The courage of a lion

As physiotherapists we are motivational, we drive patients to push through pain and frustration, to persist to reach their goals. We are their motivation to achieve health. For the first time in my physiotherapy experience I have been awed by the courage of one patient to push through.

When a frail elderly female patient was experiencing 10/10 pain, it was not the over exaggerated kind you sometimes come across. The screaming and crying were no put on. This patient was in extreme pain. Yet she was determined to move, even though moving at all caused her left hip to give her excruciating pain. We had to log roll her then do a cradle transfer with two keeping her legs straight just to sit on the edge of the bed. The pain was already tiring her out, but she continued to say "no, I want to move, let's go" and when we did with less pain she was ecstatic saying "yes, we are going girls, we are going!" Just to move without pain was a blessing. And when I say move, my sock foot was the means by which she managed to slide her left foot along the floor with two assist and a 4WW. Slow but steady we managed to go two meters. It was a miraculous moment for the severity of pain but also the immobility the patient had endured for two days.

You might ask why I persisted in mobilising this patient, considering the pain and the fact it took 40 minutes to get out of bed to walk two meters. But we all know the perils of immobility and when a patient is even more driven than you, you know you have to encourage that kind of attitude when it is safe to do so.

Through out the ordeal, breathing control and relaxation helped to reduce her pain perception and re-energise her for further efforts. She wept and was grateful to get back into bed, but she was also elated. And I must say, all three medical staff that it took to walk two meters were in awe of her courage and her persistance through excruciating pain. Some times you come across great moments of great character that inspire you to plough on. In all future situations I will remember her determination and achievement. We see alot of the negative side of health and the community in hospitals, but there are also moments of greatness.

Cervicogenic Headaches

An increasingly common presentation to musculoskeletal outpatient departments are cervicogenic headaches. During my four week musculo placement, I recall having three patients with this presentation. I found though, it is quite a difficult condition to treat. For example, when the patient presents to the clinic, they usually do not have the headache so it’s hard to fully determine the efficacy of you treatment.

Quite often there are associated problems, such as decreased ROM (due to tightness + pain), tight musculature (especially sub-occipitals, cervical erector spinae, upper traps), and hypomobile PAIVMS (+ pain reproduction) & PPIVMS. There is also usually poor postural awareness and poor deep neck flexor strength. Therefore, much of the treatment centres around postural education (inc. ergonomic advice) and postural re-education exercises, ROM ex’s, PAIVMS/PPIVMS and muscle length activities (e.g. STM, stretch, trigger point etc).

Despite treating these physical impairments, it is hard for the patient to judge their progress by your treatments, as cervicogenic headaches may not occur during the time of your clinical placement. Therefore, ensure the small improvements in physical signs are adequately explained, as if they are not, the patient may become despondent and not comply. Therefore, explain the gains you are making and ensure the patient monitors frequency, severity and duration of headaches to see if changes occur. Also, if the patient experiences a headache between the clinical visits, don’t be disappointed and feel as if you have failed. Rather look to see if there are any changes in duration and intensity of the headache, if they required as much medication, and if there was the same amount of time between the headaches as normal. By using these as clinical markers, I found I could be pleased with the progress that was being made, and these positive indicators could then be told to the patients.

Discharge?

Stroke rehabilitation can be frustrating at times particularly in the outpatient setting when you are only seeing the patient for three hours a week. It is very difficult to determine whether the patient is improving within one session or even over a week. I am currently treating a patient who had a right mca stroke. The patient can ambulate independently and perform all transfers safely so now we are working on her left upper limb.

The patient has poor scapula control due to increased tone in teres major and latissimus dorsi, weakness of serratus anterior and rhomboids and stage 5 recovery of her arm and hand. Over the past four sessions with this patient I have performed SIMMs to her teres major and latissimus dorsi, stretched the upper trapezius and neck flexors, performed passive accessory mobilisations to the shoulder and have stretched the elbow and finger flexors. I have also worked on shoulder stability in an air splint with external rotation and weight bearing through the upper limb in 4 pt kneeling. Functional tasks have included reaching, grasping and releasing. In order to improve her sensation and proprioception I have done sensory work and stereognosis testing.

This patient has shown little improvement over the past couple of weeks and in the last session I tested her stereognosis and the patient couldn't even identify if she was picking up an object or her hand was empty. As a therapist I begin to question whether my treatment techniques are having an effect or if because this patient is over 8 months post stroke my techniques won't improve her motor patterns. It is difficult to decide whether this patient should be discharged or similar treatment should continue. I am trialling hydrotherapy with this patient to improve range of movement and shoulder stability. Hopefully by using this new approach I will begin to see improvements in the patients upper limb.

walking with your hands

I have been treating a patient with an acute (L) CVA for two weeks now. His main impairments have been an inability to walk without two mod-max assist, a flaccid upper limb, expressive aphasia and a two assist transfer. We have focused on his poor hip mobility and ankle range to progress to walking. Recently he has progressed to a one mod and one min assist with a quad cane or parallel bars, for about 6 steps. He fatigues so quickly and becomes emotional, so our sessions are quite exhausting and yet both physios and patient are determined to persist. So today it was incredibly satisfying to witness something quite unique.

Today, he ambulated 4 times the distance he ever has before, with minimal use of a quad cane, one person supporting the UL, one min assist at the hips. The pattern was lovely, his independence incredibly improved. A day that made you appreciate being a physiotherapist.

And interestingly, the key seemed to be in his UL. We had experimented previously with UL facilitation in sitting. But today we chose to do MPG weight shift for increased weight bearing in his arms and improve weight shift. He then improved his trunk extensor activation and scapula setting, improved foot alignment in walking and posture. By facilitating the UL in his ambulation, he was centred, taking full weight through straight legs that we had struggled to get extended sufficiently for weight bearing. It was incredible to watch. And further more, he began to string words together. Where he previously mumbled yeah or no, he said a slurred version of "that's ok" and "my shoulder is hurting". It was incredible!!!!!!!

So lets not forget the UL. Lets not leave it to the OT's. It is instrumental in facilitating appropriate trunk control and therefore weight shift. The sensation of weightbearing through the upper limb facilitates this in patients post stroke and improves the subluxation. I will never again let the upper limb fall second priority in physiotherapy sessions!

Healthy Living

I am currently treating an 18 yr old patient with multiple sclerosis. The patient has been diagnosed since she was 11. She does have periods of remssion however, she is now unable to stand without upper limb support and cannot ambulate.

When I met this patient she was extremely bubbly and ourgoing. I didn't expect this knowing that she had such a progressive condition. I immediately admired this patient's enthusiasm. This experience made me feel extremely lucky and I couldn't believe how much I took for granted. I looked back on my experiences as a teenager and compared it to how she had spent her past few years.

We chatted a lot during the treatment session and she began to show me photos of her family and friends and tell me stories about her weekend. During this discussion she was talking about her night out clubbing and how she'd drunk a bottle of vodka before going out. Prior to this session her notes said that she promised to reduce her alcohol intake. I'm unsure whether the physiotherapy student had advised her to stop drinking or if she had said that she wanted to reduce the amount of alcohol. In the notes it mentioned that her family were worried about her drinking havits as they were worried that she would injure herself or that men would take advantage of her.

As physiotherapists we promote a healthy lifestyle. I am unsure when a problem like this becoumes our business or responsibility. Obviously I am concerned for this patient and her well being. Even though I want this patient to be safe and to optimise her rehabilitation I want her to life her own life. She has many impairments restricting her participation in activities that teenagers would enjoy doing. Life isn't easy for this patient and occasionally she has mood swings and becomes quite depressed. I have subtly mentioned that the amount she drinks ais a lot more than the average person and I have shared my concern but I haven't told her off like previous therapists. I don't think it is our place.

I would very interested to hear if anoyone has had a similar experience or has thoughts on the issue.

A MET call

Last week I experienced my first MET call.

Whilst on lunch in a room adjacent to the gym, a patient started shouting for help. The physio responded immediately, with a few students in tow soon after. Another pt had arrived at the outpatient department, seated himself and whilst waiting for his session to begin he had had a seizure, fallen off the plinth and hit his head on the ground (which is the point at which the other patient started shouting for help). The pt was still in seizure for the next few minutes. During this time the physio put the pt in sidelying and I put a pillow under his bleeding head and applied pressure to the wound (even managed to remember to glove up first). Another physio entered the gym and made a MET call.
The patient was conscious throughout, was scared and was aware of his pain. He was concerned about his bleeding (he’s on blood thinning meds) and was also aware that his already hemiparetic side, which had previously made good recovery, was now weaker (he’d had a stroke 8 mths ago, which is why he was receiving rehab). The MET team took a little longer to arrive than I had expected and unfortunately the crash cart didn’t arrive with them.
The patient was much calmer now, still obviously shocked though and concerned that he had had another stroke. After the team had done their examination they decided he should be transferred to another hospital. The health team were chatting amongst themselves, when the patient asked if I thought perhaps he should see a doctor.. I quickly explained that the doctor had already assessed him and that it was thought he had had a seizure. At this point one of the physio’s explained to him that about 10% of stroke pts go on to have seizures post stroke and that the increased weakness he was currently experiencing was usually transient. The patient was visibly calmer and was even able to start making jokes.
Ultimately, the patient was ok - before leaving that afternoon we had news that he was being discharged that evening with anti-seizure meds. I was so pleased the physio was able to provide him with that info about seizures post stroke - I guess with experience we will have more to offer in such a situation. In the meantime though, this experience has re-iterated to me how important it is to keep the pt informed about who they’re seeing and what has been found, especially in an acutely ill pt.

Patients with Too Many Problems!

For those of you who have had your musculo placement, you would know that it is important to set time limits when performing the subjective and objective examinations. I remember I once had a new patient who was referred to the clinic with shoulder pain and headaches. As a “good” physio, I questioned her about her pain and started to fill out her body chart. As I questioned further, it became very clear this lady was a chronic pain patient. She had pain everywhere! Not only that, the pain she experienced was very severe, quite often close to 10/10. Of course, I tried to figure out the relationships between the different pains, and the aggravating/easing factors for each pain, which as you could imagine, the list became very extensive. As a result, it took me around 40 minutes just to do the subjective!

When I went to tell my supervisor what I had found, he told me that it is ok with patients like these to simply question them only about their initial presenting complaint (i.e. her shoulder pain and headaches), rather than any other associated pain. By doing so, it should help with time management. Then, over the next coming weeks, it is ok to question further about the other pain they are experiencing to better determine relationships.

She was definitely an interesting (and somewhat difficult) patient to see. I guess it’s a good learning experience though, as it is very easy to approach an initial consult as a tick box process. Quite often, I find I will know most of the questions that could be asked, and I will tend to ask them all, simply to have a thorough assessment sheet. Rather, it’s important to consider the absolutely vital parts of the examination that must be determined on the initial consult, and gather the rest of the information over coming sessions. I definitely will be trying to do this, but I guess the more I see patients, the easier this will become as our clinical reasoning process will also develop.