Monday 28 July 2014

S2W4: Physio Culture

This week I discovered Pinterest! So I've put up some images that seemed relevant to physio! Looking through the images I noted that there were different cultural ideas associated with the images and so I thought it would be interesting to discuss the culture of physiotherapy, at least superficially for the first two paragraphs anyway!

You may remember different social groups at high school - it probably reflects similarly to the movie "The Breakfast Club" directed by John Hughes. At university we hope to be more culturally aware but we still gravitate to certain people who share similar cultural norms or to fill our own social needs. Just for crudeness sake I'm going to match physio disciplines to a stereotype like in the movie 'The Breakfast Club' (in reality it is not like this at all): private practice musculoskeletal practitioners are the 'Jocks', neurological physiotherapists are the 'Nerds' and cardiopulmonary physios are the 'Princess/Prince'. But in reality we are all jocks, nerds and princess/princes... and probably outcasts too (just like the movie portrays). Note that none of us are criminals! (Parking tickets don't count - we have 'police vetting' next week which shall deem us 'safe' to practice in a clinical setting). As therapists we create our own identity which shows through in our treatments. Some therapists are known to be 'hands off' (that was the case for our MSK lecturer, who appeared to love the idea of not having to palpate the patient) whilst many therapist's touch feels empathetic and you know you will be taken care of. Other therapists have a firm touch and you know there will be no mucking about! Hopefully they don't rip your limb off when clearing joints!

There is a culture within Physio students at the University of Otago to be widely accepting of one another. We're all a bit different, and that is perfectly fine. There is a sense of unity between students. Furthermore, we don't feel pressured to compete against each other for the best marks (like medical students may) which allows us to compete against ourselves and to achieve the best patient outcomes. We are known to share and discuss ideas openly but when it comes to answering questions in class the cultural norm is to hide behind your notes. However there is always a voice or two that has a go - followed by a friendly response by the lecturer. Our understanding is what matters at the end of the day! It's very hard to explain cultural identity when you consider the diverse upbringing of each student and generalise across the student cohort. I could talk to you about cultures surrounding ethnicity, gender, sexuality, socioeconomic status, religion, disability, education... but it'd be too long for this blog. With all these differences, at least we have physiotherapy in common!

Placement! I'm placed at Unipol (the Otago University student's fitness centre) for the chronic disease exercise class (we just call it the diabetes exercise class haha). This placement required some pre-placement reading/refreshing on diabetes and other common chronic conditions with questions being asked before we began to ensure that we understood the conditions.. This is a community class but most participants are referred by their local general practitioner or from Diabetes education through their district health board. I had one patient with poorly controlled diabetes decide to increase their resistance on the cycle ergometer while I was off assisting another patient (my supervisor spotted them working with their HR nearly at their predicted maximal! Oh dear!!)


On Friday morning after our pharm lecture we decided to make the most of the stunning weather by going sand skiing!

Phty254: McKenzie management of low back pain featured this week. We learned about mechanical diagnosis therapy (MDT) for the lumbar region. This was pioneered by the NZ physio legend (Robin McKenzie) that invented the 'lumbar roll'! The lecturer was very keen on us identifying 'derangement', often overemphasising "derangement" in different tones for humorous effect. I was very amused by this. I was also used as a demonstration model for the therapeutic movement which meant continually moving my hips between two postural positions (e.g. hips poking out to the left then right) while the lecturer discussed points. The second MSK lab focused on clinical biomechanics of the foot and prescription of footwear.

Phty250: Muscles of the hip and thigh were covered this week. We were also given an anatomy assignment last week which I think is due next week. I chose to research the adductor longus muscle of the thigh, in particular any anatomical conflicts in the literature. For example, the adductor longus muscle is not reported to have fibres attaching to the rectus sheath at the proximal attachement in anatomy text books, however in dissection studies the fibres are said to be fused (this could have clinical relevance for patients with groin pain).

Tip for surviving physio: backup your electronic assignments to a cloud service like Dropbox (or email them to yourself). My flatmate lost her assignment due to a computer malfunction - lets all learn from this and prevent such a disaster happening to ourselves!

Phty252: The pharm lab this week had us physio kids consuming drugs (well... one drug)! We were measuring heart rate and peak expiratory flow rate after low and high intensity exercise, then again after taking metoprolol! Metoprolol is a b-Blocker which decreases heart rate and heart contractility. There is nothing much to add here (you can probably guess what happened to our measured variables). I think it is interesting that the pill is heart-shaped! The stamp is for the unlikely incident of an adverse reaction - it is so the medical staff know what we had consumed. The lecturer supervising the lab had a keen sense of humour; we were talking about the assignment which required looking up drugs on MIMS or Medsafe, "In my day I use to walk to uni in the snow... wait that's a different story! In my job I look up drugs every day that I don't know about - you should get into the habit too".



I found some physio related memes on Pinterest / internet too! ...
 
 
 
 
 
 



 

Monday 21 July 2014

S2W3: Roles & Rolls

Role of the physiotherapist - what do we actually do?
Physiotherapists play an important role in the health care team and wider health service umbrella. As primary practitioners (like doctors) we are able to assess, diagnose and treat ailments within our scope of practice. The scope of the physio is very large, from musculoskeletal, neuro to cardiopulmonary and other disorders (like renal) where management of their condition partially comes in the form of exercise, movement strategies etc. Often the scope of practice of a health care provider overlaps with the that of other health care providers. As a consumer of health services, you should decide to what extent you trust the clinicians educational basis for treatment... for example, if a soft tissue therapist told me they were altering my muscle "cell memory", I would be very suspicious! I will list and describe different health care providers briefly (hopefully without undermining their health profession). We haven't had a lecture on this as of yet, but this is my current understanding.
  • Doctors/physicians. In western society, Drs lead the health care team. Although autonomous, physiotherapists must refer back to the doctor in some circumstances such as suspected cancer, ordering X-ray imaging and when we think medication may be beneficial. Drs usually refer to physiotherapists for diagnosing physical ailments like sprained ankles, and then physios may refer the client back to the Dr or a specialist (orthopaedic surgeon) if we suspect surgery is necessary. Doctors don't usually offer exercise prescription or physical rehabilitation, rather they use pharmacological agents to interact with biological processes to improve health outcomes.
  • Occupational Therapists. OT's are all about functioning at home and in the community. They assess and initiate the modification of living areas or teach clients to move more effectively in certain environments or with aiding instruments/tools (such as transferring). Some common ground include prescribing ambulation aids and using hoists. If physio's can teach client's to move, OTs will teach them to dance! OT's also are trained to test some neurological disorders, similar to physiotherapists.
  • Chiropractors seem to come in two flavours; traditional/philosophical and biomedical. Physiotherapists and chiropractors have slightly different histories/philosophies but are both trained to manage musculoskeletal conditions. I believe the biomedical orientated variety have become similar to physiotherapists over time. Chiropractors are spine adjustment specialists but also work on soft tissues and other joints. Physiotherapists are very exercise/function orientated with techniques to manipulate the spine and techniques to mobilise joints and soft tissue. Physiotherapists, with further training, may practice acupuncture (this may be considered alternative medicine) whilst chiros have their own alternative methods/tools.
  • Osteopaths use manual therapy and mobilisation techniques like physios and chiros do. Historically, chiropractic roots lie with osteopathic practice. All three professions, in the musculoskeletal realm, claim to offer similar treatment outcomes and a holistic approach. Of the three, osteopathic medicine is the one I have the least knowledge about. In New Zealand it is not uncommon to hear health professionals refer to osteopaths as 'Gypsies' - but we certainly do respect their practice.
  • Acupuncturist. As the name suggests, they practice either western or eastern acupuncture medicine. 
  • Psychologist. We are taught some psychological techniques for motivation, managing stress and anxiety. Physios only manage mental health issues when they co-present with physical rehabilitation or training. Physios consult with psychologists on delicate situations and often refer the client to psychologists or counsellors when it is believed to be in the best interest of the client.
  • Podiatrist. Lower limbs and feet can be considered to be the foundation of our postural health (did you see what I done there?!) Physiotherapists and podiatrists can prescribe splints and wedges to adjust the position of any lower limb joint. Podiatrists specialise in the care of leg and foot; from clinical biomechanics (with prescription of a certain shoe/insole) to the care of the skin (managing corns and calluses - this is something physiotherapists don't primarily manage).
  • Soft tissue therapist (massage therapist). Physios know how to massage, the principles, contraindications etc. Our focus is on therapeutic effect and our understanding of the body as an integration of multiple systems allows us to work with wider scope than that of a massage therapist. Massage therapists can often specialise in a style of massage (like Thai massage) - this is something physiotherapists don't usually consider being trained in. We apply the necessary strokes/techniques to impact physiological and psychological parameters. Some massage therapists are more 'in tune' with soft tissue than physios due to their specific discipline and hands on patient contact. Both physios and massage therapists learn about trigger points and soft tissue manipulation.
  • Personal and high performance trainers. Physiotherapists know a lot about exercise and health, much more than a personal trainer. Physios know about high performance too, but generally leave that to specialised trainers who have industry knowledge and can better apply training principles for specific peak performance. However, injury prevention and rehabilitation falls almost exclusively within the scope of a physiotherapy or in collaboration between both parties.
  • Speech language therapist. Physiotherapists recognise the neurological and physical aspects of speech disorders like a speech language therapist. We can help the client with TMJ pain and problem joint kinematics. However physios leave sound articulation and mastication training to the speech language therapist.
  • Paramedic. Paramedics provide first aid. Physios don't attend to first aid incidents in the community (unless physios are already on-site and basic first aid can be given) but generally work in a similar capacity in a sporting context.
  • Sport Medic, Sports Paramedic, Sports Physio & Sports Doctor. This is the medical team that attends major sport functions. There may be a nurse amongst the team too. Sport medics apply basic first aid, strapping, massage and are the support hands to any other health professional in the team. Sports paramedics are qualified to complete any emergency medicine but most of the time they will be suturing up lacerations and possibly even relocating subluxed joints. Sports physiotherapists are experts on strapping, massage, therapeutic exercise and return to play. Sport/team doctors are the leaders of the health care team.
Some people roll with their pants (most commonly jeans) halfway down their bottom when they walk. ["Roll" =  it's their style]. According to our anatomy lecturer, people who do this are in danger of compressing their lateral cutaneous nerve of the thigh (also the risk of their pants slipping off their bottom). If they feel pins and needles on the lateral aspect of their thigh, our treatment plan would start with them pulling their pants up!! (A walking/transfer belt would not be suitable).

Foam rolls in hydrotherapy are called 'noodles' and they can be used to stop us from rolling (rotating in the water) by increasing the radius about our longitudinal axis.  Other rolls in the pool were rolls of adipose tissue - especially mine! I rationalise this as a mechanism for insulation (but I should look at adapting my physical composition in preparation for summer!) This was our last week of hydrotherapy. It finished with an assessment where we were given a case study and had to integrate principles of hydrotherapy into a rehabilitation plan. Our case was a 35 year old female tennis player with rotator cuff tendinitis - we were given more details than this though.

Foam rolls are like 'noodles' (only more solid) and are used on land to massage / stretch our IT-band (amongst other muscles e.g. gluteus muscles). Those who haven't used it regularly will think it is slightly tortuous! It is particularly good for an athletic population because tissues need to be stretched and often stretching won't have the same effect as IT-band rolling. Other rolling strategies that are effective are to use a tennis ball under the sole of the barefoot, apply some weight to the ball and roll out the plantar fascia. Give it a go when you have the opportunity!

At the beginning of this week I was busy using a toilet roll / paper as tissues! Yep. I had another cold. Thankfully it is on its way out. I'm actually surprised about how many 'rolls' I managed to talk about! There are other rolls which I may cover in future weeks e.g. Lumbar rolls to support the lumbar spine lordotic curvature and the Million Dollar Roll which is a lumbar vertebrae manipulation technique.

Many of the lecturers, especially lab and clinical placement staff for 254 and 255, are wonderful role models! They bring wisdom and passion to the field of physiotherapy. It is truly inspirational for us students to observe and interact with them. I have mentioned this before (with one lab demonstrator learning all of our names), but now that the year has progressed it is clear that most of the lecturers want to help us achieve a high level of practice. Not only this, but they treat each student as individuals and interact with us on a semi-personal level.


PHTY254 Neuro required the class to assess a few neurological conditions, such as multiple sclerosis and stroke patients, rolling from a lying position onto their side (side lying) then into a sitting position. This was part of the objective assessment. Our aim is to make everyday tasks easier by providing strategies to move, increasing their strength and mobility. This is the last week of Umove for me this year. Next week I begin my second placement!


We have an electronic resource for tests of the upper and lower limb (previous years were able to purchase a DVD - so I borrowed it because our internet is slow!)

I've found some more vids!! Have a good weekend!



Tuesday 15 July 2014

S2W2: Snorkle.


Just for a change, I'm going to highlight all the fun things we did this week (and are looking forward to) starting with our PHTY254 lab on hip examination. When examining the hip we want to either clear it as a source of pain or document what specific movements bring on the pain. To clear the hip we perform tests, for example the 'quadrant test', 'SI joint provocation test', 'isometric tests' and through 'active physiological movement with overpressure'. The second PHTY254 MSK lab taught us special orthopaedic tests (joint integrity tests), neurodynamic tests and neurological examinations. These practical labs are fun. They are hands on but most importantly they are meaningful skills used by physiotherapists.

Umove was good fun this week. It was quieter in the first hour which meant we were able to play with a few toys in the lab! Toys included an air-splint (would be ideal for inflatable suit wrestling), a tilt-table (strap the client in and tip them from lying to standing position) and we also played darts (magnetic) and badminton! Good fun! I had a different client this week (yes we done some work too). The client was able to show me what he was able to do / had been doing, and I was able to introduce some new ideas for improving left quadriceps strength.

The pharm lab explored some of the foundations of pharmacokinetics; bioavailability, distribution of volume, half life, plotting semilog graphs and effects of multiple dosing. It was an interesting lab and I can certainly see how pharmacology serves an important role in physiotherapy care even though as physiotherapists we cannot prescribe drugs.

We've had some interesting quotes this week from lecturers across subjects. "The sciatic nerve is so long and strong that you could hang yourself with it" - anatomy. A little insensitive, but it's true that it could hold our body weight! "42 cups of regular Starbucks coffee will kill you" - pharmacology. This was with reference to caffeine and the therapeutic index... "You will not be able to commit suicide using a drug with a large therapeutic window, e.g. therapeutic index of 40". What a grim week! "Groin Clock" - PHTY254; does not refer to a time where your groin has certain urges!! Rather, it refers to angles of femur placement within the acetabulum - the quadrant clearance test of the hip.

Physio is a social professional course and as such, the social events are continuing this semester. Tip for surviving physio: get involved with social events. They usually involve alcohol, but that doesn't mean that you have to drink too. Hang out with your peers and enjoy a few laughs. These posts are aimed to motivate us to be involved whilst providing a humorous undertone. Semester two inter year (2nd and 3rd year) lab group BYO is on the 6th of August! Physio is very social!!


Cultural dinner on the 30th and Miss Physio Competition next Friday!! 

Here is a more detailed post about the Miss Physio comp!!

The physio ball will be held in August, so I'll tell you about this social event closer to the time. Wait... how do you spell physio?? Haha!!
Physio vs Physical Education girls rugby this Sunday!
Clinical debrief is all about sharing and learning from one another's experiences. It highlights the importance of presenting a case, which will be useful in seminars or in 3rd and 4th year when consulting our supervisor. Presenting cases is a skill that I will continue to work on... documenting all the relevant information during the clinical placement would certainly help me with that haha!! I heard about other conditions that my peers encountered on their placements such as TB, low back pain and Crohns disease. Very interesting!

The premier grade Dunedin Technical Football Club players, manager and coaching staff have given me a nickname. I have no idea how it came about, but I'll play along. It's very creative. "Snorkle". It's good to be a part of the team!

During the hydrotherapy session we put knowledge / principles about hydrostatics and hydrodynamics into practice. Did you know movement in water is 799 times slower in water than it is in air - due to skin friction drag and the resultant effect of the weight of water. I'm thinking that the nickname 'snorkle' would be ideal if I were good at holding my breath underwater - unfortunately although I am a good swimmer, my breath holding abilities are average. I'll figure the whole nickname thing out some time, haha!!

In other water related events going around social media, I completed the Ice Challenge for cancer awareness with my girlfriend (we were both nominated by her friend).  We completed the challenge on St Kilda beach at 6:30pm (which meant the sun had long set) and after brief rain showers throughout the day. The challenge itself involves having buckets of ice water (water with ice in them) poured over your body. To finish the challenge we decided to go for a dip in the ocean! It was a chilling experience!

Wednesday 9 July 2014

S2W1: No Diving into the Deep End!

Semester two: week one!

We've nursed our egos having received our exam results back the other week and slept away our tired eyes. Time to get back on our physio horse and ride that pony to town! Or, at least to our Monday 9am lecture. Only the occasional 8am lecture this semester!!

Kia ora! We're back to the books after having a three week break! The official university break was two weeks, but we had an extra week off due to finishing exams earlier in the examination period. The physio-related highlight over this period happened whilst medicing the Saturday game following our last exam. One of our players was struck in the nose by an elbow when challenging to head the ball. The result: one broken nose! I was lucky enough to be able to relocate the nose as soon as the player came off. I then sent the player to be taken to the Sport Injury Clinic for further assessment and the player was back to cheer the team on in the second half of the game! Had the player dislocated a major limb, I wouldn't have had the pleasure of relocating that. Dunedin Tech Football Cub won that match 11 - one. I think the boys had been taking mental notes from games being played in the FIFA world cup!

Halfway through the year already! Here are our papers for Semester Two!!
- PHTY250: Anatomy! The focus will be on all things periphery (muscles, nerves, etc.)
- PHTY252: Pharmacology for physios. Sex, drugs & rock 'n roll! ... Naa, just drugs!
- PHTY254: Rehab science continues to expand the physio student tool kit.
- PHTY255: Clinical practice features hydrotherapy this week but will include two more clinical placements later in the semester.

New additions to the physio student book bank for semester two!


PHTY254 is split into MSK and Neuro this semester: Looking ahead to future musculoskeletal (MSK) labs, I am most looking forward to learning McKenzie management techniques for low back pain and other manual therapy techniques as well as other soft tissue techniques for the lower limbs (we look at techniques for the upper limbs and higher vertebrae next year). McKenzie and Mulligan manual therapy techniques were developed by New Zealanders and are world renowned. This is partly why NZ trained physiotherapists are believed to be among the best in the world. This week MSK covered more in depth info on physical examinations (looking to differentiate between pain sources and developing hypotheses and testing hypotheses). In the second lab we practised the mobilisation technique 'passive accessory movement' on our peer's wrists, ankles and hips. We also covered movement diagrams. This is a subjective tool for documenting resistance/pain/spasm throughout a joints physiological (normal) and accessory movement. During a 254 neuro lecture we were given the task of accessing a building around the university with a walking aid and pretending that we had a stroke. This meant altering our gait. From doing this we have a better appreciation for the challenges they face on a daily basis. For example, we were much slower at crossing at the traffic lights, battled with the cold wind, held up people trying to pass us and got a few interesting looks from passers-by. Looking ahead to future neuro labs there are only self-directed learning tasks (4+ hours per week) & Umove clinic (4 hours per week for three weeks)... thankfully the SDL doesn't have to be completed when attending Umove clinics. I have two more weeks of Umove this semester to go.

Umove is a public service (free) for people with neurological conditions to be physically active. It focuses on the clients goals and allows us undergraduates some hands on experience facilitating safe and effective exercise. The session on Tuesday was thought to be overbooked for the number of physio students present. The clinical supervisor was sure they were going to arrive all at once, before she had a chance to give us a little heads up for what we actually had to do. We were thrown into the deep end (but not as deep as the supervisor had previously anticipated). On my first Umove clinic a patient told me that my eyes look tired (it's true, they do) but then he likened me to Gerard Butler I'd say he was looking at my name tag ... I had to ask a physio peer whether this was a compliment - she told me that it was. Having now googled this apparently famous actor, I will take it as a compliment (although I don't look anything like him - I took a selfie so you can compare for yourself).



A common joke between physiotherapists (and sometimes their clients) is not being able to count... "not being able to count is a prerequisite for physio", "you've got three more reps to go..... [three reps later] you've got one more to go". 

In other papers this week...
  • PHTY255 - Hydrotherapy. Our hydrotherapy sessions were held at the Dunedin Physio Pool. The temperature of the pool is a constant 35 degrees Celsius - a pleasant escape from the Dunedin winter. I'll tell you about this and our clinical debrief next week.
  • PHTY252 - Pharmacology this week was all about pharmacokinetics or 'what the body does to the drug'. There were a few new concepts such as the 'vehicle' (not a BMW or Porche, which you might expect Pharmacists to drive); basically this is another substance that facilitates the absorption of the drug.
  • I almost forgot to mention anatomy, PHTY250! We have self directed learning tasks on top of the usual weekly load (one hour lecture, 2x two hour labs, a short mastery exam + self directed learning tasks). We began the second semester covering the anatomy of skin through to deep fascia & muscle, developmental bone anatomy (and a few other things). That is, 38 pages of lab content to fill in this week alone. Busy times ahead!! Next week we begin what I believe to be anatomy for physiotherapy, ... the lower limbs!
 When writing these blogs, I seldom report what is happening in my life away from studying physiotherapy. It often feels like study takes up a large portion of our daily lives - I'm sure on paper it actually does! In this paragraph I wish to address the wider context of living and how I came to reflect upon it this week. I assure you that other life events don't stop while you're studying, so you need to keep up with them too! Brazil lost in the soccer world cup by 7 - 1 to Germany this week! The commonwealth games are due to start in a few weeks! NZ is leading up to a general election later this year. It was my dad's birthday this week. It's good to celebrate the current life of loved ones. I'm off to a friends birthday dinner on Saturday! These people make your own life worth living. A friend from high school is about to give birth to her second child - I saw this one via Facebook. Good on her! We need to celebrate the creation of life; life is precious. Student's do however participate in relationships all of their own; friendships, romances, family. I am lucky to have a wonderful girlfriend. We cook meals for each other a few times a week, text message and occasionally hangout. We are, ourselves, super busy - but that's working out just fine. I try to keep in touch with many friends with the odd facebook conversation. I often have a coffee (more typically, brunch) with friends passing through Dunedin or who are otherwise studying hard and need a social break. Because I enjoy dabbling with photography, a friend and I are trying some experimental photography styles - matching our local scenes into a fictional scene (he lives in Wellington). Then there are those people closer to home. My flatmate is having some difficulties recovering money off her friends old boyfriend as her mother has cancer and that friend had to return to another country. Relationships gone wrong and daily struggles with money are all to present in students lives. Other flatmates are reconsidering their future goals re: semester one results and developing their sense of self / identity  too. I have been keeping an eye out for a job in addition to full time study and luckily I had a job interview last week - my fingers are crossed that I get that. Being a student is not simply about studying. It's good to live in the present moment, but reflection on the past and of the future are important too. I actually came to reflect upon this when hearing of a death of a friend from high school. He committed suicide. A client at Umove asked me if I took walking for granted. I admit that I probably do. But I certainly do not take life and the life of others for granted and neither should you. So my tip for surviving physio this week is to be involved in the process of living. Be there for friends and family. We cannot personally be there for everyone, but collectively as the human race we can. Lets not go diving into the deep end.

From one serious note to another! Here is a look at next weeks timetable. Classes generally stay the same. My second tip for surviving physio: half an hour putting your timetable in electronic form is worthwhile (saves printing costs). Normally there is a 254 MSK lab on Wednesday from 1pm to 3pm... Hopefully this isn't a timetable error (I'll have to check!) But you can see how busy we are as physio students.

If you're after an entertaining lecture about pain, then watch this (~50min).

It's been a busy first week back!