FInal Entry

On reflection of my initial journal entry, many of my concerns and anxieties were ungranted. The first issue was my concern about the family I stayed with- they were very welcoming and easy going so I settled in well within the first week. The second issue was my concern regarding my preparation for my placement. I feel as though I had adequately prepared for most of the tasks and presentations that I was exposed to on prac, and otherwise I had the appropriate study material to facilitate my learning.

I was indeed exposed to a wide range of physiotherapy practice. I was involved in and helped run hydrotherapy classes (in particular ante-natal post-natal/baby, and arthritis sessions), used the RTUS machine to help diagnose and train core stability, participated in and conducted Clinical Pilates classes and individual sessions on the reformer and trapeze equipment, and performed musculoskeletal Ax and Rx sessions for patients ranging from paediatric to geriatric age groups.

My prediction that I would be more of an observer in my first week was also correct. As placement progressed I was given the opportunity to perform ‘hands on’ Ax and Rx in the second week, and conduct Pilates, antenatal, and post-natal classes by the fourth and fifth week.

I was very grateful for the experiences and learning opportunities that this prac provided me with. My supervisors Emily and Craig were inspiring clinicians and such welcoming, supportive, and caring people that I could not have asked for a better prac or a more enjoyable rural experience. In particular I was thankful for the opportunity to be introduced and trained in Pilates, and realise the importance and role of core stability in treating such a wide range of conditions. I also really enjoyed the women’s health aspect of this prac, which has inspired me to consider pursuing this area of physiotherapy in the future.

Week Five Albany

S- Over the last 5 weeks I have been treating a 48yo lady for chronic bilateral neck pain/stiffness. She described her P1 as a deep dull aching pulling pain aggravated by L&R rotation, L&R SF, and extension. She works as an OT doing geriatric home assessments, as well as administration duties which involves many hours of computer work. She demonstrated a kyphotic thoracic and cervical posture with increased muscle bulk and pain in upper-trapezius and levator scapulae which the pt reports to have developed over the last 25yrs in concurrence with commencing work. Her symptoms have been present for about 9 years but increased in intensity approximately 2 months ago particularly on the R. Treatment over the weeks has involved STM (to upper trapezius, levator scapulae and ES Thoracis) including the use of a cyrostix, cervical manual traction and SNAGS into R rotation, thoracic mobilisations (SNAGS and PAs), a shoulder girdle and neck stretching and strengthening HEP, and the loan on a theracane for additional soft tissue release. Initially treatment was directed at soft-tissue work, but with some improvement in the muscle after 2-3 sessions, the treatment was later focussed more on joint mobilisations with only some soft-tissue work and additional stretches to do at home. On re-ax during and after Rx, the pt would report a reduction in pain and stiffness and demonstrate a slight increased ROM. However after ~2-3 days the pt’s symptoms would re-emerge and therefore the pt was coming into physio 2x per week.

T- On my last day of prac it was my task to perform a reassessment and evaluate the progress that the patient had made since initial ax in week one. It was also necessary to establish the most effective line of treatment and consequently the focus for her short and long term goals. Throughout the 5 weeks it was my goal to improve the patient’s symptoms to a point where she was able to manage at home with a HEP and progress to physio only 1x a week.

A- At the beginning of the treatment session I took 10 minutes to discuss what the patient thought was the most effective treatment and what she believed was the focus for the next 1-2wks vs the next 6-8wks. To reassess the pt’s progress I measured her Cx ROM and performed Cx PAs to establish her mobility of C2-C7.

R-The re-ax showed that there her L and R rotation had improved from 1/2 ROM to ¾ ROM over the 5 week period. However after discussing her long and short term goals, the patient expressed that they had not achieved as much progress as she would have liked and that the changes were only temporary. The patient reported that the soft-tissue treatment had relieved her stiffness but the results were only temporary whereas the joint mobilizations did not seem to make as big a difference to her symptoms but seemed more permanent. As a result we agreed to set the short term goal to focus on joint mobilization and progress her stretching and soft-tissue HEP and the long term goal to achieve more permanent soft-tissue changes.

E- I believe my strengths were the way I conducted the interview with my communication skills. I discussed with the patient that if there was still no change by the end of another 3weeks or another 6 sessions that we would need to refer her on or discuss alternative therapies. I was able to work cooperatively with the patient to establish patient centred goals that would optimise her outcome. My weaknesses in this session and throughout her whole treatment history have been an inability to cause a significant permanent change in the patient’s symptoms. After the treatment session there was again only a slight increase in ROM to ¾+ ROM.

S-Although I achieved the task of establishing long term and short term goals and an accurate re-ax of the patient asteric movements, I did not however reach my goal of being able to see the patient only 1x a week to maintain her symptoms. Strategies I could have used include referring the patient to a massage therapist sooner in order to achieve soft-tissue release independent of physiotherapy. Or otherwise I could have acted upon my supervisor’s suggestion to get the patient myofascial release injections. I do believe however, that I exhausted many of the physiotherapy options that were available to treat this patient’s neck pain. Maybe another strategy for this patient would be to extend the time frame of expected results due to the chronicity of her neck pain.

Week Three Albany

S- This week I had the opportunity to independently perform a complete subjective and objective assessment along with the corresponding treatment. The patient presented with 2 pains and some numbness of her foot. Her worst pain(P1) was across the metatarsal heads of her L foot and was described as a dull ache, intermittent, deep, 6/10 at worst and 0/10 at best. The pain was aggravated with 25 mins+ of running and barefoot walking around the house and eased with relative rest and heat. Her second pain (P2) was in the proximal lateral leg near the STFJ. The pain was described as dull and aching, intermittent, deep, 2/10 at worst and 0/10 at best. This pain was aggravated during breast-feeding where she assumed a cross-legged position and eased with neutral sitting position. Her numbness was in the S1 dermatome along the dorsal aspect of the lateral L foot. This numbness had been present since pregnancy and did not change with position or activity. The patient reported that there was no relationship between the pains.

T-With this information I was required to perform the relevant tests and treatment with a 30 minute period to establish the source and nature of her symptoms and provide some relief of these symptoms.

A-To assess her P1 I palpated the area, performed accessory movements, OP and passive physiological movements on metatarsophalangeal and interphalangeal joints, assessed active and passive ROM of her talocrural and subtalar joints and observed her gait pattern on treadmill walking/running for 5 minutes. None of these tests were able to reproduce her pain. However I did observe a pronated gait pattern with early toe off which increased from walking to running and an increased muscle bulk to Tibialis Anterior. As a result of this testing I decided to discuss footwear options with the patient, advised to use rest, ice and elevation when symptoms occurred, suggested a referral to the local podiatrist for an in-depth gait analysis and possible orthotic prescription, as well as giving her a dynamic rotational calf stretching HEP. For her P2 I assessed Tibialis Posterior, Fibularis Brevis and Longus muscle length as well as palpation. Upon palpation of Tibialis Posterior the patient reported similar symptoms to her pain. I did not have time to perform a neural integrity or neurodynamic test to investigate this patient’s numbness.

R-The patient reported that she was keen to investigate her gait pattern with a podiatrist and had thought for a long time that she might need orthotics. My analysis of her P1 was that insufficient support of a pronated gait pattern when running was causing localised inflammation and increased loading to her medial metatarsals, which may be exacerbated by her recent pregnancy and continued breast-feeding. During her assessment I believed that P2 may have been the result of a tight Tibialis Posterior muscle.

E- Upon review of this assessment I believe I need to work on my time management in order to complete the testing of all this patient’s symptoms. I also think that I did not assess P1 and P2 in enough depth. I think I should have gotten an objective measure of the patient’s Soleus muscle length instead of just Gastrocnemius before giving her a calf HEP. I also think it would have been worthwhile to perform a neurodynamic SLR +PF/INV to ensure there was not a neural contribution to her P2 considering the proximity of her symptoms and her Fibularis nerve near the STFJ.

S- In future I think it maybe necessary to consult briefly with my supervisor between subjective and objective assessment to discuss the progression of the assessment and again between objective assessment and treatment of the patient. I think this would help to organise my analysis of her symptoms and lead to a more efficient and accurate diagnostic and treatment process. I also think I need more practice at performing the assessment in order to achieve good time management…practice makes perfect so hopefully it is only a matter of time!

Week One Albany

S-During this week I had the opportunity to individually treat a patient that had been seeing my supervisor for the last 4 weeks. She originally presented for physio as part of a worker’s compensation claim with L lower neck, scapula and radiating arm pain following a struggle with a child in a school classroom. So far she has been prescribed scapula setting and strengthening exercises, treated with trigger point release and laser to T3-T6 and upper trapezius, Tx mobilisations to T3-T6, and given Butler ULNT stretches. When the patient presented to me she complained of additional radiating pain and twitching sensations into her L scapulo-thoracic region and some radiating R scapula pain. Upon questioning, the patient reported she had not been doing the ULNT stretches.

T- In order to address these new symptoms it was my role to re-assess her ULNT and explain the nature of her pain (twitching radiating pain is associated with neural involvement and is most likely a neurogenic non-compromise condition.) In addition I was required to continue her previous line of treatment.

A- I identified positive results upon testing her L ULNT1 and R ULNT3. I then explained that these symptoms were due to an inability for the nerve to move within the surrounding tissue, which places tension on the neural structure leading to her radiating twitching pain. I then progressed by explaining the importance of her ULNT stretches and trigger point release as the best line of treatment, and that her symptoms would persist and progress if she did not cooperate with her HEP. Other components of the treatment session involved Tx NAGS mobilisations, STM, laser treatment and a review of her strengthening HEP.

R- Although the patient promised to perform their HEP more diligently, she did however express confusion about the nature of their pain and how testing the UL nerves indicated neural involvement in her scapulo-thoracic pain.

E-The strengths of this session included my execution of her STM and Tx mobilisations treatment (she reported feeling less stiff and less pain with an increased ROM into Tx rotation.) As a result of this treatment I believe the patient’s condition had improved. Nevertheless I feel as though I need to improve my ULNT assessment in addition to my communication and education skills when attempting to explain the nature of neural involvement to a patient. In particular I feel as though I need to document the onset of her neural symptoms more accurately during assessment. As a result of my poor explanation I think the patient may not have understood the nature of her pain and the importance of performing the HEP.

S- As a result of this treatment session I have found an ULNT assessment sheet, which allows documentation of the pt’s symptoms at each stage of the tests. I also plan to research the nature of her thoracic radiating pain and prepare an information page on the neurogenic pain and the corresponding treatment. As a very intelligent woman I think this patient would benefit from knowing the technicalities of her condition and treatment which might also motivate her to perform her HEP and optimize her outcome. 

Initial Entry- Rural Prac 2009

On Monday I’ll begin my rural placement at the Shiel Family Practice in Albany. Although I’m excited about my rural placement and the experiences it will bring, I also have additional concerns that I didn’t experience in my preparation for metro placement last year. There is definitely an element of the unknown- not knowing the family I’m staying with, not knowing the area I’m living in, not knowing my role or expectations in the family home, not knowing if I’ve prepared enough for the varied clinical presentations etc.

It is my understanding that I will have a very broad exposure to the different areas of physiotherapy (as is the nature of rural practice). I expect to be involved in hydrotherapy classes (in particular ante-natal and post-natal/baby sessions), using the RTUS machine to help diagnose and train core stability, learn and begin to teach elements of Clinical Pilates, observe and begin to perform musculoskeletal Ax and Rx sessions and complete the required documentation.

As a student in this setting, I predict that I will be more of an observer in my first week as I learn the necessary skills and protocols of a practice that is dominated by the concepts of Clinical Pilates. As the placement progresses I hope that I’ll quickly pick up the skills and be given the opportunity to perform ‘hands on’ Ax and Rx.

I believe that this placement will allow me to experience some of the areas of Physiotherapy that I am most interested in including Pilates, women health, and musculoskeletal. For this reason I look forward to meeting my supervisor, Emily, and learning as much as I can from this placement. I also hope to embrace any opportunity to get involved in the community including sports, events, and exploring the local area…Albany here I come!

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.

Week 3 Day 15 Entry 3

Today my supervisor was off sick, so I spent most of the day doing tasks independently or with other health professionals around the hospital. Today was, however, the first session of one of the Parkinson's groups at SCGH. This session usually consists of the OT and PT undertaking baseline assessments on all the participants. But due to lack of resources and staff, there was no replacement for my supervisor, so I was left to carry out the PT assessments by myself. This was a really good opportunity for me to think and act independently whilst also getting more experience in assessment procedures. I felt confident in taking the assessment unsupervised as I had performed the assessment numerous times previously, and still had the OT for support. The assessment involved taking a questionnaire and balance assessment including TUG, Pastor/Marsden, and timed step-stance/SLS.

I think I managed the assessment of the group well. In particular I think I was very efficient with the assessment of the patients such that I had completed the assessment and had extra time to generate a discussion with the group before the end of the session. One thing I could improve on is the accuracy of timing SLS. Often when pts perform this test they are unable to hold the position for an extended period of time (sometimes only 1s or less) which makes it hard to comply with standardised test procedures and measure with a timer (to the nearest 1/100).

In the future I should look at previous measures of an individual's SLS (if they exist) to determine if it is necessary to use an accurate timer or estimate by counting (for patients who measure 1 or 2s or less). Other than this I don't think I would change my assessment process as I found it worked quite well in the group setting.

I was pleased with my performance today, but I still feel as though there are many areas for improvement. After one of the Rx sessions today, I would like to review a 2 person transfer from sitting to standing as I did not agree with the technique that was performed with one of the patients. I plan to discuss this with my supervisor next week. I also hope to receive my mid-placement assessment next week as my supervisor was unavailable today.

Week 3 Day 13 Entry 2

One pt my supervisor and I saw yesterday was a 41yo Sudanese man whose native language was Dinka. The pt had moved to Australia 3 years ago, and was diagnosed with Parkinson's 8 months ago. During his time in Australia the patient has been residing with his cousin who also speaks predominately in Dinka. This meant that he did not speak much English, combined with microphonia and slurring of speech which comes with Parkinson's disease. Therefore this was my first face to face pt where there was a significant language barrier. Most of the time the pt would have an interpreter (as his cousin was unavailable to accompany him) but due to costs and some understanding by the patient, this service had ceased. Not only was this pt's native language a consideration, his culture, attitudes and beliefs were also an issue. To a certain extent the Dinka culture and way of life revolves around roles of women and men in society, in which men are predominately responsible for the welfare of the community. In this respect I had to be cautious not to be patronising or condescending as my actions may be offensive.

I think the Rx session ran smoothly and the situation was dealt with appropriately. I was sure to introduce myself and explain my role in his Rx. I allowed the pt sufficient time to mount a response and to process any information. When I spoke to the pt I ensured my speech was clear and my sentences simple and concise. The only part of the session where the pt was uncomfortable was during the balance Ax. One of the balance tests (the Pastor Marsden) involves testing the pt's balance reactions in response to a pull back on their shoulders from behind. In this situation the pt was afraid of falling and refused to participate in the test. The pt did not trust my supervisor or my ability to save him from a fall. In this situation more effort should have been made to reassure and the pt to make him feel more comfortable and at ease with the test procedures. Instead, I did not perform the test and said I would test it some other time when the pt was feeling more confident/steady.

Throughout the Rx session I felt very comfortable with the pt as he was patient and friendly during our attempt to communicate and understand him. I also had the support of my supervisor to assist with translation during discussion. In the future the presence of an interpreter may make communication easier and the Rx session more efficient.

From this session I learnt that it is necessary to take the time to ensure you understand the pt and have patience when communicating and discussing the pt's concerns. Although this may be a very time consuming process, it improves the pt's compliance and develops rapport and you demonstrate an interest in their wellbeing.

Things have gone well so far this week, yet I still feel as though I have room to improve in the area of documentation and subjective assessment. I need to refine my 'A' and 'P' of my SOAPIER documentation, as the hospital format for this in is slightly different to what I am used to. I also need to work on attaining specific patient goals, which can sometimes involve a lot of prompting and lengthy discussion to establish their motivation etc. Over the weekend I plan to look at my notes on dementia and depression to help me understand the characteristics of some of my patients.

Week 3 Day 12 Entry 1

Today I observed another very interesting Ax and Rx session. The pt was an 80yo Italian man, who had significant cognitive impairment, hearing impairment, and behavioural signs. It was because of these characteristics that my supervisor chose to run the Rx session, and for me to observe. The pt has been attending the clinic for 5 weeks, and is approaching discharge from Pd physio sessions. When the pt presented for therapy this morning, he appeared frustrated, short tempered, and easily distracted. The pt began to demand the need for a walking stick even before entering the Rx room. When asked why he felt the need for a walking stick the pt was unable to give a logical or convincing answer. Nevertheless, my supervisor began the session by observing the pt walk with and then without the stick. It was clearly evident that the pt lacked the co-ordination and dual tasking skills to walk/turn safely with the walking aid. It was necessary at one point for me to catch the pt when turning/changing direction with the walking stick. In this gentleman's case, as with many Parkinson’s pts, his concentration was being diverted from the task of walking to coordinating the stick movement such his ambulation was more unsteady and a falls risk.

Yet when these reasons were explained to the pt, he became angry, more vocal, and resistive. In fact the pt began to walk out on the Rx session, but was soon brought back into the room. It was obvious that the pt had become fixated and obsessed with the idea of a walking stick, despite the physio's professional recommendations against the idea. Even when the pt was diverted to another subject matter, in an attempt to distract the pt, he continued to persist with the matter, believing that we "didn't want to help him, and didn't want to give him the walking stick." So the session continued performing some of his HEP, and balance assessment to the best of our ability between the frequent outbursts or protest.

This patient therefore required a lot of patience, firm handling, and time spent reasoning/discussing his concerns. The best strategies used included; being calm reassuring and unhurried, distracting the pt and providing alternative activities, as well as being empathetic to the pt's feelings and concerns. One of the improvements that could have been made in this session would be to avoid the confrontation altogether at the beginning of the Rx session. Instead of avoiding the confrontation, the majority of the Rx was spent rectifying the situation.

I still felt comfortable in the presence of this pt, as I had dealt with the pt before and not had the same level of behaviour directly towards me. Therefore I rationalised that the pt was having a difficult day, which he confirmed, and the behaviour may have been the result of the fluctuations that have been reported previously. In the past the pt had been reasonably friendly and compliant, so he did not make my supervisor or myself concerned.

If this were my pt I may have discussed with his GP/consultant the change in behaviour observed to determine the cause of these fluctuations (behavioural signs can often be exacerbated by original personality traits or the effect of meds, illness, or discomfort).

Unfortunately there were 2 cancellations today which meant I had planned Rx sessions (that last an hour and a half) which I was unable to perform. Nevertheless, I think planned and performed the other Rx sessions well, choosing an appropriate exercise level/intensity and appropriate assessment measures.

Before tomorrow I need to look at ways to modify lawn bowls for a pt that experiences decreased balance, tremor, reduced LL muscle strength.

Week 2 Day 10 Entry 3

On Friday I was given the task of doing phone reviews. This process involved finding the patient's notes, reading through the treatment notes and doctor’s letters, phoning the patients and going through a subjective questioning with them to establish their level of function and the need for any intervention. Although the process was long and sometimes frustrating (missing notes, not being able to contact patients etc.), it was a good opportunity to practice my subjective questioning, problem solving, and clinical reasoning.

I found one particular patient particularly challenging. This man was of Lebanese background, he did not speak much English, had a history of dementia, was hard of hearing, and had a sever tremor in both hands. His tremor meant that he was unable to hold a phone, and instead spoke/listened through a speaker phone. In order for me to communicate with him I had to speak very clearly, with short and simple instructions and with a loud voice (whilst trying not to shout down the phone!). This meant I had to adjust the way I would usually phrase and explain my questioning, and also be cautious not to be patronising or make him feel disempowered. I think I modified my approach well in a way that was appropriate to the patient and for the information I had to obtain. I think sometimes during the call I may have been shouting to ensure the patient could hear my voice, when I should have been trying to project my voice. So I aim to improve this skill in future phone review sessions.

I was confident with the subjective questioning as I had planned prior to the phone call ways to phrase difficult or complex concepts such as festination, bradykinesia, akinesia, dystonia, dyskinesia, and tremor. This made the process a lot easier and it is something I would continue to do in the future.

The phone review session went well today, I was able to get through a number of these patients as well as attend to patients in the clinic. I think my time management skills are perhaps improving as the weeks go on.

I plan to clarify with my supervisor the hospital procedure for referring patient's from phone reviews to other health professionals within the MDT.

Week 2 Day 8 Entry 2

Yesterday I observed a significantly different treatment session. The patient was a frail 82yo woman who suffered from severe depression, diabetes, Meniere’s disease, and Parkinson's disease. The patient was reporting frequent urinary urges especially during the night (sometimes getting up 10 or more times in a night), causing her and her husband/primary carer sleeplessness and fatigue. The pt had been referred to a continence nurse, yet the patient's symptoms were persisting. As the pt had significantly reduced mobility and cognition, the husband was required to transfer her out of bed, onto the toilet commode, and then back into bed each time.

It became obvious after initial questioning that the husband was suffering from severe carers stress, and was not coping with his wife's high level care demands. The husband was planning on admitting his wife into hospital so he could have some respite. Therefore the treatment session involved educating the patient and her husband about the possible care options and how to go about applying for a placement at a nursing home, and some emergency respite. My supervisor and I provided the patient with brochures (such as commonwealth care link), spoke with their son and daughter in law, and organised a referral to an ACAT officer/ social worker to make an assessment.

The patient was very weak and fatigued; therefore I considered her health to be unsafe and a contraindication to her treatment program at the clinic. It was necessary to use this session as counselling and education so that the couple had a chance to speak to someone about their troubles and worries (as the social worker has a huge waiting list and would not be able to assess the patient for a few weeks). I think my supervisor and I did the best we could to try and ease their present situation, yet I was still left feeling that we should be able to do more. It is very hard to place a patient into emergency respite, and it takes many weeks for all the complex forms and assessments to be processed and the patient moved into a faculty, so unfortunately this was all we could have done in the circumstances. This experience was also about recognising the boundaries of physiotherapy and where/when a social worker/councillor/psychologist referral should be made.

This situation didn't make me feel confident nor comfortable, as I was aware of the extreme stress and depression that the patient, and to a large degree the husband, was under. I do think, however, that I would have provided the same advice and education to a patient if a similar situation arose. Yet it would be ideal if a social worker was more available and the emergency respite was more accessible.

I learnt from this session that it is essential to recognise and attend to the carer, as their health and well being has a large impact on the welfare of the patient. So I now understand the necessity to treat the patient holistically which includes considering the carer and their environment.

In addition to observing this patient's treatment, I also performed a number of time trials and more objective assessment which has been useful and worthwhile practice for me. Tomorrow I am learning about the government statistics database (AHS) and how to perform phone reviews.

Week 2 Day 7 Entry 1

This morning I got the opportunity to run my first full assessment independently. The patient was new to the Parkinson’s clinic and had been referred from his GP. I was a bit nervous, but quite excited to have the opportunity to go through the subjective and objective assessment process with a real patient. I finally felt as though I was able to put into practice all the work we have done on communication, types of questioning, active listening, clinical reasoning etc over the past 2 years.

The subjective assessment with the patient was held in the presence of the patient's wife. One of the challenges I had to overcome during the assessment process was ensuring the questioning was directed at the patient and the answers were coming from the patient and not influenced by the wife. The patient was a reasonably quite man, with a withdrawn nature, whereas his wife was quite outspoken. Throughout the assessment I felt my attention being drawn to the wife as she was providing more detail about the questions I was asking. I had to then modify my questioning, communication, and positioning to ensure I was constantly redirecting the question back to the patient so I could get his perspective on the matter. This also meant that I could keep the subjective assessment focused on the information I had to obtain and thus maintain an efficient assessment process.

I think I managed this situation appropriately, as I was able to obtain the necessary information from the patient, and subdue the wife to a certain extent whilst not offending or alienating her from the interview. What I think I need to improve on is obtaining more specific and meaningful goals from patients. When I have asked for the patient's goals in the past I don't think I have obtained enough detail or depth such that it is hard to forward plan and construct long term goals for the future. Next time I see this particular patient I plan to clarify and re-question the patient regarding his goals, as well as obtaining more base-line measurements for his mobility.

In the situation described above, I felt comfortable performing the subjective and objective assessment. I think this was because I had ensured that I knew the assessment forms well, and the procedures/normative values for carrying out the OMs. If I had a similar situation again I would perhaps change the wording of some of the questions in the subjective so they were a bit more specific and not so broad. Even though open questions are useful to obtain large amounts of information, they can also cause the assessment to go off on a tangent.

I am really positive about my experience at the clinic this week. I feel as though I am building on my knowledge and learning a lot from my supervisor and the other health professionals around me.

There are a few things I plan to look up in the next few days these include; how to make "SMART” goals, information on the medication Propranolol, and Meniere’s disease.

Week 1 Day 5 Entry 3

I spent this afternoon with the Parkinson's OT on home visits. There was no particular incident or issue during these visits but I thought I would share my experience and what I learnt. I found the experience really useful as it gave me first hand knowledge about what an OT does and how we can work together to provide the best possible care for a patient.

The visit was to an 83yo man who lived with his wife in a retirement unit. He was diagnosed with Parkinson's disease and suffered from dyskinesia (abnormal overactivity of muscles due to dopaminergic effect of meds), tremor, dysarthria, festinating gait, cognitive impairment, and a long/frequent history of falls. The reason for the home visit was to assess the patient's function following the installation of a new front step, hand rail, and opening door mechanism. These modifications were made in order to facilitate the patient's ability to leave the house independently and decrease the falls risk associated with the environment (as this had been a site of several falls in the past). The setup was designed so that the patient could prop the door wide open with the lever, walk through the door with his 4ww onto the porch step, push the walker off the step whilst holding the bar (positioned on the opposite side to the door), turn to face the bar and then side step down the stair to where his walker was positioned. This process was taught to the patient, with many repetitions and practice to consolidate the knowledge due to his memory deficits. The wife was also told what instructions should be used to prompt her husband to act in a safe and practical manner.

The patient did express his apprehension regarding the step, and commented on the fact that he was keen for a ramp (like his neighbour). With Parkinson's disease there is often a high risk of falls associated with any slope, in particular ramps as this can cause the COG to be displaced and the person to fall either forwards or backwards. The ramp was also inappropriate due to space constraints. According to the Australian Guidelines for builders and designers of ramps, the must be a 1:20 ratio. This means that every 1 cm displacement in height gained occurs across a 20cm horizontal distance (therefore a 10cm step would be the equivalent of a 2m long ramp). Therefore, a large part of the home visit was spent educating the man and his wife about the inappropriateness of a ramp and the need to conduct his actions without rushing and in a safe, controlled manner. This was necessary as we both observed the man's impulsive behaviour and his frustration when tasks could not be performed with ease.

I felt that the treatment session could have included more strategies for the man's festination habit (which was causing many of his falls). Although it is usually the physio that instructs the patient with these strategies and the OT does not usually include this in her treatment, I was able to provide the patient and his wife with a few ideas to trial before a more formal assessment at the day hospital/outpatient clinic.

Both the patient and his wife were very friendly and welcoming into their home which made it a very pleasant and comfortable treatment environment. I felt confident speaking and educating the patient on strategies for his Parkinsonism as I could easily recognise his symptoms, how they were contributing to his falls, and the interventions necessary to help prevent further falls.

Next time I might ask if I could have practiced the strategies with the patient a number of times and ensured that the patient could demonstrate how and when the strategies should be employed, instead of purely having an education role in his treatment session.

Overall it was another very informative day with lots to learn and absorb. I look forward to next week where I will have more involvement in the treatment and assessment of patients.

Week 1 Day 4 Entry 2

Today I was allocated a different supervisor in the Day Hospital Outpatients Clinic as a replacement for my Parkinson's supervisor, who is away at a conference. Unfortunately it was also this lady’s first day in her new position, so again my interaction with the patients was mainly observational with limited hands on experience.

One of the clients we saw in the day hospital was an 80 yo man who was referred from inpatients for further rehabilitation following a fall. After reading the medical notes I came across the underlying reason for his fall, according to his initial assessment he fell "after consuming two bottles of whisky on the election night." Therefore I already had alarm bells ringing about possible alcohol issues. In addition the patient was obese, and seemed to have significantly decreased range of movement and mobility due to his size. The patient's size did have me worried about the how the treatment could be carried out, the patient's safety in the case of a fall, and the ability for my supervisor and I together to be able to handle the man. The man lacked a great deal of insight and perception particularly when considering possible risks and safety issues. He seemed to rely heavily on his 4ww whilst not using it in (what I consider) a safe manner. Therefore a large part of the treatment session was spent attempting to educate the patient about safe and appropriate use of the aid. I also suggested to my supervisor that we should consider a less complicated, safer, and more supportive walking aid (such as a ZF). However, due to the patient's other cardiorespiratory co-morbidities (frequent episodes of AF, dizziness, and SOBOE) it seemed necessary to have the seated walker.

When reviewing the man's home exercise programme, the patient was particularly impulsive and non-responsive to commands or feedback. Nevertheless, he did appear to know what the exercises were even though they were not performed with the best possible technique. The patient also expressed the need for a "whisky break" during the treatment session. Obviously this was inappropriate behaviour, yet once my supervisor discussed this with him he did respond to the request and he didn't mention it again.

My supervisor and I concluded that it would be a good idea to direct this man back to his GP concerning his possible alcohol issues and educate him on the detrimental effects that alcohol will have on his well-being. I also discussed with my supervisor how it was better to be maintaining the patient's exercises and activity as much as possible to prevent a decline in his physical condition, even though the exercises were not performed with the perfect technique.

On reflection of the treatment session, maybe I would try to include the wife in the education and instruction of the exercises. This may have improved the effectiveness and technique of the man's exercises. I think it was a difficult situation, and I believe it was handled in the most appropriate way for the circumstances.

Although I didn't feel confident, as I have never had a patient similar or been in the same situation, I still felt comfortable and in control throughout the session.

What I learnt from this experience was mainly the importance of education and discussion when confronted with difficult situations. Even though it is essential to ensure there is sufficient intervention and treatment of patient's during a session, I am becoming increasingly aware of the need to incorporate education as a strategy for dealing with many situations.

Overall I think today was good as I got the chance to observe a different area of physio and work with another very experienced and knowledgeable supervisor. Yet, I feel as though I should ask my supervisors if I could have more hands on experience tomorrow. I tend to learn best when combining VRK strategies. When it comes to learning practical skills, however, I don't think there is a better way then actually practicing and applying the skill so hopefully I will have more of an opportunity tomorrow.