PT in Shanghai

Hi Guys, I'm not sure but looking back I think I have only done 3 posts and 4 comments, so here is a little bit from Shanghai, hope you find it interesting!

Today we arrived in Shanghai about 1am! (following another nervous plane ride and an even more nerve-wrecking car-ride- my understanding was always that red lights were for stopping at.. apparently not here!) In the morning we explored. My initial feeling is that I like Shanghai better then HK, not quite so crazy-busy and with a little more character. The juxtaposition between old and new, between western and eastern and between wealth and poverty is even more amazing here. You can see modern cement trucks pouring cement into rickshaws carried by old men back and forth to the building sites. In a busy intersection a bus gives way to a flock of bicycles while a taxi narrowly avoids a lady manually towing a rickshaw filled with what looks like all the furniture from her house.

We saw these men pruning trees. They were dressed in orange jump suits with helmets on but their similarity to workmen at home ended there. To prune the trees they stood in the trees amongst the power lines, with a rope far longer than the distance from the tree to the ground tied around their waist and onto the power lines! They wielded electric saws and let the branches fall onto the footpath and street, which was not petitioned off in any way, causing motorists and pedestrians to swerve and duck! Amazing! Any fraction of that picture would have had Occ Health and Safety tearing their hair out. Similarly within the first hour we had seen several groups working with welders on the footpath with no goggles or protective clothing and workers bent double, perched on top of high walls doing brick work by hand. Just another example I guess of what we take for granted, the right to a safe profession. A comment made was that this picture makes you realise that what we call “common sense” is not necessarily common. I am unsure if it is a difference in training, recourses, or the role played by the worker but here the responsibility for safety doesn’t seem to be held by anyone.

Some of my initial observations included:
- Limited play/ fun between children
- Limited age appropriate interaction
- The lerge percentage of athetoid and ataxic CP
- Poor standard of wheelchairs- no support or padding, very poor posistioning (although the comment was made that at least they don’t spend too much time in them)
- Poor manual handling- large necessity for parents to carry children
- Very poor facilitation of movement by staff and other handlers- no encouragement of independent movement between positions
- Excessive use of pull-to-sit and pull-to-stand
- The hydro pool is green- I’m hoping that’s just because its being fixed and the hygiene instruction passed on from the previous group have been taken on board

Downstairs there is a lot of very old strength-training equipment with questionable usefulness in this setting. The comment was made that there is perhaps a confusion between tone and strength, which often rings true back home as well. As this was part of my honours project hopefully I can have a closer look at this while I’m here. With this, the other comment was that the gifts given to centres such as this need to be carefully considered so that they are actually helpful and not just given to dump equipment that is not useful.

Neuro is interesting!

My clinical tutor gave me a tutorial today regarding variables used to assess and train balance, I found it quite useful and would like to share it with everyone:

1. motor planning (eg. apraxia, percepture disorder)
2. strength
3. ROM (eg, ankle DF in ankle strategy)
4. CoG (eg, move it up and down, in and out BOS)
5. Visual Spatial disorder
6. BOS
7. limit of stability (eg limit of ankle sway, limit of functional reach)
8. dural task interference (distraction)
9. endurance (eg, repetition of ankle strategy)
10. segmental movement (eg, rotation of neck on shoulder, trunk on pelvis)
11. environmental factors

If we can integrate the above variables into balance training, our exercises program and progression will be very specific. Also, try to address all these variables in one position before you move on to the next. I tried to use this principle to treat my patients with balance problem and the results were fascinating. I never thought movement re-training can be so analytical and specific-I never looked normal movement in so much details-today I not only learnt a new way to train balance but also a new way to study.

Carer stress

Please ignore my previous entry for I made some grammar mistakes... Just read the following instead. thanks
What will be the best strategies we can use if some patient's carer showed signs of carer stress (abusing verbally to patient and complianing about slow progress of patient and blaming staff for doing their job). These was what I encountered in my neuro prac.I felt really nervous when the carer stood aside watching me treating his wife. Lucky enough, nothing happened that afternoon, he was quiet through the session. But what happen if the patient's carer started to interfere with our treatment...what strategies we can use to handle the situation? do we just clear the patient's carer from the sene or do we stop the treatment and discuss the issue with the carer? Is there any support/service available for patient's family to relief their carer stress?

Complicated case

A patient with multiple small strokes (mainly on prietal lobes and frontal lobes) was admitted to my ward. Talking to my supervisor we agreed that the patient presented a mixture of Parkinsonism (patient couldnt stop herself during walking and need to remind the patient to "plan ahead" during transfers or negotiating obsticles during gait), cerebellar ataxia (ataxic gait, central vestibular dysfunction evidenced by occular nerve pulsy, nystagmus and symptoms of dizziness), and frontal lobe behaviors (lack of insigt, very impulsive).However, she ambulated inderpendently (poor balance, but adequate saving response, she walked like she was drunk-she said she felt like she was on a boat when she walked). I had no idea where and how to start to treat this lady. Functionally,she was fine because she doesnt need any assistance. But her gait movement was really astonishing...The treatment I gave her was education on how to rise from floor and I gave her ankle weights to practice walking with. The theory behind using ankle weights was weights would reduce ataxia. Result of 6 minute walk test showed her improvement (from 28 to 16 seconds). But still, I would never feel that I did a good job because quality of her gait was really poor. I wondered if any neuro out patient would be interested to treat her because her functional level is very high...What is your suggestion? where can I go from here? do I just discharge her and offer her some nonspecific community class to attend?

stroke pt with WZF

I had a patient recently admitted to ward for a small stroke. She fractured her hip and had a DHS 3 month prior to current admission. She had been walking with a WZF since the DHS incert. I felt hard to treat this patient because I was tought in neuro placement that we should restore normal movement of the patient esp at acute stage. For instance, using a WZF is not restoring normal movement... What shall I do with this patient? She wasnt capable to walk independly prior to stroke. So walking with aids should be the goal of my gait retraining? But is walking with aids going to maximize patient's chance of recovery in terms of her lower limb function and core stability?

Motivation

A patient admitted to my ward with active gout and he was await for a placement to hostel. Knowing that he would end up in a hostel, the patient tended to rely nursing staff to do ADL's for him and reluctant to initiate any althought that he was capable. At physio section, the patient was polite enough to be compliant but I feel that the patient is just doing the exercises for me because he was mouning all the time and really reluctant to do the exercises. I discussed this issue with the clinical tutor and we decided that I would need to change my communication skills and emphasize the importance of independence and link exercise to functional goals.
My way of approach was like this:
I acknoledged to patient that he would go to a hostel where there staff for basic help. But the level of assistance he would get in the hostel would be much lower than in the ward. And even if he would get the same level of assistance in the hostel, however, I suggested that it would be simply nice to do things by yourself like going to toilet, getting your self a cuppa, walking to dinning room and socializing with new friends in hostel. Then I re-introduced each of the old exercises to the patient with spacific functional goals eg practiced waling is for walking to dinning room or visiting friends in other room in the hostel. I felt that patient's motivation was boost significantly and he was really trying hard to do the exercise with me FOR HIMSELF. How great was that!

Movement analysis

A petient was accepted for gerontology assessment in my ward for frequent falls. I did the routin assessment which is filling the geriatric assessment form for her. Her glute med strength in sidying position was definately a grade 4+ and no pelvic drop in single leg stance position. so I presume that her glude med was fine. However, my clinical tutor picked up that she had a compensated trendelenberg sign. The reason I failed to identified patient's weak glute med is that I failed to check patient's alignment as a whole ie shoulder over pelvic, relation of pelvic and CoG etc... and I was only looking for signs ie "pelvic drop".

Treatment conducted based on the diagnosis that patient had a weak glute med was very successful and patient's balance and confidence improve rapidly. I really think that as a PT, I need to make sure that analyse patient's movement as a whole not just focusing on signs.

Importance of the Allied Health Team

I had the opportunity to spend a lot of time on my rural prac working very closely with paediatric OT’s and SP. The team feeling on prac was amazing. Everyone had their role and was valued by the other team members. Weekly meetings were held to discuss common children and prioritise current issues so as not to overwhelm families with too much information from different allied teams. Often there would be joint treatment sessions with OT’s/SP or PT/OT or SP/PT or OT/SP/Dietetics.

I also had the opportunity to work with these various professions in different play groups. One person would lead the session for the day and coordinate the activities (a combination of gross and fine motor skills, language and communication skills, and social/behavioural skills) in preparation for these children to start kindy the following year.

I don’t think I’ve ever seen the “allied health team” at work before like I did here. And although we discuss the importance of the team approach at uni, I very rarely ever see it on prac. People tend to be too preoccupied with their goals and treatments than seeing the patient as a whole. It reinforced the need and desire to work hard towards maintaining a team approach as we begin to ready ourselves for the work force next year.

What are our obligations to notify DCP?

What are our obligations to notify DCP?

I was recently conducting a home visit with my supervisor to see a child who was almost 12 months old and was severely delayed in his motor development. He was as yet unable to roll between supine and prone, was only just starting to sit independently.

The child is the youngest of 6 children (aged up to 17) and all children are still living at home. The 17 year old female recently had a child who is now 2 months old and is also living with her partner in the family home. 3 step children lived in the area and would occasionally stay. The family’s financial situation was very poorly and on initially entering the house I observed a lot of rubbish and old mail and broken furniture that would be dangerous to young children.

As we continued our assessment of the child, I noticed a dark spot in the child’s fair coloured hair. On closer look it was a flea. We found several others on the child’s body. The mother was extremely embarrassed by this and apologetic. We completed our assessment and left.

Following this I was discussing with my supervisor if the family accessed appropriate support services and whilst they were known to local services the family often did not attend appointments. I continued to ask further questions as to what our obligations to notify services such as Dept of Child Protection about the living conditions and the fact that flea’s were found on the baby. My supervisor defended the mother as she believed she was trying to do the right thing by her family but wasn’t getting help from her partner that had led to this situation. Despite this I continue to be concerned by what I saw…maybe there are other families living in worse conditions (I was recently in Derby and did some worse housing conditions) however I did not feel it was safe for a child to live in that environment.

Since the subject was closed in my supervisor’s mind I couldn’t ask the question…what are our obligations to notify DCP?

Weeks later and I still wonder about this poor child.

Parents Handling skills of their child

I was somewhat intrigued on my prac by the number of children who presented with torticollis. What I noticed with most of these parents and spent a lot of time discussing with my supervisor was the parent’s poor handling skills.

A lot of parents noted that they placed their child on their stomach for ‘tummy time’ however none of the parents we saw would roll their child to place them in prone, but would lift them in an almost A-P direction, turn them then place them down on their stomach. Additionally when going to pick up their child, very few added any rotation to the movement. For most of these children they did not know how to roll or reposition themselves as they are never given an opportunity to do so. I was amazed by the number of parents who did not appear comfortable positioning/handling their child and verbally expressed their lack of confidence in doing so…

With demonstration and practice of some handling techniques involving how to roll and pick up their child differently, most parents would come back the next week and tell us how much their child had improved and would now roll to both sides and was now more comfortable in turning their head to both sides as well. The parents also told us how they now felt more comfortable in handling their child and placing them in varying holds and play positions.

In this age with fewer siblings, or fewer family members around (parents/grandparents), are we lacking the opportunities to play and hold little babies anymore and learn these basic skills?

Post Botox Guidelines

Whilst on rural prac, I spent most of time working in paediatric community physiotherapy. One of the most common conditions I was working with was Cerebral Palsy (CP): spastic diplegic/quadriplegic of varying severity. We had several children referred from PMH post botox treatment (each had injections into either gastroc or hamstrings). They were referred with an attaching form asking for “intensive physiotherapy”.

However on further investigation, no one seemed to know what the best practice/guidelines for physiotherapy treatment was post botox. I spoke to PMH, TCCP and various other experienced paediatric physiotherapists. Each had their own idea of treatments (techniques, frequency, duration of therapy) but with no consensus.

I then proceeded to do a literature review to investigate the recent research into this area. Although there is a lot of literature about the benefits and best practice for botox injections there is very little information about physiotherapy input. Almost every article recognised the importance of physiotherapy and other allied health input, stressing that botox should only be used as an adjunct to physiotherapy, however as to what type of physiotherapy is best is not clear.

Obviously, maintaining muscle length, muscle strength and gait re-education are all important, but how do you justify to a government agency that a child needs 3 x week input of 45-60 mins of therapy for 6 weeks to maintain and improve the gains from botox injections. How do we treat according to evidence based practice when there is none. There is a variety of ideas about physiotherapy post botox, inlcuding:

Duration: between 4 weeks of “intensive” or “comprehensive” intervention up to 8 months.
Frequency: 1 x week up to 7 x week
Types of intervention (not specific): strength, balance, stretching, gait reeducation, functional training (no indications of strength reps or sets or even which muscle group – often suggested you need to strengthen the botoxed muscle as much as its antagonist)

Therefore, we saw our clients 1 x week for 60mins to monitor gait, ROM, muscle length, and took them through strengthening exercises (concentric and eccentric) and provided a home exercise program. The plan is to provide treatment over a six week block. At that point in time, there were not the resources to be able to provide further therapy. My supervisor plans to conduct her own informal research and see what improvements she gains/maintains by conducting relatively similar treatment protocols (type, frequency, duration).

Whilst very few conclusions can be drawn from the lit review about best practice post botox, it does indicate an area that is lacking…maybe a good research project for the future…..?

X-Rays

As far as X-ray's are concerned can anyone please clarify exactly where we as physio's stand? I have received conflicting answers from a variety of sources. Some people saying that we can order them, but then they aren't covered by medicare, and others saying that it's better coming from a physio and if we believe it's warrented it should be done? I think the former sounds more familiar.

Recently I have come across three situations in which I believed an X-ray necessary. One patient had a fall and the next day started to complain of hip pain (worse than he had the previous day); secondly a lady presented to the outpatients department with a severe 'ankle sprain' which was very bruised and with some tingling in the toes a few days on; thirdly a lady with CVA and consequent global aphasia with very internally rotated hip, no increase in adductor tone and obvious pain (facial expressions) on hip and knee flexion - she however pointed to her knee as the source of the pain. The third case in particular was rather worrying and both my supervisor and I thought that an Xray to exclude dislocation of the hip, or infact a knee problem, was warrented. The nurses said I could order the Xray but agreed to inform the Doctor for me anyway, and the next day and X-ray was ordered and performed.

We are in a unique position to screen for if not diagnose fractures and dislocations, due to the fact our science is largely movement based. So once again I pose the question? Can we order X-rays? Secondly is it better for the patients hip pocket if we don't?

Communication skills

I thought that my communication skill has improved immensely over this year but that was until I met my last patient on my last prac. She has been complaining of LL weakness and sensation chances and recently had a fall and admitted to hospital. She showed signs of demyelination after a EMG was performed. But the horror was that she spoke no English at all.

This little but quite voluptous asian lady would be slumped in her bed everytime I saw her and in the nursing notes it would describe that she refuse to cooperate. The challenge was to explain to her that she needs to get up and moving or at least sitting upright in a chair but without using English. I drew stick figures and made some very interesting gestures but all I managed to get out of her was a smile as if 'you want me to do that, no way!' I had such a difficult time with her to get her to move. I spoke to my supervisors but they came up with the same techniques but they did ellaborate on handling skills. My supervisor told me that in order to get someone to move just the hand placements will be sufficient enough to guide them. But the issue with this lady is that she doesn't want to move, she quite like the idea of being provided for...any thoughts on this?

difficulty running class

I run/ ran weekly pre-primary balance/strength/coordination classes at prac. There are 6 kids in each class and we run a circuit type of class which required at least one person supervising at each station. We routinely run into issues regarding parent help with the activities especially in the last week. One of the parents with twins in the class told me that "she was here to gassbag and not be our slaves",two of the others went out to smoke and one other staued in the waiting room, leaving 2 mothers to help as out over 6 stations. The session ended up being really hectic as we had to continually run around checking for child safety and technique. My supervisor was going to say something to the parents about their lack of help, but chose not to in the end. She said since I was running the class I could have said something along the lines of could you please help out more during the next week, but I didn't feel like it would have been appropriate for a student who doesn't have any kids etc to say something like that. Would you guys agree, or would you have said something?

Impingement

In the last three weeks alone I have had three patients present to me with cervical and shoulder pain – all with classic shoulder impingement symptoms. For these patients I have found that the lower traps exercises are good, and mostly they are compliant with completing them. All presented with cervical 'stiffness', but on PAIVM assessment it was more the thoracic vertebrae showing signs of hypomobility. Treatment included mobilisation to the thoracic spine, soft tissue massage to the affected area, and a home exercise program including lower traps exercises and postural re-education. All three patients responded favourably within one week, and are continuing to improve on both a subjective and objective level. My supervisor reported that thoracic mob's can often work wonders, especially when all else has failed with nerve symptoms, for example tingling in the hands, which you would think would respond to cervical work, when it doesn't thoracic mobs sometimes help. He reported this may be due to the fact that all sympathetic nerve fibers originate from the thoracic spine, whereas the parasympathetic nerves come from the cervical and lumbosacral spine. Has anyone else found this whilst on clinic?

Pts and their notes

Hello all,

This week I saw a pt who had had surgical repair on his flexor tendons after punching his fist through a window. Prior to seeing him, I had a look in his medical notes, which reported that alcohol was involved and there was a domestic dispute. From this information, I wasn't all that keen to see him, especially as he was booked in for my final assessment with my Clinical Tutor. However, during the assessment, I asked how the injuries happened, and he explained that he had an argument with his sister and he punched his hand through a window. He was very remorseful, and said that he would give anything to be able to change what happened. He was very keen to be doing exactly what we told him, and was very compliant. What I learnt from this: don't judge pts by their notes, always ask them what happened because it may be different to what you assume from the limited information in the notes. Everyone makes mistakes, and we as physios are not there to judge people, but to treat them and help them.

Patients getting worse

My fellow student and I were treating a man for "chest physio" post MBA and pneumothorax. He spent a week on the ward and during that time, he was extreemly confused and unsure of what time of day it was or how he got there. He started telling stories of incedents that were not related ot his injury. Treatment consisted of ambulation, ACBT, incentive spirometry, and ROM exercises as he was on suction for the ICC.

Within the stay, he started to improve but rapidly declined. The ICC on the left was removed. He contracted a pleural effusion on the right so another ICC had to be inserted. When we arrived on the ward this week, there was a mad rush as the patient began to crash.

He was rushed into surgery with a HR of 170 bpm and on 12L O2 via Non-Rebreathing mask. He is now ventilated in ICU. We went to see him yesterday and he is very ill. We both feel terrible because it was so hard to get him to take deep breaths (plus his sputum was frank heamoptysis!!) and had we tried different stratergies, could it have been prevented? How much of a role do we really play?

Doctors and getting patient to ambulate

On this, our final prac, I came across a rather interesting situation. One difficult patient, who is a long term admission, has recently been refuing to ambulate. Many different stratergies have been implemented to no avail.

The doctors have decided to offer the patient a bribe - if he walks downstairs with the physiotherapists, he is allowed to have a can of beer. How ethically correct is that? And seeing as were the ones that have to take him for that drink, can we decline if we don't approve?

Getting a job

I'm not sure if I am alone in this one and I am not suggesting that the physio course has an abundence of room for more information to be squeezed in but...In trying to get a job I realised there are quite a few things I didn't know about, just basics and most things I have chatted to a lot of my supervisors throughout the year and most have been more than helpful but I just think if people have had less helpful supervisors or prehaps juniors who havent known as much about recruitment then this whole thing could be pretty tricky! I just think maybe some of the practical basics could maybe be included earlier in the semester, the careers expo was really great but I think some of the info would have been more helpful earlier. Just the really practical stuff, what to ask who? when to ask? when to send applications etc.
...Anyone else feel the same way?

Difficult parents

On my paeds placement, I have been finding that it is the same parents that regularly fail to bring their children in for appointments. This one particular family have missed their appt 4 times in 3 weeks and when they bring their child in for treatment they constantly question what we are doing with them and why. Whilst it is good that they are asking questions, as soon as me or the senior PT explain why we are doing a certain treatment or that their child is slightly delayed in a certain area, the parents become very defensive. I completely understand how hard it must be to sit there and listen to someone say that your child is not doing things that he/she should be doing at a certain age, but it's not like we don't say it tactfully and we always point out the things they are doing well before hand. Due to the fact that they seem to miss more appointments then they attend, they don't do their child's HEP with them and everyhting we do with their child they don't like (no matter how much we explain why we're doint it), i feel as though my time would be better spent with a family that appreciate what we are doing for their child. Also, because this family dont attend regularly we are blocking up times that other clients could be getting treatment. In saying this, the child is the main focus, and they're not the one causing the issues. Just wondering if anyone has any ideas how I could manage the situation more appropriately (I have tried asking the parents what they would like me to work on with their child but they don;t know themselves).

hyperactive child

For my mid place Ax i was assessing this young boy who had suspected DCD as well as significant behavioural issues. He was very in tune with what his limitations were and as soon as he knew he couldn't do something he would play up / run off in the middle of my Ax, therefore a lot of my Ax was spent trying to calm him down and focus his attention to the tasks at hand. Whilst this Ax was going on his mum was freaking out saying that his co-ordination / behaviour was not normally as poor as he was showing during the Ax. The difficulty was that my facility tutor had asked me to fill out the entire Ax form as it was the first time that I did a full sensori motor Ax but the Ax procedure is long and rather boring for a child to complete. Needless to say, whilst i was supposed to testing half of the items the child was bouncing off the walls and I couldn't focus him back onto the tasks despite trying to make the Ax into a game and as fun as possible. At the time i felt like i was doing the best i could be doing, but after I felt as though i would have got more out of the vhild and session if I picked out the key areas first and just Axd those parts. I also would have been able to chat to the mum more and re-assure her that her child was not doing as poorly as she thought. Any thoughts on juggling the pt and the carer at the same time as completing an Ax form??

CRPS

I am treating a pt at the moment who underwent a fusion of some of the carpal bones 8 weeks ago, after years of pain in the wrist. She was immobilised in plaster for 6 weeks, but all the fingers were immobilised as well, and now she has a very stiff hand. She is also very hypersensitive, and my supervisor has said that in her experience, hypersensitivity is usually one of the first signs of CRPS (chronic regional pain syndrome). I am treating her for the hypersensitivity, as well as for the decreased ROM in the hand and wrist. She also has many chronic pain behaviours, and I have been trying to not focus on the pain during our treatment sessions. I am finding this difficult, particularly as she volunteers information about the pain without me having to ask about it. I feel as though I am ignoring her when she does give me this information as I am trying to not focus on the pain. I know that this is for the pt's benefit, and that progress will be slow, however I still find it difficult because I will not really see much progress because of the limited time that we have on placement, but just have to trust that what I am doing is making a difference. But, I suppose that that isone of the reasons why we have supervisors, and that we need to make use of their knowledge and experience in treating pts. What does everyone else think?

Bargaining

I am currently on my neuro prac and have come across a young adult with an intellectual disability and severe cerebellar ataxia due to an unkown cause. He experiences severe vertigo when turning his head and is very fearful of rolling in bed due to his dysmetria. He is also fearful of standing despite adequate support. My partner and I have been trying several strategies to help overcome his fear such as aligning ourselves in his field of vision and positioning ourselves in a front on position with transfers so that he feels safe, however he still feels very fearful of falling and this means that we are often only able to get a maximum treatment session of about 15-20minutes. We feel that he would show greater improvements if we could get more time out of him, but no matter how much we bargain with him he still constantly asks to be returned to his room. Has anyone faced a similar situation and have any useful strategies for gaining his trust in us as students and therefore hopefully leading to a more productive session?

oral dyspraxia

Sorry everyone I was going to blog while I was on my deferred overseas prac because it will probably be more interesting but I just remembered I have to comment and there is probably no point if nobody else is blogging too...so here is my 2nd delayed post.

On prac today the physios were talking about oral dyspraxia as opposed to expressive aphasia. As I understand it oral dyspraxia is when the patient knows what he/she wants to say but has trouble articulating the words voluntarily. Pts with dyspraxia apparently may be able to sing or speak in another language words that they cannot speak appropriately in English. English is apparently very hard to recall when you have dyspraxia and some patients find it easier to learn a new language, particularly one that is more phonetic. Apparently the reason singing may be easier is not completely understood, it may be to do with the rhythm or maybe because the words are already learnt and therefore more automatic. Has anyone else come across this distinction on prac? The physios suggested using singing of previously well known songs may be helpful to tap into some of that more automatic communication. Sounded interesting but I haven’t seen it in practise yet, has anyone else?

Scapulothorasic posture

I have a pt, a 22 year old boy post with a TBI post MVA, with decreased truncal tone, ataxia and decreased segmental control of lumbopelvic movement among many other things. He remains in PTA and is unable to remember from one Rx session to the next. He also has marked bilateral scapular winging, thoracic stiffness and tight lats, pecs and teres. We had been focusing on his lumbopelvic mobility, increasing AP tilt and facilitating pelvic tilt within functional movement including gait and sit to stand. We have had some success in increasing his AP tilt and Lx mobility but this didn’t transfer into functional movement. Our supervisor assessed the pt with us today and suggested that working on his thoracic stability and posture and scapulothorasic posture may actually be more beneficial. We did some thoracic mobs, PNF style scapular strengthening, muscular releases and postural retraining with lateral thoracic support. I was quite surprised that this actually made a much bigger difference to sit to stand and walking ability. Our supervisor explained it that the pelvis and lumbar spine need a stable base of the scapulae and thorax to work off. Not really life-changing I know but I just thought this was interesting because I have always thought to work from the bottom up with the trunk and this was just another way to look at things.

Elbow splints

Hi everyone,

Last week on prac (I'm doing hands at Freo), my supervisor was referred an inpt who required an elbow splint. She told me that she had never done an elbow splint before, but had seen one done. She started doing this just before I went to have lunch, and was finding it difficult. After I came back from lunch I was with my CCT, and she was still working on it. Eventually the splint was finished, but it required 3 sheets of thermoplastic material and the OT's to come and help to make the splint (the physios and OTs work together in the hand therapy clinic). The moral of the story: no matter how much clinical experience you have, there is always something you don't know how to do, and that even supervisors have their "student" moments, when they feel totally incompetent, and they have to ask someone for help. It was a bit comforting to see that someone who had a lot of clinical experience still needed to ask for help, especially as I often try to figure things out on my own, and find it difficult to ask for help.


P.S. I got to see surgery on Monday afternoon, of a repair of a Dupuytren's contracture, which was pretty cool. Then I saw the pt today (day after surgery), which was also pretty cool, because I saw what the pt was like before, during and after surgery.

Palliative Care

An issue that has been raised a few times throughout my rural placement has been physio’s role in palliative care. I have been asked on a few occasions to provide a falls risk assessment / mobility assessment on palliative and terminal care patients. I have at times struggled with this as in my mind, this is probably not a top priority for patients, especially if they are trying to sleep.

In the end I decided to reach a compromise. I introduced myself to one of the patients, told them what I was there to do, and gave them the option of wether or not they wanted treatment. On most occasions when the patient was sleeping I decided to come back later, however when it was evident the patient was awake I tried to do an assessment, but often didn’t really achieve even basic falls risk / mobility… in fact didn’t get past sitting. Obviously, like any patient care is warranted, and patients have the right to refuse this. The only thing I’m questioning are priorities.

Has anyone else come across a similar situation?

Difficult patients

On prac, i was faced with a young man hwo had suffered a pneuomothorax following a stabbing injury. He sufferes from Bipolar disease andis a known drug addict. Earlier in the shift, it was reported that he was verbally abusive to nursing staff. He had also been for a smoke earlier with an ICC in place!!!

On approaching this patient, I was already cautious. He was sitting in bed, alert and very talkative. He continued to tell me how the pain medications he was being given were insufficient as he was an addict and needed somehting stronger. I tried to explain why he had the drain in place adn taht smoking whilst having an ICC was not appropriate. We offered nicotene patches but he was convinced he needed 2 patches as he was an addict. He continued to tell me about his habits of inserting needles into his arms and how only certain veins work.

When his family arrived, he was bragging about how 15 people had to hold him down to insert the ICC in the first place. He was easily distracted, he wouldnt listen to me and I felt very uncomfortable around him.

I chose to seek advice from my supervisor and he agreed to see this patient. I chose that I was unhappy treating this patient as I was not comfortable to get close to him. Upon reflecting, I realised that next year I would most likely have to treat this patient. Where can we draw the line? In this situation, there was someone else to treat the patient, but this might now always be the case.

Being judgmental

I am currently on a paeds prac. Last week whilst on prac I was faced with the following situation, and from the very outset (ie reading the pt notes) I found myself being rather judgemental. From the notes and my supervisor, I was told that my 18 month old pt had been in and out of foster care from an early age. Although the babies mother had recently been found injecting herslef on a park bench at 2am in the morning WITH the child sitting next to her, she was fighting for permanent custody of her. Being fully aware of how the foster care system runs as I had a foster sister for many years whilst growing up, I was aware that the childs mother will probably be granted these rights and my supervisor confirmed my suspiscions. So, before I even met the childs parents I was thinking 'how could you do this to your child? They would be so much better off in foster care if youre on drugs etc' THEN the family walked in... my supervisor and i just looked at each other secretly going OH DEAR. The parents were swearing their pants off infront of their 18 month old, they both had their OWN pants hanging down by their knees, they stunk of smoke and alchol and had food bits dangling off them. Not to mention the fact that they were both morbidly obese but still managing to wear pretty much nothing. So at this time for one of the first times in my life I was lost for words. The little child ended up beinf one of the cutest little things I have ever met but simply delayed because she was ignored for the first 6 months of her life. As the session progressed, i found myself getting more and more annoyed because the parents didn;t even speak properly to their child and every single leyer of clothes the child had on ie 3 was covered in dirt and food and reaked of ETOH and cigarettes. Anyway, as much as i kept on telling myself to not let my frustration show, it totally did and my supervisor could tell (but luckily didn;t mind cause she was really annoyed too). Just wondering if anyone has effective stratergies to hide their unwanted feelings?

Awkward situation

On my last prac (late entery) i ran daily hydrotherapy sessions. On one occasion, one of the new pts began to reveal highly personal information to do with being abused as a child (aurthorities were aware of this). At this time there were 5 other clients also in the pool. As the session went on the details became more and more graphic and the whole class were giving their 2 cents worth, which ultimately lead to the other class members revealing their personal information, including further abuse and the likes. As the lesson went on a tried harder and harder to focus the class on their exercises to pretty much no avail. To make matters worse 2 PT assistants were sitting at the edge of the pool staring at me as if to say "do something" whilst i just stayed away from the conversation entirely whilst trying to take control of the class. I could see that some of the class members were quite awkward, but i couldn't exactly tell the person that was speaking about their abuse to quiten down. All in all, the session was quite unproductive and quite uncomfortable. Just wondering if anyone else would have handled it differently ie other than just carrying on with the session as if nothing had been said??
Thanks.

A cultural experience

I've been feeling like a bully recently to one of my patient on prac. This gentleman in his late 50s suffered a pontine infarct which gave him mild L sided weakness and a mild ataxic gait. He has no aphasia or perceptual deficits ,orientated to TPP and is independent on ambulation.

It all seemed straight forward when I read the notes and gathered what I'm going to do with him, until I met him. He showed severe depression and was crying in his room. He constantly repeated to me "why me, my mother/nephew/cousins died of stroke and now it's going to happen to me".

After the 1s treatment session which took ages because half the time I was trying to settle his emotions, he saw and felt some positive changes to his condition. In the next session, he all of a sudden became over confident in me as well as himself. When I took him for a walk to observe his gait, he decided, 'I'm going to get better now' and started to run without telling me. I literally had to physically restrain him and tell him "NO" like a child and yet he still struggled to continue. I never trusted him from that occasion on.

In the subsequent treatments, I made sure that specific instructions were given and that all boundaries are clear cut, but this patient still goes off on his own tangent and jeopardise his safety. His impulsive behaviour was getting to a point where I was reluctant to discharge him even though he was physically fit to go home with a HEP.

I couldn't figure out why the patient's behaving like this when I've explained infinite times about his condition, the likely prognosis and for him it was very positive after liasing with doctors. Until the OT came in and said he's Greek, which openned a whole new ballgame.

My patient's behaviour is perfectly normal for a man of his age from a greek background. He's the leader in his extended family. He doesn't want to be a burden on his family so therefore tries really hard in therapy and conseqently overestimates his abilities. Until he's tried it out for himself, he will persist. I suppose I'm generalising here a bit, but this was an interesting experience.

Sternoclavicular Joint

I have a friend who suffered a (R) sternoclavicular joint injury over a year ago when falling onto the point of his (R) shoulder in a football game. At the time he said the joint felt like it 'moved forward' and he was unable to raise his arm past 90 degrees. He rested for two games and found that he was able to gain full AROM of the GHJ however still complains that the joint doesn't fell 'quite right' during certain movements. The main movement that exacerbates his pain is eccentric horizontal extension (such as the lowering of a weight during chest press). I have found that although the clavicle rolls posteriorly as it is supposed to during this movement, the movement of the clavicle in the anterior direction on the manubrium is excessive and my friend claims that it feels 'unsteady'. Relying on my quick thinking (or lack there of) I tried to do a Jenny McConnel and invent a taping technique of my own! I couldn't find any info on effective taping for the SCJ so I placed an 'X tape' over the anterior SCJ, anchoring one piece at the sternum and pulling it over towards the medial border of the (R) scapula and one piece anchoring over the right rib cage (approx rib 5) over towards the medial border of the (L) scapula. For the first few sets of chest press, my friend found this effective but as he started to fatigue and move into more horizontal extension the clavicle started to move more anteriorly again and the pain began again. This truly is a strange case, any suggestions on treatment for the SCJ?

Expressive Aphasia

I am on my neuro prac at the moment and have come across an elderly lady who is now 5 days post (L) MCA stroke. From my assessment, it appears that the patient is able to understand spoken language and is able to answer simple 'yes' or 'no' questions, however suffers from expressive aphasia therefore I am unable to make any sense of her spoken words. She expresses herself fairly well using facial expressions, so I am able to detect if she is in pain or shows that she has a general interest in what is going on with our treatment sessions. I still feel that I could get more information from her non-verbally. I was wondering if anyone has come across a similar situation and has developed their own strategies to more effectively deal with the situaiton?

Negotiation and time managment

There has been several occasions in this prac where I had to wait for such a long time for the patient to get ready for therapy. One occasion was when 2 of the patients that I was suppose to see are both in the same room. This room had 4 patients and were all waiting to have a shower. I wish my supervisor who allocated these patients to me in the am could have told me...this would have saved a lot of time.

Negotiation with the staff could also be an nightmaire. I wrote in the shared diary that I would like my patient showered and in the chair ready for PT by 9:30. Then the nurse comes hustling in and happily told me that the patient is in the shower now and will be out in the chair in 10min. I thought great, however when I walked into the patient's room, she was still in her nighty waiting to hop into the shower. No matter how I managed to convince her to even do some UL ex in bed she refused boldly. I was not very pleased.

Patient Handling

Hi guys, I'm currently in G66 neurology and what I found really challenging was transfering stroke patients. Whether its performing sit to stand or from w/c to bed, or supine to sitting, applying our handling skills that we learnt at uni to a patient was totally different. Not in terms of hand positions but my body mechanics were all altered.

A patient with a dense L hemi basically slumps into you when you stand them up. We never had this kind of exposure. I mean I did anticipate what will happen when i stood the patient but I never knew it could feel so different. What I suggest is that practicing on peers are great to get the idea of what to do but what also would be great is to get them to actually act out and relax on one side of their body, then we will really get a sense of how much effort is required.

the over active patient

As a physiotherapist on a surgical ward, we spend most of our time convincing patients that getting out of bed, no matter how painful it is, will actually make a difference!! So when faced with a patient who wont stop walking 3 days post 4x CABG, i was lost on what to do. She has an interesting social history and is a carer for both her son and husband. This patient has just had open heart surgery and cant wait to get home so she can help out.

In terms of cardio problems, her SpO2 remains stable however she gets SOB post walking. Her chest is clear, she does ALL her breathing exercises, she does ALL her UL and LL exercises and she walks around as much as she can. The problem is.... she wont stop!!!

She has an anxious personality and is continuously on the move. I am currently trying limitation stratergies with her to minimise the work she is doing. I have told her to walk only 4-5 times a day and only do her breathing exercises 4 times a day. She is NOT to try ANY lifting of carer duties for the first 3 months. We are CONSTANTLY reminding her that she is to put herself first. If she is unwell and requires more surgery, it will take longer for her to recover completely. She is a hard patient to monitor because all the usual tricks don't apply.

Assumptions

Hi Everyone,

This experience happened to me on my last prac which was my rural. I was doing a community placement. During my second week, I was taking the No Falls group, along with the therapy assistant. We had a new patient, who had a long history of falls, and who's balance was severely decreased, and in hindsight was not really appropriate for that particular type of intervention. The therapy assistant and I were spending most of the time with this new pt, showing her what to do, however, one of the other paticipants of the class called me away, so I left the new pt with the therapy assistant, assuming that everything would be alright, as that particular activity was only standby assist. However, the new pt then had a fall. What I learned from this incident: Do not assume anything! The therapy assistant had a very confident personality, and I assumed that she knew more than she did. At the end of the day, we are the physios, we have the knowledge and no matter how confident (or bossy) a therapy assistant might be, we are the ones who have to take responsibility for all of our pts.

Osteitis Pubis

My recently completed self directed study involved researching some of the literature into the definition, aetiology, signs and symptoms, diagnosis and treatment for five common musculoskeletal conditions. One of these conditions was osteitis pubis. Unfortunately I could not find much literature relating to evidence based physiotherapy treatment for osteitis pubis. All I could find (as usual) were some very broad treatment/management ideas such as rest from aggravating activity (sit ups, twisting, forceful adduction), gentle massage, gentle stretching, core re-training etc...I was wondering if any of you guys had come across a patient with osteitis pubis or been a sufferer of osteitis pubis and shed some light on a specific exercise program that you had found useful in resolving this problem.

The Pusher Syndrome

I am on my neuro placement at the moment and have been treating a (R) MCA stroke patient (who is 6 days post-stroke) with my partner for the week. He has stage 1 voluntary movement of his (L) UL and LL, very low tone of his (L) LL and UL, no sensation (light touch or proprioception of his (L) UL and LL) and severe (L) sided neglect. We have tried some alignment and balance exercises with him sitting over the edge of the bed and have found that he tends to align himself posteriorly and to the left (as expected). To add to his tendency to bring his CoG posteriorly and to the left he often pushes with his non-hemiplegic hand to the left. As suggested, I have read the article on 'the pusher syndrome' however have found that their suggestions for PT treatment are limited and not so helpful as we havn't been able to take him to the gym yet or gain access to a mirror to help his sense of verticality. I have found that reminding him to place his (R) hand palm up on his lap is often useful to prevent him pushing but besides this I was wondering if anyone had come up with some other nifty treatments for this problem.

silly patients

As the year goes on, i am finding that i am getting sick of spending 90% of my time on 10% of perth's population who land themselves in hospital simply because they did something dumb. The trouble i have with these pts is firstly i think what's the point in treating them if they'll be discharged and they'll continue doing stupid stuff and as a result be back in hospital within a year...and the cycle goes on...Secondly, i figure that my time would be much better spent on those pts who can't help being admitted to hospital. I am probably being too judgemental, but does anyone else ever feel like this???

Dealing with other physio staff

I am on rural prac and have 2 supervisors. IOne of my supervisors wanted me to fully run the ward and see all of the patients by myself (as appropriate) which i was quite happy and able to do BUT a new physio has just started at the hospital and my other supervisor want her to do most of the work. The same supervisor also wanted the new physio to come on see all of my patients with me with the view of her taking all my caseload. This has lead to all of my patients going to the new physio and suddenly i have no say in what happens on the ward ot with any of the patients. Furthermore, of the one pt that they left me with, the new physio keeps telling me what treatments to do when they have said themselevs theyhave had little ward experience and they also don't know the pt from a bar of soap. I feel like i am getting caught up in the middle because one senior wants me to control the ward and the other (my clinical tutor) doesn't. Basically, i have been doing what my clinical tutor has told me to do but i am slowly getting more and more fed up because now i can't see my pts who i have worked so hard at treating them. I was considering explaining myself to the physio who wants me to do more around the ward, but i don't want to make a huge fuss or annoy my clinical tutor...Any ideas???

Confusing referal pattern

I had an elderly pt this week who was complaining of pain down her mid-shaft of humerus. Although she had reduction in shoulder and elbow movement, she had no pain in the shoulder and nil TOP of any shoulder tendons. As the Ax went on the only think that was troubling her was severe pain in the mid-distal arm which was not in the distribution of deltoid referred pain. As a result i was rather stumped and thought it could be something more sinister cause her descriptions made it sound more like specific bone pain. ANYWAY as i turned out it was adhesive capsulitis of the shoulder and the pain was just wierdly referred....
In hindsight I think I was too cuaght up in DX the pts problems rather than just looking at the pt's symptoms and trying to fix them. Just wondering if anyone else has had this problem (ie looking completely baffeled infront of a pt) OR do you do what oprah says and fake it till you make it??
Cheers,
Nicki

Flags

In the outpatient department on rural placement, i had a young patient present with a 9 month history of left wrist pain. She described the pain as a constant throb that occasionally increased suddenly to a sharp stabbing pain (about once a month) which takes 20 min to half hour to settle. As far as she is aware the onset was insidious but does have a history of multiple wrist fractures (ie. 5 on left and 3 on right). Her last set of xrays were 2004. There are no aggrevating factors or easing factors she is aware of.

Objective assessment showed normal ROM with P1 at EROM for wrist flexion and extension. She had pain on resisted supination at EROM but nothing reproduced the symptoms she experienced. She then mentioned her "party trick" which consisted of subluxing her distal radio-ulnar joint - bringing on her sharp pain immediately.

I consulted with the senior physiotherapist and she too agreed that something was not normal. We decided to refer her to see the orthopaedic surgeon for further review (who was conveniently in town that week). We explained the situation to her and she was happy to have further investigations done. We also gave her some tubigrip for extra support and advised she avoided her "party trick". Is there anything else we could have done?

multidisciplinary team

On rural placement, a male patient was referred to physiotherapy from doctors with a history of hip pain following a work accident. On assesment, the physiotehrapist picked up numerous red flags - weight loss >40kg in 5 weeks, vomitting and nausea, insidious onset of pain associated with a cracking noise in the hip. We made the call to send him back to GP for further investigations.

The patient was admitted to ward later during the week. His x-rays from four weeks previous were deemed normal for changes to hip. On review of current xrays, the physiotherapist picked up on a lump on the lung and changes to the pelvic rim. We alerted the doctors ASAP and further investigations concluded that this patient had cancer.

So the doctors had to tell the patient that it was too advanced and there was no possible treatment. It just shows, that as a physiotherapist, we have a role in diagnosing patients and always look at the xrays - you may see something the doctors didnt and never be affraid to voice your opinions.

Aboriginal communication

One of the most challenging things I found whilst on my rural placement in Kalgoorlie was communication with the local Aboriginal people. All the things that we had learnt in second year regarding Aboriginal communication such as lack of direct eye contact, importance of non-verbal cues, simplicity of information etc as well as information regarding their culture such as importance of family and community and response to white authority figures all came to make so much sense on this placement. For those of you about to embark on your rural placement and those likely to come in contact with Aboriginal people, my advice to you is to persist. I found that subjectively on most occasions I had difficulty getting enough information even with much prompting. Patient adherence to exercise and willingness to participate in treatment sessions also seemed an impossible barrier to overcome after my first week, but I hade found that with time, most of my patients would warm to me and be happy to participate. I found that taking a relaxed conversational approach often worked best, and although some patients remained quite shy, most Aboriginal patients proved to be the more memorable characters during my stay in Kalgoorlie. Having a glimpse at the living conditions of some of the Aboriginal communities on the outskirts of town it was no onder that these patients became all too well known to the hospital staff as they repeatedly presented with recurrent chest infections. Along with this, the growing rates of alcoholism and diabetes highlights the need for more focus to be placed on wider education of these communities.

developmental delays

On the ward at kununurra hospital we have a 7 month old girl admitted a month ago due to failure to thrive and severe malnutrition. Since she has been on the ward, her mother went AWOL and she was left in the care of the nurses (please note baby was still being breast fed)

On physiotherapy assessment, her AIMS is terrible, she has a score well below the 5th percentile and is still struggling to stay in prone (keeps rolling onto her back). Were trying to improve her function and get her mother involved in her treatment (ie. different play positions, vestibular input) but shes a severe alcoholic!!!! so where do we go from here.

she is currently nearing discharge but has no where to go. Her mother is unfit, so she may go to her aunt - who has 4 kids of her own of which none are that healthy. What chance has this poor kid got that anyone will follow any form of physio regime.

And the worst part is - she's adorable!!! you cant help but love her and feel so so sorry for her. but there is so little we can do!

Faking it

I have been treating a patient now daily for the last week, who I admit has frustrated me to no end, and is the first one who has really gotten under my skin.

J is a 14 year old girl with a diagnosis of reflex sympathetic dystrophy (another name for complex regional pain synddrome). She was admitted following a 2 week hx of increasing pain, resulting in fainting episodes due to pain for 2 weeks of intense physiotherapy and psychosocial review.

On first seeing J, she reports she is unable to walk without her leg shaking uncontrollably and 'collapsing' frequently. Our walk to the physio department took 20 min (a usual 2-3min walk). Over the following days she proved to be a handful, a really nice kid but attention seeking and completely disrespectful towards me and other medical staff. She would put on "performances" where suddenly she could not walk anymore and would cry and loudly abuse me in front of other staff. Whilst I was well supported by other staff who too knew she could walk normally and was just performing for the crowd I became increasingly frustrated and her undermining, manipulative manners. In addition she was absorbing far too much of mine and other staffs time at the detriment of other patients.

However despite numerous psych consults nothing within her family life, school life etc that would provoke such a performance. Her family is sick of her performances too, as they have observed J doing all the normal things she says she can't when unawares (as I too have) so my question was what do we do as physios, when she can do it all ok but just chooses not to???

My supervisor and I have spent a lengthy time discussing this and her comment was physio isn't going to change her, but it may allow her an opportunity to 'get out of this hole that she has dug". she has dug so deep that how can she just turn around now and do it normally. Because that would make her look stupid and open for ridicule.

She is unaware that we all know that she can do these things normally, because calling her a liar would just make the situation worse. So despite my frustrations (which have been at times very near the surface) we have had to use heaps and heaps of positive reinforcement so she can prove to herself and give her opportunities to do the normal things.

So, start of the week this girl couldn't walk...end of the week "lisa, look how well I can walk!" was her comment to me. I only hope this continues and she doesn't relapse into old habits or I don't know if I can keep up the very enthusiastic feedback!!

Functional retraining: yes or no

H is a 54 yo male presented to my neuro clinic with 6 month history of
R hemi. He used work as a handyman in a hospital and expecting to go back to work after he recovers.I have been focusing on treating his upper limb function.
Treatment consists of mobs, exercises (to facilitate selective movement
of upper limb and hand) and functional skill retraining. He does the exercises well (reaching, hand stereognosis, wt bearing). however, when he comes to functional skills (eg picking up an object from a table, folding up a tower) he becomes frustrated/distressed and he appears to rush as well. As a result, his tone and ataxia really gets worse after the functional retraining. Does that mean that my functional tasks is not appropriate for his stage of recovery? There is Psychological issue here? I would like to retrain his functional skills in each session to maximize the outcome of my treatment, however, the real outcome is that the functional retraining really undoing my previous work.I discussed the issue with my supervisor and he thought my facilitating technique is OK and it could be due to his emotional issue. Anyways, shall I stop the functioal retraining or shall I carry on? Is there any suggestion here?

The Talkative Patient

During my stay in Kalgoorlie, I encountered many interesting characters but none more interesting than a patient (Mr Z) who presented to the outpatient clinic with a 6 week history of low back pain. Mr Z reported that he had initially injured his back whilst serving a ball in volleyball (combined Lx flexion and rotation). He had already been to see his chiropractor for 6 sessions with minimal changes to his pain and finally decided that he would give physiotherapy a try. Upon my first session with him I barely had time to ask him about his pain as he had already come to a specific self diagnosis of his injury which he had found on an internet site. Mr Z began to ramble on and on about why he thought this was what was causing his pain, and was very keen to learn more. I explained to him that it was very difficult to specifically diagnose the cause of low back pain without imaging but began to educate him on the different structures that may have been affected from his initial injury. Mr Z found this very interesting and had found that this education made him feel more secure in knowing what the possible sources of his pain may be. After two treatment sessions his pain had begun to improve but I had noticed that he began to become very analytical of his pain, noting the changes in his pain each day and constantly questioning the manual treatment I was giving him. As I continued to treat him for a few more sessions, I found it hard to keep him on track as it was difficult to cut him off without coming across as rude or disinterested. I have come across quite a few patients similar to this through out this year, I was wondering if any fellow students had used different styles of communication to overcome this?

bacterial menigitis

im currently on a rural placement in far north WA. a 15 year old aboriginal boy form halls creek was transfered to darwin by air med (NT version of RFDS) with an acute case of bacterial meningitis. He was extreemly unwell and not expected to live.

He pulled through and has now been transfered back to our dept to continue neuro rehab following the infection. He is currently walking independantly and his major problems are cognitive, fine motor and sensory defecits. So far Rx has included working with the OT to improve fine motor skills and work on improving proprioception (UL affected greater than lower limb).

The department is working together to improve his function so he is able to return home to halls creek ASAP. This patient shows severe developmental delays (ie. he cant write his name and doesnt know if he is left or right handed). We are currently trying to determine whether these problems were pre or post infection. On consulting with his teachers, It appears that there may have been a degree of developmental delay and substance abuse prior to the infection.

For physiotherapy, this patient is very challenging.He has a very short attention span and rarely engages with the staff. He will walk out a treatment session mid Rx once he is bored. We have tried to make activities more functional and interesting with short sessions as often as possible (yet up here resources are very stretched!!). He is very motivated but fails to succeed and he is getting very frustrated (as are we!!!)

On the weekend he was allowed to return to halls creek for the weekend (with the physio) and return via bus on Monday. It is now tuesday and we have seen no site of him. As they live rurally with no phone, we have to get the aboriginal social workers to go bush and track them down.

SO not only are we dealing with an extreemly rare condition in a young boy who doent want to be in hospital and has decided to go walk about. How do we get maximal results and keep this kid interested so he can improve?????

Paediatric placement stirs the heart strings

I've been really touched by the patients I've seen this last week at PMH. I'm on the oncology ward and dealing with a wide spectrum of cancers and ages and good/bad prognosis. Almost every kid has brought a tear to my eye, but their strength of character is amazing during these difficult times and has a direct relationship with the attitude of family and doctors and all support staff.

Of course there are hard times but when I see kids who have to be in isolation for a month following stem cell transplant and are limited to a 5mx5m area I just don't know how they cope...

Its also great to see the kid who has been really unwell all week and sleeping most of it, finally smile as he starts to get over the chemotherapy.

It has really brought to light the psychosocial aspect of treatment, and each week a team of ~15 staff from every health field meet to talk only about the psychosocial care of these kids. The medical team are amazing and every aspect of their care is well thought out and discussed as a team... here's a great example of a medical/alloed health team.

patient with dimentia

In my rural prac, i had a patient who needs transfer assessment for discharge. She has early stage dimentia. She is 1xminimum assistant supine to SOEB.I thought that a bed rail will be benefitial for her transfer at home sinceshe lives alone. However, she refused it and stated that she can 'grabeon something' to sit up on the edge of bed at home like a walking frame.I told her that it is not safe and she said 'I will grabe on something else'. I told her that (according to her son) she has nothing at hometo help with bed transfer. Then she said she will grabe her frame. I I dont think I am going to win this case because she will just simply goon and on around the circle with me.Anysuggestion here?

To walk or not to walk...

One of the hardest things I’ve found on my Cardio prac so far is finding the balance between leaving patients alone, and trying to help them. I understand the importance of rest for these patients, some of whom are quite unwell, as well as the benefits of getting them up and moving to prevent further complications. Many patients, especially those of the older generation have the belief that as they are unwell they should stay in bed. In the last week I have spent most of my time chatting to these patients and ‘coming back later’ to check if they are ready yet to go for a walk. It works at the moment, but I realise as a new graduate and beyond, I will not have the luxury of that much time. The best way I’ve found to get around this problem is to compromise with a shorter treatment time. It also seems to be a lot easier once you have built up rapport with the patient (I had a win on Friday with a patient who previously wasn’t keen to ambulate!). If anyone has any other suggestions I would be most grateful.

How Embarrassment!

This is a story of an event which just so happened to occur today. My student partner and I were to ambulate an 80 y.o. man via zimmer frame, 2 days post op after an anterior resection of his bowel. As this was both our first cardio prac and we had minimal experience ambulating patients with multiple attachments, this proved more difficult than first thought. After taking time to plan our treatment area and positioning for each of the attachments (IDC, epidural, hemivac, nasogastric tube, nasal prongs) we began assisting our patient with ambulation. After a few meters he had began to speed up so we asked him to slow down, but by this stage he was now complaining that his attachments were beginning to pull. As he was unsteady on his feet, my partner and I found it difficult to both move the stand and portable oxygen, whilst guarding the patient at the same time. We decided to turn around and return him to bed but upon return his nasogastric tube had become loose and became removed as he leant forward on his zimmer frame. Despite having an understandably grumpy patient on our hands, we then had to inform the nurse, and as expected this did not go down well at all. This was a lesson learnt the hard way that we will never forget. Moral of the story, always carry tape and safety pins with you on a surgical ward! You will need these to pin the various attachments to the patient’s gown.

Developmental Delay?

There are many paediatric community settings in Singapore, most of these are accellerated learning programs. Its interesting though that even though the child is not delayed in any sense, the parents would send their child for 'extra practice' so their child would out shine the rest. These programs are so intense ranging from 2yr old to 16yrs old, I find my self incompetent at year 9 maths, because it was acturally calculus!

So this leads me to the question, what is cognitive developmental delay? If the expectations are so high on every child, the poor soul would get a scholding if he/she was unable to perform algebra at 12. This is the norm for a singaporean child. Incredibly scary, but these children are incredibly smart. So what if the child doesn't meet the norm? Well, they are classified as 'developmentally delayed'. The fact that they start to learn what we learnt at yr 1 when they're 2yrs old, it's not that hard for them to perform complicated equations at 12 or 13 etc. In this case, the children who are really developmentally delayed ( western classification) are handicapped and the ones that are slow to learn(but really a normal child who's just better in certain areas than others) are delvelopmentally delayed. I feel so sorry for these children, because I don't think they know what is 'play' or 'fun'.

upset patients

Hey guys, I think I missed last week I can't find a fourth post so here is another one.

Do you remember that OSPE we had for Penny's class where the patient was an actor and had a breakdown in the middle of treatment. I think that was a good assignment because it made you think way back in second year that the patients are actually people and can do unexpected things- a very valuable lesson as it turns out.

This last week I have had 2 patients (both I had been seeing reguarly for shoulder pain) cry during treatment sessions about things completely unrelated to physio or their injury. I have to say although that exam in 2nd year terrified me the situation didn't throw me at all in real life.

With both patients I chatted to them about what they were crying about, applied a heat pack for a while and gave them a gentle ST release (indicated through previus Ax in both cases). In terms of progressing their treatment all I did was to check their HEP exs and encouraged gentle stretching of UT and Cx mobility exs to ease tension.

In both cases my supervisor was perfectly happy. He agreed it would have been inapprpriate to push them further under the circumstances (both patients had pretty substantial things to be crying about by anyone's standards). I was comforatable I had made the right decision because having seen both patients for a while I had built up rapport with them. However I was concerned that since my supervisor didn't know the patients he might not have been happy with me doing so little hands on treatment. So I was pleased he agreed with my line of treatment.

Chronic pain patient

Wow these patients seem to be following me from prac to prac. This particular chronic pain patient is 2 years post MVA and had recieved a full year of passive PT (mobs and ST massage) and chiropractis treatment at the expense of the insurance company- this improved her pain and dizziness markedly. She then came to the hospital I was at and the previous student did a further 5/52 of passive Rx which also improved her pain.

I then came along- luckily on that day accompanied by my CCT who advised me to go completely hands off. At the end of the first Rx session where I gave her deep neck flexor exs, postural correction, mobility exs, stretching and heat application as well as education ++++ she turned to me and said so no physio today then? Clearly the message hadn't got through. I then explained that PT= exercises not just passive treatment. She was most unhappy with this and I thought she might DNA after that.

She didn't, she kept coming back which was great, but every Rx session reported incraeased pain (usually 10/10 or more) dizziness, nausea etc. Now I know that passive treatments are not the answer for these patients and I have done exercise programmes instead for heaps of patients but it gets so much harder when someone else has already given them the passive treatment, and even worse when it has worked.I think if I hadn't had my CCT pushing me to stick to my Rx choice I would have given in and at least tried both. I suppose both might work too with some patients but the student before had given the patient one HEP exs an UT stretch and she couldn't even remember that- she was just so fixated on the hands on treatment she couldnt even combine it with active exs and my CCT thought it was best to just leave passive treatment for a period of time.

Physio Meetings

Hi all,

Last week I attended a meeting with my supervisor for Paediatric Development Physios in WA. They have this meeting once every two months, and quite often they develop tools and assessment forms for the common conditions that they see. It was really interesting to see how a group of physios interact in a meeting situation. At this particular meeting, they were asked to develop a list of the common conditions they see and the assessment and treatment tools they use so they could pass this information on to people who refer kids to them (eg community health nurses). What was interesting is that even though they all worked in the same area, the variety of kids they saw was quite amazing. Some would only accept kids under a certain age, and some would see more of one type than another. It really showed me how diverse a particular area can be, as well as when you are a physio, you do have some choice of who you want to see in some situations. It is also really good to see that even though there is diversity, there is also unity between physios, and that when people work as a team, they can provide incredibly useful information. This group of physios was also a kind of support network, which is really good, because in this area, you are mainly working in a facility where there are only 1 or 2 physios, so having a support network would be really beneficial.

Business vs Healthcare

For all of you out there who have heard the different levels of medial treatment that different classes of people receive in hospitals in Singapore well, here it goes. Class C- no air conditioning and patient pays for all costs including blueys :. these patients bring everything and they share a room with 8 people. Class B2 has no air conditioning, where as Class B1 has but patient still pays for everything, 4-6 people share 1 room depending on your luck. Class A has 2 beds per room, some items are government subsidised. Class A1 which are presidential suites and the best rooms that hospitals provide is ~45 square metres with huge plasma, dining room, ensuite, bar and views overlooking the ocean.

In terms of Physiotherapy treatment...as the patients needs to pay for everything, physios don't really have a part for the C and B2 classes because most patients don't want to waste money to see a physio! These wards are run by junior doctors with a registra over looking . As we move up the ranks to A class, these patients are looked after by only consultants and these patients are extremely demanding. Some patients will request that the physio to come on sunday or after dinner because it suites their timetable.

In terms of the treatment provided, the consultant's knowledge and experience will definately be more superior than that of junior doctors. The fact that most Class A or A1 patients are referred by the doctor for physio when they don't need it, yet some of the C class patients will really benefit from our treatment but is unable to afford it really frustrates me. I queried the staff in the hospital and they all say that it's just the way it is. If they don't provide top quality treatment for the upper class, they'll make a loss, and if they provide too much for the lower class, the hospital will also make a loss. What a sad medical system when there are more than 30 hospitals in such a small country with 85 % being private hospitals...is this business or healthcare?

Exercise and Pregnancy

I amazed at the number of ladies I've seen over the past 4 weeks who seem to have decided that its just too hard to exercise anymore once their bump gets a little too big. There is a strong correlation (observed by me) between ladies who have difficulties (pubic symphysis pain, SIJ pain, leg pain) through their pregnancy and don't exercise.

Maybe its because they're having difficulties that they don't exercise (I don't know), or that they were never one to exercise in the first place. But having observed a birth, I can fully appreciate now the amount of energy required to get through the experience and the fitter you are the better. Speaking to all the ladies who have had 'dream' labours - quick, and with nil complications were all very active right up until labour first began...

Let it be a lesson to all us females, and to males: don't let your partner get away with being too lazy during the pregnancy!!

Expectations

Hi all,

This week with my Clinical Tutor I was seeing a 13 month old boy who was referred because he wasn't sitting much independently and wasn't yet 4 pt crawling. He also had been diagnosed with a seizure disorder approx 6 months before, and is on medication for it. I (and my tutor) were expecting to see a kid who was not really moving much, possibly low tone. However, this was absolutely not the case. The child we saw was very active, he was 4 pt crawling (the referral was a month old, and in that month he had started 4 pt crawling). He went exploring all over the room, and quickly moved his attention from one thing to the next. Both my tutor and I were astounded at the difference between what we expected and what we saw. What I learnt from this is that even with a detailed referral, you cannot predict what a child or any other pt will be like. Sure, it's good to have an idea of what could be wrong with the pt in order to direct your attention to certain features that could affect assessment and treatment, but it is really important to keep an open mind and expect the unexpected!

Proven: ultrasound works...I saw it!

Not wanting to undermine the research or make you believe that I never thought ultrsaound worked as we listened to our EPA 252 lectures, rather, I just hadn't realised the scope of its use.

For the first time last week I ultrasounded a ladies haemmarhoids that had developed as a result of labour. The patient had tried everything under the sun to manage them, but it was only on a friends advice that she decided to try ultrasound treatment.

The result was remarkable. The gel is quite soothing to the skin, but to my amazement the haemmarhoids softened and literally shrivelled with 10 minutes of treatment to 1/2 to 2/3 of their original size. The results were maintained overnight and on treatment the next day we managed to shrink them again.

Yes, Danielle, I am now a believer, it works!

organised swelling

This is just a note of something a physio on my prac called me in to see on one of his patients because he felt it was of particular interest. The patient was a 78 year old lady post fractured shaft of humerus. She had been immobilised for a six week period finishing 3 weeks prior to my seeing her and had not been referred for physio so had literally just sat with her arm in a collar and cuff for that time. When I saw her she had this huge collection of tissue around her distal humerus, elbow and proximal forearm. She had a significant biceps contracture with 20 degree lack in active and passive extension. I was just amazed at this extra tissue, it wasn't soft and fluid like regular extra articular swelling but it was palpable in the axtra-articular tissue. It was hard but not quite as hard as bone and since the patient has no pain on palpation you could sink quite firmly into it and differentiate it from the neighbouring bones. The fracture site was more proximal but the swelling had just tracked distally and acumulated and organised into this fibrous lump in places protruding up to 4cm from where the skin should have been. The wrist and hand luckily had been spared as the arm was immobilised in elbow flexion with the hand sitting near the contralateral shoulder. The management the physio had undertaken was massage, ultrasound and active extension. The physio felt that over the last 3 weeks this had been successful with a slight softening of areas of the tissue and an increase in elbow extension range. He was however doubtfull that full recovery would be possible. Interesting to see I thought although quite dissapointing that it had occured given that it could have been prevented, or at least decreased, you would think by proper swelling management and movement within restriction during the 6 weeks.

Communication

Working in a paediactric setting in Singapore was very interesting especially in terms of communication. Communication with children of all ages was difficult enough, but in a couple of different languages was even more challenging. Even though most people here speaks english, but it's on all different levels. The hospital I'm working in is a public hospital :. the patients are of a mid-low social-economic background. Their languages range from English, Malay, Mandarin, Hokkien and other dialects but patients usually speaks a mixture of all of the above...and I just get so confused. My tactic was to read body language. I had a 7 yr old boy who presented with spastic diplegia came to clinic and the first question was ' when will it finish?'. About 5 minutes into therapy, I was thinking of all sorts of different ways to motivate the kid to walk up stairs...it was really energy consuming.

Parents and paeds

Hi all,

I'm on my paediatrics prac at the moment. A lot of the stuff that I'm seeing is developmental problems such as delayed development. Something that is different about doing paeds is that the involvement of the parents is very important. I know that it sounds obvious, but without the parent's help and motivation, the outcome will not be the optimal outcome. For example, I saw a 4yr old for the 2nd time this week, and one of his problems was decreased ball skills. When I first saw him, his mum watched what he was doing throughout the treatment session (where one of the things we were working on was ball skills), and at the end of the session my supervisor asked them to practice some throwing and catching at home. The 2nd time I saw him, his ball skills (particularly in catching) had improved dramatically. It was really good to see such an improvement, just in one week. It really did show the importance of the parent, as well as the importance of the parent's paying a bit of attention during the treatment session, which we can do by getting them involved in the treatment session.

Paediatric experience.

Hi everyone, recently I've just started a placement in Singapore in paediatrics. My patients range from neonates to 16 yr olds with a wide variety of conditions such as CP, TEV, DDH, scoliosis, fragile-x, SB etc musculoskeletal issues. The health care system here is very different, each physio only has roughly 1/2hr to see each patient regardless if it's a neuro or ms or cardio problem, they have long working hours 8-5:30 everyday and after hours care. They cram in patients whenever they have the time, very much like a private practice except a whole lot bigger. What striked me the most was the fact that there are a huge population of disabled children in singapore, and a large percentage of these children all attend therapy with a maid ( common for every house hold) instead of there parents. So far in my third day i've only seen 1 child accompanied my her family, but the father refuses to come into the treatment room. I'm not sure whether the parents are traumatised because of there child's condition and that's why they don't want to attend or that they can not be bothered? The child needs a warm and supportive environment especially at this age, is the maid sufficient?

the over zealous pt

I have decided that even worse than the non-compliant pt is the over zealous pt! I have a patient at the moment who is only 4 / 52 post major joint replacement and has decided he no longer needs to stick to the surgeons post op precautions. He never reports any pain and thinks he is completely fine. He basically told me on my initial Ax that he feels its time to push on, he wants help to do it properly but if I didn’t help him he would move on with his programme anyway! I have done education +++ I have explained healing times, insurance companies and why you cant drive, the possibility of dislocation etc. He says he understands it but then says things like “you have to understand I am a lot younger and I need a higher level of function for my job so I can’t wait”. I got the feeling he had no respect for me and considered my education irrelevant.

The only thing that has actually helped is I got him in a hydro class and really pushed the strength and high level balance within the limits of his post op orders. By the end of the class he seemed to understand he can still do high level strengthening within the restricted range, he was feeling a little pain and could appreciate that he had worked hard and achieved a fair bit without having to push through the surgeon’s restrictions. It worked quite well too because the water prevented him from taking to much weight through the limb or being at risk of a fall. I felt like I was back in control of the Rx session and he was actually listening to me. I think, I hope, now he will take my advice regarding post-op orders a little more seriously too.

Tummy Time

Hi all,

I'm on my paeds prac at the moment, and I'm seeing lots of babies with torticollis, plagiocephaly and preferential head turn (so that assignment we did last year has come in really handy). From seeing quite a few of these infants, it really does highlight the importance of knowing what "normal" is, but also keeping in mind that "normal" has a huge range. There are so many different factors that might be affecting the infant, that we don't really consider. For example, playing in the prone position (or tummy time) is encouraged ++++++. However, I saw one baby that was incredibly chubby, and reportedly didn't like "tummy time", which wasn't that surprising because it wasn't a really easy position for him to be in because of his chubbiness. So, to encourage tummy time, we suggested that the baby could be held in the prone position by the mother when standing, with one leg up on a chair and the baby resting on the leg (because he was heavy). It really highlights that we need to look at the overall picture when we are assessing, because something that we might not have learnt about or expect may be affecting the patient, and we need to be able to give treatment that will actually help fix the problem, and consider that there are random things that will hinder the treatment, and we need to work around it, and not just give a prescribed treatment for every patient that we see who has the same problem.

Physiotherapists (or just actors?)

I've just begun my women's health prac and have realised how invaluable our body language/non verbal skills can be, especially when trying to teach a new mum about pelvic floor exercises when English is not her first language. The hospital has a good resource file of pamphlets in languages other than English, but despite reading these pamphlets most mums look at me blankly afterwards.

I've thoroughly enjoyed miming and using my hands to teach these ladies pelvic floor exercises, as have the nursing and medical staff who walk past the room and seen my performance too!

Central Key Point

Whilst on neuro prac, one of my patients, who presented with a stoke had a complicating kyphosis, which meant that her ‘normal’ O2 sats were around 86%, it was also hard to correct her postural alignment, as ‘normal’ for her was obviously different to true ‘normal’. One technique we learned during the prac was central key point - a facilitation technique to enhance posture. We tried this technique on our patient to see if we could change the posture, or if it were fixed. After a few days, with two sessions a day we thought a noticeable change in posture was evident; however we were looking for it and decided an objective measure would be in order. The patient also reported a decrease in breathlessness. After checking her O2 sats again we came up with a reading of 96%!!! We were unable to believe it, however sure enough, after several readings it was clarified that her sats had were at a raised level. We couldn’t be certain that it was only to do with the central key point, however we believe it did have at least something to do with it. Which just goes to show that there is a cross over in all areas of physio!

This technique also proved to be very useful for most stoke patients in enhancing posture (forward and contralaterally), it is a fantastic technique which i highly recommend for use across the spectrum.

Patient Outings

A patient I have been treating throughout my prac. requested a day visit on the weekend to a family members home. She was able to transfer sit to stand independently, however still required help for step around transfers (2 x min assist in physio – due to weakness of left LL). She gave us a weeks notice, and after chatting to our supervisor we decided that given medical clearance and her family being able to transfer her, she would be able to go. We arranged a wheelchair and a bed pan with OT, as well as a time with the family to teach chair to car transfers.

We thought that a slide board transfer was the best and safest way to go, and easiest for family members; however on seeing the car, and the massive gap between chair and car seat, had to change to a step around transfer. After demonstrating the technique to our patient’s daughter, and having her practice on us, she tried to transfer her mother. The technique worked transferring to the car, however coming out of the car the transfer was towards the hemiplegic side. A three person transfer was then required – as one person had to hold the unsteady wheelchair and one to place the foot. The daughter was unable to bend her knees to complete the transfer, so risked injuring herself and the whole thing just didn’t look quite right.

After a chat with the supervisor we decided the transfer just wasn’t safe enough, and recommended a wheelchair taxi. Understandably the family was very disappointed as they felt that it was safe, so we requested they came in again the next day for the senior physio to assess the transfer. The next day the family said after some thought they agreed with us and had booked the taxi… however unbeknownst to us a bed had become available at another rehab hospital, and our patient was to be transferred there that afternoon. The other hospital then said that she would most probably not be able to go on day leave… and it just goes to show the best laid plans…

So advise for similar situations would be to go with an instinct feeling, and not get caught up in family emotion, at least we knew that there weren’t going to be two patients coming back to hospital, not just one!

Physio on a ward

My first true ward experience has been on a neuro ward, and I must say it’s adds a whole new dimension to the word challenging. It’s not only your’s and your patient’s timetable you have to work around, but all the medical and other AH staff as well. One particular day comes to mind as particularly ‘dynamic’. After arranging our day in the morning, around patients appointments, each other’s timetables (as we worked in pairs for some patients), as well as clearing times with nursing staff, it seemed that none of our plans were going to work out. Even after helping nursing staff to get our patients ready, we were all running behind, and eventually were unable to see many of our patients that morning. The afternoon seemed to run a little smoother, except when I got to one of my patients who had been up and took a few steps in her room (but still remained a hoist transfer on the ward) the day before. I started to assess her more formally – including going through the Stroke Assessment form, and realized she had deteriorated quite a lot. Before I was able to test ‘muscle strength’ her nurse came in and asked if she could be taken to the toilet. I did not want to get the patient up again before doing some sort of muscle and voluntary control assessment, and so proceeded to do this. The nurse came in again two minutes later and told me that it was rather urgent that the patient went to the toilet, and told me to walk her. Eventually I did get the patient up (with 2 by min assistance), however found her gait was VERY slow. It took us 15 mins to walk about a meter. Eventually another nurse came in to help us, but left shortly after stating she would be back soon.

To cut a long story short, the other physio student helping me had to go, and I was left with the patient to take her and stay with her in the toilet, and get her back to bed again. It was an awkward situation, one which I believe I was unable to effectively do on my own – or even with the help of another physio student. By the time I got her back to bed, my session was over and the patient missed out on effective treatment for the whole day. The next day, the same nurse came in at the beginning of my session again and requested I do the same thing – despite me having written her as a definite hoist transfer on the ward. This time I asked for her help, however she said I only needed two people (myself and the other physio student), so I merely asked her to watch while I demonstrated the patients complete inability to carry out the task. She then requested that we hoist the patient to the commode and take her to the toilet. I did not know how to use it, nor feel safe operating it, so she said she’d show us and leave us to it….

To cut an even longer story short, the nurse helped us to carry out the hoist transfer and stayed with the patient this time, however begrudgingly. Soon after I informed my supervisor as it was more than a one off occurrence, and my patient was missing out on treatment time due to the situation. My question: Is it right to say no when a nurse asks you to toilet a patient in the above outlined situation?

Patient Compliance

In the clinic I am in at the moment, I had one lady with post muscle tear and fracture of the shoulder who is 2 months down the track in terms of rehabilitation, but her active range was shocking on examination. When I asked her if it was possible to take her shirt off so I could palpate the area and the effected mm groups while she moves and access her shoulder passively, she replied 'if I have to take my clothes off, I'm never going to come in again'. This lady was also refered by the doctors to begin hydrotherapy. I couldn't imagine anything worse for this lady, if she was so uncomfortable removing her top, let alone wearing bathers in a group of 8 others. This lady self discharged herself when really she was not appropriate for discharge. I wanted to give this lady a call to convince her that she really needed physiotherapy but I'm not sure whether it's appropriate or not. Any suggestions?

Disclosure?

On my neuro prac I treated a man from day one post stoke who presented with comparatively very mild symptoms. That is mild weakness in the LL and UL on one side, slight sensation loss LL > UL in that side, and once the doctors deemed him medically stable, mild gait deviations. He asked me on a number of occasions if people were as bad as him, if they had as many problems as he did. I tried to assure him that he was getting better each day, and just how good his strength was (within a few days, L = R). However I’m not sure he actually believed me, as ‘better’ is a relative term. I realized that I couldn’t say just how dependent my other patients were, nor how good he was in comparison. I was wondering if anyone had come across a similar situation, in which you just want to say: ‘You’re actually really, really good compared to most other patients!’

In the end I was able to take my patient to the gym, and other much more dependent, non ambulant patients happened to be in the gym at the same time. I think he got the message, and then said to me just how lucky he was.