FInal Entry

On reflection of my initial journal entry, many of my concerns and anxieties were ungranted. The first issue was my concern about the family I stayed with- they were very welcoming and easy going so I settled in well within the first week. The second issue was my concern regarding my preparation for my placement. I feel as though I had adequately prepared for most of the tasks and presentations that I was exposed to on prac, and otherwise I had the appropriate study material to facilitate my learning.

I was indeed exposed to a wide range of physiotherapy practice. I was involved in and helped run hydrotherapy classes (in particular ante-natal post-natal/baby, and arthritis sessions), used the RTUS machine to help diagnose and train core stability, participated in and conducted Clinical Pilates classes and individual sessions on the reformer and trapeze equipment, and performed musculoskeletal Ax and Rx sessions for patients ranging from paediatric to geriatric age groups.

My prediction that I would be more of an observer in my first week was also correct. As placement progressed I was given the opportunity to perform ‘hands on’ Ax and Rx in the second week, and conduct Pilates, antenatal, and post-natal classes by the fourth and fifth week.

I was very grateful for the experiences and learning opportunities that this prac provided me with. My supervisors Emily and Craig were inspiring clinicians and such welcoming, supportive, and caring people that I could not have asked for a better prac or a more enjoyable rural experience. In particular I was thankful for the opportunity to be introduced and trained in Pilates, and realise the importance and role of core stability in treating such a wide range of conditions. I also really enjoyed the women’s health aspect of this prac, which has inspired me to consider pursuing this area of physiotherapy in the future.

Week Five Albany

S- Over the last 5 weeks I have been treating a 48yo lady for chronic bilateral neck pain/stiffness. She described her P1 as a deep dull aching pulling pain aggravated by L&R rotation, L&R SF, and extension. She works as an OT doing geriatric home assessments, as well as administration duties which involves many hours of computer work. She demonstrated a kyphotic thoracic and cervical posture with increased muscle bulk and pain in upper-trapezius and levator scapulae which the pt reports to have developed over the last 25yrs in concurrence with commencing work. Her symptoms have been present for about 9 years but increased in intensity approximately 2 months ago particularly on the R. Treatment over the weeks has involved STM (to upper trapezius, levator scapulae and ES Thoracis) including the use of a cyrostix, cervical manual traction and SNAGS into R rotation, thoracic mobilisations (SNAGS and PAs), a shoulder girdle and neck stretching and strengthening HEP, and the loan on a theracane for additional soft tissue release. Initially treatment was directed at soft-tissue work, but with some improvement in the muscle after 2-3 sessions, the treatment was later focussed more on joint mobilisations with only some soft-tissue work and additional stretches to do at home. On re-ax during and after Rx, the pt would report a reduction in pain and stiffness and demonstrate a slight increased ROM. However after ~2-3 days the pt’s symptoms would re-emerge and therefore the pt was coming into physio 2x per week.

T- On my last day of prac it was my task to perform a reassessment and evaluate the progress that the patient had made since initial ax in week one. It was also necessary to establish the most effective line of treatment and consequently the focus for her short and long term goals. Throughout the 5 weeks it was my goal to improve the patient’s symptoms to a point where she was able to manage at home with a HEP and progress to physio only 1x a week.

A- At the beginning of the treatment session I took 10 minutes to discuss what the patient thought was the most effective treatment and what she believed was the focus for the next 1-2wks vs the next 6-8wks. To reassess the pt’s progress I measured her Cx ROM and performed Cx PAs to establish her mobility of C2-C7.

R-The re-ax showed that there her L and R rotation had improved from 1/2 ROM to ¾ ROM over the 5 week period. However after discussing her long and short term goals, the patient expressed that they had not achieved as much progress as she would have liked and that the changes were only temporary. The patient reported that the soft-tissue treatment had relieved her stiffness but the results were only temporary whereas the joint mobilizations did not seem to make as big a difference to her symptoms but seemed more permanent. As a result we agreed to set the short term goal to focus on joint mobilization and progress her stretching and soft-tissue HEP and the long term goal to achieve more permanent soft-tissue changes.

E- I believe my strengths were the way I conducted the interview with my communication skills. I discussed with the patient that if there was still no change by the end of another 3weeks or another 6 sessions that we would need to refer her on or discuss alternative therapies. I was able to work cooperatively with the patient to establish patient centred goals that would optimise her outcome. My weaknesses in this session and throughout her whole treatment history have been an inability to cause a significant permanent change in the patient’s symptoms. After the treatment session there was again only a slight increase in ROM to ¾+ ROM.

S-Although I achieved the task of establishing long term and short term goals and an accurate re-ax of the patient asteric movements, I did not however reach my goal of being able to see the patient only 1x a week to maintain her symptoms. Strategies I could have used include referring the patient to a massage therapist sooner in order to achieve soft-tissue release independent of physiotherapy. Or otherwise I could have acted upon my supervisor’s suggestion to get the patient myofascial release injections. I do believe however, that I exhausted many of the physiotherapy options that were available to treat this patient’s neck pain. Maybe another strategy for this patient would be to extend the time frame of expected results due to the chronicity of her neck pain.

Week Three Albany

S- This week I had the opportunity to independently perform a complete subjective and objective assessment along with the corresponding treatment. The patient presented with 2 pains and some numbness of her foot. Her worst pain(P1) was across the metatarsal heads of her L foot and was described as a dull ache, intermittent, deep, 6/10 at worst and 0/10 at best. The pain was aggravated with 25 mins+ of running and barefoot walking around the house and eased with relative rest and heat. Her second pain (P2) was in the proximal lateral leg near the STFJ. The pain was described as dull and aching, intermittent, deep, 2/10 at worst and 0/10 at best. This pain was aggravated during breast-feeding where she assumed a cross-legged position and eased with neutral sitting position. Her numbness was in the S1 dermatome along the dorsal aspect of the lateral L foot. This numbness had been present since pregnancy and did not change with position or activity. The patient reported that there was no relationship between the pains.

T-With this information I was required to perform the relevant tests and treatment with a 30 minute period to establish the source and nature of her symptoms and provide some relief of these symptoms.

A-To assess her P1 I palpated the area, performed accessory movements, OP and passive physiological movements on metatarsophalangeal and interphalangeal joints, assessed active and passive ROM of her talocrural and subtalar joints and observed her gait pattern on treadmill walking/running for 5 minutes. None of these tests were able to reproduce her pain. However I did observe a pronated gait pattern with early toe off which increased from walking to running and an increased muscle bulk to Tibialis Anterior. As a result of this testing I decided to discuss footwear options with the patient, advised to use rest, ice and elevation when symptoms occurred, suggested a referral to the local podiatrist for an in-depth gait analysis and possible orthotic prescription, as well as giving her a dynamic rotational calf stretching HEP. For her P2 I assessed Tibialis Posterior, Fibularis Brevis and Longus muscle length as well as palpation. Upon palpation of Tibialis Posterior the patient reported similar symptoms to her pain. I did not have time to perform a neural integrity or neurodynamic test to investigate this patient’s numbness.

R-The patient reported that she was keen to investigate her gait pattern with a podiatrist and had thought for a long time that she might need orthotics. My analysis of her P1 was that insufficient support of a pronated gait pattern when running was causing localised inflammation and increased loading to her medial metatarsals, which may be exacerbated by her recent pregnancy and continued breast-feeding. During her assessment I believed that P2 may have been the result of a tight Tibialis Posterior muscle.

E- Upon review of this assessment I believe I need to work on my time management in order to complete the testing of all this patient’s symptoms. I also think that I did not assess P1 and P2 in enough depth. I think I should have gotten an objective measure of the patient’s Soleus muscle length instead of just Gastrocnemius before giving her a calf HEP. I also think it would have been worthwhile to perform a neurodynamic SLR +PF/INV to ensure there was not a neural contribution to her P2 considering the proximity of her symptoms and her Fibularis nerve near the STFJ.

S- In future I think it maybe necessary to consult briefly with my supervisor between subjective and objective assessment to discuss the progression of the assessment and again between objective assessment and treatment of the patient. I think this would help to organise my analysis of her symptoms and lead to a more efficient and accurate diagnostic and treatment process. I also think I need more practice at performing the assessment in order to achieve good time management…practice makes perfect so hopefully it is only a matter of time!

Week One Albany

S-During this week I had the opportunity to individually treat a patient that had been seeing my supervisor for the last 4 weeks. She originally presented for physio as part of a worker’s compensation claim with L lower neck, scapula and radiating arm pain following a struggle with a child in a school classroom. So far she has been prescribed scapula setting and strengthening exercises, treated with trigger point release and laser to T3-T6 and upper trapezius, Tx mobilisations to T3-T6, and given Butler ULNT stretches. When the patient presented to me she complained of additional radiating pain and twitching sensations into her L scapulo-thoracic region and some radiating R scapula pain. Upon questioning, the patient reported she had not been doing the ULNT stretches.

T- In order to address these new symptoms it was my role to re-assess her ULNT and explain the nature of her pain (twitching radiating pain is associated with neural involvement and is most likely a neurogenic non-compromise condition.) In addition I was required to continue her previous line of treatment.

A- I identified positive results upon testing her L ULNT1 and R ULNT3. I then explained that these symptoms were due to an inability for the nerve to move within the surrounding tissue, which places tension on the neural structure leading to her radiating twitching pain. I then progressed by explaining the importance of her ULNT stretches and trigger point release as the best line of treatment, and that her symptoms would persist and progress if she did not cooperate with her HEP. Other components of the treatment session involved Tx NAGS mobilisations, STM, laser treatment and a review of her strengthening HEP.

R- Although the patient promised to perform their HEP more diligently, she did however express confusion about the nature of their pain and how testing the UL nerves indicated neural involvement in her scapulo-thoracic pain.

E-The strengths of this session included my execution of her STM and Tx mobilisations treatment (she reported feeling less stiff and less pain with an increased ROM into Tx rotation.) As a result of this treatment I believe the patient’s condition had improved. Nevertheless I feel as though I need to improve my ULNT assessment in addition to my communication and education skills when attempting to explain the nature of neural involvement to a patient. In particular I feel as though I need to document the onset of her neural symptoms more accurately during assessment. As a result of my poor explanation I think the patient may not have understood the nature of her pain and the importance of performing the HEP.

S- As a result of this treatment session I have found an ULNT assessment sheet, which allows documentation of the pt’s symptoms at each stage of the tests. I also plan to research the nature of her thoracic radiating pain and prepare an information page on the neurogenic pain and the corresponding treatment. As a very intelligent woman I think this patient would benefit from knowing the technicalities of her condition and treatment which might also motivate her to perform her HEP and optimize her outcome. 

Initial Entry- Rural Prac 2009

On Monday I’ll begin my rural placement at the Shiel Family Practice in Albany. Although I’m excited about my rural placement and the experiences it will bring, I also have additional concerns that I didn’t experience in my preparation for metro placement last year. There is definitely an element of the unknown- not knowing the family I’m staying with, not knowing the area I’m living in, not knowing my role or expectations in the family home, not knowing if I’ve prepared enough for the varied clinical presentations etc.

It is my understanding that I will have a very broad exposure to the different areas of physiotherapy (as is the nature of rural practice). I expect to be involved in hydrotherapy classes (in particular ante-natal and post-natal/baby sessions), using the RTUS machine to help diagnose and train core stability, learn and begin to teach elements of Clinical Pilates, observe and begin to perform musculoskeletal Ax and Rx sessions and complete the required documentation.

As a student in this setting, I predict that I will be more of an observer in my first week as I learn the necessary skills and protocols of a practice that is dominated by the concepts of Clinical Pilates. As the placement progresses I hope that I’ll quickly pick up the skills and be given the opportunity to perform ‘hands on’ Ax and Rx.

I believe that this placement will allow me to experience some of the areas of Physiotherapy that I am most interested in including Pilates, women health, and musculoskeletal. For this reason I look forward to meeting my supervisor, Emily, and learning as much as I can from this placement. I also hope to embrace any opportunity to get involved in the community including sports, events, and exploring the local area…Albany here I come!