saw outpatient MSK referrals (as well as a few cardio and stroke patients!!). My supervisor was correct, I think I saw 90% back, neck and shoulder complaints, and about 95% of these were chronic complaints. (It showed me how well versed you need to be in chronic pain management in a community setting). I was involved in many classes, up to 3 a day. It was nice, almost a bit of down time before your next patient.
STRUCTURE: I was very independent!! I even had my own treatment room! My supervisor really left me to do my own thing, but I knew he was just in the next room. If I had a complex patient, needed advice or just wanted to talk through my reasoning he was very approachable.
ROLE: I did see a full caseload, and I feel I worked as if I was a new graduate. Sometimes we saw 9 patients/day including classes. If was great to know I could do it!! And it did involve good time management. The classes were very ‘client run’, we just supervised. The patients attend 8 weeks of class work and running it themselves gives them the confidence and skill to continue to do so independently.
CONCERNS: It was really hard to clinically reason in such a short time frame, but I’m glad I had to do it. It became easier and easier as the weeks went on, and now I have the confidence to do it in the workforce. Generally, as I was writing my patient notes, I had time to clinically reason and reflect on my chosen treatment. If I had missed something I would immediately put it in my plan for the patients next appointment.
All in all, I had a truly fantastic time. This last prac gave me the confidence to know that I can work independently and as part of an allied health team.
Friday, July 23, 2010
MSK week 5
S-I was referred a patient, Miss B, with an acute exacerbation of chronic low back pain. She was in a car crash in 1988 and from that time onwards she has been in constant pain, at the neck, shoulder and low back. She was initially involved in a compensation claim and has been off work since that time receiving a disability pension.
From the first moment I met her I knew she would be a tough patient. Miss B is only 44 years old, yet she walked into the treatment room with a WZF! I think now that this is in an attempt to display her sickness, especially seeing as she didn’t use it correctly. My first question to Miss B was ‘can you show me exactly where your pain is’…her response was ‘L4/L5.’ I couldn’t believe it! Throughout the assessment, many more yellow flags became apparent. She had underlined x-ray findings for me (degeneration at L4/L5, arthritic changes), she was on such a cocktail of pain meds she was unable to drive and had had numerous hospitalizations with CLBP.
In my first treatment session I tried a bit of everything. No movements of the back were relieving whatsoever, even gravity eliminated PT induced. I then tried IFT therapy with a heat pack but even this was aggravating. TENS also had the same effect. I then tried some grade II mobilizations to achieve a pain gate effect. Miss B had to sit in a special pregnancy chair as prone lying was out of the question. Doing these gentle mobilizations turned out to be disastrous. Miss B became so sweaty and was in so much pain she almost threw up. This shook me a fair bit, so I decided to leave her with just gentle pelvic floor contractions. (Even these tugged at her low back). It seemed hopeless.
T-my task was to provide appropriate treatment at her next session.
A-I realized that the above treatments I tried were not the right things for her. I had already recognized that Miss B’s pain was dominated/maintained by psychological factors and so my treatment really should have been directed at her thoughts/feelings and beliefs. So I decided to research pain in an effort to best describe it to her and decrease its threat value.
I re-read the book ‘explain pain’ and summarized what I thought was most important on 2 A4 pages. I booked an hour appointment for her next session and the first half of that we spent just talking about chronic pain and explaining her x-rays. The next half of the session we brainstormed a graduated exercise program. Miss B’s goal is to get back into pilates. Thus we made an 8 day program that encouraged gently re-entry into some basic moves…starting in sitting, moving to side-lie and then on day 7-8, into crook lying (to perform Miss B’s goal of leg slides). On day 8, she made another appointment to see me, and assuming everything goes to plan, we are aiming to start a graduated walking program.
R- Initially Miss B didn’t seem too won over by me. I think I was bit nervous because I didn’t want her to think I was suggesting she was making the pain. (Which she wasn’t…she was DEFINITELY in pain, it almost made her throw up! It’s just that the way she thinks and feels is sustaining this pain). After a while though I eased into it. Miss B seemed to be particularly open to the idea of increased sensitivity. (Having more ‘sensors’ in her low back and a lower threshold for them to fire). She understood the analogy of a car alarm that used to go off normally, and that now goes off when just a bird lands on it. This means that hurting doesn’t mean you are causing re-injury; rather it’s just a throwback to a state of heightened sensitivity.
Miss B left feeling quite excited and ready to take part in her graduated program.
E- I’m beginning to realize that with many patients, what you say can be SO MUCH more valuable to the person than what you do with your hands. It’s amazing, and probably the best tool we have.
STRENGTHS:
-Good preparation. The session would not have been successful otherwise!
-Incorporating Miss B’s goal into the graduated program. This enabled her to get on board with the idea…which I’m sure seemed very foreign to start with.
-Building a good rapport with Miss B, which was essential in order to get her to believe in what I was saying.
-Picking up on what Miss B responded to (pain hypersensitivity), I could then use this throughout the session to keep her on track.
WEAKNESSES:
-I was nervous to start with. I didn’t want Miss B to think I was saying she was making her pain up. My nervousness probably made it even worse to start with! I think next time I’ll practice my spiel on someone first so that I’m more comfortable with how to word things.
-Until I got into the flow of things, my talking may have seemed a bit rehearsed (I had written down all my important points on paper). Hopefully it becomes more natural with practice!
S- Good preparation
- Practice first on somebody I know
- Build a good rapport
- When describing complex concepts, create simple analogy’s to aid understanding
- Find out patient goals and use them to create a meaningful treatment
- Remember to treat what you identify as the cause of the problem
From the first moment I met her I knew she would be a tough patient. Miss B is only 44 years old, yet she walked into the treatment room with a WZF! I think now that this is in an attempt to display her sickness, especially seeing as she didn’t use it correctly. My first question to Miss B was ‘can you show me exactly where your pain is’…her response was ‘L4/L5.’ I couldn’t believe it! Throughout the assessment, many more yellow flags became apparent. She had underlined x-ray findings for me (degeneration at L4/L5, arthritic changes), she was on such a cocktail of pain meds she was unable to drive and had had numerous hospitalizations with CLBP.
In my first treatment session I tried a bit of everything. No movements of the back were relieving whatsoever, even gravity eliminated PT induced. I then tried IFT therapy with a heat pack but even this was aggravating. TENS also had the same effect. I then tried some grade II mobilizations to achieve a pain gate effect. Miss B had to sit in a special pregnancy chair as prone lying was out of the question. Doing these gentle mobilizations turned out to be disastrous. Miss B became so sweaty and was in so much pain she almost threw up. This shook me a fair bit, so I decided to leave her with just gentle pelvic floor contractions. (Even these tugged at her low back). It seemed hopeless.
T-my task was to provide appropriate treatment at her next session.
A-I realized that the above treatments I tried were not the right things for her. I had already recognized that Miss B’s pain was dominated/maintained by psychological factors and so my treatment really should have been directed at her thoughts/feelings and beliefs. So I decided to research pain in an effort to best describe it to her and decrease its threat value.
I re-read the book ‘explain pain’ and summarized what I thought was most important on 2 A4 pages. I booked an hour appointment for her next session and the first half of that we spent just talking about chronic pain and explaining her x-rays. The next half of the session we brainstormed a graduated exercise program. Miss B’s goal is to get back into pilates. Thus we made an 8 day program that encouraged gently re-entry into some basic moves…starting in sitting, moving to side-lie and then on day 7-8, into crook lying (to perform Miss B’s goal of leg slides). On day 8, she made another appointment to see me, and assuming everything goes to plan, we are aiming to start a graduated walking program.
R- Initially Miss B didn’t seem too won over by me. I think I was bit nervous because I didn’t want her to think I was suggesting she was making the pain. (Which she wasn’t…she was DEFINITELY in pain, it almost made her throw up! It’s just that the way she thinks and feels is sustaining this pain). After a while though I eased into it. Miss B seemed to be particularly open to the idea of increased sensitivity. (Having more ‘sensors’ in her low back and a lower threshold for them to fire). She understood the analogy of a car alarm that used to go off normally, and that now goes off when just a bird lands on it. This means that hurting doesn’t mean you are causing re-injury; rather it’s just a throwback to a state of heightened sensitivity.
Miss B left feeling quite excited and ready to take part in her graduated program.
E- I’m beginning to realize that with many patients, what you say can be SO MUCH more valuable to the person than what you do with your hands. It’s amazing, and probably the best tool we have.
STRENGTHS:
-Good preparation. The session would not have been successful otherwise!
-Incorporating Miss B’s goal into the graduated program. This enabled her to get on board with the idea…which I’m sure seemed very foreign to start with.
-Building a good rapport with Miss B, which was essential in order to get her to believe in what I was saying.
-Picking up on what Miss B responded to (pain hypersensitivity), I could then use this throughout the session to keep her on track.
WEAKNESSES:
-I was nervous to start with. I didn’t want Miss B to think I was saying she was making her pain up. My nervousness probably made it even worse to start with! I think next time I’ll practice my spiel on someone first so that I’m more comfortable with how to word things.
-Until I got into the flow of things, my talking may have seemed a bit rehearsed (I had written down all my important points on paper). Hopefully it becomes more natural with practice!
S- Good preparation
- Practice first on somebody I know
- Build a good rapport
- When describing complex concepts, create simple analogy’s to aid understanding
- Find out patient goals and use them to create a meaningful treatment
- Remember to treat what you identify as the cause of the problem
Saturday, July 10, 2010
MSK week 3
S- Mrs A was referred to me with R shoulder pain. After a thorough examination, I concluded she had a R shoulder impingement secondary to poor posture, namely a stiff and stuck thoracic spine (into flexion), protracted and ante-tilted scapulae, and an anteriorly sitting and internally rotated humeral head.
Taking her history, I began to realise she was also very dejected about her shoulder and the treatment she had received. The initial injury occurred 19 years ago (a SS tear). She was put on the waitlist for surgery. After being on the list for so long the surgeon told her it had gone beyond repair, and due to her age etc surgery was no longer an option. She was under the care of GP following this, and seemed to get lost in the system. She said she had been waiting two years to see a physio. She really felt like no one took her problem seriously. She knew it wasn’t going to miraculously recover, but she desperately wanted guidance in things she could do!!
T- Provide appropriate treatment and create a meaningful home exercise program.
A- I spent so long with the assessment I actually had to re-book Mrs A the following day for a treatment session. At this session I decided that my best tool was communication. I needed her to understand how posture causes shoulder pain to have any hope of her getting on board and performing her HEP. Most importantly though, I needed to reassure that her problem was important to me and that I was going to go out of my way to treat her as best I could. If I could get her feeling more positive about the care she received I felt we could make a real difference to her problem.
We spent 20 mins going over shoulder impingement and I made use of skeleton to demonstrate. I then performed a passive physiological in thoracic extension, provided an individualised HEP and referred Mrs A to the upper limb hydro classes.
R- Mrs A was extremely happy to have been listened to, taken seriously and be given the tools to start to take control of her life. At her follow-up appointment, 2 weeks later, she stated that her pain had reduced by up to 80%! And that she had regained function of the arm.
E- I was really amazed at the success Mrs A experienced! I’m not so sure she would experience benefits that rapidly from exercise, but I do think having an understanding of your problem and being given the ability to self-manage would make a huge difference….the power of the mind!! No one had explained any reason for her shoulder pain. Once she had an understanding she could start to control it. She no longer viewed her problem as completely unfixable and ruining her life. I’m sure that positivity changes your pain experience.
I was really proud that I could do that for her. I think it helped that I booked an hour appointment for her following our assessment. I feel that she benefited most from the time I put into education and demonstration and I feel that I communicated this really well.
However, my assessment time management DEFINITELY needs some improvement. I spent so long with her assessment that I needed to re-book her for a treatment session. She did benefit from the extra time I was able to put into her treatment, but I can’t be doing that for every patient I see! What would make everything flow faster and smoother, would be not to perform every single test I know. I need to be more streamlined, right from my initial observations. For example, I only really need to test what I see. Looking at Mrs A’s posture (as described above) the key muscles to test the length of probably would be pecs, infraspinatus and lats. Whereas I tested every muscle around the shoulder/neck. In retrospect this definitely was a time waster, and had no impact on my treatment. I need to know what tests to omit rather than doing every single test I know! I’m hoping this improves with experience.
S- listening!
-education
-communication
These 3 things are, I think, what made my treatment successful, more so than any hands on treatment I could offer. I'm realising how important this is with every patient. You need them to be confident in you in order for them to do any home exercise/self management.
TIME MANAGEMENT! omit those things that are unnecessary to test in order to make my assessment smoother and faster!
Taking her history, I began to realise she was also very dejected about her shoulder and the treatment she had received. The initial injury occurred 19 years ago (a SS tear). She was put on the waitlist for surgery. After being on the list for so long the surgeon told her it had gone beyond repair, and due to her age etc surgery was no longer an option. She was under the care of GP following this, and seemed to get lost in the system. She said she had been waiting two years to see a physio. She really felt like no one took her problem seriously. She knew it wasn’t going to miraculously recover, but she desperately wanted guidance in things she could do!!
T- Provide appropriate treatment and create a meaningful home exercise program.
A- I spent so long with the assessment I actually had to re-book Mrs A the following day for a treatment session. At this session I decided that my best tool was communication. I needed her to understand how posture causes shoulder pain to have any hope of her getting on board and performing her HEP. Most importantly though, I needed to reassure that her problem was important to me and that I was going to go out of my way to treat her as best I could. If I could get her feeling more positive about the care she received I felt we could make a real difference to her problem.
We spent 20 mins going over shoulder impingement and I made use of skeleton to demonstrate. I then performed a passive physiological in thoracic extension, provided an individualised HEP and referred Mrs A to the upper limb hydro classes.
R- Mrs A was extremely happy to have been listened to, taken seriously and be given the tools to start to take control of her life. At her follow-up appointment, 2 weeks later, she stated that her pain had reduced by up to 80%! And that she had regained function of the arm.
E- I was really amazed at the success Mrs A experienced! I’m not so sure she would experience benefits that rapidly from exercise, but I do think having an understanding of your problem and being given the ability to self-manage would make a huge difference….the power of the mind!! No one had explained any reason for her shoulder pain. Once she had an understanding she could start to control it. She no longer viewed her problem as completely unfixable and ruining her life. I’m sure that positivity changes your pain experience.
I was really proud that I could do that for her. I think it helped that I booked an hour appointment for her following our assessment. I feel that she benefited most from the time I put into education and demonstration and I feel that I communicated this really well.
However, my assessment time management DEFINITELY needs some improvement. I spent so long with her assessment that I needed to re-book her for a treatment session. She did benefit from the extra time I was able to put into her treatment, but I can’t be doing that for every patient I see! What would make everything flow faster and smoother, would be not to perform every single test I know. I need to be more streamlined, right from my initial observations. For example, I only really need to test what I see. Looking at Mrs A’s posture (as described above) the key muscles to test the length of probably would be pecs, infraspinatus and lats. Whereas I tested every muscle around the shoulder/neck. In retrospect this definitely was a time waster, and had no impact on my treatment. I need to know what tests to omit rather than doing every single test I know! I’m hoping this improves with experience.
S- listening!
-education
-communication
These 3 things are, I think, what made my treatment successful, more so than any hands on treatment I could offer. I'm realising how important this is with every patient. You need them to be confident in you in order for them to do any home exercise/self management.
TIME MANAGEMENT! omit those things that are unnecessary to test in order to make my assessment smoother and faster!
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