Exercise Classes

On my placement with Community Physiotherapy Services I was able to observe and run several different exercise classes. I got to see many different styles of leadership in a class and among several different levels of abilities among the clients.

I learnt that one of the most important aspects of running a class is the level at which you aim the class. I thought that I would share a few of the tips that were given to me.
First you need to know what the age group you are targeting is. However this may be misleading as you will need to look into the various conditions of the patients. Even by looking at these two factors you will not be able to tell the functional level of the clients/patients. This information might be gained from a handover from a previous physio. If there is no handover available to you my advice would be to take it easy for the first few sessions and observe the clients carefully as they walk into and out of the class and their participation during the class. Once you have gauged the client’s different functional abilities you need to structure the class around these. The class should be targeted towards the lowest functioning individual and then progressions made available for the higher functioning individuals within the class. This becomes difficult when you have a large class or if the difference between the clients is quite significant. If one or two of the clients are much more able than anyone else in the class you might want to consider different options such as attending a gym or community exercise class.

One of the physiotherapists I observed took an aquatic exercise class and she targeted her class very highly. I found it quite a challenge keeping up with her and wondered how all the little old ladies were keeping up. I asked her about this after the class and she said to me that she liked to make the class a challenge so that everyone in the class would progress. She stated that even if they were unable to perform some of the tasks they would be putting in 100% to attempt them as opposed to putting in a smaller amount of effort doing tasks they could already do. I thought that this was an interesting point and made me think about how I target my classes. I hope that all of this info helps. But bear in mind that she has been practising physio for many years and has been taking these classes for a long time. We don’t quite have that experience yet so still err on the side of caution.

Hospitality

We have all been on many different community and hospital placements this year, and by now are getting used to different staff and supervisors every month! I'd just like to say, however, how much of a difference it is having staff make the effort to be welcoming.

Although most staff go through the standard "orientation" checklist, on my current placement I found the staff so much more hospitable. Every one of the therapists I have worked with has assured me, many times, that they'd like me to ask lots of questions, and that if I have any problems whatsoever to let them know. I have found that some supervisors think asking questions is a sign of 'poor knowledge' of a lack of independence, so this meant a was a lot more comfortable asking them and could therefore learn as much as possible!

Furthermore I found that in hospitals, a lot of the time staff come and go and you barely learn their names. Even other therapists have often not learnt my name over the month id been at their hospital. At this facility, my supervisor makes sure to introduce me to every staff member and patient we come across. this too makes me feel so much more comfortable and part of the team.

I think that had i assessed some of my previous supervisors again, I would have definately suggested they encourage student questions and say something to that effect at the start of the placement, as by feeling so comfortable in my current prac i believe i have learnt as much as possible!

Supervisor/Student Interactions

At the prac I am currently on, I have been allocated 3 facility supervisors. These are all with me at different times, and they are collaborating on my final assessment. Although I have worked with many different supervisors before, I found it very difficult in this situation, mostly because all three of my supervisors had very different ways of doing things, writing notes, assessing patients, etc. I found I was consistently uttering the words "oh, thats what 'other supervisor' said to do.." Only one of the supervisors acknowledged that this was occuring, the other two seemed ignorant of the fact that i was having to try an adapt constantly to whoever my supervisor was at the time (sometimes i'd go through all three in one day)

Eventually I mentioned this to the supervisor who had aknowledged the differences between their techniques, and specifically mentioned that I didn't think the other two were aware. That small initiative made my life so much easier.. the next day when i worked with the other supervisors, and they asked me to do something a certain way, they said they knew it was probably another supervisors preference. Although I still have to try an adapt to each supervisor's techniques, I now feel much better knowing that they are aware of this. I also feel more comfortable making my own choices about how I want to assess/treat a patient and letting them know that that is the way id prefer to do so.

So from this, I've learnt that if we do have problems and feel that we can't say anything or we will be looked down upon, sometimes our supervisors simply aren't aware of the issues, and by just letting them know we can save ourselves a lot of stress!

referals

I am currently on a burns ward and I am also involved in some outpatient classes for burns patients. A man who had been recently discharged from the ward, came to the clinic last friday. The physio that runs the outpatient department was unaware that he had an appointment because no referal had been sent down from the ward. Seeing as the gym was quiet she invited the patient to attend the session. The patient had sustained a burn to his axilla and thus the physio began some intense stretches to his upper limb. When I came in I recognised this man from the ward because I had written a referal for him that my supervisor said he would take care of. I noticed the physio doing the stretches and began uming and aring as to whether this was appropriate as he had only had a skin graft 3 days ago and thus should only be really doing active exercises. I decided it was my responsibility to let the physio know this because I was more familiar with the patient than she was because she had no referal and thus no guide to treatment. When I told her this man was only 3 days post op she immediately stopped the stretches and rung my supervisor up on the ward who told her he had forgotten to give her the referal and that I was correct in that he should only be doing AROM exercises and stretching should begin next week. I am so glad I trusted my own knowledge and told the physio about the patient otherwise the graft may have been damaged. From this experience I have realised I should trust how much I know and have learnt how important referals are and how they guide the refering physio on the expectations and plans for treatment.

Sensory bombardment

For a continuing education lecture we had at RPH, we were taught about the important role sensation plays in relearning your body’s movements. We were demonstrated different techniques of sensory bombardment and how to then incorporate the newly awakened sensory pathways into functional tasks (like reaching, grasping, WB’ing). Walking back after the tutorial I had thought of a couple of patients that I could practice this on; we had been warned that it can provide some noxious results on some patients and therefore to choose them carefully! With slight hesitation I fulfilled the sensory bombardment techniques, adding on a few extra components of scratchy and soft surfaces which I compared left to right. I then followed this up with some WBing activities of the UL with facilitation of shoulder girdle and arm extension (as the patient has no voluntary control of UL), reaching and grasping activities etc. By the end of the session the most rewarding part of it was that the patient said to me “my arm actually feels a part of me.”
Despite my reservations of not having used the technique before, and not knowing if I was applying it to the appropriate patient it was very fulfilling for the patient to have responded in that way without any verbal prompting. From this, I learnt that it doesn’t matter if a treatment is not perfect, or if you’re not sure if it’ll work because if it doesn’t work out you just don’t have to do it again! It also reiterated the importance that we should not neglect the impact that sensation has on patients movement and spatial awareness, and that it should be integrated into patients programmes as early as tolerated despite them not having any return of voluntary control. If we can encourage the patient with sensory bombardment techniques, visualisation techniques and any activities to involve limbs that have no movement, this may enhance their speed of recovery or at least reduce any hurdles that may arise later due to neglect, neuropathic pain, avoidance etc.

Too many physios in charge

At the start of this prac we were under the charge of two/three different physios, and we were explained that we would receive an orientation of the ward, patients and what would be expected of us. However, the latter part was not done and instead in the confusion of who was looking after us, the physios would briefly whip us off to explain this treatment, then another treatment, then another physio would explain her treatment etc. By the end of the first week we hadn’t once followed our supposed daily treatment plan once and I was extremely confused as to what was expected of us in terms of our treatment rationale and strategies. As the patients we were seeing were also meant to be treated by the physios I thought it would be best to communicate with the patients treating physio so that we didn’t overlap in our sessions ie. If I did UL, they’d treat LL, or I treat sitting balance or standing balance, they do STS and walking etc. When I suggested this, I was told they no such collaboration was necessary and to treat irrespective of what they were going to do or their short term goals. The following week, the physios were changed and the treating physio came up to me, whilst I was treating the patient, and politely asked if next time we could talk about what we were going to treat so that didn’t both treat the same thing?!? What was I supposed to do…. It has been like that the whole way through the placement, a mixture of trying to please all the physios and not get in the way as well. I think that it would be useful if during our placements there was a definite one person who was in charge of us rather than a group. But, like most placements one needs to be extremely flexible and not take supervisors comments too personally!

Secret ally...

At the moment I am treating a patient who has not only received severe trauma and multiple residual deficits but does not originally come from an English-speaking country. His mother, who cannot speak any English, is present everyday and during their first week at the ward insisted on attending every physio session. The language barrier with the mother was causing difficulties due to the fact that during our treatment we were providing rationales to the patient for the exercises, but the mother couldn’t understand these. During the sessions, her anxiety and worried looks and comments to her son were presenting a hindrance to our treatment sessions and the pain-threshold of our patient. We have since asked for the mother to stay outside for treatments and he has progressed really well. This week, we have decided to bring in a translator to help explain the rationales for encouraging as much active movement as possible, as well as providing her with a HEP they can do together in his room. The fact that she is in a foreign country and cannot freely communicate with us must be extremely stressful for her and hence on her son to translate and explain everything. So, although she has been encroaching on our progress during our sessions I think it is really necessary to keep her involved in the process. I also believe she will be a strong ally in helping gain as much potential as we can from her son.