During my paediatric placement, I was treating a 1 year old child with diabetes who had spent her whole life in the hospital setting due to other circumstances. The treatment for this girl was carried out in the hydrotherapy pool. I knew that it would be difficult because obviously she could not swim and I had to carry her the whole session. Being a cute 1 year old and being raised in the hospital she had been used to getting her own way with the nurses who essentially had raised her. She did not approve of the exercises, instead wanting to be help close instead of kcking her legs and blowing bubbles. She started pulling at my bathers and crying loudly which was interrupting the other people in the pool.
Because of my lack of experience around young children, my first reaction was to give in and just let her do what she wanted. I did not know if I was allowed to let my patients cry or if she was disrupting other treatment sessions and to let her play quietly. When my supervising physiotherapist took control of the session, she became quiet and did what she was told! She was protesting when we were alone because she knew she could take advantage of the situation and by crying I would let her have her way. By the end of the placement, I was able to reach a compromise and was more assertive when treating the patient.
Trying to persuade patients to do their exercises or to work hard even though they may just want to lie in bed or play in the pool (depending on the patients age) is a problem that faces physiotherapists. Knowing how to motivate and deal with these patients will be a valuable skill. Next time I deal with this type of patient, I will try and be more assertive while still being optimistic and motivated during the treatment session.
Thursday, May 29, 2008
Monday, May 26, 2008
Working with minors
I was recently on an outpatient’s musculoskeletal placement and dealt with new situations each day. I think the case I will describe is quite relevant to all of us, in particular the males. For one of my first initial Ax pts A 15 year old girl came in with a back pain complaint. I had not really seen many new patients to this point and especially not many back pain cases, so I guess you can all relate when I say I already wasn’t feeling the most confident due to a lot of unknowns. I actually walked passed the patient and her mother in the waiting room and heard them speaking. The young patient was saying that she didn’t want a male PT as she didn’t want to take off her shirt in front of a male. On hearing this all kinds of thoughts started going through my head. One of my biggest fears is not been able to gain patients compliance and not been able to build their confidence in me. As well as doing embarrassing things in front of patients which is quite common for me :P. I’m also the sort of person who doesn’t like to put people in uncomfortable situations. On top of this I really wasn’t comfortable with draping techniques due to years of “not bothering” with fellow students who don’t care what we see of each others bodies. So I’m really stressed that I won’t be able to figure out what is wrong with her (which is another story),that I will make her feel uncomfortable, do something really embarrassing or even get myself in trouble for doing something inappropriate (accidentally of course) and having her mum sitting in the room watching and listening to my every move that I made around her young daughter added to the crappy feeling.Anyways one of the great things about 4th year is we have no choice but to put ourselves in situations which we don’t feel comfortable with. So I tried to put on my biggest “good, mature, relaxed, non-Joe physio front” and introduced myself to the patient and her mother. When they saw I was going to be treating this girl they both looked at each other as if to say “oh no a guy”. After intro the first thing I asked was whether the mother would like to join us as she had not stood up as if to suggest she wanted to watch in on the session. Even though personally I’d feel less pressure with out the mother watching I thought it would help decrease the patient’s anxiety.During the subjective examination things went pretty well and I think I built quite good rapport with mother and daughter as well as builing their confidence in me. During the objective exam I had no choice but to ask the patient to remove her top if I was to Ax her effectively. I did this by giving the patient a towel and explaining to her exactly what I wanted her to do and made it really clear that I would not see anything inappropriate, then asked her “are you okay with this?” and then stepped out of the room whilst she disrobed. During Ax I made sure the patient could see my eyes the whole time she was disrobed. Throughout my time working with this patient I had many challenging situations arise including some involving bra straps and another involving teaching pelvic floor exercises to the young patient and her giggling little sister. But I will save these scenarios for later. I guess the point I’m trying to make is as a male it is really important to be very careful how we approach our contact with female patients especially with younger ones, as it is so easy for someone to misinterpret an innocent action or word. This was a really good learning experience for myself, firstly it put me in uncomfortable positions but also added to my clinical exposure in a very important area. After going through this once I think I will feel a lot more comfortable in the future working with teenage girls, not only am I more confident in my ability but also I realized that teenage girls won’t just giggle and act like fools but can also act mature when in a situation like this. Thanks and have a good week ?
Sunday, May 25, 2008
Clinical decision
I am currently completing my gerontology placement at an outpatient day-hospital where most of the patients are at risk of falling or have balance problem. I have started to treat patients under supervision. I found some interesting information to share with you in terms of patients’ cultural background for balance issues.
77 year old Malaysian lady was assessed in the falls clinic. She tells a fall-specialist she remains independent in her activities of daily living. She is living in a two storey home and is a non-drinker and non-smoker. The main problem is a two-year history of gradual decline in balance and gait. This is associated with her complaint of numbness in her bilateral fore foot. It is not associated with history of stroke, TIA or onset of arthritis, or leg weakness. Her performance deteriorates on uneven surface and there is a concern that she is thrown off balance by her small dog which she continues to walk with on a daily basis. Moreover, her gait seemed abnormal. She seemed off balance when initially standing and when turning. However, there was no evidence of tremor or cogwheel rigidity. She reports she does not understand why she needs to come to see physio and she does not feel she has any problem with her balance and gait.
Overall, as far as I am concerned, her balance is not as sever as other patients in my placement. Here is my question in terms of clinical decision whether she can be discharged after first session of physio treatment. Do we need to see her more to prevent further deterioration, even though her level is good enough to be discharged.
77 year old Malaysian lady was assessed in the falls clinic. She tells a fall-specialist she remains independent in her activities of daily living. She is living in a two storey home and is a non-drinker and non-smoker. The main problem is a two-year history of gradual decline in balance and gait. This is associated with her complaint of numbness in her bilateral fore foot. It is not associated with history of stroke, TIA or onset of arthritis, or leg weakness. Her performance deteriorates on uneven surface and there is a concern that she is thrown off balance by her small dog which she continues to walk with on a daily basis. Moreover, her gait seemed abnormal. She seemed off balance when initially standing and when turning. However, there was no evidence of tremor or cogwheel rigidity. She reports she does not understand why she needs to come to see physio and she does not feel she has any problem with her balance and gait.
Overall, as far as I am concerned, her balance is not as sever as other patients in my placement. Here is my question in terms of clinical decision whether she can be discharged after first session of physio treatment. Do we need to see her more to prevent further deterioration, even though her level is good enough to be discharged.
Children Just Don't Understand
I am currently on placement at PMH doing both inpatient and outpatient orthopaedics. Prior to this placement I have also completed an inpatient orthopaedics placement at Hollywood Private Hospital. It has become apparent already that the approach to dealing with a child in pain after an orthopaedic procedure is VASTLY different to that of an adult.
This week I have been treating a young boy who fractured his femur whilst skateboarding in a country town. He was flown down to Perth with the RFDS and had to wait three days before having surgery to place Nancy nails up his femur. I expected that he would be quick to recover because of how active he was before the injury and because of his age. When I saw him for the first time post-surgery, however, I realised that his recovery would be very different to what I had expected.
After his surgery he was extremely anxious about moving his affected leg. Any slight movement of his leg caused him to cry and hyperventilate. On questioning he said that it was more "scary" than sore. He also had distinct crepitus that could be felt through his thigh when the hip and knee were flexed. He would cry out every time a "clunk" was felt in his leg. This crepitus is normal and often occurs with Nancy nails as they have some give in them so the bony segments can move with leg mvts. This fear avoidance behaviour that he was showing made it extremely difficult to progress quickly with his rehabilitation.
With adults it is easy to overcome this fear avoidance behaviour as an adult is better able to comprehend explanations of things such as crepitus and the fact that it is safe to move the leg. With young children, however, other techniques to reassure them need to be thought of, as opposed to simply explaining things to them.
In this situation my supervising PT and I used a lot of distracting techniques, such as talking about his favourite things, about his school and friends back home, etc... We also made sure we involved his mother as much as possible to be hands on, i.e. holding his leg during transfers and helping him wiht active assisted exercises. It was important that any gains we made be continued when he goes home, which meant him being comfortable and not scared with his mum helping him instead of the physiotherapists. We also tried to create fun goals for him after he completed his treatment sessions, such as going to the Starlight room iafter transfering to a wheelchair for us.
This different approach to patients is a very important lesson for me to have learned during my first week of a paediatric patient and one that I will have to use throughout my time at PMH.
This week I have been treating a young boy who fractured his femur whilst skateboarding in a country town. He was flown down to Perth with the RFDS and had to wait three days before having surgery to place Nancy nails up his femur. I expected that he would be quick to recover because of how active he was before the injury and because of his age. When I saw him for the first time post-surgery, however, I realised that his recovery would be very different to what I had expected.
After his surgery he was extremely anxious about moving his affected leg. Any slight movement of his leg caused him to cry and hyperventilate. On questioning he said that it was more "scary" than sore. He also had distinct crepitus that could be felt through his thigh when the hip and knee were flexed. He would cry out every time a "clunk" was felt in his leg. This crepitus is normal and often occurs with Nancy nails as they have some give in them so the bony segments can move with leg mvts. This fear avoidance behaviour that he was showing made it extremely difficult to progress quickly with his rehabilitation.
With adults it is easy to overcome this fear avoidance behaviour as an adult is better able to comprehend explanations of things such as crepitus and the fact that it is safe to move the leg. With young children, however, other techniques to reassure them need to be thought of, as opposed to simply explaining things to them.
In this situation my supervising PT and I used a lot of distracting techniques, such as talking about his favourite things, about his school and friends back home, etc... We also made sure we involved his mother as much as possible to be hands on, i.e. holding his leg during transfers and helping him wiht active assisted exercises. It was important that any gains we made be continued when he goes home, which meant him being comfortable and not scared with his mum helping him instead of the physiotherapists. We also tried to create fun goals for him after he completed his treatment sessions, such as going to the Starlight room iafter transfering to a wheelchair for us.
This different approach to patients is a very important lesson for me to have learned during my first week of a paediatric patient and one that I will have to use throughout my time at PMH.
Personal boundaries
During the first week of my neurology outpatient placement I was treating a male patient with left hemiplegia due to a stroke which occurred 15 months ago. A fellow female student was observing the treatment session.
As I was doing the foot mobilisations (with the patient sitting on the plinth with his foot on my thigh while I was kneeling) the patient remarked to the student observing the session, “She must be used to begging to her boyfriend.”
I continued with the foot mobilisations and a few seconds past in silence. The patient then looked me in the eye and said, “That was the wrong word wasn’t it?”
“Yes, that was the wrong thing to say.” I replied.
“Oh well, you have to have a sense of humour.” He responded.
I believe the patient had made a comment with a derogatory sexual connotation that was inappropriate. The fact the patient recognised that his remark was inappropriate led me to suspect that similar behaviour would not occur in the future. However, the incident made me feel a little uncomfortable and on guard with the patient throughout the remainder of the session. Although uncomfortable, I did not feel threatened by the situation. My feeling of safety was due to the gym being open and busy with other people and the decreased physical function of the patient.
I can not say for sure why the patient made the comment he did. Perhaps due to behavioural disturbance resulting from his stroke, or maybe such conduct is an inherent part of his personality. Maybe it was a reaction to emotional issues regarding his impairments or a response to the stress posed by the huge challenge of rehabilitation and living with disability.
The situation prompted me to consider where my personal boundaries are and where formal legal boundaries lie regarding the issue of sexual harassment and verbal abuse by a patient. Is it acceptable for a therapist to refuse treatment? Is it acceptable to terminate a treatment session? When is it appropriate to do so? Are certain pathologies such as frontal lobe disturbances or other causes of impairment of socially acceptable conduct exceptions for tolerating inappropriate behaviour? These were some questions guiding my consideration.
The APA code of conduct which states that “physiotherapists have the right to refuse to provide a service where there are reasonable grounds for doing so especially when, in their opinion, it is not in the best interests of the client.” This did statement does not specify what the reasonable grounds for refusal of services are. Would
The Equal Opportunity Act states that sexual harassment can be “unwelcome conduct of a sexual nature” and can take the form of “suggestive comments or jokes” and “insults or taunts based on sex”. It also states that “The behaviour must be such that the harassed person has reasonable grounds to believe if they reject the advance, refuse the request or object to the conduct they will be disadvantaged.”
The act says there is legal protection against sexual harassment in the workplace through laws that make harassment from colleagues and employers illegal but nothing is mentioned about harassment from a patient in a patient clinician interaction.
I appreciate that my view on the issue may change as I gain more experience with physio, but for now I have a better idea of where my boundaries regarding this kind of issue lie and am therefore more confident to deal with and respond to similar circumstances in the future:
If I felt personally threatened by a patient’s comments and behaviour I would not hesitate to terminate the treatment session and believe this would be reasonable grounds on which to do so. Even if I did not feel threatened, but felt uncomfortable with a patient and their behaviour to the point where this uncomfortable feeling was impeding my ability to deliver the most effective treatment I would also refuse to treat the patient and ensure they received treatment by a colleague who was comfortable to do so.
I feel I did the right thing by continuing the treatment session with the patient in the above scenario as I did not feel threatened or feel very uncomfortable with the situation.
As I was doing the foot mobilisations (with the patient sitting on the plinth with his foot on my thigh while I was kneeling) the patient remarked to the student observing the session, “She must be used to begging to her boyfriend.”
I continued with the foot mobilisations and a few seconds past in silence. The patient then looked me in the eye and said, “That was the wrong word wasn’t it?”
“Yes, that was the wrong thing to say.” I replied.
“Oh well, you have to have a sense of humour.” He responded.
I believe the patient had made a comment with a derogatory sexual connotation that was inappropriate. The fact the patient recognised that his remark was inappropriate led me to suspect that similar behaviour would not occur in the future. However, the incident made me feel a little uncomfortable and on guard with the patient throughout the remainder of the session. Although uncomfortable, I did not feel threatened by the situation. My feeling of safety was due to the gym being open and busy with other people and the decreased physical function of the patient.
I can not say for sure why the patient made the comment he did. Perhaps due to behavioural disturbance resulting from his stroke, or maybe such conduct is an inherent part of his personality. Maybe it was a reaction to emotional issues regarding his impairments or a response to the stress posed by the huge challenge of rehabilitation and living with disability.
The situation prompted me to consider where my personal boundaries are and where formal legal boundaries lie regarding the issue of sexual harassment and verbal abuse by a patient. Is it acceptable for a therapist to refuse treatment? Is it acceptable to terminate a treatment session? When is it appropriate to do so? Are certain pathologies such as frontal lobe disturbances or other causes of impairment of socially acceptable conduct exceptions for tolerating inappropriate behaviour? These were some questions guiding my consideration.
The APA code of conduct which states that “physiotherapists have the right to refuse to provide a service where there are reasonable grounds for doing so especially when, in their opinion, it is not in the best interests of the client.” This did statement does not specify what the reasonable grounds for refusal of services are. Would
The Equal Opportunity Act states that sexual harassment can be “unwelcome conduct of a sexual nature” and can take the form of “suggestive comments or jokes” and “insults or taunts based on sex”. It also states that “The behaviour must be such that the harassed person has reasonable grounds to believe if they reject the advance, refuse the request or object to the conduct they will be disadvantaged.”
The act says there is legal protection against sexual harassment in the workplace through laws that make harassment from colleagues and employers illegal but nothing is mentioned about harassment from a patient in a patient clinician interaction.
I appreciate that my view on the issue may change as I gain more experience with physio, but for now I have a better idea of where my boundaries regarding this kind of issue lie and am therefore more confident to deal with and respond to similar circumstances in the future:
If I felt personally threatened by a patient’s comments and behaviour I would not hesitate to terminate the treatment session and believe this would be reasonable grounds on which to do so. Even if I did not feel threatened, but felt uncomfortable with a patient and their behaviour to the point where this uncomfortable feeling was impeding my ability to deliver the most effective treatment I would also refuse to treat the patient and ensure they received treatment by a colleague who was comfortable to do so.
I feel I did the right thing by continuing the treatment session with the patient in the above scenario as I did not feel threatened or feel very uncomfortable with the situation.
Thursday, May 22, 2008
Patience with Patients
I am currently on my neuro placement, on an inpatient neurosurgery ward where patients have acquired brain injuries resulting from many different causes. As I have only been on the ward for a few days, I haven’t treated any of my own patient’s independently yet, but have observed the physio’s during their treatment sessions in the physio gym and assisted where able. One patient in particular that I have observed is a man who underwent surgery to remove a brain tumour on his pituitary gland. He is high functioning and able to walk with 2x physio assist. Cognitively, he is normal however I query whether he has frontal lobe signs…
His main problem at the moment is hypersensitivity on his (L) upper and lower limbs. At the start of each session, the physio has been massaging and stimulating his (L) foot with the aim of desensitising it. This proves quite a difficult task for the physio, as the whole time, the patient complains and whinges about the pain and accuses the physio of trying hurt him constantly. For the rest of the session, he continually accuses the physio of having unreasonable expectations of him and that her treatment is ineffective. Of course, the physio’s treatment plan is appropriate and the poor thing must battle through each session, tolerating this patient’s behaviour which is unreasonable, and borderline aggressive. He even directs questions to me about whether ‘they teach us this crap in physio school because it’s a load of bulls**t, and we should have more empathy for our patients…’
I think I’m only scraping the surface of what is to come from this patient when I begin treating more closely, because so far, he's been pretty nice to me. I’ve observed the physio deal with the situation by explaining her reasons for doing the treatment and that it is to benefit him, but sometimes she just has to stay silent and ignore his inappropriate comments. The physio appears to get quite frustrated with the patient’s behaviour, but she is very patient with him and always gets through the session. I hope that when I become more hands on as the placement progresses, I will have the same patience and tolerance in the situation that the physio has and hopefully get through the sessions without too much trouble – for all involved!
His main problem at the moment is hypersensitivity on his (L) upper and lower limbs. At the start of each session, the physio has been massaging and stimulating his (L) foot with the aim of desensitising it. This proves quite a difficult task for the physio, as the whole time, the patient complains and whinges about the pain and accuses the physio of trying hurt him constantly. For the rest of the session, he continually accuses the physio of having unreasonable expectations of him and that her treatment is ineffective. Of course, the physio’s treatment plan is appropriate and the poor thing must battle through each session, tolerating this patient’s behaviour which is unreasonable, and borderline aggressive. He even directs questions to me about whether ‘they teach us this crap in physio school because it’s a load of bulls**t, and we should have more empathy for our patients…’
I think I’m only scraping the surface of what is to come from this patient when I begin treating more closely, because so far, he's been pretty nice to me. I’ve observed the physio deal with the situation by explaining her reasons for doing the treatment and that it is to benefit him, but sometimes she just has to stay silent and ignore his inappropriate comments. The physio appears to get quite frustrated with the patient’s behaviour, but she is very patient with him and always gets through the session. I hope that when I become more hands on as the placement progresses, I will have the same patience and tolerance in the situation that the physio has and hopefully get through the sessions without too much trouble – for all involved!
Language Barrier
I was recently on a cardiopulmonary placement in the area of intensive care and had to treat a large range of patients. I treated a 60 year old water polo player from Romania who had a cardiac arrest and had undergone a coronary artery bypass. I had seen this gentleman, day 1 post op and this man spoke no English and was very agitated because he did not understand what was going on around him and did not have any family or friends in this unfamiliar environment. A translator was present when gaining consent from the patient for the surgery but due to the priority of other patients, the translator could not be with the patient at all times and was only called on for important decisions that needed to be explained.
When gaining a subjective assessment from this patient, even when I used gestures and facial expressions, he seemed lost and confused. At first he seemed agitated and was speaking in Romanian. As I kept trying to explain my questions, he seemed to give up and just nodded in agreement with everything I tried to explain. I had never experienced this before in any of my other placements and was at a lost on how to get my message across.
It was hard to communicate to this patient and it made me feel helpless because I knew how alienated he would have felt and I could not give any comfort or ease his anxiety because I did not know what was the issue. In the end I simplified my treatment and got him to copy my actions. I tried to draw out some of the instructions and gave that to him to take with him to the ward. The more complicated actions I tried to communicate but in the end could not be understood.
According to the nurse, a lot of patients that are admitted into hospital cannot speak English and this is an issue that physiotherapists would have to overcome. It is important to develop a better method of communication with the patient, especially because they would be feeling worried in an environment that they do not understand what is happening. I understand next time that I encounter a non English speaking patient, that I have to use my body language and tone of my voice to help calm the patient. Also the use of flash cards or pictures are useful but I have to work on drawing more legible pictures.
If anyone has methods of communicating to a patient that does not understand English, please let me know because I am eager to discover more ways.
When gaining a subjective assessment from this patient, even when I used gestures and facial expressions, he seemed lost and confused. At first he seemed agitated and was speaking in Romanian. As I kept trying to explain my questions, he seemed to give up and just nodded in agreement with everything I tried to explain. I had never experienced this before in any of my other placements and was at a lost on how to get my message across.
It was hard to communicate to this patient and it made me feel helpless because I knew how alienated he would have felt and I could not give any comfort or ease his anxiety because I did not know what was the issue. In the end I simplified my treatment and got him to copy my actions. I tried to draw out some of the instructions and gave that to him to take with him to the ward. The more complicated actions I tried to communicate but in the end could not be understood.
According to the nurse, a lot of patients that are admitted into hospital cannot speak English and this is an issue that physiotherapists would have to overcome. It is important to develop a better method of communication with the patient, especially because they would be feeling worried in an environment that they do not understand what is happening. I understand next time that I encounter a non English speaking patient, that I have to use my body language and tone of my voice to help calm the patient. Also the use of flash cards or pictures are useful but I have to work on drawing more legible pictures.
If anyone has methods of communicating to a patient that does not understand English, please let me know because I am eager to discover more ways.
Sunday, May 4, 2008
behavioural issues
I am currently on a Paeds placement treating inpatients with a variety of diagnoses. I am currently treating a 6 year old below knee amputee. This patient suffered from a traumatic open tib fib fracture just proximal to the ankle joint just over one month ago. The road to recovery has not been smooth, since her original operation she has undergone five washouts and debridement of necrotic tissue around the wound. The patient has been experiencing high levels of pain and in early days was needing to go to theatre and be anaesthetised for dressing changes. Throughout the patients time in hospital, there has been regular out episodes of severe distress which involves the patient being extremely non compliant with uncontrollable screaming and crying for upwards of 15minutes. This can occur upwards of twice daily and has caused great concern amongst all staff involved in the treatment of this patient. Originally it was thought that these episodes were pain triggered or phantom pain or limb hypersensitivity related and were managed with drug therapy to increase patient compliance with dressing changes and stump bandaging. This view has since changed as a large behavioural element has developed. Psyc med and social work are heavily involved in the treatment of this patient and their family.
This patient has since progressed and is now approaching discharge. Physiotherapy treatment has progressed from strength and conditioning bed exercises to ambulating the patient in the gym. I have been given the task of treating this patient twice daily for hour long sessions in the physiotherapy gym. During these sessions a concerted effort is made to disguise all formal movement tasks as games and maximise pt compliance. Screaming episodes were occurring after about the 30minute mark during every treatment. Due to the gym environment being a common area, the sessions had to terminate. This had a detrimental effect and endorsed this bad behaviour thinking that the pt can get out of anything just by screaming and complaining of stump pain.
It has been interesting to see the management of this child by all staff. Legally when a patient complains of pain, medical staff are obliged to provide drug therapy for pain relief. Although in this situation, how valid are the 6 year old's pain complaints and when do you ignore them and get on with the session? This is a very fine line.
Management of this patients behavioural issues has included giving choices, they pt is provided with two alternate games for example and is given the choice. This gives the pt a sense of control. It also gives the therapist ammunition that if an episode were to occur, the pt has made the choice and therefore has less ground to stand on should they complain. A reward system has been implemented, the pt is rewarded if they perform all exercises scream free. Four weeks of building trust with this pt and we are finally getting somewhere!
This patient has since progressed and is now approaching discharge. Physiotherapy treatment has progressed from strength and conditioning bed exercises to ambulating the patient in the gym. I have been given the task of treating this patient twice daily for hour long sessions in the physiotherapy gym. During these sessions a concerted effort is made to disguise all formal movement tasks as games and maximise pt compliance. Screaming episodes were occurring after about the 30minute mark during every treatment. Due to the gym environment being a common area, the sessions had to terminate. This had a detrimental effect and endorsed this bad behaviour thinking that the pt can get out of anything just by screaming and complaining of stump pain.
It has been interesting to see the management of this child by all staff. Legally when a patient complains of pain, medical staff are obliged to provide drug therapy for pain relief. Although in this situation, how valid are the 6 year old's pain complaints and when do you ignore them and get on with the session? This is a very fine line.
Management of this patients behavioural issues has included giving choices, they pt is provided with two alternate games for example and is given the choice. This gives the pt a sense of control. It also gives the therapist ammunition that if an episode were to occur, the pt has made the choice and therefore has less ground to stand on should they complain. A reward system has been implemented, the pt is rewarded if they perform all exercises scream free. Four weeks of building trust with this pt and we are finally getting somewhere!
Thursday, May 1, 2008
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