Week 5 Final Entry

After completion of prac today I have mixed feelings. In one respect I'm glad it’s over as it was a pretty intense five weeks, with constant pressure and absolutely exhausting working 7:30-4pm! But on the other hand, I really enjoyed my placement at OPH. The staff at the hospital were very welcoming and friendly, and were very easy to get along with. I was also sad to leave some of my patients who I had become close with over the duration of my prac. I received some truly touching Thank Yous from pts, and that in itself was very rewarding.

I was happy with my overall performance and felt as though I improved over the course of the prac. I have also now identified my areas of weakness so I can now work on improving my performance at future pracs and with other patients.

A few things I learnt from prac include;
1. the importance of a really thorough subjective assessment
2. the role of communication, and how effective it is in establishing rapport and cooperation with pts
3. the importance of establishing a good relationship with co-workers and members of the MDT-they can help you out a lot!
4. the key elements of SOAPIER writing in practice-not just theoretical knowledge
5. useful exercises and how to modify/apply to individual pts
6. how far a little initiative and extra work can get you

Week 5 Day 23 Entry 3

This morning I took a particularly interesting time trial. Time trials are conducted on an interval basis to assess pt’s function and mobility to determine if their condition is being maintained or if the disease is progressing and require intervention. The time trial I took today was of a 61yo man who had been diagnosed with Pd for some time. During the subjective questioning, I asked the man if he was experiencing any writhing mvmt, or any uncontrolled excessive mvmts (called dyskinesia). To this the man relied that he often felt as though he had squirming under the skin as if maggots had infested his body and were crawling through his system. This raised a few alarm bells both for me and my supervisor. With additional questioning the pt also stated that he experienced frequent unprovoked and intense episodes of rage, anger, and urges of aggression. The pt stated that he had not yet acted on these feelings of anger but they were disrupting his socialisation and interaction in the community. The pt appeared to be isolating himself from those around him as a kind of protective mechanism. As a PT I understand that we do have a role in education and some degree or reassurance/counselling but I identified this as a case beyond the scope/skills of PT. My supervisor informed me that these symptoms maybe a result of certain medications &/or mental health conditions.

In this circumstance I suggested that the pt mention these feelings in his consultant r/v next week. I also suggested that if the pt felt as though his feelings were getting out of control, then he needed to seek immediate counselling, social work, or psychiatric help. The pt was quite open and responsive to these suggestions, and seemed motivated to want to change. In this respect I felt as though our response was appropriate and still within the role of PT intervention.

When the pt initially explained his symptoms he did mention a shaking feeling within his chest and trunk. With this description I assumed the pt was describing a Pd symptom of internal tremor. I should not have made this assumption, as with further prompting his symptoms did not correlate with Pd characteristics. I think I should not have been so hasty to assume all of this pt's problems were related to his Pd- as I found out later on in the session; there were clearly other cognitive/mental health issues on top of his Pd.

I felt very comfortable assessing this pt. As much as his symptoms of anger and aggression were alarming, the pt was a very pleasant person to work with, and did not present with any of these characteristics during the Rx session.

In the future I will continue to recognise my limitations in education and counselling when it comes too developed or complicated cognitive issues. There are many alternative avenues for these pts where there needs can be more appropriately met.

In general, today was a reasonable quiet day, as many of my pts cancelled unexpectedly due to poor health or transport issues. But I’m hoping this will not be the trend for the rest of the week!

Week 5 Day 22 Entry 2

Today I saw one of my more high function pts. This man is 60yo and was previously a very athletic and active person. The reason for him coming into the Parkinson’s clinic is to maintain his high level function by participating in some more disease specific balance and strengthening exercises. In addition to this, I identified during his assessment today that the patient was having some difficulty with bed mobility and complained of shoulder pain. After making these discoveries I aimed to progress my mobility assessment, give the pt some bed mobility strategies, and assess his shoulder pain.

I began by observing the pt's normal movement patterns for getting into bed, turning over in bed, and getting out of bed. I was able to then provide some simple tips such as bending his knees up more, pushing down into the bed with his heels, and reaching when turning onto his side. The pt noted that the turning strategies made moving on the bed much easier. Other than his turning, the pt had good technique moving in and out of bed, and did so with ease.

Next of all I assessed the pt's shoulder pain. I began by observing the pt's AROM and found that he experience a painful arch between ~80-120degrees of shoulder abduction. I was then able to reproduce the pt's pain by performing the Hawkins-Kennedy test where the pt experienced more pain when moved into lateral IR than medial IR. This indicated to me a sub-acromial impingement issue, in comparison to a sub-coracoid impingement. My supervisor then noted his very forward flexed posture. I then observed the pt's scapulo-humeral rhythm and found that the pt had very protracted shoulders both at rest and in dynamic movement. We then gave the pt a scapular setting exercise to pull the pt's scapular down and medially, and asked the pt to re-perform shoulder abduction with this scapular position. The pt noted straight away a decrease in his shoulder pain. I think a large part of the pt's problem maybe tight pectoral muscles which places the shoulder girdle in an abnormal position and prone to impingement problems. If I were to continue with this man's treatment I would have liked to further investigate the cause of his thoracic kyphosis and scapular protraction. There were many other factors that I think could have been contributing to the pt's symptoms that could be addressed.

During this Rx session I was a little unsure about my assessment of the man's shoulder. As I have been on a Parkinson's placement I haven't seen any other musculoskeletal cases, so I have not had the opportunity practice any assessment on real pts. In the end I think the assessment was a success and my supervisor and I were happy that we were able to identify one of the contributing factors to the pt's pain, and be able to address it to some extent.

In the future I would like to have planned out my assessment of his shoulder a bit more. As this problem is not a common presentation in the Parkinson's clinic I was not prepared for doing a musculoskeletal assessment. Nevertheless I still felt comfortable and confident with the procedure, having done PHTY221 this semester.

I learnt today to expect the unexpected. The Pd clinic can present with a great variety of pts with different function and ability and I should be prepared to be able to address a whole range of conditions. I think prac is going well, but I'm actually getting a bit sad about having to say goodbye to my pts. Over the 5wks it is very easy to develop quite a rapport and relationship with the people we see. I think I will find it difficult not being able to see how the pts progress, especially those new pts that I assessed and have worked with from the beginning.

Week 5 Day 21 Entry 1

During Monday's visit to SCGH, I assisted with an OT/PT Rx session of a 74yo man. This pt had recently been discharged from OPH following a medication trial, in an attempt to find a balance between increasing the pt's mobility & avoiding confusion/compromising cognition. After this trial the pt and his family elected to be non-medicated for his Pd mobility disorder in favour of being cognitively alert. The pt described that medication caused significant confusion, and disorientation. This pt presented in the clinic today as a particularly alert, friendly, and witty man. Even from my initial contact with the man, it became more obvious to me why someone would choose to be virtually immobile if it meant that their personality, mood, and behaviour remained unaltered.

The aim of the PT/OT Rx was to try to optimise his function and modify ADL to maintain or increase his quality of life. This has become even more pertinent since the pt has come off all Pd medications.

From a PT perspective, this man's Rx involved practising STS and walking in the parallel bars. Although this does not sound an extensive Rx program, it was about the extent of the pt's mobility limits. For the pt to stand from his w/c and walk down the 4m parallel bars it took close to 10mins. It was then necessary to instruct and prompt the pt with many cues to allow turning. The pt then required rest due to fatigue (but no SOB was reported). I then challenged the pt to walk to the end of the parallel bars, where we collected his 4ww and with 1xA the pt was able to walk over to a chair about 2.5m from the bars. This was then the limit not only of the pts exercise endurance and mobility capacity but also the end of the 45minute Rx session.

I think I managed this client well as I was able to identify his limits. I was also able to identify and modify an exercise appropriately to help with the pt's decreased unilateral trunk strength. When working with this pt a great degree of patience was required due to the extreme slowness of the pt's mvmt, and I think I handled this challenge well. This pts main problem was akinesia or excessive inhibitory output from the basal ganglia which causes cessation of mvmt, so I provided appropriate cues such as saying to take big steps, count, or visualise stepping over a line/log.

One area that could have improved was controlling the pt's descent into the chair. The pt tended to flop into the chair, and did not have the ability/strategies to control this mvmt. I think I should have either assisted the pt into sitting or provided more input on how to control getting from standing to sitting before allowing the pt to perform this independently.

I felt confident and comfortable in this Rx session as I was not the only therapist present. I was working with the OT in attempt to assess and modify the pt's mobility as a MDT.

From this session I have learnt that it is very important to recognise a pt's limitations and how then to modify what you think would be an ideal Rx to the ability of the pt. So far this week has gone well, yet I hope to fulfil my supervisor's expectations when it comes to the final assessment on Friday.

Week 4 Day 20 Entry 3

Today I was involved in a group class held at SCGH. This week's session was based on education and strategies for speech and swallowing, and was run by a speech pathologist from OPH. I found this session very interesting and informative, as it addressed many issues regarding both disease specific and age related changes.

For Parkinson's patients, speech and swallowing can become significantly impaired. The muscles that create the vocal cords of the larynx often become slack and begin to bow instead of forming a taut orifice capable of creating clear loud vibrations that we perceive as a voice. The consequences of the change to the larynx structure are microphonia, slurring, and husky speech. This is problematic as communication with others becomes difficult and can impact on people's quality of life and socialisation.

Swallowing can be equally as troublesome. The peristaltic movements of the oesophagus are reduced, therefore food is harder to digest and can easily become lodged. Food can also be difficult to digest as saliva secretions may be reduced, and the mouth/throat may be dry when attempting to swallow a bolus. Swallowing can be helped by implementing strategies such as thickening of liquids. When swallowing medications, it is often advised that pts use yogurt or custard to swallow tablets instead of water as the viscosity of the liquid assists with the movement of the tablet down the oesophagus.

After educating the participants on the reason for their speech/swallowing difficulties, the SP then proceeded with some exercises to assist with the volume and clarity of the pt's voice. The key to these exercises was taking deep breaths from the base of the lungs before projecting any sound. Song like exercises were introduced to encourage projection of voice. It was evident from after these exercises that the pts not only found it interesting but very useful and applicable. The change in clarity and volume of some of the patients was almost immediate.

In terms of reflecting on my performance, I actually only saw one pt independently today. The rest of the day was spent observing treatment, helping in the group, and performing admin jobs. During the Rx session of my pt, I planned further objective assessment, balance exercises and revision of freezing/turning strategies for her second appointment. I observed and analysed the pt's gait pattern, and bed mobility as well as revising the pt's progress on clock turning and visualisation strategies. I then went on to prescribe the pt with a balance exercise for her HEP and provided a handout with written instructions and guidelines. My supervisor's comments were that there were many issues I could have addressed but I felt that balance was the most pertinent impairment for this pt in the prevention of falls and further injury. I also choose to review the previous week's strategies and only introduce one new exercise to avoid confusion and overload of information for the patient.

The patient and her husband stated that the strategies from the previous session were effective in improving the patient's ease of movement and safety during turning and ambulation. I therefore felt as though this approach was particularly effective for this pt and her circumstances. I would like to improve on the clarity of my explanations when breaking down complex tasks. I found this afternoon that I could have used more effective concise language to describe the task/activity at hand. I felt very comfortable in assessing this pt, as I had performed the pt's initial assessment and had a clear idea of the impairments and pt goals to work towards.

In the future I may take more time to think about my explanation to pt's before launching into the next task with verbose language. I felt as though I achieved a lot today, even though my clinical contact was not as long as usual, I was still effective in completing the necessary tasks that I was assigned.

Week 4 Day 18 Entry 2

One of the pts I saw today has a history of depression, lack of motivation, and is often non-compliant to Rx suggestions. The pt suffers from frequent falls mainly due to his increased tone (and subsequent abnormal biomechanics of his LL), gait disturbance, and impulsivity. In order to help reduce the number of falls, prevent further injuries, and improve the pt's gait pattern, it was necessary to prescribe a narrow WZF. Previously the pt has already trialled a 4ww, but refused to use it (without reason or explanation). After requesting that the pt trial the WZF at home, the pt presented today with reports of reducing his falls over the wk. Nevertheless the pt had fallen twice when he had refused to use the frame in confined and difficult places around the house. Today's treatment involved problem solving with the pt how he could perform his normal tasks around the house whilst still using the frame to provide balance support. The pt's problem areas were the kitchen, bathroom, and bedroom due to the small size and large amount of obstacles and furniture. I wrote out a handout detailing how the pt could position his frame and perform his activities whilst remaining safe and supported. Although this education and discussion took up the majority of the Rx session, I still considered this treatment to be an efficient and effective intervention in an attempt to reduce his falls.

The instructions given to the pt were clear and concise, and the pt appeared to understand and comprehend the information. The pt agreed to try the strategies at home, as the pt did display some motivation to reduce the number of falls he is having. If the pt was still experiencing problems in the home, I would get a referral to the Pd OT for a home assessment. Other than assessing the pt's use of the frame I should have been able to incorporate some exercises into the time limits of the therapy session.

I felt comfortable and confident giving the pt these strategies for the home, as I had discussed some of these strategies with my supervisor with a previous pt. I would have changed my approach by reviewing some more of his HEP within the session, if time permitted.

In the future I would attempt to improve my time management with explanations and discussions. I think it would also be necessary to explain the importance of this education and explanation to the pt as part of their Rx process.

Overall today went well, I was able to see a range of pt's and was involved in either taking the entire Rx session independently or a component of the Rx.

I am continuing to read up on the Guidelines to Treating and Assessing Pd patients, as well as researching and writing my presentation topic.

Week 4 Day 17 Entry 1

Today I was given a patient to treat and assess unexpectedly. In the past this patient has been seen by my supervisor and I have only assisted or observed the sessions. Although I had read the pt's notes from the previous weeks, I still felt ill prepared to run the session independently with the pressure of my supervisor assessing me on my performance. I don't think I handled the session that well and I was left feeling disappointed at the end of the treatment.

I began reasonably well by determining if the pt had experienced any new problems or falls since her last visit, and then when onto begin some balance exercises. From her initial assessment and the previous medical notes it was evident that the pt had decreased balance but had not yet been prescribed exercises. Therefore I proceeded by giving the pt a high stepping exercise (performed by lifting knees very slowly, standing without holding onto anything) to challenge her single leg stance balance and strengthen her pelvic stabilising muscles. My supervisor then noted that it would have been more appropriate to re-assess the pt's balance tests first to establish a baseline from the day of exercise prescription.

I had also noted from the pt's records that the pt had reported feeling weak in her LLs. Therefore I went on to perform manual muscle testing of hip flexion/extension/abduction, knee flexion/extension, and ankle DF/PF. Yet I found this testing very difficult and was not very good at modifying the standardised test positions to suit the client's needs. Unfortunately the pt found lying supine and prone very uncomfortable, so I had to limit the time and number of tests performed in this position. The pt was also unable to lie on her L side due to a medication pump positioned on her L hip. In addition the pt had decreased ROM in her LLs (due to increased tone?) which made side lying difficult and the rating of her muscle strength performance hard to assess. In general I felt as though my time management for performing this assessment was very poor, and not well planned.

In the future it would be helpful to know (prior to the assessment time) the positions the pt is able to move into for testing procedures, when the last assessment was made and what the results were, and develop a plan for pt positioning to reduce the numbers of transfers/change of positions the pt has to make.

Therefore, I didn't feel particularly confident or comfortable during this assessment as I felt unprepared and inadequate at performing the assessment. I hope to revise the other assessment options I could have used in this situation and discuss this with my supervisor.

After this session today, I felt as though my confidence levels dropped, which then reflected in my assessment and treatment of my other pts for the rest of the day. If a similar circumstance were to arise again I would attempt to clear my mind of my previous Rx performance and start afresh with each new pt.

I am currently doing research for my end of placement presentation into disease specific risk factors for falls in Parkinson's disease. So I will also be revising PHTY223 notes for background information on falls and balance etc.