Week One Entry - Analysis and Planning

Situation: I was asked to see an 74 year old male on the rehab ward, 2 weeks post a lacunar infarct involving parts of the basal ganglia, internal capsule and thalamus. Relevant past medical history included two left gluteal tendon repair and hypertension. The patient lives at home with his wife in a two storey apartment and receives no services. He was previously independent with his mobility and activities of daily living but post surgery on his left hip he was ambulating with one elbow crutch on his right side.

I performed the initial neurological assessment which looked at assessing tone, sensation, coordination, muscle strength , joint range of motion, reflexes and balance. It also required me to observe the patients posture in sitting and standing as well as looking at his mobility and gait.

He was independent with his bed mobility, transfers and ambulation over 200m with one elbow crutch. His distance was limited by fatigue. The patient demonstrated a trendelenburg on the left, had decreased trunk rotation and arm swing, a lack of heel strike and left knee hyperextension when walking. Other asterisk findings of the assessment included glut med weakness, which was greater on the left, and bilateral hip extension weakness. The patient also demonstrated delayed righting and protective reactions in standing.

Task: To analyse the assessment findings and plan an appropriate intervention.

Action: I decided to structure my analysis by identifying the patients activity limitations and then deciding on which impairments from my assessment could contribute to each functional limitation. My plan would be to address each impairment and where possible relate the exercise to function so that it would help facilitate development of his independence.

Result: I identified some of the activity limitations as being unable to walk with a normal gait pattern, a lack of ability to weight transfer to the left and having difficulty turning and performing step ups in a normal period time (as assessed by the berg balance scale). The main contributing impairments to the trendelenburg gait and ability to weight shift laterally was weakness of the hip abductors and reduced balance. I thought that the knee hyperextension was mainly due to the lack of hip extension on the left. My plan was to practice weight shift mainly to the left, by performing reaching and step up activities and also strengthening the hip extensors and abductors. Gait retraining in the parallel bars to control the amount of knee hyperextension on the left was also a priority.

Evaluation: Overall I think I analysed the assessment findings reasonably well and got some good feedback from my supervisor which was reassuring. Something that I noticed in the observational assessment was the lack of heel strike on the left lower limb. I had also measured the patients range of motion in the ankle and found that bilaterally he had a lack of range into dorsiflexion. When processing the analysis I failed to think about the effects that this could contribute to the patients left knee hyperextension. This was something that my clinical tutor discussed with me and it became evident that the lack of dorsiflexion could lead to the compensation of hyperextension at the knee. I think the reason that I had not considered this before discussing it with my tutor was because the lack of range at the ankle was bilaterally but the hyperextension was only on the left. Hence I thought the two did not relate but as my tutor highlighted to me the patient could be using their right lower limb external rotation to allow themselves transition in stance phase rather than by compensating at the knee.

Strategies: If there is an impairment with gait or with any movement for that matter always consider that there often more than one contributing factor. I think if I look at what is happening above and below the affected joint and at least analyse whether it could contribute to the dysfunction would be a beneficial strategy. It would help make sure that I am more thorough in my analysis in the future.

Initial Entry 4th Placement 2010

I'm feeling mixed emotions about this upcoming neurological rotation. Being the fourth placement of the year I'm a bit over clinical practice and really just want to move onto shaping my own career. In saying that it is exciting that I am so close and I just hope I don't stubble at one of the final hurdles.

It is a common belief amongst the physiotherapy community that neurological physiotherapists are strict in their expectation of one's knowledge of the neuroanatomy of the human body. This makes me a little nervous but from conversing with some of my other peers I have heard that the physiotherapy department at Hollywood hospital are very supportive and happy to help facilitate a student's learning.

I expect that my supervisor will want me to have a general knowledge of the neuroanatomy, be able to recognise how it impacts on a patients function and be able to facilitate movement accordingly. I think that I will be working with mainly stroke patients so a knowledge of the types of stroke and the common impairments, activity limitations and participation restrictions will be important. I expect that most of the treatment will be based on improving a patients function by facilitating from various key points of control. Something that I am a bit unsure about is communicating with some of the patients that I will be seeing. A few will have a low level of consciousness and others might have speech disturbances so it will interesting to see how the physiotherapists at Hollywood approach communicating with these types of patients and the types of strategies they use.

Reviewing my neurological units I feel a bit overwhelmed with the amount of knowledge that I need to have going into this placement. Probably a bit more concerning is the need to be able to call on this knowledge when treating a patient and apply it appropriately to help with their rehabilitation. This skill is not something new and is in fact something that every physiotherapist needs to do but I feel that because neurology appears quite complex I think this is going to be a challenge for me. However because I have heard that as far as neurological placements go this is one very enjoyable, it makes me look forward to the challenge rather than be afraid of it.

Final Entry: Placement 3 2010

Reflecting back on my initial entry it's clear that I was quite concerned about how I would go working with kids but after being on this placement I feel that should I need to work with kids in the future I'd be reasonably confident. I took me a couple of weeks to really become comfortable playing games, making child sounds and generally interacting with the kids but once i realised you really can't worry about what you look like it seem to be a lot easier!

I thought at the start of placement that I wouldn't have as much hands on experience as my other placements and this did turn out to be the case. However, it was not necessarily because I was working with the kids and that the parents were uncomfortable with me doing so but rather because of the model of care that Disability Services Commission offer. Part of the model is that each chid has a key contact that attends most of the home visits regardless of the purpose of the visit. So in some circumstances I was attending visits with my supervisor, who was the key contact for the child, to trial a wheelchair or view mealtimes where hands on physiotherapy was not required. A positive was that I learned a lot about other allied health professionals and was exposed to different ways of thinking when treating a child.

Knowing a child's developmental milestones did turn out to be beneficial but I guess I did most of my learning on the placement. As I was seeing a lot of children with Down Syndrome it was probably more important to know the typical milestones for a child with such a condition and fortunately the commission had a lot of information on this topic. Knowing normal posture and patterns of transition was a priority and having an idea of basic handling techniques was preferred. Having a creative and enthusiastic nature was also a necessity!

Something that was an expectation was to have the ability build rapport with the child and the family. This was sometimes more difficult because I might have only seen a family once but it meant that you had have a good nature from day one. I think it was easy to build rapport with the family when you were engaging with their child and showed a general interest in the child's development. It was almost like if you demonstrated this the families trust and respect for you as a physiotherapist followed. So looking back at my initial inclinations that I would cross families that weren't happy with me working with there child, I think I was wrong.

Overall I did enjoy the challenge of working with kids. I had a lot of fun and found that I learned a lot about observing movement patterns, facilitating movement and family centred practice.

Week Five Entry: Presentation

Situation: The majority of the patients that I have seen on this placement have low tone. One of the first patients that I saw was a 3 year old Down Syndrome child who was at the stage where she was pulling to stand and starting to cruise along furniture, however with her lower limbs in external rotation. I had a strong feeling that this was a compensatory mechanism for a lack of stability around the hip joint and so it got me thinking more about the anatomy around the hip joint. From seeing many other patients with a similar presentation it became apparent that a lot of the activity limitations that children with low tone display are the result of impairments around the hip and trunk. Discussing this with my supervisor we decided that for my 5-10 min presentation that I was to give in my final week, a functional anatomy review of the trunk and pelvis would be beneficial.

Task: Give a 5 -10 min presentation on the anatomy around the trunk and pelvis and discussing the implications it has for paediatric physiotherapy on the child with low tone.

Action: I started getting back into the books, reviewing the anatomy. I decided that two of the major impairments that were evident in this type of of client demographic were muscle weakness and instability. Furthermore I felt that focussing on muscle tissue would be appropriate as it was what we as physiotherapists good impact with our treatment. Whilst reviewing the hip joint I noticed that all the textbooks state that glut med is an internal rotator of the hip joint in practice we always treat glut med weakness with clams. Clams is an exercise based on abduction and external rotation of the hip joint, so appeared to contradict the literature. I contacted my musculoskeletal lecturer to confirm the actions of glut med and felt that his would be a good discussion point for the presentation. I then planned to discuss when each muscle group becomes active during a child's activities of their daily routine, completing the presentation with the common compensations that child will display for weakness and instability.

Result: My lecturer highlighted that glut med can be divided into anterior and posterior fibres. The anterior fibres are internal rotators and the posterior fibres are external rotators. It is these posterior fibres that become weak an effect a person's function, hence why we prescribe clams, as an exercise for glut med. This became a good discussion point during the presentation. I wasn't too sure how to structure how each muscle impacts on function. I could have identified each activity of a child's daily routine (e.g. crawling) and then list the muscles that contribute to the task but decided to group the muscles according to their common action (e.g. hip flexors) and then highlight when they are important to function. I felt that highlighting the common muscles that are impaired in a child with low tone and then the compensations that are observed as a result created healthy discussion between listeners.

Evaluation: I felt that my presentation went better than expected. Whilst reviewing the literature I was worried about how to structure the presentation. It appeared that there was a lot of information to cover within 10 mins and I felt that grouping the information together so that it was relevant and engaging was going to be quite a challenge. I was happy to hear some positive feedback from my supervisors as they felt I was able to turn a reasonably dry subject into an engaging discussion. My presentation did go overtime though. Overall I was pretty happy with how it went.

Strategies: Something I learned from this presentation is to always question what you read. I guess this is a strategy that I will continue to use throughout my career.