Final Reflection

This was my first placement in the field of neurology. It was refreshing to be learning and practicing new skills. Although I was on the stroke unit, I also had a few non-stroke patients with neurological deficit secondary to pathology such as a meningioma or an abscess. These patients were very interesting to follow as their rate of recovery was often quite unpredictable, and as physio’s we spent a lot of time liaising with the MDT about their medical status and their improvement in performance. I had a nice variety of stroke patients, for example I had a TACS, a PACS, POCS and a LACS. Because of this varied caseload, I had exposure to cognitive, perceptual, motor and sensory deficit.

Throughout my 5-week placement I found I needed to be extremely versatile with my treatment techniques for different patients. I discovered that although patient A and patient B may have the same motor deficit (left hemiplegia) they are unlikely to respond to the same approach and technique as they have different co impairments, such as dyspraxia, or poor insight.

As expected a large focus of my placement was on discharge planning. From the initial assessment of each patient we would device a problem list and set likely short and long term goals. There would be regular meetings with the multi disciplinary team and the patient’s family to discuss progress and set new goals. This was a great opportunity for me to become more familiar with the discharge options and the services or facilities available in both metropolitan and rural districts. During these meetings I was often asked to present a progress report. This enabled me to develop good liaisons with other members of the MDT, and gave me confidence in both my analytical skills and my public speaking skills.

Although my manual handling skills were adequate at the commencement of this placement, I feel I have refined my techniques and gained confidence in deciding upon the most appropriate transfer technique for a particular patient. I have been responsible for updating my patients’ mobility status to the nursing staff. For example if the patient requires minimal assistance or only supervision for their ambulation.

Prior to the commencement of this placement, I was concerned about what treatment approaches and techniques they might use on the stroke unit. I was curious as to whether the physiotherapists would be more dominant in Bobath or motor relearning techniques, and whether the focus would be on function, or facilitation of normal movement and error free practice. What I discovered on my placement was that according to the evidence, most recovery from stroke occurs in the first 4 to 6 weeks. For this reason, the stroke unit would focus on facilitating normal movement and getting recovery of voluntary movement for the first month. The team would then look realistically at the long-term goal, and start to focus on function and if need be compensatory movement.

This was an excellent placement; I had exposure to many different types of strokes and neurological conditions. Although a lot of my patients required the assistance of two physiotherapists, I had a lot of autonomy in the assessment, treatment and discharge planning procedure for each patient. I had the opportunity to work with 5 different physiotherapists, thus was exposed to a broad range of neurological techniques and treatment approaches. I feel very lucky that I have had such a good learning experience in the neurological field.

week five post

Situation:
Pt A had a left MCA CVA six weeks ago. She has a right hemiplegia and dysphasia. Pt A attends daily physio for gait re education, balance training and lower limb strengthening. Patient A is a stand by transfer with the nurses and ambulates using a walking stick with moderate assistance from one person. During the family meeting it was discussed that the goal is for patient A to return home with her husband as the primary care giver. I had not previously met patient A’s husband, or observed their interaction during his visits.

Task:
It was discussed during the meeting that in the preparation for discharge, we would need to teach patient A’s husband how to safely assist her to transfer into and out of the car. I booked a session with patient A and her husband to teach him the transfer and assess his appropriateness as the primary care giver.

Actions:
I took patient A down to the car in her wheel chair. First I explained to the husband that patient A needed constant assistance on her weak side. I demonstrated correct use of the wheel chair, indicating where the brakes and the tilt option were. I then showed the husband how to put her supportive sling on her right arm correctly. After this I explained that we wanted patient A to always lead with her strong side, so her approach to the car seat was very important. I suggested that as the car seat was low, she was likely to need assistance getting her legs into the car. To finish off I demonstrated the full transfer into the car. I then asked the husband to perform the same task as I had done.

Results:
Patient A’s husband attempted to put the sling on the wrong arm, when I corrected the sling; he explained ‘that he had got confused’. He then tried to get patient A into standing without putting the wheel chair brakes on. Once in standing, the husband stood at over a meters distance from his wife, and tried to control her movement by holding onto her right arm that was in the sling. He directed her into the car leading with her weak side, and did not assist to get her right leg into the car. When I asked patient A’s husband about his current health, he informed me that he had bilateral ongoing rotator cuff problems and had just recently been back to hospital for a scan and ultrasound. The husband told me that he often has sleepless nights due to pain and has next to no overhead shoulder movement.

Evaluation:
It was very clear from the husbands attempt at assisting a car transfer; he would not currently be a safe primary care giver for her. He appeared disengaged and disinterested in the advice provided. He also did not demonstrate any understanding of providing support or assistance for her right hemiplegia. I was unsure whether the husband’s lack of involvement was indicative of disinterest or of fear of responsibility. We have not had any previous interaction or discussion with him, so it is difficult to gage how he feels about being a full time carer. The husband’s health will also need to be discussed, as his shoulder pain is likely to impede on his capabilities as a carer.

Strategies:
1: Document the events of the session and reflect on my current thoughts about the husband ‘s potential as a full time carer
2: Liaise with the Occupational Therapist
- Discuss home visits, a repeat session with the OT on car transfers + slings + night splints
3: Liaise with the social worker
- Discuss organising a family meeting so we can do some realistic goal setting with the husband and their kids.
4: Liaise with my physio supervisor about getting the husband to come in for physio sessions so that he can start to learn how we help patient A transfer and ambulate.

Week 3

Situation:
Pt A had a Left MCA CVA on the 21/05/2010 and was found on the floor by her husband. She was transferred to SCGH with right-sided weakness. Patient A has a pacemaker and a previous medical history of paroxysmal atrial fibrillation and mitral regurgitation. The progress notes handed over from SCGH indicated that patient A had been non ambulant on the ward and was a two assist step transfer. When I entered the room, the patient was alert and sitting out of bed.

Task:
My task was to perform an initial objective assessment of patient A. I needed to assess gowlands, Covs the motor assessment and Berg balance. I then needed to create a mobility chart for the patient’s room to direct the nurses as to the appropriate transfer and aids.

Actions:
I got consent and then took patient A down to the gym in her wheel chair to commence the assessment. I did a two assist step transfer from the chair to the plinth, as was previously recorded in her notes from SCGH. Once lying on her back I commenced the gowlands assessment. On completion of gowlands I assessed Covs and MAS. I did not have time to assess patient A’s berg balance, proprioception, sensation or vision.

Results:
Patient A had expressive dysphasia. This made it very difficult to interpret her response to questions. Patient A would often muddle up her ‘yes’ and ‘no’ response. I needed to repeat myself numerous times throughout the assessment. It was also very difficult to determine the limiting factors in each assessment. For example when I asked patient A to perform a task I did not know if the limited performance was due to pain, weakness or confusion. I did not get the opportunity to discuss goals with my patient. When I assessed Gowlands, I had to constantly transfer my patient from supine to sitting for the different starting positions. This caused my patient to fatigue very quickly, resulting in deterioration in the performance level during the second half of the assessment.

Evaluation:
Due to patient A’s dysphasia, it was very difficult to determine the accuracy of her verbal responses. For example patient A would often say ‘yes’ when she actually meant ‘no’. When analysing my problem list, I found it very difficult to interpret the cause of her impairments. For example during the assessment of patient A’s shoulder, it was hard to tell if her limited range of motion was due to pain or weakness. I felt that my Gowlands assessment was very inefficient and poorly structured. As I was unfamiliar with the outcome measure I did not choose an appropriate order of assessment.

Strategies:
1: Find alternative means of communication e.g. facial expressions, body language, hand gestures, Draw or write, I could ask the husband to assist in interpretation during the sessions.

2: Plan my assessment better. If my patient is likely to fatigue quickly, I need to think about the sort of things I will assess in each different position (supine/ sitting/ standing For example, assessing Gowlands). This will enable me to structure my session more efficiently with less transfers.

3: I will plan a shorter session, so that my patient does not fatigue so much. (Split the initial assessment over two days)

Week 1

Situation:
patient A is a 65yr old who had a left anterior cerebral artery stroke one month ago. He has a right hemiplegia, very poor sensation in his Right upper and lower limb (particularly lower limb), he has short term memory loss, and is confused and disorientated. Patient A is leaning to the right in sitting, and pushes to the right when assisted to perform a sit to stand. Patient A also has a history of chronic lower back pain, which he has been complaining of over the last month. Today patient A is sitting in his recliner wheel chair, he has an arm support for his right arm. Patient A's wife has been visiting for approximately 5 hours every day and attending the physiotherapy sessions.

Task:
My task is to work on Patient A's sitting posture. I need to try and stop him from leaning to the right, increase his trunk extension and get him into more of an anteriorly pelvic tilted position, as he has been sitting very 'slumped'. My next task to practice a sit to stand. As patient A is 2 assist for all of his mobility, my supervisor will be assisting in the session. My final task is to practice standing posture and facilitate some weight transfer.

Actions:
I started off by asking Patient A if he could feel that his alignment was off center. I asked him to line his nose up with the middle of his knees. I then asked him to reach to the left for my hand, and kept him reaching until he brought his trunk back to the center of his body. As patient A was having difficulty with these tasks, i used a mirror to give him some visual feedback. I then progressed the treatment to a sit to stand with 2 assist. We blocked the right lower limb and facilitated hip extension, using a zimmer frame for support whilst we worked on standing posture.

Results:
Patient A was extremely distracted throughout today's session. He complained of back pain the whole time and seemed very confused and very distressed about something. When we questioned him as to what it was he was thinking about, patient A explained to us that he was confused about what had happened to him and why his body would not do as his brain wanted it to. He explained that he had lost all sense of time, and he was constantly paranoid that his wife was leaving him and not returning. Patient A stated he thought it had been a whole year since he had seen his wife, when really it had been one day. When i asked patient A if he could feel where his trunk was in space, or if he could feel how much pressure he had on each buttock and through his feet, he explained he couldn't feel anything and that he felt like he was sitting 'in the middle'. We had to stop the session early as patient A was experiencing very bad lower back pain and was very distressed and fatigued.

Evaluation:
It was apparent from patient A's behavior and response to the treatment today that Patient A has a lot of frontal lobe changes that are interfering with his physical progression. We are unaware as to whether the confusion is a result of his medications or whether it is a result of the stroke. Patient A 's lower back pain also seems to be exacerbated by his decreased mobility and poor sitting posture. We will need to liaise with the occupational therapist and the nursing staff to find some strategies to decrease patient A's level of distress. We will also need to give patient A's wife some strategies to manage his behavior.

Strategies:
1: Sensory bombardment; I am going to try and give patient A's right LL and UL lots of sensory input such as, pounding, approximation, weight bearing through the right lower limb and tapping of the muscles to see if i can awaken any of his sensory receptors, to give him more feed back about his posture and body position.
2: educate his wife and the nurses to constantly correct his sitting posture by asking him to reach out to the left.
3: Ask his wife to write down and date whenever she comes into the hospital or leaves, so that patient A is not distressed by her absence.
4: Start getting patient A to use a diary to write down his daily activities and thoughts. This may help to lessen the confusion and disorientation.
5: get some routine into patient A's daily activities. For example arrange physio so that it is at the same time every day. Twill enable patient A to have some consistency in his day to day life.
6: liaise with the nursing staff and doctors about giving patient A his pain medication before physio so that the lower back pain does not interfere with the session.
7: Liaise with the occupational therapy staff about a cushion for patient A's wheel chair (maybe one side more raised, to help correct the right lean.)

Initial Entry

This is my first placement in the field of neurology. I am excited to be nearing the end of my practical experience and still be looking to develop new skills. My placement is at the Osborne park stroke unit. According to my clinical mix form my caseload will be all stroke inpatients, the majority over 65 years old. I suspect that I will be spending at least an hour with each patient. As my caseload is all stroke patients, I think I will be treating impairments and activity limitations such as abnormal tone, sensation, strength, balance and gait. I think there will be a large focus on discharge planning and working with patients to achieve their optimum function so they can return to their home environment.

Although we spent a lot of time in tutor sessions going through various assessments and treatment techniques, I have never actually assessed or treated a patient with real neurological deficits. For example, although I am comfortable with my techniques to assess tone, I have never actually felt what abnormal tone feels like. I think I am likely to be challenged by the physical component of my sessions; I am going to need to focus on my manual handling skills.

My other concern for this placement is the treatment approach that my supervisor and co workers will be dominant in. During our university studies, we were exposed to many different methods and techniques. Although our course focused largely on motor relearning and functional rehabilitation we were also educated on bobath and techniques such as sensory bombardment. At the time, our lecturer informed us that depending on which facility we would attend the methods of treating and techniques used would vary. I hope that my depth of knowledge will enable me to adjust and modify my techniques as appropriate for my environment.

Final post

My placement at Bentley hospital was very different to what I had expected. As it was my third experience in a musculoskeletal outpatient department it was interesting to compare the differences in the structure, the physiotherapy techniques used and the patient caseload. I found that there was a very strong focus on soft tissue techniques and massage, with a very minor focus on mobilisation. This was very different to both my university experience and my previous learning experiences on placement.

During my placement at Bentley I found I was liaising with my supervisor a lot more than previous placements. My supervisor asked that I come and speak to him after my subjective assessment and before I commenced my treatment, so that we could discuss my findings. I found this strategy really challenged my clinical reasoning. My supervisor questioned my analysis and my planning of my treatment sessions, where we often had conflicting treatment plans, and analysis findings. Initially I found these discussions with my supervisor testing. I felt that my previous methods of reasoning and treating conflicted with those that my supervisor was advising. However as the placement progressed I learnt to have a more flexible treatment plan and be more open minded to different treatment techniques.

The patient presentation was quite different to what I had expected. There was a much more pronounced population of chronic, central pain patients. This population required me to alter my treatment approaches. I gained a lot of experience in the education and self management component of a treatment session. My supervisor showed me various home exercises and pain relief techniques that I was not previously familiar with. For example the use of a walking stick for self massage of the shoulder and neck region. I also found that there was a large Middle Eastern population that attended the clinic. This was very culturally challenging as my patients were often unfamiliar with colloquial terminology and had a very different understanding of the human body and movement. I had to find more simplistic and precise instructions for these patients. I also found it very difficult to gain the trust of these patients. I needed to do a thorough subjective assessment, and ensure that I informed my patient of why I was performing each technique. One skill that I did improve on was my ability to design an effective home exercise program around a patient’s lifestyle and activities of daily living. For example “Do this shoulder exercise every time you pray” (8 times a day).

Prior to commencing this placement I was concerned about the accuracy of my assessment. Previous feed back has been consistent with my tendencies to get excited about a diagnosis and rush through a certain part of the assessment. My supervisor at Bentley has spent a lot of time encouraging me to slow down my patient time, in order to gain an accurate assessment and a depth of understanding of my patient prior to initiating my treatment. During my end of placement assessment my supervisor explained to me that he felt I had really improved in this area and that my assessments and my reasoning had improved in accuracy over the final two weeks.

This placement was very different to my previous musculoskeletal theory and practical experiences. I feel I have finished these 5 weeks with more of an open attitude and flexible approach to clinical reasoning and planning. I am aware that there are many different techniques available to us as physiotherapists, and that each practitioner has unique preferences and strengths based upon their clinical experiences and background. On this placement I feel I have strengthened my soft tissue techniques and I have gained accuracy and depth in my assessment and analysis.

week 5: Proffessional behavior

SITUATION:
Patient A presented of 31/05/2010 two months post right medial collateral ligament rupture. Patient A was a young, athletic 22yo male. It was his first appointment at Bentley outpatient hospital.

TASK:
My task was to perform a subjective and objective assessement. In my subjective i would need the history of the trauma, any related history of knee pain, general health, social history and i would also need to find out what my patient's goals were in terms of work and return to sport. In my objective assessement i would need to assess gait, general function, palpation, ROM, Strength and proprioception.

ACTIONS:
I carried out my full subjective and objective assessement as above. I then discussed my treatment plan with my supervisor. Before finishing the session i gave my patient some education on modyfying his exercise as appropriate and pacing himself with his daily activieties. I also went through two exercises for him to practice at home. The first exercise was a wall squat. I facilitated the correct foot position and palpated his VMO to check he was getting a co contraction of his quadracepts. The second exercise was a balance exercise in which i needed to facilitate glut medius. After i was happy patient A could perform the exercises correctly i booked him in for a follow up appointment in one weeks time.

RESULTS:
During the 'social history' conponent of the subjective assessement Patient A began to ask me questions about my study and practical experience. None of the questions were inapprpriate so i breifly responded to the questions and then returned the conversation back to my patient's general health. I had no difficulties carrying out the rest of the assessement and my supervisor was happy for me to teach the home exercises i had chosen. My patient performed the wall squat well with verbal feedback, however had difficulty with the balance exercise. I could see that patient A was not activating his glut med, as his hips were tilted and he was hyperextending his stance knee to balance. I facilitated glut med by putting his hips so they were on an even plane, prompting his knee to go into fifteen degrees flexion and slightly externally rotating the non stance hip. With this feed back Patient A was able to activate his glud med.

During the week leading up to patient A's consecutive appointment, i recieved a facebook email from him. The email was not harmful or threatening however i knew it was extremely inappropriate for a patient to contact me on a social level. It was quite clear that patient A had searched my name on facebook and seeked out my email adress. I informed my supervisor immediately of the situation and put all of my facebook settings on private so they were no longer accessible or visible to the public eye.

EVALUATION:
After this episode i realised that i needed to take more care with my body language and my approach to younger patients, in particular males. It was not that i acted inappropriately in this scenario, however what i realised is that it is sometimes necessary to adapt my body language, my approach, the type of questions i may ask my patient and the form of feed back i may give them for their exercises. For example whether i use verbal or tactile cues, or whether i use a wall for support during a balancing exercise or whether i use my hands. I also discovered that there are ways in which i can set the professional boundaries with my patients without having to discuss with them what is or is not appropriate conduct. I realsied i needed to change some of my strategies and methods of communication before my next treatment session with this patient.

STRATEGIES:
1: Body language: I need to have slightly less open body language and more formality in my approach. I think it is important to establish my status as a practitioner.

2: Verbal instructions: I need to direct the discussion more in my subjective assessement, so that when my patient starts to discuss anything non physio related i can quickly divert the discussion back to what is appropriate and relevent.

3: When giving feed back for the exercises i am choose to give less tactile feedback and more verbal prompts. The other option is that i can use a mirror for feedback rather than physically corrected the patients body position myself.

4: Ensure all of my email and facebook settings are on private and are not accessible to my patients!