Final Entry: Placement 4 2010

Reflecting back on my initial entry for this last placement it's clear that my main thought feeling was that of concern. This was due to the expectation that I would require an extensive knowledge of the neuroanatomy of the human body and the impact that compromise to any one of the structures could have on function. I also expected that we were going to be asked a lot of questions to test our knowledge but this was far from the case. As expected I needed to have a clear understanding of the types of strokes and how to define them, the difference between a left and right sided stroke and the possible impairments that can result. My supervisor expected that we were able to understand these aspects of the neuroanatomy but more importantly expected that we could reason as to how they impact on a patients function. It was never a case of asking questions for the sake of finding out how much we know and rather questions were asked in relation to a patients presentation and what could be causing the impairments that were observed.

Something that I didn't expect on the placement was that there would be a neurological assessment form. This meant that I knew what I needed to assess and helped me perform the assessment in a structured but fluid manner. Like any aspect of physiotherapy when you have a thorough objective assessment it makes clinical reasoning a lot easier and helps drive an appropriate intervention. I think that because I was so focused on the amount of information that I would need to know I forgot about this important principle because I soon came to the realisation that although a patient may be diagnosed with a certain lesion it is the assessment that identifies it's impairments and not the diagnosis. There's no doubt that knowing the area of the brain affected, when it comes to stroke, helps explain a persons presentation but treatment is driven by what we see in the assessment not what we could see from a diagnosis. This relieved some of my concern because being the last placement I've had a fair bit of a practice with clinical reasoning and although I have a lot to learn I would rather back these skills than remember all the aspects of neuroanatomy.

I think something that I learned from a very early stage in the placement was that patients are rarely ever textbook. For example, I was expecting that a patient who had a posterior circulation lesion and that the cerebellum was affected they would have impairments down the ipsilateral side of that that the stroke occurred. I remember in at least one circumstance that this was not the case and it made me further realise that the assessment is what drives our treatment rather than the diagnosis. Moreover this reiterates the importance of a thorough objective assessment.

The expectation that I could be working with patients in a reduced conscious state and that this would impact on my ability to communicate with them was way off the mark. Working on the stroke rehab and with patients admitted into the stroke rehab unit meant that a lot of the patients were sub-acute. Occasionally patients were drowsy but this did not impact on my ability to communicate with them which I thought might occur. I did however come across a lot of other issues that made communication difficult. A handful of patients that I saw suffered from various levels of expressive or receptive dysphasia, some had dysarthria, some suffered from dementia or were experiencing delirium, some were extremely deaf and others had english as there second language. This meant that I had to draw on other means of communication such as gesturing and reading a persons expressions.

Overall I can't believe that this placement has been and gone.From an early stage I was given my own caseload which gave me confidence knowing that my supervisor was happy for me to work independently in an area of physiotherapy that I was a bit unsure about. I lot of the patients that I saw, because they were high level, had impairments such as reduced gluteal strength that were similar to those seen by some in the musculoskeletal setting which I really enjoy and performing gait analysis on patients who have suffered from a stroke was really interesting. It was really satisfying seeing patients who presented without sitting balance progress to taking their first steps but as expected in the neurological setting their were very few patients that we saw improve that drastically over the 5 week period. Looking back I enjoyed most of the placement but being the last of 4 rotations towards the end I was really looking forward to it all being over so that I could move on to the next stage towards becoming qualified. I'm sure the next month will go just as quick as this prac did and the excitement that I had prior to my placement has only fuelled as I get even closer to the end of my degree!

Week Five Entry: Assessment

Situation: I was asked to see a 96 year old male on a general medical ward who had been recently transferred from Sir Charles Gardiner Hospital (SCGH) with the diagnosis of a right sided occipital cerebral vascular accident. He presented to SCGH via ambulance for reduced mobility and left sided weakness on the left in the patients upper and lower limbs. His past medical history included heart disease, a coronary bypass (25 years ago), deafness and dementia. From reading through the integrated notes from SCGH and the hospitals own integrated notes, I found out that the patient lived in a low level care (LLC) facility and was previously independent with his ambulation with a 4 wheeled walker over approx. 300m. It was unknown what he was like with his activities of daily living.

It is important that when a patient is admitted that physiotherapists perform an initial mobility assessment on admission as evidence, although not strong, suggests that early mobilisation is beneficial in improving a patients outcome. Once a mobility assessment is performed the initial neurological physiotherapy can be conducted. I was notified that I needed to see the patient the day after he was admitted as there was a breakdown in communication in the handover to the physiotherapy department. This meant that I would need to prioritise my assessment to include a mobility screen and part of the initial neurological assessment.

Task: Perform a mobility assessment and prioritise my initial neurological assessment to complete as much as possible.

Action: The patient was resting in bed in supine. I knew that my main goal for the session was to get an idea of the patients mobility so I decided to assess the factors that could affect the patients mobility first. I started with subjective assessment, getting idea of the patients orientation to time person and place so I could determine whether the patient was in a confused state and whether mobilisation would be safe. Confirming the patients previous level of mobility would also be of importance. When it came to the objective assessment I chose to work methodically so perform the tests I could in supine first, then get him into sitting and then standing etc. I reasoned that a quick screen of of voluntary control and muscle strength would be useful. A lack of sensation would also affect standing balance and mobility, as would tone, so that would also need to be assessed. Once I screened these areas I assessed bed mobility (rolling left and right) and then transition from supine to sitting. As the patient was 96 and suffered from dementia I thought I would just ask him to sit up without teaching him the correct technique so not to confuse him. After I looked at the patients sitting balance I got the patient up into standing. I had the help of my colleague because I wasn't sure how much assistance the patient required. Finally when the patient was in standing I got him to do some weight shift left and right and then marching on the spot so that I knew that it was safe for us to get the patient ambulating.

Results: The patient was extremely deaf so communicating with the patient turned out to be the biggest challenge overall. This made the subjective difficult and combined with his dementia meant that I was unable ascertain, with confidence, his previous level of mobility. He displayed reduced muscle strength in his left upper and lower limbs but each muscle group gave a score of a least 3 (on the manual muscle chart) and each joint was able to move out of synergy with no associated reactions observed. I was therefore confident that he would have enough strength and control to attempt a stand, at least with assistance. Tone was also assessed and although there was increased thixotrophy in his left biceps and hamstrings there was no deficit that suggested to me that mobilisation would be unsafe. No impairments in sensation were evident. Then I performed my mobility assessment and the results were that the patient was independent with rolling left and right, he was 1 x min assist with supine to sit to the left, 1 x min assist with sit to stand, 1 x min assist with a step/stand transfer to the left with a 4 wheeled walker and then 1 x min assist with ambulation for approx. 10m with his 4 wheeled walker.

Evaluation: Overall I think I prioritised reasonably well and performed the assessment in a reasonable time considering the difficulty in communication. I think I my assessment was reasonably well structured as my patient did not to have to keep changing positions back ad forth before I began my mobilisation. I feel that I took all of the necessary precautions, whether that was getting assistance or making sure that the patient was physically able to mobilise, to ensure that a mobility assessment would be safe for the patient. There were however a few things that if I had my time over again that I would change. Something that became evident when ambulating with the patient is that I should have assessed his vision. When walking with the patient he appeared veer to his left and required verbal prompts to avoid objects on his left hand side. As soon as I saw this I realised I should have tested his visual fields, acuity, eye tracking and convergence and divergence because each of these factors could too impact on a patient's safety when mobilising. I also forgot to assess the patients tone until after I had performed the mobility assessment. There was no evidence prior to mobilisation of significant issues with tone (hypotonia or rigidity or gross spasticity) that would impact on the safety and performance so I think my clinical judgement at the time was reasonable. I could have also improved my documentation on his mobility chart as even though I stated the assistance and direction required with his bed mobility and supine to sit I forgot to mention which side we performed the step/stand transfer to. Overall I was pretty happy with my performance and I feel I have definitely improved in my neurological assessment skills over the time on this placement.

Strategies: I think planning the assessment before I started would have been beneficial. Although I had an idea of what I wanted to assess I didn't really take the time to think about which order to perform the tests would be the most efficient. Rather I tried to reason as I went. Eventually assessments become second nature (or at least I hope so) but I think to become really good taking even a few minutes helps. Reflecting back and realising that the patient was on a stroke pathway I could have read over the physiotherapy assessment form in the pathway document. This is a more broad assessment form and includes 'tick' boxes etc. but would have given me a further idea to what should really be assessed as a minimum and in checking over it I may not have forgotten to assess aspects such as tone.

I think a strategy to continue to use throughout my career is to reflect back on my performance whether its assessment, reasoning or intervention. I think if I continue to use this strategy it will help me to improve as a physio and better my skills as a clinician.

Week Three Entry-Progessing my Intervention

Situation: I have been treating a 74 year old male who is 6 weeks post a left sided cerebral vascular accident (CVA) with daily gym sessions since starting my neurological placement on a stroke rehab ward. Currently his main problems include his decreased ability to weight shift to the left, lack of dexterity in his right hand, left trendelenburg gait pattern, requirement of 1 standby assist for mobility, right hemianopia and ideomotor dyspraxia. The thing that has made treating this patient even more complicated is that he suffers from expressive dysphasia. This means that he is unable to verbalise what he wants to say because of impairment in higher level function. This tends to be very frustrating for the patient and is difficult for the therapist as they can't get much feedback from the patient. Due to this dyspraxia most of my treatment has been based around functional tasks. To encourage weight shift to the left and use of his right hand I have been using a clothes line for reaching exercises, facilitated sit to stands has encouraged improvement in pelvic stability and gait retraining has helped normalise his gait pattern. I have also used obstacle courses that require the patient to look to his right to address his problem of a right hemianopia.

I felt that the patient was now at a level where I would need to progress his treatment to further enhance the strength in his left hip abductors and develop a more normalised gait pattern.

Task: To progress his treatment but use exercises that the patient can understand and perform correctly.

Action: I decided to try performing step ups with his right lower limb to facilitate weight shift to his left. Initially he had difficulty understanding the task and would often forget to take his foot off the step so would just rock forward and back on his planted right foot. Even when he did work out the purpose of the exercise and the correct technique it became evident he did not have the pelvic stability to control the weight shift to the left to put is whole foot up on the step. The gym in which we were working in has a clock set up on the floor with targets so I thought I'd try putting the patient in the middle and have him step with his right foot. Then I tried performing the step ups in the parallel bars.

Result: Stepping to the targets on the clock face turned out to be too much of a challenge due to his dyspraxia as he became confused and frustrated at not being able to perform the task correctly. The step ups in the parallel bars proved to be a better exercise which he was able to perform correctly. I was also able to progress the exercise by taking one of his hands off the bars without jeopardising his control and technique.

Evaluation: Although it took me a while to come up with an appropriate exercise I think I analysed the situation pretty well. I recognised the reasons as to why the patient was finding each different task too difficult and was able to come up with one that met his level in function physically and cognitively. Looking back I probably could have tried stepping towards a single target rather than having a lot of different targets to chose from. This would have also simplified the exercise so that he could understand the task and perform it correctly.

Strategies: The ability to evaluate an exercise and make adjustments to suit the patients ability but challenge them at the same time is a skill that physiotherapists always use. A strategy that I will utilise is to ask myself "why"? If I try an exercise and it doesn't work I will try to always ask myself "why isn't it working"? It will help me determine whether I need to change it to suit a patients impairments such as dyspraxia or strength or endurance or balance etc.

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.

Week Three Entry- Intervention and Education

Situation: I had previously attended a home visit to see a 12 month old girl with Down Syndrome. The purpose of that visit was to perform an initial observational assessment and discuss the role of physiotherapy in the service that the commission provides. The mother, being a single parent, worked full time and would drop the child off at daycare in the morning and pick her up at the end of the day. I was therefore asked to attend a visit to the child's daycare with my supervisor, the occupational therapist and speech pathologist. The plan was to observe the child in the environment she spends most of the day in.

On the day that the visit was planned my supervisor called in sick so I had to attend as the acting physiotherapist. On arrival the young girl was asleep and so what had planned to be a visit to observe her routine at the daycare became more of a discussion with the head of the daycare about the child's daily routine.

She was very interested in how she was able to help this child develop but had not worked with a child with Down Syndrome previously. From discussing about what aspect of the child's development she wanted more information about her priority was how she could help the child physically mature. Acting as the physiotherapist, this meant that I would have to educate her on the best ways to facilitate the child's develop. By this stage the child had woken up and so apart from giving education I would also be demonstrating possible handling techniques to progress her development.

Task: Handover the information from the previous visit to the head of the daycare, educate her on the possible strategies that could help facilitate the child's development and demonstrate a few intervention techniques that they could use in the child's routine.

Action: As I had already seen the child at a previous home visit I was able to handover some of the information about what I had observed in regards to the child's mobility. The girl was able to sit independently for greater than 20 mins and reach forward outside her base of support. When she wanted something that was left and right but outside the width of the base she was sitting, she would pivot around to face the object and then lean forward to pick it up. This demonstrated to me that she lacked strength and eccentric control in the trunk particularly in side flexion (left and right) and rotation. The girl was able to mobilise to get toys by rolling with a good segmental pattern. Occasionally when rolling from prone to supine she found it difficult to clear the underlying shoulder and so had create momentum by kicking her legs, performing the movement with less control. In prone lying she was able to prop onto her elbows and weight shift to one side so she could play with toys with the free hand.

It was interesting to collaborate what I had observed at the initial visit with the information they were handing over to me and what I observed when the child was awake at this particular visit. Something that I had not seen that the daycare workers reported was that girl had started commando crawling in the past week. This was not observed during the session but she was able to propel herself backwards using her arms to push off. They highlighted that this was also new.

I mainly educated the head of daycare about the rate of development in a child with Down Syndrome and the main impairments that contribute to there slower development. She reported she was concerned about how slow this girl was developing compared to the other children and appeared worried that they may be doing something wrong that is slowing her down. I reassured her that the girl was developing normally for someone with her condition and that in fact she was progressing well and that it was great to here she is commando crawling, wanting to move at her age. I highlighted that Down Syndrome children lack the tone, strength and endurance of other kids of a similar age and hence the reason that they tend to be quite flexible, which was another concern of the theirs. I described that children will develop trunk control with forwards and backwards movements first and then develop their "side-bending" and rotation last.

When it came to the intervention, as I knew that she was focused a lot on the child's rate of development, I highlighted the idea that we may not change the rate of development with our intervention rather impact on the quality of each milestone so that the next stage of development may be better. My intervention was directed towards areas in which they could incorporate it to their daily routine. I encouraged them to carry her in side lying and demonstrated the technique. Teaching them to lower her from sitting via side sitting rather than straight back was something I addressed and I also covered how to facilitate her to come into sitting by providing a downward force at the hip and tactile feedback at the shoulder. I also demonstrated how to block the hip when she wanted to pivot to reach for something left and right so to encourage rotation at the trunk when reaching. Each of these focused on improving trunk control whilst being simple enough not to disrupt the workers daily routine and limit their available time with the other kids.

Result: By the end of the session I felt the daycare workers understood the purpose of each technique and how to perform them. It was good to see that when for example, I demonstrated how to block the hip, the girl attempted to reach for the toy by rotating at the trunk as this reinforced to them how the technique can help. They appeared more reassured by the end of session that the girl was progressing normally for someone with her condition.

Evaluation: I think overall I handled the situation pretty well. I was particularly happy with how I delivered my education. I felt I was clear and concise, identified what was normal for someone with her condition and as well as what she lacks, which is causing her develop at a slower rate. I think my choices for the intervention were appropriate but where I think I performed poorly was in the demonstration of how to pick up a child in side lying and in the fact that I didn't get the daycare workers to demonstrate the facilitation techniques that I showed them. This was pretty disappointing because now I'm unsure that the intervention will be effective outside the treatment session. Fortunately the head of daycare had told me that have carried babies in side lying before and blocking the hip from pivoting is reasonably simple. Facilitating side lying to sit maybe something I will need to re-visit at the next session. Making sure that the person who is performing the intervention can perform it correctly is something that applies to all areas of physiotherapy and is a vital concept.

Strategies: I think it mainly comes down to remembering to always evaluate a patient's performance of the exercises I prescribe but always thinking about how my intervention will stay effective outside the treatment session will hopefully jot my memory. I also could practice my handling skills with my baby cousin or dolls.

Week One Entry - Assessment

Situation: I attended a home visit with my supervisor to see a 3 1/2 year old girl with Down Syndrome for a mobility review. She is an only child and from previous meetings it was noted that the team around the child included her stay-at-home mother, father, nanna, disability services commission and paediatrician due to the complications associated with the girl's condition.

From the latest individual family support plan (IFSP), which is the name given to the goal setting meeting at Disability Services Commisions, it was identified that the main goals for the family were to progress the child's mobility and more specifically for the child to begin cruising along the furniture. Other goals included the child verbalising action words such as "up" and "help". At the time of the last home visit the girl's main form of mobilisation was via bottom-shuffling and she had not yet been observed crawling with the correct technique. She was able pull herself into standing at the couch but demonstrated a lack of ability to weight bear through her lower limbs with increased hyperextension of the knees and large reliance on the upper limbs for support. She was not yet able to cruise along the furniture, hence the goal set at the IFSP meeting.

Another issue that would need to be discussed at the home visit is that the child is at an age that the family will need to start thinking about enrolling her in a kindy. The commision offers support through the local area coordinator and therapist if the family desires, so a discussion about the possibilities for kindy and whether they would like some support would be useful.

Task: To perform a subjective and objective assessment aimed towards the child's mobility development.

Action: The main aim of the subjective was to get an idea of how the child was developing. When working with children you are not always going to see their best performance on any given home visit so an effective subjective assessment with the mother/father is important to get an insight on how the child is going. I asked the mother about the child's daily routine and if there was anything new or whether there were any concerns. I wanted to find out how the child moves, when does she move and whom does she move for? I also asked about how her communication was going because this was a priority for the family.

As the Disability Services Commission is based on family centred practice I based the objective around observation of the child in their natural environment and looking at how they played and interacted with others. If there was something looked altered from normal I aimed to correct it and see if the child could perform the movement in the correct manner.

Result: The mother identified that the girl had been cruising along the furniture throughout the day but more when her father or nanna was home. Although it was not observed the mother also reported the girl was now able to crawl and did so on various occasions. It was reported that the child's communication was progressing and that the girl had identified on two occasions the need to use the potty with success at using the toilet. The mother voiced some concern in regards to the child's behaviour when playing and that to settle her down she needed to put her in her chair or in her room after persistent poor behaviour. The child would settle for 20 mins but then return to her previous actions. The father would punish her immediately after the poor behaviour was observed so when the girl returned to the room she would not regress back being troublesome.

It was observed that the child was able to pull into standing independently and cruise along the furniture, however each time she did so she led with the left foot from high kneeling with that limb in approx. 70 degrees external rotation. When we tried to facilitate her to lead with her right lower limb she was unable to perform the task. There was no hyperextension of the knees observed. She still used bottom shuffling as the main form of mobilisation and no crawling was observed.

The girl enjoyed turn taking and pretend play with her toy tea-cup set and telephone in cross legged sitting, prone lying and when cruising. She also liked imitation and was able to verbalise two syllable words such as "yellow" (pronounced "lellow") and "mummy". She enjoyed scribbling and attempted to copy straight lines and circles when prompted. The girl did however like to throw toys on occasions and she did not stop when told to do so. The mother identified that it was this type of behaviour that was becoming more common.

Evaluation: I don't think I performed as well as I would have liked to. It was the first time I led the assessment and I think I found it difficult to adapt to working with children. Moreover I found it difficult to communicate and ask the mother questions whilst trying to play with the child and build rapport with her. So although I got the information I needed it could have been a lot more neat, fluid and efficient.

I need to also work on my facilitation and handling skills but I think this will more or less come with practice. I found it difficult to try and facilitate the girl to lead with her right foot especially because she was trying to prevent me from doing so. Observation is something I also need to work on so I am better able to identify impairments and deviations from the normal. For example my supervisor highlighted to me after the session that when the child lowered herself from the couch she would come into sitting through a deep squat rather than controlling it through high kneeling, something that I hadn't observed. I think observation is really important as it seems that the physiotherapists at the commission base most of there objective around this skill.

One positive was that I was able to recognise the major impairments and activity limitations in regards to the child's movement and document it effectively. I feel I did this whilst building rapport with the child and mother so that hopefully I can perform better at the next home visit.

Strategies: As I mentioned I think both these skills are going to improve as I practice and see more patients. I think one strategy that would be useful would be to make sure that I know what normal is. Knowing my developmental milestones and being able to identify normal will mean that it's a lot easier to identify deviations from the norm and recognise impairments in movement.

Intial Entry

I am quite unsure about this upcoming paediatrics placement. Having never had any experience working with kids as a physio I am quite concerned about how I'm going to perform. Although we have been taught the techniques in class there has only ever been one opportunity to get "hands on" experience and so I hope I pick it up quickly. I guess my concern is further fuelled by the fact that not only am I dealing with the child but I'm also working with the family. Something that I seem to be thinking about is whether the parents are going to be happy with a student physio working with their child? I expect that a sceptical parent would be not uncommon and might be something that I will cross during my time at Disability Services. One positive is that I have worked with kids at football clinics before so I'm not completely naive to working with children.

I expect that my supervisor will ease me into this placement. I think she will already know that I lack experience working with kids and recognise that because paediatrics is such a special discipline that I will need some time to develop my skills.

I already know that I will be doing home and school visits so it will be really interesting and valuable to see how each child copes and performs in their normal environment. The way I picture the placement is that I will be doing a lot of observational work, watching how my supervisor handles, treats and communicates with the kids and predict that it wont be until later in the placement that I have more autonomy. Speaking to others who have had paediatrics placements this seems to be the case across the board and I guess its due to both our inexperience in this specialty area but also the concerns of the family.

In regards to my preparation for the placement I think I'll need to know a child's developmental milestones, have a background knowledge of the various conditions and be able to come up with a treatment program appropriate to the child's age and interests. Maybe even know a few nursery rhymes! To be honest though, because our paediatric units involved so much information and it was difficult to go into each condition in depth, I think I'm going to do most of my learning whilst on this rotation.

Beyond my concern is some genuine excitement for the challenge that lies ahead. Although I don't think that I will work within paediatrics in the future I think it is going to be a great opportunity to improve my interpersonal skills and my ability to build rapport. If I by the end of the placement I have improved my ability to talk with kids and their families I think I'll be more confident with communicating with any patient that I cross. Overall it's going to be interesting to see how the program works and the effect that it has on the lives of kids within the community.

FINAL ENTRY: Placement 2 2010

Reflecting back on my initial entry for this placement it appears there were a few expectations that were accurate but there were other aspects of the placement that i had not considered.

Having the ability to interpret your objective findings and create an appropriate problem list was a must, as expected. This ability not only provided the foundation for treatment but was also how our supervisors judged our clinical reasoning. Needless to say it was a necessary skill to have.

Teamwork proved to be an important part of my placement. As per my initial inclinations, there were times where there were a lack of high priority cardiorespiratory patients and so you would treat patients together with another student. Furthermore, working on an acute surgical ward meant that patients had many attachments and so most of the time there were at least two of us working with the patient. Having the ability to manage attachments was something that I had not considered prior to the placement and proved to be an important skill.

I was right when I thought that I would not have the same level of autonomy as with my musculoskeletal placement. My supervisor needed to be sure that I was safe in regards to interpreting obs and with my manual handling before I was able to see patients on my own. As mentioned before I often needed an extra set of hands with patients which meant that I also had to be able to communicate effectively and take control of the situation at hand. I also found it beneficial having the support of my supervisor in the early stages. I felt more confident dealing with patients and it was great having a another person there to "bounce" thoughts off each other when there were alarms going off and a medically unwell patient lying in bed. I think if I didn't have that support early on it would have been too overwhelming.

I thought that I would need an extensive knowledge of pathology for this placement. This tended not to be the case for me because I was working on an acute surgical unit. Although I needed to have a basic understanding of some cardiorespiratory conditions what was more important was having a knowledge of the various procedures and how that surgery would effect a persons risk of developing a post op complication. I also needed to know the various protocols for each surgery.

Overall I have really enjoyed this placement. I have learnt a lot about how to deal with complex patients and prioritise them appropriately. I enjoyed the opportunity to work with other health care professionals and work as part of a team to improve a persons wellbeing. As I previously expected by the end of the placement I was managing my own caseload and running the ward and I feel that having that responsibility has progressed my learning immensely.

Week Five Entry: Discharge Planning

Situation: I had been seeing a patient a couple of weeks ago who had been admitted to emergency via ambulance with respiratory distress. He had collapsed and was transfered to ICU with the diagnosis of an infective exacerbation of his COPD. The 68 yr old male underwent a surgical trancheostomy as he was heavily sedated and was therefore unable to manage his own airway and secretions. He was transfered to the ward I was working on after a length of stay in ICU of close to two weeks and upon removal of his tracheostomy.

After the initial assessment it appeared that his chest was clear and that his main cardiorespiratory problems were airflow limitation (as a result of his asthma) and decreased exercise tolerance. He was morbidly obese and was a full sling hoist transfer, when previously he was independant with a walking stick. Something that further complicated the situation was that he was experiencing significant memory loss in regards to some aspects of his lifestyle prior to admission. He was confident about his living situation at home and how many flights of stairs etc. he had but was unable to identify whether he drunk alcohol or whether he normally had a cough, to name a few. His confusion was gradually improving but he occasionally was inconsitent with his answers to subjective questioning and often responded inappropriately.

Task: As the patient was improving medically and his chest was clear it was time to start thinking about discharge planning. My task was to come up with an appropriate discharge plan for the patient and discuss it with my supervisor.

Action: As the patient was significantly deconditioned and nowhere near his baseline, as he reported to us, I knew that this patient would require some form of rehab. Currently he was able to stand with a wheeled zimmer frame with 2 x mod assist and was able to stand for 30 secs only. Because the medical team was close to discharging the patient I automatically thought that they were thinking of sending him home so I had decided that sending him with RITH and possibly a home care package would be appropriate.

Result: It was decided by the team that he would require inpatient rehab and that V5, the rehab ward at Fremantle, would be an appropriate option.

Evaluation: Reflecting back i felt like i performed this task poorly and my discharge planning requires significant improvement.Unfortunately up to that date I did not really understand all possible discharge options available. Being on a surgical ward most patients that I had seen were close to there baseline by the time they were medically stable, so discharge tended to be simple. I automatically thought that because this patient was independant beforehand that he would be able to return home with a program such as RITH and be fine. I never even asked myself the obvious question, "can the patient go home?". I think if I had asked myself this I would have planned a lot better. I guess I also didn't realise how quickly the medical team were planning on discharging him and did not consider factors such as his length of stay and confused mental state. Looking back it seems obvious that he required further intensive rehab so inpatient rehab would be appropriate.

As the patient was quite confused and suffering from considerable memory loss it would have also been appropriate to contact the next of kin to identify what his true baseline was and how he was coping at home prior to admission. This would have given me some valuable information to make an educated decision about his discharge plan.

Strategies: Whenever I attend a new placement or am working at a new facility I am going to make sure that I understand all the discharge options available. I think that now that it is week 5 of my placement that my discharge planning has improved significantly because I have progressed my understanding of each of the discharge options and the various packages and services available. I think that as I become more experienced this will naturally improve and I will be able to make better discharge decisions.

Week Three Entry- Analysis and Planning

Situation: I was asked to see a 80 year old female for mobilisation on 8.4.10 . She was admitted via the emergency department with the onset of severe abdominal pain within 24 hours and underwent a incisional hernia repair on the 30.3.10 by midline incision. She had a revision laparotomy and hernia repair 2 days later due to complications. The patient had a past medical history of unstable angina, myocardial infarcts, postural hypotension and multiple transient ischemic attacks. Between the time of her revision surgery and the day I was due to review her mobility she had had 3 codes, all for decreased oxygen saturations. I had already seen the patient for chest physiotherapy and she had been taught deep breathing exercises, a supported cough and techniques to relieve shortness of breath. The fact that she had not yet mobilised was due to her unstable medical condition. On the 8.4.10 it was handed over that the patient was now medically stable enough to commence mobilisation.

Subjective examination revealed no pain at rest, moderate dyspnoea and a productive cough as the main findings. O2 saturations were at 98% on 37% high flow nasal prongs, BP was 131/69 and other obs were stable. Cough was strong, dry, productive of minimal clear sputum and effective. Auscultation revealed early fine inspiratory crackles bibasally and fair breath sounds throughout. Basal expansion was fair bibasally and left equaled right.

Task: Plan an appropriate treatment for the patient.

Action: I decided that transferring the patient to a high back chair would be an appropriate intervention. This would help to improve lung volumes and encourage basal expansion. Mobilising the patient would also improve tidal volumes and help shear secretions off the airway walls. The plan was to sit the patient over the edge of the bed. I would expect that the patient would be dizzy from lying in bed for an extended period of time. Once the dizziness subsides, with a wheeled zimmer frame we would stand and perform a step transfer to a chair next to the bed. I would require the assistance of another physiotherapist/nurse throughout and due to the nature of her condition I would be monitoring her vital signs closely.

Result: The patient was a 1 x minimal assist with rolling onto her side and a 2 x max assist to sit over the edge of the bed. As expected the patient experienced substantial dizziness and nausea when sitting over the edge of the bed, which eased after approx. 3 mins. Sats were stable at 97% and HR was within normal limits. Even so my supervisor suggested that we take a blood pressure reading. It indicated a drop in systolic BP with a reading of 120/67. We still deemed it safe to attempt a transfer as the patients symptoms had subsided. Upon standing with 2 x max assistance and a wheeled zimmer frame the patient reported dizziness and nausea. The patient could only tolerate standing for 5 secs before the dizziness increased so we sat her back on the bed. This time the dizziness took 5-6 mins to ease, her saturations had dropped to around 90 and she reported some minimal chest pain. I decided that transferring her to a chair would be a bit optimistic. Hence once her symptoms eased I got to perform one more sit to stand and take a few steps sideways so that I could position her in a more upright position in bed. When she stood up the second time the patient was a lot more stable and her work of breathing was not as high so I encouraged her to attempt stepping towards the chair for a transfer. The pt was reluctant to do so, even with encouragement, so we sat her down and transferred back into bed, with it tilted in an upright position.

Evaluation: I think transferring the patient to a chair was an appropriate choice of treatment. I think where I needed to improve was my ability to quickly change my plan when things don't go as expected. I thought that the patient would be able to complete the transfer after the second standing attempt but because the patient was reluctant to do so we had to decide on the next best option. I guess I feel my ability to plan before treatment was sufficient but where I need to improve is my ability to quickly plan the next step throughout the treatment session.

I always need to remember to ask "why?" when symptoms appear and then think of what I can do to ascertain the cause of the symptoms. In this case I should have realised that taking the patients blood pressure would have been a appropriate measure to ensure safety with performing the transfer.

Strategies: I think this is going to take practice and will improve with experience. The more patients I see the better I'm going to get a planning ahead. It's important not to get flustered in situations such as these so taking a few seconds to pause, think and take a breath would be a good strategy.

STARES WEEK ONE: Assessment

Situation: I was asked to see a patient day one post elective surgery for the removal of an abdominal hernia. Her obs were stable, she was saturating at 100% on 2L of oxygen via nasal prongs, she was alert, orientated and afebrile but had not mobilised since surgery. She had an indwelling catheter and nasal prongs as attachments. It was documented that the patient had experienced no operative complications, her chest was clear and that she was previously independent with her mobility. The only possible complication to early mobilisation was that she was overweight. Although it would be important to see her day one post op I had planned to see her in the afternoon as she was not a high priority patient for physiotherapy. The patients nurse, however, wanted to get her up for a shower in the morning and so had asked for my assistance. The task would have to be quick and brief as there were other patients that were a priority for me.

Task: Together with my peer, perform a brief subjective and objective assessment, and with the nurse transfer the patient from the bed to a commode so the patient could be showered.

Action: We performed a subjective assessment asking the patient about pain, nausea and vomiting, dizziness, shortness of breath, cough, previous level of mobility and how she ambulated pre surgery. When it came to the objective assessment we decided it would be important to do a quick manual muscle test of the lower limbs so we could get an idea on the best way to transfer her. As she reported that she did not have a cough and she didn't have any shortness of breath we decided, with the limited time available, to not perform a routine cardio objective assessment today.

Result: The patient reported pain, 5/10, over the incision site, which increased with movement. She reported no chest pain, no cough, no production of sputum and no shortness of breath. The patient was previously independent with her activities of daily living and ambulated independently over indefinite distances with a quad stick. We decided to transfer her from supine to sit so we could perform the manual muscle screening. She was a 2 x max assist to get into sitting over the edge of the bed. This increased her shortness of breath score from 0/10 to 4/10. From the screening it was established that she had on average a grade 4 strength in the muscles of her lower limb and so it was decided that a step transfer would be suitable. Using a pulse oximeter we measured her 02 sats on room air (RA) as we would need to remove the oxygen to get her into the commode. Her sats were stable at 100% on RA so we decided it was safe to perform the transfer. With 2 x minimal assist and the patient using her quad stick, she took 5-6 steps forward so we could simply place the commode behind her to sit back down.

Evaluation: I felt the actual transfer itself was done efficiently and in a safe manner. It was performed in a way that did not put strain on us as therapists and that did not increase the pain of the patient. Reflecting back on the situation we should have performed the manual muscle test prior to positioning the patient sitting over the edge of the bed. This would have given us an idea that the patient had reasonable muscle strength so we may have chosen to perform a "supine to sit" transfer that was not a 2 x max assist and instead chosen one that encouraged a greater level of patient involvement.

Strategies: I think it's always important to encourage as much patient involvement as possible in our treatment sessions, after all one of the main aims of physiotherapy treatment is to get patients back to there previous level of function. I think an important strategy is never to assume that a patient is at a certain level of function based on initial observations. I think the best way to choose a transfer option is to consider the most independent transfer first and then if you don't think the patient is capable, consider the next most independent transfer and so on. This way you will promote patient independence and speed up their recovery.

Initial Entry 2nd Placement 2010 (Cardiorespiratory)

All of my placements to date have been musculoskeletal based so I am quite nervous about my upcoming cardiorespiratory (cardio) placement at Fremantle hospital. Not only this but it is also my first placement in a purely inpatient setting of a hospital, which is further enhancing my anxiety. Amongst this uncertainty I am excited at the prospect of working on a ward with a multidisciplinary team (MDT) and working with patients with more complex and critical conditions.

I expect that on my first day I will have a general orientation, be introduced to how the department works, how the ward functions and some of the types of patients that I may be seeing. I don't think I will have the same level of responsibility as early as I did with my musculoskeletal placement. I'm expecting that initially I'll be under the supervision of a physiotherapist because I will be dealing with patients in a more critical condition, but by the end of the placement I am sure that my supervisor will be wanting me to manage my own caseload. Speaking to students whom have already attended the placement it seems in some circumstances there are a limited number of patients that require cardiorespiratory physio and so they have been paired up to work with another student. This could possibly create conflict when a pair has contrasting ideas on the treatment of a patient but overall I think it would be beneficial to be able to "bounce" ideas of each other and clinically reason as a team. It would probably enhance our communication skills and facilitate our learning.

I expect that knowing the cardiorespiratory problem list is a must. I will need to be able to use my objective findings to justify my analysis and be able to document all the information appropriately in a soapier format. I suspect that knowledge of the various cardiorespiratory pathologies, types of surgeries, the effects of anaesthesia and the different types of interventions will also be vital.

The fact there is so much information compiled into out third year cardio unit is one of my major concerns. The idea that I could be presented with any one of the conditions we have studied, and possibly more, then have to interpret the vast types of objective markers and treat accordingly seems a little daunting. As mentioned before, I'm also a little concerned about working in a hospital setting when I have never really worked in one before.

Although it probably seems that I am quite fearful about this forthcoming placement I am looking forward to the challenge. As I have been based in the musculoskeletal setting for each placement thus far I have always felt that musculoskeletal physiotherapy was for me. I see this placement as my first opportunity to experience and discover another aspect of physiotherapy that I may enjoy.

Final Entry

Reflecting back on my initial entry for this musculoskeletal placement I feel that I was reasonably accurate with my expectations. From day one I was given the autonomy to see my own patients without having someone over my shoulder. Although it seemed daunting to start with I think that it was the best way for me to learn and I have gained valuable skills from being put in that situation. For the first two weeks I needed to report back to my supervisor after both the subjective and objective to show that I was conducting a safe and relevant assessment and that my clinically reasoning was valid. By week three I was completing my assessment and then discussing the treatment with my senior and by week four I was assessing and treating my patients without having to consult my supervisor. I think it was in these last two weeks that I thrived and felt that I really improved. I think maybe it was because by him having the confidence in me to see my own caseload it gave me more confidence in myself.

The expectation that I was going to see an array of patients and those with complex cases was accurate. I treated patients with MRSA, pain dominant presentations, centrally dominant pain mechanisms, obesity, diabetes and cancer to name a few. It really made me have to take a holistic approach to treatment and consider issues of infection control, appropriate exercise prescription and education etc.

Time management was another key skill that was required and something that I feel I further need to improve on. As my caseload increased so did the paperwork and so being able to perform a relevant assessment then treat appropriately and document the session became a challenge. I learnt the key to time management is a thorough and accurate initial assessment, I think if this is achieved and assuming you have treated the diagnosis appropriately, it makes the follow up assessment easier. If you don't perform a thorough initial assessment the problem can become more complex than you initially thought and chew up time that don't have.

Overall I thoroughly enjoyed my musuloskeletal placement. Having the responsibility of seeing my own caseload has really prepared me for the future. Being put in the deep end at the start of the placment really challenged my assessment and clinical reasoning skills and I think I have really benefited from the experience. One of the biggest things that I learned on the placement is that although we learn a lot about common presentations and patterns for certain conditions, it is not always the case in real life. Patients are often more complex so it is important to have an open mind during assessment and restrain from looking for issues that you think make up the problem but are not there. I found that it's important to treat what you see and always ask yourself "why?" when there is an impairment. I feel that this placement was a truly valuable experience and one that has prepared me to step out in the workforce at the end of the year.

STARES WEEK THREE: Analysis and Planning

Situation: I had been treating a 60 year old female who had been referred for headaches. On presentation the patient reported that they had suffered from "migraines" for 20 years. The headaches sometimes came in clusters having 3 or 4 in a row every 3 weeks. She described the pain as an ache that started in the neck and worked its way into the head. The pain most commonly occurred on the right but could shift to the left between episodes. She complained of no nausea or vomiting and only had described an aura on one occasion. Aggravating factors included stress and fatigue.

On objective examination I was unable to reproduce the patients neck pain with active movements, over-pressures, sustained movements or combined movements. Passive accessory examination produced no asterisk level. The patient did have a chin poked posture so I decided to assess her deep neck flexor recruitment and sternocleidomastoid seemed quite overactive. Her neck pain was then reproduced on palpation of the sternocleidomastoid origin. She also had decreased muscle length of upper trapezius which could be a result of her stress.

Although I don't think the patient suffered from true cervicogenic headache, on examination it seemed that the neck pain could possibly be a trigger for a her headaches. Treatment therefore consisted on addressing the patients postural issues with deep neck flexor recruitment exercises, stretches for upper trapezius and education on pain management such as the use of heat and relaxation techniques.

Task: The patient had been progressing well and not suffered from headache since starting treatment so the task was to start organising her discharge.

Action: For discharge the patient would need a comprehensive home exercise program and learn to manage her own neck pain. I continued with postural activities and stretches to maintain muscle length. I also addressed her ergonomics when sitting at her computer. As her aggravating factors were stress I taught her some relaxation techniques and suggested the use of heat for pain management. Part of my intervention was to educate her on the different type of headaches that she suffered from. I had to explain the headaches that we could manage biomechanically but that if she suffered from another aura that she would need to take her medication for migraines. Overall I had to make sure she no longer suffered from her symptoms and that she would be able to self manage in the future.

Result: The patient was going on holidays for 6 weeks so I had to decide whether to discharge her or transfer her to another physio upon return. Although she had been progressing well I had only been treating her over a 2 week period and since she suffered from headaches in clusters every 3 weeks, I was unable to tell if my treatment had been truly effective. Hence it was decided to write a transfer summary explaining the clusters of headaches and that should she need a follow up she would book an appointment after her holiday.

Evaluation: Overall I think I made the right decision. The aim of treatment is to make improvements in a patients symptoms. I was unable to ascertain whether my treatment was effective or whether natural history was the reason for her not having suffered from a headache during the time I had been treating her. Therefore giving her the option of another appointment if she suffered from a cluster of headaches in a week or twos time seemed appropriate.

Strategies: Always consider a patients natural history of symptoms when considering discharge.

STARES WEEK THREE: Communication

Situation: I received a referral for a patient with chronic low back pain. The patient is in his 50's. On presentation he complained of pain in his lumbar spine and a broad pain in the lateral aspect of the thigh. The onset was insidious dating back 2 years ago. He has been working as a gardener three times a week for 5 hours a day in that time and was frustrated that he has been unable work more due to his back pain. Aggravating factors at work include lifting loads and bending. Pain is eased my sitting. After half an hour of work he needs to sit down as the pain is too severe and it takes 5-10 minutes for the pain to ease. The difficulty in communication was due to the fact that his primary language is Cantonese and although he does speak some English he tended to repeat himself and focus on how work has been so frustrating.

Task: To perform a subjective and objective assessment that was not only effective but safe.

Action: I had to make sure that I spoke clearly and precisely. I established early that it was going to be difficulty getting as much information as possible from the subjective so I decided to focus getting the basics first. Finding out where his pain was, what aggravated it, what eased it, how long its been going on for and making sure that an objective assessment was going to be safe to perform. Where I could I tried to use gestures to help. I overall had to spend more time on the assessment part of the session to get an understanding of the problem that I would normally.

Result: It was difficult to even get a basic understanding of the problem from the subjective. The body chart and aggravating factors were the two areas of the subjective that were most difficult. Even though I knew the general area of pain in both his leg and back he had difficulty understanding the concept of specifically mapping out the area of pain and couldn't really describe his pain. Nor did he have an understanding of what I meant by how bad the pain was. I was able to determine the aggravating factors to the pain but trying to get more information about them was hard. I didn't really know what part of lifting was hurting him and what the duties at work were the worst for his back. When performing an objective in the musculoskeletal setting it is important when finding the source of symptoms that we ask the patient "is that the pain you've come to see me about". Many people have pains that are not those they are complaining of but could be a contributing factor or a different problem completely. The barrier in communication meant that although I was finding structures that were painful but I didn't know if this was his main pain. Nor was I able to find a true asterisk motion segment in the lumbar spine because multiple levels were sore and he was unable to tell me which one was truly worst. Generally getting him to perform different movements was also difficult.

Evaluation: Overall I don't think I did all that well in this situation. As much as he was repeating himself I was probably repeating myself. I found it really difficult to get my messages across which meant I didn't have all the information I wanted from the subjective. I was able to get a basic understanding of the problem from the objective and eventually was able to determine which direction of movement caused his pain and what level seemed to be the worst from the way he reacted to my palpation. In saying that it meant that I had to spent a lot of time with this particular patient.

Strategies: I think next time rather then asking opened ended questions I should delve more into the aggravating factors about questioning him about certain things. Whats it like walking uphill? Downhill? Gardening above your head? and other questions of the like. Using visual cues and the reactions of the patient is also beneficial. Bentley Health Service also have the option of the interpreter so I think that if it is still too difficult next session I may have to go down that path. My hesitation to do so is that I think it makes it difficult to build rapport with the patient but I guess at the end of the day getting a true understanding of the problem is in the best interest of the patient and if communication is a barrier then it should be addressed. Hopefully my second session with the patient will be more successful.

STARES WEEK ONE: Assessment

SITUATION: Working in a musculoskeletal outpatient setting I received a referral from a local GP for a patient that suffered from neck pain and migraines. The lady was middle aged and had suffered from this neck pain and "migraines" for 25 years. The pain that she described was an ache that starts in the neck, usually on the right, and expands into the head unilaterally to behind the eye. She highlighted that the headaches were mainly on the right but occasionally shifted to the left in a separate episode. She had only described an aura on one occasion but most headaches were not associated with such a symptom. Occasionally she experienced nausea but had never vomited as a result of the headaches. Aggravating factors for the headaches included lack of sleep and stress. The only easing factor identified was the use of Imigran, a prescribed pain medication. By the end of the subjective there was significant evidence to support that this patient suffered from cervicogenic headache, so an appropriate and thorough objective examination would be able to confirm or deny the diagnosis.

TASK: Perform an objective examination for this patient to rule in or rule out cervicogenic headache.

ACTION: The objective examination included observation, palpation, active movements of the upper cervical spine, overpressures and combined movements in an attempt to reproduce these ladies symptoms. It was also important to highlight to the patient the reason for wanting to reproduce her pain and that as soon as she felt her pain to let me know as to not create fear and unnecessary discomfort.

RESULT: The patient had a classic "chin poked" posture. The asterisk sign from her active movement examination was right rotation which was limited to half range. There was no pain reproduced with active movements or overpressures. I decided to perform a combined movement exam but unfortunately the symptoms could not be reproduced. It was at this stage that I was starting question the suspected diagnosis aswell quality of my objective examination. Having still not found where the patient's pain was stemming from I performed sustained movements of the upper cervical spine. Again this offered no answers. I moved on to the muscles around the neck. The patient had a decreased ability to recruit her deep neck flexors so I thought that this could be a contributing factor to the problem but without the ability to reproduce her symptoms I didn't have a distinct answer. I decided that I would go to my supervisor and explain the situation. He suggested that I try a more aggressive palpation of the musculature around the cervical spine. Palpation of sternocleidomastoid turned out to be the asterisk sign with pain reproduced with palpation of the muscle's origin.

EVALUATION: Even though it took me a while to find the patients symptoms, I felt like my examination wasn't too bad. Each test that I performed stemmed from the result of the previous test and I progressed examination with each test. One aspect that was done poorly was that I tended to focus on the joints of the cervical spine, disregarding the musculature. When the patient performed deep neck flexor recruitment it was evident that sternocleidomastoid was working overtime. I thought that this could be a contributing factor but never really considered that it could be a direct source of symptoms. Reflecting back on the situation the fact that right rotation was limited further supports tightness in the right sternocleidomastoid so one group of tests that could have been beneficial in this case and which were not performed were muscle length tests. I learned from the situation to consider more that just joints as a source of symptoms but consider muscle and all other relevant anatomical structures that could produce pain when performing an objective.

STRATEGIES: Consider all anatomical structures when performing an objective examination and make sure that palpation is specific and directed towards those structures that are likely to be the source of symptoms.

Initial Entry Ist Placement 2010

I'm thoroughly looking forward to my placement at Bentley hospital. Although I had a musculoskeletal based placement in my second year of studies, this rotation allows me to integrate all that I have learnt about the periphery and in particular the spine, and apply the principles to real patients. I feel that by the end of this placement I should be ready to step out into the workforce and work in a musculoskeletal setting. I think this would be the expectation that my supervisors will have and what we will be working towards.

As I am working in a public hospital I think the patients presenting to the clinic will be quite complex. I'm expecting many will have comorbidities such as diabetes and obesity as the demographic will generally be from a lower socioeconomic profile. This will challenge my clinical reasoning skills but I am excited at the prospect of developing this aspect of my profession.

The structure of the placement will probably change as the weeks progress. I think that as I get more practice and improve with my assessment, treatment and clinical skills the amount of supervision that I have will reduce. Initially I may have to consult my supervisor after each the subjective and objective so that they can make sure that I am covering all that I need to to make an educated diagnosis. I suspect that if they feel I can conduct a safe and appropriate assessment and produce an effective treatment plan they will wean their supervision and allow me to work more independently.

The thing that I am a little concerned with is time management. If conducted properly there is a lot of information to gain from a subjective and objective assessment and the more complex a patient the more information there is to get. The ability to get the right information, clinically reason through it and treat the patient in a limited period of time is definitely a skill in itself and one that I think comes with experience. Therefore I am hoping that by the end of this placement I have improved on this skill and am able to conduct an assessment and treatment in a similar timeframe to a more experienced physiotherapist.

Overall I'm looking forward to being able to manage my own caseload and improve on my clinical skills so that I am best equipped to step out into the workforce at the end of 2010 if i were to choose to go down a musculoskeletal path.