Topic 2- Evidence Based Practice

Situation: A 14 month girl was referred for physio with large undiagnosed developmental delays. Paediatricians, speech pathogists, social workers and more are working with this patient and her family to try to improve her skills. Currently, the patient has had an MRI which was clear, and a series of tests that have all come back with no diagnosis. The patient can sit unsupported with a wide base, can roll with assistance, can prop in prone, and can pull to stand with support. She hardly keeps eye contact, she is not interested in her environment, does not reach for toys and has only just gained righting reactions and equilibrium reactions to stop herself from falling. All this information is making her development about that of a 5 month old. It is also believed that she may have a visual impairment and is reported by the her mother that she had a seizure a couple months ago, but has not had another one since.


Task: My roll with this patient is to work with the my supervisor to facilitate the developmental skills of this patient. Through positioning, play, facilitation techniques and repetition.


Action: The physio and i have been practising different positions such as propping in prone, propping to the side in sitting, four point kneeling and weight-shift in standing. The patient is placed in these positions and left to encourage her to figure out how to move into and out of different positions. Toys are placed in front of her and used as a tactile stimulation however the patient generally wants nothing to do with them. She can pull to stand but does not move once she is in standing. She like to put her fingers in her mouth but nothing else. With facilitation the patient can weight shift and step in standing, which is a large improvement after a month of therapy, however most other progress is slow.

I was facinated but this patient and her lack of diagnosis. So with thinking of evidence based practice and the presentation of the patient, having now done 4 therapy sessions with her, i questioned Autism with my supervisor. My initial question was just regarding the diagnosis of Autism, but as my supervisor did not know the answer, i decided to do some research myself. I looked through a series of Paediatric books in the Physiotherapy department, and discovered how similar the symptoms of Autism where to the presentation of this patient.


Result: The results of my research proved that the patient could possibly have Austism. This is because of her gross motor and speech delays, uninterest in her environment and toys, the vague look she has (no focuse), a lack of motor planning and many other symptoms that match Autism.

I then explained my findings to my supervisor, who then expressed this idea to another member of the multi disciplinary team (MDT), who agreed that Autism definately seems like a part of the patients diagnosis (+/- some other comorbidities).

Evaluation: I was very happy with my research skills and the way i communicated this to my supervisor. I could have possibly done further research into this area, for instance how it will affect the family, support for the child and family, and further treatment suggestions, instead of just being concerned with the diagnosis. I do have to remember that there is no real diagnosis tool for Autism and so this may not be the case or all of this patients problems, even though symptoms are identical. I was happy with my communication and believe i will raise the idea at the next team meeting so it can be discussed further with all members of the MDT.

Strategies: To further my research into this topic i could research journals and talk to doctors and people with experience with this diagnosis, before jumping to conclusions. I need to ensure i have done enough research and have enough evidenced based proof to support my idea before pitching it to the whole MDT. Hopefully all my research may give me further successful treatment ideas and ways to find further support for the family.

Topic 1- Assessment

Situation: I arrived to Collie District Hospital on day 1 and after orientation read the referral for my first out-patient. Patient A was referred for R hip pain post bladder surgery. It was later explained to the patient that whilst in surgery her leg slipped out of the stirrup holding it up, which therefore would have caused many different problems with the hip joint due to the torsion and position of the leg while it was out of the stirrup. The hospital where the surgery was performed, undertook an xray once patient A woke in excrusiating pain post op, however the xray came back clear of any bony problems.
Task: My roll was to discover the source of patient A hip pain through a thorought assessment of the hip joint and to treat as appropriate.
Action: I began with taking a subjective history on this patient, where i was informed she is an ex nurse, and had pain in the groin and hip flexor region, gluteals and hamstrings. I then moved to my objective assessment where i tested the patient's hip ROM, length and neurodynamics. The patient was independent with all transfers and mobility, however complained of increased pain with sitting, walking after and period of time and R sidelying position of sleep. She had decreased hip flexion and adduction due to pain, and decreased muscle length of hamstrings and quadriceps. Straight leg raise (SLR) was positive in this patient. It was also discussed with the patient at the point in regards to the need for an MRI and hospital contacts where given to discuss the patients complaint.
Result: After a thorough assessment my supervisor and i believed that the patient had a hip flexor tear and sciatic nerve aggrevation secondary to the leg being left hanging out of the stirrup for the period of time, however this diagnosis warranted further investigation with an MRI. We believe the patient had a hip flexor tear because of the location and boundaries of the pain, the fact that the leg would have dropped into extension and the decreased strength and intense pain with hip flexion. The positive SLR indicated sciatic nerve irritation and we believe this was secondary to muscle spasms and tightness in the gluteals and hamstrings.
Evaluation: I was fairly happy with my assessment of this patient. I was very nervous as she was my first patient and due to prompting by my supervisor to begin the objective assessment, did not finish my subjective history to the best of my ability. I was very happy with my objective assessment skills and handling for this patient. However, without prompting from my supervisor i believe that i would have completed a full objective assessment without taking into consideration that the patient is in pain and we do not want to increase this or stress the structures too much.
Strategies: I have thought about strategies i could use to improve my assessment skills. I feel that if i do not finish my subjective history it would be more important to get the necessary part of the history and further questioning could still be done during objective assessment and treatment. I have learnt to just test the most necessary objective tests in patients with intense pain to not stress the structures and further examinations could be completed on future appointments, it does not all have to completed straight away if it is deamed not as important in leading to a diagnosis. I believe that now that the first patient is out of the way, i will not be as nervous and i will have more time to prepare before each appointment.