patient with a pre-morbid disability

Whilst on my orthopaedic prac, i treated a patient who was quite disabled. He had been involved in a car accident and had a broken NOF, however was also wheel-chair bound most of the time pre-morbidly. He came across as having a mental disability as well and so when i first saw him, i used very simple language and treated him like someone who had a mental disability. After my first treatment session with him, his mum told me that he was actually fine mentally and quite intelligent. This was rather embarrassing for me as i had been treating a 19 year old like a 5 year old. It was still hard when i treated him later on because i would start using really simple words and then have to remind myself that he actually had near perfect cognition. This taught me just to take extra care when working with people with a disability and to properly check what their disability is before you see them. This would just help this happening again in the future and will help us gauge the best way to interact with them.

Perseverance

The biggest challenge doing prac in a country where they speak a foreign language is developing effective non-verbal skills to get the intended result. There are positives and negatives about working with children over here. Firstly they primarily respond by non-verbal communication anyway but it is the simple commands that hold you back. Secondly, even though you don’t need an extensive vocabulary, these children (especially the ones with Autism and ADHD) have very limited attention spans. 

One child in particular was very reserved, however constantly seeking visual and tactile sensory stimulus. Over a couple of days I noticed that he thrived off repetition and habitual activities, such as walking on the beams in a continuous circle holding your hand. He would go on all day if you didn’t stop him. Having poor core stability and balance this boy needed to progress. Reaching outside his BOS was a foreign idea for this boy. 

I attempted to gradually challenge this boy by taking my hand away. Eventually after much perseverance I was able to get his walking sideways and backwards. This activity required two of us using primarily manual handling to guide his feet. On this placement, I have learnt to pick up on small improvements as things happen a lot slower over here with the language barrier. In addition, my non-verbal communication skills have improved quite a bit.

continuing ed.

I found it very challenging having never worked with Autistic and ADHD children before. One child in particular was excessively hyperactive. He would bounce around and around on those bouncing balls without loosing any energy. Any attempt at a one on one treatment session with this child was a mission. He would follow commands of the Chinese speaking staff but obviously we struggled in that department.

 I had been allocated with two other students in this sensory integration room who are studying Occupational therapy. Sensory being one of the domains of OT, they came up with some sound ideas that I have taken on board and thought I’d let you all know about if you don’t already. 

The first technique is to firmly wrap the child like a sausage in a blanket for ~ 5 minutes. As the child can’t move their limbs, they are calmed down. It worked a treat. The second calming technique I adopted from the centre was the use of a large fitball that had rubber spikes all over it (like those easy grip catching balls). All the children laid down on the mat and for 15 mins the therapist rolled the ball up and down each child in supine and prone. I gave it a go and it almost put me to sleep. This experience has taught me to feed off other health professionals for new techniques and knowledge that may improve the effectiveness of your treatment. 

Thinking outside the square

I am currently on placement in Shanghai, China working at a children’s rehabilitation centre. I have been working with a 16yo child with quadriplegic cerebral palsy. As she is quite dependent, she tends to be left in her wheelchair off of to the side, poorly positioned. Rarely are her footplates ever down for her feet to go on which leaves her in a slouched and abnormal posture. She is not the only child in the centre that I have observed with poor wheelchair positioning and footplates not in use. With the language barrier it is hard to communicate the purpose behind our treatment. I felt very frustrated and helpless in this situation. Some of the staff are unaware of the consequences poor positioning can have on a weak and hypertonic body. With the help of an OT student who spoke fluent Mandarin to translate, we demonstrated and explained correct wheelchair positioning for this child with additional methods for support. Using what we could find we adjusted the foot plates, applied a hip and chest strap, rolled towels either side of the trunk for support and finally a sandbag in between to assist with the adduction/IR contracture. The rationale was clearly translated and the therapist was appreciative. Every day since, effective positioning has been applied for this child. This child is now more alert in this position and will participate in more activities. This experience really made me aware of the mental/emotional effects good positioning can have on someone's confidence. It just shows what you can achieve with limited resources. It is also now our aim to develop a staff handout informing them of the importance and reason behind correct positioning.

Bronchoscopy

This semester I was able to sit in on a bronchoscopy of a patient who had suffered lung cancer and had had previous surgery to implant a stent in her right main bronchus. The consultant who performed the inverstigative procedure was kind enough to explain to us the entire procedure from start to end including the process of anaesthetising the patient and its effect on the respiratory system.

Although I have been able to observe surgery and video assisted procedures before, what made this experience so valuable was that the consultant, medical students and anaesthetists all took the time to treat the procedure as an educational tool. What would of taken 10 minutes to see whether the stent was still in situ and to laser off any scar tissue ended up taking half an hour due to the consultants willingness to explain and allow us to get as much out of the experience as possible. He even ended up quizzing myself and the other physio student in a non threatening way, assuring us that we know more than we think!

I valued this expreience greatly as it was nice to know that there are other professionals out there who insist on sharing their knowledge and time rather than seeing us as annoying students and ignoring us which I'm sure we've all experienced by someone this year. It makes such a difference to our learning when people strive to get the best out of us.

wry neck pain

What is wry neck. How do we treat acute neck pain.

Neck pain as a whole is a major contributor to disability worldwide, with about 70% of the population experiencing an episode of neck pain at some point in their lives. Wry neck is a recognised syndromes causing pain in the neck it occurs as involuntary contractions of the neck muscles, leading to abnormal postures and movements of the head. Fortunately wry neck is a transient and self limiting condition that can usually recover in a few days to a week. There are usually no risks or complicating however neck pain can return. Statistics show that around 10-15% if the population has neck pain at any given time.

What causes wry neck?
The exact cause of wry neck is not know but usually results from unusual movements or prolonged abnormal postures. It is thought that one of the joints in the neck become jammed or locked, resulting in a painful, protective muscle spasm. Any one can get wry neck but is typically occurs in young people between 12– 30 years of ages

Characteristics of Wry Neck
• A sudden onset of sharp neck pain
• Pain can be anywhere in the neck extending the head, shoulder and upper back, usually worse on one side.
• Difficultly turning head in one direction
• Patient is unable to correct posture due to pain and muscle spasm.
• Palpable neck spasms on affected side.

Differential Diagnosis
It may not be Acute torticollis
• Non Specific neck pain
• Cervical postural syndromes
• Cervical spine degeneration
• Acceleration / deceleration injuries
• Cervical spine fracture
• Acute never root pain


Explaining the Symptom
As Wry neck an abnormal contraction of the muscle in one side of the neck, people may appear with their head turned to one side. Their head is rotated due to the attachments of the spasming muscle and the pull of the muscle on the neck whilst contracting. The loss of movement in the neck may be due to pain and tightness of spasming muscle.

Evidence based Treatment

What work and what doesn’t
Multi-modal treatments – stretching/strengthening exercises and mobilisation/manipulation
Proprioceptive and therapeutic exercise—Muscle energy exercise
Massage - release tight affected muscle and reduce pain
Thermotherapy - heat pack applied to painful muscle
Acupuncture—short term pain relief. Can help with muscle tightness.
Temporary use of a soft collar – collar can provide support and comfort for a short period for acutely painful necks. Not generally recommended as the neck is best kept mobile and exercised naturally

Thank you

AGED CARE LOW VS HIGH

Recently on my gerontology prac, I wondered what determined whether a patient that required aged care went into low care or high care.

There was a patient on my prac who was admitted due to hospital from an aged care facility due to functional decline, staff at the low care facility report this particular patient was to not able to return to the facility because they were unable to cope with their needs, and basically admitted the patient to hospital because they believed they required a high care facility to “cope” with this patient.

This patient’s mobility was limited in terms of distance although they were independent with a WZF up to 30 metres. If they were to return to the low care facility they needed to walk independently to the dinning room, which was 80 metres. My aim of treatment was to build to this level so that the patient could return to the low care facility. The patient’s mobility had a big influence on whether or not they went into low or high care. This reflects in the staffing and funding difference between the low and high care facilities.

From this example we see that mobility has an influence in whether a patient requiring aged care goes into low or high care, but not the whole picture.

Assessment of patients going into residential care is done by someone on the Aged care assessment team (ACAT) they ask a number of questions relating to the patients needs and determine what appropriate placement for each individual is. This essential determines the funding paid to the residential care facility.

Funding is based on three domains
Activities of daily living
Behaviours
Complex Health Care

In reflection, it is not the physiotherapist job to determine whether or not a patient goes into aged care, although in the hospital system we are the experts on patients mobility and are uniquely positioned to rehab patient to a level which achieves there maximal level on functionality. I thorough knowledge of discharge options is required to discharge patients to the most appropriate facility to care for there needs.

patella femoral pain

My musculoskeletal prac, included a lot of patients with anterior knee pain. I would say it was one of the most commonly seen area of visits by patients. I effectively treated this condition but I wanted to search the literature to see if my treatment techniques had any evidence base behind them.

Patellofemoral pain (PFP) is used to describe pain in and around the patella. It is an umbrella term used to embrace all peripatellar or retro patella pain in the absence of other pathologies. Other terms of chondromalacia patellae, anterior knee pain, patella malalignment and patellofemoral arthralgia have all been used synonymously with PFP. PFP is often seen in physically active individuals and may account for almost 10% of all visits to a sports injury clinic, reported incidence rates of 7% exist among young active adults. The cause of pains may differ among patients, with the pathologic origin of the disorder not clearly understood. Numerous structures within the patellofemoral joint PFJ are susceptible to overload. A number of these intra and extra articular components can be responsible for the generation on neurosensory signals ultimately responsible for the perceived pain.

PFP is believed to develop when an individual experiences an increase in the magnitude of the PFJ load. The increase in magnitude of load can be considered in two categories intrinsic and extrinsic. Extrinsic load being affected by the bodies contact with the ground therefore moderated by body mass, speed of gait, surface and footwear. Intrinsic factors can influence both the magnitude and the distribution of the PFJ load. Increased femoral internal rotation, knee valgus and subtalar pronation are all intrinsic factors that can contribute to the development of PFP. The overload the PFJ structures may be sufficient to initial a painful response. The increase in PFJ load results in PFP through injury of the musculoskeletal tissue from supra-physiological loads, either single maximal loads or lower repetitive loads. Injury to these tissues initials a cascade of events encompassing inflammation of the peripatella synovium through bone stress. Thus any number of pain sensitive structures can results in the conscious sensation of patella femoral pain.

Differential Diagnosis
• Patellar tendinopathy
• Fat pad impingements
• Osgood-Schlatter lesion
• Referred pain from hip
• Quadriceps tendinopathy
• Patellofemoral instability

Characteristics of Patellofemoral Pain
• Pain in anterior knee may be non-specific or vague. Medial, lateral or infrapatellar
• Pain aggravated by activities that load the patellofemoral joint – eg stairs, running
• Insidious onset unrelated to traumatic incident
• May have small amount of swelling above or below the patella

Functional Anatomy of the patella femoral joint
At full extension, the patella sits lateral to the trochlea. During flexion the patella moves medially and come to lie within the intercondular notch until 130 degrees of flexion, when it starts to move laterally again. The patellas mediolateral excursion is controlled by the quadriceps muscles, particularly vastus medialis oblique (VMO) and vastus lateralis (VL) components. With increasing knee flexion a greater area of patella articular surface comes into contact with the femur, thus offsetting the increased load that occurs with flexion. Loaded knee flexion activities subject the PFJ to loads many times the body weight (eg 7-8 times for climbing stairs) Anatomically the lateral structures of the PFJ are much stronger than the medial structures, so any imbalance in the forces will cause the patella to drift laterally.

Intrinsic contribution factors
These factors may contribute to the development of patellofemoral pain
Remote factors
Increased femoral internal rotation
Increased knee valgus
Increased tibial rotion
Increased subtalar pronation
Inadequate flexibility
Local factors
Patella position
Soft tissue contribution
Neuromuscular control of the vasti

Diagnostic features of PFP
• Display typical clinical features without other pathology on the knee
• Positive McConnell’s Critical
• Pain on palpation of patella facet joints
• Medical Imaging
• X-ray – can show osteoarthritis and an increased likelihood of sinding-larsen-johansson lesion
• MRI- increasing popularity of investigating PFP, due to its capacity to image the patella articular cartilage.
The majority of patients do not require imaging although it may be useful to confirm a clinical impression obtained from the history and examination.

Evidence based Treatment
What work and what doesn’t

Based on summary of Literature found in Brukner and Khan (2006)

Multimodal Intervention – rest from aggravating activities, ice, short course of NSAID’s, electrotherapeutic modalities, mobilisation, acupuncture and taping.
Level 1 evidence
Taping – aim to correct abnormal position of the patella in relation to the femur.
Level 1 evidence
Strengthening exercises – VMO training program, generalised strength training
Level 1 evidence
Stretching—Stretching tight muscles—NA
Hip muscle retraining – retraining hip abductors and external rotators helps to control the lateral pelvis and has been associated with pain reduction in patients with PFP— NA (no available literature)
Foot Orthoses – in shoe orthoses can be an effective management for PFP
Insufficient evidience—Level 1
Surgery – to be avoided. In very resistant cases surgical options may be considered.


Thank you

shin splints

Whilst on my musculosketal prac I treated a patient with anterior shin pain, not having come across shin pain before I had very little treatment ideas and advice for this patient in regards to managing his pain and preventing it in the future. I thought in my blog I could elabourate on what shin splints is and give some evidence based treatment advice If other student s treate a similar patient.

Shin splints are described as pain and discomfort in the leg from repetitive activity on hard surface, or due to forceful, excessive use of foot flexures. The term shin splints have historically been used as an umbrella term for shin pain which is not stress fractures. More recently descriptive terms of Medial tibial traction periostitis MTTP and Medial tibial stress syndrome MTSS have been used to more accurately description the involved anatomy and presumed pathophysiology of this common condition Beck (1998). Published studies report that shin splints accounted for 6-16% of injuries among runners, this been the third most common injury reported among runners. There is still no clear consensus of the pathophysiology in this condition thus naming of this condition may change with further research.

Differential diagnosis
• Medial tibial traction syndrome
• Bone stress reaction or stress fracture
• Chronic exertion compartment syndrome
• Popliteal artery entrapment
• Muscle-tendon injuries, strains and tendinopathy.

Signs and symptoms of Medial tibial traction syndrome
• Dull ache in over the distal one third posterior medial cortex of the tibia.
• Pain may decrease with warm up
• Pain typically worse with loading and resistance
• No focal area of pain present as that may indicate stress fracture

Diagnosis is made through
Hallmark clinical features - tenderness over a 4 to 6 cm area at the posteromedial margin of the middle to distal third of the tibia
Ruling out other pathology - Special test for stress fracture. Using a tuning for over the site of tenderness can provoke pain in the presence of a stress fracture
X-ray - indicated to rule out TSF, infection or neoplasm but findings are generally normal with MTTS
Triple phase Tc bone scan - scan is highly sensitive for tibial stress injuries with the added advantage of being able to distinguish between MTTS and TSF
MRI - has become an increasingly utilized modality for assessing tibial stress injuries.

Patho-anatomy
Neither the exact pathophysiologic mechanism nor the specific pathologic lesions are completely understood in MTP. Traditionally researcher believed the underlying mechanism was repetitive microtrauma to the periosteum and fascial attachments as a result of traction forces from the soleus and the flexor digitorum longus musculature. Although more resent research Beck (1998) is suggesting MTTS like TSF is a bone stress reaction caused by chronic repetitive loads that induce tibial bending forces. It is believed MTP is merely a symptomatic expression of normal periosteal modelling at the site of maximal tibial strain whilst under load.

Evidence based Treatment
The foundation of treatment is based on symptomatic relief, identification of risk factors and treating underlying pathology.
• Activity modification - relative rest and activity modification
Level 2 evidence
• Cushioned orthoses with a semi rigid medial arch support to assist with shock absorption and support pronated foot – can significantly reduce the overall incidence of and specifically prevent medial tibial periostitis
• Level 1 evidence
• Appropriate footwear
• Resolve acute inflammation and promote analgesia - Non-steroidal anti-inflammatory, ice, massage, ultra sound whirlpool baths and acupuncture.
Level 2 evidence
• Soft tissue therapy – digital ischemic pressure, sustained myofacial tension and transverse frictions.
Insufficient literature
• Vacuum cupping
Insufficient literature
• Surgical release – in very resistant cases, has a projected success rate of 70% improvement in high-performace elite athletes

Returning to Sport
The return to activity for athletes after treatment for MTTS must be gradual and individualized. Cross training (eg cycling, swimming, deep water/pool running) and altered training is essential to resolve with conditijavascript:void(0)on. Athletes must adhere to the “start low and go slow” mantra. Once athletes are asymptomatic, it is recommended to start at 50 percent of their baseline training load and increase the frequency/intensity/duration by 10 to 15 percent per week. They should avoid back-to-back days of repetitive impact activity for the first two to four weeks, depending on the severity of the case. If symptoms recur, two additional weeks of rest are recommended and should be followed by a “downgraded” training regimen. Patients can often achieve a return to full, unrestricted activity in three to six weeks. However, a delayed return is not uncommon for this often refractory condition.

I hope this information helps any other students if they treat anterior shin pain.

Abuse on the ward

Recently on my cardio placement, myself and another student happened to encounter a patient with an extremely violent history with unresolved severe mental illness, drug abuse and was Hep C +ive. He was admitted to the ward with a severe chest infection and subsequently stayed for most of the duration of our 4 week placement.
Although we did not directly have to treat the patient as he was deemed too aggressive, we did on occasion have to talk past him and talk to him when he confronted you. The patient hadd 14 code blacks (personal threat) called against him and required 4 point restraint on the bed and sedation on multiple occasions. He also required security guards to follow him whenever he left his room.
The patient became increasingly aggitated and restless as the weeks progressed and his behaviour more unpredictable to the point where he lashed out at a nurse who was not even looking after him and proceded to assault her. Knowing this it made it made me feel anxious and nervous around this patient when I passed him in the ward as he had a tenedency to talk to anyone he wanted to very unexpectably and would demand you reply. I found myself not acting like I usually would and becoming quite reserved around this patient.
Unfortuntely the patient picked up on this and and the change in behaviour toward him and not other patients was enough to set him off into a spat of abusive insults to all staff on the ward.
I learned as the days went on that the best way to deal with this patient was to be alert and on your toes at all times due to his unpredictability but also to treat him like anyone else and ask him how he was and try to relate things to his life even though I was not treating him in any way. The patient responded well to this and would often initiate harmless conversation with me knowing that I wouldn't judge him for his past.

Unprofessionalism

Recently I went to a neuroloigical consultation and multidisciplinary team meeting with my senior to discuss the progress and future care plan for one of my patients. What utterly shocked me the most was the extreme unprofessionalism of the meeting particularly on the neurological consultants behalf. I had been preparing myslef thoroughly for the meeting so that I could provide all the health professionals with the best handover I could so that the team looking after my patient and the consultant knew his progress (and also so I didn't look like a really unintelligent student and make a fool of myself). I had always looked up to consultants, respecting them completely for the amount of hard work, effort and years of dedication that they had given to their field of expertise.
The meeting opened with jokes and comments regarding flatulence, with the consultant proceeding to ask all 15 people in the room their preferred way of using toilet paper (folding/scrunching). I thought that this was highly inappropriate especially for someone like me who was new to the meeting and had never met many of the health professionals before.
It took over 45 minutes to begin the actual discussion on each patient and even then the consultant continued to make bizarre and inappropriate comments about patients and other topics.
On leaving the meeting over 1 hour and 45 minutes later, my senior proceeded to tell me that she also felt that the situation was very unprofessional however I would have to draw my own conculsions on the matter. Was it purely just a bit of fun and humour? I feel not, I felt like all the staff there also thought that the behaviour was unaccebtable but laughed along anyway because it was the consultant, a senior staff member. However to me he will not be so respected in regards to his communication with other staff.

Helping those that do not help themselves

How do we assist someone who does not want to or have the desire to help themselves? On a recent placement one of my patients who was morbidly obese with severe arthritis of most of her large peripheral joints which in conjunction with each other and her lack of motivation had resulted in a severe loss of function.
On the second time that I visited her I found that she would rather blame her lack of mobility on everything else other than her weakness, escessive weight and lack of motivation. In the public health sector, resources and staff are stretched to full capacity as it is, there simply is not the time or manpower to do everything for these patients and treat them on an ongoing basis.
I know that this particular patient may have thought I was a little cruel but I refused to be lenient as I knew she had the ability just not the motivation or the determination. When pushed this patient could get up and walk to the physio gym from her ward rather than be wheelchaired. On one particular session I managed to push her to walk 250m after she had previously been to or from the gym. On subsequent session, the patient displayed utter disgust and shock when I arrived to her room without the wheelchair in tow. She complained the whole way but I didn't care, she was safe and stable which was the most important thing. The only reason she was still in hospital was becuase of her weight and her instistance that she was not ready to go home.
She could abuse me or any other physio all she liked but we are only trying to ensure that she receives the best health outcome. Sometimes shock tactics is what is required to motivate people or to get them to take ownership of their own health. No one else is responsible for their lifestyle and health choices. She may like the nursing staff that come round to see her rather than physio but it is not their respoonsibility to know what specific areas this particular patient needed addressing in.
At some stage treatment and care for these patients has to cease, but when? However it is a fine line between ceasing treatment completely and maintaining treatment to prevent readmittance to hospital. In such an instance what do you do?
In the end the patient was discharged much to her disapproval and was provided with rehab in the home to focus on functional goals within a contextual setting. Quite frankly I was glad she had left because I felt that there were so many other patients that could of benefitted from my help, I really didn't see the point in wasting my time, her time and resources on someone who was draining the system.

Protection

Over the course of this year, we have been exposed to the depressing and sometimes unfair reality of the hospital system. Personally I have experienced two patients who have died overnight and a number more with terminal illnesses. If I have encountered this number of morbid situations in my relatively short time working in hospitals, I give full respect to those that have worked for much longer than me. Especially the professions that are exposed to death and dying on a much greater scale than a physiotherapy student can imagine.

At the beginning of the year I was shocked at the amount of humour that was related to death, dying, injury and the general disease process and its effects. I could appreciate the humour from a comical standpoint but was nonetheless disturbed by the prevalence of it. And it wasn't young, uneducated laymen who were making these jokes, it was educated, experienced, professional medical, nursing and allied health staff that had the largest comedic repertoire.

It bought up a memory from high school where a good friend of mine was telling me about his older brother who had recently graduated from medicine. My friend and the rest of his family had intensely strong christian beliefs and values and the older brother especially was a role model in his faith. So I was shocked to be told about how only a year into his medical profession he was having major doubts about his faith and the place it had in situations he was seeing in his career. Fortunately these doubts were dispelled and this doctor was able to use his religion to protect himself from the deeply affective nature that a working in a hospital has on you.

For those of us who do not share similar beliefs or embrace religion, humour seems to be the most effective way to protect ourselves from the emotionally jarring circumstances that we encounter in hospitals. This isn't humour that insults, patronizes or belittles a patient but humour that allows us to sometimes detach ourselves from terminally ill patients that we have undoubtedly formed an emotional connection with. Some strategy of coping, whether it is humour, physical activity or an ideal home environment is essential in our line of work.

reputation

Earlier this semester I completed my rural prac in Kalgoorlie. In an overall sense Kalgoorlie is quite a large town, but the portion of the town that is permanently based there is significantly lower. As such it falls prey to the usual country town syndrome of gossiping. From what other students have told me, they too have experienced this, whether it be another WA rural town or an international placement in a small community. Coupled with this is the fact that the majority of students are still in their early to mid 20's, a well known stage in life in which we are still prone to do silly and even stupid things.

During our rural pracs most of us would have worked longer hours than our metropolitan placements and had no days off. Therefore it is logical to assume that over the weekend we had quite a lot of steam to blow off. The country pubs and international nightspots in south east asia are great places to let your hair down and have a bit of a party. What I only realised after I had done my rural placement, was the potential for anything we had done over the weekend to trickle back to our places of work.

Luckily for me I had an established group of friends in Kalgoorlie and did not get up to any real mischief over the weekends. The real danger is the affect an event over the weekend, in a non-professional setting, can have on your professional reputation during the working week. Not only can you lose respect in the eyes of your fellow health professionals, but you could lose the respect and necessary authority that is needed to be an effective professional in the eyes of your patients. Especially the local ones who would know anything that happened to occur over the weekend. This affect may not even be obvious but it could be sneaky and insidious and undermine your reputation.

So although those that choose to work in a rural and remoter communities over the following years would be aware of this more than I could be, I thought it was important to re-iterate this point. Remember you can have plenty of fun, but be prepared for the consequences to your professional reputation if something you do is considered great gossip material.

bouncing around ideas

In my last blog I mentioned my feelings towards my musculoskeletal outpatient prac. One other aspect of this prac that I thought really appealed to me was the number of students that were in the placement at the same time. Even though it meant less face-to-face time with our tutor, it facilitated a social environment which I believe improved our skills as physiotherapists. Maybe as a result of the decreased time we could spend with the tutor, there were many times when we bounced treatment and management ideas of each other. Although most of the time we didn't drastically change our approach according to any person's advice, it did guide our decision making and clinical reasoning process for the better. By receiving input from other students with differing ways of thinking, ideas that we might have missed were made clear to us. All in all it was a highly effective way in which to provide the most comprehensive management for our clients.

Once we begin working in the following years, those of us working in a hospital or large group setting will still have the advantage of being able to confer with a multitude of other physio's. Not just physio's though, every other health professional we are associated with can assist us in some way or another, which leads me to my final and illuminating point.

I believe it is absolutely necessary for those beginning their careers in a private practice, to establish a network of professional health workers that are able to assist in clinical reasoning and decision making skills. I know there are some freakishly smart students among us, but even they can not possibly know enough (as new graduates) to provide the most effective treatment possible to each of their patients. Even a close group of new graduates that are working in private practices throughout Perth, can be utilised to share ideas on how to best treat their patients. Remember we do have facebook...

job direction

Before I completed by musculoskeletal placement earlier this semester, I was in no way planning to work in private practice physiotherapy. So I was pleasantly surprised to find out how enjoyable physiotherapy in a musculoskeletal outpatient setting really was. This was because it gave you the opportunity in most cases to completely manage a patients care based on our own knowledge and clinical reasoning skills. We were still guided in our decisions by doctor's referral letters, but the final decision on the patients diagnosis and subsequent treatment was mostly up to us.

In an in-patient setting the patient, in most cases, already has a diagnosis made by the medical team and we are asked to apply our skills to complement their plans and ideas on how the patient should be treated. Now in no way do I disagree with this process, in my limited experience it seems like this way works the best. What I am trying to emphasize is the greater opportunity to clinically reason and make decisions in an outpatient or private practice setting.

I still believe the direction of my career will lead me to a hospital setting, but in this situation I really appreciated this full year of clinical placements and how it exposes to work settings that we never even considered just a year or two ago.

Coming to grips with mortality

Working in hospitals makes us become so much more aware of our own mortality. It's difficult not to empathise too much with patients, or want to become too involved in their lives.

A patient I saw on the ward was an example of this. She was a 59 yo woman presented to hospital after a dizzy and fainting spell. I was asked to review her due to her unsteady gait, and decreased equilibrium responses. During my initial assessemnt, I felt a real connection with this lady- we got on very well, and joked a lot. I recommended she use a zimmer frame, whilst medical testing was being completed to work out the cause of her sudden onset of symptoms. She shared her history with me, she just left her job to start her own business from home. She had put down her dizziness to overwork from the amount of work she had put in to setting up her business, working up to 18 hour days some days.

However, her symptoms continued, and she did not appear to be making any improvements. However, I built a stronger and stronger rapport with this patient, and looked forward to my daily treatment sessions with her.

Then at the ward meeting, the medicos told me news that shocked me. This woman had lung cancer, which has metastasised to her brain, and was given maximun of three months left to live.

I felt really uncomfortable with seeing her after I knew this. What do I say to someone is such a situation? Our friendly comraderie had gone, we lost rapport.

Looking back, I feel we lost rapport on both sides of the therapist- patient relationship. I couldn't believe such a diagnosis could be given to such a young and active person, and this lady was coming to grips with her prognosis. I don't know how to prevent this in the future, but this was my initiation to the unexplainable events of life and death that are an everyday occurence in hospitals.

Patient perspective...

In the final week of my final prac for this year I managed to badly injure my knee and end up in a knee splint and on crutches. I was able to see first hand the emergency department of the hospital I was working in, and was instructed to take the week off. Scared of failing my prac, I didn't take time off, and persevered through the week.

What I learnt during this week as a patient/therapist was invaluable. When we are able bodied, we take for granted our mobility, freedom and ability to do the tasks we are required to do with little or no effort. Day to day we see patients either in outpatients or on the wards who are on crutches, have a cast on, are in pain, post-op or in a great many other conditions. Its so easy for us to instruct people to use crutches, or to say 'use this brace for a few weeks', often without realising how hard that will be for the patient in their day to day lives. On doctors orders, I was only allowed to talk to patients, verbally give exercises, do easy hands on tasks and have an assistant for my initial assessments. I wasn't aware of how frustrating this would be! I had to totally change my way of looking at things, and the way that I ran my treatment sessions.

Another 'lightbulb moment' I had during this week was the frustration of not having a diagnosis or prognosis for my injury. Patients often come to us searching for answers, and we are not always able to give them what they want. Due to cirumstances, I was left not knowing what damage I had done to my knee, whether I would require surgery or whether I would simply wake up the next morning and it would be better! This is a scary situation to be in, and we need to be aware of this with all of our patients - be aware of the psychological impact of the injury, as well as the physical marking such as swelling and pain. Mental state can have huge repercussions for recovery and good outcome. Tell them as much as you can - don't assume they won't understand, or shouldn't know. Communicate!!!

Last but not least, I learnt that when you walk with crutches, or limp, or can't do things due to pain, people stare. They just can't seem to help themselves. Don't stare at someone on crutches!!! Help them out if they look like they're struggeling with a heavy door, or simply offer them a seat if you can see they have a brace on and are hurting (I know, as physio students I'm probably preaching to the converted, but I had a surgeon at the hospital take a chair that I was about to sit on, and then say 'that looks painful'. Duh.)

Although injuring myself whilst on prac was not a good thing to have happened, it gave me an invaluable insight into how life is for so many of our patients. One of my patients has been on crutches for 5 years, and will be using some sort of walking aid for the rest of her life. She didn't have a lot of sympathy for my sore wrists from hopping around the hospital on crutches!! Put yourself in the patient's shoes (hopefully not literally like I did...) and then rethink what you want to tell them, or prescribe them to do.

ignorance about PT

I have just realised how little some other health professionals think some physios do. Last week there was a meeting held mainly between orthopaedic surgeons and the anaesthetists to try and establish what the best form of anesthetic was to enable early mobilisation and post-op recovery. Members of the allied health team were also there to provide input when appropriate.

In a nut shell, the surgeons were asking if there was any evidence-based literature to support a form of surgery where patients didnt need to have an epidural or regional anaesthetic and therefore had less chance of a motor block preventing standing on day 1.

What shocked me was that several anaesthetists boldly said they thought mobilising day 1 post -op had little benefit. When the physios and surgeons promptly told them that yes it was infact beneficial, they asked why a few orderlys couldnt just stand them up and support the quads if a motor block was in place. Most people were shocked by this statement as it showed just how little these anaesethetists knew about physio and patient treatment. This therefore highlighted to me the need to be able to rationalise our treatment choices and have a strong justification for what we do as there will be many people out there who try and challenge our choices.

staff communication

Since this last prac has been the first one for me on an inpatients ward, it has really helped me to work as a team with the other staff. I have learnt how much easier everyone gets along if people help out even when a task isn’t really in their particular field. For example just little things like taking the time to help a nurse roll a comatose patient over so they could change them meant that the next day that same nurse helped me walk a day 1 post-op patient that needed x2 assist, when really it should have been the other physio student.

It has also shown me how important it is to coordinate tasks with other staff. Since walking is so tiresome for some older people, they can often walk only a few metres before being tired for the next few hours. This means that its really essential to time it so that when we get a patient OOB, it fits in with the nursing staffs plan of when to shower them, sit on the commode etc. It has just really opened my eyes to the benefits of talking with the other staff so that everyone knows exactly what’s happening and can work together to a job done the most effective way for us and the patient.