On paeds prac at a child development centre I see a wide variety of outpatients with tort/plag and gross motor skill delay. When referred for PT these children have already been screened by a by paediatrican for any neurological involvement. Children often attend their appointments with parents. When seeing these patients especially the infants and toddlers it is important to establish rapport with the parents but inparticular the child.
During my first few treatment sessions I found establishing rapport with parent's really easy as they were obviously adult. A challenge for me was to establish a relationship with the child. I found it especially difficult due to my limited exposure to infants and toddlers previously and did not know where to begin.
I have now seen children for the past fortnight and have developed a few strategies to establish rapport which i would like to share. In outpatient setting such as these often the child will be seen in a block of treatments. At inital treatment sessions I think its important just to let the child play in their new surroundings and just observe their play. This allows them to familiarise themselves with the environment and develop trust in you the therapist. There is no point trying to force the child to do a tone or other assessment at inital assessment as in some children they become very distressed and cling to their parent the whole session.
Another strategy that has worked well is positioning both of the therapist as well as the parents. Although the child may be playing with you, its important to position the parent in the child's view so that they always feel safe. This may mean positioning toys near the parent or encouraging crusing with a toy towards their parent. Often if a child is total un-cooperative with the therapist I encourage the parent to modify their play with the child so I can observe their behaviour.
Through this prac it has really developed my skills treating and communicating with younger patients. I now use these strategies when I encouter a difficult child who is un-cooperative or in distress at PT. This makes for a more trusting relationship between you and the child, making the physio session more productive and enjoyable for the child. Wasting an entire session forcing the child to do something they do not want to do will only decrease productivity of the session and make them less co-operative with future PT.
Monday, November 3, 2008
Sunshine
Whilst on my rural prac this year I had the task of running a exercise class for a group of over 60 year olds each Tuesday morning. The exercise class consisted of exercises including balance work, general stretching and flexibility and also some very lite cardio work (really walking and air punches was about the most we did), and due to the fact that it was a small town there were only about 8 or so participants. The class was run at a recreation centre in a freezing dark gymnasium and would generally go for 45 minutes to an hour.
Whilst on my prac it generally rained most days or was overcast, so the gym was the safest bet. On my last week however the Tuesday was sunny and quite warm, so whilst on the way to the recreation centre with my supervisor I suggested almost in jest, not expecting anything to come of it, that we hold the class outside today. My supervisor thought this was a great idea (I think he was kicking himself he hadn't thought of it) and proceeded to open a sliding door which led to a basketball court which had the full sun.
The usual activities were completed, but following the class you could see how much difference doing it in the sun had made, they all seemed a lot more chirpier and couldn't stop thanking us for having the class outside.
SO FROM THIS EXPERIENCE I LEARNT THAT ALTHOUGH SOMETHING AS TRIVIAL TO US AS YOUNG GO GETTER'S AS DOING SOMETHING OUTSIDE, FOR THE PEOPLE WHO PERHAPS AREN'T ALWAYS ABLE TO DO THINGS OUTSIDE IT MADE A HUGE DIFFERENCE AND IT WAS REWARDING FOR THEM AND FOR US AS YOU COULD SEE HOW MUCH ENJOYMENT THAT THEY GOT OUT OF IT.
Whilst on my prac it generally rained most days or was overcast, so the gym was the safest bet. On my last week however the Tuesday was sunny and quite warm, so whilst on the way to the recreation centre with my supervisor I suggested almost in jest, not expecting anything to come of it, that we hold the class outside today. My supervisor thought this was a great idea (I think he was kicking himself he hadn't thought of it) and proceeded to open a sliding door which led to a basketball court which had the full sun.
The usual activities were completed, but following the class you could see how much difference doing it in the sun had made, they all seemed a lot more chirpier and couldn't stop thanking us for having the class outside.
SO FROM THIS EXPERIENCE I LEARNT THAT ALTHOUGH SOMETHING AS TRIVIAL TO US AS YOUNG GO GETTER'S AS DOING SOMETHING OUTSIDE, FOR THE PEOPLE WHO PERHAPS AREN'T ALWAYS ABLE TO DO THINGS OUTSIDE IT MADE A HUGE DIFFERENCE AND IT WAS REWARDING FOR THEM AND FOR US AS YOU COULD SEE HOW MUCH ENJOYMENT THAT THEY GOT OUT OF IT.
Sunday, November 2, 2008
Surgery
Whilst on a rural placement, I got to see a TKR surgery. Not only did I get to see the surgery, but I scrubbed in, wore one of those astronaut like head pieces and got to help out in the surgery by drilling, hammering, holding instruments and stapling. It was the highlight of my physio year! It was great to see the surgery, meet the surgeon and treat the patient post op. As fantastic as it was being able to be a part of the surgery, I wonder whether physio students or other allied health professionals are legally allowed to be so involved with such surgeries.
Whilst treating the patient post op, I never told her I had seen her surgery, let alone drill her new knee together. By being a part of the surgery I feel a little guilty as the patient would probably only expect a qualified surgeon to do their TKR. If I was the patient, I know I wouldn’t want an allied health student doing some of the surgery. Fair enough a medical student, but any other health professional seems a little dodgy.
From the surgery, I have learnt more about the process of a TKR and understand why orthopaedic patients are in so much pain post-op. I would be interested in finding out whether anyone else studying physio has been allowed to be hands on in an orthopaedic surgery. In future, I will continue to see different surgeries as it gives more of an understanding about the procedures, therefore will help when educating patients. If given the chance to be hands on again in a surgery I wouldn’t say no, unless of course this was breaking hospital rules/laws. Would really like to know your views on this issue.
Whilst treating the patient post op, I never told her I had seen her surgery, let alone drill her new knee together. By being a part of the surgery I feel a little guilty as the patient would probably only expect a qualified surgeon to do their TKR. If I was the patient, I know I wouldn’t want an allied health student doing some of the surgery. Fair enough a medical student, but any other health professional seems a little dodgy.
From the surgery, I have learnt more about the process of a TKR and understand why orthopaedic patients are in so much pain post-op. I would be interested in finding out whether anyone else studying physio has been allowed to be hands on in an orthopaedic surgery. In future, I will continue to see different surgeries as it gives more of an understanding about the procedures, therefore will help when educating patients. If given the chance to be hands on again in a surgery I wouldn’t say no, unless of course this was breaking hospital rules/laws. Would really like to know your views on this issue.
Patient goals
While on my rural placement, there was a patient who had been transferred from a neighbouring town’s small hospital. His wife was also staying at the hospital. He had a discectomy at T11/12 and L4/5 with resulting weakness in the lower limbs. Whilst in hospital in Perth after the procedure the patient did not receive any physiotherapy and as a consequence was de-conditioned and unable to walk. The Physiotherapists organised for a transfer to our hospital for the sole purpose of physio rehab. I was seeing this patient twice a day and I had given him an exercise program to do independently. However, despite a strong desire to return home, this patient was not completing his exercises, therefore was not progressing as well as I had hoped.
Myself and my supervisor had decided that although the patient would have benefited from a longer stay in hospital, he wanted to be discharged and therefore we would use this goal to motivate him. Through using patient oriented goals we were able to motivate the patient. Together with the OTs we prepared him for returning home, but first he needed to stand independently. With a coordinated effort from the nursing staff and even the personal care assistants, the patient was reminded continually throughout the day to complete these exercises. This co-ordinated effort ensured the patient gained enough strength to stand independently to be able to be discharged.
This patient demonstrated the need to keep goals patient oriented, even if they don’t always match your own and that using these goals can be very motivating. This situation also demonstrated the benefit working as a multi disciplinary team to achieve patient outcomes.
Myself and my supervisor had decided that although the patient would have benefited from a longer stay in hospital, he wanted to be discharged and therefore we would use this goal to motivate him. Through using patient oriented goals we were able to motivate the patient. Together with the OTs we prepared him for returning home, but first he needed to stand independently. With a coordinated effort from the nursing staff and even the personal care assistants, the patient was reminded continually throughout the day to complete these exercises. This co-ordinated effort ensured the patient gained enough strength to stand independently to be able to be discharged.
This patient demonstrated the need to keep goals patient oriented, even if they don’t always match your own and that using these goals can be very motivating. This situation also demonstrated the benefit working as a multi disciplinary team to achieve patient outcomes.
Wednesday, October 29, 2008
Yet another difficult patient..
In one of my placements, I met a 53 year old lady, was admitted to the hospital 2/52 after a CVA. She is still employed as a CEO in a very reputable accounting firm. She sustained right (R) sided hemiplegia from the CVA . She has been attending inpatient physio rehab daily. Since then, she has shown some improvement in motor recovery. She was going to be discharged in a few weeks and will be attending outpatient rehab. She is very anxious about her recovery as she is adamant about returning to work as soon as she is able to. She has been one of my difficult, non-compliant patient as her frustration builds up quite easily during treatment sessions. One day however, she asked me about acupuncture and whether it is a good idea to pursue it once she gets out of the hospital. I had done a bit of research into it before so I gave her an answer. I told her that I can’t promise it will be helpful for her as research does show that acupuncture to some extend helps with recovery but not everyone really benefit from them. So my advice was to give it a try and see whether it works for her. Clearly she wasn’t happy with my answer and just looked away. Anyway I went on treating her that day and she appeared really apprehensive about me treating her. I wasn’t sure what was going on then I asked her politely, if everything is alright and then she became rude and used inappropriate words against me. I was so frustrated because I had worked so hard to get her on my side and then suddenly she reacted that way. I had to just leave her that moment. I spoke to my supervisor and she decided to take me off her case.
When I looked back at what had happened, I am still not sure how I would have handled it differently but I have a certain regret that I was taken off the case without a chance to learn a way of dealing with a situation like that so that when faced with a similar situation in the future I will be better at knowing how to handle it. However in the future, if I do come across a situation like that, I probably will give them the space they need for a bit and come back on a different time and attempt finding out what the issue really is. I guess in a lot of patient it important to make them realize that we are there to help them in their recovery and we can only achieve it if they allow us to. Whether this is the way to go, I am still not sure, anyone have any ideas?
When I looked back at what had happened, I am still not sure how I would have handled it differently but I have a certain regret that I was taken off the case without a chance to learn a way of dealing with a situation like that so that when faced with a similar situation in the future I will be better at knowing how to handle it. However in the future, if I do come across a situation like that, I probably will give them the space they need for a bit and come back on a different time and attempt finding out what the issue really is. I guess in a lot of patient it important to make them realize that we are there to help them in their recovery and we can only achieve it if they allow us to. Whether this is the way to go, I am still not sure, anyone have any ideas?
Tuesday, October 28, 2008
maintaining control during a treatment session for the safety of the patient and physio
Whilst on my neurology placement I encountered a patient who presented with a cerebellar bleed, as well he was displaying frontal lobe behaviours, was highly impulsive and quite a tall man which complicated matters a bit. The patient had also had a trache and as he was improving his trache was removed so he began to be able to communicate a bit more.
The first few occasions of treatment were really based upon transfers and basic functional exercises, this was progressing well but as the patient improved in terms of there function they became more impulsive, and it became harder to complete a full worthwhile treatment session which would address the goals I would set out at the start of each session.
Following a discussion with my supervisor they provided some tips on how to achieve these goals. The first tip was to make sure each time the patient did something for example supine to SOEOB that they would perform it in the correct manner and pattern and if they didn't to make them perform it again. The second was to try and keep the sessions short as the patient would tend to lose interest so perhaps two shorter session in the day would be more effective. A final tip that I was given was to. The final tip was to take a more of a controlled role in the session using verbal and tactile measures to make sure the patient was paying adequate attention and performing the correct task, and even if the patient became impulsive it would be easier to get them back on task.
THROUGH IMPLEMENTING THE ABOVE TIPS ALTHOUGH THE PATIENT WAS STILL DIFFICULT AT TIMES IT ALLOWED FOR THE SESSIONS TO BECOME MORE EFFECTIVE IN ADDRESSING THE IMPAIRMENTS, WHERE AS BEFORE A LOT OF THE TIME WAS SPENT ON JUST TRYING TO GET THE PATIENT TO PERFORM THE CORRECT TASK, NOW THE TREATMENT WAS BECOMING EASIER FOR ME AND ALSO MORE BENEFICIAL FOR THE PATIENT, AND SAFER FOR BOTH OF US.
The first few occasions of treatment were really based upon transfers and basic functional exercises, this was progressing well but as the patient improved in terms of there function they became more impulsive, and it became harder to complete a full worthwhile treatment session which would address the goals I would set out at the start of each session.
Following a discussion with my supervisor they provided some tips on how to achieve these goals. The first tip was to make sure each time the patient did something for example supine to SOEOB that they would perform it in the correct manner and pattern and if they didn't to make them perform it again. The second was to try and keep the sessions short as the patient would tend to lose interest so perhaps two shorter session in the day would be more effective. A final tip that I was given was to. The final tip was to take a more of a controlled role in the session using verbal and tactile measures to make sure the patient was paying adequate attention and performing the correct task, and even if the patient became impulsive it would be easier to get them back on task.
THROUGH IMPLEMENTING THE ABOVE TIPS ALTHOUGH THE PATIENT WAS STILL DIFFICULT AT TIMES IT ALLOWED FOR THE SESSIONS TO BECOME MORE EFFECTIVE IN ADDRESSING THE IMPAIRMENTS, WHERE AS BEFORE A LOT OF THE TIME WAS SPENT ON JUST TRYING TO GET THE PATIENT TO PERFORM THE CORRECT TASK, NOW THE TREATMENT WAS BECOMING EASIER FOR ME AND ALSO MORE BENEFICIAL FOR THE PATIENT, AND SAFER FOR BOTH OF US.
Monday, October 27, 2008
Autism
On paeds placement at a child development centre, my first patient at this setting was a 4yo child with autism who was generally small for his age and had developmental delay. I was to see this patient following initial assessment from another physiotherapist. When reading through his file it was evident that he had problems with jumping, kicking, hoping, climbing and stairs.
I subsequently set up the gym with equipment I thought could be useful having not seen the patient. Having created a curcuit I had to think of strategies for this child to engage him in play. What would I do?
I made a checklist for the child with all the activties drawn on the sheet, which included SLS, trampoline, jumping through series, hopping, strairs with and without railing, basketball and soccer. Next to each activity I put a square so I could either get the child to tick it once he had done it or put a stamp/sticker on completion.
This suprisingly worked well. I allowed the child to do what they would like first rather then trying to have some flow to my session. The child I felt they were more in control of the play session because they could choose what they were doing, but he also knew he had to complete all the tasks on the sheet. This was my first strategy I used to deal with a child with autism and by the end of the session I had achieved the goals I had set out to do.
From this session I learnt that treating children half the battle is motivation and attention. By creating an environment mimicing a fun play session I achieved what I had set out to assess and treat and the child was allowed to play, and I think will be more likely to attend physio again.
Next time I see this child or in fact any other children with motivation and attentional problems I could use this strategy. But also I think its important to have a couple of strategies that you can call upon. Some of these which I have used subsequently with this child are, playing whats the time Mr. wolf with heel-toe walking, and hide and seek at the end of the session.
I subsequently set up the gym with equipment I thought could be useful having not seen the patient. Having created a curcuit I had to think of strategies for this child to engage him in play. What would I do?
I made a checklist for the child with all the activties drawn on the sheet, which included SLS, trampoline, jumping through series, hopping, strairs with and without railing, basketball and soccer. Next to each activity I put a square so I could either get the child to tick it once he had done it or put a stamp/sticker on completion.
This suprisingly worked well. I allowed the child to do what they would like first rather then trying to have some flow to my session. The child I felt they were more in control of the play session because they could choose what they were doing, but he also knew he had to complete all the tasks on the sheet. This was my first strategy I used to deal with a child with autism and by the end of the session I had achieved the goals I had set out to do.
From this session I learnt that treating children half the battle is motivation and attention. By creating an environment mimicing a fun play session I achieved what I had set out to assess and treat and the child was allowed to play, and I think will be more likely to attend physio again.
Next time I see this child or in fact any other children with motivation and attentional problems I could use this strategy. But also I think its important to have a couple of strategies that you can call upon. Some of these which I have used subsequently with this child are, playing whats the time Mr. wolf with heel-toe walking, and hide and seek at the end of the session.
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