P4R5W7: Potential.

I was again privileged to watch another surgery this week! A reverse shoulder replacement. They swap the ball and socket joint around so the glenoid of the scapular has the ball, and the humerus head becomes the socket. It was a similar experience to the last week; the surgeon stopped to show me specific things (like a torn rotator cuff that happened to be present). 

There was a symposium happening throughout the week; there were both staff and members of the pubic present. On Tuesday I attended a session on pelvic floor training for incontinence and prolapse led by our physiotherapist. For a sensitive topic, it was a lighthearted session with strong recommendations. Can you lift your pelvic floor 12 times? That was the challenge given to the audience after we went around teaching pelvic floor activation and transversus abdominalis activation. The second part of the presentation was about 'emergency deification situation training'... almost. More like, how to improve toileting with posture optimisation. As you would expect from a physio, demonstrations were shown and the audience encouraged to practice the techniques themselves (postures only!)

Thursday I attended a presentation 'dicky tickers' on reading basic ECG strips. The nurse educator had five of us stand at the front of the group in a line. We were each given a name tag: 'SA node, AV node, bundle of his, bundle branches, and perkinje fibres'. Recognise the order? Of course you do, its the order of conductivity in the heart and subsequent order of p-waves, P-Q interval, QRS complex, T-wave. Here's what we were instructed to do: The first person (SA node) lobbed a ball into the air to the second person (AV node), this is the p-wave. The second person would then hold the ball briefly (P-Q interval) then bounce the ball high into the air passed the bundle of his and bundle branches so the last person (perkinje fibres) would receive it - the bounce represents the QRS-complex. The third and fourth people in the line (bundle of his and bundle branches) would perform a Mexican wave to show the wave of conductivity toward the perkinje fibres. Once the last person had the ball, they would run it back to the beginning of the line. This visual demonstration was useful for describing defects in the conductivity pathway as well.

On Friday the symposium offered presentations from orthopaedic surgeons on topics including: compartment syndrome, multi-trauma patients, femoral fractures and dealing with angry patients/family.

On Wednesday the physio (and ?Occupational Therapy) staff came together to celebrate the last week of placement for the year by sharing a lunch. I brought brownies but didn't actually attend the shared lunch as I was observing the shoulder replacement surgery. I talked to another student physio later in the afternoon who reported that it was a success, having given gifts to our clinical educator, Michael M. and to the physio department in thanks for all their support and patience during the year.

There is a planned end of year celebration at each of the placement centres (CHCH, Dunedin, Wellington) and some of the satellite sites, like Nelson. The plan is to share a few drinks and nibbles between ourselves on Friday.

To conclude the year, we hand in our hospital ID cards and as per usual there is a portfolio to submit for the placement. Typically, students will be gearing up for graduation, registration and job hunting by now. I'll be returning to complete papers next year, so I'll resume this blog then - I'm undecided about whether I'll continue weekly updates, or block-updates. Congratulations to my fellow peers who graduate in December and go on to be great physiotherapists!

I'll finish with a page from the Physio Matters magazine - I was lucky to be asked for a second second entry. This one sums up the year pretty well (minus a few hick-ups / speed bumps along the way).

P4R5W6: Theatre

This week I was privileged enough to watch an elective orthopaedic surgery. It was a total hip joint replacement. Watching this surgery completed the clinical picture in my mind / the clinical pathway from treating patients with disabling OA hip, their surgery, the immediate post-operative phase and rehabilitation after discharge. I was pleasantly surprised how happy the orthopaedic surgeon and the patient were for me to observe the surgery. In fact, the whole experience was incredible. I was a fly on the wall through the pre-op formalities - admission and welcoming them to the day stay / inpatients service, including taking baseline readings, getting them appropriately dressed and comfortable until they are seen by the anesthetist assistant, and then from the registrar or consultant/surgeon. They are then shown the way to a waiting room next to the operating theatre (OT) until the OT is ready. As a student observing a surgery, I also had to wear scrubs/hat/mask - so I was shown where to get suited up. The OT is quite a large room with the equipment you have probably seen on TV medical programmes / movies. The anesthetist had his playlist going "I shot the sheriff, but I did not shoot the deputy....", there were computer screens with the patient's x-rays (the registrar talked me through the interesting features), I put my name up on the whiteboard as an 'other' in attendance for the surgery (followed by introductions to other staff; one funny moment happened after the surgery with a nurse helping with the clean up, 'you should tell the surgeon to be quieter and less messy'... as he went about cleaning the blood off the overhead lights). I had a great learning experience during the surgery; although I wasn't able to assist, the surgeon had me standing on a stool overlooking the action, stopping to show me muscles & explain the procedure (like measuring the right leg length). Points of interest were the very warm concrete put into the shaft of the femur, the dislocation of the hip technique itself and of course the range of instruments used to get the job done (including a mallet... bang, bang, bang...). I watched a second surgery afterward, the removal of screws in the metatarsal-phlangeal joint, and the insertion of a plate to stabilise the joint.

We had an in-service presentation on dynamic taping as a rehabilitation aid for hand-therapy and MSK physio ailments. Dynamic taping is not kinesio-tape or rock-tape, it's a different type of taping... but I would still consider it to sit under the umbrella of 'therapeutic adjunct', of which k-tape and rock-tape fall under. The texture of dynamic tape feels similar to some togs - a joke was made that it might actually improve performance through its streamline feel rather than its suggested musculoskeletal altering properties. This tape also comes in different widths and resistances to stretch. It can be 'doubled up' with a second piece of dynamic tape. An interesting concept, but I'm not convinced (yet).

I would consider Nelson to have that 'small town' feel, that walk down the street and see a familiar face sort of place. What better place, to see a familiar face, than at the grocery store. I happened to make eye contact accompanied by a 'where have I seen that familiar face before?-kind-of "hello"' which started a conversation with a person who I treated in MSK outpatients on a previous placement. They volunteered information about how well their neck had improved (which I was quietly curious about) then going on to tell me about how they were shifting to Christchurch at the end of the month.

P4R5W5: A good variety.

This is the end of my fourth week, and I'm still working toward running the surgical ward.

The week started with two of the acute physiotherapy team members on unplanned sick leave. This somewhat stretched physiotherapy resources. Tuesday and Wednesday were a little different on the wards too (normal physio staffing resumed) - the junior doctors had their strike against the DHBs for better working conditions.

I saw a variety of conditions this week, so I'll briefly mention them here.

There was a patient in ICU who had had a cardiac arrest. The patient was intubated and suction was performed to stimulate a cough and remove secretions. As this patient's status improved, they were extubated and put on airvo (high flow oxygen device). The supervising physiotherapist encouraged vibrations with deep breathing and oral suction (having checked the CXR, chest x-ray). The nurse also showed me how we collect sputum samples using suction. Physiotherapy encouraged movement of arms and legs, then sitting etc too. Patient comfort is obviously very important; one thing I learned this week was about identifying other means of ensuring the patient is comfortable. One aspect I overlooked was addressing the patient's dry mouth by using water from a sponge on a stick (I'm sure it has a proper name) - these are good tips and ticks that I hadn't thought of. Having a cold wet flannel on the forhead is another trick that can make a patient feel more comfortable.

Another thing I learned this week was: when a member of the MDT request for you to see a patient, particularly for a mobility review, you need to make your own informed decision about whether you need to see the patient, and what you will do / offer for the patient, and then justify or inform the MDT about your decision... it may well be that all the information they need about a patient's mobility is described by the hospital level residential care facility that the patient resides in, in the patient notes already. All that is needed is for the patient to confirm this information and a wheelchair to be brought up (...because the residential service didn't send it in with the patient).

Bird flu? Parrot fever? Psittacosis? This was the suspected diagnosis for a chest infection for another patient I saw this week. Other than the odd [potential] source of infection, the main reason I'm mentioning this case is because the physiotherapist performed 'induced sputum' to (as the name suggests) get a sputum sample for laboratories to examine. The process involves hypertonic saline (9%) in a nebuliser and the ACBT (active cycle of breathing techniques i.e. deep breathing, huffing and a cough or two) to be performed. The patient breathes in these vaporised droplets for about 20min to moisten secretions and produce a productive cough.

Mountain biking is a dangerous sport. We've had two patients with injuries sustained from mountain biking this week. The first patient had a contusion of the lung and a concussion, the second patient had fractures of their first six ribs, clavicle and scapular. Yikes! After an orthopaedic sling was fitted, I encouraged them to use a towel or wall to brace against to take deep breaths and cough to manage their pain and gave advice about returning to mountain biking.
 

The whitebait are running ?swimming and the seasonal tramper will be gearing up for another year in the wilderness (labour day / long weekend this week). A word of warning, be careful with gas canisters. We had a patient with burns to their hands, chest and face following an incident earlier in the week. As there were no burns to the airways or grafts needed, I encouraged deep breathing through incentive spirometry (given they had lower blood SpO2, probably pain related), and gentle hand/finger range of motion exercises.

In an interesting experiment with a patient who lacked touch sensation and was not able to voluntarily walk as a consequence of a back injury, but had reflexes intact, good muscle definition after weeks post-injury, could get themselves into standing and use a cross-trainer at home (not to mention, unremarkable imaging)...  a physio had a genius idea of tieing each of the patient's feet to a high walking frame with a theraband and pushing them down a ramp to get a gait pattern / walking movement going. Of course, there were plenty of hands on board to ensure the patient's safety. The set-up showed potential as the patient was able to continue stepping on the flat surface having gained momentum.

The last interesting case of the week involved a patient who had a tibial plateau fracture. There were a few unexpected post-surgical events that delayed their recovery. Anyway, the short story is the team is trying to get his knee straight. A range of motion brace was trialed and found to be a nuisance for the nurses to put on and off, so there was a collaboration between a few physio team members, and a thermoplastic brace was made to encourage knee extension. I was fortunate to watch the designing and making of the thermoplastic device.

It's Labour weekend, so I'll get an extra day to get my portfolio up to date!

Flat photo!

P4R5W4: Used with good effect.

The third week on the wards rolled around pretty quickly. I've listened to some interesting sounds through my stethoscope, including wheeze, creps, heart murmurs, people talking to me whilst I try to listen to their lungs, as well as the rare burp & hick-up that coincidentally occurred whilst auscultating! I am more often finding myself excited for my patients when they clear secretions from their lungs. I even had an exciting conversation with an older lady who, after a few days, had finally passed some wind. The excitement continued later in the week when she had a bowel motion. Exciting stuff!

There are some great patient attitudes out there. One patient stopped me in passing to tell me a joke. I was somewhat busy, but I stopped to listen (who wouldn't pass up an opportunity to share a laugh). The joke was about an elderly person who took their neighbors 'dog' for a walk down the street when a passerby asked why the person had a cabbage on the leash, to which the elderly person retorted that they would go back to their neighbor to apologise for not walking their colly.

On the ward I've had the opportunity to perform a bit of chest physio, there have been a range of patients with a range of conditions; post-abdominal surgery under local and general anaesthetics (some following the ERAS enhanced recovery after surgery protocol... different booklet to that of normal notes), traumatic injury (mountain bikers beware, your sport is dangerous!), pneumonia and upper respiratory tract infections. Incentive spirometers seem to be the flavour of the month - from my short experience, these devices really do motivate people to breathe deeper more often each hour! I've had many patients demonstrate their improvement with such pride. I've also made some DIY bubble PEP devices out of unused saline bottles (rinsed and filled with tap water) and unused catheter tubing (cut to size!) stuck together with some sellotape, with a post-it note covering the saline bottle label (instead showing instructions for bubble PEP). Bubble PEP is not just for paediatrics... geriatric patients enjoy it too.

There are plenty of wound drains, IV lines, PCA (personal controlled analgesia) line, catheters, telemetry lines, nurse-buzzer button, SCDs (sequential compression device i.e. calf pump machine), Airvo/nasal oxygen tubes, blood pressure cuffs + pulse oximeter lines etc to be cautious of and searching for. I have noticed that patients are often put on supplementary O2 via nasal prongs by the nursing staff on their arrival, this is something that physios commonly remove from the patients soon after they are assessed and deemed safe to have the oxygen removed (these patients are relieved, as the oxygen nasal prongs reportedly dry out their throat). 

I had some friends visit over the weekend, so we made a day trip into Abel Tasman national park!

P4R5W3: Tertiary Physiotherapy

Last week I failed to talk about the role of the physiotherapy in the acute care setting... obviously, we don't have a set client list so we print a handover sheet like we did on the AT&R ward. Patients are then prioritised based on their health status and rehabilitation goals, the risk for chest infections/falls/pressure sores/ability to self-manage, and with consideration of their planned date of discharge. We liaise with other healthcare professionals and services about their physiotherapy management, often getting information that makes our input more effective or safe. 

The typical day on the wards starts with printing off the handover sheet and annotating it with notes from the previous day's handover sheet (otherwise I might forget what I've done or going to do with the patient). We then scope out likely candidates for physiotherapy services from the list, check their notes and cross-reference the ward patient board (which is a large whiteboard with patient names, their room/bed number, nurse + Dr, planned discharge date and a list of services (OT, PT, SLT, Nutrition, Social work etc) that may have had input requested for a given patient. There's a triangle system: one side of the triangle symbolises a referral/input needed. Once the healthcare professional sees the patient, they can add another side of the triangle. When the healthcare professional has discharged the client from their service, they can add the final piece to complete the triangle... they can also put a red or green dot in the triangle to indicate that the patient is safe and ready to discharge or not. Of course, communication extends beyond the whiteboard and we discuss patients status / our findings with the healthcare team as well as reading their notes/making note entries into their medical documents. Depending on the ward, there will likely be some form of ward rounds... the ortho ward has a round at 8am every day, the surgical ward has two rounds during the week and a grand round on Friday, the medical ward will likely have daily rounds too (I haven't really observed this yet).

So we've got a list of patients to see, time to get on with the job! We start by visiting the HDU (high dependency unit) to see whether we can offer physio input there (at other times people at the HDU will page/ring for us). We take a couple of flights of stairs up for a fleeting flyby through the ortho ward to see how that's looking, and up another set of stairs to surgical.  At morning tea time the acute physiotherapy team regroups in the acute services office to ensure there is adequate cover across all wards (if one ward is particularly busy, then another physio will take on a couple of patients from another ward for the day). At lunch, the PTs regroup again to discuss how the morning has gone. By the end of the day, we are likely to somewhat regroup and tie up loose ends of paperwork etc.

Our role ranges, but generally we aim to have patients stay physically conditioned and mobilising safely (walking) and effectively for returning to their home environment (ie. do they have stairs with a rail that we need to see them complete before discharge) and performing chest/respiratory physio (assisting patients to clear lung secretions, breathe easier or otherwise maintain good lung health for their stay in hospital). There is, of course, a lot of patient education and information collecting (i.e. patient's previous level of function & home situation).

These are the common wards that are covered by the physiotherapy acute care team.

• General Surgical ward
• HDU/ICU
• Medical ward
• Orthopaedic ward
• Paediatric ward
• Emergency department

This week was very quiet on the Surgical and Orthopaedic wards, so I got to hang out on the medical ward and revamp patient information sheets for Bubble PEP and Incentive Spirometry. I also took to Snapchat whilst the draft copy was being sent to the printer! 

By all accounts, it was a very enjoyable week.

P4R5W2: Orthopaedic Physio

My tertiary physiotherapy placement will be divided into two main areas. The first week was on the orthopaedic ward. The next five weeks will be spent on the surgical ward. As an added bonus, I've shadowed a paediatric ward patient (we played games in the AT&R gym), and had my first medical ward patient. I have also spent some time on the surgical ward earlier in the week. It seems like I might get a bit of everything in small quantities over the next few weeks.

I've got back into the swing of things. The 8am rounds with the surgeons / orthopods and charge nurse (printing off my own handover sheet and annotating it from the previous day). Teaching people how to use frames and crutches. Liaising with the nurses and checking obs charts. Patient education. Listening to patients and their lungs (not at the same time). Writing notes and entering in the days work in Trendcare (a statistical software that tracks patients and the services they have received).  

I've had plenty of great moments with my supervisors, and other staff at the hospital. My supervisor has a great sense of humor, she introduced me to the 'Care Principle', an acronym that stands for 'Cover ass, retain employment'. Simply this means to tie up all loose ends (figuratively) and do a thorough job.

I've had some experience with the Arjo and standing hoists, ROM knee braces, ERAS (enhanced recovery after surgery) total hip replacements... I even encountered an Airvo humidifier. There's a continuous passive motion device that I'm eyeing up for next week (maybe)! I was fortunate to join the Occupational Therapists for a half-hour excursion to deliver home equipment to a patient's house ready for their discharge in the weekend. This opened my eyes to the amount we assume when a patient tells us there is a ramp or stairs in their house. The patients house we visited had a nice ramp that led directly onto small pebbles, with a step down to the driveway... we didn't hear about the pebbles, which will make using the low walking frame interesting! Another patient we saw lived in a house-bus and another patient wasn't able to safely use crutches up the stairs, so we taught one to bottom shuffle up and down the stairs and suggested the other find alternative accommodation for a few weeks.

All fourth year students will have received an email that looks like this and feel quite excited! I've got neuro to repeat, so that will be done next year in Feb (so I won't be graduating this time around).

Not all fourth year students will have received an email that looks like this. I'm hoping the CHCH based research group members decide to go along - it'll be great for them!

The weekend was spent studying and seeing more of the scenery around Nelson... My flatmates and I went to Cobb Valley for a day tramping excursion!

P4R5W1: PSW Tertiary Edition

Beginning of St James Walkway, Lewis Pass.

This is our last professional studies week (PSW) of the year (or for the degree, for those graduating in December). This week begun with presentations from student's who had community placements in the last rotation. We had a range of presentations including: use of acupuncture for tennis elbow, effect of respiratory muscle training for patients with spinal cord injuries, psychosocial factors impacting return to work, appraisal of clinical guidelines for management of spasticity and associated MSK conditions in children with cerebral palsy,  elbow extension restoration in tetraplegics, adverse neural tension in hamstring strains, and physio management of fatigue for patients following mild traumatic brain injury or concussion. My presentation was on Cupping therapy in MSK and Sports Physiotherapy... I came in feeling prepared, but I'm not the most confident public speaker (especially when there's a clock ticking and a few dozen eyes beaming back). 

Tuesday began early with an area preparation tutorial for my next placement, physiotherapy in a tertiary setting. Christchurch students were given placements in paediatrics, orthopaedics, medical respiraotyr, burns and plastics, cardiology/cardiac surgery, general medicine and surgical wards. Nelson students are privileged to get a mixture of surgical and medical wards... I'm not exactly sure what my placement will look like, so I'll tell you more about this next week. A highlight of the tutorial was listened to a mannequin's chest to identify different lung sounds, both normal and abnormal. I'm excited to get to put my stethoscope to use next week.

Later that morning we had a three minute presentation on our PHTY459 research project. Again, there were some interesting studies done by my 4th year peers and their supervisors. One included evaluating public spaces, namely gyms/pools, for usability for persons with a disability. Another project evaluated the use of a Troidometer II in measuring elbow extensor strength in tetraplegia. Tagged onto the end of this was a presentation about post-graduate study opportunities at the University of Otago (acupuncture, neurorehabilitation, occupational health, sports physiotherapy, orthopaedic manipulative therapy as well as research pathways)

Tuesday afternoon was especially entertaining and informative; we had two presentations. The first was from a neonatal acute care physiotherapist about "navigating the teenage brain". One key message from this presentation was to target your communication to the stage of brain development. Fun fact, the female brain matures at the age of 23, whilst the male brain matures at the age of 25. A mature brain can better 'access' the prefrontal cortex and 'over-ride' the earlier-developed limbic system. This explains differences in risk-taking behaviours and logic thinking between males and females during teenage years. We also discussed how stress (catecholamines) can influence how easily we can access our prefrontal cortex (i.e. a mental block). The second presentation was on the physiotherapy management of haemophilia. I hadn't given much thought to managing haemophilia until this lecture... and I was surprised how important the physiotherapists role was in diagnosis of a bleed vs other injury (particularly chronic or severe bleeds... arthritis in joints or myositis ossificans in muscle tissue!)

Wednesday was likened to job shopping. There were a number of representatives from private practices pitching potential jobs for their clinics to us, as well as describing what they expected from new graduate physiotherapists. Next up were representatives from the Physiotherapy Board of New Zealand, they gave us a run down on registering as a physiotherapist and obtaining an annual practicing certificate. Then the Board ran a session on ethics. There was one hysterical moment from a class member who made a fairly inappropriate joke given the seriousness of our ethics discussion. I'll elaborate. In groups, we were given situations where a physiotherapist was in a bad situation that had professional consequences. The group in question had a situation like 'a physiotherapist treated an 18 year old female for a shoulder injury. The day after the client was discharged, they were engaged in a sexual relationship. The mother of the client found out and lay a complaint with the Physiotherapy Board of New Zealand'. What ethical concepts are woven into this situation? Well, it's unlikely to be justice (fairness), but my peer had a crack at making it relevant (for humerus effect; nobody should be offended by this). My peer suggested that there was an injustice made because the physiotherapist did not share sexual relationships with all of their clients. I'm not going to get politically correct, the joke is what it is. You can reach your own conclusions as to what the most relevant ethical principles are that makes that a poor situation.

Thursday morning we had a session on the cervical spine from an orthopaedic manipulative physiotherapy approach which reinforced what the Nelson placed crew had learned from Michael Monaghan. The lecturer from Otago had recently been to a workshop / conference in the US led by Stanley Paris. Thursday finished with a group of first year graduates working in a range of physiotherapy practices came to share their experiences from their first year working as a physio, as well as sharing the inside scoop on selecting a job.

Back to Nelson for round five!

P4R5W0: North Island Adventures (Holiday!!!)

Quick catch up from my week break... I had a second attempt (first attempt was earlier this year) at reaching the summit of Mt Holdsworth (via Powell Hut) in the Tararua ranges, this time with success. It's a much easier walk when it's not pouring with rain, gusting like a hurricane or lighting up with lightening. It was a stunning sunny, clear day and at the summit both East and West coasts of the North Island and the top of the South Island could be seen. As a bonus there was some snow that had not yet turned into a slab of ice.

Powell Hut

Trig point of Mt Holdsworth in background

Mt Holdsworth Summit

P4R4W7: 100th Blog Post

My blog has reached a milestone, it's my 100th blog post.

Celebrations? I think I'll take the week off next week... ha!

It was my last week of my Community Physiotherapy Placement at Sports Therapy and I was busy setting myself up to pass the placement - prepping for clients, preparing an in-service presentation and finishing off my written project (with additional powerpoint + script for the next PSW week).

My Tuesday session with Michael was, as always, insightful. Apparently skeletal models made out of real human bones could be brought and were used by medical, physiotherapy and osteopathic students (historically). Michael happened to own a set of joints - I didn't think I'd see any more real tissue models since anatomy in second year. We used these joints in a between-patient time to examine the foot, neck and elbow. A few more manips for the foot were taught, one in particular had the patient in prone lying, with the foot placed and pronated flat on the plinth... the practitioner uses a manip similar to the screw technique for thoracic spine, the manip is to the calcaneous and talus to gap the sinus tarsi / subtalar jt. The elbow was another interesting jt to manip... here's a Youtube video that is similar: https://www.youtube.com/watch?v=-FKNdj0UmTk

Book & dvd on Monaghan's techniques!!

Sessions with Michael were most valuable. He offered a 'less is more' approach, with great handling skills, consideration of alternative positioning for older patients and irritable conditions, a fine-tuned biomechanical approach with techniques utilising a sensing hand for joint interplay, and of course osteopathic manipulations! I am very privileged to have met and had some hours with him over this placement. I think he should update his book / DVD to include his techniques for the peripheral joints so that his wisdom isn't lost.

My placement at Sports Therapy has been equally rewarding. I feel that I have begun to developed a better, more relaxed approach of chat with my clients. My supervisor has challenged my thinking on political correctness within physiotherapy practice, which isn't necessarily a bad thing - it's a realistic view on physiotherapy practice. It's fair to say I have almost had a laugh a minute there.

World Physiotherapy Day on the 8th of September!!

I had my presentation on cupping therapy on Friday and it was a little bit rushed, but I think the physiotherapists there already knew a lot about cupping anyway, so they got the brief version. I was able to show some fire cupping, that's all that mattered in the end, haha! I also got my project submitted to my educator on time and within the word limit. I've got a formal presentation to give on cupping in the next PSW week. I might dedicate some of the break to write a post about cupping therapy specifically.

On Friday I baked brownies (again... you'd think that was all I knew how to bake... you're not far wrong there!) I also whipped up some bacon and onion cheese rolls (a Southland delicacy) for my supervisor who is shifting to Invercargill. A client mentioned that cheese rolls and Speights beer will soon become the norm for his breakfast. I wish my supervisor Phil all the best in the deep south.

And that is the end of my community placement. Time for a week break (after I finish my clinical portfolio for this placement haha! Due before Monday).

P4R4W6: Sports Outtings

This week there was a South Island Secondary Schools womens soccer tournament at Saxon soccer fields in Nelson and in my non-clinic hours I was down at the soccer fields (it's been a full on week). There was a range of acute conditions, as you would expect. The highlights from this would be watching new ways of strapping, learning more about K-tape (I'll describe this soon), hearing about physiotherapy business and what to aim for in an employment contract. I had some practice with ACC read codes and having clients add extra details or fill in missing boxes on the ACC45 form. In the clinic we completed an online ACC32 form, request for further treatment, for a client and we had it accepted within the week.

Prior to this placement I understood K-tape to increase proprioceptive input (due to its adhesion to skin and elastic nature), or facilitate the reduction of swelling (jellyfish cut k-taping, with the tentacles/tails draped over the area of swelling towards the body of the jellyfish... best I can describe it). This week I learned that k-tape "in theory" can be used to facilitate or inhibit muscle activity depending on the amount of stretch and direction of elastic recoil. Cool idea, but I don't feel entirely convinced...

• To facilitate muscle activation: Apply the tape proximal to distal, aligned with the muscle fibres with 25-50% stretch - the elastic recoil pulls the skin towards a shortened muscle position.
• To inhibit muscle activation: Apply the tape distal to proximal, aligned with the muscle fibres with 0-25% stretch - the elastic recoil pulls the skin towards a lengthened muscle position with the idea that a muscle is more relaxed under stretch.
• To apply a mechanical correction, such as a medial glide of the patella e.g. applied from a bent knee position with  maximal stretch in a horse-shoe shape  on the lateral boarder of the patella, as the client straightens their knee you taper off the stretch (the ends of K-tape shouldn't be under any stretch... so it won't peel itself off). A mechanical correction could also be an AP glide on the GH joint.
• A decompression technique acts to lift the skin and fascia to minimise irritation from additional tape applied over-top (rigid tape). For example, to decompress the skin over the achillies tendon, apply one strip along the length of the tendon itself, stretching 25%, then a second strip is applied at 25% stretch directly over-top of the first strip (the ends can extend passed the first tape to adhere to the skin). Rigid taping, such as an ankle lock can then be applied over-top of this.

I then stumbled upon an article by Lee K, Yi C & Lee S (2016) The effects of kinesiology taping therapy on degenerative knee arthritis patients' pain, function and joint range of motion. The authors applied K-tape applied to the hamstrings, tibialis anterior on patients with pain on knee flexion OR quadriceps or gastrocnemius on patients with pain on knee extension. The control group of patients got a heat pack and some interference wave therapy. Results? Those older persons who had degenerative, painful knees had significantly less knee pain, increased range of motion and improved WOMAC scores (better function, reduced stiffness). Interesting stuff.
 

Tuesday Michael taught us how he goes about examining a foot. The main points that captivated my interest was how to manipulate (grade V mobilisation) the ankle & foot. One of particular interest was the talonavicular joint and talocrural joint. Dorsiflex the ankle into a closed-packed position (end range), then slightly plantarflex it (so it isn't quite at end range). With one hand on the calcaneous (heel), other hand on the talus with hand rolling the navicular away from the talus (gapping the talonavicular joint). Take these joints into a grade 4+ distraction / mobilisation in a caudal direction, then thrust. Amazing! Tuesday was also the first client that I've assessed and treated that required an interpreter.

This weekend I'll be frantically writing up my community project / mini-review for presentation at an in service training session on Wednesday and submission on Friday. Coincidentally, the group research project about falls (my research placement) is due next Friday too - it'll need to be printed and submitted sometime next week.

P4R4W5: Pain is weakness leaving the body.

Sports therapy wrap-up! More good yarns, some hot goss and trivial conversations... and physiotherapy in between. The eye opener for me was a yellow flag presentation of shoulder pain. This person was taking double dose of prescribed sleeping tablets for their constant shoulder pain and cannabis each night to get to sleep... this concoction was apparently very effective, but I was quite concerned. Yellow flags are interesting because the consequences seem more 'real'. Sure, people can put on a brave face but there's a point where they do other things to cope. And physio seems to be an appropriate place to notice and support them through education and referral if needed. 

New to this placement was a couple of strapping sessions for the lower limb - ankle, plantar fascia, knee... Oh and thumb (just to break the lower limb trend). Something I've learned this placement (between Sports Therapy and the sessions with Michael) are applying techniques in different positions, and strapping the MCL was of particular interest this week. Usually you strap it with the client in standing with their knee bent 15-30deg, however it can equally be applied with the clients in a long sitting position (Ie with their feet up). This was a revelation for me (simply didn't think to do the MCL strapping any other way, not sure why haha!) There was a big emphasis on applied anatomy which will make my strapping skills (and adapting it) top notch. Now I just need the numbers to practice on to iron out the crinkles!! 

Next week I will be helping at a soccer tournament in addition to the normal placement hours. Perfect chance to practice strapping, but it'll make for some late nights as I haven't really made much progress with my community project yet (Cupping Therapy)

Tuesday with Michael had a few new neck patients come in. Each was interesting in their own respect. Two had light sensitivity, one had headaches whilst the other had balance problems and nausea similar to vertigo. One had a constant neck pain and the other didn't have any neck pain.

My weekend was spent in Wellington at the ABs rugby game versus Australia. Great game! But I missed my flight back on Sunday (factors out of my control... traffic) - not a good start for Monday!

P4R4W4: Cupping therapy in Physiotherapy practice.

This was my third week on my community placement. 

The week at sports therapy was pretty standard, so I thought I'd show you my work environment at Sports Physiotherapy, pretty cool!

I had a box of Cadbury's Favourite's chocolate in a little blue bag waiting from me at the Physiotherapy Outpatient Clinic on Tuesday when I came in for the session with Michael. The note said "To Phil (Student Physio) from x These are for all your help in my recovery". The chocolates were shared around to the other physios and left in the Outpatient Clinic. I felt very grateful to be a part of that client's recovery.

Brought myself a cheap cupping therapy set (~$13NZD incl. postage).

Cupping Therapy... There are quite a few different ways to apply cupping. The top three ways to do cupping is dry, wet or movement cupping. Dry cupping just means to stick the cups on your body, movement cupping is done by moving the dry cupping around (use massage oil). Wet cupping is a bit odd... you stick the cup on, get a nice read mark of burst capillaries, then remove the cup to slice some small holes in the skin, put the cup back on and bleed into the cup (I told you it was odd!). There are other ways to do cupping which may involve needles, medication (ointments) or combinations of things. I've brought a manual suction cupping set, but there are glass cups that you burn alcohol inside of then quickly place them on the patient's skin - the same effect, but one's a lot safer.

My community project will look at cupping therapy used in MSK and sports physiotherapy practice, in particular the treatment parameters of different cupping techniques, in addition I will also compare cupping therapy to myofascial release. Myofascial release is a technique that doesn't require cups, but targets the same soft tissue... fascia.

More relevant posts about cupping therapy.

• https://www.facebook.com/evidencedbasedexerciseandtherapy/posts/935474026561174:0

•  https://thesportsphysio.wordpress.com/2016/08/12/do-no-harm-do-nothing/

It was my birthday mid-week and my flatmate gave me my own medal for reaching 25yrs! And a play-dough cake (she's a kindergarten teacher... makes sense now, doesn't it?!)

The weekend was a great opportunity to go and explore Wharariki Beach, near the top of the South Island. This is probably my favourite beach in New Zealand.

P4R4W3: High performance sport physiotherapy

This is my second week of placement at Sports Therapy, Nelson. I spent much of the weekend wrapped up in the Rio 2016 Olympic ceremony and sports performances. Given that I'm placed in a sports physiotherapy clinic I thought I would look briefly to see what physiotherapy-olympic related articles there were in the UoO library database and I came across one of particular relevance - looking at the role of the physio at the 2012 London Olympics. I imagine the physios at the Rio Olympics will see similar trends.

Grant, M., Steffen, K., Glasgow, P., Phillips, N., Booth, L. & Galligan, M. (2014). The role of sports physiotherapy at the London 2012 Olympic Games. British Journal of Sports Medicine, 4(8), 63-70.

• Fun fact: 2012 Olympics were the first summer games which had accredited osteopaths and chiropractors practice within the medical team.
• The medical team in the polyclinic treats both IOC accredited athletes (69%) and non-athletes (31%: coaches, officials, press etc). 
• Physiotherapy services were available over 31 days, from the pre-competition period, the opening ceremony and finishing two days after the last competitive event. During that time, ~1860 first appointments were made to physiotherapy services with about half receiving follow up physiotherapy services... (~60 visits first appointments per day on average... except visits were better represented in a normal distribution curve with the peak number of appointments nearing 200 during the middle of the Olympic competition period)
• What did physios see? Overuse injuries were most common (43.6%: most were pre-existing injuries), followed by non-contact acute injuries (23.8%: of which approx one third of these occurred during a warm-up, and approx 15%  of these occurred during competition).
• What did Physios do? Manual therapy (mobs & manips), Soft tissue techniques (massage, stretching), strapping, cryotherapy, exercise, therapeutic ultrasound, education, acupuncture.... and to a lesser extent they used laser, interferential current and TENs

There are a few avenues for physiotherapists in New Zealand to be involved in specialist groups, like sports physiotherapy or  sport medicine interest groups:

http://sportsphysiotherapy.org.nz/

http://sportsmedicine.co.nz/

Back in the world of private practice, Sports Therapy. I had a range of new client experiences. I've now used ultrasound on a shoulder and Achilles tendon and must say that making sure the contact medium (gel) doesn't liquefy and go everywhere is a must. Otherwise, I have done a lot of exercise therapy, manual therapy - mainly Maitland style mobilisations... but I also done a Mulligan shoulder mobilisation which was effective too. Otherwise, taping and soft tissue mobilisation is pretty useful. Heel raises, lumbar rolls and back braces have also been seen/used during the placement.

Continuing the Olympic theme, I decided to do my community research project on cupping therapy... yes, you probably did see those circular welts on many athletes, including 23x gold medal swimmer Michael Phelps. I am aware that the evidence for cupping is not strong.... at all. But with all the hype, I became interested and had to have a go at it myself (both on myself, and my patients) - luckily for me, there was a cupping set at the clinic and my supervisor was more than happy to teach me how to use it. My project will look at the different types of cupping techniques (as it pertains to musculoskeletal conditions and sport performance). I'll give an in-service in a few weeks about what I've found, then a presentation in the next PSW week in CHCH. Did you notice that cupping therapy was not listed as a common treatment modality in the 2012 London Olympics... watch this space (but don't get your hopes up). I'll tell you a bit more about cupping therapy next week.

Here are some articles on cupping at the Olympics... a social media frenzy! ...nb. Probably not the most reliable source for accurate & well represented information on cupping therapy...

• http://motherboard.vice.com/read/michael-phelps-cupping-rio-olympics-pseudoscience
• http://www.iflscience.com/health-and-medicine/whats-with-all-the-red-spots-on-the-olympic-athletes/
• http://www.stuff.co.nz/life-style/well-good/teach-me/83053294/cupping-its-not-just-for-olympians
• http://bigthink.com/21st-century-spirituality/religious-roots-of-cupping?utm_source=Facebook&utm_medium=Social&utm_campaign=Echobox#link_time=1470870814 

We had an in-service training from one of the physios at Sports Therapy. I missed the background story about the weekend training course that he attended, but from what I understood it was about primitive reflexes in adults; these primitive reflexes seemed to affect posture and pain (thus relevant to physiotherapists). I felt that there might be more evidence for cupping therapy than this primitive reflex therapy thing. Anyway, the knowledge of what to test, how to test it and how to reduce the problem was passed on to us. For example, one primitive reflex to test was the ATNR (asymmetrical tonic neck reflex) or the 'fencing baby pose' (lying on your back, legs straight, elbow straightened and shoulder abducted to shoulder level... then turn your head to look at your out-reached hand). This test was positive if you lifted or bend your opposite leg/knee. If I remember correctly, to fix this we must pull our knee against into flexion of the hip against a resistance. Re-test, and the problem should be fixed (something like that). I'm not convinced.

There seems to be a trend by some companies (particularly job recruitment agencies) to do an pre-employment physical screening whereby a company has a screening sheet that the client brings in for the physiotherapist to complete with them. The tests aim to identify any physical problems prior to employment. I've seen two screenings done so far - here are some examples of things they had to complete: the first client was seeking a trades job... the client had to lift 35kg from the floor to a waist high bench; hold their hands above their head for three minutes; and be able to kneel on the floor for two minutes on each knee... the other client was applying for an office job and was required to complete a hand strength test (hand held dynamometry); walk in a crouched posture for a certain number of meters; and have full symptom-free neck range of motion. I'm not convinced that they would actually be useful for describing or predicting anything... but that's for the job recruiting agencies to evaluate - we're just filling in the form so they can tick boxes.

My Tuesday sessions with Michael Monaghan continue to be beneficial and enjoyable. We had two clients, the first had multiple yellow flags - I won't go there. The second was a client I had seen, but only had slight improvements in his neck pain (spondylosis / cervical arthrosis). Michael modified my distraction technique and reminded me of the applied anatomy for the cervical spine. We then evaluated my treatment and assessments of each treatment with this client - we found that I had done a pretty good job. So I was feeling good after that! We'll catch up with this client next Tuesday to see how they got on.

We had an educator from CHCH come to Nelson for a quick visit to see how everybody was going - more to look at how students, the University and placements can improve the student-placement-University experience. There was a shared lunch at the hospital, but I was not able to attend due to having placement at that time.

An orchard in Nelson... on the cycle/walk track to Rabbit Island