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?