Y3S1W13: Winter is coming!

On Monday morning we woke to some snow around the region. Suprisingly North Dunedin wasn't too badly affected whereas South Dunedin was. Odd! Our plan was to travel to Mosgiel on Monday morning to visit a new patient with COPD, but after checking the road status we rang the patient to make sure they were still alive. They were, thank goodness! In the end we didn't go to Mosgiel as the patient was not feeling well enough for a visit. We then rung around other patients, many wished to have a physio visit another time (because it was so cold and miserable). Much of the time on Monday was spent preparing Heart Foundation booklets for our Friday placement and drinking coffee in the staffroom. In the end we visited one patient while there were small snow flurries going on outside.

On Wednesday morning I saw my usual clients. I've enjoyed having some clinic time with patients with chronic illnesses. What hasn't worked well one week is improved upon in the next, and is even better the week after that. We have had a chance to practice independently - with the occassional visit from the educator to check up on the patient and share a good yarn or two. Following the session I have enjoyed debriefing whilst I'm writing my patient's notes. Debriefs have challenged my critical thinking and clinical reasoning - we've discussed psychosocial aspects which in theory have simple solutions, but in practice these are not at all easy to influence. I feel that one of my patients has taken onboard the message that he needs to continue exercising regularly. This patient in particular is known for being 'stubborn' and having zero compliance with exercise programmes. However, it seems that over the three weeks I have found an activity that the patient enjoys and they have indicated that they will start exercising at home. To me, this is a success. If we put in the hard work, physiothearpy has its rewards.

 On Thursday afternoon I decided to explore Waipori Falls!

On Friday we were handing back the risk assessments for 'cardiovascular disease risk in the next five years'. We were following up with some education - discussing the results and allowing for some Q&A so they could be better informed about their health. 

We have covered all the musculoskeletal tests we will need to begin practicing as musculoskeletal physiotherapists. Our manual handling skillls, communication, subjective and objective assessments are getting pretty sharp too. Our last lab for the MSK module in our degree was left to us to practice what we wanted - there was a lecturer roaming the room helping us with techniques. So we're well versed in soft tissue therapy, Mulligan and Maitland manual therapy, exercise therapy, taping, etc. In addition we've covered the fundamental electrotherapy techniques (thermotherapy, cryotherapy, ultrasound, laser, TENS, FMS, NMES, biofeedback). Our toolbox is getting bigger! Our last physical agents lab (electrotherapy) was on biofeedback. To demonstrate how the equipment worked (and it's set-up) the demonstrators had two students arm wrestle each other. The biofeedback measured their muscle activity, the highest muscle activity theoretically won (this was reinforced by the outcome winner of the arm wrestle). Unfortunately the winner didn't face-off against a lab demonstrator... Anyway, the biofeedback machine beeps when a your muscle isn't activating enough or is overactive (we control the settings) - this can help train us to relax our muscles when we're stressed or to target specific muscles (amongst a host of other uses).

Neuro portfolio in... check!
Physical agents assignment in... check!
PHTY355 clinical placement portfolio for semester one in... check!
Evidence based practice assignment... it can wait.

I'll write one blog to cover this exam period... catch you in a few weeks!

Wish us luck!

Y3S1W12: Holy neoplasm, Batman!

I've taken to modified Batman quotes this week as we near two major deadlines (neuro modules and electro assignment), for no other reason than at times like these we need a little bit of humour.

Holy slipped disc, Batman! We've got a pain in the neck. This is the last MSK lab where we're asked to master new treatment techniques for the upcoming exams. It was an important lab that would either make or break our careers as physiotherapists (slight exaggeration). If we got it wrong we could do catastrophic harm to our lab partner and if we got it right it would prove our sensitivity to detecting and treating the movement of underlying tissues. What were we learning you ask? Lower cervical spine manipulations or the down-slip manipulation of the cervical spine (and somewhat the 'up-slip' technique too as it's a similar treatment plane and set-up). In the lab, we went through the full risk assessment for cerebral artery dysfunction (which encompasses vertebral artery insufficiency) with our peer whom we were practising on. After the all clear (screening and informed consent) it was on to grade four mobilisation and grade five (manipulation) of the neck. It was interesting that nobody in our lab group actually performed a cervical manipulation in the lab - either the acting patient wasn't comfortable or the practising student wasn't confident. Obviously we're not to practice the cervical manipulation unless supervised by a registered physiotherapist, so our flatmates are safe. Actually, when screened properly the risks of dissecting the vertebral or carotid artery are very low (1 in 1,000,000)... to put it in perspective, the risks of death from NSAIDs are much higher.

In our physical agents lab we were applying FES and interferential therapy. FES stimulates your muscles to contract - it's particularly useful in neuro-rehabilitation. Interferential current is good for treating deeper tissues. Interferential therapy basically uses a low frequency of electricity to treat the tissue, but this cannot happen directly from the electrodes because it will also activate pain receptors on our skin. Because higher frequencies don't activate pain signals we can use two different moderate frequencies (e.g. 4000Hz and 3950Hz) to create the low frequency treatment needed deep in the tissue. When the two frequencies mix, the low (50Hz) treatment is produced. Interferential current seems like a useful and easy therapy to apply. Sometimes I wonder why we charge so much for treatment, because the process is relatively simple (unless we're using an interferential machine with suction cups).

Better three hours too soon than a minute too late. We're getting on with our neuro modules. I hope to be finished with it soon... as we'll be getting another assignment next week for Evidence-Based Practice!

Holy crystal ball, Batman! How did you see that coming? If you were looking through RCT (random control trials) then you mightn't have! You probably should have looked for a consort statement before believing everything you read. This was the theme for Phty355 evidence based practice. We used this theme to discuss how we will go about in-service presentations to colleagues (i.e. when we're asked to contribute to current knowledge in the workplace by giving what will resemble a 15min lecture before our 8:30am patient). Goodness, that sounds like a good way to start the day!

Quick, to the bat-mobile (Asthma Society vehicle)!! Second week out protecting the city of Dunedin from menacing modifiable risk factors and disease... "I'd better get out of my death bed" joked a patient we rang prior to visiting on Monday for COPD community placement. This patient had a few things going against him including T2DM, postural hypotension, ischaemic heart disease, idiopathic cardio-myopathy, osteoporosis, COPD (emphysema), and regularly got pneumonia. This was a new patient, so I got to observe our clinical educator and another student interview the patient. Although there were a few barriers to gaining the rapport of the patient, we got there in the end with motivational interviewing techniques. We revisited two patients' whom we saw last week, both were doing very well health and exercise-wise.

On Wednesday I had two patients of my own and I assisted another on an exercycle and bosu-ball. My first patient was the same as last week. A challenge with this patient was encouraging him to engage in a suitable aerobic exercise. Biking and rowing was out of the equation because his legs would fatigue quickly and long walks weren't particularly engaging (boring). We did ascend and descend the stairs four times which was a good enough leg workout for the day. I came up with aerobic boxing - surely I was on to a winner! When the patient arrived we asked the general health question "how are you today?" to which he replied that he was having some pain in his wrist. You might have thought that my plan was spoiled, but thankfully it wasn't. We did a brief MSK assessment and found that by stabilising the carpals we were able to reduce a lot of his wrist pain when he gripped. At the end of the session we took off to use the Umove boxing bag + gloves. The gloves offered some wrist support and the patient was able to bout out 4x 30s rounds of boxing. "Pain is the feeling of strength being sucked out of you." This patient has gone to hell and back. To reduce this patient's pain, our plan is to strengthen his muscles to pre-coma health. The second pt had severe COPD and we became suspicious of whether the oxygen saturation machine was reading accurately when at one stage it was reading 68%... this basically means that ~70% of his blood is filled with oxygen (ideally we all should be reading ~99%). The patient (almost 90y/o) was fine and I had him complete a 3MWT and some balance and core stability exercises. We're saving the world, one patient at a time!

On Friday we were back in South Dunedin (after a bit of admin) for an exercise class with the Pacific Island group. We were asked to coordinate and lead an exercise session lasting ~45minutes. After a warm up we ran three stations working on strength, aerobics and balance followed by a combined group challenge and a warm-down/stretching. Following our exercise session, there was a presentation by the Stroke Foundation and a healthy lunch. We didn't stay for the presentation on Stroke, but we were given a cup of pumpkin soup each on our way out... how well looked after are we!?! Very well looked after!

Holy strawberries Batman! We're in a jam. Pathology continues to use food stuff to describe what pathological tissues look like e.g. sloppy porridge for liquifactive necrosis/puss, fried egg whites and yoke for oligodendrocytes, and intracranial aneurysms that look like berries! Our lab investigated COPD whilst our lectures raced ahead and covered neoplasms & cancer. In the lab, the thick mucus in chronic bronchitis was likened to cheese off a pizza (the stringy cheese that ends up on your chin). Our cancer series has used skin-cancer, endometrial and colon cancers to highlight the many pathways which can lead to benign or malignant cancer.

It was a privilege to attend an inaugural professorial lecture on Tuesday afternoon 'Physiotherapy: Enabling health and enabling lives through movement and support'. We celebrated Leigh Hale's promotion to a professor and her successful application to becoming the Dean of the School of Physiotherapy. It seems that when lecturers get a promotion, they celebrate by giving a lecture! Classic. There were plenty of highly important people in the room including representatives from the Board of Physiotherapy, Physiotherapy New Zealand, Vice Chancellor of the University of Otago, and many more distinguished guests. There was also staff (most distinguishable people themselves), a few students and others from the community too. Leigh shared her physiotherapy journey, research and passion for physiotherapy - in particular neuro-rehabilitation. A key message was that by giving support for activities the patient chooses, we are able to build our patient's self-efficacy, thus to enable them to engage in life-long enjoyment and participation in physical activity. By the end of the lecture we were feeling inspired and thankful that the school will continue to be in good hands. Like Batman, Leigh is also a bit of a superhero!

Professor Leigh Hale.

Watch one, perform one, teach one. In the sport injury clinic we were taught how to suture wounds. We were taught two suturing techniques and practised this on cotton towels. The process is quite tricky as it requires steady hands and dexterity... but if you've had some practice tying hooks on a fishing lure, you're half way there. There are a lot of other important aspects of suturing, including patient comfort, local anaesthetic and sterile practices (this includes scrubbing and irrigating the wound). It's not within the scope of practice for the physiotherapist, physio student or sport medic to suture, but the opportunity is given to sports medics at the Otago Sports Injury Clinic because we're closely monitored and have our handy-work signed off by a medical doctor. There was a patient that turned up requiring a suture to a laceration on his arm following a ruck in rugby union. We were only allowed to watch that one (set up, irrigate, cut and clean up). Next time, it's all us.

Planting a time-bomb in the medical library is a felony... but that's just what we need.

Next week is the last week of this semester, then it's exam time!

Come on, Students', to the Bat Cave! There's not a moment to lose!

 ...to be continued!

Y3S1W11: Community Physiothearpy (COPD)

An extra-curricular event turned into a major highlight of the week. It started on Wednesday, 5:30pm, with a presentation on auroras organised by the director of the Otago Museum, Ian Griffin. Ian is an avid aurora photographer whom shared his passion for auroras and photography journey. There were other guest speakers who explained the science of auroras, the history of auroras in NZ (of which dated back many decades), and how to go about photographing them. There just so happened to be an aurora storm brewing that night, so after the presentation I raced out with my camera (already in the car, set to go...) and snapped up some more scenes around Dunedin. I spent the first 3h hiking around an unfamiliar farm walking track to only find one composition worth taking a picture of (Paradise track to Highcliff track). The storm was almost over by this stage, so I promptly made my way to Hoopers Inlet - a safe composition location, to make the most of the southern light display.

...Right, back to physio talk. Respiratory pathology was the theme of our Monday morning. The 8am pathology lecture discussed COPD, which was useful because my placement at 9am was a community COPD placement. This is my last placement block for the semester... lets break it down a bit. 

On Mondays we do home visits to patients referred to us by the asthma society, these patients tend to have severe COPD, amongst other chronic health conditions. I jumped at the chance to get the ball rolling and called dibs on telephoning and taking the lead as physio for the first patient. We travelled in the asthma society vehicle then it was shoes off at the door (figurative and literally). My patient was an older female with COPD, recent respiratory failure, diabetes, sleep apnoea, osteopenia and at higher falls risk. I checked in on her diabetes management and energy levels before we went outside to complete a 6min walk test. The second part to the visit was to make sure she was confident with her home exercise programme. "Compliance to a home exercise programme is measured as the thickness of dust on top of the their exercise printout". Thankfully there was no dust collecting on this patients exercise programme. With such positive rapport gained, she happily showed us her CPAP (continuous positive airway pressure) machine to treat her sleep apnoea and oxygen tank in her bedroom. 

The second home visit was to a middle aged female with bronchiectasis (COPD). She was having trouble clearing phlegm. We put our chest auscultation, percussion and vibration techniques into action. She was able to clear some sputum from her left lung - we probably could have got more if she hadn't coughed a large amount up before we arrived. This lady also has a nebuliser with saline topical inhalant which is used similarly to washing a bowl in the kitchen - the water (saline) is put into the bowl (inhaled in to the lungs), in the bowl the water loosens off the foodstuff (thick mucus), and then the patient attempts to empty the contents into the sink (coughing the phlegm into a tissue).

On Wednesday, we were based at the clinic treating patients who weren't quite ready to return to the respiratory rehabilitation programme but well enough to attend exercise sessions at the School of Physiotherapy. One patient of interest that I was treating was a middle aged male who was recovering from a recent liver failure with COPD, low back pain, oesophageal varices (think varicose veins normally found on the legs, but these veins are in the gastrointestinal tract), and has had a few joint replacements. By now I hope you can appreciate the complexity physiotherapists are trained to rehabilitate.

Friday was a new setting again. We were providing education and exercise to the Pacific Islanders (associated with the Pacific Island Trust). These Pacific Islanders are keen to make healthier lifestyle changes. What makes this placement unique is the intervention style, which better meets the needs of the ethnic group. We will attempt to be especially culturally sensitive and incorporate cultural knowledge (games/activities/other values) into our Friday sessions. Today we were assessing their individual cardiovascular risk factors. There were three stations: height/weight/waist circumference, blood pressure, and blood glucose/cholesterol. I was in charge of taking blood pressures and calculating their risk of cardiovascular disease within the next five years. You can find more info about measuring your own risk factors here (contact your GP or physio if you have any concerns): http://www.knowyournumbers.co.nz/

Our MSK lab was on lumbar spine manipulations (yes, that's our Million Dollar Roll technique!) We also refreshed our palpation skills and assessment of mobility for the cervical spine as some preparation for next week MSK lab on manipulation of the lower cervical spine. In our MSK tutorial we had a shoulder case study and we worked through a differential diagnosis and treatment strategies. I found time to practice the MSK content covered so far with a peer on Thursday... I dear say that there will be plenty more peer-practice sessions to come!

Neuro had us examining the use of physiotherapy in long term management of progressive neurological conditions. An update on my modules... I've taken a 'lets do bits of everything' approach with the last three modules: paediatrics, spinal cord injury and peripheral nervous system conditions. I'm almost finished. A group of students booked a room out to watch the neuro DVDs associated with the modules. It was useful to have an open discussion about the impairments everybody else was observing.

Physical agents lab focused on TENS (transcutaneous electrical nerve stimulation). We had these hand-held devices sending tingly sensations through electrodes placed on our skin. There were different treatments including: conventional, acupunture-like and high intensity. The tingly TENS, from conventional treatment parameters, can be left on muscle tissue for almost 24/7. By the end of the lab I found myself playing with the machine, increasing the stimulus to contract my muscles... as it turns out, the 2x AA batteries can produce more stimulation than I can tolerate. Later in the week we had a lecture on interferential current - this will be next weeks toy... I mean treatment modality. Interferential current is slightly different to TENS (although appears to be similar). The main point of difference between TENS and interferential current is in its applicability. Interferential current uses two different pulse frequencies to treat a common (often deeper) tissue without stimulating pain receptors. The treatment pulse is the difference between the two frequencies. This is used to preserve muscle mass... it is especially useful if you had a spinal cord injury... or if you plan to sleep all day. TENS is mostly used to treat pain.

We have an assignment for the physical agent component of PHTY354. It's a vague case study with a few questions to answer in a 1500 word essay (basically, what is the likely diagnosis and how would we treat it with electrotherapeutic agents). This is due at the end of the semester (i.e. two weeks from now). The word limit isn't too much of a problem, rather it is fitting in time between the other demands and preparation for exams... and the rare time-out for yourself.

Hoopers Inlet

Y3S1W10: "Laser Beams"

The week started on May the fourth with pathology lectures on the GI tract and a tutorial on diabetes. The diabetes tutorial had two case studies. The first ended up with gangrene and nephropathy/nephrosclerosis. Our tutor made a Wizard of Oz reference when describing the kidney tubules "I'm shrinking, I'm shrinking" due to coagulative necrosis process (kidney tubules shouldn't be likened to the wicked witch). The second had a diabetes proliferative retinopathy - we could see aneurysm, infarcts "cotton wool spots", haemorrhages and protein/lipid deposits in the retinal scan. Laser is used to destroy the newly formed blood vessels (which are leaky... so, not good!) in the eye  to reduce the ocular pressure - saving your retina from detaching from your eye completely!! ... but as physiotherapists, it's not our job to do laser eye surgery - even if we do use therapeutic laser.

May the fourth, as a Starwars reference was an interesting coincidence because in our physical agents lab that day, we were using therapeutic laser (unfortunately not light sabres). We had our glasses on (no laser eye therapy for us!), laser pointers out and applying laser beams directly on our skin. Like ultrasound, the mechanism of treatment is to pass energy through cells to stimulate healing via a conversion of photons to biochemical energy. It can be used to facilitate the healing of wounds, tendinopathies, inflammation and can be used on acupuncture points. The down side to treatment (from a therapist's perspective) is calculating the energy, depth, intensity, duration and deciding how many points (and which points) to treat. There are a few guidelines (cheat sheets) which make the process easier, but you still need to understand how to use it and how it is affecting the tissues being treated. Laser therapy is unlikely to be used in the physiotherapists ploy for world domination any time soon.

We had another lab on the SI joint (the previous lab was in second year). We were taught five techniques with a clinical prediction rule so we could rule in or rule out the SIJ as a source of symptoms.

At the Otago sports injury clinic I saw a few new conditions including a middle aged male with a complete rupture of the long head of bicep brachialis and a young male with Sever's  disease.