January 2014, Week 4: The power of preparation

The session I wished to reflect was last Monday’s with CGFC, a 7-year-and-1-month-old female, diagnosed with global developmental delay, Rett syndrome and neuromuscular thoralumbar scoliosis. The aspect I wished to highlight in this entry was how the session went through.

Most of the time, I do preparations for my clients’ sessions.  I usually work best with Plans A, B and so on and I am quite certain that that’s how it also works for everyone else. Anything goes wrong and I still have Plan B. I have to admit though that when my finite number of plans were exhausted, I usually panic; that’s probably why I have been called rigid by most (I hope not all) my clinical supervisors most (I hope not all) of the time.

During my session with CGFC, I brought my bookstand and my tablet for the session. The first one was for story-telling and the latter for music therapy. During my session with another client whom I also did story-telling for sitting maintenance, I had a difficult time because of simultaneously translating the story to the Filipino language, holding the picture book and doing what I should do with the client. (The caregiver did not stay in the clinic.) However, during this session of concern, I could concentrate on correcting the client’s postural faults, which was the focus of the activity.

During my previous session with CGFC, the mother also played nursery rhyme songs on her mobile phone to facilitate the client’s movement. However, besides the volume’s being low, the room did not also loud enough due to the large room so there was difficulty using the phone as a tool for facilitation. During the session of concern, the session was held in the Sensory Integration room, a smaller room than the previous one. (I could have use the Isolation Rooms 1 to 3 but the former room had the pediatric standing frame, which I also planned to use for the patient’s physiologic standing.) I used the tablet, which provided me three advantages: (1) it has greater number of nursery rhyme songs; (2) it shows the lyrics of the rhymes and; (3) it is easier to manipulate than the caregiver’s mobile phone because of its larger screen.

I also prepared the pediatric standing frame for CGFC. However, the client could not be properly positioned due to her flexed knees that were difficult to straighten passively, most likely to the client’s fear of assuming upright. In the end, I decided against using it and proceeded with the physiologic standing with I and the caregiver’s providing the support. Despite not using the frame, standing was still maintained with proper joint alignment. Also, the table complement of the standing frame was where the client propped her arms.

I consider the session successful because the activities were executed properly and the client responded, although not optimally, in a way that she would still benefit from these activities. Moral of the story: Preparation counts.


I may not be like Aizen of Kubo’s Bleach whose plans were almost always realized, but just like what Kagami of Fujimaki’s Kuroko no Basuke said, “There’s no such thing as useless effort.” Something from this unrealized plan, or from this useless effort, may come in handy later. Just like the standing frame table.

January 2014, Week 3: The Week Before All Ends

I would like to call last week the "Week of Requirements". During this time, I rushed to accomplish most of the clinic requirements before the rotation ends this week. The rotation of the batch in this clinic was cut to 6 months, stripped of two months due to the Christmas break, so the interns have to work double time.

In this journal entry, I wish to chronicle what transpired last week and reflect on my course of actions:

At the start of the said week, I still had the following requirements yet to be done: (1) three evaluations (performance and documentation); (2) endorsement notes for all my patients and; (3) clinical case presentation. [Case Pre]. Add to these were the handwritten running notes that I had to do daily.

During the past weekend, I failed to finish the requirements I could have done such as the endorsement notes and Case Pre PowerPoint slides because I was busied by another important academic-related matter.
I decided to do the endorsement notes in a day-by-day basis and not pass all of them in one go. I had planned to start doing the three evaluations on Monday but only did so on Wednesday because the patients set for re-evaluation did not attend their sessions.

On Wednesday, I had one evaluation documentation due on Friday, three running notes, and four endorsement notes due the next day. On Thursday, I had two evaluation documentations, four running notes, two endorsement notes and PowerPoint slides due the next day. Fortunately, I finished the requirements although much to my chagrin, the quality of each was compromised.

All those cramming were admittedly my fault. As I had said on the second paragraph, I  could have done most of them in advance but did not do so. What I did was technically procrastination but I like others to empathize and see it as a sign of my giving up. I am probably at the threshold of my frustration tolerance.

I started the rotation with an optimistic attitude, genuinely hoping that I could maximize my stay in the clinic and help all the pediatric patients entrusted to me by the institution . I tried to keep the optimism but cannot keep it from wavering. I believe I did a good job of keeping my optimism at its highest every my patient care because I did not want to do disservice. My goals for the patients were genuinely considered, the treatment properly done, and the evaluations performed thoroughly, all to the best of my abilities, all in the hopes that the patients would benefit.

I seem to have no place in this profession, considering all my feedback as an intern. Despite doing my best, I failed at an institution. I tried to prove that my failure was a mistake but before I even proved it, I was told that my claim was all in my mind.

I had initially intended to end this entry in a bad note but decided against it in the end. I believe that despite my performance's being barely average as rated by my supervisors, as long as my intention is sincere, I can still do my purpose. Also, with the sincerest hopes of my instructors for me to improve, why should there be an option for me to fail?

The "Week of Requirements" may have already passed. The week where all ends will pass soon. The impression that I am not a good pediatric physical therapy intern may not be changed even after all ends, but that does not mean that my future as a physical therapist in the future has already ended.

January 2014, Week 2: Sympathy to pediatric patients

If anybody asks me now why I chose BS Physical Therapy as my first-choice program in the university, I will explain, "people say PT's a financially-rewarding job abroad." Surprisingly though, my reasoning is kind of off because I never really have planned of working abroad.

My second reason is the cliche, I care for animals. I did not say "humans" because I also care for other animals besides humans. Truth be told, I probably care for other animals more than I care for humans. Surprisingly though, I never really have planned of becoming a veterinarian.

What makes me care more for animals is what I perceived as their being powerless before humans. I am not just particular to animal abuse but also to the reality where humans cook and eat animals. I see how cows, chickens and goats are butchered and displayed for sale at the wet market and I cringe at the though of animals' serving as food for humans. (Although again, surprisingly, I never really have planned of vegan.) Of course I am well aware of the fact that we are also predators so what happens is only natural. But the fact still remains, as Mikasa Ackerman of Attack on Titans (episode 7) has clearly put it, "this world... is crammed with cruelty".

Using the same reasoning, the ones I care for the most among humans are the children because they are the least powerful among us. Children are at the mercy of every adult. And among these children, the ones I care for the most are those who have disabilities. (It took me a while to establish the relevance of this entry to this blog. Haha!)

What inspired me to write this entry was my encounter with two pediatric patients this Week 2 of January 2014. (I deliberately chose not to include their initials or medical diagnosis to maintain the confidentially of these patients.) I learned about their parents and somehow I choose to believe that their parents are to blame for their condition.

I believe the parents (not just those of these children) have some sort of control in preventing their children to have these debilitating medical conditions. Conceiving a child at a high-risk age (too young or too old) or conceiving child despite financial incapacity to raise a child are just a few and what I've observed on the cases of these two children. With the lack of financial means, a mother cannot afford to have frequent medical check-ups or worse, will be force to work beyond the extent of therapeutic effect of physical activity on a place exposed to every kind of pollution.

What happens then is that it is the children who suffer. I dislike the injustice, wherein these children live the rest of their days with disabilities. This is different from what Zidane Tribal of Final Fantasy 9 said,  "It's not fair... but that's the way things are. The choice is yours." The choice is not theirs.

Pediatric therapists are heroes for empowering these children with disabilities. I hope that there will be also heroes, or more heroes if already there, who can keep the occurrence of these disabilities to a minimum.

January 2014, Week 1: Patience

The session I wished to reflect on was with MA, an 11-year-old male with global developmental delay secondary to mental retardation/autism spectrum disorder, to consider fronto-parietal atrophy. His schedule is a co-treatment session between physical and speech therapy interns. However, during this session, no speech therapy intern was present.

Gross assessment of the child shows no marked physical therapy therapy problems on the impairment level such as deficits in strength, range of motion and balance. On the other hand, the following therapy problems on the "activity limitation" level were identified:
1. difficulty in stair negotiation, manifested by refusal to do activity
2. level ambulation, manifested by assumption of cross-sitting >50% of the time

Basically, what his mother sees as problematic was the frequent and sudden sitting of the child when they are walking in public. During these events, the mother sings "Twinkle, twinkle star" and the English alphabet, songs used by the interdisciplinary care team (group of physical, occupational and speech therapy interns) who previously handled the child. These songs serve as a cue for the patient to stand up.

Because I did not identify any physical therapy impairment, I focused on these two activity limitations and addressed them through the functional training organized by the said team.

The main difficulty was making him follow my instructions. I utilized what the occupational therapy interns called the Therapeutic Use of Self [TUS], namely, active friendliness and kind firmness but with no success. When instructing him to stand without success, my last resort was to pull the child into standing with my grip on the guard belt. The child then immediately flung his arms to me upwards so I had to move my face away to continue pulling without letting myself get hurt

I learn to muster more patience every time I see this child. Back then, i gave the child an ample time (random duration between >1 to 4 minutes) to respond before forcing him to stand. I chose not to force him to stand right away so he would learn how to even without anyone forcing him to do so.

December 2013, Week 3: Caught red-handed

The incident I wish to reflect on in this entry happened last December 16, 2013 Monday.. For that day, there were not patients scheduled for treatment and so the interns were to do administrative duties (or admin duties for short), which I understood simply as clinic-related tasks. However, what I did instead of doing these was that I watched a movie, which is against the clinic rules.

Although I had initially no plans of watching a movie before I entered the clinic, what I did was my fault because no one forced me to do it. I do not blame anyone for having a movie on his or her laptop or for not reminding me that I was breaking a rule because I know the rules and the decision to watch was mine alone. My action reflects my  lack of ability to set my priorities straight. I know that this is my weakness and I am trying to improve.

I am somehow grateful that a clinical supervisor had caught me in the act so that the lesson of “first things first” will be deeply ingrained into my mind. (I had to admit though that I find myself severely unfortunate to be caught red-handed, considering that most of the time, I religiously observe the rules, including the most easily evaded ones.)

Now if I were to go back to that day, what would have I accomplished if I was not reprimanded for watching? I may have added a movie or two on my list of “Already Watched Movies”.  But now, I think it is more fulfilling to share that I had already done the 2014 attendance sheet of the patients decked to me, finished encoding the demographics for their endorsement notes and  got to know my patients better by reading their previous notes.

Not that big accomplishments, but because I take a good amount of time to finish paper works, the things I did feel like a great head start to finishing my backlogs for my pediatric rotation.

December 2013, Week 2

The session during the second week of December 2013 that I wished to reflect on in this entry was with patient LD, a 9 year-old male with the medical diagnosis of visual and hearing impairment. The father's chief complaint about the child is his inability to feed by himself, manifested by non-grasping of utensils.

The child basically demonstrated impaired hand function due to his behavior of throwing everything he would hold with either hand. The case was novel because the causes of impaired hand function I encountered so far were spasticity, loss of motion or muscle weakness. LD did not have any of those at the time of assessment. He could grasp the ball, for instance, but then I could definitely see the deliberate throwing motion after approximately 15 seconds of holding, evidenced by finger extension.

This session was the first time I meet the patient after he called to cancel during my first week in the clinic. Upon gross assessment, he demonstrated poor visual tracking, auditory localization and tracking and inabilityfor visual localization. Most likely because of these impairments, he was rarely, if not never, facilitated with toys.

Upon assessment, I came up with two goals for the patient: (1) to walk without assistance on level surfaces for at least 2 meters and; (2) to improve hand function, congruent with the father's chief complaint. My hypothesis was that his balance deficits and associated apprehension for falls prevent attainment of Goal 1 while his sensory issues and associated developed habit prevent attainment of Goal 2.

Let me discuss the problems I had encountered during the session:
First was the lack of visual and auditory localization and tracking. These caused difficulty in facilitating the child during the session because he was not attracted to toys. In which case, I learned to maximize myself, or what the other paramedical professionals perhaps call as the "Therapeutic Use of Self". During session, I switched between what I understood as "Active Friendliness" and "Kind firmness".

Second was the presence of sensory integration issues, namely tactile, vestibular and proprioceptive hypersensitivity, as endorsed by his previous OT intern. During these times, the importance of notes became evident. I addressed this issues based on the home program attached on the child's chart. I was reminded that other disciplines such as OTs are as needed as PTs and no one is a genuine "Jack of All Trades", even the OTs. I appreciated the importance of interdisciplinary approach in treating patients.

During my session with LD, I learned to be patient; that is, I should not be frustrated when I do not see any improvements during the session. I also learned that I should be confident with what I do. During the session, I was unsure if I was doing the right management. After the session, I consulted my clinical supervisor and was told that I was on the right track.

December 2013, Week 1: To crawl or not to crawl

The session I wish to reflect on in this entry was with patient JF, a 4 year-old female with the medical diagnosis of CPSQ. The patient’s primary means of mobility was wriggling her pelvis while in ring or long sitting position. She has no other means of independent mobility, such as creeping, crawling or cruising. This current means of mobility was obviously not typical (in the sense that it is not included on the long list of motor milestones) so the first goal I came up with after seeing her in person was for her to learn how to crawl (quadruped mobility). I did not immediately deem cruising as a goal, being a more advanced skill than crawling, which she was unable to do. At the back of my mind, however, I felt that something was amiss with my goal: the patient is a 4 year-old female and a child of her age is already expected of walking. After a quarter of the session's hour had elapsed, the patient still was not showing the slightest hints of improving in crawling despite manual guidance. Maybe, if I were to train mobility, I might as well train her to walk. The impairment, however, that kept me from choosing walking as the goal for that session was the severe lower extremity extensor spasticity of the patient. When assisted to walk, she presented with hyper-extended knees and plantar flexed ankles, which only went to neutral after short duration of rest (<30 seconds). I thought that by training how the patient to crawl, I was training her to move out of this extensor spasticity. I might have, but the carry-over of reduced spasticity would probably limited to activity of crawling. Again, I should remember that spasticity will never be completely resolved so I might as well just work with it with the skill I want her to develop. The lesson now is that first, I should try to be more specific with the activity. From then on, I can apply Motor Relearning principles (now appropriately called motor learning principles for the pediatric setting). In JF’s case, it is probably impractical to religiously subscribe to the neurodevelopmental approach of training motor milestones because doing which would perhaps prevent me from progressing my goals. What I can think of right now is to incorporate training of these "earlier" motor milestones on training walking alone. For instance, maintenance of quadruped position for JF would be used to promote weight-bearing on his lower extremities.