Week 3 Day 5

Pretty good day yesterday, was dealing with one of the regular outpatients at the gym. He is in his forties, has had poorly controlled type 1 DM, cardiac myopathy, peripheral neuropathy and retinopathy. He is a TTA and is terrified of falling. Inside the parallel bars, he can walk reasonably, but outside of the parallel bars, and especially outside of the gym, he is very timid and lacks confidence, even when walking with 2x sticks. So it has been kind of difficult thinking of ways to progress his treatment and rehab. Before, I suggested we go outside to walk and walk on an uneven surface suchas the grass, but decided agaisnt it as he was clearly nervous about falling.

Yesterday I realised he is capable of doing it, just his nerves are getting the best of him. So I treid to increase his confidence and initiate positive feedback and encouragement. And of course he could do it! I guess at first I was nervous about making the patient nervous. Today was useful as it showed a firsthand way how physios can be important motivators during rehab, and that simply employing positive feedback and encouragement can overcome patient fears.

Week3 Day2

I was providing standby assist to a man who was walking around the gym in 2x sticks. This guy is a fairly emotional person who has been finding it hard to get used to the TFA a month or so ago. I know that he often expresses his experiences at being an amputee and it obviously makes him feel better when he has someone to listen. However he stopped halfway through his lap of the gym to continue telling me about his stump and phantom pain. In some ways this was my 'fault', because I was trying to engage the patient and build a level of rapport with him to try and make him feel comfortable around me. I guess the negative aspect of this was the fact that he stopped for a couple of minutes to let out his feelings, ultimately to the detriment of the gym session. Looking back, I should have allowed him a short period to rest, but re-focussed on his gait training and got him walking again, 'forcing' him to talk to me as we walked. However, as he left the gym, he mentioned he had decided to leave shenton park and not attend the afternoon session (he had driven from Northam this morning for rehab) as he had had enough physically and emotionally. The physios pointed out that to achieve his goals it is in his best interest to attend the gym. He recognised this fact and appreciates what the physios do for him, but he still decided not to attend. I guess sometimes al we can do is motivate and educate, and ultimately it is up to the patient to engage in the service.

Week 3 Day1

Worked on my outcome measures with one of my regular patients, did the 10 metre walk test, 6 minute walk test and TUG. Was also involved with a patient in their first day presentation for rehab at shenton park. He is a 60yr old TTA following complications of an ankle fusion, caused by abnormal bony changes due to longterm walking posture problems. He came into the fym in the morning, where I interviewed him subjectively. At the amputee centre, an initial assessment generally always has the amputee rehab assessment sheet and a locomotor capabilities assessment (LCI), which asks the patient their former mobility capabilities prior to amputations and gives them a score out of four for each question (eg. could you walk on uneven surfaces, ranking the answer 1-4). 0= Not at all, 1= yes with help, 2= yes with ambulation aids, 3= yes with supervision and 4= yes. The rehab assessment sheet gives a subjective history (Social, past medical, current medical), current mobility (which we didn't do but incorporates a Functional Independence Measure). The patient didnt really seem interested so I tried to employ active listening to build a rapport and reiterate why we were doing it. I then measured his LL ROM and muscle strength. Of the few measures I've done on placement so far, I think I did these the best. But it helps when you have a guy who is compliant and understanding of what is going on, unlike some of the older patients who aren't as much. I then dropped him off at his roomfor lunch. He arrived after lunch for the afternoon session, and now I had to prescrive him a gym program. This wasn't really that hard at all, especially considering all LL amputees essentially have the same exercises (need to be strong in the UL for transfers and strong in LL for stability). The patient also made it easier as he is a strong bloke and knew how to do the exercises. I definetely felt he felt more comfortable this arvo and he mentioned how he was keen to get started with his programme tomorrow. Looking back, he probably seemed disinterested this morning because he is from the country and runs a hotel, so he probably has been worrying about his business recently.

All in all, a good day. Was able to work on my subjective interviewing skills and objective measures. And i finshed 5 minutes early.

Week 2 Day4

Something that is slightly concerning me is that fact that because amputees is such a niche 'market' and all the people have essentially the same problems, I dont feel I am able to incorporate or test out the musculoskeletal knowledge I have been exposed to this year. If a patient does have a problem relating to something other than their amputation, generally the employed physios have a look at that while we monitor people in the gym. Having said that, a physio Richard who was a top bloke was keen to let us sit in while he assessed an amputee with concurrent shoulder pain. Although the patient has complex pathologies at play, I dont feel her initial assessment was something that I couldn't have handled (poor scapula setting. setting was all that was assessed and treated as patient was highly irritable). Again, in fairness to Richard the patient was more 'his' than she was 'mine'. I guess I'll monitor this situation and see if it changes. Something that is a positive is to see the progress patients are making. Only last week a bilateral TTA patient newly fitted with prostheses was having amazing difficulty walking with 2x assist on a pulpit frame, now a week later she can walk around the gym by herself pretty easily. Really pleased for her

Anyhoo, on to today. Morning began with ortopaedic team meeting/on-going education, as it does every Thursday. Each week a member or members of the staff present a case or topic for the rest of the staff to listen in on. This week Richard and another physio had been at a shoulder course, and have been presenting themes that came out of it. The session finished up with an important point from last week when we discussed what to do if a pateint mentions they feel suicidal. A staff member had spoken to the onsite clinical pysch and given us the relevant procedure to follow.

9.30-12: Gym session: Oversaw programmes, assisted with gait training. Applied heat pack to a patient with porr comliance issues and possible arthritis.
1-3: Afternoon gym session: Mainly spent most of my time with one particular guy. Been an amputee for over a year, but struggles to make any improvements. Healing is fine, but physical improvements are hard to come by. The patient is approx 50, poorly controlled T1Dm, peripheral neuropathy, retinopathy and poor CV fitness. Outside of the parallel bars he is vary timid in walking, even with sticks, as he is scared of falling due to his poor vision and peripheral sensation. I performed some outcome measures to compare to previous measures. We did 10 metre walk test and 6 min walk test.

As i have mentioned before, for every patient we spend enough time with in the gym ,we write SOIERs for. I can definetly say I am improving my notes in this aspect which is something to be pleased with I guess!

Week 2 Day 3

First part of the morning was hydro. Chris and I never really do much in these classes as the patient are all independent, however we were helping out a young bloke with a TFA as he is new to hydro. Basically the physio in charged asked us to come up with some exercises that coul work the core and trunk. Initially we found this a little difficult to come up with good exercises (partly because we are only really familiar with LL or UL hydro Xs, and the fact that the patient has only one leg and neds appropriate Xs). Although we came prescribed standard glut med/max strength and balance xs, we needed the physio to prescirbe good trunk ones. As much as I would have liked to come up with these by myself, at least now I know some basic trunk hydro xs.

9-12 was the amputee nultidisciplinary team meeting/ward round, and it was my turn to sit in this week. Basically the team discusses the in-patient's progress, where they are at, goals and discharge plans and/or suitability for discharge. Not that I was intimidated, but I definetely wasn't confident enoguh to ask more questions in front of all these professionals but I was able to put things forward when discussing patient's I had been dealing with. Each member of the team brings their specific input to the table, and I guess this morning really showed how important a team approach is, as I saw how the Drs, Nurses, Physios, OTs, Social workers and pyschologists all play critical roles in providing holistic care to patients.

The afternoon gym session was pretty quiet as some patients didn't turn up, so all I did was take a lady through her parallel bar prosthetic Xs, some of her strength Xs and assess her stump healing. Also, I was asked by my supervisor to take a social history of a man regarding his home and living situation. This was done to gain a picture of where he plans to go when he is discharged from hospital. He is bilateral TFA and doesnt want prostheses (which is not uncommon), so will return to the community in a wheelchair. My questioning focussed on the presence of stairs at his house, how he thought he could overcome the problems and what modifications may be needed. Of course, the OT will provide a more thourough assessment of his house, but it is always helpful to know the patient goals and have them on records for the physios.

Week 2 Day1

The first half of my day involved me visiting the Wellington St campus and accompanying the had amputee physio and the amputee consultant doctor on their weekly round as they visit the acute inpatients. Basically this involves assessing their suitably for moving to the rehab setting at shenton park. For this they must be medically stable and have appropriate transfer ability. Out of the 6 or so patients we saw, only 1 was deemed aappropriate to be moved shortly, indicating the stringent criteria. The main factors that prevented people being moved to shenton park was that either they were still medically unstable, not strong enough for independent transfers and mobility, and unsure of their future accomodation options (which somewhat directs Rx goals and direction).

After lunch I returned to shenton park, where I resumed the normal afternoon gym sessions and treatment. So again I supervised a lady do her exercises and provide assistance to a guy in the parallel bars with his newly fitted trans femoral prostheses.

Week 1 Day 4

Pretty mixed day today. Started off with an orthopaedic team meeting, where a couple of cases were discussed amongst the physios. One issue to come up related to a patient who said she was having suicidal thoughts. The main discussion point was what was the next step for the physio to take. The (student) physio at RPH had tried contacting the patient's GP, but he was away till Tuesday. The main concensus amongst the group was that he (the physio) should continue trying to contact someone (anyone!) from that GP practice to try and get them to see the patient. If that was unsuccessful, and as we are dealing outside of our expertise, speak to the psychologist at shenton park campus and ask her opinion or ask her to contact a mental health service.

Following this, it was my weekly turn to observe the outpatient amputee clinic. Basically people come in 3-monthly to have a medical/physio/prosthetic/ot checkup. As anyone who has attended an outpatient clinic knows, these can be pretty slow going and generally nothing of note really happens. In all honesty, today was nothing different. Basically the morning primarily involved the registrar reviewing the patients, with my head physio assessing any blisters or stump issues. The last patient to check was a man from up north, who we saw using Telehealth. This is basically a webcam using a TV. We could see and talk to them and vice/versa. The wonders of technology!!!

After lunch is generally the same each day, gym sessions take place and I write up SOIERs about the patients session. Only saw one lady, who has quite a complex case. Poorly controlled chronic T1DM, peripheral neuropathy, cardiac myopathy, renal failure and L shoulder pain following an altercation with her son. Currently the physio team cannot definetively say what the shoulder problem is, but we are leaning towards a traumatic dislocation. Following her gym programme, I gave her some very light soft tissue massage over her shoulder and 15 minutes of heat pack.

The rest of the day was spent gathering notes/info for my final SOAPIER presentation for patient BR.

Week 1 Day 3

Yesterday I was treating JW, a 19 year old male transfemoral amputee from a motor bike accident. He is 12 weeks post, and just had his prosthesis casting by the prosthetist (would have been done earlier but JW had concurrent pelvic fractures and suffered a fall which resulted in a haemotoma, prolonging the casting process). Following his casting, I had to assess his hopping balance in the parallel bars prior to assessing his use of elbow crutches. The main issue from this session was that as JW is a fit, young and strong person, he is confident regarding his mobility and doesn't really consider safety aspects, often acting spontaneously. For example, upon entering the parallel bars he immediately began hopping madly down the bars without holding the bars! I had to then tell him to take it easy and start off slowly and hold on to the bars. A smiliar situation followed when he unsuspectingly decided to sit down following using the elbow crutches and education. He sat down (while still holding them), which is unsafe and not approriate. Of course in reality JW didn't really endanger himself, these events highlighted the fact that safety instructions need to be clear and constantly be reinforced with people like JW who may unsuspectingly do things we as physios are not predicting.

I will modify my treatment next time to clearly clarify instructions and reaffirm them with him next time. I guess I got lulled into the feeling that because I was dealing with someone my age, of good strength and of good cognition, we were on the same level on what JW was doing. How wrong I was! I think it was pretty good something like this happened so early in the placement, as although it was something small, it will hopefully keep me sharp to similar situations that may present itself in the future.

Week 1 Day 2

One of the client's I was involved with today was Mrs R. She is an elderly lady ( I didn't get an opportunity to get her exact age) who is currently an in-patient at the hospital following bilateral TTAs, Right wrist amputation and L finger amputations following ishaemic complications following pneumonia. I had already helped oversee her programme yesterday and know that she is medically stable and has sound balance and is able to sit unoccupied on a plinth. Clinically reasoning from this knowledge, I know she is safe while I get equipment or have to leave her momentarily. I got on well with Mrs R yesterday, so I was confident and comfortable around her today. From the normal ageing process, we know that older people have reduced thirst mechanisms, and because Mrs R has two exercise sessions a day, I suggested she increase her water and fluid intake. I made a point of suggesting she increase it because she said she drank very little during the day. I also clarified with her how to corectly perform her hamstring stretches. Mrs R has a past history of spinal fusion, so straight leg hamstring stretches would be indicated. Her hamstring extensibility is very important because yesterday my facility tutor, the prosthetist and I got her up into her new legs. However her alignment was not ideal because she had decreased knee extension which impaired her balance, meaning it was slightly centred posteriorly to the prostheses.

Overall, I was pretty pleased with how I went with Mrs R today. Our session was cut short because she has had her new prostheses fitted out, however when put on they cause her considerable pain on her tibial condyle areas. I could maximise her gym sessions by ensuring she completes not only her leg strengthening exercises, but also her UL exercises, which she was unable to complete today.

pre-placement write up

I am really looking forward to the upcoming clinical placement. I will be going to the Amputee Rehab centre at Royal Perth Shenton Park. I suppose it is primarily a musculoskeletal placement, but I expect it to cover a broad spectrum of the units we have already covered, for example, the patients there will probably have complex pain issues (210), CR issues following surgery and deconditioning (202) and there will be a lot of manual handling (111/223 Gero).

Aside from incorporating all I've learnt so far and seeing where I am at, I'm looking forward to gaining an insight into the rehab physio sector, which is something I could see myself doing in the future. Hopefully there will be an opportunity to see an amutation operation aswell.

I think my concerns would be the same as any other student going into an inpatient setting; scared that I may do something unsafe, perform something incorectly or do the wrong technique

At the Amputee centre, I imagine the physiotherapists work (alongside the other health professionals there) to maximise the patient's rehabilitation following amputation to a level that addresses impairments and prevents activity limitations from turning into participation restrictions so that they can have the best quality of life and community function/interaction that is possible.