week 1 post- assessment (prac 2)

S: A 48 year old female patient presented to the outpatients clinic 3 months post- TKR for ongoing rehabilitation. The patient had been referred from her doctor for rehab and also due to her reporting high levels of pain in the knee despite still taking a strong form of pain relief. On observation, her knee was still very swollen (although this is common post- operatively) and judging by the patients facial expressions, walking into the treatment area was very painful. My clinical tutor was present during the assessment.
T: Conduct a thorough (initial) subjective assessment to discover possible mechanical (or non-mechanical) reasons for her pain levels.
A:I conducted a full subjective assessment with the patient (including past medical history, social history... and so on). In particular, I focused on determining aggravating/easing factors as well as twenty-four behaviour of the pain and enquired about the history of the presenting complaint (i.e. pre-op function and post-op progress).
R: By the end of the subjective I gained further insight into possible causes of her pain and was able to reassure and educate the patient based on what I had found. Possible causes included the fact that she was trying to do too much daily such as doing the lawn mowing and other strenuous activties around the house. The exercises that she had been given post-operatively also had not been progressed greatly over the past 3 months and I felt that if they had her knee would have been able to cope with more strain that it currently is. The patient had also not been using many strategies to ease the pain apart from taking analgesia. On observation during my assessment, I noticed the patient was wearing flat hard-soled thongs. I found that the patient had a lot of questions related to prognosis and was concerned that she was not where she should be in terms of her function and pain 3 months post-operatively.
E: I thought I managed to ask key points under each of the 'subjective headings' and used open ended questions to obtain as much information as I could and also to get an idea of her main concerns and what she thinks about the pain experience. I think I was a good active listener and enabled the patient to feel empowered. I observed the patient right from the minute she walked in and throughout the subjective interview which I believe helped contribute to me getting a good picture of the patients presentation. For example, as mentioned I noticed that she was wearing shoes that did not provide much support for the knee which could potentially be a contributing factor to her pain. I determined some distinct aggravating factors however I did not explore these as much as I should have. I needed to establish clearer time frames i.e. how long the pain took to come on with a certain activity, how long it took to ease and what the intensity of the pain was like with each activity. In doing this I could have gotten a better idea of the behaviour of her pain as well as how irritable her presentation was. This could then be used as a baseline measure to assess if her pain is improving on subsequent physiotherapy sessions.
S: In order to improve on this as the placement goes on, I need to continue asking open ended questions however also guide the patient a little more to obtain information that is meaningful to me in order to assist in my clinical reasoning. I need to establish more specific details under certain parts of the subjective, for example, by asking questions based on my theoretical knowledge and narrowing the open ended questions into more specific ones. In this case, finding out about time frames associated with the onset of pain, etc would be very useful to look back on to assess whether there is any progress with regards to her pain. Also, if I have a better understanding of a patient's pain I can educate and reassure them for effectively and with more confidence.

Initial entry placement 2

I am really looking forward to this placement. I will be gaining experience in the musculoskeletal field of physiotherapy which is I find really interesting and have always enjoyed learning at university. I haven't done a placement at a tertiary hospital yet so it will be interesting to see how everything is run there, particularly the musculoskeletal outpatient department which I will be spending most of my time in. It will be a good opportunity to work in such a busy environment (I would imagine).

I am expecting to be given a case load at the beginning of everyday and hopefully get the chance to discuss a few things with my supervisor prior to of after seeing a patient. I'm sure I will see a huge variety of injuries and conditions as well as deal with patients of different ages and backgrounds. After talking to another student about this placement, there is a day every week allocated to complex cases. I am anxious about this as I don't feel as though I have the experience to be able to deal with these cases as ideally as I would like to. On the other hand, it will be good to see some unusual conditions and how these are managed with physiotherapy. I do think my supervisor will be mindful that I wouldn't have as much clinical experience with such cases/conditions and as long as I 'have a go' I can learn from the experiences and build confidence so that I can handle them better as the placement continues I will be okay.
I imagine I will be doing some taping following injuries which I am eager to practice and I think this will provide an opportunity to learn some new techniques for future use! I think I will have to teach lots of exercises and stretches and learn to be an effective educator in regards to injuries and self managment strategies as well as rationales for why I am doing certain treatments. I'll most probably be doing a lot of manual therapy and have to do mobilisations which I am fairly confident with in terms of when these will be appropriate to use. However I don't feel that my technical skills are refined enough and may reduce the effectiveness of the mobilisations.
This placement will be a good refreseher of the electrotherapy modalities.

It is likely that I will see a large proportion of patients post-surgery, for example total hip replacement surgery, and will therefore have to follow appropriate rehabilitation protocols. I am expecting to see many people coming in with lower back and neck pain. I had some experience with this at my placement in third year however I still find that assessing and treating spinal pain is sometimes very challenging and that you have to be very biopsychosocial in your approach to it. I am worried that I will not do this as successfully as I should. Lastly, I am a little anxious about my time management, I feel it has improved however it is still not as good as it could be and I am not sure how large my case load will be as this will affect how I choose to manage my time.

In conclusion, I am excited to gain further experience in a musculoskeletal outpatient setting. At the same time I am very anxious as it is always hard to predict what to expect at a new placement! There are certain things which we have learnt at university but which we have had no clinical or hands on experience with and this is quite daunting especially as being a fourth year I am expected to be much more independent.

Final entry

The placement was reassuring, I found, as initially I felt as though being a fourth year carries so much more pressure and responsibilities and it all seemed very daunting! And even though I still feel like a little like that I know more than I thought I did thanks to the placement.

Reflecting back on these past 5 weeks, I feel I have definitely learnt many new skills and had others reinforced. Manutention is integral to protecting yourself and your patients and I had many opportunities to practice appropriate manual handling i.e. when lifting and then repositioning someone in a wheelchair with a hoist and sling. I got to do both home and school visits for children with disabilities and learnt about what goes on at the visits and the physiotherapist's role in these which I would not have otherwise known about.

Some concerns that I had prior to starting the placement included being able to problem solve in order to do assessments and treatments. I found that this was not as difficult as I expected. My supervisors helped guide me with problem solving and in a few situations (not all!) it came naturally. For example, when assessing children if they did not want to do something, I would try and make the activiy fun and age appropriate i.e. "pretend to be this animal"...etc. At times I found I was able to effectively probem solve by planning beforehand unless it was a situtaion that couldn't be predicted or planned for! I learnt from one experience and found it helped me problem solve a lot better in another. I was also worried about having to educate the families about a condition. However while on placement I learnt that it was within my role as a physiotherapist to discuss functional implications of the condition, etc but it was more the role of the neurologist to inform the family in more depth about the condition i.e. what causes it/ how the child got it and so on. My supervisors assured me that it is okay to answer families questions but to make sure I was still staying within my scope of practice.

I thought that I would have to do a lot of wheelchair and equipment (e.g. AFO's) assessment and prescription however I did not deal with this as much as I thought during my time at the placement. Many patients had already had their equipment prescribed for them. I did get to see a few patients trial new electric wheelchairs which was interesting as I needed to assess their posture and potential functional and physical implcations of how they were positioned and how their wheelchair was set up. I attended a seminar about posture and wheelchairs which was very helpful in showing how modifying things such as the tilt on a wheelchair can remarkebly change a person's posture and therefore benefit their musculoskeletal system and therefore their functional abilities, comfort and so on.

I was apprehensive about communicating with children and their families while on this placement. I did have difficulty during my placement with talking to children in an age appropriate manner now and again- I often spoke too quickly and gave instructions that at times could not easily be followed by a child! This is something I improved upon as my placement continued but also something that I will have to continue to work on. Despite this I felt I managed to build a good rapport with the children and their parents that I worked with and became more confident with talking to parents about their concerns and how to address these.

I learnt that you can either just do enough so that you are doing your job, or you can go beyond that and do your job as best you can and really want to make a difference to the quality of life of each patient (and their family's) life that comes to you. This placement was a great opportunity for me to see what a holistic approach to treatment is and how a multi-disciplinary team approach is so important especially with neurological paediatrics. For example, I went on a home visit with my supervisor to see a 7 year old boy with duchenne's muscular dystrophy. His mother had not heard of half the options that my supervisor and myself suggested were out there for her son and their family that our facility could make possible such as seeing a speech pathologist for his speech difficulties and having the OT or physio visit his school to educate his teachers about strategies to involve him in sport and other activities. The mother was so surprised that none of these options had been mentioned to her previously and was very thankful that we had informed her of them. That experience also taught me a great deal about the roles of other health professionals and how it is important to know what they are even as a physiotherapist so that you can make referrals to other professionals if needed or is asked.

Another thing that really stands out for me that I learnt from this placement was how to analyse my assessment findings and make my intervention functional/ goal directed and family centred based on these. I also learnt that it is vital to know your milestones and what is considered 'normal' in paediatrics in order to analyse your assessment findings correctly. These aspects have been driven into us at university and I thought this placement was very beneficial in reinforcing these.

week 5 post- intervention (treatment planning)

S: My supervisor has discussed with me the importance of making treatments functional and relevant to a patient's goals and daily lives (the importance of this has also been stressed to us at university!). That day I saw a 15 year old boy with limb girdle muscular dystrophy and was asked to conduct a full assessment. Taking on board what my supervisor had said, I made an effort to find out his goals and functional abilities in my assessment so that I had a clear idea of where to direct my treatment ideas. Once I had done the subjective assessment , I found that he enjoyed doing sailing at school once a week as he found it challenging and that he noticed he had difficulty walking up inclines and stairs as he tended to lean forward and walk on his toes. He was very physically active (often cycled to friends' houses and walked to school, etc). His goals were to maintain his strength and fitness; slow the progression of the disease as well as be able to walk up inclines/hills with less difficulty. Objectively, some of my findings were that he had reduced dynamic balance (with higher level tasks) and when squatting. He fatigued quickly after doing squats and bridges. His calves were very tight as he had reduced ankle dorsiflexion range. In general, hisupper limb strength and range was slightly lower than what is proposed as 'normal'. He also toe walked when ascending/descending stairs which made it slightly harder for him to balance.
T: My task was to plan a short treatment programme for him that was functional and directly linked his goals while at the same time being achievable and realistic for him.
A: I developed a treatment program with the above findings in mind. In forming the programme, I did a bit of research into sailing to find out what gross movements were involved in the sport. I found that (depending on a person's role on the boat), sailing requires upper limb strength for pulling the sails, good dynamic balance for maintaining balance on a moving boat, squatting and leaning out of the side of the boat. These requirements I found were what the patient had had some difficulty performing in my objective assessment. Therefore, based on this information; my other findings and his goals, my treatment plan consisted of the following (complete plan not written here): Squats (double leg and single leg/double leg while catching a ball/ standing on foam, etc), balancing on a wobble board and other high level balance activities, calf stretches, bridging (to maintain his hip extension strength), light resistance exercises with theraband for his upper limbs and more. These exercises I felt targeted things which he struggled with and would aid him in being able to continue with sailing as well as prevent deterioration in his balance, strength, fitness and joint range. If these deteriorated, his functional abilities would reduce to an extent.
In terms of his cardiovascular fitness, he was doing an appropriate level of physical activity already so I did not suggest many new ideas to target this apart from swimming (which would also be good for his joint range and maintaing strength). I noted down to encourage him to continue living an active and healthy lifestyle so that he could continue with his ADL's and sailing and prolong his ambulation. In planning this intervention, I also made a note to educate the patient that due to the disease process, with physiotherapy we can only maintain his strength and that there would not be a significant training effect on the muscles so his strength would not necessarily increase by too much. The importance was ensuring he could continue doing activities he enjoys and optimise his functional ability as the disease progresses. I also made a note that we did not want to over work (or overstretch) his muscles due to the disease processa and that stretching his calves will help him toe walk less however it is likely he will continue to toe walk once again due to the inevitable disease progression but we can work on his balance, hip extension strength and on preventing further tigthening of his calves.
R: I explained my treatment plan to my supervisor. He thought that it was good in the way that it addressed the patient's goals and was very functional while at the same time achieved some aims of physiotherapy which would be typical for a patient with limb girdle muscular dystrophy. These include preventing contractures (with stretching and weight bearing), optimising function and ability to participate in activities with peers and so on. I got the opportunity to trial a few of the exercises from the programme and explain why I chose certain exercises to the patient before finishing my placement. The patient was happy with his exercises that were trialed and others that were suggested and felt that they were relevant to his goals.
E: I felt that I did a good job in making my intervention functional and patient specific while also ensuring I had goals of physiotherapy in mind and that these were being achieved simulatenously. It was important and satisfying that the patient was happy with my proposed treament program. I think I could have enquired more about what aspects in regards to sailing the patient found challenging and specifically what his role is on the boat to make the treatment even more relevant to him and his needs. I completely forgot to investigate further into this in the subjective!
S: I think I could practice being a better investigator in my subjective so that I can make sure my treatment is as relevant to the patient as possible and so that I am not making any assumptions about what the patient needs to do. This will help maximise the patient's satisfaction with the treatment they are receiving and also be more beneficial to them from a physiotherapy perspective.