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.
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:
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).
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.
Farm house north of Carterton (near Masterton, NZ)
With the research rotation over, I spent most of my week on holiday in the lower North Island.
...the Nelson farm house (featured in an April 2016 post) has now been demolished.
My holiday in the Wairarapa took me to the southern most point of the South Island, Cape Palliser lighthouse!
Ocean Beach, near Lake Ferry
The Pinnacles, near Cape Palliser (looking down)
The Pinnacles (looking up)
Sealion pups playing in a pool, sheltered from the waves (near Cape Palliser)
White kiwi (difficult to photograph... bit dark!) at Pukaha Mt Bruce National Wildlife Centre
What would an adventure be without a few selfies?! So we did.
The final week of the research rotation is over. I'm once again on a one week break. This research rotation has been productive. Our group has completed a full draft copy of our research project, our supervisors are currently giving it a read over and then we will make some final adjustments before we submit the final copy later this year.
Our draft submission was about 38 pages long (not including 20-odd pages for one appendix, and references, cover page, or our research log, etc)... and no, we didn't use double line spacing. So there is much to show for our six weeks of research. But 'what about the content...', you say? '...is it of good quality and useful - did you make any discoveries?' Our research project hasn't yielded any Nobel Prize worthy discoveries, but it is a nice succinct review of the literature (with a number of limitations). Here's a brief overview of our drafted article (expect some level of self-plagiarism):
Falls self-management by people with long-term conditions and their support worker/s: An integrative review.
Research by Awesome research group that Phil's in, et al, 2016.
(We haven't yet decided on an order for our names to be published, knowing that the first person listed will be the famous one of the group if we ever get published e.g. Butler et al., 2016 if alphabetical order is chosen... and it'll likely be 2017 if it is going to be published).
Introduction
Currently falls prevention is popularised in community level healthcare for older persons. We problematise the narrow conception of falls, instead suggesting that 'fall prevention' should target a collective population of people that are at risk of falls. Falls affect people of different health statuses (long term illness / disability), as well as across the lifespan.
We then discuss the global and local burden of falls from an economic perspective - this seems to be the current language that is spoken at a political / policy level, so we have added this because falls prevention is important and we want to see improvements in healthcare. Furthermore, with reflection to the booming population, we foresee an increased burden of falls in NZ.
Did you know that a fall that incurs cost (not all falls directly cost our health system, but of the ones that do) on average cost $500 per fall. That cost is doubled when we exclusively look at the average cost of a fall for people older than 85 years of age!!
An argument is made that all healthcare
practitioners play a role in falls prevention, and physiotherapists are
particularly well placed to bring about meaningful change - to reduce
the risk of falls. Two New Zealand interventions (The Otago Exercise
Programme, and it's modified 'Steady as you go' programme) are two
economically viable means to reduce falls for older people at risk of
falls (n.b. the Otago Exercise Programme is no longer funded by the
government, instead they fund TaiChi). We know that a large number of people that would benefit from falls prevention information do not receive it - this includes information for informal caregivers. In summary, it is our opinion that falls prevention literacy should be improved in the country.
The purpose of our integrative review was to explore the literature for self-management and confidence strategies used for falls prevention ('common sense' strategies) by community-dwelling people with long term conditions (i.e. with greater falls risks) and the strategies used by the people who support these people (their informal caregivers e.g. family, friends, neighbours).
Methods
We searched for articles that fulfilled our research purpose (using keywords, MESH terms etc) then screened the results using the title / abstracts. Selected articles were then critically appraised (we used JBI, but there are other tools out there CASP, Pedro, QUADAS-2, STARD... depends on the type of study you're critically appraising e.g. qualitative vs quantitative. We pooled information (age, sex, country etc) from all of the studies into a table, then in another table we summarised the aims, results and limitations for each study. We described the process of extracting the data for another table in our results section - this table illustrates quotes and themes from each of these studies.
Results (Spoiler Alert!!!)
We presented self-management strategies used by individuals, and their informal caregivers separately.
We came up with the following categories (then described and illustrated each of these):
Discussion
We discuss the results with respect to our aim. A discussion about the current falls prevention climate (prevention policies and strategies pushed by policy makers around the world; the reach of falls information to people at falls risk; falls literacy and the general population). Etc.
A suggestion for future research, limitations, strengths of our study and implications of our study for rehabilitation were then made.
Conclusion
We conclude, as all good research studies inevitably do, that falls is a problem and we should do something about it. Lets stand up to falls!! p.s. Stand up to falls is a campaign to increase awareness of falls - it's not specifically mentioned in our study.
...And that, my friends, is what research looks like! There is plenty of fall prevention information online - health professionals will find these three links useful...
As with all of our rotations, we have to write a reflective statement. The reflective statement for the research rotation had to integrate working as a team and the University of Otago graduate attributes. These graduate attributes include: a global perspective, interdisciplinary perspective, lifelong learning, scholarship, communication, critical thinking, cultural understanding, ethics, environmental literacy, information literacy, research, self-motivation and of course teamwork.
Another week, the same friendly smiles! Our research project is coming along (a bit slower this week - we will need to find some momentum for our last week of research). What have we achieved? We've got a very very rough results section completed. I'll do a big reveal next week and summarise the research rotation (next week is the last week of the research rotation!!).
Interesting website targeted at physicians, but it has some good info and newsletters that students may find interesting --> http://www.bpac.org.nz/
Michael Monaghan. Physiotherapy's fourth 'M' (alongside Mackenzie, Mulligan, Maitland) in the field of manual therapy. Monaghan has integrated osteopathic and physiotherapy manual therapy techniques for the cervical spine. His book 'Spinal Manipulation: A Manual for Physiotherapists' has been a key text in his post-graduate teaching. Monaghan is widely known for his contribution to teaching manual therapy in New Zealand, and particularly to undergraduates placed in Nelson. He is a major draw card for choosing your fourth year placement in Nelson. Here's an article you should look in to:
Hing, W. A., Reid, D. A., Monaghan, M. (2003). Manipulation of the cervical spine. Manual Therapy. 8(1), 2-9.
Our tutorial with Michael Monaghan on Friday morning was extraordinary. We started with a list of case studies to work through - how we would apply manual therapy techniques to correct a problem (some cases had sneaky red flags). Monaghan's style is very biomechanically focused and requires reliable and accurate palpation skills, strong arthrokinematic knowledge and clinical reasoning. Monaghan's manual handling and ability to perform manual therapy in a range of positions, using various locking/stabilising techniques (or using alternative manual therapy techniques - mainly high velocity, low amplitude mobilisations) is incredible. Furthermore, he is a great teacher. We were shown how to assess and mobilise spinal segments C0-3, with an emphasis on C0 (occipitoatlantal). Other than fine-tuning our pistol manip and lumbar manip, Monaghan showed us a transverse gapping HVLA technique for the upper thoracic / C-T junction, and the pistol manip performed on a person in sitting.
Hot tip!
Here's one really basic aspect of the physical assessment that is often overlooked by clinicians. When assessing neck range of motion, in particular side flexion, the clinician must remember that the upper cervical joints function quite differently to that of the lower cervical joints. We typically remember that the C1-2 joint can flex whilst the other Cx joints extend (i.e. the double chin), or all segments can flex (i.e. the 'did I spill tomato sauce down my front'). Clinicians often ask their clients to side flex (bring your ear to your shoulder) and commonly believe that only one movement is occurring in the neck (side-flexion). Wrong! Sure, side flexion is occurring in the lower cervical spine, but there is a slight rotation at C0 to the opposite direction (to keep the head forward, eyes as level as possible), that is forgotten about. I.e. if you side bend your neck to the left, there will be compensatory right rotation at C0. Why is this important? Say your client has a headache that is brought on by neck rotation and side-flexing the neck in the physical examination, the clinician is probably going to get confused about where the problem lies - is it in the upper, lower, or a more global cervical neck problem? Well, the answer probably lies in the subjective assessment, but you will confuse yourself in the physical assessment if you forget about these movement couplings. It's always good to assess the upper and lower cervical spine, in particular manually assessing C0 in a physical examination of the neck.
Physio Matters!
It was an exciting week - I got to feature
(albeit, a cut-down version of what I had written) in the physiotherapy
magazine 'Physio Matters'. I had comments over my Skype research meeting on Tuesday, a tweet from @LeonMabire and a request to promote the NZ Physiotherapy Board's new summer scholarship for 3rd year student (see the end of this post). So there we go, this week I was famous in the small world of New Zealand physiotherapy. Here is the full exert that I had written for
the magazine:
Social
media is wonderful (mostly). We simply cannot get enough of it, and there is a
lot of it out there. It’s our daily addiction. Between all the weird and
wonderful content online, I can imagine (with some certainty) that we’ve all experienced physiotherapy
on social media. Facebook ads, physiotherapy memes and infamous physiotherapy
legends on Twitter and bloggers like @AdamMeakins ‘The Sports Physio’. Informative,
thought provoking, entertaining, interactive, great!
I’m a fourth year physiotherapy student from the University
of Otago and I have been using social media too. It has become apparent that
Physiotherapy New Zealand keeps tabs on social media, and has miraculously stumbled upon my blog. Now,
having been welcomed to write a short article for Physio Matters magazine, I
thought I would take this opportunity to share a little bit about my blogging
experience and my undergraduate experience of fourth year.
I write a weekly recount of my physiotherapy experiences in
a blog. I started writing my
blog in 2014 and have subsequently
covered every academic week in
a post… Unfortunately
it’s not an original idea. There’s not a lot of detail in each of my blog posts; just enough detail for my
friends and family to keep up-to-date
with my undergraduate experiences – this was the purpose of writing the
blog. I have since used it to reflect upon the journey I’ve had so far. Others might recognise it
as a promotional resource for studying physiotherapy in New Zealand – it is, after all, online and open
for everybody to view. I don’t claim to have written anything masterful,
but it is my personal little project and I am enjoying it.
As mentioned, I am currently a fourth year student. My peers
are placed around the South Island and mid-lower North Island. For the students who made Dunedin their
home, they will feel quite separated from friends, possibly family and a little lost for finding an equivalent
local ice cream parlour to Dunedin’s Rob Roy. This is the great
adventure of fourth year but settling into a new location for the year can be a
challenge. This is a challenge that I face. Luckily I’m placed in sunny Nelson. I'll take this moment to brag. Nelson
and the surrounding area is stunning and the weather is a bonus. Don’t be
jealous, just come and visit – bring your tramping boots.
Blogging
whilst away from my family and friends has become quite useful for letting them
know that I'm alive and well, but I've recently discovered that being in a new
location away from the people you usually hang-out with will leave you feeling quite
isolated. Social media does not replace having a catch-up in person or over the
phone. Chatting about the experiences had by your peers is very necessary for
both your mental health and being effective on your placement – the placement
itself can be quite stressful too. My clinical educator kindly reminded me of
this, but some things you've got to learn the hard way.
I have had
many great moments over my first placement this year, lots of laughs with
clients and made to feel like one of the team by physiotherapists and other
healthcare staff. Luckily for me I will have more placements in Nelson
Hospital. Social media is wonderful (mostly) and I shall continue my weekly
blog updates for the year, amongst more person-to-person interactions (I think
I’ve learned that lesson now). Fourth year is great, but not without its
challenges. Embrace these challenges with the company and wisdom of others.
Written by
Phil Butler, 4th Year Physiotherapy Student.
Also in social media, as alluded to by Leon Mabire, the School of Physiotherapy was looking good on YouTube - the promotional video for the school was released to the public this week, and what a fantastic video it is.
A friend and I went on a mission to find some more DOC huts around Nelson. The three huts that we visited would be three of the easiest huts there are around the region - so no excuses not to look these up online and get out to walk them (@LeonMabire, you'll be pleased about all this walking I'm advocating). The huts are Bushline Hut (Nelson lakes national park), Flora Hut and Mt Arthur Hut (Kahurangi national park). Both starts of the walking tracks are about 1h drive from Nelson and the loop tracks can be done within 4h (thereabouts).
Mt Arthur Hut, Kahurangi National Park
Flora Hut, Kahurangi National Park
Bushline Hut, Nelson Lakes National Park
Back to the topic of research! You'll be quite aware that there is a research module in the 4th year of physiotherapy (unless you've mistaken it for a tramping module - I can see how that might happen). The NZ Physiotherapy Board (the team that will issue you with your licence to touch / registration as a physiotherapist at the end of your degree... not to be confused with Physiotherapy New Zealand who I've mentioned earlier in the post about Physio Matters magazine) are offering 3rd year physiotherapy students a summer research opportunity to the tune of $5000 (you'll like the sound of that). What better way to get some paid practice for 4th year! But to trump that, you will also be doing a great service to Physiotherapy in New Zealand. All the details you need are online.
Sunrise at John Reid Hut, Kahurangi National Park (near Nelson)
Another week, another weekend tramp before winter sets in. I made my way under the cover of nightfall (headlamp and torch beaming) to John Reid Hut. Excellent overnight adventure! I then popped down to Waimate to spend a few days with my parents.
"Fear of falling was reported as a debilitating condition that brought on feelings of
worthlessness due to limiting activities of daily living, and feelings of being
a burden on their family" (Honaker & Kretschmer, 2014).
This week, my research group really got down to business. I ended up fairly sick on Wednesday-Thursday, so wasn't able to contribute much. Here are some things that we did get done:
Extracting quote by quote, statement by statement, categorising them and analysing them (using an inductive analysis method). On Friday, we began our search for themes... we printed and cut out each of the quotes/statements and began sorting them into piles.
Writing a first full draft of the introduction & methods.
I've grouped our included studies (the ones we will be analysing) into EndNote. EndNote is a citation / bibliography software which allows you to create your own library of articles (and attach .pdf copies of the articles). We can send these libraries to other EndNote users, insert citations and bibliographies directly into Microsoft Word. It's all pretty useful stuff. Here's what it looks like!
Endnote in use!
Only two weeks of research to go! Where has this time gone?!
References
Honaker, J. A. & Kretschmer, L. W. (2014). Impact of fear of falling for patients and caregivers: Perceptions before and after participation in vestibular and balance rehabilitation. American Journal of Audiology, 23, 20-33. doi: 10.1044/1059-0889(2013/12-0074)
