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.