End of prac reflection

At the end of this prac I feel so much more confident with my handling in children. We had not been shown how to handle children at uni and instruct and teach them to learn basic developmental milestones. I have just learnt so much on this prac and I think anyone will benefit from this very valued experience. I was exposed to so many conditions that I didn’t have a clue about and some that I had heard of but didn’t know specific clinical features and symptoms. It was very hard, because although I had had a half unit of paeds exposure and learnt so much valuable information, I could hardly relate any of this to my prac. In terms of SOAPIER and torticollis I could but all the children I saw had conditions that we had not covered. I new a little about spasticity from a neuro stream in first semester but this was very briefly covered. A lot of research was required throughout the prac to understand these conditions.

I also was very pleased with my supervisor and how much she has helped me get my head around concepts. She is a fantastic physio and I believe I have learnt a lot of valuable things from her and her many years of experience. The other staff at Kids Are Kids are all friendly and would help me when I had a question.

I have learnt that every child is different and even child with the same condition each have their own strengths and weaknesses. I know now how important it is that you know your developmental milestones. This is not only for therapy treatment but for writing reports and planning sessions and for explanations to parents about where their child is at developmentally.

You need to get down onto the child’s level and not be embarrassed to waddle around or quack like a duck and bounce around like a bunny rabbit. The kids enjoy your involvement and you have to make sessions enjoyable for the children and have elements of fun otherwise they will not get involved and participate or reach their full potential.

I have learnt that you are not only treating the child, you are treating their whole family. It was great to meet the parents of children, to talk to them and establish a rapport with them. It is amazing to see the love of the family and how much this reflects on their children and their progress.

I also learnt a lot about writing reports and the detail and appropriate language used to make it sound professional and accurate.

Overall, this was a very valued experience and I have learnt a lot. I have been exposed to rare conditions I have not been exposed to previously in my life or studies which was highly interesting. I loved the home visit, as this gave me great responsibility and a sense of being an ‘actual physiotherapist’. When the mum of this girl was on the phone to a friend, she said, can I call you back because Leah’s** therapist is here. This lifted my spirits and made me feel important and that I was making a difference.

**Name changed

Final week- Entry 3

Thursday 13th of November 2008
Melanie**

Thoughts and feelings in the presenting situation…

Melanie is 14 months old who has developmental delay in her gross motor skills. I have seen Melanie a few times and she is the cutest, happiest little girl. She is clapping herself after she has performed a task successfully. Melanie is improving drastically. She is beginning to independently move her hands forward while we are assisting her legs in the attempt to crawl. She is not crawling yet, but she is bottom shuffling. This needs to be stopped because crawling is a very importance developmental milestone. A reduction of upper arm strength and coordination may result if Melanie is not using her hands to get to places at her age. She is improving in assisted standing. Mum is very loving and is very happy with her progress throughout therapy. Her STNR is still not fully integrated.

How I managed the patient…

Constant distraction with toys is necessary to motivate Melanie to move towards them while crawling. At any time she wants to go somewhere and she begins to bottom shuffle, we must immediately put her into the crawling position by putting her arms in front of her body and pushing her legs up into her chest in the prep for crawling position. We are hoping she will adopt this method of transportation. Positive reinforcement and clapping is always facilitated to keep therapy as a positive environment.

What I did well…

I believe I have established a great rapport with her mum and also with Melanie. I can always make her smile when she is a little down. I gave lots of positive reinforcement and I jumped in when I could see her bottom shuffling. I would also not give her lots of support in assisted standing. I would make her do the work so her muscle strength increases.

What I could have done better…

Sang more to Melanie as she loves music! However she did have some fun musical toys to play with!

Forward plan…

Continue fitness ball work for propping and equilibrium reactions. Practice backward propping, so if she falls backwards from standing she will know how to protect herself.

Changes for next time…

Climb up and down the stairs. Spend more time practicing crawling.

Overall thoughts and feelings of how today has gone…

Once again today was another busy day. I was very disappointed in Liam today and his non-compliance. I believe he can do tasks but his struggle for independence is limiting him from showing this to us. I has such a nice Session with Melanie today. I am so thrilled with her improvement in coordination and strength. I am also happy that mum is happy with her progress.

Strategies to improve my performance…

I think you need to know how much support a child requires. As they become stronger and more coordinated in their actions, less support is needed. It is hard to judge at times with having a range of children with different conditions. Through practice and working with these children for a period of time I think I am confident now in how much assistance is necessary to give.

Questions…

I wanted to check if Melanie was actually diagnosed with global developmental delay. I also went through some of the questions in my clinical workbook with Jenny, about protocols and procedures.

** Name changed

Final week- Entry 2

Thursday 13th of November 2008
Josh**

Thoughts and feelings in the presenting situation…

Josh is almost four and has global developmental delay. I have seen Josh a few times and have reflected on him before. Josh is demonstrating an increase in confidence, increased head awareness and proprioception, increased muscle strength, coordination and motor planning. This has improved through therapy but through practicing tasks and activities at home. Josh is showing great improvement and loved the new play equipment we had today, especially being on the seesaw with ‘Candy’. Josh is still having absences from therapy, which could possible be absent seizures. Josh was very compliant today and listened carefully to instructions. He was doing some good talking today and he is showing an increase in his comprehension and understanding of words and ability to create sentences that make sense.

How I managed the patient…

I have conducted therapy sessions with Josh before. Today we had so much out that we didn’t need to refer him back to the task chart because he was leading a lot of the therapy himself, doing what we wanted him to do. Only a few times did we have to say “This one first then the seesaw’. I interacted with him and played with him on the seesaw as his breaks in between some hard work. I also leaded him to tasks if he was not responding. I did this by getting down on his level, holding his hand and explaining what we are going to be doing next.

What I did well…

I believe I was down on his level and made the therapy fun by demonstrating things using Candy and myself. He loves Candy so this was effective. I set up some good equipment for therapy and he enjoyed the new obstacles and challenges. If he was ever unsteady or required assistance I would reassure him first and then if necessary give him one or two hand assist.

What I could have done better…

After seeing Josh on a few occasions I have learnt how to work with him. I probably could have made him do some animal walks and attempt to jump on the ground, not just the tramp, therefore increasing his jumping skills further.

Forward plan…

Keep new equipment out and progress to some harder tasks.

Changes for next time…

Next time I think we should have the task chart again, this is good and keeps him on track. It also give children a sense of responsibility. I think on this occasion it was a hectic and busy morning and we ran out of time to find items to place on the chart.

Overall thoughts and feelings of how today has gone…

Today was my last proper day with Jenny. It was good and she was quizzing me on tone, protective reactions which kept me on my feet. She also went through the sensory-motor system and what everything means, so the next assessment I do, I will have an increased understanding of this. Today was very busy and two of our patients were having seizures so the sessions involved a lot of talk and gentle play.

Strategies to improve my performance…

Time management- If you go overtime for one you are rushed and late for the next client.

Questions…

I had questions about the sensory-motor system. This was explained to me. Also some definitions of reflexes.

** Name changed

Final Week- Entry 1

Tuesday 11th of November 2008

Liam**

Thoughts and feelings in the presenting situation…

Liam is four in December and has autism spectrum disorder as well as global developmental delay. I have seen Liam on a few occasions. Liam is reluctant to be compliant in therapy lately and is asserting his independence. He is not doing the tasks we want him to do. He replies with ‘no’ or ‘mum’ and has a tantrum and falls to the ground. Liam is hypermobile and has low muscle tone. He was fine today in the beginning on the tramp and climbing up the ladder, but as soon as I asked him to perform other activities he would fall in a heap and throw a tantrum.

How I managed the patient…

I had to be firm with Liam at times and direct him to activities and tasks. On a few occasions I had to remove him from the ball pit, which he did not like at all. He can’t just lay in the ball pit in therapy. We are trying to help him do it is for his best interest. Half way through he was not doing anything. We asked him what wrong? He just cried, so we said ok are you finished? Put your shoes on and find mum. He cried even more and refused to put his shoes on. I put his shoes on for him. It was extremely difficult today, this day the worst of them all.

What I did well…

I could only do what I could do. I wasn’t going to make him get distressed by forcing him to do a task. I could only try and explain to him what we were doing. I was firm with him and didn’t let him have his way and stay in the ball pit. I also stopped him when he ran away.

What I could have done better…

I could have said in a firm voice. ‘Liam you need to do some work before leaving’ or sat him down and asked him more than once, what is the matter. Etc. I couldn’t really do much. I could have maybe gotten his mum to come in and speak to him, but this may have made matters worse.

Forward plan…

Introduce Liam to some new equipment so he doesn’t refuse all therapy. He seems to enjoy new activities but not activities he used to enjoy.

Changes for next time…

Next time I think we need to be a little bit more firm. Get his mum to sit in, she left when he started throwing tantrums, and I don’t know whether that made him do less work.

Overall thoughts and feelings of how today has gone…

Once again today was another busy day. I was very disappointed in Liam today and his non-compliance. I believe he can do tasks but his struggle for independence is limiting him from showing this to us.

Strategies to improve my performance…

Know that you cannot introduce children to new activities every week. This is not helping them as they are not becoming confident in a task through practice. They will eventually just forget the skill if not repeated and taught to them with the correct technique.

Questions…

I wanted to have a chat about Liam. He will be joining a group environment in the New Year. This may allow him to model off other children and get more out of therapy.

** Name changed

Week 4-Post 3

Friday 7^th of November 2008

Leah**

Thoughts and feelings in the presenting situation…

Leah is a 5 year old little girl with Tubular Sclerosis, autism and due to this has a delay in her development. Leah also suffers from seizures daily but has a very loving and supportive family to support her all of the way. Leah is a gorgeous, smiley little girl who warms to friendly and familiar voices. This was my fourth home visit with Leah, but today was not a very successful session due to the fact that she had woken when I arrived and had a series of nasty seizures. After these seizures she was extremely fatigued and did not want to have a therapy session. She looked exhausted so I did not push her to the point of exhaustion. The week before we had taken a visit to the centre of cerebral palsy to get her Sir David Brand walker reviewed by two specialist at the CCP. We are finding that Leah is beginning her movement forward through back extension and retraction of her arms and shoulders. She is not independently placing her hands on the bar which is on the tray in front of her. The connection is not there yet. We lowered the padding down on the chest support to help the positioning of her arms. We also put cable ties on her back two wheels to prevent movement backwards or sideways. This will encourage Leah to take steps forward because she cannot get from one place to another anymore unless it is in the forwards direction. It was not a very successful session, but it made mum and I have a chat about Leah in general and her progress so far.

How I managed the patient...

When I had arrived, Leah had just awoken and had just had a series of very bad seizures. I waited until mum had put her AFO’s on and Leah had woken up in her own time. Today I took her for a little walk without the walker with me assisting, she was not initiating many steps and started to get upset from the sheer exhaustion state the recent seizures put her in. I carried her to the walker and we began here. She was resisting a lot with holding her hands over the bar. When she started to get annoyed, I let her recover in her own time. I could only get her walking over to the wall where our next activity was, she was too tired to go any further. I always tried to cheer her up, and used the dummy to initiate a lot of tasks. We did some sit to stands, but she was not holding any of her weight today. I then carried her over to the play area and mat where I did some bouncing on the peanut ball to finish. She was not in an ideal state for therapy, so I cut it short.

What I did well…

I also reassured Leah everything was ok and when we were nearly finished I would make her aware of this. I gave positive reinforcement when she attempted the tasks. I always let her calm down in her own time and I had to allow for plenty of rest time in the session. However, I wouldn’t keep the rests long otherwise she would get too tired and dose off to sleep.

What I could have done better

It was lucky little Leah tolerated anything today. She was exhausted and not motivated to work. To keep Leah more awake during her rests I could sing to her or use toys to keep her mind stimulated.

Forward plan…

I may give mum a call Thursday to check how Leah was during the week. I might bring some more toys in or ask mum for more toys and when Leah is resting I may engage with her and play with her so she doesn’t continue to get sleepy and be tempted to fall asleep during therapy.

Changes for next time…

If the next session is more successful I will focus a lot on her weight bearing and encourage Leah to support more of her weight. Also dad was going to tighten the cable ties, because mum and I both noticed that the walker was moving backwards. This was more than likely due to Leah forcing herself backwards in frustration.

Overall thoughts and feelings of how today has gone…

Today was not a successful therapy session due to seizures. I did however, have a chat to mum about Leah and her progress which is also an essential part of the therapy.

Strategies to improve my performance…

Therapy is also engaging with the patient. When the child is having a rest continue to engage with them by using toys, songs or other verbal communication.

Questions…

I need to ask Jenny about booking in Leah for a visit to Kids are Kids for the upcoming week, to review her and see how she is adapting to the new modified walker.

Name changed**

Week 4- Post 2

Thursday 9^th of November 2008

Mark**

Thoughts and feelings in the presenting situation…

Mark is a 3 year old boy with spastic diplegia. He has not been diagnosed yet because mum does not think he has a cerebral palsy. This little boy has increased muscle tone in his upper and lower limbs, but predominantly in his lower limbs. He cannot walk independently yet, but can crawl quite quickly reciprocally. There have been a lot of issues in the family and they have cancelled three sessions over the period I have been there. My feelings were that this child needs help. He was very frustrated throughout therapy because he is extremely eager to walk and communicate. He is quite aggressive to mum when he is venting his frustration even to the point of biting her. Mum has made us aware that Mark is waking in the middle of the night screaming in pain because he gets chronic muscle cramps in his legs. We gave mum a brochure on sleeping for children with cerebral palsy and instilled the importance that it is vitally important for Mark to get a good night sleep. We also were borderline demanding mum to get botox therapy for Mark to relieve the cramping at night or in the meantime to go on medication to help him sleep better and to relax his muscles. He was a happy but very shy boy around new unfamiliar faces. Jenny began the session with him as he was shy and not participating with me present. About 5 minutes into the session I started to get hands on so he became familiar with me. The mum also has to carry Mark around a lot and this is detrimental to her health and back, always having to carry him. This is another reason why she needs further help, possibly by the Centre of Cerebral Palsy.

How I managed the patient…

At the beginning of the session I watched Jenny handling Mark, because he was shy and wasn’t performing as best he good when I was there with him. I had to provide a lot of assistance with his walking and from sit to stand. In sit to stand he would rise up through hyperextended knees and would not lean forward. We had to place him in the squat position and then raise him up, constantly holding him to give him assistance. I gave lots of positive reinforcement and tickled him to engage with him. After the session had finished and our next patient came in, I took him out on the tramp to do some further work with him. I stretched his hamstrings again as well. I would sing nursery rhymes per each stretch to indicate to him how long the stretch was to be held for. This made it fun and I would encourage him to sing along to make it all less serious.

What I did well…

When I took Mark out on the tramp, he was eager to just go back inside to find mum. I always directed him back to the tramp, and said ‘ a little more work, and then we can go find mum’. Or I would say ‘5 more bounces on the peanut ball’ then we can go back inside and find mum. He was doing very good assisted walking towards the end of the session back to mum and we were all happy with his steps. When he is eager and determined to get to a destination he will walk better and pick both his feet up independently.

What I could have done better…

I think I could have tried to encourage him to take a bit more of his own weight. I think I may have been giving him too much support and not getting him to do enough work. This is something through practice, I will become more aware of and therefore be able to benefit myself and the patient more.

Forward plan…

To assist mum books in for botox treatment or temporary sleeping medication to ensure Mark is getting quality, long sleeps at night and not waking up in pain. Keep encouraging mum and advising her of the importance of this.

Changes for next time…

Next time I will get in there first, and now he knows me so he has no excuse to be shy around me. The more I work with him, the more familiar he becomes of me. Next time I may get mum and brother to come outside so she can watch him and I on the tramp. This would prevent him from wanting to go see mum so badly because she is in his field of vision. Also next time I will let Mark do more of the work, so it is not so hard for me.

Overall thoughts and feelings of how today has gone…

Today was quite a busy day and we saw many patients. Chantelle was the most interesting because I became aware of how to manage her type of injury to the neck. It was also good to be able to communicate verbally with a slightly older child and one that is not developmentally delayed. It was a change from the patients we normally see so it was a great experience. I also finally got to see Mark, and have been waiting to see his case for 3-4 weeks. It was an interesting experience to handle and work with him. Apart from my 17year post mva patient who walks independently, Mark is the first spastic diplegia patient I have seen where I need to help facilitate walking and rising from stand to sit correctly.

Strategies to improve my performance…

Give the children incentives, “5 more and then your choice” for example. This works wonders with children and it also gives them something to work towards.

Questions…

I was curious as to what Mark’s family home situation was, so I had a chat to Jenny about this. It really is treating the whole family, because the mum needed just as much help from therapy as Mark needed. She also has a baby to take care of as well which adds to the struggle.

Name changed**

Week 4- Post 1

Thursday 9^th of November 2008

Chantelle**

Thoughts and feelings in the presenting situation…

Chantelle is nearly turning six and was a new outpatient girl who had a fall from a playground ship earlier on this week. Mum began to notice that Chantelle was keeping her head towards her left shoulder, and therefore decided to bring her in for physio. Chantelle was very quiet and reserved and we often had to repeat questions to the mum to confirm Chantelle’s response. Sometimes she would not say anything and would just nod and shake her head in response to our questions and we had to ask mum to assure Chantelle that is was ok to answer us honestly. She had slightly low muscle tone and her upper body posture was poor, sitting always with her back hunched. I was wondering how we were going to treat her, as the neck is something we have not covered in a lot of detail in terms of treating and mobilisations. Due to injuring her neck, she adopted an antalgic position/posture because it did not hurt and also to protect herself from further damage. Mum alerted us to the fact that she carries a very heavy back pack to and from school and also receives quite strong hugs by her friends at school.

How I managed the patient…

Due to the fact that the neck was something we have not covered in detail, Jenny took the reins on this patient and I wrote down the subjective and objective findings, and also ask Chantelle and mum relevant questions. We tested muscle strength, sensation, active and passive range of movement and treated her with traction to the neck and slight rotations. This was performed to re align the cervical vertebra of the spine and to also spread out any swelling that was present. We took a baseline assessment and then tested her range after the mobilisations. I think she found it a little uncomfortable because she didn’t want Jenny to perform the technique again. She agreed to just the traction but did not want the rotations performed. I was very friendly and asked her about gymnastics, hobbies and her school dance she and her older sister who was also present were going to that night. We educated the mum of the importance of Chantelle not carrying the heavy backpack as this was more than likely contributing to her pain and restriction. Also we showed Chantelle how to do a forward roll properly so her head does not touch the ground as this could be detrimental to her injury. I also corrected her posture using both verbal and tactile responses to facilitate an upright posture.

What I did well…

I talked to Chantelle about her hobbies, made jokes and made her laugh so she felt a little less scared. I also corrected her posture when I could. I was constantly observing her to see whether there was anything else we needed to be aware of. I also prompted Jenny that we should also test shoulder flexion, abduction, extension and external and internal rotation for muscle strength.

What I could have done better…

I could have written down the points to remember for mum and Chantelle just to make sure they left with something in writing in case they forgot what we made them aware of.

Forward plan…

If she did come back, I would suggest to Jenny to watch and observe her posture. This is because she did have slightly low muscle tone and I would also write down for Jenny to do some postural correctional techniques to help facilitate her to adopt a correct posture.

Changes for next time…

As above

Overall thoughts and feelings of how today has gone…

Today was quite a busy day and we saw many patients. Chantelle was the most interesting because I became aware of how to manage this type of injury. It was also good to be able to communicate verbally with a slightly older child and one that is not developmentally delayed. It was a change from the patients we normally see so it was a great experience.

Strategies to improve my performance…

Use the family for questioning, they know the child the best and can often come up with very good ideas.

Questions…

At the end of the session I had a talk with Jenny about Chantelle and what the diagnosis was.

changed**