Final Entry

1. Final thoughts and feelings finishing this unit.
This prac has been the best physio experience I have had! I absolutely loved this placement and just learned so much. Treating and assessing other students in labs is very different from treating real patients. It was great to get out there and have a go at everything and try to apply all the theory we have leant. It’s funny because while I used the theory we have learnt, I found so much had to be adapted to each client and there are so many different ways of doing things. I feel I did well on this placement and learnt a lot of things that would be difficult to learn at uni.

2. Things I have learned.
I learnt that there are so many ways of doing manual therapy techniques, and they all get results.
I learned how to use older electrotherapy machines, the theory is the same, the buttons are different!!
I have learned how to adapt my treatment for individual clients.
Another thing I have learned is the importance of setting goals with clients and discharge planning.

Tuesday - Handovers and Discharges

Today went very slowly as one client cancelled and one client didn’t show up for her appointment. This meant I only saw one client in the morning, and the one I was meant to see in the afternoon cancelled too. Such a slow day!! I did take the Peripheral Conditioning Class as well. I filled the rest of the time studying and writing handover summaries and discharge letters. I didn’t realize so much paperwork was involved in physio!! As we cannot discharge all our clients we are handing them over to the other physios. My handover summaries were brief but contained the relevant information. It was certainly handy having done them at uni in the labs (thanks Jo!). For the clients we are handing over, but they will probably only come in once or twice more, we have to start discharge letters for them. It would be hard for the physio we hand them onto to write a good discharge letter if they only see them once (although they would have all our notes). For this reason we start the letter now, with initial findings etc, and they will finish it when they discharge the client.

Compromises with Clients

I was involved in a situation today where one of the physios had made a compromise with the client. Even though it was not an ideal situation it worked for the client, which is the most important thing. This particular client has had 2 previous strokes and struggles to walk at all. His aim is to walk his daughter down the aisle in her upcoming wedding. The physio showed me how his gait was anything but normal, and usually she would not allow a patient to walk like that in rehab. The client doesn't care how he walks, as long as he is walking. His gait pattern is not something she would encourage, but as the client only wants to participate in physio if he can walk his daughter down the aisle, she has agreed just to get him walking, no matter how it looks. I suppose this is better than the alternative (him not participating in rehab at all). I guess with experience it gets easier to make the call as to whether it is appropriate to make a compromise with a client or not. In the end it is up to the client what they do or don't do, and we should just try and get the best possible outcome we can with what they are willing to put in.

Another week is over...

Well the past week has been the busiest so far!! We learnt how to do discharge letters. It was pretty simple as there was a template on the computer for us to copy. We didn't put enough detail in our first attempt but with a few pointers from our supervisor they have been getting better. We were aiming to discharge as many of out clients as possible. We have discharged 3 so far and are planning to discharge some this week. We will have to do handovers for the other clients which will take a bit of time to get sorted.

We have started seeing more clients each day and I prefer it when we are busy. I found I am getting better at doing the objective assessment and a lot faster with it. We easily managed to see 6 clients the other day. I asked my supervisor and he said it would be normal to see around 12 clients a day if that was all you were doing (i.e. no meetings or paperwork etc). I feel as if I could handle a few more a day but certainly not 12 just yet!!

There was one situation that occured in the past week that left me a little upset. One of our clients had a TKR and was told by the surgeon he could go back to work in approx 6 weeks. We gave him rehab and he was doing really well. I thought he could definatley go back to work. Unfortunately he went back to see the surgeon and was told he couldn't go back to work at all. He has had to retire. The surgeon said that the knee replacement was not made for work. The client said he would have liked to have known this before hand. He still would have had the op but would have been in a different mindset. The client said he was too scared to ask the surgeon why he had changed his mind. I just found this unfair and the client was clearly upset about it.

3 Weeks Over

The end of the third week finished well. On Thursday I got to go into surgery! It was such a great experience!! I saw 2 procedures – a knee arthroscopy and a lateral release. The surgeon was very friendly and explained everything to me. As the images came up on the screen he explained what everything was and went through the anatomy. I found it really interesting to see this – it was very different from seeing it on cadavers. I had to change into scrubs and wear a hairnet and facemask. There were quite a few people in the operating room but they didn’t seem to mind that I was there too. It was such a great opportunity to see surgery and I’m hoping that sometime in the next two weeks I will get to go in again and see a different procedure.

A guy came in on Thursday and did a little presentation on braces and orthoses etc, that the physio staff may be interested in buying. He bought a heap with him and let us have a fiddle with them. He explained how most of them worked and what they were best used for. It was really interesting. The only problem was some were very expensive and some clients might not be able to afford them. On Friday we had a guy come and talk to us about a machine that assists with coughing. I didn’t understand fully how it worked but it used positive and negative pressure and helped with coughing. It’s been great how we have been able to see these little presentations, the braces and machines we have seen have been really interesting.

We are still getting new clients, so it is unlikely we will be able to discharge them all before we finish the placement. We will aim to do this but we may have to hand some over to the other physios. We are starting to see more clients each day so have been busier than when we started. I much prefer this, even if it means we don’t have as much time to prepare before seeing a client.

We had a client come back on Thursday (it was her second visit). She had damaged her Achilles and has now been out of plaster for a few weeks. She is going very well, which was good to see. There is the added problem that both her legs are very swollen. We didn’t really address this last time (apart from giving her tubigrip and advising her to elevate it) so I was keen to do more about it this time. I did some DTF on her Achilles before Matt and I did effleurage to both her legs. I felt this was very effective, but not a permanent solution in this case. We only did it to the calf muscles and around the heels, but next time I’d like to do it to the front of her legs and tops of her feet as well (as there was quite a lot of swelling in her feet). I felt like I did the massage well (I have plenty of experience after my 4P hours!) I have never really done effleurage on someone who has some much swelling before, it has generally been massage on athletes. It was amazing how much difference it made, I could feel the fluid moving under the skin. While I was doing the DTF if I lifted my fingers off there were indents of where they were on the skin. This gives an idea of how much fluid was in there! I think massage in the future will definitely be a good option to help with the swelling, as long as she is still doing her part with wearing the tubigrip and elevating the leg. She is starting to do some active movements (like cycling and calf raises) which will also help pump the swelling. She comes in for an exercise class (sometimes twice a week) as she has COPD, which will also be beneficial. I just feel there is so much more we can do for her. Her Achilles is healing well and we were able to progress the exercises. The hands-on massage experience with someone with so much swelling was a good experience.

Notes

I will never underestimate the importance of client notes!! We are only seeing a few clients a day yet still have trouble remembering everything we did with them previously. Writing down clearly what treatment we did and what we plan to do next time is so important! It will be so much harder when we are working as physios and are seeing so many more clients a day and have less time to write up the notes. It is definitely something I will not be taking short cuts on!

A Lazy Wednesday

After such a busy day yesterday we started off with a really quiet morning. We were meant to have a client at 8am, but they just didn’t show up. This makes me really annoyed because it just wastes everyone’s time. We could have been seeing another client instead. With this hospital system the client was sent a letter with the date and time of his appointment. Perhaps it would be better if they were sent a letter and then given a follow-up phone call to confirm the appointment. Maybe sometimes they are. I just find it so annoying when people don’t show up. We had the opportunity this morning to join in a teaching session (on exercise prescription I think) which would have been really good to go to. As we had a new client booked in we couldn’t go, so when they didn’t turn up I definitely felt like I had missed out!

Our second client for today cancelled (but at least they called to tell us they weren’t coming in!) I figured Matt must be scaring all our clients away. So we spent the morning preparing for clients we didn’t end up seeing and doing some exam study. Its good having a plinth by our student area so we can practice stuff. At least it didn’t feel like a total waste of a morning. In the arvo we only had 2 clients booked in.

I saw the final client for today by myself, which was a good experience. It’s the 3^rd time I’ve seen a client all by myself. We had seen this client before but I did some new things with her today. Even though I do the same things when Matt and I work together with a client, it still feels different seeing someone by myself.

A Very Busy Day

What a busy day!! Definitely the busiest we have had so far. We saw 5 clients and helped with the Peripheral Conditioning Group. There was also a fire drill – which turned out not to be a drill! We had to get everyone out of the gym (and there were quite a few people as we had the class on at the time). At first we thought it was a drill, but then we found out there really was a fire in the kiosk.

When we see clients and need to make another appointment, we generally just ask if the same time the following week is ok with them. We said this to a few today and nobody wanted an appointment next Tuesday because of the Melbourne Cup!! I don’t think we will be very busy!

We saw a client today that we have seen previously. Matt saw him by himself last time, but I read through the notes and worked out what was going on.

1. This client had fractured both his calcaneii. Today was our third session with him. His ROM was slightly better, but not much. The pain was much less (only 1/10 when doing things and no pain when he was resting). He was slightly worried about WB in case he did more damage. This feeling is understandable but WB has been cleared with his orthopaedic surgeon and would be good for healing. We gave him a new WB exercise and encourage him to put more weight through his legs as he walked with his crutches. We also did some passive physiological movements into DF. I was glad to see the improvement with this client – he lives by himself and has been getting frustrated that he cannot do everything he wants to. He wants to get back to work and I got the feeling that he is getting lonely.

2. I think we did well with this client, especially with the educational aspect. Explaining the need to WB and teaching him exercises went very well and I think we made our point. Next time we are hoping the increase his WB and progress the exercises.

3. I was pretty comfortable around this client as we have seen him before and he is very co-operative. He likes to talk and chats a fair bit during the session. It was easy to build a rapport with this client.

4. One change I would make is to do the passive physiological mobilizations before teaching him the new exercise. It just seems to make the session flow better if we finish off with the exercises.

5. Have a set structure of the session in mind and plan the order in which we will do things. Also by keeping the order as consistent as we can between clients it will be easier to remember and also makes sure we don’t forget to do anything or miss things out.

6. I’m very tired today and found it harder to concentrate. I felt today went well but definitely not one of the best days. Nothing went wrong; I’ve just had much better days in the past couple of weeks. I still felt the way in which I dealt with the clients etc went well. Being very busy was a good experience, and I much prefer it to sitting around trying to find things to do. We are starting to see more clients and our supervisor would like us to have them discharged by the time we leave. I’m not sure if this will be possible with all of them, but it’s a good aim.

Disrobing

We had an interesting situation today in which a client came in wearing long trackpants and stockings underneath. She had been referred for trochanteric bursitis, so obviously we had to look at the greater trochanter. This presented a bit of a difficult situation with what she was wearing. I ended up getting her to roll her trackpants and stockings down and her underwear up a little bit and draping with a couple of towels. This seemed to work but it was still very difficult to massage her ITB and apply IF treatment. We managed the best we could and the client seemed happy and comfortable. Hopefully next time she will wear something a little more appropriate, but as she was an elderly lady I didn’t feel like I could ask her not to wear stockings, as she is obviously comfortable in them.

Week 3 Begins

We had a presentation today after lunch on Generational Differences in the workplace. All the physios attended. It went through the different generations and their good and bad points. It was very general with these!! Surprisingly we had a majority of Gen-Y in the room, whereas the presenter expected a majority of baby boomers. It was interesting but to be honest it felt like a little bit of a waste of time. Perhaps if the topic seemed more relevant it may have been more important. I’m not sure if we will be around for another presentation while we are there, I don’t know how often they have them.

We had a new client come in today. She had fractured her ankle. Unfortunately we didn’t have time to check the x-rays on the computer to see exactly where the fracture was. Her ROM was alright, but not as good as it could be and her strength was decreased. She didn’t like to WB on it, but we will hopefully encourage her to do so. We gave her some theraband exercises and a towel stretch. Her husband came into the session with her and was keen to help in any way possible. It was a little crowded in the cubicle (which normally has 2 people) as we had 4 people in there!! The client asked me if she could continue with her driving lessons and unfortunately I had to tell her not yet (she is 60!). The whole session went very well and I am really looking forward to seeing this client and her husband again.

Friday

We had a new client who had been seen by another physio at SDH, who discovered she had torn her Achilles tendon. She was then treated conservatively and was in plaster for 10 weeks. We now see her as an outpatient and saw her on Friday (she had come out of plaster on Wednesday).

1. At first I wasn’t sure what to expect in terms of ROM, swelling, pain etc. The client’s ROM was very good and within normal ranges. There was also no pain which I was surprised about. It was good there was no pain, I’m still getting used to the fact sometimes we have to be a bit mean and make people do things that hurt!! Both feet and ankles were very swollen. The client said they were swollen even before the operation or injury, but now the operated side is more swollen (but only slightly). We gave her some new tubigrip for her legs, to hopefully reduce the swelling. The other tubigrip she had was too short and caused all the swelling to accumulate in her forefeet and toes. We also gave her some exercises to increase strength and since they are active movements will hopefully help pump the swelling. There is a computer program we can use to print off some exercises, which is great as the diagrams help remind the client exactly what they should be doing.

2. There were a few things we did well such as taking the subjective history (which is becoming much easier) and doing the objective (although with this client it was pretty basic). We also modified the exercises we gave her as when she demonstrated them she had a lot of difficulty. We made them easier and plan to progress to the harder ones as she gains strength. One thing to improve the session would be to organize the assessment so we didn’t have to get her moving around so much (i.e. do all the standing ones, then all the supine, the prone etc.) We are getting better at this but still sometimes get the client to move around quite a bit.

3. I felt quite confident as I knew what was going on and what we should be doing as our treatment. I was a little uncomfortable at first touching her legs that were very swollen as I had never really done this before and was worried I’d cause her pain. When she didn’t appear to be in any pain I became more confident and moved the joint properly.

4. Next time I won’t butt in on Matt when he is taking the subjective history. Ok…well I probably will, but I’ll try not to!

Interesting Client - Turgid Swelling

We were called in to look at a physios client. He had injured his knee and had swelling. He client let us feel it and when you pushed on one side it bulged to the other side and was really obvious. The physio explained that when blood gets in the joint is obviously causes swelling. The blood then gets reabsorbed but leaves the protein (I think albumin) behind. This protein is what we were feeling and the physio described it as a “thick tomato soup” feeling – and it did feel different from other swelling I’ve seen or felt. This will reabsorb over time by itself but this kind of swelling is a clear indicator if there is blood in a joint.

Second week is over!!

Our first client this morning was interesting as he came back with more pain than last time. We had seen him previously for knee pain. So far all our other clients have come back with less pain.

1. When our client first said that he had more pain I assumed he meant the knee pain had become worse. When we asked a few more questions though we found out that the original pain was the same, he just had a new pain in the VMO area. We had given him a HEP to work the VMO so this was to be expected. We decreased the HEP to once a day and advised him to ice after the exercises. We had previously taped his knee and he came back with a rash (in a line on his knee). I had put fiximull under the elastoplast but had obviously missed a bit. Where the elastoplast was touching the skin directly there was a rash. The taping did help decrease the pain, but this only lasted for 3 days, and when it was removed the pain returned to the original level.

2. I think we did well with the client – it wasn’t anything difficult, just a little different from what I have been getting used to in the fact he came back with more pain. Once we realized it was probably the exercises causing the pain (it was in the area we were targeting) we explained this again to the client and will see if by decreasing the HEP it makes a difference with the pain. It is normal to experience pain after starting a new program.

3. I felt comfortable around this client – we had met him before and he was very cooperative and patient. While he was on IF we talked about different things – telling him about our course, talking about his Christmas holidays etc. It was easy and comfortable to talk to him. I was confident in what we were doing as well. I have now become much more confident in using US and IF.

4. I think last time we did explain the exercises could cause a little pain, but next time I will make it much clearer to the client. If I tape again I will be very very careful to make sure the fiximull is all the way under the elastoplast.

5. Just making my explanations clearer about what to expect after the treatment and after doing a HEP.

6. I felt the day went well as we got to see a few exciting things and interesting clients (such as an Achilles rupture). I am still learning so much as I go and I think that's the great thing about physio - there is always something more to learn.

Removing Sutures

One of the physios called us in to see his client today as he was removing sutures. The client had an operation on his ankle and had been stitched up. I didn’t realize physios removed sutures. He showed us how he cleaned the area with an alcohol wipe and then using scissors and tweezers removed the sutures. He said by pulling gently on them first it caused less pain. There were 3 sutures to remove. The actual process didn’t look too hard, you just have to be careful to clean to area properly. It was certainly interesting to see. I doubt I’ll get a chance to try it myself on this prac but if I ever had to do it in the future I think I could manage.

Infection Control

We wash our hands constantly but in all honesty we haven’t had to do much else for infection control. They sheets on the plinths are changed every week (unless they come into contact with skin or body fluids, and are then changed straight after than client). I had my first problem yesterday in that a client had leg ulcers. The pus was coming through the bandages. I really didn’t feel comfortable touching it with bare hands and did my best to avoid it (which was kind of hard when we were assessing her knee). The pus got on the sheets so I changed them afterwards. I’d never really had this problem before. I imagine it would be more prevalent in acute care situations. I scrubbed my hands before doing anything else. It was a different experience and a clear reminder of the need for infection control.

Thursday

It’s interesting how often clients come in and have been referred for a single problem (such as knee pain) yet have so many other things wrong with them. We generally just treat what they were referred for (unless there is something else related). When I read the referral letters I start thinking about what could possibly be wrong (sometimes a diagnosis is given to us in the referral but we still need to check if it’s correct) and what possible treatments we may use. It is unusual for someone to come in and only have one problem, and generally there is always something unexpected with each client. I now try not to make assumptions as to how each client will present.

Today started off slowly so we showed some initiative and cleaned up the supply trolley. It was such a mess – and unfortunately will probably be messy again in a week. It’s getting harder to fill in some of my spare time so will probably start some exam study or something. We talked to one of the other physios and she said she will definitely call us in to see interesting or different things, as we would like to see as many different conditions as possible. We finished the day by tidying the storeroom and just generally trying to be helpful. It’s not what I had in mind to be doing on prac but we volunteered as we had free time and I really didn’t mind helping out.

One of the clients we had today was a returning client. We had seen him once before. He had a TKR. Last time we saw him he was doing well. This session is discussed below.

1. Our client came in as was just as cheerful as last time. I immediately noticed how much easier he was walking – which he commented on later. The improvement in his knee was obvious. The swelling had gone down a little and his ROM had increased. It is just so good to see one of our clients doing so well and improving so rapidly. He desperately wants to get back to work and I think he is well on his way. We progressed his exercises and told him about the Peripheral Conditioning Class. This is a class run in the gym every Tuesday and Thursday for people who have had things like knee replacements. There are a range of conditions catered for. There is a small circuit and we devise exercises for the clients. Matt and I have supervised some of the classes before but never had one of our own clients there. It would be good if our TKR client would come, however he has been doing very well with his exercises at home.

2. I think we did well with progressing the exercises. We moved up to a harder theraband and increased the time on the bike. For the knee extension exercise we also increased the weight.

3. I felt very confident in that I knew what I was doing and we have a clear goal (set with the client). Having already met this client I knew he was a great guy so I felt comfortable in this session.

4. I don’t think I would change anything – it all went really well. He is doing very well and constantly improving. We offered to write down the changes to the HEP but he said he could remember them and didn’t need it. For other clients perhaps it would be better to write them down (but I’m sure with this one he will remember them).

5. This client is improving but if we had a different client I would have to be a lot more patient and not expect the same results as quickly. This goes back to what I was talking about at the start – people recover in their own time and just because one person with a TKR recovered and was back to work in 5 weeks doesn’t mean all our other TKR clients will do this.

6. Things went well with our first client and seeing the improvement was great. It’s good that we get to see some of our clients returning as we are having a chance to build a rapport, rather than just seeing them once. It’s different from Elle and Jeff, I was talking to them and they get to see the same clients often, so have much more opportunity to build a rapport. I like being able to get to know the clients, rather than just treating them and not knowing anything else about them apart from what their injury/condition is.

7. Our supervisor told us tomorrow we have a client with an Achilles tear who has just come out of the plaster (I think they have been in it for 10 or so weeks). It will be interesting as I haven’t treated this before but I should definitely read up on it!

Learning Experience...

It was interesting today in that we saw our second TKR client who was completely different to our other TKR client. They both had their operations at a similar time, yet have very different outcomes. Client 1 stopped using his WZF after 2 weeks (because the wheel fell off and he didn’t want to bother fixing it!) and now has a lot of range in that knee. Client 2 however is still using her WZF nearly 5 weeks later and has barely any ROM in her knee. She also had added complications, such as leg ulcers and the fact her other knee is very sore. This shows how people recover in different times and that we need to treat each client as an individual.

We had some difficulty with our last client today and called our supervisor in to have a look (he had treated her after previous surgery so it helped that she already knew him and felt more comfortable). The client’s knee was so sore that we could barely move it – she left me move the patella around, but not bend the actual knee. This limited our ability to properly examine her. Our supervisor came in and helped us, but even he couldn’t get her to move her knee properly, everything caused her pain. He did push her harder than we did and didn't seem as worried as we were that she appeared to be in so much pain. It is going to be beneficial for her to start moving her knee, so maybe we should have pushed a little harder to get her to do it. It was certainly a learning experience as we have always practiced on normal people with no pain in our labs. This is the first time I’ve really come across a client where we couldn’t really do anything because of the pain. Our treatment pretty much consisted of pain relief (using IF) and we gave her some home exercises.

Tuesday

I was a bit excited about today as we had booked in 3 of our own clients (we have generally only been seeing 2 of our own each day). It became very interesting when we realized we were actually seeing 4 clients and that we had double-booked! We had 2 clients booked in for 9.30am. This incident is discussed below. We saw our clients individually – this is the first time I treated a client all by myself!

1. We booked in 2 clients for 9.30. When we realized this both clients were already waiting outside and it was 9.30! We had seen both clients previously and this was their second time seeing us. We quickly decided to spilt up and treat each one separately. There wasn’t really any other option. At first I was a little nervous as I haven’t seen a client by myself but I realized it would be a great learning experience and there really wasn’t anything to be worried about.

2. I thought I handled it well. It didn’t take long to get over the nerves. I re-assessed the client and provided a treatment I felt was appropriate. The client felt better by the end of the session so I think that it went well.

3. I gradually started to feel more comfortable. I discussed an issue with my supervisor regarding the client and we decided the treatment could still be done. I felt confident after talking to my supervisor as there had been issues with the sharp/blunt test but we got this sorted out.

4. Next time I think we would just not double-book! We should be more careful about booking in clients and make sure we write down everything in the appointment book.

5. We should write down future appointments as soon as we make them with the clients. We write it on the card for the client and should transfer it straight into the book.

6. I think we managed seeing clients individually very well and I wouldn’t be so worried about doing it in the future. Seeing more clients in a day went very well too – I think it’s better when we are actually doing something!

7. We had questions about the IF but caught our supervisor at a good time when he wasn’t busy and he helped us out. It had 2 dials with HZ so we got a little confused. I also want to query braces as we taped a client’s knee but she got a rash from the tape, so I was wondering what the procedure for braces is.

Start of a new week!

Week 2 started off pretty well. We had our first returning client and I encountered my first “cultural” problem. The cultural issue is discussed below.

1. A male client came in (obviously from a different culture – I’m thinking he was Middle Eastern). We had seen him before and I could kind of tell he was uncomfortable with me doing any of the assessments. In the last session however Matt did the tests and massage and I just took the subjective history. He seemed ok with this. The only time I touched him last time was when we taught him an exercise and I touched his knee. This time when we said we wanted to do more ITB massage he specifically asked that Matt be the one to do it (Matt and I had already discussed this as we realized it was an issue last time). He said in his culture the females cannot touch the males. I just left the cubicle while Matt did that part of the treatment.

2. I thought we managed it pretty well in the fact that I left for the treatment part, but we could have done better by realizing just how uncomfortable he was last time and I could just not have been part of this session at all. If Matt had done the assessing and treating by himself the client would probably have been a lot more at ease.

3. I felt very uncomfortable knowing that I wasn’t wanted in the cubicle – I was glad to leave!! It was also awkward going back in for the exercise part of the treatment because I wasn’t really sure if he minded me being there. He seemed ok with it.

4. I would let Matt do it by himself. I could still help by coming up with ideas for exercises etc but wouldn’t have to be in the treatment cubicle.

5. I need to work on picking up non-verbal cues from clients who aren’t comfortable.

6. Overall I think we dealt with both clients very well. Today went well except for the fact we don’t get to spend a lot of time with clients. Apparently we can ask to see more clients each day, so hopefully soon we can see a few more.

7. I will do a little research on sleep apnoea. A client mentioned they had it today and talked about a mask he sleeps with. I wasn’t sure exactly what he was talking about so should probably look it up. I would also like to talk to my supervisor about the cultural situation. It worked out well this time as I could leave and Matt could do the treatment, but what if I was the only physio student? Who would have done it then if he didn’t want a female? I’ll discuss this with my supervisor as to what happens in this situation.

End of the First Week

On Friday our first client cancelled. After waiting around this was a bit disappointing! I spent some time answering some of the questions in the workbook. Seeing only one client that day seems like a waste of a day. The other physios did let me sit in on some of their sessions with other clients. We asked if there was anything we could do since we had a lot of spare time, but nobody had any tasks for us. In the info we were given it mentioned doing some research and a presentation so I will look into that next week. It has been easy to keep busy though – I’ve been studying some of the conditions we have come across and have been going over the notes I have made. I now feel a lot more confident about filling in the examination form. It will also be good to use this time to over some of the UL techniques for exams after prac.

On Friday we had our first client where we could not work out what was going on with her shoulder. This situation is discussed below. It was certainly a great learning experience.

1. We had a client come in with shoulder pain that extended down her arm. We were not given a diagnosis in the referral and therefore had to try and work it out for ourselves. In some ways, this is a lot more satisfying than having the diagnosis handed to us. We ran through the subjective history and then went through a number of tests in the objective examination to try and pinpoint exactly what structure was causing the pain. We did integrity tests for the rotator cuff muscles, impingement tests, ligament integrity tests, and just about every other tests we could think of. They all came back negative – so we knew what wasn’t causing the pain, but couldn’t work out what was! In the end another physio came in to look at her shoulder (he specializes in this area). It was really good as he explained to us everything he was doing. We should have known to look at the cervical spine – we only asked her about it, and didn’t actually look at her neck movements. The physio also showed us how to look at the MRI scans. I found this really interesting as we have not really done this at uni. In the end the physio worked out it was a problem at the AC joint. He also quizzed us on cranial nerves which I had no idea about!! Better revise them! We gave the client IF treatment but couldn’t do passive accessories on the AC joint as she was too sore from all the poking and prodding from the examination. We plan to do this next time we see her.

2. As for what we did well…we ruled out a lot of structures that could possibly have been causing the pain. We remembered the tests we had to do (for example, impingement and integrity). We didn’t look at the cervical spine or AC joint, which we should have. In the future we need to remember to look at the all joints above and below the pain and assess all of them so we don’t miss anything. We sorted out the IF machine and have planned what we have to do with the client next time. I thought we took a good subjective history and gave a good treatment. We didn’t do so well with the diagnosing of the problem though!

3. I felt comfortable with the client – she was very friendly and cooperative. We took awhile with our assessment and she was very patient. I wasn’t very confident after ruling out everything we could and then still not having a diagnosis!

4. From now on I will definitely be looking at all joints around the area! When we are trying to work out the source of the pain we should think more laterally and consider different structures.

5. Again, just making sure we examine all the different joints and structures in the area if we cannot work out the source of the pain.

6. The day dragged on a bit as we weren’t very busy. It was quite productive in the paperwork and study I managed to get done, but seeing only one of our own clients makes it feel like we wasted a lot of time.

7. I will look into the presentation or other ideas for things to do in our spare time.

The 4th Day...

I have been arriving at prac quite early and always allow much longer than what it actually takes me to get there! (Don't worry Jo, I won't ever be late!!) We didn't have our first client until 9.30 which meant we had a fair bit of time to get organized. It's good how we get the referrals the day before so we van see what we will be dealing with and look up anything we are a little unsure about. It has been a good way to ease into the prac, having the referrals. We haven't really have to diagnose anything from scratch, we are given some idea of what is wrong by the referrals and we assess if it's the case. We had a client today where the referral only said some degeneration in the knee and antero-medial knee pain. This gave us more of a chance to work out what was wrong for ourselves. I took the subjective history and Matt did the objective. I realized I had forgotten quite a few of the special tests for the knee and have since gone over them again.

We ended up giving a VMO home exercise and also taped the knee. I felt quite confident in taping the knee after all the practice I have had on my own! We will wait and see if the taping helps her pain at all as the patella was only slightly mal-tracking. Hopefully we can then give the appropriate exercises so the muscles can hold the patella in the right position.

I felt we dealt with this client very well. It took a long time to go through all the tests as we were trying to rule out everything else that could be causing the pain. I try to be mindful of the clients and if they need to be going anywhere in a hurry - we generally just ask them and most have been very patient and happy to give us the time we need. I do feel as if we are getting faster in our assessing though!

It is getting easier to recognize certain conditions and I am starting to find coming up with treatment and exercises a lot easier for the more common problems. We did have some trouble today when trying to prescribe exercises to a client who has had a TKR. We couldn't work out the proper theraband exercises. We had an idea of some we thought would be good but the client couldn't stand up on one leg (as his other knee was bad too) and we struggled to manage doing them in a sitting position. If I get time tomorrow I am hoping to grab a piece of theraband and practice a lot of different exercises!

We also hope to score some brownie points tomorrow as we volunteered to be on the morning tea roster - I have been baking :-)

Day 3 :-)

The driving each day is exhausting! I’m feeling less tired at the end of today than I did the past 2 days though – maybe getting used to full days at work! Yesterday we learned about stats and how we have to enter them into the computer each day. Our supervisor seemed surprised that we hadn’t been shown how to do this at uni. We now enter them in at the end of each day – but it is such a hassle! We also went back and filled in the first day. Each day has to add up to 7 hours, 45 mins, which is hard when we only see a couple of clients. We fill up the rest of the time with admin kind of stuff and study. I have been going over the history taking and need to remember to ask about the social history. When I took the history from our second client today I did remember, and found out a bit about her living arrangements and job. Part of my job today was look after a baby of one of the other physio’s clients. She was such a heavy baby!! So I walked around with her for about half an hour while her mother received treatment. I was glad to be helpful but could have thought of a few better things to be doing! The mum was very appreciative though and I really didn’t mind.

We were called into a session of another physio to see a patella alta. I hadn’t heard of this before but it is where the patella sits very high up. It looked quite unusual and I’m not sure how I would treat it if I came across it. Perhaps taping? Or surgery? It was quite interesting. I plan to look up some more info on it. It’s great how the physios call us into their sessions if they have an interesting client – we are getting to see quite a few different and unusual things.

The following is about a client we saw today. I feel as if we are getting much better with the history taking process and the objective examination. Matt and I have been taking it in turns – one of us does the subjective and the other does the objective, then we switch for the next client. It seems to be working well and allows us to be a little more independent even though we are working together with clients.

1. We had a client come in today with OA in her knees. As we had already seen a client with OA I felt a little more confident. I did more research on OA last night and felt I knew a little more about the treatments for it. On assessment however we found more problems. The client suffers from shoulder pain and has had some elbow pain. This is common to see as arthritis generally affects the larger joints. The ROM of her knees, particular the right, was very limited and there was a great deal of pain. Her muscle strength was generally decreased.

I felt as if the objective assessment went well, however we missed a dew things we should have assessed. Our supervisor pointed these out and we went back and assessed them.

We decided to only look at the knees to start with and deal with the shoulder in another session. It was hard to understand her with the strong accent and she talked a lot. She insisted on telling us a lot of irrelevant things in great detail. I had to cut her off occasionally so I could ask important questions. She also insisted on showing us demonstrations of how she cuts up chicken and gets up off the floor. We gave her some exercises for her to do at home.

I just get the feeling that no matter what we manage to fix for her there will always be something wrong.

2. There was one particular thing we did not do well. The client insisted about 3 or 4 times on showing us how she gets up from the floor. We kept saying no, we would like to look at her walking on stairs, but she was adamant. Sooo…we said ok we’d take a look so she tries to get down on the floor and gets into a low squat before just tipping back and falling onto her bottom. She looked like it hurt a bit! Then she couldn’t get up. We instructed her to get into 4 point kneeling and to get up from that position, then she nearly hit her head on the plinth. It’s a good thing nothing bad actually happened – it came close! Next time we will just say no and if she insists on showing us something we will ask her to explain how she does it before letting her try!!

3. I felt quite comfortable with this client, except for having trouble understanding her. I seem to have a problem understanding people with accents and I feel bad when I keep asking them what they said. I was quite confident as I knew what treatment we should give her.

4. I would definitely not let her demo anything without explaining it properly first!! Maybe also cut her off a bit more and ask more questions to keep her on track.

5. One strategy would be directing the conversation in the history talking. This was our first client who really talked too much about irrelevant things. We can show we are listening but when they start rambling and go off track we should immediately steer the conversation back to their reason for being there. Otherwise the history taking just takes too long!

6. Overall today I thought things went well and we are definitely improving. I still forget little things in the history taking but nothing as major as I was before. I feel a lot more comfortable in dealing with the clients now.

7. I will do a little research on patella alta (and also patella baja).

Second day...and very tired!!

Hrrm so many posts – making up for yesterday. I was so tired after the first day I did the necessary preparation for today and had an early night. Today I learnt about the notation // when we were writing up our notes. It means “after treatment” and reminds me of the importance to reassess after treatment (can’t believe we forgot yesterday!!). The Curtin 4^th year students who are also there are very nice and have been extremely helpful. One guy in particular has gone out of his way to be helpful.

Today we saw another two clients. It feels like we are wasting a lot of time – we could definitely fit in a couple more clients! I am hoping by the end of the 5 weeks we are seeing a few more. One client we saw today had bilateral calcaneal fractures. Apparently is it not unusual to fracture both heels due to the common ways the injury occurs (such as falling). This client had ORIF in on foot and non-surgical management for the other. I thought it was quite unusual. I did some research last night on calcaneal fractures. It is handy having the referrals, we can check what we will be seeing the following day and do some homework the night before! He came in a wheelchair but can walk short distances with crutches.

The other client had chronic Achilles tendinopathy. She had already had steroid injections. It is unusual for an Achilles tendinopathy to last this long (generally it would be around 3 months). It might suggest a central issue, rather than just a peripheral. I was glad we had gone over the US as this is one of the treatments we used. She did, however, point out she does not think US does any good. She said it “felt nice” while we were doing it. If she doesn’t think it will help there is probably not too much point in doing it – the mind is powerful and she seems to have already decided it won’t work. We are considering IF as an alternative as it is something different. There are also other options we are exploring. We are seeing her again next week so we have some time to prepare.

We are already getting a lot faster at the assessments. I am getting better at taking a subjective history but still find I miss a few questions. Our objective assessments are running a bit smoother as well. Overall I am quite pleased with how I am going. I am not sure what our supervisor thinks, it is hard to tell. He will only be our supervisor until the end of this week and then somebody else will be back from long service leave.

Notes from the first day...

Here are some thoughts...ideas...feelings...situations...from the first day. Just didn't get around to posting it up yesterday!!

When not seeing clients much of our time is spent preparing for the next client (or the next day’s client) or going over our own personal study – generally things we felt we need to brush up on. I have found I spend a lot of this time writing up the notes as well. I now understand how if you don’t write everything down (especially what you plan to do with the client next time they come in) it is so easy to forget!!

There are text books in the office we can refer to as well as protocols and some info on the computer. I also take the little physio pocket book with me each day and it has come in handy! I like how they are giving us the freedom to manage our own time around seeing clients (and letting us book clients in – probably dull when you have been working as a physio for a while, but exciting to book our own clients in when we first start!!). They are trusting us to use the time constructively and giving us some tasks like writing up goals for the clients. So far I feel Matt and I have definitely been making the most of this time.

I decided to write about the following particular client in my journal (our second client!) as his condition is one I have suffered from myself, so I found it particularly interesting. We saw this client yesterday, on our first day.

1. The client was referred with bilateral anterior knee pain. He had lateral mal tracking of the patella and a high Q angle. When I first read this I was pretty confident as we have covered this condition in class and I felt as if I knew what to do.

On assessment we found the client had a tight ITB (both left and right) and weak VMOs (bilateral). Our thought was the tight ITB was pulling the patella laterally while the weak VMO couldn’t pull it back medially. We got the client to do a squat, which caused him pain. When w applied a medial glide on the patella there was no pain on squatting. The lateral tracking of the patella was causing the knee pain.

The client was very keen to learn about what was happening in his knee in detail, so we spent time explaining it to him. I felt as though we gave a good, clear explanation and the client was certainly happy and said he understood what was going on. In terms of communication I found it difficult as he had a very strong accent, and I couldn’t understand everything he said. I had to keep clarifying to ensure I had heard correctly. In the history taking I did not ask him enough about the subjective history. My supervisor pointed this out and I asked him some more about it while performing the treatment.

Our treatment consisted of a massage to the ITBs to loosen them up and increase the length. The client was wearing long business pants but said next time he was happy to bring along shorts. We taught him an exercise for VMO strengthening (legs over a rolled towel, knee extension with foot turned out). He said he would do this at home. We also taught him a stretch for his ITBs to do at home. He said he could manage these two exercises at home and seemed keen to do anything that would improve the situation and get rid of his pain.

We asked him to come back in a week. I thought the treatment went very well. Next time he comes in we plan to do more massage to the ITBs and maybe progress the VMO exercises, depending on how he is going.

2. Overall I think this session went very well. The client was happy and I think we gave an appropriate treatment. We did not reassess the squat after treatment, and this is something we definitely should have done, and will do with all the clients in the future.

3. I felt quite comfortable as I knew about the condition and this was the second client we were seeing (after the first one I wasn’t s nervous!)

4. Reassess after treatment!!! This is something very important that I will not forget again! I think I could also have explained the ITB stretch a little better and shown him how to lean up against something.

5. Be more thorough in the history taking – find out about the social history.

6. Overall I think things went very well. I missed a few points in the history taking but overall we gave effective treatments and assessed the necessary things for each client. I was exhausted after my first day!

7. The Q angle – have since checked in an anatomy book :-)

I also needed to check how to use the US and IF machines – on our first day we noticed they were different to the ones at uni. Our supervisor showed us first thing this morning.

First Client...

1. We had a client referred for pain and OA in his ankles. This was our first client. When I read it was OA I was a bit worried as I wasn't really sure what to do for OA treatment. Matt took the subjective history.

On assessment we found a significant decrease in DF and an increase in swelling around the ankles (we measured using a tape measure). There was also a decrease in other movements
at the ankle, but the limited DF was tge primary concern as it was enough to limit his walking ability (on one ankle he was -2 degrees, and you need 10 degrees DF to walk properly).


The limitation of DF could be due to a number of things - we clinically reasoned that it was due to a tight gastorcs and increase in swelling (and there was enough swelling to limit movement). It was also due to the OA in joints.

Our treatment consisted of passive accessories in an AP direction to improve DF. We reassessed after treatment and there was an improvement in DF. We tried to teach him a stretch against the wall for gastrocs but it was difficult due to the DF limitation. We gave him another stretching exercise to do at home (stretching sitting down using a towel around the foot to pull it into DF).

The treatment had an effect and increased DF so I feel as if we were effective. Next time we should work on the pain and swelling as well. I'm not convinced he will do the stretching at gomr so we will need to follow ip on that next time we see him, which will be next week.


2. I think as this was out first pateint I was very nervous and forgot a few things for the assessment. We eyeballed his ROM then had to go back and use a goniometer (which we should have done to start with!) The client was very patient and cooperative.



3. I was very nervous to start wth going into the examination with the client. As we started I realized it was ok and I relaxed a bit. Our supervisor didn't prompt us at all, but waited to go through stuff with us after we had finished.


4. I could probably get through the objective assessment (measure ROM etc) alot quicker than what I did.


5. I should plan the objective assesment as much as I can before I start so I don't forget things and have to go back later and do them - it just wastes time.


6. Overall I am feeling confident and pleased with how we handled the client and what we have done so far. As we go along I'm feeling more relaxed and confident. Our supervisor is supportive and helpful - he doesn't have a go at us if we do something wrong or forget something, but rather gives constructive criticism. He is busy with his own clients so we are being given a chance to be more independent.


7. Read up on OA and find out more about treatments and current ideas - journal articles...

Initial Entry

Before prac...

My feelings are mixed - nervous, excited, worried. I'm definately looking forward to it and am excited we are finally going out on placement! I am worried about financial issues while on prac, not being able to work and spending about 5 times the amount I would normally spend on petrol. I am worried about not knowing or remembering things, so I have been revising relevent stuff (particularly anatomy). I still feel like I won't know enough.

As it is an outpatient facility at a hospital I imagine there will be a few physios working there. Each will probably have their own caseload.