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The patient that AJ and I discussed today is a bit of a unique situation. He is roughly 4 visits away from his hard medicare cap due to a THA in February. His wife is telling me one thing (that he still has pain/limitations following the THA as well as him having some mild cognitive decline), however when the wife isn’t there, he’s telling me that he does not want to be in therapy because he denies any pain/limitations. He states that he is doing his exercises every day, however when he demonstrated them to me, he performed them extremely quickly and is unable/unwilling to perform them slower and with correct technique stating that “its harder that way”. AJ and I were discussing possible methods for getting this patient to recognize his limitations and “connect the dots” between proper exercise technique and improvements in condition. One method we discussed was presenting him with the status quo, i.e. “you’ve been doing these exercises for months now and are still having trouble” and presenting him with an alternative: “what if we tried them this way to see if there was any change in your symptoms?” I think that this is going to be a hard sell to this patient while he is denying limitations due to his hip symptoms.
I think what I took out of this article (and today’s discussion with AJ) is that I need to have a more in-depth conversation with this patient regarding his limitations, expectations of exercise, opinions about how exercise relates to his condition/sx and his perception of limitations as they relate to functional goals. I also think asking him questions like “why don’t you do the exercises like this?”, “why do you think they are harder to do this way?”, etc. might help him realize the relevance of performing them correctly. I think once he and I have a better understanding between the two of us of what he would like to get (or not get) out of our time together, I will be better able to develop an appropriate plan of care for him.
I agree in thinking this study is applicable to the US, and specifically my patient population here in Woodstock. We have a large population of older individuals with LBP and chronic pain that is often managed with opioids. I thought their concern about the prescription of opioids as conservative management and the potential side effects is something we need to be very aware of as physical therapists. AJ had me read an interesting article on patterns and predictors of persistent opioid use following TKA/THA (attached), that I also think is relevant when considering those with chronic pain conditions. I think the sooner we see these people, whether it be those with LBP or knee/hip OA, the sooner we can start to positively influence these people’s pain and function without the use of potentially dangerous and harmful medications (or surgery). I also think it is part of our responsibility as PTs to advocate for our profession and our role in conservative management of those with chronic pain conditions prior to potential surgical intervention. This study found that those who participated in the recommended levels of physical activity had lower ODI and pain scores than those who didn’t, which is something that our patients need to be aware of and something we can use as an educational “nugget” during our treatment.
I agree with Sarah about the emphasis on patient-centered care, patient education and empowerment. I like the emphasis in this article on increasing patients’ self-efficacy in order to promote and develop a successful treatment plan. I definitely believe that the more involved a patient is in their care and the problem-solving related to their pain and function, the more adherent and invested they are in their care.
One of the most profound points of this article to me was the point about reflection on practice, especially so soon after reading the SCRIPT-tool article. This is one of the things I desired most out of a residency and one of the things I am most looking forward to gaining through mentorship. As a new grad, I feel that there is so much to learn in the area of self-reflection and it’s role in critical thinking. I want to be able to apply knowledge from previous patient reflection into my future care, and for it to become second-nature in my practice.
Justin, I also really liked their description of utilizing the reasoning form to “show their math”, I feel that so often I may (or may not) do something in an evaluation for a specific reason, and unless it is explicitly stated, that reasoning may go unnoticed or overlooked. I think it is an excellent way to facilitate thought and discussion between us and our mentors. I also agree with your point about utilizing these discussions with our mentors to articulate our decisions, I think it forces me to be concise and make a decision, which I find myself having trouble with when presented with more challenging patient cases.
Tyler, I agree about the organization factor of VOMPTI’s CRF. I have used it several times with more challenging patients and I am always glad to have put all of my exam findings and thoughts down in one place. Every time I use it, I find myself thinking about what I “could’ve/would’ve/should’ve” done or asked in my initial evaluation. I find this exceptionally useful when planning my follow up treatments, it helps me prioritize what I want to assess in order to clear up any remaining questions or unclear areas, but also helps me plan what I would like to re-assess as my asterisks. I also think the PICO portion helps me gather my thoughts in order to focus on what interventions and impairments I really would like to address with my treatments and the literature pertaining to it.
While I agree that it is not feasible to assume 90-minute evaluations are always an option, I definitely do see the merit of taking several breaks with a mentor throughout the evaluation to discuss findings. Throughout my clinical rotations in PT school, I have seen several evaluation techniques, and by far my favorite is the technique that I have utilized with my VOMPTI resident CI’s. Discussing differential diagnoses prior to the subjective, taking a break after the subjective exam in order to re-order/add/eliminate differentials and plan the objective exam, then taking another break after the objective exam to discuss findings was the most successful way for me to organize my thoughts and stay on track. So, yes, while it is time-consuming and takes away from immediate patient care, I think the benefits of taking time to analyze and synthesize the information gathered in the initial evaluation in real-time is essential for development of clinical reasoning.
Katie, this case is definitely a tough one, but it sounds like you are already doing some great things.
1. I have not treated any patients myself with CRPS, however during the last week in my last clinical rotation (SNF) we had a patient put on our schedule that we didn’t normally see s/p ankle fx 2/2 fall who I was very concerned had developed/was developing CRPS. She had severe sensitivity to me taking her sock off to inspect the area, she had redness from the toes to the mid-tibia, lack of hair in the same distribution, as well a shiny and tight skin appearance from toes to just proximal to the ankle. I alerted the nurse to the appearance and my concerns, however I never got to follow up on the patient since I never had them on my schedule after that.
2. I have had limited parent+patient interactions and even more limited experience with emotional patients specifically during evaluations. But similarly to what August mentioned, I think body language is important and making sure the patient knows that they’re being listened to. At that point, I think building a positive relationship with the patient can be just as important if not more so than the objective data that can be collected at the next follow-up.
3. I think in this case I would want to keep an open line of communication with the PCP/referring doctor. I would want the patient to know that we are all on the same healthcare team and are all playing our part to help her get better. I don’t think its something I would initiate first day, but something I would want to do within the first couple of treatments.
As stated previously, I don’t have any personal experiences treating patients with CRPS, but I wonder about treating them similarly to a peds patient with tactile defensiveness? Maybe utilizing something like shaving cream to get her touching her limb and introducing gradual tactile stimulation (similar to what Michelle mentioned above?