FINAL ENTRY - AMR Physiotherapy

Five weeks of rural physiotherapy in Margaret River has been a blast! The placement gave me invaluable experiences in a broad range of physiotherapy fields, including musculoskeletal, gerontology, neuro, paediatrics and cardiorespiratory, in both a private clinic and public hospital setting. Having such a vast array of clinical presentations kept me on my toes, always wondering what would be next.

Three days of the week were spent in the private sector at AMR physiotherapy, a private practice. Here the case mix was broad, from children with trampoline injuries and wine makers with low back pain to yoga students with knee strains and surfers with complete gastroc tears. The rest of the week was spent in Augusta, housing a somewhat older population. I got close with the members of the community, having one on one physiotherapy sessions as well as weekly exercise groups and outings.

Looking back at my initial entry, my perception of this placement is the same, if not better. I have thoroughly enjoyed the atmosphere and the unpredictable nature of the rural setting whilst expanding my clinical experience greatly. My initial anxiety subsided within the first week, after meeting my friendly and supportive supervisor and treating some amazing patients who appreciated the extra time spent with them, as well as learning a lot themselves from my learning.

The issues I had to prior to commencing this placement were dealt with throughout the five weeks and by the end I felt very comfortable, reluctant to leave.

To start with I had concerns about my ability to recall information from my studies to apply this to my patient. In the clinical setting, it seems to come naturally and the lectures become clear and relevant. My supervisor was also very supportive with a broad knowledge base and over 30 years of experience in physiotherapy. Even if I was unsure of a test or technique, he would always be close by to assist, or show me a completely different approach to broaden my skills. The close supervision was nerve racking for the first couple of days, though as my confidence grew, so did my supervisors confidence in me and he took a back seat in the sessions, only giving input if I asked or he felt it was absolutely necessary.

The only issue that I had throughout the placement was physical ability. I often came against the problem that I could not overpower my patient in a strength or muscle power test, nor did I have the arm span or size to perform some techniques. My supervisor was very understanding and supportive in this area and taught me some strategies to overcome this, which I employed throughout my time there and this gradually became a less evident issue. I also found that some of my own physical faults, for example internally rotated and valgus knees, became evident when trying to teach a patient how to perform a certain task correctly, like squats. This is something I will continue to face, and hopefully with live what I preach and correct such postural anomalies.

Overall I have enjoyed this experience and have restored my confidence as a physiotherapy student. Having a supportive and welcoming supervisor makes all the difference when on clinical placement and I feel this is 80% the reason I have enjoyed this prac as much as I have.

Musculoskeletal private practice physiotherapy is a great area to work in, and I felt comfortable in my skills and performance in this area.

STARES 3

SITUATION

In my final week at AMR physiotherapy I was acting as an independent practitioner, seeing my own patients individually. A particular patient I saw, referred to physiotherapy by his school, was a 5 year old boy complaining of knee and hip pain when running and walking. Informally observing his posture and gait, the following was noted; bilateral pronation of the feet, internally rotated hips bilaterally, valgus knees and wide stance. By questioning the mother and son it was evident that the pain was worst with running and had been gradually worsening over the past month. The boy felt his left was sorer than the right and that it was mainly his knees that hurt. On formal examination it was evident his feet were over pronated with complete loss of arch, though he was able to actively achieve one, his knees were in valgus; left greater than right, he had adopted an abnormal gait pattern and there was no evidence of a leg length discrepancy. The mother had been in correspondence with the school in regards to the complaints of pain and teacher had observed the flat foot posture and recommended physiotherapy as an appropriate place to seek advice for treatment. The mother had also done research into flat foot posture in children and had become quite anxious about potential surgical treatments and outcomes.

TASK

My task in this situation was to ascertain the source of the pain by acquiring information from the teacher's referral as well as the young boy and his mother and perform a thorough examination. I was also required to establish the activity limitations and goals to make future treatment as functional and meaningful as possible.

ACTION

On subjective examination, I initially spoke directly to the child, building rapport by asking about school etc. From this I gradually became more specific, asking about what he was experiencing when he ran and exploring his thoughts. From the information I gathered from the boy, I then proceeded to confer these details with his mother and her perspective of his pain. This provided me with valuable information about where the pain was, what aggravated the pain, what had already been done and what the mother felt would help. Using the information I had retrieved, I began my objective assessment. This included postural and gait analysis, as well as specific tests of the knee, hip, ankles and feet. My supervisor assisted me in this element of the assessment, and he performed additional tests he had acquired over his physiotherapy career.

After the examination, we concluded that the main source was the altered foot posture, overly pronating affecting knee and hip alignment. I then instructed the boy through active supination by trying not to squash an egg that he had to keep safe under his foot. This was a game that I showed the mother to continue at home as often as possible.

On speaking with the mother I noticed her anxiety towards the pain her son was experiencing and possible surgical interventions that had been suggested on the internet. I reassured her that considering she had noticed it so early, children can change and adapt rapidly, so with correct input we would be able to make significant improvements. This alleviated some of her anxiety and she left feeling confident that she was on the right path to resolve the issue.

RESULT

As a result of this session, we had a clear understanding of the issue at hand and had a rough plan of our future treatment approach. I had also reassured the mother to reduce her anxiety, which also reduced anxiety in the child.

EVALUATION

In this session I was able to effectively build rapport with the mother and child through effective communication and a good approach. This rapport then translated into the assessment, and the boy was willing and trusting to allow me to do the assessments I needed to do.

My objective examination was less fluid, as I was unsure of which assessments were applicable. I also found it difficult to keep an open mind to any other underlying impairments, as the pronation and altered posture was so obvious.

In this situation I had a few treatment ideas that I had acquired from Notre Dame practical lessons, so was able to instruct the boy on how to perform these and give a few suggestions of running at the beach and wearing thongs as other strategies to encourage altered foot posture.

STRATEGIES

A strategy I found useful was starting the session with general conversation about school and friends to build rapport with the child. It is important that the child feels comfortable with you, especially when you will be asking the child to de-robe and be performing assessments on them. In future I will have a better knowledge of this impairment as I have now seen it presented clinically, so will be able to perform the objective examination in a more efficient and effective manner. Another strategy crucial to a good clinician is keeping an open mind, to discover all underlying impairments and get a whole picture of the patient in front of you rather than putting all presentations to text book as everyone is an individual.

STARES 2

SITUATION

A middle aged male artist presented to the physiotherapy clinic with left hip pain being his main complaint. On subjective examination I was able to uncover that he had recently sprained his right ankle and consequently ceased his normal activity for a period of 3 months. After his 3-month break he had rejoined martial arts class on a Wednesday afternoon. He found this activity to be aggravating, particularly falling to the ground onto his hip and the jarring of landing was most painful. The morning was stiff and sore with slight improvement after some movement, though excessive exercise also aggravated it. He also reported a prior diagnosis of arthritis in his hips, which he is currently taking medication for. When asked further about any other pains, he reported symptoms in his shoulders bilaterally that became most prevalent with driving. On a long drive the shoulder pain progressed to pins and needles in his hands, in the median nerve distribution and shaking his hands alleviated the pins and needles temporarily, though not the shoulder pain. He had no troubles with painting. He no longer had pain in his ankle. From this subjective examination, the relevant objective examinations were carried out on the hip, shoulder and wrist joints. It was found that the left hip had significantly reduced ROM, especially into flexion and was painful on Quadrant and Faber’s test. On muscle power testing it was found that he had mildly reduced EHL power on the left indicating an L5/S1 nerve root issue. The shoulders both demonstrated positive impingement signs, particularly of supraspinatis as well as a lack of correct scapular stabilisation and posture. Finally from the subjective and objective examination of the wrists, he was found to be positive for carpal tunnel syndrome.

TASK

In this clinical situation I was to undertake this patients full initial examination and treatment independently with background supervision. This also included writing a letter back to the referring GP explaining my findings, treatment and recommendations.

ACTION

On subjective examination I proceeded to thoroughly investigate not only the referring and presenting complaint but also all other pain experiences and retrieve all relevant information to guide my objective examination. From this I developed theories on each of the pains and their source of symptoms, which I would confirm or negate through my objective. I undertook the relevant tests of the hip, shoulders and wrists with occasional hints and suggestions from my supervisor. From this I made an clinically reasoned diagnosis of what was causing each pain experience; arthritis in the hip joint and tightening of the hip capsule, decreased mobility at the left L5/S1 facet joint, bilateral shoulder impingement and carpal tunnel syndrome at the wrists. I explained these to my supervisor who agreed with my findings and told me to proceed with treatment of these. My treatment incorporated mobilisation of the L5/S1 facet joint, mobilisation of the hip joint, instruction on scapula setting and posture as well as a home exercise program including hip stretches, rotator cuff stretching and strengthening and carpal tunnel stretches. After treatment, I wrote a letter to the referring GP, firstly thanking him for the referral and then proceeding to explain my findings, treatment and recommendations.

RESULT

The patient felt better and re-assured following his session. My supervisor was happy with my performance of the subjective, objective and treatment of this patient and felt confident in my clinical reasoning to identify the source of symptoms and treat accordingly.

EVALUATION:

Overall I feel I performed well in this case. I was able to thoroughly examine the patient as well as apply sound clinical reasoning to determine a diagnosis and treat this appropriately. In particular, I feel my subjective examination ability has thoroughly improved while on this placement and I am able to structure questions as well as drawing from their answers to get information that I previously would have missed. I also felt my ability to recognise possible source of symptoms from the subjective examination to narrow down my objective tests has improved and was effective and more efficient, again paying credit to my subjective examining ability. Throughout this session though, I had a few difficulties, which I would like to work on and improve my technique for future patients that may have similar presentations. Firstly, on examination of muscle power, I initially missed the EHL weakness, due to lack of experience in identifying poor quality of movement, as well as a poor technique. Secondly I lacked the endurance or strength to apply the hip mobilisations for an extended period. My supervisor then showed me a different technique that was easier, though still taxing. This is something I would like to practise and improve on. Lastly, I have had little experience in writing letters to fellow health professionals. My supervisor assisted me in writing the letter to the GP, though in future I would like to be efficient in doing this independently. My main issue with this was the language and terminology that would transfer to other health professions as well as what to include and what to leave out of the letter.

STRATEGIES:

As mentioned time and time again, having good background knowledge is the key to success in any situation. Being able to explain yourself to a fellow clinician, as well as to a patient is a skill that develops over time, though having a prior understand the concepts yourself, helps a great deal. When questioning a patient, I find asking more questions rather then less helps significantly in understanding the patient’s experience. Strategies I will employ in the future will include; practising techniques and working on techniques that I find more efficient and effective, especially for treating male patients that are a lot bigger and stronger then myself, as well as getting experience in writing letters to other health care providers and members of the community.