STARES 1

SITUATION

A young woman had been referred by her GP for physiotherapy assessment, treatment and advice. Her presenting complaint was right-sided pain in her neck, shoulder and arm along with some pins and needles in her forearm. The onset of symptoms had been associated with her task at work, and consequently a workers compensation claim was undertaken. To qualify for workers compensation she required proof from relevant medical professionals as to the relationship between her injury and her tasks at work. The task was working at a supermarket checkout which involved reaching and lifting objects placed on her right side, just over arms length away and some weighing up to 3kg. This involved extending her right arm and twisting to the right repetitively. In the 2 years she had been with this employer she was rarely switched to an opposing till that would require her to use her left, evening out the demand on the body, rather she remained at the same till for about 90% of her employment. This had resulted in a gradual wear and tear of her right side and a consequent injury in her neck and upper limb. On examination it was found that she had sustained significant damage to her rotator cuff with positive impingement signs and tenderness on supraspinatus and supscapularis tendon palpation and stretch. Her neck was tight throughout with muscle spasms, decreased left rotation and left side flexion and her neck pain was reproduced at C3, 4 and 5. She also complained of pins and needles on abduction and elbow extension with left side flexion (stretching the nerves) and had a positive neurodynamic tests for median and ulnar nerves. From this information we agreed that the injury was work related and that the claim should be pursued. We then applied appropriate treatment to mobilise the neck into the direction of restriction, used electrotherapy to settle the swelling around the shoulder and provided stretches for the neck and shoulder.

TASK:

In the above described situation I was working with a fellow physiotherapy student from the Curtin GEM program, under the supervision of Robert Lane, the Margaret River physiotherapist. The two of us has to assess this young female, apply the relevant treatment and then present our findings to the GP and the supermarket manager to be documented on the workers claim report.

ACTION:

During this session we discussed appropriate assessments and treatment ideas and both had an attempt at applying these. I noticed that the Curtin student approached things differently and had a different understanding of the application of both assessments and treatments. For example they were doing the neurodynamic tests in one movement by putting them in the end position and then asking the patient to move their neck to change the level of pain, whereas we are shown to slowly add the components of the movement to further stress the neural tissue. I demonstrated our approach to neurodynamics to the student and the supervisor and it was shown that our method was far more sensitising. Another difference I noticed was the treatment of the neck. The Curtin student applied a side flexion PPIVM with the patients head on the pillow and swinging it from side to side as well as general PA to C3,4 and 5 with the patient in supine as they were unable to apply anything to the right side as it was too painful. Again I had to opportunity to show my clinical reasoning in this situation. I demonstrated a cradle hold PPIVM of side flexion as well as applying a side glide at EOR side flexion specifically at C3, 4 and 5.

RESULT:

From this session it was clear that there were differences in education in between the Curtin GEM program and the Notre Dame Physiotherapy course. In this situation I was able to demonstrate my learning and application of knowledge, which my supervisor was pleased with. We were able to improve our patient’s pain and available movement, as well as effectively translate our findings to the GP and supermarket manager. It was also a learning experience for both the Curtin student and myself as we were able to teach each other different approaches to assessment, treatment and clinical reasoning.

EVALUATION:

When evaluating my performance in this situation I feel I had a few strengths. Firstly I was able to demonstrate my ability and knowledge effectively to my supervisor, as well as to my patient and peer in a confident manner. This was a new experience for myself, as I have not yet felt confident in my ability to correctly assess and treat a patient. Secondly, my best strength was being able to demonstrate my approach to the Curtin student in a non-derogative way and combine it with her treatment and assessments as another option rather than a better one, even though my techniques proved to be more effective I was able to then teach the Curtin student how to do it and gave her the chance to try it. My weakness in this situation was efficiency. I have not yet established the experience to know what tests are needed and which can be disregarded in particular situations, therefore I am often very thorough, though this works to my detriment, as I am unable to see the patient in the 20minute slot provided.

STRATEGIES:

I think knowing that clinical placement is not only a learning opportunity for yourself, but also for your supervisor, patient and fellow students from other institutions changes your whole outlook on your clinical placement. Your teaching skills become just as important as your ability to learn. Also being confident in the way you present yourself and conduct the session has a large impact on how the patient perceives your ability and how they respond to your treatments. Be confident, learn and teach.

Initial Entry - Margaret River

Now to embark on a rural placement based in Margaret River and Augusta, I am both intrigued and nervous. Intrigued by the environment, both physical and social as well as the exposure I will have to a vast array of presentations. Nervous about the demands of musculoskeletal physiotherapy in a private practice setting and the extensive background theory required to stay afloat in this rural situation. I am hoping I have the knowledge required and am able to utilise what I have appropriately to excel in this placement, as from my last I have grown very anxious towards physiotherapy and feel my success in this placement could be vital in me continuing physiotherapy as my chosen career path.

AMR physiotherapy practice in Margaret River is a single treatment room private practice. Being rural, I expect the nature of this placement to be quite different to those in the metro areas. From peers I have learned that rural placements offer different patient-therapist dynamics, such that rapport is easily established and patients are open and accepting to any therapy on offer. Also, that rural covers an extensive field of treatment areas, mainly musculoskeletal based and movement dysfunction related, though the occasional patient (human or animal) may arise with something different.

In terms of the structure of this placement, I have discussed this with peers as well as the physiotherapist based at the Margaret River practice and have established that I will indeed be thrown into the deep end and shown how to swim. Initially I will be seeing patients at my own pace, with full supervision. I will be sharing the one treatment room between myself, my supervisor and another Curtin student; I will also have opportunities to observe. As the placement progresses, I will need to develop efficiency to be seeing my patients in 20 minute time intervals, and supervision will grow scarce.

My role in this experience will be to act as a professional physiotherapy student, with all the relevant knowledge of a new graduate. I will be expected to apply, expand and share my knowledge while in this clinical setting so as to develop myself as a physiotherapist.

Prior to starting this placement I have the following concerns:

· My ability to recall information from my knowledge base when it pertains to the patient opposite me.

· My physical capacity in musculoskeletal physiotherapy could be limited.

· I tend to get flustered when under close observation and find this quite intimidating. Having close supervision in the initial weeks could impair my performance, which would limit my supervisors faith in my ability and therefore lead to further close supervision, vicious cycle.

· Rural setting, being somewhat disconnected from my supports in Perth could have an impact on my overall performance. This could swing both ways, flourish with independence or crumble under it all.

Overall I am looking forward to a fresh start and a new opportunity to restore my desire to become a physiotherapist. I am hopeful that this field will be something I enjoy as it seemed that the musculoskeletal aspects at PMH, such as hip surveillance and BOTOX clinic were the areas I enjoyed the most.

FINAL ENTRY

Looking back at my five week placement at PMH I am disappointed. With such large expectations for this placement I have not achieved all that I would have liked too. I feel this is for two reasons;

Firstly, the placement structure was hard to familiarise myself with as I had different supervisors each day, as well as attending many clinics throughout each week. Often my schedule was not planned until the Monday of each week. This left a lot up in the air and I found it hard to prepare for the upcoming days. To a degree this made me feel slightly unnerved as I prefer to be organised and prepared for the upcoming week.

Secondly, I was rarely given the opportunity to demonstrate my skills. I understand that it is a matter of the family’s wishes and our involvement is largely dependent on the family’s acceptance of student participation, though certain supervisors allowed for minimal hands on experience and as a result I was marked low in this area. Given consistent opportunities I feel I would have been able to learn and develop skills in this area though as my main supervisor only treated complex presentations, it was rare for such an opportunity to arise. Also having no consistency in patients was difficult as I was unable to gain familiarity with the family or the child.

In hind sight I should have taken a more proactive role and asked to have my schedule done in advance. Also getting hands on by coming forwards and requesting to try everything that the supervisor demonstrates.

This is a very difficult placement. The most difficult element would have been the instability and variability of the placement structure. In terms of the paediatric physiotherapy I feel I could have done well given the opportunity.

I was able to come out of this placement with a few new experiences such as, suctioning, facilitation, working with children and exposure to a very broad range of patients. Particular areas I enjoyed were Hip Surveillance clinic on CP children of all ages and plastics clinic. I also enjoyed working with the older children and teenagers as they were able to take on board my feedback and respond appropriately. You can also gain a clearer subjective from the child directly rather than through the parents.

Recapping on my initial concerns;
- The emotional attachment issue did crop up on occasion and at times it was a challenge to stay composed. PMH has the worst paediatric presentations from the whole of WA in the one location and this can be overwhelming but I managed control this majority of the time.
- Communicating with families wasn’t a strong point for me as I often found it hard to try and gain handling opportunities as well as relating to the families.
- The barrier to students treating children was a prominent issue. This was evident in most treatment sessions and it was obvious when the parents changed their tone and general posture when I went to try a treatment. When asked a question by myself, they would often answer by addressing my supervisor which I found frustrating at times.
- And as previously mentioned, getting hands on experience was difficult.

From my initial expectations and desire to do paediatric physiotherapy my plans have changed somewhat. I enjoyed the musculoskeletal side of paediatrics and found these patients were more willing to have student input, though when medical complications were added to a substantial history of complaints, this is when student input is less welcomed. Community based paediatrics would be an area I would consider.

STARES 3

SITUATION

A 3 year old boy presented to outpatient physiotherapy department to be treated for gross motor delay. Past medical history included pre-term birth, a liver transplant at 18 months old as well as numerous hospital admissions for respiratory infections, fevers and eczema. On assessment he presented with a significant gross motor delay, not yet creeping, 4 pt kneeling or standing with support. His gross motor abilities seemed to be largely limited by his associated movements or dystonia in his trunk, arms and legs. Mother appeared positive and proactive in helping her son develop.

TASK

For my final placement assessment I was to plan assessment and treatment of this child and then proceed to carry out this plan under the supervision of my clinical tutor.

ACTION

As the child was significantly delayed for a 3 year old, many assessment tools would merely state the obvious. Therefore I deemed it more appropriate to take more qualitative observations of this boy and describe his movements and abilities in detail to best get an idea for areas of improvement. From this assessment I learnt that the next stages in his development were improved sitting balance and reaching beyond his base of support, transitions from sitting to prone and sitting to 2 point kneeling. Using toys and available cushions etc I went through with my treatment ideas.

RESULT

Throughout the session I found it hard to obtain the result I was after as the dystonic movements made it difficult to facilitate movements as well as keep the child’s attention. When placed into a posture, limbs would spontaneously contract or the spine would go rigid, setting the child off balance. At one stage the child knocked his head with a plastic toy. As I had no prior experience with this child or with anyone similar, I was unable to predict this and I was to slow to prevent it. As a result the child spent about 2 minutes crying and had to be settled by the mother. After this however, we were able to resume activities.

EVALUATION

From this session I have developed heightened senses or increased awareness to the environment, actions and risks for each child I am presented with. Personally I feel it was a challenging situation and hard to predict potential risks. On this particular incident I was able to deflate the situation by getting the mother to settle the child. She was also complaisant and understanding, stating that it was a regular occurrence for him to hit himself in the head. From that point on I removed all hard toys and continues with softer balls and teddies.

STRATEGIES

- Start the session with simple, minimally stimulating toys, for example teddies and balls. This also works well with children who have heightened senses.
- Keep a hand close by even when on the floor to prevent accidents or provide facilitation.
- Don’t be afraid to ask the supervising clinician for support or advice.
- Talk through reasoning and ideas to show interest and this is also helpful for the parents as they learn from this also and can occasionally provide input in what they do at home and what works for them.