Help with this patient please!!! - Ankle #

Hi,
I am a 3rd year physio student on a clinical placement that involves outpatients. I am really struggling with the whole outpatients concept, I just feel like I have no idea what I am doing/where to start with each patient that I see!

I have one patient that I want to get some advice on in particular. They broke their distal fibula (can't remember how long ago) and are in a camwalker which they can remove this week. I have seen them twice already, two weeks ago I did some plantar fascia massage because they were complaining of pain and it was very tight, and last week I did some ankle mobilisations and did some gait retraining in the parallel bars (had previously been using one crutch so wanted to practice walking with nothing).

They have reduced dorsiflexion and plantarflexion range but not too bad, strength is not too bad either. With my next session with this patient, what should I mainly be focusing on in the 30 min outpatient session?? Any help would be much appreciated.

(If anyone could also point me in the direction of books or websites that could help me with outpatients in general I would be very grateful, as I'm at the point of having extreme anxiety at the thought of having to go each day :( )

Hi Kayelle...

ok... breathe... third year means you're not expected to know how to handle it all! Do you have a good rapport with your supervisor?? They would be the best person to approach about how you're coping. It's guaranteed that you're not the first student who's not sure on how to tackle the OPD, but your supervisor can help you with direction for patients, where to find information, and adapt your workload to suit... you need to be able to take on enough clients to get a feel for things but not so many that your brain explodes and you don't end up learning anything.

When in doubt... go back to basics. Know your anatomy (this is one of my soapboxes when I supervise students)... if you know what bits are where, and what they're meant to do, then you can figure out what isn't happening and how to perhaps start things doing what they're meant to!

Also think FUNCTIONAL... clients/patients are WAY more likely to be compliant with your programs if it's relevant to them and they can see/understand why they're doing something. if you can't justify what you want to do (either manual treatment or exercise plan) to the patient in a way they can understand... then have you chosen the right thing?? try selecting only 1 or 2 really functional exercises for the client to do that you can measure each week and they can feel/see results.

As far as information/treatment ideas goes, i'm not going to do your homework for you... make sure you know your anatomy, and what should be normal (joint mov't, gait, weightbearing, proprioception etc) and start there.... and do talk to your supervisor - you'll be looked upon far more favourably if you can recognise when you need guidance (but not spoon-feeding) and seek it appropriately.... we all do this still and it's a healthy reflection of practice.

Don't panic!

msk101

Hi Kayelle,

Msk101 gave you a great response. It is easy to feel overwhelmed with your placements in third year, particularly if they are some of your first 'real' experiences as a fledgling physio.

The first step in dealing with a situation you aren't all that comfortable in is to not panic. Not only will it make your thinking all jumbled, but it is relayed to the patient as well.

Once you have your senses back, you just need to stop and think -- which can be very tiring on placement because these things don't come naturally yet.

As a student you tend to get hung up on the diagnosis and forget about the patient a bit. Here are some steps that make it a little easier until you experience a bit more, and start to feel more comfortable in your placement.

1. What is the diagnosis? We know that the patient has had a lateral malleolus fracture, what we need to take into consideration is what stage of bony healing the fracture is at. Dig up some physiology notes and see what's happening when. Obviously use mobisations with regard to the stage of healing. Otherwise be aware of basic fracture management.

2. What are the patient's main problems? Asterisk signs and patient reports tell you what you need to work on, not diagnosis, really. If your patient wants to walk without an aid, painfree and without a limp -- do a gait analysis.

Look at what's not right, and use your knowledge of anatomy to figure out what you need to do to help them target it.

3.) Based on your asterisk findings, choose a treatment technique to try to improve that finding. If a joint is stiff, try mobs. If it's soft tissue tightness, try DTM or PNF work. If their limp is a residual thing from habit, re-educate using part-practice.

4.) Reassess your findings. See whether your intervention has helped. If not, try something else. It's a good way to learn what works.

Tips:
- Do a gait Ax: Early on in post ankle # rehab patients are just interested in walking pain free. Identify problems.
- Do a balance Ax: Proprioception -- need I say more. ;)
- Have clear measurements. How reduced is their DF/DF range? What about Inv/Ev? Grade of muscle strength? Remember calf grades are better measured with single leg heel raise. (Usually max no in 30secs, I find useful) Gives you a better idea of how much improvement.
- Hint: Wobbleboard. :D

Good luck. Relax. You know your stuff, just don't get overwhelmed. :D

Thank you both for the replies...

Musc isn't my strongest area and I'm finding it quite overwhelming. I'm a sufferer of anxiety anyway and I guess being in this situation has taken me right out of my comfort zone! I appreciate your guidance and will take it on board.

Thanks :)

hi friend
hope you are happy with the replies of some of our great friends.
there is nothing to get panicked
always keep a cool and systematic aproach-stick to basics
interact with patients with sharp ears and detect for information thru non verbal sources
seek help of superiors whenever neeeded

with god's grace you will evolve as a great physio

Best advice i've heard or passed on for people worried about outpatients is to draw up a simple problem list with what you've found eg weakness, lack of ROM etc, including there functional problems and treat what you find - if there's stiffness focus on movement, if there's weakness strengthen and if it's a functional task either practice it or practise components of it( eg walking after a # - get them to do it non or partial weight bearing in a pool and focus on technique

I think the reality is that sometimes looking at patient's you can identify a million problems, and the fact is with today's posture's they are all probably true to some extent. However, focus on getting it right with the paperwork. Use a crib sheet with the key questions to ask, and make it a habit. Of course this cookie cutter approach does not make do in a busy work environment, but it will help develop good habits for when you start doing things alone.

Hi kayelle,

Excellent replies above. If i could add some things?

1. anxiety is usually due to uncertainty. If you don't plan on doing outpatients/MSK in the future, DO NOT do what i am about to say ;) Go and find a physio who is reputable to be their physio assistant. This will let you watch good physios and be around common problems and so ain confidence.

2. I have lots of patients with anxiety. We use NLP with them - Neuro Linguistic Programming. Works a treat. Find a good NLP therapist and invest in yourself!

3. With all patients, your clinical reasoning should ask 6 questions (IMHO)
a. What are the main myofascial probable casues of this patient's problem
b.What are the main articular (joint) probable casues of this patient's problem
c. What are the main neural (including motor control) probable casues of this patient's problem
d. What are the main visceral probable casues of this patient's problem - not even your supervisor is likely to give good answers here!! hahaha - things like scarring of internal organs from operations, tumors, dysfunction, ANS dysfunction etc...
e. What, if any, psychosocial issues that are relevant - what is the patient's story, what give's their pain meaning, what beliefs do they have etc etc etc
f. What are their current coping strategies - they can be mal-adaptive and be perpetuating the problem.

If you keep that line of thinking up now until you retire, you will always be learning - lifetime learning is the only viable option for good physios.

I won't say "don't stress" because you can't think about what NOT to do without think about IT (stress) first !!! ;)

Rather, i want to encourage you by saying "Be cool, calm, confident and relaxed!!!"...

...Just a little snippet of what NLP look at ;)Good luck!!