Week 8: From Paper to Plinth

Week 8: 28 April-1 May...

Reaching the last 2 weeks of fieldwork, I'm over the moon to have two constant clients, with whom I've been able to work with for at least three sessions already.

Planning treatment sessions has become easier, now that I have a better idea of my clients, and can anticipate their reaction to treatment more accurately. I have a better idea of how to structure items to achieve the desired movements, and how high to pitch the activity. Having established a better rapport with the clients, it becomes easier to decide on appropriate activities within the treatment regimen.

Implementing treatment according to the plans I've drawn up has become easier, but there are still aspects I have to work on. The therapist must always be one step ahead of the activity, evaluating and grading as the activity unfolds. With my limited experience, I find myself becoming caught up in the present of the activity thus missing many therapeutic implications, opportunities and considerations until after the session, when I begin to critically think through and evaluate it.

I've also found that while I'm beginning to be more assertive in getting the required action from the clients, I tend to adopt a gentle, encouraging approach to prevent the breakdown of the rapport I've established. This has worked for my clients so far, but when I face more difficult clients, I will have to work hard to find the balance between  maintaining the client-centeredness of my treatment and still achieving the aims of therapy.

With my burns client on Tuesday, I had planned to do a bed-mobility activity. However, the client was in pain, had just had blood taken from her and a drip inserted. She was seated in a chair and was not willing to transfer to the bed as she was fearful of falling. Here, I faced the assertiveness dilemma once again: should I do my best to convince the client to comply with the treatment plan by explaining the importance of being able to mobilise, especially given her developing pressure sores; or should I simply respect her decision and pain, and do another activity instead?


After trying to convince the client that I would not let her fall, and could even get someone to help me just to be safe, she continued to refuse. Hence, I decided to do some upper limb mobilisation, encouraging the client to reach for food items and make use of the affected arm for bilateral hand movements during the task of eating her lunch. This way, she was still receiving therapy, but was able to remain in the chair as per her wishes. In subsequent sessions, I intend to continue with the mobility programme, as I feel it has become a priority, perhaps using incentives, such as a sweet treat, to encourage participation.


With my CVA and below-knee amputation client on Tuesday, I decided to focus on bilateral hand function in self-care, using a grooming activity.
I incorporated dynamic weight-bearing over the affected arm into my structuring to normalise muscle tone for activity participation.  The items required for the preparation and grooming task were placed to the right of the client, allowing weight-bearing to occur when she reached over to fetch the items with her left hand.

This helped to normalise muscle tone, allowing for better right arm movement during the actual activity, as she was able to hold the comb, with the help of a built-up handle, and raise it to her head. She required assistance at the elbow joint to lift her arm up to her hair, so support was provided at the elbow joint.

To prevent compensatory shoulder elevation during arm movements, a mirror was placed in front of the table at which the client was seated, allowing her to correct her own movements through visual feedback.

One aspect of structuring that could have been improved was the distance at which the client's chair was placed from the table. To allow for better posture and weight-bearing, the chair should have been closer. However, once the client had transferred herself to the chair, it was difficult to shift her forward due to her weight and the angle of her left prosthesis. The wheelchair-to-chair transfer will have to be carefully managed in the next session to ensure the client is seated the correct distance way from the table.

The best part of session was hearing from the caregiver that she has found in improvement in the client's hand function since therapy has begun. For me, this only increased my motivation to continue planning and implementing therapy that would increase the client's hand function even more.