Compliance at first sight

On my rural prac in Kalgoorlie I was introduced to a patient suffering from Parkinson's Disease who had recently undergone cardiac surgery in Perth. He had been transferred back to the rural hospital and was in need of basic post-op physiotherapy that would also take his PD into consideration.
The physio treating him before me was not having much luck, as the patient would often feel depressed, not willing to do exercise and fearful during any treatment. Subsequently he was not achieving his goals as well as was hoped for.

My initial assessment with the patient was with the physio's supervision and we were not able to persuade the patient to partake in our treatment plan. He got tearful and requested to go back to bed. The next time I saw him it was by myself and the treatment session consisted of ambulation and basic bed mobility. Even though it was quite a short session, the patient was performing the tasks set by me with relative ease and was enthusiastic about them. I saw him for a total of 2 weeks for twice a day and was able to observe improvements that would impress even the most disillusioned physio or physio student. I was quite happy with the thought that I had succeeded where working physiotherapists had failed.

During the remaining time I had left in my prac I realised I might have been a little full of myself during that time. I was able to observe my supervisors deal with patients and situations that had left me baffled and frustrated and also see which patient's responded the best to each of us. What I'm trying to highlight is the fact that how well your patient is improving might not always be a direct reflection of the quality of physiotherapy you are providing. Sometimes a patient may not be responding well due to factors out of your control. In this case the patient and myself automatically 'clicked', we had similar senses of humour and were also able to discuss our aims of treatment in ways that we both understood and were happy about. In no way was this a reflection of any superior physiotherapy skills I might have compared to my experienced supervisor but rather an example of two personalities that worked well together.

In conclusion, palming off a patient to a fellow physio might sometimes actually be the right thing to do, as a last resort. Not with the aim to reduce your workload and make life easier for yourself but with the realisation that for reasons out of your control, a different physio with a different personality might be better for the patient and his well being.

viscous cycle

At university we are taught the gold standard. It has come to my attention that this may not always be possible. No matter how hard you try.

While treating a patient with an ABI resulting in dense left hemiplegia, for 2 sessions we attempted to improve this mans standing capacity. I was using the Gold standard technique of no shoes to enhance proprioception and everything. For this particular patient, his ability to stand was limited by immence localised pain and discomfort on the sole of both of his feet (pain meds had been administered). He would easily be able to stand longer if he had no pain. On assessment, dorsiflexion was slightly limited due to pain and a nodule was found on the sole of his left foot, which reproduced this mans pain when palpated. For 20 minutes i mobilised this patients feet with a variety of techniques which improved range but did not eliminate pain.

When standing this patient (x2 assist) post rx, he experienced pain immediately and was able to maintain for no longer than 1 minute.

It seemed that a viscous cycle had formed. this man had painful, tight feet due to prolonged recumbency and tone which prevent him from improving his standing capacity and therefore he remains off his feet.

Clutching at straws, i approached the medical team about re-assessing his pain control and in the mean time brainstormed. We trialed standing with his joggers on as the sole has arch support. This improved his standing capactity to ~5 minutes before limited by pain.

It is in these situations i feel that minor changes need to be made to break the viscious cycle. This prac has definately challenged my problem solving skills in a good way!

A supervisor: it could be you next year!

On my current cardiopulmonary placement I am being supervised by a Physiotherapist who graduated only two years ago. Although she is young and may not necessarily have a wealth of knowledge behind her (considering she has only been working as a physio for a short time) I think she is the best supervisor I have received so far.

There have been a few things that I’ve noticed that makes her supervising style effective. They include:
- Thorough orientation on first day: highlighting our expectations and the format of our placement
- Continually asking us questions (for example interpreting investigations or assessment findings, or giving rationale for treatments) in a non threatening manner
- Using the Sandwich approach of feedback (positive, negative, positive)
- asking us to write draft copies for the initial few extracts in patient notes, of which she edits. Once the standard is high enough we are able to complete them ourselves.

There is a high possibility of us being supervisors within the first few years of graduating. We should take note of the styles the supervisors adopt, and consider if they are effective or ineffective.

Hopefully we can make the students learning experience memorable for all the right reasons!

Prolonged stretch as a HEP for hypertonia

I recently completed a placement in a rehabilitation centre in Malaysia for people who have undergone stroke. Time frames ranged from 3 months to 5 years. Although impairments were various, the majority of patients endured problems with hypertonia (spasticity) in the trunk, upper limb or lower limb. Presentation of the upper limb usually consisted of increased tone in pectoralis major, biceps brachialis, wrist pronators and flexors, and finger flexors. Affected muscles in the lower limb usually included hip adductors, hamstring muscles and muscles of the posterior leg (gastrocsoleus, FHL, FDL and Tibialis Posterior).

There was an apparent difference between those patients who routinely stretched their muscles each day and those who did not. If they came to their treatment session having reduced tone in their muscles, then the majority of the session could be focused on other impairments (muscle strengthening, reduced balance etc) and functional retraining. However if they did not come prepared, the majority of the session was spent conducting prolonged stretches of each muscle until tone was reduced. By the end of the session, fewer outcomes were achieved.

I believe prolonged stretches of muscles with increased tone should be considered as one of the primary home exercises prescribed by the practitioner. They are easy for the patient to administer. And as they take a long time to do, they are inefficient for the practitioner.

I suggest it is a good idea to create a comprehensive muscle stretching program, with written diagrams and explanations, as well as frequent re-assessment to ensure the patient is conducting it effectively.

In an acute setting, this may not be as effective, as the patient is likely to be seen by the physio for up to four hours per day. But it appears effective in the case of long term rehabilitation, where the patient may only see the physio for an hour each week, of which time must be spent wisely.

student overload

In the rehabilitation setting, patients tend to be in hospital for an extended period of time, some even up to 9 months. Consequently over that time, many students come and go. When dealing will ABI patients, there is always a probability of behavioural issues, therefore to get the most out of our neurology experience the supervisors will tend to allocate patients with little behavioural problems and always a good hemi. Unfortunately with low turn over of patients and such a specified patient presentation, it can be the same patients that get allocated students. This means a slow thorough ax and analysis before treatment. By the third student, the patient begins to know more about his presentation than us in addition becoming frustrated and unmotivated.

So being the 6th round of students for this particular patient, it was fairly obvious that he has preconceptions about physio students. I could completely empathise with this patient. For both of us students there, we both felt very unworthy of assessing and treating this patient. The supervisors were already aware of this patients feelings and his motivation to just continue with his usual physio sessions. We were not allocated this patient for our daily sessions.

Over the weeks spent on this placement, gradual rapport was built with this patient and made me realise that even though we are here to learn from the patients, the patients expect the therapist to use their time efficiently and see results. I will now always endevour to prepare for patient sessions and make sure ax, analysis and treatments are explained and related to the patient for a combined goal vision.

Appropriate treatment progression

I am currently on rural prac based in a hospital which treats many indigenous and fly-in/fly-out patients. As well as working on the ward I am seeing many musculoskeletal outpatients, which has presented an issue that I have not come across in metropolitan areas. The frequency of non-attendance is very high for appointments, as patients forget, organised transport is unreliable and appointments are often not a high priority.

I have found it difficult to establish ongoing treatment programs with time-specific goals with most of my patients for one reason or another. The low attendance as mentioned before means that when I see someone, although we can book another appointment in, say one week, there is a good chance I won’t actually see them for two weeks for various reasons. Similarly, it is difficult to book appointments with the patients who fly in and out of town for work as they are often not here yet not based in the metro area either, so referring on doesn’t necessarily work either.

Yesterday I had a specific example of this where a 24 year old female had sprained her MCL one week earlier and I was seeing her for the first time. She was then flying to Perth a couple of days later for two weeks, which I could see would make it difficult to give ongoing advice and intervention that was progressing at the appropriate rate.

My approach to this problem was to recommend that she see a physio back in Perth during her time there, and to give advice for the next two weeks as much as possible. For example I told her she needed to keep trying to improve her knee flexion range guided by pain, however also information about what she would be best doing if the pain resolves within a week in terms of graduated return to activity. I found this difficult with all the “what-ifs” and felt frustrated that she could easily come back from Perth with an aggravated injury or a lack of progress.

I think it is important with these patients to always explain the plan beyond the next week or two as future appointments at the ideal times may not be possible. Does anyone else have any suggestions to provide the best management for patients in these circumstances?

frontal lobe deficits

With only experience thus far in the main fields of musculo and cardio, my neuro placement specialising in head injury was something very different. Not only were there physical deficits but a variety of frontal lobe injuries. One patient in particular, (i was in charge of for a week while a physio was absent) had predominately behavioural problems. This young man required a companion 24/7 and constant attention.

Physiotherapy sessions with this man, consisted of a 1/2 hour basic exercise program for strength and balance as he had regained most high level function (walking and jogging). I was instructed to supervise and guide this mans exercise program every morning for that week. i can tell you now that i exhausted all of my persuasive powers and was mentally drained after each session. He would never initiate an exercise unless 1. instructed and 2. wanted to do the exercise. On my first day with this patient i took the 'lets be friends first' approach as he was similar to my age. This worked relatively well as the patient was compliant with all exercises, except for him putting his arm around me by the end of the session. I wasn't sure what to do in this situation, so i changed the exercise swiftly to something requiring both his ULs and nothing more was said

This situation didn't make me feel too confident in dealing with the situation if it were to arise again. At uni, we are made aware of frontal lobe issues that can occur however there was not much insight on how to deal with them. I was also unaware of what the patients behaviour variance was like and therefor not sure how he would react to me saying that his behaviour was unacceptable.

I discussed the situation with my supervisor as she said that what i did was perfectly fine and that every patient is different, requiring team consistency and trial and error. I was informed that this patient had lost the ability to determine a level of social appropriateness, for example he will talk about 10cm away from your face and put his arm around you. Together we derived some strategies to try the next day. A Strategy utilised by the other health professionals was consistently reminding the patient to shake hads instead of hugging as a component of re-teaching the patient appropriate social skills. Other strategies that were successfull included myself participating in the exercise and having a rewards system, whereby if he was compliant he got to go outside in the afternoon and play sport.

After this experience, i have learnt that discussing strategies that can be utilised by all staff work the best, as this reinforces consistency. Also that each patient needs an individual approach. The next day i employed these strategies which worked very well. In the future i will endevour to discuss ideas with other staff members and make our treatment meaningful to the patient.

Patient who does not like physios

On my last day at rural prac, I was given an interesting patient to work with. She is a patient who just got transferred from hospital in the city. She required basic physiotherapy services like a mobility assessment and ambulation. She has been in hospital for 6 months now and the nurses have told us that she is sick of physiotherapy, sick of physiotherapist shouting at her demanding her to do stuff.

I approached the patient who had just finished with the nurse and was lying in bed. I started off with introducing myself and giving her an overview of what we would be doing. She consented to the session and I thought to myself that she is not as scary as the nurse made her out to be. I started asking her some questions being very careful not to repeat any questions that she has been asked before by other staff but half way into it the patient stoped short in her replies and stated that she has already answered these questions to someone else who came in before me. I apologised and acknowledged that she is probably tired of repeating the same stuff but because the information has not been put in the notes I would need the information to plan my treatment with her. The patient was very understanding and we continued with the subjective assessment. Later I managed to proceed through my objective assessment without much hiccups except that the patient was not willing to stay standing for longer than 1 min or ambulate. I did however managed to get her doing many incidental sit to stands and completed my objective assessment. However, the patient dictated the end of the session by going straight back to bed when she decided that she’s had enough. I spoke to the nurse regarding what I managed with the patient and suggested that the nurse encourage the patient to ambulate simply because the patient might be more receptive to other health professionals.

I came out of the session wondering why she was portrayed as such an intimidating character for physios. Personally, she felt like a patient who is just not very complaint. However, with patience and true empathy, the patient was quite co operative. I suppose if future similar situations arise I will not go into the session with preconceived idea as it will make me nervous and cloud my judgement about the patient. It is also a good opportunity to practice multidisciplinary team effort by communicating with the other health professionals to incorporate some of our treatment goals into their session. This would be especially helpful for patients who do not work well with certain health professionals and thus time spent with the patient can be more efficiently used by concentrating on the goals that can only be achieved by physio intervention.

Our role with young neuro patients?

I have not been on my neuro prac yet but I’ve had the opportunity to see a patient who suffered from head injury on my rural prac. On reading the handover notes, it seems like walking was an important functional goal for the patient. Although the handover notes did state swimming as a long term goal, my supervisor and I both thought that the patient should be contented if he could walk normally.
However, when we saw the patient, he was more abled than what the handover described him to be. The issue with this patient was that the facility I was at could not afford to offer him ongoing services. Hence, we wondered about the future management of this patient.
I was not sure how much services the patient could access. For instance, for patients who are at falls risks, they would come in for about 6 sessions to get them to a level where they could participate in one of the community groups before eventually doing their exercises on their own. Yet with this patient, he is already at a good functional level but because he is such a young patient, I feel that he has more potential which might go undiscovered should he just continue with maintenance exercises at home. There are no suitable community classes for him and limited resources for his needs. I guess this is the dilemma of people who cannot access the necessary healthcare. At least this patient is functional but he probably will not be able to attain his full potential due to the above mentioned reason. This makes me wonder how many do we actually rehabilitate these young patients who have a neurological deficit which will probably stay with them for the rest of their life? I will probably get a better insight into this when I start my neuro prac.
Coming back to this patient, I started to explore the possibility of him swimming. It so happened that the Paralympics was on at the same time I had these thoughts. It occurred to me that many of the participants in the swimming event could not even walk. Therefore, it would be highly possible that this patient would be able to swim after all. Yet I note with regret our limitations as physios as we are probably not trained enough to help this patient achieve such a goal. As it was my second last day at the facility, I was not able to attend the meeting where his rehab plan is discussed but I would suppose I will be better equipped to answer these questions when it comes round to my neuro prac.

Treatment of possible shoulder dislocation in stroke rehabilitation

On my international placement I treated a left sided stroke patient with severe left shoulder pain. He reported pain on movement in all ranges of shoulder and elbow motion. The condition had increasingly worsened over the period since his stroke. He had not undergone any investigations on the joint, it was unclear whether it was subluxed or dislocated. Upon observation the head of humerus was displaced from the glenoid cavity and his arm was supported in a sling. Shoulder active ROM was 10 degrees abd/Flx P2, elbow F 30 degrees P2. Touch and pain sensation was intact. There were no P&Ns, numbness or reduced blood flow distal to the joint. His functional ability was restricted: he required assistance x 1 to move up/down/side to side in bed, and to roll (of which he did to his affected side!).

I had seen a dislocated shoulder a number of times, and this presentation was very similar. I was almost sure of it. But I was unsure of the role I could play as a physio. I was not qualified to reposition it. And even once repositioned, it was likely to sublux or dislocate again due to increased laxity in joint structures.

My choice of treatment was firstly to reposition his sling so the weight of his upper limb was well supported, and his HOH approximated to his glenoid cavity. I educated him on sling use: to wear it consistently throughout the day, but take it off to complete his stretching program. I recommended he see his GP for an X-ray. I suggested surgery may be an option (however it was unlikely he would financially be able to do this). I taught him how to roll to his unaffected side.

I am unsure whether the course of action I took was the most appropriate, or if there were other treatments I could have performed. I was in a foreign country and did not have adequate supervision. Basically the treatment was discussed and justified between my fellow student and me. I am curious about what course of action to take, as this is a case not covered in our course, and I want to know the best way to treat such a patient in the future. Does anyone have any suggestions? Did I do anything you wouldn’t do? Do you have further suggestions on treatment or management?

Communication with pts who do not speak english

On my international placement I learnt how to communicate with patients who have a verbal communication barrier. This skill will be important when faced with patients whose primary language is other than English. These patients are continually increasing in Perth.

From the first day of the placement, I was expected to conduct exercise classes for patients of Malay and Chinese backgrounds, who spoke various languages including Bahasa Malay, Mandarin, Cantonese and Hokkein, to name a few. This was difficult at first. Initially I spoke in English, using descriptive sentences on what I wanted them to do. I did all the talking, and they listened and attempted to follow. Some patients who understood English comprehended the activities well. However the majority appeared quite lost. By the end of the session was dissatisfied with the results of the class and felt I had confused them. I had failed my role as a health care provider.

Over the next few days I refined my skills. I found with concise, simple word instructions, complimented with body language, effective communication was possible. I used one worded instructions such as ‘up’, ‘down’, ‘left’, ‘right’ etc, along with demonstrating the action. I learnt basic instructions in Bahas Malay, which improved their understanding of each instruction, as well as improved my rapport with them as they realised I embraced their culture. When it was apparent they had not understood an instruction, I repeated it again. Simple things like slowing down the pace of the exercises and repetition were useful. I included them in the instruction process as often as possible by asking them to count (‘kirra’ in Malay), which in turn ensured they were always paying attention.

It is possible to conduct physiotherapy without speaking the same language as your client. Yes, it is more difficult. But the desired results can be achieved.

Professionalism

On my international placement I was confronted with a difficult situation that taught me to control my feelings of frustration and stress in order to remain professional. I learnt that authoritative figures often are not open to compromise and will only do things their way. If challenged they may exert their authority to our detriment. As students, or new graduates, we can only accept their decisions because attempting to change their point of view is impossible.

This is applicable when facing an employer as one single mistake may taint their opinion of you, which may not be reconciled for a long time.

I made the mistake of requesting to compromise leave for a mountain climb. My supervisor thought this very unprofessional. After telling me how she felt, I was taken a back. I continued to defend my action, saying that I thought it was quite professional of me to approach her to make a compromise. She did not agree. Throughout my mid and final placement assessments, this situation haunted me. I left my international placement, not having won her respect back.

It is important for us to make careful calculations of our employers. Even if we don’t agree with them, or think they are too harsh in their judgements. They hold the key to our employment, thus livelihood!

In the future I will ensure I will judge my employer correctly. Then decide what requests are appropriate. I will take much consideration prior to making any form of request that may potentially upset them.

Delayed acceptance

Whilst on my paediatric placement I was assessing children with spastic Cerebral Palsy to determine whether botox injections were likely to improve their function. I was also able to assist the Doctors who gave the injections to ensure the optimal part of the muscle bulk was injected. Generally in this placement I found that the parents of these children were willing to making sacrifices to ensure the best for their child, were very tuned in to what health professionals had to say and seemed to have accepted that the disability was permanent.

During my final week at this placement I witnessed an episode where the parent of a child awaiting injections became very angry. The two year old child had been given the local anaesthetic and was waiting in a room with five other children and their parents for it to take affect before having their injection. I did not see what triggered everything, but my supervisor and I heard her yelling and came into the room to find her slamming a chair on the ground swearing at the nurses and saying that she wished her son had died (I later learnt that he had been in a car accident at 11 months of age).

Some of the nurses were able to settle the woman down eventually and she was asked to leave without her son having the injections. Although I was able to avoid involvement it was still a very important moment for me as a strong reminder that people may not be coping with life-changing issues such as the permanent disability of a loved one. The fact that she was the only person I saw expressing their frustration and anger at what has happened to their child certainly does not mean that she was the only parent who was not coping with their situation.

As a result of this situation I expanded my questioning at all appointments to find out directly or indirectly how the child’s family was coping. Although this seems of obvious importance, it is very easy to focus on the child once you feel that the family is coping and happy with how the management of their child is going. In this situation the child had been disabled for 13 months and yet the mother reacted as if she had just understood the position her and her son were in. This also made me consider that new treatment options or changes to health management or even schools and other aspects of life can trigger responses that may be unexpected. I have become more aware of considering the impact certain terms or procedures can have on a person’s understanding of their condition or that of a loved one, which is very important when dealing with families, palliative care and permanently disabled patients in particular.

not much done?

Patient was a 60 year old lady who is a R-hemi. She had been admitted the night before with an undisplaced fractured R ankle. She previously ambulated with a quad stick but is unable to transfer at present. According to the nurse, she has a fear of falling and is not willing to use her quad stick at all. The nurses are having huge problems with her transfers. I went to see her and found that she was either unable to extend or flex her knee. I did suspect that she did not understand what I wanted but I tried demonstration and moving her limb to show her what I wanted and she was still unable to move her r knee. I did the same with her L and she was able to demonstrate what I wanted so I believe that she was either unable or unwilling to move her R knee. However, I did not know if she was unable to move her R knee prior to her fracture.
I brought her a zimmer frame for better balance and she agreed to try standing. Initially she was like a dead weight, however with some encouragement, she managed to stand with one minimal assist. Her R hand had very high flexor tone and she required assistance to get a grip on the zimmer frame with her R hand. In the standing position, we were still unable to get any movement at the knee. Since it was too painful and probably not advisable to put any weight on the R foot, she had to take her weight through her arms in order to hop or pivot on the L leg. However, due to the involuntary control in her R arm, this was not possible. I ran out of ideas and so consulted my supervisor to see if I had really exhausted my options. She agreed with me that the best we could do is to get patient to stand for the nurses to get the wheelchair or commode behind her. We then went to the nurse and she was happy enough with what we managed to achieve. The nurse shared that they had problems even getting her standing so although I felt that I did not achieve much with the patient, it was significant enough for the nurses.
I was glad to have such a patient that really challenged my problem solving skills. It also made me realise that some things such as transfer can seem like a very basic intervention yet it can have a very significant outcome both for the patient and for the team providing services to the patient. With this perspective, I can go into future practices without stressing too much about doing a proper treatment session when a lot of times the assessment will already form part of your treatment for the day.

when a patient slips through the cracks

While on my rural prac I went out with a staff member to perform an ACAT Ax on an illiterate patient who was exercising his power of attorney and in doing so required a review of the current services he was receiving. All that was known about his PMH was that he had long suffered from COPD and HTN. When queried about his current health status he stated that he was due for a consultation with a specialist in the city for reasons unknown to him. He also stated that his bowel weren't working properly and that he had lost a lot of weight in recent months. His exercise tolerance was extremely poor and as such he had barely moves from his chair not even to go to bed. The only meds he was on to assist with chest function was ventolin.

I questioned the pt over whether he gets any pain, numbness or tingling due to prolonged sitting and rapid wt loss, however this had gone unoticed by all the carers and medical reviews that he had had. The patient's memory was intact and while asking the patient these questions it seemed that the rapid wt loss, poor bowel function, lack of mobility and conflict in medications was pointing to something more sinister.

It apeared that with all the services this patient was receiving and all the appointments with varying Dr's it appeared that each health professional had diagnosed this patient with something different yet no one ha bothered to Ax this pt as a whole & look at his health in the global sense.

Ideally the pt needed to be Ax by a geriatrician who can accumulate all of the findings and tailor the patients medications and services so that he receives the best care. I felt like common logic had failed in this instance not so much from an allied health perspective but from a medical one who failed to notice the change in symptoms and medications. I learned that just by being patient and asking the right questions you can gain far more important information rather than just relying on medical records.

Notes

During my last prac we were required to pick up the previous student's ongoing patient loads and continue the treatment as we felt was required. Often these patients had been receiving treatment for quite significant amounts of time. The hardest part of this was picking up the patient from where the previous student had left off, trying to make the transition as smooth as possible. The main hindrance to making this transition smooth was quality of notes. Most of the notes and handovers for the patients I was to see were great, and told me everything I needed to know and what to prepare for before I saw the patient, but on rare occasion, they had some gaps. This led to frustration on my part, and also on the part of the patient, because it meant that their initial treatment session did not run as smoothly as possible. Although I know that this is what happens in the real world, and part of our profession is being able to pick up where other therapists have left off, for a variety of reasons, it was often challenging. However, this experience made me aware of the importance of clear and concise handovers and notes, and the importance of clarity and detail when recording the main assessment findings. As a result, when the prac was drawing to a close, I ensured that I had enough time to provide the next batch of students with detailed handovers and notes to ensure that their first week was as stress-free as possible!

Reserving Judgement

Whilst on prac in paediatrics I was assessing a 3 year old girl with foetal alcohol syndrome (FAS). The clinic I was in meant that this was a one-off assessment rather than ongoing treatments and appointments. During my subjective assessment I was horrified when her mother confirmed what I had read in the notes, that she had been drinking 48 cans of beer (yes, 2 cartons) a week for several months whilst pregnant with her daughter. She also reported that she had significantly reduced her drinking since giving birth.

I found it extremely hard not to say anything to her about my opinion of what she had done to her child and the 'life' that was given to her. My supervisor was not with me at the time and I spoke to her at length after the patient and her parents had left as I could not believe what I had heard. She did not seem ashamed to admit this either, and although 3 years had passed and she had probably told a number of health professionals before me, I still could not believe what I was hearing.

I had to restrain myself in what I said and how I said it throughout the assessment, which I was able to do by focusing on the child rather than the parents (no family-centred practice here) and focus on what the current problems were as opposed to the cause which could not be reversed. I did not feel I could possibly avoid judging this mother (or father for allowing this to occur), but felt I had to keep this judgement to myself for professionalism, but more importantly so that they would continue with the assessment and treatment their child needed.

This experience was a real wake-up call for me, and although I don't think I would do anything differently if something similar happened again, it was one of those situations where I felt that I wasn't doing the right thing at the same time. This was an extreme example of a lifestyle condition that was not the fault of the person who suffers from it, which I found far more difficult to deal with than, for example, COPD sufferers who continue to smoke.

Patient responsibility...

On my current prac I am treating a number of patients with back pain due to poor postural or motor control. Treatment of these patients includes a 'hands-on' element, but the main emphasis has been on prescribing a convenient and simple home program to help strengthen their often VERY poor core stability muscles. However, most of these patients come to their subsequent treatment sessions and have very obviously not done their home program, or have only done it once and not correctly. Obviously this can be very frustrating for the therapist, and it happens not only with back pain patients but patients with any number of problems.

From this experience I have discovered the importance of explanations to patients in terms of treatment progressions and importance of self management. Often they are expecting a quick fix, or a 're-adjustment' to cure their pain, only to have a recurrence of this same pain weeks or months down the track. Often all it takes is a simple explanation of WHY we are getting them to do all of these exercises, and how long they might have to do them for, and then the patient can take more control over their recovery. Simple education can do wonders for compliance, as a number of people I have spoken to have revealed that the reason they don't perform their HEP is that they can't see the relevance of it, and don't understand that muscle activation is not instantly automatic.

For the remainder of this prac, and in future clinical practice I will ensure that each exercise I prescribe a patient is relevant, and the patient knows why they are doing it. Because after all, it's their body!!!

Rapport...

On my current prac I am treating a patient who seemed very shy at first and difficult to extract information from in both subjective and objective examination. Over the subsequent treatments, she became more and more talkative, until last week, when a simple question seemed to open the floodgates, so to speak. All of a sudden, she was telling me things about her life that I was not expecting, and I was shocked at what I was hearing. No wonder she came across shy to begin with! Patients can become very comfortable with us as physiotherapists and we need to be very aware of this. Some patients often just need to get things off their chest, and in our profession, we are often the ones to hear it. The main things I have taken away from this experience is not only how important therapist-patient confidentiality is, but also how important it is for us as professionals to have coping mechanisms and referral options when cases such as this arise. Patients may tell us very private things if they feel comfortable with us, and we need to ensure that we have ways to debrief, or refer the patient on for appropriate counselling etc if appropriate. If we take on board all of what a patient tells us it can be quite emotionally distressing, and can be a trigger for professional burnout. Therefore we need to be able to cope, and not put our health at risk for the sake of the patient.

It's nice to be noticed!

Apologies for not posting a blog earlier, my semester has been a little different from other students in regards to prac so I hope you are all well.

Whilst on my rural prac in Northam I had the opportunity to sit in on an initial geriatric assessment with a geriatrician that had travelled from Perth to assess some patients in particular. The patient had come to the consult with her son and the thought prior to the Ax was that Parkinson's Disease may be present. Fortunately, I have had experience in a particular Parkinson's Clinic and was able to understand thoroughly and contribute to the discussions taking place.

Watching the Ax take place without the geriatrician making any deductions until the end of the consult gave me the opportunity to make my own conclusions regarding the patient's health. The doctor really made me feel like part of the health team and constantly asked me to take over manual handling and asked me to clarify for the patient the physiotherapy input in the management of living with Parkinson's and occasionally even asked for my advice. I also had the opportunity to perform manual transfers, an area the doctor admitted that medical professionals needed more training in. This made me realise how important it is for our own safety and for that of the patient, to perform correct transfers particularly when their motor control is already compromised. The doctor did not explain things to me as she went along her Ax, rather she made comments to me regarding what she had found in her assessments making me feel like less of a student and more of a colleague which was really encouraging.

I have seen the signs of PD in the past many times before although in past circumstances a Dx had already been made. In this situation, because the patient did not have a Dx it was necessary to apply my clinical reasoning to the observations made and formulate a Dx by exclusion and rule out any other cause for the signs and symtoms. However, when the symptoms of akinesia, bradykinesia, rigidity, festinating gait, mask like appearance, micrographia and low BP are present, the Dx was obvious. Learning the theory behind the disease is one thing but actually obsevring the symptoms clinically is something else completely. Being told what to look for doesn't compare to seeing it first hand.

All in all, its nice to be noticed for our input as PT's and valued for our advice.