Blog two (week 3)

Stares Entry two

Situation:

Mrs T presents to MCHC with low back pain. When I begin my subjective assessment I quickly realise that Mrs T’s English is not that well developed. She answers most questions with yes or no and is unable to describe her pain, only outlining where she can feel it.

I am thinking that understanding this woman’s problem is going to be extremely challenging, given that so much of what we learn about a person’s problem is gained through good communication. This will likely effect both my assessment and treatment of Mrs T.

After trying to understand this pain though the subjective questioning process with little success I began the objective assessment. Mrs T was unable to describe what she was feeling as I carried out my assessment. I attempted to use other methods of communication besides verbal. I payed particular attention to her face, the way she moved etcetera. Even this did not reveal much. The only piece of information I really gained was that she had a pain down the side of her thigh. Flexion and extension seemed vaguely uncomfortable. However to my understanding, I was unable to make a significant change to her pain on active movements. I then moved onto PPs, checked nerves and cleared SIJ. I didn’t have much to go on, having found nothing, I moved onto PA’s. A PA on L5 was the * sign. I thought because the lady seemed to have a large ROM on all active movements, particularly extension, it was likely that his may be an extension control dysfunction.

Task:

Treat this patient, aiming to make a positive difference to her back pain.

Action:

After mobbing L4/5 into flexion and then getting the patient up to reassess, there seemed to be little or no change in the pain. I then thought perhaps this is a stiffness problem because the lady was in her late 60’s. So I mobilised the joint into extension, I then got her up to re asses again. Once again there was not really a distinguishable change that I could note. Felling very confused, I thought I should do at least something to make this woman feel good before the end of the session. I had noticed some increased tension and development of the lumbar para-vertebral muscles so I decided to do some soft tissue techniques to this area and put a heat pack on Mrs T. I had just done two treatments and had no idea if either of them had done any good.

Result:

There was not a clear result in this situation. From observing Mrs Ts movements and trying to decipher what Mrs T meant when she was trying to describe the way she was feeling, I suspect there may have been no change in this lady’s pain. This is a poor result because if there was a change it may have been altered by the treatment/s done before / after the first treatment. This lack of results is what tells me there was probably a problem with the treatment I chose to use with this patient.


Evaluation:

Reflecting on what I did with this patient, I can see that it may have been better to stick to one treatment aim per session. I understand that in reality you may not get crystal clear clarity about the patient’s problem in the first time you meet them, especially when you have such severe language barriers to deal with. However I think there are ways to make life easier. If you are able to stick to one treatment aim, you can get the patient back and review if there was any change over a short amount of time. If this patient comes back with a positive effect, your treatment is then easy. If they have a negative effect you have a clue where to look. I do think it is worth noting however, this is not a luxury you would have if you were working in the private sector.

Strategies:

• 
  Write a list of evidence for the problems you suspect the patient should have. At the end of assessment, make a strong decision on what you are going to treat for.
• Try different things that treat the same problem and stick to this plan as long as you are not making the patient worse.
  
• Reassess frequently and note any minor change in the patient’s problem.
  
• Utilise additional services if they are available to you e.g. – interpreter.
  
• If you don’t quite get a clear response keep asking questions even if you feel like you are repeating yourself.

Week One – Journal Entry

Week One - Journal Entry

Situation:

Mr J presented with a referral stating he had a constant deep ache in his low back with intermittent pulling in his lateral thigh. Before I had even said anything to Mr J regarding his pain, he had given me a 15 minute run down on every injury he had had as a child, everything he could think of in his current history, including details of his recent divorce, problems with his children and work. Each time I would try and interject Mr J would go off on a completely new tangent. Even when prompted to clarify it was difficult to make allot of sense of the symptoms he described because he might say one word and then use that as a segway to talk about something else. After 30 minutes of attempting to clarify this patient’s pain I decided to cut my losses and move onto the physical. Through the physical Mr J also had allot to say and carried on in much the same way as he did in the physical. Nothing seemed to be particularly painful except for a twinge of pain into extension in mid range. After going through everything in the examination book I had very little to go on for my treatment plan, not to mention I only had about 15 minutes left to do my treatment.

The main problems I was presented with / anticipated were:

· Lack of clarity about which treatment option to take.

· Lack of time to do anything useful with this patient.

· Difficulty communicating with this patent.

· Difficulty keeping the patient on task with any Rx I choose to do. – particularly neutral spine and core muscle training as that would require communication back and forth between therapist and patient.

· Difficulty making an accurate assessment of any Rx preformed – I felt the patient was having trouble describing what he felt in his back.

Task:

My task was to treat this patient in 15 minutes. The information I had obtained from the assessment was questionable because of the difficulty I was encountering getting this patient to stay on task.

Action:

I quickly nipped out to my supervisor who told me that the clinical world isn’t always going to be like how assessment and treatment of a patient is described at uni. Sometimes you won’t have much to go on but you have to go with a treatment plan that you have the most evidence for. In my case it was an extension control dysfunction of L3/4. My treatment was as follows:

· PP flexion Gd 4

· Flexion exercise for home – knees to chest (+ prescription for home).

· Education and advice on neural posture and activation of TA, multifidous and pelvic floor (+prescription for home).

Result:

Unclear how this treatment affected the patient at his stage as I placed most of the focus of this Rx on things he could do at home. I had allot of trouble communicating with this patient. Each time I would try and explain something he would talk so consistently and for so long that I felt rude constantly interjecting. It was my feeling that although I did the best I could have done with my treatment plan given what had happened in the assessment; I felt the patient did not really soak in anything I had to say about muscle activation for neutral spine or advice for his home program. I would not be surprised if this patient comes in next week and cannot demonstrate a good neural spine with correct co contraction.

Evaluation:

The desired outcome was not reached with this patient. The reasons I can see for this were primarily due to communication. I was trying to build a patient rapport by allowing the patient to tell me his story; however this came at a cost of getting little useful treatment into the hour long session he was allotted.

From the problem of poor communication between the patient and myself came many other problems. Because of time constraints and lack of clarity in assessment, my treatment plan was limited. My ability to follow up and reassess my treatment was also limited. Because of this I am unsure of my results, however due to the way the patient continued to talk over the top of me during the education and advise part of his treatment I am almost certain that poor communication and time management rendered my treatment ineffective.

Strategies:

Find a balance between building a rapport with the patient and getting the job done. In the future if I find myself in a similar situation I will aim to take better control of the situation. This will help to make Ax and Rx flow more easily and hopefully will avoid many of the problems I encountered with this patient.

Be positive with this patent even though the last session did not run smoothly. Perhaps change tact from open to closed questions in this case.

Better prioritise the parts of subjective and objective that I absolutely need and try and fill in the gaps in my knowledge as I go along. I think this will also come with experience.

Make one definite goal. In cases such as this have limited goals and make an effort to get that done well. Rather that coming to the end having attempt a few things with a poor result.

Review this patent’s notes before next visit and have a clear plan of the most important goals for the session. Make a real effort to stick to this unless I find it is no longer relevant.

Initial entry

INITIAL ENTRY

I am excited to finally be starting fourth year. Although my supervisors expectations of what I will be doing day 1 - week 1 are at this stage unclear, I have formulated a few expectations about what this placement will be like for me.

I am expecting this placement to be more challenging than any other prac I have been on. This is not only because it is the first rotation in fourth year when the supervisors expectations often jump significantly. I will also be expected to use a great deal more clinical reasoning than in past rotations and take on allot more individual responsibility for my patients.

I expect the prac to be interesting as I have heard that there will be a vary varied case load. I am looking forward to this as I have not yet had great exposure to a wide array of musculoskeletal problems (mainly only backs and necks so far).

I am expecting to learn allot very quickly. Being in musculoskeletal outpatients and working somewhat independently will be a bit of dive into the deep end for me, however I am looking forward to this opportunity as I feel it is a great way for me to learn.

After speaking to one of the supervising physiotherapists at Mandurah Community Health I have a better idea (although still not sure) of how my time will be structured on placement. It is going to be a mix of seeing outpatients individually and taking group classes. I am unsure of how quickly I will be expected to take on a full case load, and have allot of reservations about what tasks might be waiting for me Monday morning. However by the end of placement I expect I will be confidently and independently taking the group classes, as well as seeing my own load of outpatients individually with limited guidance from my supervisor.

I am looking forward to this placement as I have never had an opportunity to have this level of independence and responsibility before. Although it is a little daunting right now I am hoping it will work out to be a rewarding learning opportunity.