I have had an excellent final placement in both a musculoskeletal and rural capacity. As usual my initial concerns regarding my supervisor’s expectations of me on day one were quickly laid to rest. Once I was in the clinical environment I realised that I knew more than I thought I did and the further through my placement I got the more specific information I thought I'd forgotten came back to me. Although I did initially struggle with the finer details of assessment and functional anatomy in the upper and lower limb, I was able to learn on the job and study as I went to cement my knowledge.
My assessments weren’t perfect, as I had expected, but improved dramatically with clinical experience and as I felt more confident with the processes. As well as revising my musculoskeletal notes, I believe it was the hands on practice and clinical experience that really propelled the improvements in my clnical skills and knowledge base. I now feel able to perform a thorough and client specific assessment and develop an appropriate treatment plan from that.
In addition to the musculoskeletal patients I saw I was also able to gain experience with women’s health patients, treating many pregnant women and being involved in ante and post-natal classes. This was really beneficial for me as I hadn’t previously had any experience in this field and it is an area that I feel is important to understand as it required a varied approach to assessments and treatments and different handling skills.
The other class I took part in whilst away were for older adults to improve balance and mobility. Unlike similar classes I’d been involved with in the city, these classes often only had two people in them and at most had five or six patients. This meant you were able to be more specific in exercises used and use more equipment, such as weights and fitballs.
As I had hoped, I got the opportunity to visit two of the three local communities serviced by Tom Price Hospital. The communities I saw were a lot smaller than I had expected but it was great to see another aspect of working in rural Australia and the different approaches to working as a physio in these communities.
Although I was nervous about living so far from home, I loved my rural experience and found it very refreshing to have a good break from my ordinarily hectic city lifestyle. I also found that I excelled and enjoyed the musculoskeletal component more than I had anticipated, getting to experience such a wide variety of conditions that constantly challenged me and inspired me to continue learning more and more right to the end of the placement.
Sunday, July 25, 2010
STARES #3: EBP
Evidence Based Practice
SITUATION
My placement for this rotation is in the outpatient physiotherapy at Tom Price Hospital with the majority of patients falling under the musculoskeletal category with a small number of women’s health, paediatric and neurology patients. Tom Price is a small, rural mining town with the majority of the patients we see being mine workers and partners of those employed by the mine. Due to the demographics and occupational hazards there are many people with chronic low back pain and other persistent pain problems. Often these conditions are self limiting but in a small portion, usually with multiple yellow flags, pain becomes chronic and is very detrimental to the patient in regards to physical, social and work issues.
TASK
As a part of my placement in Tom Price my supervisor asked me to design a brochure on the central sensitisation of pain and an introduction to chronic pain management that can be given to chronic pain patients.
ACTION
Once told of this project I immediately got to work on finding appropriate resources to gather information from. I decided that I was going to use the book Explain Pain by David Butler and Lorimer Moseley as the foundation for this project as it nicely summarises essential information on pain in terms able to be understood by both patients and therapists. Obviously I was not going to be able to include all the information portrayed by the book in an A4 sized pamphlet so it was important me to have a good understanding of the book in order to decide which aspects were most relevant to my patient population and hence what I wanted to included in my brochure. I chose to start with a brief explanation of pain and reassurance that it is normal. I also briefly summarised the mechanisms of pain production in the initial phases of a pain experience and then discussed how pain can be maintain by other factors than purely tissue damage. I concluded the main body of information with an overview of key strategies for taking control of pain – education, knowledge, understanding and movement, with emphasis on active coping strategies. As well as the facts about the pain experience I also gave a couple of examples of patients who had extreme injuries such as amputation in war time, but felt little or no pain because of the context of the pain experience.
RESULT
The result of this task is an informative but not overwhelming resource that can be given to patients as an introduction into understanding about pain and how to best manage it. This task has also resulted in me having a greater understanding of central sensitisation of pain and ways to incorporate pain management into a treatment plan for chronic pain patients.
EVALUATION
I think that this brochure was a very good resource for a first attempt at designing a brochure for patient in a clinical setting. I felt that my prior understanding of the pain experience provided a solid base of knowledge for me to build on and develop into something able to be understood by someone with no prior knowledge or understanding of the pain experience. One area that I believe could have been improved was the number of resources I used to get information from for this project. As I was in a rural environment I was limited in my access to relevant texts however I could have searched for relevant information in the form of e-Books or e-Journals. Even if they could not explain the facts as well as Explain Pain does, I could have developed my own understanding even further and developed my own terminology and analogy’s to describe the pain experience. Instead I predominantly used the descriptions as worded by Lorimer Moseley and David Butler.
STRATEGIES
Strategies that I would employ if I was required to produce another brochure under similar circumstances I would use a wider variety of sources. I also feel that the brochure may be to ‘wordy’ to engage all patients. In hindsight the inclusion of more flowcharts or diagrams to explain key ideas would probably have been better. Specific strategies I have employed since producing this brochure were to examine a wide variety of the other brochures at the hospital to see what designs/layouts really appealed to me and which ones I felt best delivered the various messages. Other methods I used to improve this area were to get a wide scope of feedback on the brochure I produced from other health professionals, nursing students, my supervisor and a chronic pain patient. This was very beneficial and confirmed that some people did find there to be too much text and not enough information provided that would entice visual learners to take in the key messages.
SITUATION
My placement for this rotation is in the outpatient physiotherapy at Tom Price Hospital with the majority of patients falling under the musculoskeletal category with a small number of women’s health, paediatric and neurology patients. Tom Price is a small, rural mining town with the majority of the patients we see being mine workers and partners of those employed by the mine. Due to the demographics and occupational hazards there are many people with chronic low back pain and other persistent pain problems. Often these conditions are self limiting but in a small portion, usually with multiple yellow flags, pain becomes chronic and is very detrimental to the patient in regards to physical, social and work issues.
TASK
As a part of my placement in Tom Price my supervisor asked me to design a brochure on the central sensitisation of pain and an introduction to chronic pain management that can be given to chronic pain patients.
ACTION
Once told of this project I immediately got to work on finding appropriate resources to gather information from. I decided that I was going to use the book Explain Pain by David Butler and Lorimer Moseley as the foundation for this project as it nicely summarises essential information on pain in terms able to be understood by both patients and therapists. Obviously I was not going to be able to include all the information portrayed by the book in an A4 sized pamphlet so it was important me to have a good understanding of the book in order to decide which aspects were most relevant to my patient population and hence what I wanted to included in my brochure. I chose to start with a brief explanation of pain and reassurance that it is normal. I also briefly summarised the mechanisms of pain production in the initial phases of a pain experience and then discussed how pain can be maintain by other factors than purely tissue damage. I concluded the main body of information with an overview of key strategies for taking control of pain – education, knowledge, understanding and movement, with emphasis on active coping strategies. As well as the facts about the pain experience I also gave a couple of examples of patients who had extreme injuries such as amputation in war time, but felt little or no pain because of the context of the pain experience.
RESULT
The result of this task is an informative but not overwhelming resource that can be given to patients as an introduction into understanding about pain and how to best manage it. This task has also resulted in me having a greater understanding of central sensitisation of pain and ways to incorporate pain management into a treatment plan for chronic pain patients.
EVALUATION
I think that this brochure was a very good resource for a first attempt at designing a brochure for patient in a clinical setting. I felt that my prior understanding of the pain experience provided a solid base of knowledge for me to build on and develop into something able to be understood by someone with no prior knowledge or understanding of the pain experience. One area that I believe could have been improved was the number of resources I used to get information from for this project. As I was in a rural environment I was limited in my access to relevant texts however I could have searched for relevant information in the form of e-Books or e-Journals. Even if they could not explain the facts as well as Explain Pain does, I could have developed my own understanding even further and developed my own terminology and analogy’s to describe the pain experience. Instead I predominantly used the descriptions as worded by Lorimer Moseley and David Butler.
STRATEGIES
Strategies that I would employ if I was required to produce another brochure under similar circumstances I would use a wider variety of sources. I also feel that the brochure may be to ‘wordy’ to engage all patients. In hindsight the inclusion of more flowcharts or diagrams to explain key ideas would probably have been better. Specific strategies I have employed since producing this brochure were to examine a wide variety of the other brochures at the hospital to see what designs/layouts really appealed to me and which ones I felt best delivered the various messages. Other methods I used to improve this area were to get a wide scope of feedback on the brochure I produced from other health professionals, nursing students, my supervisor and a chronic pain patient. This was very beneficial and confirmed that some people did find there to be too much text and not enough information provided that would entice visual learners to take in the key messages.
Friday, July 9, 2010
STARES #2: Assessment
Situation
My patient, Miss R, was a seventeen year old female with a three month history of severe, intermittent right sided hip pain. She reported that if felt like a stiffness and stinging pain and was associated with clicking and occasionally felt as if it would give way. There were no pins and needles or numbness associated with her hip pain. The pain developed gradually and no history of trauma or precipitating events could be attributed to the onset of the increased intensity. Relevant past medical history included being treated by a physiotherapist for incontinence in 2005 at the age of twelve. Miss R noted that her pain was aggravated by moving from a long sitting or crossed legged sitting position into standing with a sudden onset of pain that took around ten minutes to ease.
Task
My task was to perform an objective examination of this patient following my subjective assessment to identify the source of her symptoms and possible factors contributing to her pain.
Action
I initially looked at the patient’s active range of motion at her hip joint in supine, palpated along the joint line anteriorly and around the greater trochanter to assess for any obvious tenderness on palpation. Whilst still in supine I began performing muscle strength assessment for each direction of movement at the hip. I then performed the hip quadrant and FABERs tests in an attempt to reproduce my patient’s pain. Following this I assessed the muscle length of key muscles acting on the hip including Thomas test, Ober’s and hamstrings (90/90). I then got Miss R to move into prone lying to finish assessing range of motion and strength. Key findings from this assessment were tenderness on palpation around the right anterior hip joint; pain at end of range hip flexion and external rotation, positive FABERs on the right, and reproduction of her worst pain in this position, and reduced muscle length of rectus femoris on the right side. Miss R had full range of movement into all directions and normal muscle strength bilaterally.
Result
The result of this examination was that I was able to reproduce the patient’s pain and identify potential contributing factors; however, I failed to include some key aspects involved in this process. As a result of this I did not have a clear understanding of all factors relating to her pain and had my supervisor not been there to guide me, I would have provided a sub-optimal treatment for this patient.
Evaluation
Although I did include most parts of an objective examination in my assessment of this patient, on reflection there were some obvious areas that required improvement. First and foremost I did not disrobe the patient to expose the area I was assessing. This meant that I was unable to specific when palpating as key landmarks and prominences were not visible. I also did not initially perform quick tests such as looking at gait or her moving from sitting to standing prior to the rest of my assessment. Another area I did not assess was muscle function of key stabilising muscles around the hip. This was even more essential in assessment of this patient due to her history of incontinence secondary to poor pelvic floor and proximal muscle function. Finally I was not confident with the hip special tests and therefore did not include them in my initial assessment. I had intended to revise this area and assess it in my nest session with the patient however it would have been preferable if I knew them well enough to include them in my initial assessment.
Strategies
Following this very average objective assessment I immediately revised key aspects of a physical examination of the hip and went through the hip assessment preform that we had used in our lower limb musculoskeletal unit. I made sure that I was familiar with all aspects of the assessment including optimal positioning and special tests and then practiced the assessment again on another student. As well as this I reviewed anatomy of the hip and hip joint as I did not feel confident in knowing which muscles and ligaments I was palpating where which is essential knowledge to have to perform a thorough assessment. As well as this I wrote up an impairment list and possible treatment options for Miss R and discussed this in depth with my supervisor. I have since done another hip assessment on a patient and felt far more confident in my clinical skills following the revision I did which was prompted by seeing Miss R.
My patient, Miss R, was a seventeen year old female with a three month history of severe, intermittent right sided hip pain. She reported that if felt like a stiffness and stinging pain and was associated with clicking and occasionally felt as if it would give way. There were no pins and needles or numbness associated with her hip pain. The pain developed gradually and no history of trauma or precipitating events could be attributed to the onset of the increased intensity. Relevant past medical history included being treated by a physiotherapist for incontinence in 2005 at the age of twelve. Miss R noted that her pain was aggravated by moving from a long sitting or crossed legged sitting position into standing with a sudden onset of pain that took around ten minutes to ease.
Task
My task was to perform an objective examination of this patient following my subjective assessment to identify the source of her symptoms and possible factors contributing to her pain.
Action
I initially looked at the patient’s active range of motion at her hip joint in supine, palpated along the joint line anteriorly and around the greater trochanter to assess for any obvious tenderness on palpation. Whilst still in supine I began performing muscle strength assessment for each direction of movement at the hip. I then performed the hip quadrant and FABERs tests in an attempt to reproduce my patient’s pain. Following this I assessed the muscle length of key muscles acting on the hip including Thomas test, Ober’s and hamstrings (90/90). I then got Miss R to move into prone lying to finish assessing range of motion and strength. Key findings from this assessment were tenderness on palpation around the right anterior hip joint; pain at end of range hip flexion and external rotation, positive FABERs on the right, and reproduction of her worst pain in this position, and reduced muscle length of rectus femoris on the right side. Miss R had full range of movement into all directions and normal muscle strength bilaterally.
Result
The result of this examination was that I was able to reproduce the patient’s pain and identify potential contributing factors; however, I failed to include some key aspects involved in this process. As a result of this I did not have a clear understanding of all factors relating to her pain and had my supervisor not been there to guide me, I would have provided a sub-optimal treatment for this patient.
Evaluation
Although I did include most parts of an objective examination in my assessment of this patient, on reflection there were some obvious areas that required improvement. First and foremost I did not disrobe the patient to expose the area I was assessing. This meant that I was unable to specific when palpating as key landmarks and prominences were not visible. I also did not initially perform quick tests such as looking at gait or her moving from sitting to standing prior to the rest of my assessment. Another area I did not assess was muscle function of key stabilising muscles around the hip. This was even more essential in assessment of this patient due to her history of incontinence secondary to poor pelvic floor and proximal muscle function. Finally I was not confident with the hip special tests and therefore did not include them in my initial assessment. I had intended to revise this area and assess it in my nest session with the patient however it would have been preferable if I knew them well enough to include them in my initial assessment.
Strategies
Following this very average objective assessment I immediately revised key aspects of a physical examination of the hip and went through the hip assessment preform that we had used in our lower limb musculoskeletal unit. I made sure that I was familiar with all aspects of the assessment including optimal positioning and special tests and then practiced the assessment again on another student. As well as this I reviewed anatomy of the hip and hip joint as I did not feel confident in knowing which muscles and ligaments I was palpating where which is essential knowledge to have to perform a thorough assessment. As well as this I wrote up an impairment list and possible treatment options for Miss R and discussed this in depth with my supervisor. I have since done another hip assessment on a patient and felt far more confident in my clinical skills following the revision I did which was prompted by seeing Miss R.
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