Y3S1W14-15: Pathophysiotherapy.

50th Physio Undergrad Blog Post! (1.5 years of blogging to go!!) 

Mango tree update: it's still alive! I'll give you another mango tree update at the end of the year!

Pathophysiotherapy is the study of diseases relating to the physiotherapist. Classically you'll be thinking of osteoarthritis for manual therapists, hyperventilation syndrome for respiratory therapists and locked-in syndrome for neurological rehabilitationists. Pathophysiothearpy for the physiotherapy student is characteristed by systematic multi-organ failure followed by sporatic remission after the final exam. In the acute and subacute phase clinical signs are similar to concussion: loss of consciousness, nausea/vomitting, sadness, irritability, fatigue/low energy, nervous/anxious, difficulty remembering, "don't feel right", headache/dizziness, blurred vision, sensitivity to light, neck pain, difficulty concentrating. The chronic stage (after three months) is when symptoms peak and students are at high risk of motality or long term disability. The disease spreads via blood and nervous systems to the heart where they experience palpitations, skin where they experience palpations, secondary liver damage results from mal-hydration practices, respiratory infection from immobility, shallow breathing and prolonged hyper-kyphotic postures. It is a relapse and remitting disease through the course of a physio degree, with few reoccurances in those who complete post-graduate study. There are histological changes and gross features... some are actually gross!! Clinically there is not a lot we can do to help. The best intervention is to offer support, share lecture notes and practice. Having said this, the prognosis is similar to guillain barre syndrome, with over 80% having a near full recovery - this is good! There is high incidence of special exams, repeating papers or complete drop-out for those whose conditions progresses to end-stage examinationitis. The histological presence of inflammatory infiltrate is replaced by psychological and physical scarring and malignant emotional growths causing very high intracranial pressure and in rare cases, spontaneous combustion.

Monday was Queens Birthday weekend and plenty of people (not us students) were on holiday. It seemed the earthquake gods decided to visit the Dunedin region but couldn't leave without making some noise. It caused no damage, but the shake was quite strong - I was numbing my brain with a movie before bed at the time... this earthquake didn't help. Luckily it wasn't as large as in Napal or Christchurch.

PHTY354 MSK Practical: Wednesday 3rd or Thursday 4th, June.

I was on Wednesday morning, and it was raining heavily. After jumping puddles from North East Valley to the University, my trousers were soaked! This exam asked us to answer two practical questions from this semester's MSK labs: orthopaedic tests, manual therapy and exercise interventions. It's similar to the 2014 practical end of year final exam, except we're focusing on the upper extremity and spine. We were given a very short case study for most questions to set the scene. There was usually a brief Q&A session after we completed the task. I was asked to stay for an hour as a 'pretend patient' for others completing their practical exams. I was given the following two questions:

• Q1 Assess deep cervical flexors in supine + home exercise programme.
• Q2 Volleyball player has stiff shoulder nearing end range flexion - assess relevant active movement of shoulder and perform an accessory movement to increase shoulder flexion.

My peers got questions like:

• Patient with posterolateral thumb pain. Perform a special test for DeQuervain's syndrome and perform a passive accesory movement to the 1st CMC joint.
• Volleyball player has a sore shoulder. Perform special tests for impingement and anterior instabilty. 
• Perform longitudinal accessory movements on the AC joint in neutral and 90deg flexion for a patient with shoulder pain. Choose an accessory movement to use as a treatment.
• Patient with stiff Tx spine. Perform PAIVMs and then select one and demonstrate for irritable pain. Then, what if the patient comes in with pain only in end of range Tx extension.
• Patient with lateral epicondylitis. Perform MWM with a manual technique and a therapy belt. 
• Amongst other things like: Assess a tennis player for GIRD, ULTTs, SNAG C0-C2 rotation,  sharp perser and alar ligament tests etc.... good fun!

Although it was pouring down, and there was significant surface flooding which closed roads around Dunedin, there were the usual student antics happening on campus. Leith river runs through the centre of the University of Otago campus. It is usually a quiet stream, but today it was absolutely gushing! Whilst in previous years students have rigged tow lines to the foot-bridge and surfed the flooding river... this year it was student's kayaking down the river.... See video below!

I participated in another School of Physio research study on Tuesday/Wednesday. The study involved collecting saliva samples in the morning, midday and evening on Tuesday, then again on Wednesday. The intervention was on Wednesday afternoon. So there were two days where I had spit-popsicles in the freezer! The study is looking at the phyiological effect of manipulation on stress levels (testosterone). I feel that my data may be a little different than the norm given that I had the MSK practical that morning! During the intervention I only had to lie still for 30min and provide three more cassettes of saliva. The researcher agreed that being conditioned like Pavlov, or to have a cake sitting on the side would have make this task easier... salivating large quantities on cue is difficult.

PHTY354 Written: MSK & Neuro: Friday 5th June, 2-5pm.

This exam started with a bit of an admin error (not enough answer booklets for a dozen students) and a good group rendition of happy birthday (beyond the control of the supervisors) for one of the students. There were two MSK and two neuro questions (with subquestions). I'm not going to give the questions away for future students... just be prepared for anything. I found the exam reasonable, but I know that the examiners will be expecting more than what I wrote down.

SkySport: NZ play Myanmar at Wellington Regional Stadium!

The weekend was spent working, medicing and preparing for the oral exam. I was at the sport injury clinic all day on Sunday and the afternoon on Monday as there was a netball tournament 'Otago Secondary School's Netball Champs'. It was a perfect opportunity to practice strapping and assessing ankle sprains... I assessed what I'm calling the lateral ankle trifecter! PTFL, ATFL and CFL grade one sprains... thankfully all in different athletes. It was interesting to see a PTFL sprain, given the ATFL and CFL were still intact (i.e. quite a rare sprain!). If you're a senior sports medic, you're given the chance to assess the patients by yourself - the catch being that you have to present the case and assessment findings to either the medical doctor or physiotherapists and they can do a few tests and sign off your work/diagnosis. We then follow up with some strapping, compression, patient education etc (our medical doctor may also prescribe some medication). Senior sports medics may also have a junior sports medic under their wing to teach them a thing or two about assessment and treatment. I must admit, the role of sport medic and physiotherapy student is becoming increasingly blurred.

Otago Sport Injury Clinic, Edgar Centre

PHTY354 Neuro Oral: Monday 8th June.

This exam required us to watch a 15min video of a person with a neurological condition performing a task e.g. sit to stand or walking. We had to take notes on the condition, body structure and function impairments, strategies used. In the exam we were asked to discuss short and long term physio goals we give to the client (even though we would collaborate with the client in real life situations) and the physiotherapy interventions we would use, precautions, contraindications/safety issues we would consider. Then highlight how other members of the inter-disciplinary team might assist the patient.  I felt the 15min watching the video went very quickly. In that time I scrambled down some notes on the paper. The notes taken were a useful prompt, but I'm glad we weren't given any more time as there was nothing I could have added that would have made me any more prepared. The oral exam was surprisingly good - the examiner was very friendly and changed his questioning when my gaze shifted from him to out of the second floor window (in hope of triggering some memory). I was happy with how the oral exam went - I even shook the examiners hand at the end. After the oral exam I rushed back to the sport injury clinic to help treat the final day of netball injuries... turns out Waitaki Girls High School had the most injuries per team over the tournament weekend (eight injuries) - yes, we were keeping tally.

At the clinic I was left to my own devices to remove supra-orbital sutures (sutures just above the eye) then afterward having the medical doctor sight that it was done properly. I'm looking forward to putting sutures in by myself one weekend not too far away. Between the sport medicing role, work as a massage therapist and placements at the University I'm getting a great range of musculoskeletal injuries to work with! I must admit that I'm not a great fan of the paperwork that goes with it though (but we cannot escape paper work these days!)

PHTY353 Pathology Written: 11th June, 2:30-5:30pm.

120MCQ with mixed Q&A & case studies. No powerpoints (thankgoodness!)

I finished in two hours... but I found this exam the most difficult... so difficult I'm going to have a short grumble about it. Here is why pathology is difficult (my top three excuses):

1. Much of the cellular and chemical specifics are irrelevant in physiotherapy practice. Those specific chemokines, genes, strands of viruses e.g. HPV 6, 16, 18 etc - what does this mean for the physiotherapist? Nil, ziltch, nada. It's nice to be aware that these exist, but to be tested on it in the exam... no thank you. Quite frankly, I don't want to commit this stuff to memory! On a brighter note there were no histological images in this final exam.
2. Of the pathological conditions mentioned (some very rare), the course didn't describe how physiotherapy could help, contraindications, etc. We were taught principles of pathology, so, well, I guess we know about the condition (the acute, subacute and chronic manafestations, timeframes, symptoms/presentations etc) and can use a common sense approach (e.g. for contra-indications, aims of treatment) when treating these individuals. Greater specificity for physiotherapists would have been nice.
3. MCQs may have the question worded semi-ambiguously (the writer has a clear idea what they're asking in their mind, but it isn't clearly written / could be interpreted differently) or has multiple 'technically' correct answers which we could debate given the chance. Not all questions are like this, but it does make for a bit of a mind game when we come across them.

On the flipside, physiotherapists need to understand the principles and consequences of pathology. We speak the medical language and so as much as this was not my favourite paper (or exam) it is important to have a good grounding in the jargon, understanding of disease processes, an appreciation for the impact of disease (from miciroscopic level to global), knowledge of current treatment strategies and research directions.

Coming up next semester...
PHTY354 trades MSK and Neuro in for Integrated Studies and Cardiorespiratory.
PHTY 355 lectures and clinical placements continue.

As per usual, physio had a post-exam piss-up. As per usual, I didn't attend. Good on them though, they deserve it. I retreated back to bed to watch a few movies, sport (FIFA U21s NZ vs Portugal... the end score: NZ 1 - Portugal 2) and figeratively tape my fingers and toes into a crossed position for the few weeks awaiting confirmation of pathology exam results... I'm hoping I pass! Fingers crossed!