Ah… stroke rehab. My most recent placement was mostly involving outpatient stroke rehab, and it was a bit of a roller coaster ride. It was in an international setting, and the patients were often 10 months, or even 2 years post stroke. The poor collusion between the physiotherapy department and the doctors there pretty much means that often stroke patients do not get referred for rehab until a long time after their stroke.
For anyone who has done any stroke rehab, you’d know that this can be really frustrating, as the early phase of rehab is so critical to a patient’s outcome. Not only this, but in the time that they are not being rehabbed, they are learning poor patterns of movement, and these are getting reinforced over and over. Its exactly this kind of thing that makes rehab of these patients so challenging, and frustrating.
There were a few patients that myself and the other student were assigned to treat regularly throughout the placement. Some of these patients were quite old, had had quite a delay between their stroke and receiving rehab, and often did not want to get better. Couple those factors with the language barrier and it made for a very interesting and frustrating clinical experience.
There were days when we’d work really really hard with a patient, and get absolutely no results. There were other days when we’d work really hard and we’d get a good result, and the next time the patient comes in for treatment the results are gone and they are back the way they were. One thing that was particularly frustrating was that some patients would only learn context specific activities. What I mean is that, say for example you are trying to retrain a patients gait, and the main problem they have is improper verticality, so naturally we would do a lot of work on the patients verticality in other positions, assuming that this would carry over to their gait. And often patients would really really improve a lot in their ability to do these verticality exercised in other positions, but once we try them in gait, its clear that there has been absolutely no carry over.
However, most of the patients did improve a little bit over the four week period that we treated them, even if the progress was very slow and a lot of hard work. Has anyone else experienced this?
Friday, December 5, 2008
physios who poorly manage
One thing that I’ve seen a few times throughout my placements is poor practice. This can be a very serious thing sometimes, as obviously it can really affect the outcome for the patient. I remember the first experience I had with this was in third year, I had a musculoskeletal outpatients placement and I was watching one of the physios treat a patient with LBP. The ladies problem was so obviously a postural control disorder/ motor control disorder, yet the physio just gave the patient some random upper limb theraband exercises to do at home. It was pretty obvious that she didn’t really know what she was doing, and that she didn’t really care all that much either.
I found it kind of hard to deal with this. After a lot of thinking I realised that it’s the kind of thing that you cant stop as an individual. The only real thing that you can do is just make sure that you yourself are always striving after best practice and trying to make a big difference with the outcome of patients. What other physios do is not something that you can change. If physios want to be slack, and cant be bothered researching a treatment or doing some problem solving, then there’s nothing that can really be done about it (unless you happen to be one of the supervising physio’s- then you can crack the whip pretty hard).
In my experience outside of clinic, I have an injury that I have seen many physios for, with little improvement in my condition. I tried another new physio the other week, and already I have started to improve. After explaining my previous treatments to this physio, he explained to me that poor physiotherapy management is a very very common thing, especially in private practice. He also said that he was nearly fired from his last job for trying to manage patients correctly.
So my experiences have taught me that I should be wary of relying on other physiotherapists, and that I should always strive for best practice for every patient.
I found it kind of hard to deal with this. After a lot of thinking I realised that it’s the kind of thing that you cant stop as an individual. The only real thing that you can do is just make sure that you yourself are always striving after best practice and trying to make a big difference with the outcome of patients. What other physios do is not something that you can change. If physios want to be slack, and cant be bothered researching a treatment or doing some problem solving, then there’s nothing that can really be done about it (unless you happen to be one of the supervising physio’s- then you can crack the whip pretty hard).
In my experience outside of clinic, I have an injury that I have seen many physios for, with little improvement in my condition. I tried another new physio the other week, and already I have started to improve. After explaining my previous treatments to this physio, he explained to me that poor physiotherapy management is a very very common thing, especially in private practice. He also said that he was nearly fired from his last job for trying to manage patients correctly.
So my experiences have taught me that I should be wary of relying on other physiotherapists, and that I should always strive for best practice for every patient.
patients who dont improve
Over the past few placements I’ve noticed that there are several patients that I see in each placement that do not seem to improve in their condition. It can be quite a frustrating and confusing thing to encounter. I think there are a few reasons for this happening.
Firstly, there are patients whose conditions are of the deteriorating type (it’s not really these that I’m talking about though). For example, multiple sclerosis patients tend to steadily decline, as with patients who have motor neuron disease.
Secondly, patient compliance with HEP’s is a very large issue. One lady in particular springs to mind when I think of this. It was on my musculoskeletal outpatients practicum that I treated her, and it was a long-term (like 2 years) injury. The unfortunate thing is that she had a stack of notes the size of gray’s anatomy, and it would’ve taken a long time to go through them. As such, I decided to do a full assessment, and treat her based on my assessment rather than what the last student had done. My treatment basically consisted of shoulder muscle strengthening exercise and scapula retraining, most of which was to be done at home, daily. Unfortunately, the patient had a very set idea about what worked for her (pretty much just massage) and did not comply with the HEP that I gave her. This is probably a reason why she did not improve. And there are several other patients that I have seen with this same problem.
A third reason that patients sometimes do not improve, is that sometimes they just don’t want to get better. I encountered this mainly on my international prac. Over there (Malaysia) the family network is very strong, and younger members of the family really look after the older members. This is good in a way, but not so good in other ways. While its always good to have the support, it can lead to the patient becoming very dependent and even relying solely on the family. Some patients are perfectly happy to be waited on hand and foot by their families and not have to do a thing for themselves, and as a result do not comply with their rehab, and so don’t get better. These are just some the reasons why patients often don’t improve, im sure there are probably more. Does anyone else know of any?
Firstly, there are patients whose conditions are of the deteriorating type (it’s not really these that I’m talking about though). For example, multiple sclerosis patients tend to steadily decline, as with patients who have motor neuron disease.
Secondly, patient compliance with HEP’s is a very large issue. One lady in particular springs to mind when I think of this. It was on my musculoskeletal outpatients practicum that I treated her, and it was a long-term (like 2 years) injury. The unfortunate thing is that she had a stack of notes the size of gray’s anatomy, and it would’ve taken a long time to go through them. As such, I decided to do a full assessment, and treat her based on my assessment rather than what the last student had done. My treatment basically consisted of shoulder muscle strengthening exercise and scapula retraining, most of which was to be done at home, daily. Unfortunately, the patient had a very set idea about what worked for her (pretty much just massage) and did not comply with the HEP that I gave her. This is probably a reason why she did not improve. And there are several other patients that I have seen with this same problem.
A third reason that patients sometimes do not improve, is that sometimes they just don’t want to get better. I encountered this mainly on my international prac. Over there (Malaysia) the family network is very strong, and younger members of the family really look after the older members. This is good in a way, but not so good in other ways. While its always good to have the support, it can lead to the patient becoming very dependent and even relying solely on the family. Some patients are perfectly happy to be waited on hand and foot by their families and not have to do a thing for themselves, and as a result do not comply with their rehab, and so don’t get better. These are just some the reasons why patients often don’t improve, im sure there are probably more. Does anyone else know of any?
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