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.
Friday, October 31, 2008
Thursday, October 30, 2008
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.
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.
Tuesday, October 28, 2008
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.
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.
Saturday, October 25, 2008
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.
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.
Thursday, October 23, 2008
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.
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.
Wednesday, October 22, 2008
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.
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.
Friday, October 17, 2008
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.
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.
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