Y3S2W4: Language

Nau katoa

(Welcome everyone) 

Ko te wiki o te reo Māori

(It's Maori language week)

  He reo Māori tōu? 

(Do you speak Maori?)

 Because we're celebrating the Maori language this week in New Zealand, I thought it would be appropriate to get on google translate and translate some common physio instructions or techniques. If google translate is incorrect, please let me know!

 Relax = wātea

Breathe = whakangā

 Massage = romiromi

Exercise = mahi

Pain = mamae

Good effort = kaha pai

How did that feel? = Te aha i ite?

We were expressing language in other ways this week too... such as motivational interviewing and testing cranial nerve function.

The motivational interviewing lab for 355 on Monday was good fun. We were given the challenge of motivating our peers to change their identified health behaviour ambivalence. These were personal health problems so it was important to practice being non-judgemental / acceptance and confidentiality. Throughout the interview we could only use reflective statements and occasionally open questions. Open questions are helpful when your reflective statement closes the conversation down. The idea is for the patient to solve their own problems - we could not offer any solutions because patients are more likely to act on their own solutions than that of another person. Here are some examples the class done together before being split into peers to change our personal health problems - have a think about what you would say and you'll see that it's not an easy exercise.

• Patient: I know you want me to exercise and I can see it would be good but it's just not me.
• Physio: Exercise is something you don't currently do, but you can see how it would be good for you? How do you think exercise would be of benefit to you?

And

• Patient: I have been thinking about walking but I wouldn't like to push it, I've just had a heart attack you know.
• Physio: So you've been thinking about being more physically active but you're scared that you'll hurt your heart if you do become more physically active. What physical activities have you been thinking you could do?

 Here is how you might shut the conversation down... then save yourself with an open question.

• Patient: I've been wanting to go swimming but I don't have time to get to the pool.
• Physio: The time it takes you to get to the pool is the biggest barrier to going swimming
• Patient: Yes.
• Physio: Okay... What about the 'time it takes you to get to the pool' is your biggest barrier?

The first lab of integrated studies had us screening case studies for red flags (and risk assessments) specifically for vertebral artery and carotid artery deficiency. Part of the lab involved checking cranial nerves 7, 9/10, 11 and 12 integrity on our peers. We were watching for different things: symmetry, weakness and air leaking sounds. Needless to say, we had a good laugh at making each other wriggle their tongues, looking down to their throat while they made noises and asking them to repeat funny sounds. Here's what we did:

• Cranial nerve 7: have the patient say "pa, pa, pa".
• Cranial nerve 9/10: have the patient say "ka, ka, ka" then wriggle their tongue in and out and side to side, then have them tilt their head back and say "ahhhhhh...".
• Cranial nerve 11: resisted muscle tests for upper trapezius & sternocleidomastoid.
• Cranial nerve 12: have the patient say "la, la, la".

The second lab of integrated studies focused on Sport Physiotherapy and acute care management... mainly acute care management. We were reminded about Ottawa rules for ankle and knee, and the Canadian C-Spine rule for the neck - these rules guide referral of the patient for an xray. We had a few situations to work through such as testing chronic versus acute compartment syndrome of the leg and involvement of fracture and haematoma. We looked at multiple methods for reducing a shoulder dislocation and how we might teach somebody to reduce their own shoulder dislocation.

Cardiorespiratory labs allowed us to reassess our patients (peers) and then hand in two assignments (patient assessment and spirometry assignment). We've got two presentations to focus on now, for me that's SNAGs for neck stiffness, and a group presentation about peripheral vascular disease.

Poroporoaki hoki inaianei

(Goodbye for now)

Y3S2W3: Follow Up

By now you will have realised that most MSK physio clinics look the same: plinth, chair, anatomy posters, a few joint models, hand sanitiser - those sorts of things. It is a nice reminder that physiotherapy is a career that can be done with our head, heart and hands. We don't need too many fancy machines or products to do a good job. Nothing beats a good massage, joint mobilisation and exercise! This is one reason why I think MSK physiotherapy is so cool. Unfortunately this is the last week of my MSK placement. On Monday I got to sit back and type up my peer's notes as they were going through their objective assessment - my note taking abbreviations are coming along nicely. I got to have a follow up with one of my clients on Wednesday (other client cancelled due to feeling unwell) - this was my client with neck stiffness. Just so you know, as an abbreviation, F/U is 'follow up', and is not to be interpreted as anything else. My SNAG treatment for this patient's neck had been effective for many days post treatment, but the client felt that there was some tightness creeping back in. After a follow-up assessment I performed some more SNAGS, massage for upper traps/levator scap and taught this client how to self-SNAG using a tea towel. Although my placement ended this week, the client  will have another follow up next week with the clinical supervisor. Great MSK placement!! P.s On Friday we were shown another manip for Cx-Tx junction, this one was a rotational rather than a PA thrust. In addition we were shown manips for the cuboid and navicular bones of the feet!!

Muppets' shouldn't manip...

Five reasons why MSK physiotherapy is awesome.

1. There would be quite a few occupations out there that don't have the luxury of working in a warm environment everyday! Physiotherapy is not one of these! We get to walk into warm clinics at the beginning of the day and stay there all day if we choose to - how's that for beating the winter blues?!
2. Some occupations get to drive 10 tonne diggers... we're almost that awesome! We get to play with and show people our toy knee joints and spines. Although it's not quite a Toy Story, these models are entertaining and go 'walk about' now and then - mainly because we forget to put them back after using them to educate a patient.
3. Hands of god! Oh, are you having trouble turning your head over your left shoulder? Well let me fix that for you and tell you about my powers of science. Physio's can't always 'fix' things or find replacements for worn out faulty parts, but we can help you make the most of what you've got... and occasionally, we fix things too.
4. It is possible to do voodoo... sort of. There are dry needling courses for physiotherapists', but instead of spiritual-physical parallels between a doll and the victim, physio's get to stick the needles directly in our patients (who have given consent). We practice good healthcare, so there is no bad voodoo - instead there is only triggerpoint-undo doo! On a similar note, we can also clothe people in enough tape that even the ancient Egyptians and their mommies would be proud.
5. How many people can wake up, get out of bed and go to work, pull up a blanket and type notes on a bed (plinth) if they're free from client-contact? Not many! How many people can kick their shoes off at morning tea break with a coffee and lay back on a make-shift beach chair (plinth)? Not many! Yes, a plinth is not only for the patient, it's a vital part of the awesome MSK physio lifestyle.

The MSK assessment is made up of a series of games:

• Subjective assessment = Cluedo & Charades: piecing together a story to find the location, weapon, and suspects (Cluedo), whilst observing body language (Charades).
• Posture analysis = Spot the difference: draw an imaginary line down the spine and note the difference.
• Active RoM = Simon Says: have your client move to your instruction.
• Special Tests = Guess who? Who isn't the cause of the pain... does your pain wear glasses (have a positive Speeds test)? No, cool - I can ignore all sources of symptoms that are wearing glasses (come with impingement or the biceps brachialis).
• Palpation = Tiddlywinks: press through the muscle (counter), find a spot that is familiar pain for the patient (makes the counter jump). 

The two labs for Integrated Studies were game-like too. The first was differentiating (subjectively and with special tests) between peripheral nerve symptoms, radiculopathy and myelopathy. The second related to a McKenzie method diagnosing - this was an exceptionally fun lab. We worked in pairs to diagnose 12 case studies, with four minutes for each case. Cases were presented on a McKenzie Institute cervical spine assessment form. Some diagnoses included: reducible and non-reducible (e.g. cervical radiculopathy) derangements, dysfunction syndrome, posture syndrome, chronic pain, osteoporosis (compression fracture), ankylosing spondylitis, space occupying lesion, meningitis (we weren't given fever or rash as a symptom), mechanical vs non-mechanical headache.

Cardiorespiratory lectures & lab had us back to interpreting x-ray imaging, revisiting COPD management strategies, and learning new performance and outcome measures such as the 10m incremental shuttle walk test (10mSWT), arm ergometer protocols, physiological cost index (PCI) and 'Chronic Respiratory Disease Questionnaire for Quality of Life'.

We've got two presentations to add to our assignment list. One is an individual presentation about a clinical technique relating to our last placement (I'm picking Mulligan's SNAGs) and the other is a group presentation about a cardiovascular condition as it pertains to physiotherapy (my group has Peripheral Vascular Disease). Looking at the current research report on spirometry (data taken from my lab group), it looks as though respiratory measurements (spirometry) should be taken in standing... but I'm sure it will depend on the patient. Below is a table with interesting info. The p-value with '*' next to the number indicates that the Paired T-Test (a relevant statistical test for the research design) are significant - this means that we can be 95% sure that there is a difference between the two means (standing spirometry versus supine spirometry measures). The reduced measures in supine may reflect a displacement in abdominal content, reducing the action of the diaphragm on inspiration - which when contracted pushes against a higher abdominal pressure in supine lying.

Comparing lab group means for spirometry measures taken in standing or supine lying. 

To be fair, I used the free statistics programme 'R-statistics' to calculate most of this... it's not an interface-friendly software - but it's super powerful. Here's a snapshot of how the software R looks with my data put in (and some added commentary at the bottom so I knew what the info meant)!

Yay, statistics!!

Fourth year placement preference forms should be submitted by now.
This Sunday I've got a discounted First Aid refresher course - organised by the student exec.

Y3S2W2: Carpe Diem

Week two of MSK placement at Unipol Recreation Centre saw a gradual increase in clients. In between we practised our cervical up-thrust and down-thrust manipulations. We were also taught another manipulation technique for the Cx-Tx junction - I'm not sure what the technique name is. This technique is similar to a 'Full Nelson' in terms of the patient positioning (upright or sitting, with hands behind their head) but different in that it is more of a PA (posterior-anterior) manip than a distraction manip. We were taught two manual handing skills to achieve the same outcome (hands behind head or across their chest). Our clinical educator suggested we could try slamming doors (I'm sure we've all experienced a door that doesn't latch properly when closed) as a good way to get the feel of what a manip should be like - interesting analogy...

So the manipulation techniques we've learned in the BPhty degree so far are: the million dollar roll (lumbar manip), pistol grip manip (with various spinal loading techniques), screw manip (with emphasis on both PA and gaping the facet joint and including a unilateral costovertebral joint manip), the Cx-Tx manip (x2 manual handling set-ups, mentioned above) and the up-slope and down-slope manip for lower cervical spine. Now that's a whole lot of manip!! Just some more peripheral joint manips to learn and we'll be chiropractors (joking, of course!!)

In other Unipol placement news, I got to assess my first MSK patient. Somebody scheduled the client in for 8:30am, and I just happened to be half an hour early!! How's that for early bird gets the worm?! So this was MY first client at this placement to assess and treat from start to finish. The client had suspected ankle sprain (having cleared a broken bone out earlier in the week with a visit to ED). However, my subjective and objective findings indicated a stress injury of the distal 1/3 fibula. Interesting! My second patient on Friday was challenging because she was vague when providing the details that mattered - the onus was really on me to probe and control the conversation (and to be fair, I could have done a better job given the time available). I treated the patient's neck stiffness with a SNAG or two (or 10 to each side), and she could turn her head fully without stiffness - great!! I'll be seeing both patients again next week. I got to observe other clients with interesting presentations too. One patient that really sticks out [pun] had an acromioclavicular reattachment surgery - this patient had his AC reattached with part of a tendon from his hamstring. When the patient horizontally flexed his arm, we could see the clavicle ride up, to form a prominent step deformation, on his shoulder (... and this is after surgery, imagine what it would have looked like before surgery!!)

There was another opportunity for students to be involved in promoting the school, this time it was in semi-staged scenes to be recorded and edited into a television commercial. I volunteered and got to play the role of a student physiotherapist (I'm sure you were expecting that). The video crew aim to capture the culture and learning environments in which the physio students are in on a daily basis, such as practical skill labs, the School of Physio clinic, and at Dunedin Hospital. There were also a few short interviews with some second year students. I certainly had a good laugh playing my role which might be shown as snippets of a MSK physio consultation. The original plan was to assess a patient's ankle (it was legitimately in need of rehab) however during the mock-subjective the 'patient' flicked her hair (or something) and then we changed to assessing the cervical and thoracic spine. It was all a bit of fun, and because there was no sound recorded I could say almost whatever I wanted.... sort of. Anyway, we won't know what edits or which scenes actually make the final cut... but I'm sure many of the physio student's will have acting careers ahead of them should they choose the celebrity life. I'll attempt to add the advertisement to my blog when it is released.

Pedometer assignment... so last week I mentioned that we're recording our steps over the week with a pedometer. As you'd expect, there had to be an associated assignment - there was! This is a very small (and easy) lab report to be done in groups - the usual format: intro, method, results, discussion, conclusion, references. Here's a quick graph to show you how I got on. It looks as though there might be a trend, but I assure you there isn't - data can be very misleading.

During the cardiorespiratory lab, I thought I had beaten the system by blowing my spirometry readings off the chart (literally). What usually happens in a spirometry test (using old - manual machines) is the patient blows out as fast as they can for as long as they can, and the needle tracks the volume blown per minute. In my case, the piece of recording paper wasn't long enough (huge lung capacity, right? Unfortunately not). We decided the machine was probably at fault, so a digital spirometer was used. I recorded an above average result, but it wasn't super human or anything - I'm blaming fatigue after performing the test so many times.

Current assignments on the go:
-  EBP assignment.
-  Pedometer scientific report (groups)
-  Cardioresp patient goals / exercise programme
-  Cardioresp spirometry scientific report

Here's an interesting website about three strategies to trick your brain into coping with chronic pain: http://www.gradedmotorimagery.com/

The physio ball is coming up on August 15th and I've purchased a ticket! The theme is Grecian. I'm not sure whether that means we will dress with a single leaf covering our unmentionables, as Greek gods, in togas, like somebody from the movie 'Greece', as though our country is in a financial crisis, or to just go with a suit and tie.

Yes, that's right - it's Mrs Physio time again. I decided I would actually go to this event this year too to see what all the fuss is about. Here's a recap about Mrs Physio. It's a cross-dressing pageant, like Mrs Universe. Second years enter and compete across different sections: catwalk, interview, bikini model, and talent show. The student exec invite an honorary panel of lecturers to judge each section. Overall it's a pretty funny evening, well worth going to or entering (if you're brave enough). I've blurred the faces of the contestants and judges to preserve their dignities - can't have patients know that their future physio sung in a bikini or played the bagpipes whilst pretending to vacuum using their thighs. 

There are other groups that organise events within the student physio umbrella, such as the Physio Christian Group. I attended one of their activities prior to Mrs Physio... we went to a local business called 'Leap'. Basically it's trampoline heaven. 

 With a lot going on this week, we had to seize each day for all its worth! 

Y3S2W1: Preparing for Lift-off.

On the last weekend of the semester break, I took a physio friend (peer) into the Emergency Department at Dunedin Hospital. He messaged me just before I begun work asking whether I could offer him a lift to the hospital as he had experienced severe pain on the left side of his chest and it wasn't going away. I told him to ring for an ambulance, and that I would message him upon finishing work to check in with him (I suspected that he wouldn't call for an ambulance - I was right). Upon arrival to his flat, my friend was shallow breathing, couldn't breathe in deeply (limited by pain on inspiration), adopted a hunched/forward leaning posture (even when walking and sitting) and had pain up to this left shoulder... he had been this way (after a sudden onset) for an hour or so. At ED, his vitals were taken showing a 158bpm resting pulse, then an ECG was taken, IV line placed, blood work (D-dimer test) taken... finally an xray was taken. Diagnosis? Spontaneous Pneumothorax: 80% collapse of the left superior lung lobe due to air outside of the lung, between the lung and the chest wall. Treatment? Conservatively monitor i.e. have patient practice full breathing, supplementary oxygen and manage pain with medication. Outcome? After no change on Sat or Sun (x2 x-rays later), the decision was made to surgically remove the air to re-inflate the lung. He was discharged Sunday afternoon and attended lectures on Monday. "Just getting ahead on my respiratory physio for second semester" - friend with pneumothorax.

I was again at the sport injury clinic on Sunday before semester two began for a netball tournament. Luckily for the teams, there were very few injuries. In other sporting news over the weekend... the Highlanders won the Super15 rugby final against Wellington's Hurricanes! There was a parade at 12pm up the main street for them on Monday! Ooootaaaagoooo!!!

Two days following the highlanders touch down, we were at an info evening to begin our prep for lift off (4th year placements). In forth year, students are scattered around the South Island and Southern and Eastern regions of the North Island: Timaru, Dunedin, Invercargill, Christchurch, Nelson, Wellington, Hutt Valley, Palmerston North, Hawks Bay and possibly some places in between. We've got a couple of weeks to decide where we want to be next year. We rank our preferred choices and hope we get either our first or second pick. Third year is the last year our cohort will be all together (then we'll see each other at graduation and possibly some class reunions 50 odd years down the track). I'll discuss these placement locations and major physio opportunities in depth next year.

Our placement allocations for semester two (of this current year) are out. I've been placed at Unipol in MSK setting for these next three weeks. Later this semester I will be placed at Dunedin Hospital on the 7th floor (cardiorespiratory ward). The MSK placement at Unipol has been fairly relaxed this week. We've had one patient through the door - I got to type out the notes for the objective assessment. I'm looking forward to having a patient of my own (hopefully next week). Otherwise we looked at ways in which we can adapt our manip techniques, the application of 'dry needling', discussed shoulder assessment and muscular control of intrinsic muscles of the foot (and management for bunions).

So, we've only got two papers this semester... PHTY354 Rehabilitation Science and PHTY355 Clinical Practice... I imagine the workload will be similar to first semester. Here is next week's timetable.

PHTY354 Cardiorespiratory: We completed a cardiorespiratory assessment on our peers in a mock patient situation. The assessment included measuring chest movement and auscultating - a good referesher from last years respiratory modules. In lectures we discussed assessment findings (like specks of blood or colour of sputum, auscultatory sounds throughout the breathing cycle), respiratory conditions and types of respiratory failure, and practised prioritising patients in terms of severity based on their blood gasses (PaO2, PaCO2), fraction of inspired air (FiO2), forced expiratory volume in one sec (FEV1) & forced vital capacity (FVC).

PHTY354 Integrated Studies: We began the week with mechanisms and theories of pain and ended the week discussing chronic pain and some questionnaires that can be used in particular situations e.g. as it relates to work, ability to cope with pain, or to assess different components of the patient's pain experience. In between, we had a lab which involved clinically assessing different regions which modulate pain (from the periphery to the brain, and the synapses in between), e.g. the 'descending endogenous opioid inhibitory system'. To test this example, we used a conditioned pain modulation (CPM) technique (i.e. pain inhibits pain technique) - this involved putting a blood pressure cuff on an arm, inflating it to 240mmHg and measuring the pressure tolerated in a patients knee (measured with an algometer). A similar test was done using exercise instead of the blood pressure cuff... The pressure at which pain was first elicited was greater when using these two methods. My pre-exercise pressure tolerance was 11kgs and post-exercise tolerance was 21.4kg on my quadricep. This is important to consider if you find yourself in a horror movie situation: when running around an abandoned house to escape a sociopathic villain, be sure to run fast to a) not be caught and, b) have a high tolerance to physical torture should you be caught.

Integrated studies and cardiorespiratory will overlap in a few weeks time for the purpose of an assignment. For this assignment, we will need a daily count of steps taken (pedometer) across a one week period. So far I've averaged around 8,000 steps per day. I imagine that this will reduce across the weekend. Talking about assignments, I have got around to starting my EBP (evidence based practice) assignment. It involves selecting a case you've experienced from your clinical practice, describing it and an outcome measure used. We then dip into the research to find out what the evidence says about the outcome measure and add in our commentary about the findings and how it relates to the clinical case.
 

The Saturday night was spend with a good bunch of my physio friends roasting marshmallows over a bonfire at Long Beach.