Clinical Portfolio

Clinical Portfolio Ben Gonano Workplace ActivTherapy (Moorebank)

Clinical portfolio by ben gonano. All placement hours completed with activtherapy in Moorebank under the supervision of Andrew Rivet. 1

Each client undergoing exercise must have a completed pre-exercise questionnaire and a report from a GP if required. These forms are completed on the first visit to the clinic or if we are meeting at an alternate location, the first meeting will involve completion of these forms. We use the Adult Pre-Exercise Screening Tool supplied by ESSA for this purpose. 2.1 Screening and risk stratifying to ensure the safetyand appropriateness of exercise and physical activityinterventions

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Patient: Glenn Pre-screen and risk stratification revealed that he was at high risk during exercise.Exercise program implemented based on GP recommendations for weight loss to manage symptoms of Myasthaenia Gravis and cellulitis, as well as reduce risk of diabetes due to impaired GTT and hypertension.Pre-screening has been shown to be an effective method of reducing the incidence of exercise-related adverse events (Resnick, Ory, Coday & Riebe, 2008).Artefact 2.1

and decision was made to refer to GP prior to commencing training. 3

Artefact 2.1

Here is a completed Pre exercise screening tool that was filled out by a patient. His last name has been covered for confidentiality. 4

American College of Sports Medicine [ACSM]. (2010). ACSMs guidelines for exercise testing and prescription (8th ed.). Philadelphia: Lippincott, Williams & Wilkins.National Health & Medical Research Council [NH&MRC]. (2003). Clinical practice guidelines for the management of overweight and obesity in adults. Canberra: Commonwealth of Australia.Resnick, B., Ory, M., Coday, M., & Riebe, D. (2008). Professional perspectives on physical activity screening practices: Shifting the paradigm.Critical Public Health,18(1), 21-32.

References 2.1

Movement capacity is assessed in patients who present with musculoskeletal injuries or disorders, as well as patients who will be performing exercises that are dependent on mobility or flexibility. This can include healthy/athletic population undergoing movement screening for sport e.g overhead squat. In clinical populations such as those recovering from surgery, ROM assessment is vital to determine the ongoing improvement expected as a result of rehabilitative exercises. 2.2 Assessing a persons movement capacity in people of all ages and levels of health, well-being or fitness

Functional movement and ROM screen performed for Michael.

Artefact 2.2

Presented on the next two slides are the results of movement and ROM screenings performed on a patient who presented with low back pain. Here we assessed the lumbar spinne for and lower limb for movemet and stability with emphasis on lumbopelvic complex. 7

Initial report involving movement screening and ROM assessmentArtefact 2.2 continued

Presented here are more exerts from the report of the previous patient. I performed the functional capacity assessment based on his work demands. He is required to be able to lift up to 20kg. This sllide also outlines the areas of pain and injury the patient is currently experiencing. 8

Functional movement screening can be viewed as an analysis of the degrees of freedom present in each joint. When assessing a patients ROM we must first look at each segment of their body to gain an understanding of ROM (Cook, 2010).

The assessment items used for this patient included measures of both static and dynamic tasks (Gabbe, Bennell, Wajswelner & Finch, 2004).

The assessment of active ROM in the hip is included in the assessment items for this patient as ROM at the hip has also been shown to be associated with low back pain (Ellison, Rose & Sahrmann, 1990).

The lifting tasks were performed as this patient was on workcover. It is expected that he will return to his previous duties as a waste disposal worker at the conclusion of his treatment.

Functional movement screening can be viewed as an analysis of the degrees of freedom present in each joint. When assessing a patients ROM we must first look at each segment of their body to gain an understanding of ROM limitations and then assess their patterns of motion which may be grossly flawed but nonetheless pain free and unrestricted (Cook, 2010). The inclusion of the squat, lunge, single leg stand allow the therapist to examine these issues.The assessment items used for this patient included measures of both static and dynamic tasks. For example the examination of lumbar flexion and extension coupled with hamstring extensibility have been shown to be valid predictors of future back pain (Gabbe, Bennell, Wajswelner & Finch, 2004).The assessment of active ROM in the hip is included in the assessment items for this patient as ROM at the hip has also been shown to be associated with low back pain (Ellison, Rose & Sahrmann, 1990).The lifting tasks were performed as this patient was on workcover. It is expected that he will return to his previous duties as a waste disposal worker at the conclusion of his treatment. He is required to lift objects up to 20kg above shoulder height. Therefore we will assess his ability to do so in our movement screen.

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Cook, G. (2010).Movement: Functional movement systems: Screening, assessment, corrective strategies. On Target PublicationsGabbe, B. J., Bennell, K. L., Wajswelner, H., & Finch, C. F. (2004). Reliability of common lower extremity musculoskeletal screening tests.Physical Therapy in Sport,5(2), 90-97.Ellison, J. B., Rose, S. J., & Sahrmann, S. A. (1990). Patterns of hip rotation range of motion: a comparison between healthy subjects and patients with low back pain.Physical Therapy,70(9), 537-541.

References 2.2

One of the primary roles of an AEP is to develop safe, effective exercise programs and ensure that the patient is both capable of performing the required task and motivated to continue to do so. Programs should be based on screening and assessment results.This program was completed as part of an assessment task.2.3 Development of safe, effective individualised exercise interventions

The exercise programs given to patients are designed based on initial screening and assessment results to ensure that all exercises are both safe and effective for that persons current condition and goals. Throughout my studies I have created numerous individualised exercise programs for the purpose of assessment and examination. One such program was completed for a client with chronic low back pain11

Artefact 2.3

This is an example of an exercise prograam developed for a ficticious client with low back pain. This is a copy of the first weeks training so intensty is failry low. 12

The program was developed based on current evidence relating to interventions for low back pain.

The frequency of RT sessions was kept to 2-3 times per week

Core exercises included everyday

Generalised aerobic conditioning is beneficial in those with cLBP

(McGill, 2004; McGill, 2007; Smeets et al, 2006)

as that was shown to be effective at minimising fatigue and deteriorating movement patterns (McGill, 2004).The inclusion of core exercises everyday has been shown to reinforce corrective movement patterns in those with back pain (McGill, 2007), and thus reduce the incidence of aberrant motion that often produces compensatory involvement of low back muscles. The inclusion of generalised aerobic conditioning in the form of cycling has been shown to improve pain scores in subjects as well as serving to reduce body weight which is often a cause of back pain (Smeets et al, 2006).

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Smeets, R. J., Vlaeyen, J. W., Hidding, A., Kester, A. D., van der Heijden, G. J., van Geel, A. C., & Knottnerus, J. A. (2006). Active rehabilitation for chronic low back pain: cognitive-behavioral, physical, or both? First direct post-treatment results from a randomized controlled trial. BMC Musculoskeletal disorders,7(1), 5.McGill, S. (2007).Low back disorders: evidence-based prevention and rehabilitation. Human Kinetics.McGill, S. (2004). Ultimate back fitness and performance. Wabuno Publishers.

References 2.3

During my placement with ActivTherapy, I was involved in giving numerous presentations on the role of exercise in preventing and managing chronic conditions. I participated in a two week My Wellbeing program run by the NRMA for its roadside assist staffDuring these presentations I discussed the nature of chronic disease as well as the various risk factors associated with them as well as the relevant tests and assessments used in detecting them. 2.4 Provision of health education, advice and support to enhance health and well-being

During my placement with ActivTherapy, I was involved in giving numerous presentations on the role of exercise in preventing and managing chronic conditions. I participated in a two week My Wellbeing program run by the NRMA for its roadside assist staff where we detailed how to incorporate exercise into their daily routine as a means of preventing the ever increasing incidence of diabetes and heart conditions among their employees (predominantly males, over 35 years of age with minimal formal education) During this presentation I discussed the nature of chronic disease as well as the various risk factors associated with them as well as the relevant tests and assessments used in detecting them.

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I also gave a presentation at the wellness centre in Liverpool hospital for cancer patientsThis outlined the benefits of exercise for their condition.

I also gave a presentation at the wellness centre in Liverpool hospital for cancer patients and outlined ways that exercise could help them manage symptoms of treatment as well as reducing the likelihood of developing co-conditions. This presentation also involved providing functional assessments of the audience which was used to assist in developing an individualised exercise program that they could perform unsupervised in their homes.

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Artefact 2.4

These slides formed a small part of the presentations17

The presentations were designed to educate the audience as to how to reduce risk factors for developing lifestyle related diseases with emphasis on increasing activity an improving dietary choices (Williams, 2001).

Physical activity as a means of managing symptoms of cancer treatment was discussed during the presentation at the hospital (Courneya & Friedenreich, 1997).

During both presentations I demonstrated a simple assessment that people could use to determine their risk of developing CVD or Diabetes (Savva et al, 2000).Evidence used during the presentations

The presentations were designed to educate the audience as to how to reduce risk factors for developing lifestyle related diseases. As such the emphasis was on increasing physical activity and limiting poor dietary choices which can affect markers of health such as cholesterol, glucose and BP. A push for greater physical fitness as opposed to simply an accumulation of physical activity was also provided due to evidence that fitness may have a greater protective effect on cardiovascular health than simply low-moderate physical activity (Williams, 2001).Physical activity as a means of managing symptoms of cancer treatment was discussed during the presentation at the hospital. The likelihood of developing co-morbid conditions is greater among post treatment cancer patients due to an increase in sedentary behaviour often attributed to fatigue. Therefore an increase in exercise and physical activities may assist this population to maintain a greater degree of health and independence (Courneya & Friedenreich, 1997).During both presentations I demonstrated a simple assessment that people could use to determine their risk of developing CVD or Diabetes. The waist circumference measure was used and a tape with risk indications printed on it was supplied to the audience. The waist circumference measure has been shown to be an effective tool for predicting cardiovascular disease (Savva et al, 2000).

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Williams, P. T. (2001). Physical fitness and activity as separate heart disease risk factors: a meta-analysis.Medicine and science in sports and exercise,33(5), 754.Courneya, K. S., & Friedenreich, C. M. (1997). Relationship between exercise pattern across the cancer experience and current quality of life in colorectal cancer survivors.The Journal of Alternative and Complementary Medicine,3(3), 215-226.Savva, S. C., Tornaritis, M., Savva, M. E., Kourides, Y., Panagi, A., Silikiotou, N & Kafatos, A. (2000). Waist circumference and waist-to-height ratio are better predictors of cardiovascular disease risk factors in children than body mass index.International journal of obesity and related metabolic disorders: journal of the International Association for the Study of Obesity,24(11), 1453-1458.References 2.4

During placement I worked with clients who had impaired glucose tolerance and hypertension. These clients are at risk of developing diabetes and cardiovascular disease. The provision of lifestyle advice and exercise programs is important to ensure that these people do not continue to progress into a diseased state. I conducted group classes for those with, or at risk of chronic disease. This included persons with obesity, hypertension, pre/diabetes. The classes were part of the EPC program and participants were able to attend up to 10 classes as part of this coverage .2.5 Provision of exercise intervention and advice for those at risk of developing a chronic condition or injury

First session of weight loss clinic program with 3 levels for beginners advanced. The inclusion of core exercises every session is due to the high number of low back pain patients who attend.

Artefact 2.5

Each Class had people of varying levels of physical ability. Therefore the class required varying levels of intensity to ensure each participant could train to a level that was both safe and effective for them. We performed core exercises due to the high number of participants complaining of back pain and this has been shown in multiple studies to be an effective means of reducing symptomatic back pain.The exercises are gradually progressed in difficulty each week to ensure sufficient stimulus for adaptation throughout the classes. At the beginning all participants undergo a functional assessment where we record vital data which is used to determine the outcome of the sessions at the end. Throughut the duration of the classes every participant must report on their food intake for the week and their unsupervised exercises. We also provide each person with a measuring tape with risk indicators for both men and women. 21

The provision of nutritional advice and support was given through these classes. At the conclusion of each class, I assessed food diaries of participants and critiqued their food choices if necessary. Every 4 weeks I conducted a shopping tour which involved a visit to the nearby Woolworths store where I educated the participants on healthy food choices and how to understand the nutritional information displayed on each food item. Artefact 2.5 continued

Below are some examples of the information provided to participants on the shopping tour and throughout the classes. These brochures were developed by the Australian Government National Health and Medical Research Council and are available at www.eatforhealth.gov.au

All participants are given a rage of information brochures and resources to enable them to manage a healthy lifestyle. All resources are provided free from various government run programs such as eat for health . 23

A copy of the food diary filled out for 2 days by a participant of the classes. It also includes exercise and medications. 24

Winett, R. A., & Carpinelli, R. N. (2001). Potential health-related benefits of resistance training.Preventive medicine,33(5), 503-513.Van Tulder, M., Malmivaara, A., Esmail, R., & Koes, B. (2000). Exercise therapy for low back pain: a systematic review within the framework of the cochrane collaboration back review group.Spine,25(21), 2784-2796.National Health and Medical Research Council, Australian Government Department of Health and Ageing, New Zealand Ministry of Health. Nutrient reference values for Australia and New Zealand including recommended dietary intakes. Canberra: Commonwealth of Australia; 2006.

References 2.5

Patients with complex or chronic medical conditions often present a challenge to the AEP who must ensure that exercises are safe and effective. A delicate line has to be walked between conservative approaches and proactively pushing your client to ensure sufficient stimulus for adaptations to occur. 2.6 Provision of clinical exercise prescription, for those with existing chronic and complex medical conditions

This patient had Myaesthenia Gravis, epilepsy, hypertension, Cellulitis, Impaired GTT.Artefact 2.6

This is a copy of one weeks training performed with Glenn. He has a rare condition known as myaesthenia gravis which results in weakness of respiratory muscles during exertion as well as constant fatigue. On top of this condition he is obese, has hypertension, cellulitis in his legs and ankles which is painful during exercise and he currently has impaired glucose tolerance. His program was designed with the goal of weight loss as his doctor is contemplating starting him on diabetic medication however wants to see if he can lose weight on his own and possibly manage through lifestyle modification rather than medication. Due to his current functional stautus exercise needed to be low impact and low intensity. Aerobic exercise has been shown to improve symptoms of fatigue in persons with MG and as such this is included in his program. RT is also an important feature in a physical training program to ensure that strength is maintained or improved to enable easier performance of ADL. Most importantly the exercise has to be of sufficient intensity and volume to ensure changes in his blood profile pertaining to blood glucose. This has been studied extensively and researchers have found that 3 days per week at moderatete instensity for approximately 45-60 mins is sufficient to improve insulin sensittivity and glucose tolerance. 27

Lohi, E. L., Lindberg, C., & Andersen, O. (1993). Physical training effects in myasthenia gravis.Archives of physical medicine and rehabilitation,74(11), 1178-1180.Paul, R. H., Nash, J. M., Cohen, R. A., Gilchrist, J. M., & Goldstein, J. M. (2001). Quality of life and wellbeing of patients with myasthenia gravis.Muscle & nerve,24(4), 512-516.Pan, X. R., Li, G. W., Hu, Y. H., Wang, J. X., Yang, W. Y., An, Z. X., & Howard, B. V. (1997). Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the Da Qing IGT and Diabetes Study.Diabetes care,20(4), 537-544.References 2.6

During placement I was responsible for conducting hydrotherapy sessions with numerous patients who had undergone surgical procedures or had sustained acute injuries. Hydrotherapy has been used extensively in rehabilitation of acute injuries.

(Giaquinto, Ciotola, DallArmi & Margutti, 2010; Foley, Halbert, Hewitt & Crotty, 2003)

2.7 Provision of rehabilitation and advice for patientsfollowing the acute stage of injury, surgical intervention,or during recovery to restore functional capacity andwell-being

...and in the post-operative treatment of patients. It is known to decrease pain scores and improve functional ROM in individuals who have undergone knee arthroplasty and is also effective at improving strength and physical function in arthritic populations.

Some examples of conditions I managed were medial tibial stress syndrome, mastectomy, tibia and fibula spiral fracture who is the example provided, Rotator cuff repairs and ACL repairs. 29

Provided hydrotherapy to a patient who had recently undergone a ORIF procedure to repair fractured tibia and fibula. 2.7 Artefact

During the sessions in the pool, I focused on restoring ROM, improving muscular endurance, strength and co-ordination. We performed exercises that were extrememly low impact such as wading through the water, pendulum swings with legs, squats against the wall, bicycle with legs and progressed to walking lunges, squats using foam resistance board, resisted flexion and extension and adduction and abduction, swimming (freestyle at first and eventually incorporated breast stroke due to its greater utilisation of leg muscles.

Open reduction and internal fixation procedure. 30

A report on functional capacity done after the hydrotherapy. 31

Giaquinto, S., Ciotola, E., DallArmi, V., & Margutti, F. (2010). Hydrotherapy after total knee arthroplasty. A follow-up study.Archives of gerontology and geriatrics,51(1), 59-63.Foley, A., Halbert, J., Hewitt, T., & Crotty, M. (2003). Does hydrotherapy improve strength and physical function in patients with osteoarthritisa randomised controlled trial comparing a gym based and a hydrotherapy based strengthening programme.Annals of the rheumatic diseases,62(12), 1162-1167.Geytenbeek, J. (2002). Evidence for effective hydrotherapy.Physiotherapy,88(9), 514-529.References 2.7

Throughout my placement I was primarily involved in providing secondary care to patients. Most patients were referred from a GP under the EPC program or through work cover insurance providers. In many cases patients continued their training after their EPC sessions had run out however this is still classed as secondary care. SOP 2.8 Level of Health Care Provided