Final entry

FINAL REFLECTION

My concerns at the start of prac were valid, and unfortunately my experience was formed primarily by observation. Nether less, even though I was not directly involved in any way with the management of patients, I was able to spend plenty of time writing SOAPIERS, researching, analysing treatments performed and reflecting on patient care. I think in particular these aspects of my placement were the most beneficial and something I can take with me into my next musculoskeletal placement.

Furthermore, Observing patient care was beneficial because I now have a foundation knowledge on how different presentations were treated and why! I also have available at my disposal a very different method of treating low back pain that could be incorporated into our training at university.

In my initial reflection I commented that I would have preferred to complete my musculoskeletal placement once I had finished cervical and thoracic spine unit. I will have to do another musculoskeletal placement next year so I am not concerned about this anymore.

Also in my initial reflection I commented that I was concerned my supervisor would not be available because he was travelling and very busy. This was the case so I spent the majority of my placement with one of his colleagues. Unfortunately this clinician was very inexperienced so I valued the time I had observing my supervisor manage his patients.

Overall while my opportunities on this placement were limited I still feel I gained a lot from the last 5 weeks and look forwd to carrying these skills into my clinical year. I did enjoy the private practice setting and the patients were all very wonderful compared to my previous placement. I can see this environment as somewhere I would like to work in the future.

Reflection three week 5

REFLECTION THREE – WEEK 5

S/
I was given my first opportunity to undertake a subjective and objective examination today. The patient had already been receiving treatment for his low back pain at the private practice, so my task was not to undertake an initial assessment, but get an opportunity to practice under a mock situation.

T/
The task to be undertaken was a subjective and objective examination of a patient presenting with low back pain. I was required to perform an appropriate subjective exam in order to plan and undertake an appropriate objective examination. Whilst I already understood this patient’s diagnosis and prognosis I was required to pretend that it was his first consult so I could demonstrate some clinical reasoning.

A/
With guidance of the UNDA assessment proforma’s, I conducted a subjective examination asking all the appropriate questions for a patient presenting with low back pain. Following my subjective I planned and carried out an appropriate objective exam.

R/
The result of the assessment allowed me to hypothesise a diagnosis for this patient. I was able to ‘subgroup’ him into a peripheral neurogenic with compromise. The asterix movement was extension and Left side flexion. The motion Segment L4/5 reproduced the patients symptoms on palpation.

E/
Overall I felt as though I performed the assessment very well, considering it was my first go. The result of my assessment could have been impacted on by a few weaknesses. Firstly my technique for some of the objective techniques was poor. This was mainly because I was rushed and so was forgetting about the small things. Secondly, on reflection I forgot a few times on enquiring about symptoms and resting symptoms. Finally I had my patient moving around too much, I needed to plan my physical exam in order (i.e standing, sitting, supine, prone etc.). Finally this experience allowed me to see how important it is for musculoskeletal physiotherapists to think on the spot in order to conduct a full soapier in the 40 minute timeframe allowed for an initial consultation in a private practice.

S/
While I am learning, a strategy I would like to implement in the future as a student is to take a moment to plan an appropriate physical examination following the subjective. This would allow me to consider technique and what measurements are most appropriate on the initial consult, resulting in better outcome for myself and the patient.

Reflection Two Week 4

S/

Throughout my current placement, I have spent a lot of time observing patient care in the private practice. This private practice see’s heaps of low back pain patients, and while I am not in any way actively involved in patient management I have had many discussions with my supervisor regarding the diagnosis and treatment of his low back pain patients.

T/

Every Low back pain patient (somatic control, somatic mobility, somatic pain dominant, neurogenic with and without compromise, centrally mediated, SIJ) has received the same treatment (sometimes with slight variation).

• Superiorly directed Unilateral PA of whole lumbar spine, Both sides
• 5 half push ups
• Grade IV or V Rotation PPIVM both ways
• Bilateral Stretch of Hip flexor, Piriformis and Quadraceps.
• SNAG (MWM) 3x into flexion, extension, LSF, RSF
• IFT or Intemittent lumbar traction.
• Half pushup or backwards bends as home exercise.

A/

On one occasion a new patient presented and my supervisor undertook a quick 5 min Subjective and Objective exam (active mvmt then PAIVM’s). From what Dr Ben Wand has taught us at university this patient would have been the ultimate somatic control dysfunction presentation, even from what I gathered in the short examination undertaken. This sparked discussion with my supervisor regarding subgrouping of patients and subsequent management.

R/

The discussion I had with my supervisor really demonstrated the different style that we have been learning at university. I think it would be great for my supervisor to understand my clinical reasoning regarding LBP so I have proposed to design a short presentation based on EBP – Lumbar spine, making a diagnosis and formulating a treatment plan.

E/

I very much appreciate the evidence based approach to low back pain we have been learning at university. I have observed on placement and been able to reflect on many aspects of the management of LBP. I have noticed that from the above treatment provided that the patients which would be sub grouped into the somatic mobility dysfunction (extension bias) have been responding well, but most of the LBP patients haven’t changed in status since I began my placement. Only twice have I seen a control exercise given but with poor understanding of the purpose of the exercises I doubt the patients will do them properly, if they even do them at all.

S/ This placement has really opened my eyes to many aspect of the management of LBP. In particular what I need to take from this experience is the importance of a THOROUGH subjective and objective examination in order to appropriately subgroup patients and thus provide the best possible, appropriate treatment for each INDIVIDUAL.

First reflection week 4

S/

On my current placement I was given the opportunity to become involved in a patient’s care. I was asked to put together a hydrotherapy program for a patient that was recovering from a rotator cuff repair. The patient was 7/52 post op and the surgeons orders were to progress to active assisted exercise only until 10/52 post op.

T/

The hydrotherapy program needed to be designed based on the above considerations. The goals of the hydrotherapy program was to improve ROM of the right glenohumeral joint, decrease pain and to gently improve strength, control, endurance of the right shoulder complex musculature. My supervisor also explained that another common goal for all hydrotherapy patients includes building excellent posture and core stability so this also somehow needed to be included in my program

A/

I was very motivated to design an excellent program because I haven’t been involved in any aspect of the management of any patients until this opportunity. My project began with reading through previous hydrotherapy programs designed for a similar patient with similar goals and HPC. I also read through my PHTY 221 (upper limb) notes and readings regarding rotator cuff repair and appropriate exercise. Finally I utilized Pub MED and PEDRO and found a few appropriate systemic reviews that gave me some excellent ideas. Finally I spent lots of time observing hydrotherapy in the previous 3 weeks, so planned to incorporate many of these ideas.

R/ The program I came up with was very thorough. It included education (some rules, i.e. shoulder must remain submerged throughout program, core strength etc), appropriate warm up, cardinal movements of the shoulder, combined movements of the shoulder, gently capsular stretches, some hands on physiotherapy mobilizations, core strength and postural exercises and warm down.

E/

After the first hydro session overall I felt the program went really well but there are definitely certain aspects that could be improved. Firstly, emphasis needed to be made on the exercises being active assisted (so buoyancy assisted is OK but against buoyancy or gravity needs to be avoided unless assisted), especially because the patient has a background of working in the army and consequently pushes himself and the boundaries. I need to explain that pushing too hard and into the pain defeats the purpose of the exercises and why. Secondly I would like to add some diagrams of the exercises or stick figures because while the exercises are well described they still tended to confuse the patient somewhat.

My supervisor gave me lots of positive feedback and said in particular she thought the gentle capsular stretches were a wonderful idea and something she hadn’t thought of before.

S/

I think taking in all the above ideas when designing future hydrotherapy programs would produce very appropriate, individualized programs.

Initial entry

I am looking forwd to commencing my musculoskeletal placement tomorrow. While I am excited, I feel that I may have preferred my musculoskeletal placement next year once I had completed the cervical spine unit and consolidated my knowledge a little more. On the other hand, I have just completed my lumbar spine unit so I am fairly confident with this material. This is beneficial because a peer that attended this placement previously suggested a large patient cohort are low back pain patients. I have spent alot of time revising material from the previous units but still unsure about so many aspects... so i am looking forwd to learning alot on placement.

As a student on my musculoskeletal placement I am hoping to get involved with patients as much as possible. I am a very visual and hands on learner so I need to be involved and not just an observer. I am concerned that my participation might be restricted because I am placed at a private practice but hopefully this is not the case.

My only major concern is that after speaking to Tom (my supervisor) he mentioned that he will be taking holidays midway through my placement and I will be transfered to a different physiotherapist. I am worried that this might affect my progress or confuse me if the physiotherapists are very different, particulary in their teaching methods.