Treating chronic pain

Hey guys,

On my rural prac at a Community Health Centre (therefore treating a lower socio-economic population) I have come across a lot of chronic pain (predominantly LBP). I have tried to focus on ‘hands off’ Rx and one patient in particular I just worked on relaxation techniques and educating her movement isn’t bad for her pain, etc. Has anyone had any prac’s where they’ve dealt with a lot of chronic pain pts or been taught some really helpful techniques to use with chronic pain pts? Just after some tips on what I could try next time???

Being students...

On my rural prac (mainly musculo outpts) I was assessing and treating pts completely independently (if I needed help or anything I could go and ask) – I was in my own treatment room and would collect my pts from the waiting area and bring them in.

I was under the impression that when the pts book appts they would be told that they were seeing a student… Not the case. A number of times pts (or their wives) would ask, “so how long have u been fully qualified” or words to that effect and I would have to explain to them that I’m not actually fully qualified (but I was on my final prac). I always felt really nervous/awkward telling them that I’m not a ‘real physio’ yet and thought that they probably should have been told before they saw me. It was a government facility so at least they weren’t paying for it I guess…

One weekend is not enough...

As I'm sure you'll all agree, one weekend is not enough to switch from one mode of thinking to another completely different, as we often have had to do this year between pracs. While trying to tie up loose ends at one prac, giving student presentations, completing final assessments and updating stats, it proves almost impossible to find time to prepare for the prac starting the following Monday. Even being given a three day weekend and finishing the previous prac on a Thursday would help somewhat, do you guys think it's worth putting this to the school of Physio? I think it would greatly help with being prepared for the next practical...

Frustrations

I'd like to have a little vent about the general frustrations we as students encounter while on prac. In the last week I have been constantly reminded that we really are at the very BOTTOM of the pecking order on the ward. As our caseload has peaked in our final week, I have found it a constant challenge to get hold of patient notes to read the latest update, let alone to write in them once I've actually seen the patient! It seems such a waste of time wandering aimlessly trying to locate notes which don't seem to be anywhere, yet of course it is necessary to do this before seeing a patient to ensure there are no safety concerns etc which might impact what you do in your treatment session. When finally finding the precious papers, they are nearly always taken off you for one reason or another by any other health professional! I know we are students and they are paid employees but if we are the only physiotherapy intervention the patient is having then surely we have just as much right to the notes as a Speech or Occupational Therapist? This issue makes time management impossible!

oncology

Hello!
I had one of my pracs (elective)at the oncology ward in RPH. During my time there, i treated patients with various diagnoses of cancer, some terminal. I was amazed at how every single patient had the zest , optimism and strength to carry out their exercises and physio willingly, given that they were not limited with fatigue and nausea.

Before coming to this prac, i was expecting it to be a depressing and challenging one as i believed many of them would throw me the question of "what's the use of doing any exercise when i'm going to die anyway". INstead i was uplifted by their determination and strength to be as independent as possible. Most of them were motivated to do the exercises that were prescribed, making my job as their physio just that bit easier!

I think these patients really deserve a pat on the back!

Rural prac

HI everyone

I'm guessing most of us have done our rural prac. I did mine in Geraldton as an inpatient physio.
That time was an invaluable experience as by the end of the placement, we eventually got to run the ward. I managed to see a bit of every area including neuro, musculo inpatients, gerontology, womens health, cardio.

This experience provided me with greater confidence to continue with the rest of my pracs and most recently with my cardio prac as i had to learn to manage the ward on my own. My previous experience just made the task of managing the ward even better than the last time.

Just a not to all those who are on rural prac, make sure u have loads of fun and learn as much as you can. treasure the experience its not that bad being in the country ;>

Supervisors

On a prac in a major teaching hospital you often share the gym as a meeting place with physios and students from numerous wards. One day as I walked into the gym to collect my bag (it was late so most people had gone already) I overheard a supervisor and a CCT discussing a student from another ward. As much as I tried not to listen and grabbed my bag as quick as I could I probably heard some things I shouldn’t have.

I don’t think it was my fault, I was clearly a student and once they saw me walk in ( I couldn’t avoid it, they weren’t in a private area) I think they should have stopped and waited for me to leave. I never said anything to the student or my supervisor (regardless of whether it was positive or negative comments) but I don’t think what they did was very respectful for to the student and I wouldn’t be very impressed if I knew a supervisor was discussing my ability/skills in front of anyone, let alone my peers! What do u guys think?

Parents

Hey guys,

I didn’t get a paeds prac this year but I did encounter some ‘pushy parents’ on my ortho ward. Occasionally on the ward >14 year olds are admitted if the fracture is complicated and needs to be ORIF’d . I had seen a few young guys that had their parents present during Rx and am not bothered by them watching or asking questions etc. This one boy (14yrs from a tiny country town) had both his parents present for both Rx sessions (am and pm) every day he was on the ward. The difficulty arose when it came time to attempt crutches for the first time. The parents really wanted him to use elbow crutches and the kid was terrified (he was WBAT), their biggest argument was that they were easier to get in/out of the car!! I agreed with the parents in that EC’s were the best option but for his first attempt I was happy to allow AC’s. He had only ever mucked around on crutches and they were AC’s and he didn’t think he’d be able to use EC’s. I felt like the parents were bullying him into what was best for them. T o keep everyone happy I let him use AC’s first then later that day after he was confident he progressed to EC’c then D/C the following morning…everyone was happy. Has anyone else had to deal with ‘pushy/ parents’ and how did you handle it? I know my case was pretty minor but got me thinking there must be more exteme cases…

When to draw the line?

Recently I was treating a man on prac who was quite medically unwell. He had responded badly to pain killers / general anaesthesia and was narcotised, disoriented and somewhat delirious. The doctors and surgeons kept stressing to anyone who would listen that the only people who could help him at the moment were the physios - no pressure! My problem was, while attempting to treat this man he was so out of it that he would repeatedly fall asleep midway during an SMI and be difficult to rouse again for several minutes. He remained like this for a couple of days, yet the medical team kept insisting that we see him many times a day for chest clearance. He was in no state to even respond to questioning let alone follow commands and clear his airways. My question is, when is a patient too unwell (or almost unconscious!) to receive beneficial help? Surely they need to be able to actively participate for it to be in their best interest?

Dani

Woopsies

I had a "learning experience" at prac last week (which I forgot to blog, woops!). Steve and I were doing a joint treatment of a guy who needed 'birding'. We took the machine in and began to set it up with the portable oxygen cylinder. We detached the oxygen flow meter from the bottle, with the intention of attaching the bird machine, but before we got that far there was a hurrendously loud squealing/rushing of air as oxygen began to pour from the cylinder. As you can imagine, this was fairly comical in hindsight, but at the time we both packed ourselves! Clearly we had overlooked the small matter of turning off the cylinder valve before taking off the flow meter - OOPS! This was an error that I'm sure only students could make, and I'm sure it is one we will never make again! What I learnt from this scenario? MAKE SURE YOU KNOW HOW TO USE THE EQUIPMENT BEFORE YOU ENTER THE TREATMENT SESSION! This will save a lot of embarrassment and looking stupid in front of nursing staff...! Please take this on board :)

hydro

hi again,
this would be my final post and i thougth i would post it earlier since rural prac has provided me with alot of brand new experience to share. I have never run a hydro class before until this prac (despite requesting over and over again in the city) but never had the opportunity to do so. I believe many of you would have tonnes of experience at it and can definitely provide me with strategies to handle hydro classes as well as any land based exercises. My main problem with running these classes is that I tend to get stuck with ideas during these classes and unsure what other exercise to do next even though I did plan earlier and had it all set up in my mind but all these ideas tend to disappear then. I ran my first land based exercise with notes written in a small piece of paper and that got me through alright however I thought this would be inpractical when you are in the water. Just wondering how does everyone do it and I will really appreciate it if any advice/ideas I can have.
Thankyou so much for reading all my posts and all the comments you have given and good luck with PCR

Robin

supervisors

hi all,
hope clinics are going well for everyone. Just wondering if any of you had the same experience during rural placement. I am currently looking after outpatient physio. as well as other inpatient and community physio. My spervisor has his own ways at doing things which sometimes very different to what we have learnt in uni. as well as other pracs. An example which is that he does not agree with the idea of loading disorder and more of an mckenzie and mulligen orientated physio. It is good that I get to learn more techniques from him but in a way it really confuses me and hence completely changing all my approach to treat patients. Apart from this, the different ways of performing tests as well as issues with use of ultrasound. It's quite frustrating when you have performed well in recent musculo. prac and now having to strt all over again in a 'new musculo' prac. I understand it will be perfect to integrate all these knowledge but I think 4 weeks of part time musculo is not enough to do that. So my question is if you are in my position, would you carry on using what you have already learnt from last prac and uni or would you 180 degrees convert yourself to suit the supervisor?

Robin

yellow flag

hi everyone,
just thought I would share this little experience with all of you as I think many of you might have or will definitely come across similar situation like this.
I had a patient who came in with LBP and through subjective and objective examinations, he presented to have L4/5 disc pathology. I began treating him with lots of education, postural correction and local mm fascilitation. In the beginning, having come across similar patients before and I thought this would be pretty straight forward and easy however the patient suddenly became frustrated during the treatment and apparent he has been to physios prior to this episode and has been receiving similar treatments but has not been compliant with HEP prescribed nor advice given. His reason of not being compliant was because of the pain in the muscle spasm of the lower back so I told him to use a heat pack to reduce that spasm and he said he knows the fact that heat pack helps with muscle spasm but has not been using it.
I asked him why and he wasn't sure. The patient apparently is unemployed and is relatively young in his early 30's. I carried on with the treatment giving all the information he would require anyway and gave him new HEP which I doubt that he will be compliant with. new appointment was made and my question is, the only reason he is coming to physio was for the DTM to the mm spasm and obviously will not benefit from physio in the long term. Would any of you discharge him anyway if he continues to be incompliant?
Good luck with mid placement if you haven't had one already!

Malingering versus chronic pain

Hello!

Just thought i would begin the post by defining the terms malingering and chronic pain.

Malingering is a defined as a medical and psychological term that refers to an individual fabricating or exaggerating the symptoms of mental or physical disorders for a variety of motives, including getting financial compensation (often tied to fraud) avoiding work, obtaining drugs, getting lighter criminal sentences, or simply to attract attention or sympathy.

Chronic pain: pain that persists longer than the temporal course of natural healing, associated with a particular type of injury or disease process.

On a recent musculo prac, I encountered a patient, who according to my supervisor had been a patient at the clinic since it started operation several years ago. When i was treating her, she presented with pain in her Cx, Tx and Lx regions, which varied from a week to week basis. I thought back to uni, when we were first introduced to the concept of chronic pain and how real it it is and often how practioners brush it off as malingering.

This particular patient had a long history of treatments from student physios ever since the clinic started. I was not sure what to make of the pain and stiffness she presented with as it seemed to vary from a week to week basis. While testing her AROM, she would often ask what the normal range of motion for that particular movement was. I found this an odd question to ask as i felt she was pretending to get a value that was under the "normal" so that there would be something for us to treat. On a few occassions, i also found that this patient did not have consistent objective findings in that same session for the same AROM.

My question is, has anyone experienced a patient similar to this and how do you tell the difference between malingering and chronic pain? How would you handle a patient like this?

Yes I'm a physio student, No i won't give you free treatment

Hi there

recently on my cardio prac, i was approached by the ward's social worker asking my advice on her c/o knee pain and kindly asking if i could take a look and perhaps suggest some treatment options or provide some treatment. Since i was available during the patient rest time, i obliged and managed to give her some treatment and also some management tips for long term.

The next day, i was approached again for the same treatment as she was so happy that the treatment i gave her worked. This went on for another day or 2 and i had the feeling i was taken for granted as she got to the point where she was "expecting" treatment progressions!

I eventually told my supervisor and he advised me to politely decline as he had a similar experience before and we simply just do not have the time to treat all staff members who ask for a favour. Has anyone been in a similar situation with other staff members or even friends who expect you to give them "free" treatment just because you have the qualifications?? How would you handle a situation like that??

Ward Members

At my recent cardio prac, I had a post op patient with multiple complications resulting in him requiring multiple drips and drains. and i mean multiple! Some of his drains included 2 nephrostomy tubes, an IDC, a colostomy bag, IVC, PICC line, 2 drainage bottles.

When it came time to ambulate the patient, the nursing staff on duty at the time was kind enough to offer her assistance. Because this patient had not gotten out of bed for at least 7 days (plus the fact that he was in loads of pain) , he was quite deconditioned. It took about half an hour to ambulate the patient a mere 5m, and throughout, the nursing staff was kind enough to sacrifice her tea break to help me with the patients drains.

So often, we underestimate the importance of good teamwork and the impact it has on our job. Be it a receptionist, the ward cleaner, or even the PCA's, i feel that it is our duty to acknowledge them as they make going to work every morning, just that bit more pleasant.