P4R3W4: Since I last saw you...

I'm now halfway though my MSK placement, and I'm loving almost every minute of it! When I have follow-up patients we reflect on any changes since the previous physio session. More often than not, they have dramatic changes - reductions in pain, regained normal range of movement, had multiple nights of undisturbed sleep, confidence to perform tasks at home. It's very rewarding to be apart of their journey to recovery. I have three 'magic moments' to share with you this week...

Found this on a shelf in the photocopier room... oiling up a spine. ?Peanut oil perhaps?

My supervisor made me aware of Mulligan's SWARMs technique (spinal mobilisations with arm movement), suggesting we examine the neck more thoroughly of a client who had a classic presentation of rotator cuff impingement. The neck had been cleared with active movements with over pressure at end range in a previous treatment. On closer examination there was some minor symptom replication with accessory movement to C4/5, so we decided to try SWARMs to treat the shoulder. I applied a horizontal force to C4 spinous process, away from the affected shoulder, and asked the patient to move their arm through abduction. They did, no pain. Magic. This textbook rotator cuff presentation that I suspected would take a lot of posture and muscle balance correcting was improved with one attempt of SWARMs.

Previously I have not been a big fan of K-tape. I prefer rigid taping. I have used k-tape now for two clients. The first was on an achillies tendinopathy given the person wished to stay active and taping the achillies tendon may unload the tendon (in theory... I'm sceptical). The client found the taping beneficial. We're addressing more complex issues, so I wasn't surprised that the k-tape hadn't fixed all the problems there. However the second client I used k-tape on had some significant changes. This was a young person who reported to experience regular subluxations of the shoulder. I found no evidence for anything wrong with the shoulder - I even had this client throwing and blocking a medicine ball in more vulnerable positions that may cause subluxations... still no shoulder issues. I was wondering how genuine the problem was. On follow-up, the patient reported shoulder discomfort when I done a break test with the shoulder flexed (patient holds their arm in a position and tries not to move it whilst I do my best to break their arm position). Said shoulder presented significantly weaker than the other shoulder. I decided to test the theory that it was postural and/or psychological (e.g. confidence). So I applied the K-tape to her scapula - if anything, I could clinically reason this. Posture can influence muscle force across a joint - and what teenager really cares about their posture? The client hadn't complied with their posture awareness homework. When I retested the break test they had equal and full strength... I even tried to apply more force. K-tape is magic.

The third 'magic moment' was with an elderly female who had pain with neck rotation. C2/3 was the symptomatic joint. As I was not able to physically treat this joint, I decided to treat the adjacent C0/2 joints. I used Michael Monaghan's C0-2 isolated rotation and distraction technique. This involved fixing C2 (so it didn't move) and rotating and distracting (gapping) C0-2 gently. Upon reassessing neck rotation, the lady had regained most of her neck rotation range of movement without any pain. Next session we will work on getting her neck into full extension without pain.

Okay, so there were four magic moments. This magic moment was in treating a chronic back pain presentation. The person had full back / spine pain, and in the first session all I did to treat them was a grade 1 lumbar rotation mobilisation. This is essentially a gentle rocking of the hips whilst keeping her shoulders still. The patient hadn't slept well for months and subsequently fell asleep on the table within minutes. Fast-forward one week and they had been sleeping well and gently rocking themselves to sleep. The person appeared to be more cheerful but the back pain and fatigue was still there and really disabled her day-to-day living. My treatment was gentle massage and I taught her a body-awareness and relaxation technique. The person wasn't aware they could control their body and relax themselves, thus finding this technique revolutionary. They were now able to rotate their trunk / body. Magic!! They were so pleased! For homework I gave the client one tai-chi move to practice at home. These were huge improvements for this client and I felt blessed to be in a position to help them achieve meaningful improvements in physical and psychological health.

I had a client that I clinically diagnosed as having Sever's disease. Imagine telling a child that they have a 'disease'. This was surprisingly uncomfortable for me, given that Sever's is merely a condition that when managed well during their growth spurt will have no implication on their lives. In the meantime, the condition was having a huge impact on their life and the treatment might turn into a very conservative management... which really means I will have to inform this child that they will need to forgo their Saturday and lunchtime rugby. This isn't something an aspiring All Black wants to hear.

In other cases.... I had a client with a reported 'foot drop' that was causing them to trip. I was surprised to see her foot dorsiflexors were very strong and I had to go looking elsewhere for the problem. The problem was in hip abductor and external rotator weakness... yes, the classic Gluteus Medius weakness. I'll see whether there has been any improvement in the next session. 

One common grumble from physiotherapists is that of clients not following through on advice we give... 'how have you got on with those exercises I gave you last week?' [insert excuse]. This is where we use behaviour change tactics, but it might take a few weeks to find the right tactics / to influence the correct environmental or personal factor. Identifying and targeting these factors are not easy. But they're worthwhile... one client I had last week had 'undone all the good work they had done by the physio' by returning to work, which involved lifting and driving. How will I change their work demands? Occupational physio referral?... hmmm... it's tricky when the workplace isn't invested in their workers and the workers have little option but to continue their work.

In other outpatient antics... I helped out with the Lower limb / knee class on Tuesday and hydrotherapy class on Thursday. There was also a welcome morning tea for the new receptionists on Wednesday.  I had my midway review from my supervisor on Wednesday, which was a very positive experience. I left feeling a lot more self-confidence. I also had an enjoyable week with my clinical educator. Everybody seemed to be having a good week this week.

Made a new pamphlet on core activation for the outpatient clinic...

ED on Friday was good fun too. There was an older gentleman whom had a piece of hearing-aid stuck / presumably broken in his ear. We had a quick chat to him about his balance. He gave us the story of the week...  

" I have been having a problem with my balance lately. It has got to the point that I'm thinking about giving up driving. My wife says I'm walking with a forward lean - I don't know where she got her medical certificate from. The other day I was in the shower. There's a windowsill that I use to help me balance. I was feeling unbalanced and my vision was starting to go. I was hanging on to this windowsill thinking that this was it. This was the end of me. I couldn't see a thing, everything was white and bright. My balance was bad - I was swaying around the shower. Then I reached up to feel my face and took my glasses off. I forgot to take my glasses off! "  [Fogged up glasses from the steam]

The other funny moment on Friday in ED was hearing my supervisor read back an email about Darco orthotic shoes. Between the serious communication was a punchline from the doctor asking whether the Darco shoe was a racist shoe!?

P4R3W3: Therapeutic touch

This was my second week of the MSK placement. I have seen quite a few different cases now and the complexity of each case is slowing increasing. Having a waiting list (and triaging the most important cases) allows for me to select cases / pathology I haven't seen before. Last week I saw quite a few total knee joint replacement cases and an acute low back pain case. This week I saw more chronic back and neck pain cases.

One interesting neck pain case was of a lady who had been doing McKenzie neck retractions 'double chin' to relieve neck pain. It had not worked. The neck was very tender on palpation, especially around C2-3, so I worked on C0-C2 with some simple isolated neck rotations. I wasn't able to reduce the pain on palpation to these joints, but neck rotation was able to be increased and the patient reported a relief in severity of discomfort.

Another interesting non-specific back pain case was relieved with some grade 1, gentle rocking, trunk rotations having her shoulders stabilised. The client must have been so exhausted, not being able to get a good nights sleep and the fatigue of persistent  pain, that they fall asleep with less than five minutes of gentle rocking. They reported it to be the most comfort they have had in three months!

View from my outpatient treatment cubical on 5th floor.

Our physiotherapy assistant is amazing!! Five star quality scones!

Hydrotherapy is enjoyable for everybody. The patients love the hot water and relief from pain or stiffness. It really is quite therapeutic. I had a follow-up with both clients from the first week, with much progress made already!

In-services are a fortnightly event, and it was the 4th year student's turn to present a topic of choice (with relevance) to the team of physiotherapists. Coincidently, all three of us working in the hospital chose topics relating to elite performances. Hamstring injury and return to sport, the use and evidence for elevation training masks, and I had a quick spiel about the use of mental skills training / sports psych skills and methods applied to the clinical setting. I argued that these clients are also aiming for a best performance in abnormal environments or with unusual tasks that are probably stressful. Sure they have some physical constraints (yes, we should work on these too - and we do), but they are not totally dissimilar to elite athletes. Some patients may benefit from informal mental skills training.

ED on Friday was again quiet for most of the day. It seems that the team gets busy around 4pm, which is the time I finish up for the day. During the quiet periods I helped put together a draft patient information leaflet on gout and assisted a doctor reduce a displaced fracture of the distal ulna of an older adult. Otherwise I attended to a person who had acutely sprained their ankle. There were a few other cases that I sat in on, all equally exciting.

Weekend paint run fun!

P4R3W2: Outpatient Physiotherapy

I began my third placement, musculoskeletal (MSK) physiotherapy, in Nelson Hospital's Outpatient Clinic this week. The Outpatient Clinic typically receives clients referred from their General Practitioners (GPs). Clients tend to have: age-related diseases (arthritis) and follow up physiotherapy after orthopaedic surgery (hip / knee replacement)... but there are a whole range of cases. My week was a mixture of shadowing my supervisor and seeing my own clients. After a subjective assessment I would find my supervisor and give a handover - we would then have a quick chat about the objective assessment and the likely treatments. I saw three total knee replacement follow-ups at around the three week post-surgery mark. Although the patient cases were seemingly the same (...how different could three people who have had a knee replacement be?), I didn't offer a recipe-like approach at all. There were a range of differing presentations: different stages of wound healing, knee clunking in one case, stiffness/pain (or no stiffness/pain) and differing levels of compliance to their recovery plan.

Examples of less typical cases in the Outpatient setting this week included postural habits causing functional changes, reported frequent subluxation of a shoulder joint and  an (almost) unhappy triad (knee ligament MCL, ACL and PCL reconstruction).

The Outpatient Clinic is funded by the public health organisation, and so it is free for clients who have a referral. This is particularly great for those who are financially constrained. Physiotherapists at the Outpatient Clinic offer a range of group classes including a knee circuit training class and hydrotherapy class. I referred two clients to the hydrotherapy class and was able to guide them through their first pool session.

The images below are of my desk, my treatment cubicle and the Outpatient Gym!

The Emergency Department at Nelson hospital has Allied Health, physiotherapy and social work, services. It is one of the few hospitals in New Zealand that has a full time emergency department physiotherapist. I'll elaborate on this in future posts, but in the meantime have a read of this article:

Holmes C, Hollebon D, Scranney A, Exton H (2016) Embedding an Allied Health Service in the Nelson Hospital Emergency Department: a retrospective report of a six month pilot project. New Zealand Journal of Physiotherapy 44(1): 17-25. doi: 10.15619/NZJP/44.1.03

I am lucky to have Friday in the Emergency Department (ED). It is said that Friday is a busy day because people choose to come / 'get sorted' before the weekend. That wasn't the case this week... not between 8:30am and 4pm anyway - they probably came in after they had finished work. I was shadowing this week, however over the course of the placement I will attend to my own cases with the supervision of a physiotherapist. I saw two people with a calf injury and two people with a hand injury - the first of each injury location was the least severe. There were two highlights of the day, the first was physically assisting the reduction of a fracture i.e. closing the fracture, to straighten the bone / reposition it back as it would normally be. It was of the 5th proximal phalanx (little finger). Whilst I stabilised the proximal head, the doctor used a pen as a fulcrum and pivoted the bone back into place - the patient had local anaesthetic (as you would expect). The x-ray following the reduction looked as if no fracture had occurred. My second highlight followed on from this with the same patient. The physiotherapist took this patient to have a plastic cast / splint made. The patient was taken up to the hand therapy clinic on 5th floor (Outpatient clinic area) and had thermoplastic moulded and cut to support the hand/fingers.

In the weekend I went to find the Emerald Pools, inland following the Pelorus river (turn off and follow Maungatapu road by the Pelorus bridge). I've noted a series of huts, the first hut being 4h from the car-park (3h from Emerald Pools) that will be attempted some time this year. I think the Emerald pools may look their best in the summer with proper sunshine into the valley. The gravel road to the car-park was well maintained (very few potholes - I was pleased about this).

P4R3W1: PSW MSK Edition

Professional studies week: musculoskeletal (MSK) edition

I'm back in CHCH! On Monday a physio peer took me for a walk in the morning. Below are photos of the spectacular views! In the afternoon we listened to presentations from those who were on their community placements. We had presentations on cryotherapy (recovery in athletes post-exercise), the role of coaching in PT, using FES bicycle in spinal cord patients, exercise for patellar tendinopathy, prevention of early onset CVD in spinal cord injuries, physical activity and anxiety disorders and falls prevention.

Looking across Littleton Harbour from Kennedy's Bush track

Looking across to the Southern Alps

Myself and Mike Stevenson

Tuesday was another straightforward day; a placement preparation morning followed by self-directed learning. I sent an email to my supervisor asking for a heads-up on what conditions I would be seeing next Tuesday so I would hit the ground running. The afternoon was largely spent watching a French movie based on a real story about a man who had locked in syndrome who wrote a book by winking. The movie is called 'The Diving Bell and the Butterfly' (2007). Well worth a watch!

Wednesday was motivational interviewing morning with Chris Higgs. Chris is a class act; it's fair to say that everybody was excited to have him present a tutorial in CHCH. We put motivational interviewing into action with a few activities including pitching statements at a 'batter' for them to rephrase in a reflection.

Thursday featured a morning session on anxiety management by leaders in Canterbury DHB's mental health service, then an information session from a team leader of Green Prescription. We also heard from a final year student from University of Nottingham who is completing her elective placement here in CHCH. To finish off the day we had a BYO at the Red Elephant restaurant.

Friday students on their MSK rotation had a tutorial at the Barrington School of Physiotherapy Clinic.

Then it was back to Nelson for a long weekend.

Maruia Falls

Interesting websites:
PhysioEdge has podcasts on topics of interest: http://physioedge.com.au/
Clinical Skills Development Service has eLearning modules on various topics: https://www.sdc.qld.edu.au/