Annual Review Update... Angry!

Hi Folks

Been a long time since the last update... but wanted to renew the blog effort after a few requests to hear an update on Robbie and his DBS.

Probably best to take you back to his annual review with the complex motor disorders team, back in November 2012. At this time all was going really well, Robbie was doing great and to be fair not struggling too much with muscle contractions and problems of that ilk... However one major problem area we have encountered since the success of his DBS was a real issue with extreme mood swings. 

This issue really was very trying for the whole family as we experienced these "Red Mist" moments on a very regular basis, and it seemed once these moods took affect there was no way of calming Robbie down. He would tantrum, lash out and become extremely agitated and downright abusive (for want of a better word). 

This issue had grown so much, we did at times question is everything okay, is this years of frustration at his condition now coming to the surface and manifesting as anger or sadness?, Is this something as a family we could cope with?, was this abnormal behaviour unique, or could we find others who may have experienced similar episodes with their children? Was it a side effect of drugs he was taking?.... So many questions, and unfortunately at that time no answers...

Having raised our problem with my local occupational therapist she suggested it may be useful to see the child psychology team, and referred us on to them (Note this was November last year, and we have our first appointment with them next month - quite a waiting list!!!)

In the meantime I explored the net (something I really don't recommend) to look at the medication Robbie was on. I managed to find a link with mood swings in relation to one medication he was taking... Trihexyphenydil.  Later after discovering this and speaking to a few close, personal friends I discovered they also had experienced problems of a similar nature with this drug.

Whilst at his annual review we discussed the medication and I suggested I would like to try and reduce the doseage to establish if this had an effect on his moods, they agreed to trial this and we discussed and agreed a very gradual withdrawal. The team were keen to listen to my suggestion, indeed embraced the idea, to cut a long story short the withdrawal did help his moods, however over the months the withdrawal of the medication, did also affect Robbie in the way of a return to some dystonic posturing... Gee, fix one problem and another appears ! :) It was a bit like having to find a fine balance between posturing and mood swings.

The team also discussed how the area of the brain targeted in DBS controls movement, emotions and planning... Now the strange thing is you couldn't but feel was it a case of once the movement issues were being controlled, had other problems with Robbie now come to the fore... Alas it transpires this was not the case. I think because of the constant focus by a child on getting movement right, I cannot help but feel the emotions and planning are areas that have never had the chance to mature and develop within the child... this certainly seems to be the case with Robbie... Alas we are seeing advancement in these areas now as we, the school and medical team all work together on these areas... (Still something I feel other parents should be aware of after their child's DBS)

His main achievement since the DBS is his love of swimming, this has helped Robbie immensely to develop and strengthen some of his weaker muscle groups, he recently competed in the Fife disability swimming championships  and won a couple of medals for his efforts. He loves this sport and was fortunate to meet a local paralympian Craig Rodgie (Pic below - Robbie's hero) who swam in the London paralympics...

Watch this space as I will be updating the blog with Robbie's 18 month review update in a few days... and promise to those who have asked more regular updates...

Again I need to mention the Facebook group... The Evelina Children's Hospital Dystonia Support Group and the people who are amongst it's members... These people have helped me through a lot of rough, dark times, they are great to ask any questions to, as most have been through, or have children on their way to getting DBS...

I think the most important understanding we all take is, we are not alone, there are other individuals out there feeling the same fear, frustration and worries about our children. 

DBS has certainly changed Robbie's quality of life, but again recognise not all are quite so fortunate and see less in the way of improvement. 

18 MONTH REVIEW UPDATE WILL BE PUBLISHED IN A FEW DAYS... promise :) 

4th May 2012 - DBS 6 Month Review

It was with a bit of reservation Robbie and I headed off for this trip, we both knew the long trek that lay ahead,  and somehow as everything was relatively okay just now it all just seemed a bit pointless. To be fair we know there was slight deterioration in Robbie, through both his posture which had been dystonic when tired, and the issues with this tongue rolling and speech difficulty again this was only experienced when tired. It would have been very easy to just put this down to being overtired, and shelve as not really a problem, however one thing I have learned along this journey is to keep a journal of any changes in your child, believe me it is best to write things down so when you do meet the team you can raise all areas of change, which the team will look at and investigate, and hopefully treat where possible.

We set off on the journey, again we both found it very difficult to leave the rest of the family, and knowing the chances were the DBS settings were going to be altered, here I would like to talk a bit about my personal thoughts, feelings, worries or concerns regarding this. Personally I find it very worrying when I know a change is going to be made, I know deep down if a change is made which causes any problems it is just a matter of changing the settings back again, however I think in the knowledge we are over 400 miles away from this team there is no way to get back quick to see them if there are any issues. I worry in case there is any pain for Robbie (which is quite strange as he has never complained of any pain at any of his previous settings changes, so this concern has no reason to be there, however the thought still eats away at the back of my mind for some reason), I worry they will change something and not be able to get him back to how he was... I think many of the thought processes behind these concerns are it is still very fresh in my mind how just how bad Robbie had become just prior to his DBS indeed I still have old videos, which are painful to watch, that bring home the stark reality of how harrowing a journey this wee lad has been on, albeit, we now have a much, much better standard of life, I often ponder if this DBS treatment were not available how bad would Robbie have been now, indeed this treatment has been a miracle in our eyes.

In cases of the dystonia being the primary condition I would 100% recommend deep brain stimulation, even to an extent in secondary dystonia's although the success rate in these cases is not quite so effective, and the results seem to be very variable.

So we arrived in London at 6.30pm only to find all the car parking spaces at the Evelina were taken, nightmare should this happen to you by the way, although we did manage to find a space after waiting half an hour or so, and it was then off into St Thomas's hospital to pick up the keys for the accommodation at Gassiot House. Word to the wise Gassiot is currently undergoing development, so the entrance has been moved from where it originally was, and there is scaffolding and the likes all around the area, nothing that would hinder a wheelchair user or anything like that. I really can only assume it is the exterior of the building they are developing as nothing inside the building or sleeping quarters has changed. The rooms are the same as ever, in the lounges they have TV's (which I have to say on every visit I have been on, and in all the different rooms I have stayed in I have never found one that gets any kind of reception... (word of warning best to take a DVD or two if you actually want to watch anything) We usually take down the laptop with a couple of films on it and sit in the bedroom and watch these to pass the time.

We had some dinner, which had been taken with us and as it was a nice warm evening went for a walk along the embankment, where we went through the now usual ritual of going to hear Big Ben chime, and a walk along past the London Eye, Robbie enjoys it...

Robbie usually has problems dropping off to sleep at Gassiot, I think this is a mixture of both the travel boredom, and not being able to burn off any energy sitting so long, and the unfamiliar being away from his routine and family, however on this occasion after tossing and turning for an hour or so drifted off to sleep.

In the morning it was over to the Evelina for our 9.30am appointment with the complex motor disorder team, and Violetta and Hortensia were first to meet up with him, as this is the 6 month review the physio, OT and speech therapist all wanted there bit of time with Robbie, to run some of the assessments which are carried out with the child pre DBS, and are then repeated in full at the 12 month post DBS. The tests were not as extensive as the original assessments, however they targeted any areas of concern to ascertain the extent of any issues raised. They also benchmarked a few areas for stability, agility, mobility in order to produce a report which will compare pre DBS to post DBS 6 months on. The changes are really remarkable however they need these formal assessments to accurately measure how Robbie has moved forward.

The 6 minute walk test (which you may well be familiar with if you have previously been for assessment was also conducted) again the results were measured and will be compared against previous results.

Lesley the speech therapist also took time to have a short review with Robbie, although I think this may well have been prompted after me raising concerns with the issues with his tongue rolling, and the difficulty he was having pronouncing words when he was tired, as you would expect despite a morning of work in the gym doing physio, there were no issues with the tongue whilst Robbie was with Lesley!, we have been advised to try and capture a quick bit of video footage when/if the tongue rolling problems start again, in this event we are just to send a copy of the footage to Lesley so she can analyse what is happening during these episodes.

Again as in previous assessments Robbie is filmed doing several tasks in order for the team to take the time to analyse his performance, and this also allows them to compare where improvement is shown, and also to establish potential target areas for improvement.

Whilst conducting the assessments as a parent you will need to sit with various members of the team and discuss progress, and you will be asked to mark out of ten several areas on mobility, speech, etc etc etc. Hortensia also went through the goal setting targets which you will discuss and agree pre DBS, and assess your personal thoughts and scores on how close you feel your child is to achieving these goals.

Around 1pm, we finally got through the tests (and this was quick as Robbie had simply flew through these), and it was time to meet up with Margaret and Sarah, indeed again they went through any changes since the last visit, and they deemed that an adjustment would indeed be made, they actually turned on a second part of the implant (from my brief understanding there are 4 points (electrodes) on the implants and Robbie had just had the first electrode stimulated on each side thus far, this time they decided they were going to activate a second, and also increase the stimulator strength slightly. Robbie had an issue at his last adjustment when the left hemisphere electrode was increased his left hand clenched and he described as what felt like "Ants marching up his arm" effect and the electrode was returned to it's original setting... On this occasion both sides were increased and the same thing happened again, however Margaret turned it down a notch and this issue resolved itself (this was still able to stay at a slightly higher setting with no adverse effect)

So overall the trip was absolutely fine, my worries and concerns were once again unfounded.

One story I want to briefly touch on, a close friend of mine Alison Birkin, who I am sure many of you know had asked me to tell the team about her daughter Chloe now taking independent steps (Chloe also has dystonia and until a recent change to adult services as she was over 16 now, was under the complex motors team at the Evelina) I told Margaret and Sarah of the news and they were so excited to hear of this, indeed Sarah immediately sent an e-mail to the team to advise of the update regarding Chloe, and there was a genuine feeling of pride and genuine happiness amongst the team, I have since spoken to Alison and she has said Margaret had e-mailed her to say thanks for the wonderful news... This I believe really rings home how dedicated this team are and that despite the fact Chloe is no longer under their care, and is now a former patient, the team are so excited and pleased to hear this wonderful news... a more dedicated bunch of professionals, and caring people than I have ever met in all my years on this earth.

Finally the only thing left for us was the journey home during which Robbie sang most of the way, a short video attached (why should I have to suffer this alone :) ). No but to be fair it really is a good feeling to be going home, back to normality. Robbie is happy and that is number 1 in my book, this little guy is my biggest hero and always will be... enjoy the video... :)

21st April - 23 weeks post op

Hi all, been a few weeks since the last blog, however as we run up to Robbie's 6 month assessment I thought it best to provide all with an update.

It is with a bit of a heavy heart I write this blog today, as over the last 10 days or so, Robbie has complained of an ache behind his right knee, initially we just surmised he had maybe been overdoing it a bit, however vigilant as ever have kept a very close watch on this, as he was complaining most mornings of the pain, we decided about a week ago to use the pain scale chart for kids to assess if this was getting worse or staying quite level. 

Unfortunately Robbie has slowly during the course of the week moved from a 1 to a 5 so it would appear as though the pain does seem to be getting gradually worse and this I believe would tend to relate to his dystonia (indeed Robbie even stated the pain was "coming back again to how it used to be")

I have e-mailed the team at the Evelina to advise them I have reintroduced his Gabapentin medication, you may recall this is a medicine designed to combat neuropathic pain caused by nerve damage. Fingers firmly crossed after a few days this medicine will start to reduce Robbie's pain. (It certainly worked well for him prior to DBS so one can only imagine it will help to alleviate this current pain)

This said Robbie is still very upbeat and he seems to be able to not let this affect him, he is back down for his 6 month review in two weeks and we look forward to seeing the team again.

Robbie has now taken school dinners for the full week for the last fortnight and he is really happy to do this, he is tired in the evenings by the time he gets home, however still manages an hour or so out n his bike (He has travelled absolutely miles around our back garden)

Although the blog starts off on a bit of a down note, we are in no way disheartened, he is still able to do much more than he was able to do prior to his DBS, his school work is coming on leaps and bounds, his confidence continues to grow, his fine motor skills are really good, and he really is a happy little chappy just now... (he is even off to his friends house for tea on Monday on his own - something that certainly would have never happened a few months ago)

 

One other area for discussion with the team when I go down is his speech, this has never previously been affected by his dystonia, however we have noticed as and when Robbie gets tired (usually early evening) he has a tendency to roll his tongue, and sometimes this affects his speech (It appears as though this is an uncontrollable action) It may well be the case the dystonia is now affecting this area, however only happens when he is over tired, and not a daily occurrence... again we will continue to monitor this situation.

An update will be coming in the next blog on how the 6 month review went, what it consisted of, and of course any updates on the wee mans progress...

29th March – 20 weeks on

So here we are now 20 weeks post op, and all is relatively good with Robbie, we have now removed Sinemet and Gabapentin medication with no adverse effects whatsoever.

We had trialled removing Robbie’s last medication in relation to his Dystonia (Trihexyphenydil) however this seemed to bring on a bit of dystonic posturing again, the idea was to reduce the medication by half a tablet a week for a four week period, however by week 2 of the reduction we noticed he seemed to be struggling a bit with posturing and we decided to pull back on the withdrawal for the time being. This said we have seen a lot of really good weather the last few weeks, and whenever the weather is fairly reasonable you can rest assured Robbie is outside playing from daybreak to dusk, and he literally never stops, thus we do wonder if the posturing has been caused by the drug withdrawal, or just simply down to Robbie physically burning himself out on a daily basis. Our intention is to attempt the withdrawal again in a few weeks, maybe reducing the dosage a bit slower than we originally attempted... update will follow on the progress of this over the coming weeks.

Robbie is now confidently riding his bike (including 360 degree peddles), albeit still with stabilisers, again the next challenge come the summer will be to remove one stabiliser to see if he copes with this, then in the best circumstances hopefully the second one will come off. He is still attending his swimming lessons and again he is progressing with this weekly, he can swim well on his back, although still has quite a few issues trying to coordinate his hands when swimming on his front (as Robbie says his bum keeps sinking when he is on his front) again this is still a learning curve and he really gives this 100% effort.

You may remember I mentioned Robbie’s extreme mood swings in the last entry in the blog, the good news is these still exist, but in a much lesser state at this time, these seem to have subsided and he is now certainly more willing to listen to reason when the red mist descends.

Robbie has also had his first haircut since the op as he has a full head of hair and wanted spikes again.

At school Robbie is doing really well, his written and drawing work is coming on in an excellent fashion, his fine motor skills have improved dramatically, and he has much more control over writing implements, he loves taking part in gym although we have had a few tumbles and falls, but probably none more so than any other seven year old. He has even asked to take school lunches every day this week which is a major step forward...

Again, this little lad has changed for the better so much in this last twenty weeks it is still all a bit overwhelming, when you look at videos of pre DBS against the freedom he has now this boy’s life has turned around in a miraculous fashion... and he (and all the family) are absolutely loving the moment.

We have a six month review coming up in early May, and a full breakdown of what this entails will be recorded in the blog from this date.

16 Weeks Today 26th Feb

Hard to believe it has been 16 weeks now since Robbie’s DBS, time really has flown by, and his recovery has been truly remarkable to say the least.

Robbie has been on a gradual reduction for more of his daily medication, and is now officially no longer taking Gabapentin, a medicine designed to combat neuropathic pain (pain relating to damaged nerves) the great news is over the last three weeks he has reduced these from taking three a day, down to two a day week two, and eventually down to one a day last week, and as of Friday last week this medication ceased, and happy to report he has not mentioned any pain throughout this time (with the exception of week 1 where he complained of back pain a couple of times, we are putting this down to over exertion as opposed to Dystonia related pain.) Fingers crossed this continues and this will be another set of tablets now removed from his daily intake.

So, in essence since the DBS he has now stopped taking Sinemet and Gabapentin with no adverse effects... We intend to leave as is for a few weeks and assuming no pain or adverse effects follow we will speak to the team about weaning him off his other medication Trihexyphenydil.

As mentioned in my last update, Robbie still can be very emotional, in this I do not mean so much easily upset, but more so very temperamental, when he gets angry or annoyed he still seems to “lose control” and will go absolutely ballistic for a short time, during these episodes there is little that can be done to console him, until he calms down a bit, then he will listen to reason and apologise for his outbursts. The way we are dealing with this is to take him away from the situation causing his angst, usually his angst is directed at either me or my wife (as we are mostly the one to say no to his demands) and normally if he has, for example lost his composure with say me, my wife will take him out of the situation, allow him to vent off some steam, then talk to him and let him see the error of his ways, alternatively if my wife is in the line of fire at one of his outbursts I will take him out the situation. Is this just Robbie developing his own personality, I am not 100% sure, however the other children in the house do become quite upset by this behaviour. When he does eventually calm down he will apologise for his behaviour.

Swimming is still proving a challenge for Robbie, he seems to manage quite well swimming on his back, he often needs reminded to use both his arms to drive himself forward, however when he gets it right manages really well (I am confident once this understanding sinks in he will crack this). He is now freely going under the water to retrieve hoops etc so his confidence is growing and growing weekly. Swimming on his front is a bit more challenging for him, but given time I am sure he will get to grips with this.

Robbie has even started taking school lunches again, (he previously came home in order to take his meds which he now no longer needs to take) we are keen for him to start doing this on a regular basis (currently he is there a couple of days a week) as this again further improves Robbie’s independence, and also gives him some real quality time with his classmates, in order to run around the playground and burn off some energy. Our longer term aim is to get Robbie taking school lunches 5 days a week, which will come with time.

As the weather continues to improve, we are looking to get Robbie back out on his bike, as he still has this “half peddle” way of going his bike (Stabilisers are still required) he seems to move the pedals 180 degrees, then pulls the peddles back up to push forward again rather than using the full 360 degrees.

Robbie’s wheelchair has now sat in the back of the car untouched since the New Year, to be honest I think it is more of a safety blanket now for us, it is always there just in case it is required.

Having read back over this update it all comes flooding back how this little lad was so dependent on his chair just previous to his DBS, and it makes you reflect on what his life was like then, in little over three months his life has been totally transformed, he is free to pretty much do as he wants now, he can walk, run, play, write, dress, draw, colour in etc etc etc without the constant fear of falling over, or the Dystonia preventing him from doing what he wanted his limbs to do. He is now free, this truly is remarkable and we all have witnessed what may well be described as a miracle happen before our eyes. The team at the Evelina made all this possible and we will be forever in their debt. I dread to think what Robbie’s life would have been like had he been born 20 years earlier, or left untreated, as he was really getting to be in a bad way prior to DBS.

To any of you going through a similar situation, my prayers are with you. Seek support, it is there if you look for it. You are not alone, and most of all always remember there is hope

13 Weeks+ 11th Feb 2012

At the time or writing we have just returned from our latest review visit with the team at the Evelina, this visit entailed some video footage being taken of Robbie doing some basic things. The tasks Robbie had to do involved sitting as still as possible in a chair for 40 seconds, standing and facing different directions, then walking in these directions... to be fair he seemed to manage this without any issues, Robbie seems to like Wioleta the teams therapy assistant and had a big smile for her, and the day was improved even further with a visit from both Kylee and Hortensia, who had simply popped in to say hello to us all. It is small gestures like this that make the team so personal to the patient and their family, you really get that welcome and “We care” feeling from them.

Then it was on to see Sarah and Margaret for a quick chat on how things were progressing, fortunately there were only a couple of queries we had, one being Robbie’s quite intense emotional outbursts and the second simply in relation to a possible further reduction in his medication.

On discussing our primary concern, and I shall explain briefly the concern, it appears to be that since the DBS Robbie has been prone to what I can only describe really intense displays of emotion, a couple of examples I would give, is he will really have angry outbursts on occasions where it seems he is really affected by some form of red mist, and it is like he really loses control of his temper, in a similar fashion we have found if he becomes upset he can really cry quite hard and again he is very difficult to console during these episodes. Don’t get me wrong these episodes only last a minute or so, but he can become very difficult to handle during these infrequent outbursts... 

Margaret spoke on this and when she said about having to remember his abilities having changed drastically since the surgery, it dawned on me this may well be the case, he has had years of frustration where he was unable to do many things his friends were doing, and suddenly he has all this new found freedom it may all just be a bit overwhelming for him at times, and maybe he is releasing many emotions in one go, frustration, delight, excitement etc etc etc, as this isn’t a frequent problem and these outbursts are very short we agreed we would monitor it for the time being, and discuss again if it gets to be a real issue. (this seems to occur only at home at this time, so again my instinct is there is some level of control within Robbie that he isn’t letting this happen outside of home)

Our next discussion looked at Robbie’s medication, the last drug (Sinemet) gradual withdrawal had gone without issue, and my sights had now turned to attempting to reduce Robbie’s tablet taking even further. My initial thoughts were to ask if we could now take him off of Trihexyphenydil, however Margaret thought it would be best to focus on Gabapentin reduction. Margaret asked about Robbie and any pain he may feel at any time, and I confirmed he had not complained much at all in the way of pain caused by Dystonia since the DBS, and thus we agreed we will start a Gabapentin reduction losing one tablet once a week until his 3 a day dose reduces to nil... so three weeks today we should be Gabapentin free (fingers crossed), however in the event there is any pain we can just start the tablets up again.

Once again, with our current luck the weather did its best to dampen our spirits, with freezing fog experienced on our drive down to London, snow whilst we were in London, and black ice on the route home... so it was a bit of a slow (better safe than sorry) drive both there and back but we made it without incident. The weather cannot currently dampen our spirits with this little guy making so much progress...

Robbie has had a minor increase of power in his right implant, as when he runs or tries to move quickly a slight dystonic posturing is present, hopefully this will help to correct this problem, albeit it really isn’t a major problem whatsoever, it is all about fine tuning now. Might be best that I advise (for any of you that may experience this in the future) when the setting was increased initially Robbie’s hand went into a firm dystonic posture, Sarah immediately asked Robbie “Are you ok” to which Robbie stated “Yes”, however it was quite clear to see his hand had become postured, and Margaret asked if he felt “pins and needles” in his arm, I don’t think Robbie quite understood what this meant, however then the team said “Does it feel like there are ants marching up and down your arm” to which Robbie responded “Yes”, the setting was immediately adjusted down a bit and things went back to normal including the hand posture. To be honest I found it a bit scary at the time, however on reflection it helps you to realise that any changes made are reversible with a further adjustment, so in the event you are subjected to this don’t be alarmed an adjustment is always possible.

Overall things are still really going well, and the swimming lessons and learning to ride the bike are our short term goals, Robbie is thriving and we are all so happy with his progress.

12 Weeks today – 31st Jan 2012

Robbie took his last dose of Sinemet on Thursday afternoon, making a big song and dance over the fact his tablets are reducing I exclaimed “No more sinemet for you Robbie", to which I got the response “I will miss you Sinemet” This was the first ever medication he was prescribed way back in the early outset of the Dystonia and he has had to take three of these throughout the day, every day for the last 2 years. Only Trihexyphenydil and Gabapentin are taken now, along with a course of 3 doses of Piriton daily to try and relieve the “itchy head” he gets most days (It actually seems to be honest he is aware of the scar tissue on his head and he just keeps scratching it, hopefully a habit that will subside as he gets used to it being there)

Robbie seems to be coming to terms with using a knife to cut food; he now wants everything uncut so he can use his new found skill. We have also had a major focus on Robbie’s eating his week as briefly mentioned last week he is a really fussy eater and would only ever eat a few choice meals, as his recovery continues we have an agenda to start pushing him a bit to discover and at least try new foods, it has to be said at this early stage this has been quite successful, and so far newly added foods to his diet now include, mash potatoes, chicken, gravy, pancakes, grapes and sweetcorn. Real progress is apparent and Robbie seems to enjoy trying (at last) new foods.

We also got Robbie a new bike this week in an effort to get him trying this new skill, we have added stabilisers, however have also experienced a few falls during the first few attempts on this, and he is finding the concept of getting the pedals to move 360 degrees at this time difficult (I have added a video to show this) however he is happy enough to persevere on with this challenge, I am sure he will get there eventually.

Swimming lesson this week was an interesting event, Robbie seems to be able to swim on his back without too many issues, although co-ordinating all 4 limbs in unison is still a bit challenging for him, it is however very early days and I think given time to practice this will improve, swimming on his front is proving a bit more difficult for him as he has a stronger side which means he keeps pulling in one direction instead of a straight line, again I am sure it is something that will improve with practice... he has cracked floating on his back though (something I cannot do). It is only his third week so maybe I am the one not showing enough patience, regardless, we will persevere with this challenge and we will get there.

We are still continuing down the road of pushing Robbie to be more independent in many ways, he no longer gets lifted into the car and climbs in by himself (that said I am always right behind him in case of any falls etc) he manages most tasks unaided just now with the minimum of assistance, however we are always close by in case of any difficulties.

One slight difference we have noticed is when Robbie becomes angry or upset he seems to be really intense in his mood, and it is like a red mist descends and he loses the plot completely, during these rare episodes he becomes very difficult to calm down... this could just be a tantrum type of thing with his age, however a situation we will be monitoring very closely.

Other than the above it has been another really good week, and Robbie goes from strength to strength with his improvement in all areas...