Friday, 26 June 2015

Y3 Semester Break: Remission, intermission and a mission.

I'm on track for semester two, having passed the semester one exams.
I'll start this post with a recap of the sport medicing opportunities I've had over this semester break.

The Tuesday following our last exam I had a change of scenery, this time volunteering as a pitch-side medic (not at the clinic). The sport event was the Dunedin Co-Ed school sports tournament organised by Sport Otago. It was a freezing, fairly uneventful day until the very last 15min when, on the soccer field directly across from our medic tent, a girl was struck by a soccer ball to her shin bone (tibia) and fell to the ground. The girl was in a great deal of pain but I managed to get her soccer boot and sock off, but the shinpad (with built in ankle support) remained on. My co-medic and I put a splint on - given the signs (and patient's level of pain) were indicative for a broken bone. Everything was under control until the principal for that student wandered onto the scene and, without consulting us medics, phoned 111 for an ambulence - this wasn't our plan A (use a stretcher and take her to the injury clinic), nor was it our plan B (we had direct access to an ambulence service which services the sport injury clinic when needed). We reluctantly (having presented alternatives multiple times over that time) waited just over an hour, in the cold, for the principal's public system ambulence to arrive. I hope that principal would let sport medics do their job in the future without unduely intervening. On the bright side, the ambulence staff praised our splinting of the patient's ankle/leg.

Sunday 'there is no predicting who will turn up' clinic was quiet over the break. We had a broken nose, observed concussion screening for return to play - that sort of thing. I haven't been attending the Saturday 'if it can happen, you will see it' clinic due to work on Saturdays.

Roller derby is a minority sport which appears to have as many officials as players on the track. I wasn't aware that this sport existed until earlier this year when I mediced my first derby. It's a weird and wonderful sport where teams attempt to get a team member around the track whilst blocking their opposition from doing the same thing - they possibly do this in turns - I'm not 100% sure... it's messy and a bit confusing to watch. Each team as an eccentric name, and players within the team have eccentric names e.g. Ruby Smash, Diva DemolisHER, Ana Phylaxism and OrKazzMic. It's a bit of an eccentric sport. The Dunedin team is for females only... actually, I think most of the teams in NZ are 'female only' - don't quote me on this. It's an elite sport and these teams fly to contests around NZ and AUS. Anyway, there are a few comical moments when these ladies fall over (? this might be the entertainment value) but thankfully there are very few associated injuries. The sport medics are well looked after. The last Dunedin match we had the Super15 Quarter final playing in our clinic for derby halftime viewing. We also got to take home the unsold savory pies!
Gallow Lasses of Dunedin beat Vagine Regime, 330 to 139 points
As previously mentioned, we have an assignment for PHTY355 evidence based practice. It's due the first week back, so I'll mention it in the next blog post.

Many people take up a novel and read when they've got time to relax. I have found novels to be a bit of a 'hit and miss' with respect to engaging and becoming engrosed in their storyline. These holidays I went on another physio student blog expedition and came across a mixture of different healthcare student blogs! Here are some worth having a brief squizz at. Common themes include hard work and long hours.
  • Physical therapy


With a (debatable) bit of free time up our sleeves, I went for a cruisey Friday bike ride around Dunedin's peninsula. With adventures and views like these around, there's no wonder why I enjoy studying at Otago! Having said this, the weather changed shortly after reaching my destination and I made my way home in the rain (I was prepared). Definitely riding this track again (perhaps in summer!)
Return trip: ~30km, ~700m elevation gained, ~2h biking, ~1100Calories.



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Wednesday, 10 June 2015

Y3S1W14-15: Pathophysiotherapy.

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

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


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

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



PHTY354 MSK Practical: Wednesday 3rd or Thursday 4th, June.
I was on Wednesday morning, and it was raining heavily. After jumping puddles from North East Valley to the University, my trousers were soaked! This exam asked us to answer two practical questions from this semester's MSK labs: orthopaedic tests, manual therapy and exercise interventions. It's similar to the 2014 practical end of year final exam, except we're focusing on the upper extremity and spine. We were given a very short case study for most questions to set the scene. There was usually a brief Q&A session after we completed the task. I was asked to stay for an hour as a 'pretend patient' for others completing their practical exams. I was given the following two questions:
  • Q1 Assess deep cervical flexors in supine + home exercise programme.
  • Q2 Volleyball player has stiff shoulder nearing end range flexion - assess relevant active movement of shoulder and perform an accessory movement to increase shoulder flexion.
My peers got questions like:
  • Patient with posterolateral thumb pain. Perform a special test for DeQuervain's syndrome and perform a passive accesory movement to the 1st CMC joint.
  • Volleyball player has a sore shoulder. Perform special tests for impingement and anterior instabilty. 
  • Perform longitudinal accessory movements on the AC joint in neutral and 90deg flexion for a patient with shoulder pain. Choose an accessory movement to use as a treatment.
  • Patient with stiff Tx spine. Perform PAIVMs and then select one and demonstrate for irritable pain. Then, what if the patient comes in with pain only in end of range Tx extension.
  • Patient with lateral epicondylitis. Perform MWM with a manual technique and a therapy belt. 
  • Amongst other things like: Assess a tennis player for GIRD, ULTTs, SNAG C0-C2 rotation,  sharp perser and alar ligament tests etc.... good fun!
Although it was pouring down, and there was significant surface flooding which closed roads around Dunedin, there were the usual student antics happening on campus. Leith river runs through the centre of the University of Otago campus. It is usually a quiet stream, but today it was absolutely gushing! Whilst in previous years students have rigged tow lines to the foot-bridge and surfed the flooding river... this year it was student's kayaking down the river.... See video below!

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


PHTY354 Written: MSK & Neuro: Friday 5th June, 2-5pm.
This exam started with a bit of an admin error (not enough answer booklets for a dozen students) and a good group rendition of happy birthday (beyond the control of the supervisors) for one of the students. There were two MSK and two neuro questions (with subquestions). I'm not going to give the questions away for future students... just be prepared for anything. I found the exam reasonable, but I know that the examiners will be expecting more than what I wrote down.

SkySport: NZ play Myanmar at Wellington Regional Stadium!

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

Otago Sport Injury Clinic, Edgar Centre
PHTY354 Neuro Oral: Monday 8th June.
This exam required us to watch a 15min video of a person with a neurological condition performing a task e.g. sit to stand or walking. We had to take notes on the condition, body structure and function impairments, strategies used. In the exam we were asked to discuss short and long term physio goals we give to the client (even though we would collaborate with the client in real life situations) and the physiotherapy interventions we would use, precautions, contraindications/safety issues we would consider. Then highlight how other members of the inter-disciplinary team might assist the patient.  I felt the 15min watching the video went very quickly. In that time I scrambled down some notes on the paper. The notes taken were a useful prompt, but I'm glad we weren't given any more time as there was nothing I could have added that would have made me any more prepared. The oral exam was surprisingly good - the examiner was very friendly and changed his questioning when my gaze shifted from him to out of the second floor window (in hope of triggering some memory). I was happy with how the oral exam went - I even shook the examiners hand at the end. After the oral exam I rushed back to the sport injury clinic to help treat the final day of netball injuries... turns out Waitaki Girls High School had the most injuries per team over the tournament weekend (eight injuries) - yes, we were keeping tally.

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

PHTY353 Pathology Written: 11th June, 2:30-5:30pm.
120MCQ with mixed Q&A & case studies. No powerpoints (thankgoodness!)
I finished in two hours... but I found this exam the most difficult... so difficult I'm going to have a short grumble about it. Here is why pathology is difficult (my top three excuses):
  1. Much of the cellular and chemical specifics are irrelevant in physiotherapy practice. Those specific chemokines, genes, strands of viruses e.g. HPV 6, 16, 18 etc - what does this mean for the physiotherapist? Nil, ziltch, nada. It's nice to be aware that these exist, but to be tested on it in the exam... no thank you. Quite frankly, I don't want to commit this stuff to memory! On a brighter note there were no histological images in this final exam.
  2. Of the pathological conditions mentioned (some very rare), the course didn't describe how physiotherapy could help, contraindications, etc. We were taught principles of pathology, so, well, I guess we know about the condition (the acute, subacute and chronic manafestations, timeframes, symptoms/presentations etc) and can use a common sense approach (e.g. for contra-indications, aims of treatment) when treating these individuals. Greater specificity for physiotherapists would have been nice.
  3. MCQs may have the question worded semi-ambiguously (the writer has a clear idea what they're asking in their mind, but it isn't clearly written / could be interpreted differently) or has multiple 'technically' correct answers which we could debate given the chance. Not all questions are like this, but it does make for a bit of a mind game when we come across them.
On the flipside, physiotherapists need to understand the principles and consequences of pathology. We speak the medical language and so as much as this was not my favourite paper (or exam) it is important to have a good grounding in the jargon, understanding of disease processes, an appreciation for the impact of disease (from miciroscopic level to global), knowledge of current treatment strategies and research directions.
Coming up next semester...
PHTY354 trades MSK and Neuro in for Integrated Studies and Cardiorespiratory.
PHTY 355 lectures and clinical placements continue.

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


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Tuesday, 26 May 2015

Y3S1W13: Winter is coming!

On Monday morning we woke to some snow around the region. Suprisingly North Dunedin wasn't too badly affected whereas South Dunedin was. Odd! Our plan was to travel to Mosgiel on Monday morning to visit a new patient with COPD, but after checking the road status we rang the patient to make sure they were still alive. They were, thank goodness! In the end we didn't go to Mosgiel as the patient was not feeling well enough for a visit. We then rung around other patients, many wished to have a physio visit another time (because it was so cold and miserable). Much of the time on Monday was spent preparing Heart Foundation booklets for our Friday placement and drinking coffee in the staffroom. In the end we visited one patient while there were small snow flurries going on outside.

On Wednesday morning I saw my usual clients. I've enjoyed having some clinic time with patients with chronic illnesses. What hasn't worked well one week is improved upon in the next, and is even better the week after that. We have had a chance to practice independently - with the occassional visit from the educator to check up on the patient and share a good yarn or two. Following the session I have enjoyed debriefing whilst I'm writing my patient's notes. Debriefs have challenged my critical thinking and clinical reasoning - we've discussed psychosocial aspects which in theory have simple solutions, but in practice these are not at all easy to influence. I feel that one of my patients has taken onboard the message that he needs to continue exercising regularly. This patient in particular is known for being 'stubborn' and having zero compliance with exercise programmes. However, it seems that over the three weeks I have found an activity that the patient enjoys and they have indicated that they will start exercising at home. To me, this is a success. If we put in the hard work, physiothearpy has its rewards.

 On Thursday afternoon I decided to explore Waipori Falls!

On Friday we were handing back the risk assessments for 'cardiovascular disease risk in the next five years'. We were following up with some education - discussing the results and allowing for some Q&A so they could be better informed about their health. 

We have covered all the musculoskeletal tests we will need to begin practicing as musculoskeletal physiotherapists. Our manual handling skillls, communication, subjective and objective assessments are getting pretty sharp too. Our last lab for the MSK module in our degree was left to us to practice what we wanted - there was a lecturer roaming the room helping us with techniques. So we're well versed in soft tissue therapy, Mulligan and Maitland manual therapy, exercise therapy, taping, etc. In addition we've covered the fundamental electrotherapy techniques (thermotherapy, cryotherapy, ultrasound, laser, TENS, FMS, NMES, biofeedback). Our toolbox is getting bigger! Our last physical agents lab (electrotherapy) was on biofeedback. To demonstrate how the equipment worked (and it's set-up) the demonstrators had two students arm wrestle each other. The biofeedback measured their muscle activity, the highest muscle activity theoretically won (this was reinforced by the outcome winner of the arm wrestle). Unfortunately the winner didn't face-off against a lab demonstrator... Anyway, the biofeedback machine beeps when a your muscle isn't activating enough or is overactive (we control the settings) - this can help train us to relax our muscles when we're stressed or to target specific muscles (amongst a host of other uses).




Neuro portfolio in... check!
Physical agents assignment in... check!
PHTY355 clinical placement portfolio for semester one in... check!
Evidence based practice assignment... it can wait.

I'll write one blog to cover this exam period... catch you in a few weeks!
Wish us luck!
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Tuesday, 19 May 2015

Y3S1W12: Holy neoplasm, Batman!

I've taken to modified Batman quotes this week as we near two major deadlines (neuro modules and electro assignment), for no other reason than at times like these we need a little bit of humour.

Holy slipped disc, Batman! We've got a pain in the neck. This is the last MSK lab where we're asked to master new treatment techniques for the upcoming exams. It was an important lab that would either make or break our careers as physiotherapists (slight exaggeration). If we got it wrong we could do catastrophic harm to our lab partner and if we got it right it would prove our sensitivity to detecting and treating the movement of underlying tissues. What were we learning you ask? Lower cervical spine manipulations or the down-slip manipulation of the cervical spine (and somewhat the 'up-slip' technique too as it's a similar treatment plane and set-up). In the lab, we went through the full risk assessment for cerebral artery dysfunction (which encompasses vertebral artery insufficiency) with our peer whom we were practising on. After the all clear (screening and informed consent) it was on to grade four mobilisation and grade five (manipulation) of the neck. It was interesting that nobody in our lab group actually performed a cervical manipulation in the lab - either the acting patient wasn't comfortable or the practising student wasn't confident. Obviously we're not to practice the cervical manipulation unless supervised by a registered physiotherapist, so our flatmates are safe. Actually, when screened properly the risks of dissecting the vertebral or carotid artery are very low (1 in 1,000,000)... to put it in perspective, the risks of death from NSAIDs are much higher.

In our physical agents lab we were applying FES and interferential therapy. FES stimulates your muscles to contract - it's particularly useful in neuro-rehabilitation. Interferential current is good for treating deeper tissues. Interferential therapy basically uses a low frequency of electricity to treat the tissue, but this cannot happen directly from the electrodes because it will also activate pain receptors on our skin. Because higher frequencies don't activate pain signals we can use two different moderate frequencies (e.g. 4000Hz and 3950Hz) to create the low frequency treatment needed deep in the tissue. When the two frequencies mix, the low (50Hz) treatment is produced. Interferential current seems like a useful and easy therapy to apply. Sometimes I wonder why we charge so much for treatment, because the process is relatively simple (unless we're using an interferential machine with suction cups).


Better three hours too soon than a minute too late. We're getting on with our neuro modules. I hope to be finished with it soon... as we'll be getting another assignment next week for Evidence-Based Practice!

Holy crystal ball, Batman! How did you see that coming? If you were looking through RCT (random control trials) then you mightn't have! You probably should have looked for a consort statement before believing everything you read. This was the theme for Phty355 evidence based practice. We used this theme to discuss how we will go about in-service presentations to colleagues (i.e. when we're asked to contribute to current knowledge in the workplace by giving what will resemble a 15min lecture before our 8:30am patient). Goodness, that sounds like a good way to start the day!

Quick, to the bat-mobile (Asthma Society vehicle)!! Second week out protecting the city of Dunedin from menacing modifiable risk factors and disease... "I'd better get out of my death bed" joked a patient we rang prior to visiting on Monday for COPD community placement. This patient had a few things going against him including T2DM, postural hypotension, ischaemic heart disease, idiopathic cardio-myopathy, osteoporosis, COPD (emphysema), and regularly got pneumonia. This was a new patient, so I got to observe our clinical educator and another student interview the patient. Although there were a few barriers to gaining the rapport of the patient, we got there in the end with motivational interviewing techniques. We revisited two patients' whom we saw last week, both were doing very well health and exercise-wise.

On Wednesday I had two patients of my own and I assisted another on an exercycle and bosu-ball. My first patient was the same as last week. A challenge with this patient was encouraging him to engage in a suitable aerobic exercise. Biking and rowing was out of the equation because his legs would fatigue quickly and long walks weren't particularly engaging (boring). We did ascend and descend the stairs four times which was a good enough leg workout for the day. I came up with aerobic boxing - surely I was on to a winner! When the patient arrived we asked the general health question "how are you today?" to which he replied that he was having some pain in his wrist. You might have thought that my plan was spoiled, but thankfully it wasn't. We did a brief MSK assessment and found that by stabilising the carpals we were able to reduce a lot of his wrist pain when he gripped. At the end of the session we took off to use the Umove boxing bag + gloves. The gloves offered some wrist support and the patient was able to bout out 4x 30s rounds of boxing. "Pain is the feeling of strength being sucked out of you." This patient has gone to hell and back. To reduce this patient's pain, our plan is to strengthen his muscles to pre-coma health. The second pt had severe COPD and we became suspicious of whether the oxygen saturation machine was reading accurately when at one stage it was reading 68%... this basically means that ~70% of his blood is filled with oxygen (ideally we all should be reading ~99%). The patient (almost 90y/o) was fine and I had him complete a 3MWT and some balance and core stability exercises. We're saving the world, one patient at a time!

On Friday we were back in South Dunedin (after a bit of admin) for an exercise class with the Pacific Island group. We were asked to coordinate and lead an exercise session lasting ~45minutes. After a warm up we ran three stations working on strength, aerobics and balance followed by a combined group challenge and a warm-down/stretching. Following our exercise session, there was a presentation by the Stroke Foundation and a healthy lunch. We didn't stay for the presentation on Stroke, but we were given a cup of pumpkin soup each on our way out... how well looked after are we!?! Very well looked after!

Holy strawberries Batman! We're in a jam. Pathology continues to use food stuff to describe what pathological tissues look like e.g. sloppy porridge for liquifactive necrosis/puss, fried egg whites and yoke for oligodendrocytes, and intracranial aneurysms that look like berries! Our lab investigated COPD whilst our lectures raced ahead and covered neoplasms & cancer. In the lab, the thick mucus in chronic bronchitis was likened to cheese off a pizza (the stringy cheese that ends up on your chin). Our cancer series has used skin-cancer, endometrial and colon cancers to highlight the many pathways which can lead to benign or malignant cancer.

It was a privilege to attend an inaugural professorial lecture on Tuesday afternoon 'Physiotherapy: Enabling health and enabling lives through movement and support'. We celebrated Leigh Hale's promotion to a professor and her successful application to becoming the Dean of the School of Physiotherapy. It seems that when lecturers get a promotion, they celebrate by giving a lecture! Classic. There were plenty of highly important people in the room including representatives from the Board of Physiotherapy, Physiotherapy New Zealand, Vice Chancellor of the University of Otago, and many more distinguished guests. There was also staff (most distinguishable people themselves), a few students and others from the community too. Leigh shared her physiotherapy journey, research and passion for physiotherapy - in particular neuro-rehabilitation. A key message was that by giving support for activities the patient chooses, we are able to build our patient's self-efficacy, thus to enable them to engage in life-long enjoyment and participation in physical activity. By the end of the lecture we were feeling inspired and thankful that the school will continue to be in good hands. Like Batman, Leigh is also a bit of a superhero!

Professor Leigh Hale.

Watch one, perform one, teach one. In the sport injury clinic we were taught how to suture wounds. We were taught two suturing techniques and practised this on cotton towels. The process is quite tricky as it requires steady hands and dexterity... but if you've had some practice tying hooks on a fishing lure, you're half way there. There are a lot of other important aspects of suturing, including patient comfort, local anaesthetic and sterile practices (this includes scrubbing and irrigating the wound). It's not within the scope of practice for the physiotherapist, physio student or sport medic to suture, but the opportunity is given to sports medics at the Otago Sports Injury Clinic because we're closely monitored and have our handy-work signed off by a medical doctor. There was a patient that turned up requiring a suture to a laceration on his arm following a ruck in rugby union. We were only allowed to watch that one (set up, irrigate, cut and clean up). Next time, it's all us.

Planting a time-bomb in the medical library is a felony... but that's just what we need.
Next week is the last week of this semester, then it's exam time!
Come on, Students', to the Bat Cave! There's not a moment to lose!

 ...to be continued!
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Wednesday, 13 May 2015

Y3S1W11: Community Physiothearpy (COPD)

An extra-curricular event turned into a major highlight of the week. It started on Wednesday, 5:30pm, with a presentation on auroras organised by the director of the Otago Museum, Ian Griffin. Ian is an avid aurora photographer whom shared his passion for auroras and photography journey. There were other guest speakers who explained the science of auroras, the history of auroras in NZ (of which dated back many decades), and how to go about photographing them. There just so happened to be an aurora storm brewing that night, so after the presentation I raced out with my camera (already in the car, set to go...) and snapped up some more scenes around Dunedin. I spent the first 3h hiking around an unfamiliar farm walking track to only find one composition worth taking a picture of (Paradise track to Highcliff track). The storm was almost over by this stage, so I promptly made my way to Hoopers Inlet - a safe composition location, to make the most of the southern light display.


...Right, back to physio talk. Respiratory pathology was the theme of our Monday morning. The 8am pathology lecture discussed COPD, which was useful because my placement at 9am was a community COPD placement. This is my last placement block for the semester... lets break it down a bit. 

On Mondays we do home visits to patients referred to us by the asthma society, these patients tend to have severe COPD, amongst other chronic health conditions. I jumped at the chance to get the ball rolling and called dibs on telephoning and taking the lead as physio for the first patient. We travelled in the asthma society vehicle then it was shoes off at the door (figurative and literally). My patient was an older female with COPD, recent respiratory failure, diabetes, sleep apnoea, osteopenia and at higher falls risk. I checked in on her diabetes management and energy levels before we went outside to complete a 6min walk test. The second part to the visit was to make sure she was confident with her home exercise programme. "Compliance to a home exercise programme is measured as the thickness of dust on top of the their exercise printout". Thankfully there was no dust collecting on this patients exercise programme. With such positive rapport gained, she happily showed us her CPAP (continuous positive airway pressure) machine to treat her sleep apnoea and oxygen tank in her bedroom. 

The second home visit was to a middle aged female with bronchiectasis (COPD). She was having trouble clearing phlegm. We put our chest auscultation, percussion and vibration techniques into action. She was able to clear some sputum from her left lung - we probably could have got more if she hadn't coughed a large amount up before we arrived. This lady also has a nebuliser with saline topical inhalant which is used similarly to washing a bowl in the kitchen - the water (saline) is put into the bowl (inhaled in to the lungs), in the bowl the water loosens off the foodstuff (thick mucus), and then the patient attempts to empty the contents into the sink (coughing the phlegm into a tissue).

On Wednesday, we were based at the clinic treating patients who weren't quite ready to return to the respiratory rehabilitation programme but well enough to attend exercise sessions at the School of Physiotherapy. One patient of interest that I was treating was a middle aged male who was recovering from a recent liver failure with COPD, low back pain, oesophageal varices (think varicose veins normally found on the legs, but these veins are in the gastrointestinal tract), and has had a few joint replacements. By now I hope you can appreciate the complexity physiotherapists are trained to rehabilitate.

Friday was a new setting again. We were providing education and exercise to the Pacific Islanders (associated with the Pacific Island Trust). These Pacific Islanders are keen to make healthier lifestyle changes. What makes this placement unique is the intervention style, which better meets the needs of the ethnic group. We will attempt to be especially culturally sensitive and incorporate cultural knowledge (games/activities/other values) into our Friday sessions. Today we were assessing their individual cardiovascular risk factors. There were three stations: height/weight/waist circumference, blood pressure, and blood glucose/cholesterol. I was in charge of taking blood pressures and calculating their risk of cardiovascular disease within the next five years. You can find more info about measuring your own risk factors here (contact your GP or physio if you have any concerns): http://www.knowyournumbers.co.nz/

Our MSK lab was on lumbar spine manipulations (yes, that's our Million Dollar Roll technique!) We also refreshed our palpation skills and assessment of mobility for the cervical spine as some preparation for next week MSK lab on manipulation of the lower cervical spine. In our MSK tutorial we had a shoulder case study and we worked through a differential diagnosis and treatment strategies. I found time to practice the MSK content covered so far with a peer on Thursday... I dear say that there will be plenty more peer-practice sessions to come!

Neuro had us examining the use of physiotherapy in long term management of progressive neurological conditions. An update on my modules... I've taken a 'lets do bits of everything' approach with the last three modules: paediatrics, spinal cord injury and peripheral nervous system conditions. I'm almost finished. A group of students booked a room out to watch the neuro DVDs associated with the modules. It was useful to have an open discussion about the impairments everybody else was observing.

Physical agents lab focused on TENS (transcutaneous electrical nerve stimulation). We had these hand-held devices sending tingly sensations through electrodes placed on our skin. There were different treatments including: conventional, acupunture-like and high intensity. The tingly TENS, from conventional treatment parameters, can be left on muscle tissue for almost 24/7. By the end of the lab I found myself playing with the machine, increasing the stimulus to contract my muscles... as it turns out, the 2x AA batteries can produce more stimulation than I can tolerate. Later in the week we had a lecture on interferential current - this will be next weeks toy... I mean treatment modality. Interferential current is slightly different to TENS (although appears to be similar). The main point of difference between TENS and interferential current is in its applicability. Interferential current uses two different pulse frequencies to treat a common (often deeper) tissue without stimulating pain receptors. The treatment pulse is the difference between the two frequencies. This is used to preserve muscle mass... it is especially useful if you had a spinal cord injury... or if you plan to sleep all day. TENS is mostly used to treat pain.

We have an assignment for the physical agent component of PHTY354. It's a vague case study with a few questions to answer in a 1500 word essay (basically, what is the likely diagnosis and how would we treat it with electrotherapeutic agents). This is due at the end of the semester (i.e. two weeks from now). The word limit isn't too much of a problem, rather it is fitting in time between the other demands and preparation for exams... and the rare time-out for yourself.

Hoopers Inlet
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Wednesday, 6 May 2015

Y3S1W10: "Laser Beams"

The week started on May the fourth with pathology lectures on the GI tract and a tutorial on diabetes. The diabetes tutorial had two case studies. The first ended up with gangrene and nephropathy/nephrosclerosis. Our tutor made a Wizard of Oz reference when describing the kidney tubules "I'm shrinking, I'm shrinking" due to coagulative necrosis process (kidney tubules shouldn't be likened to the wicked witch). The second had a diabetes proliferative retinopathy - we could see aneurysm, infarcts "cotton wool spots", haemorrhages and protein/lipid deposits in the retinal scan. Laser is used to destroy the newly formed blood vessels (which are leaky... so, not good!) in the eye  to reduce the ocular pressure - saving your retina from detaching from your eye completely!! ... but as physiotherapists, it's not our job to do laser eye surgery - even if we do use therapeutic laser.

Image result for may the 4th be with you
May the fourth, as a Starwars reference was an interesting coincidence because in our physical agents lab that day, we were using therapeutic laser (unfortunately not light sabres). We had our glasses on (no laser eye therapy for us!), laser pointers out and applying laser beams directly on our skin. Like ultrasound, the mechanism of treatment is to pass energy through cells to stimulate healing via a conversion of photons to biochemical energy. It can be used to facilitate the healing of wounds, tendinopathies, inflammation and can be used on acupuncture points. The down side to treatment (from a therapist's perspective) is calculating the energy, depth, intensity, duration and deciding how many points (and which points) to treat. There are a few guidelines (cheat sheets) which make the process easier, but you still need to understand how to use it and how it is affecting the tissues being treated. Laser therapy is unlikely to be used in the physiotherapists ploy for world domination any time soon.


We had another lab on the SI joint (the previous lab was in second year). We were taught five techniques with a clinical prediction rule so we could rule in or rule out the SIJ as a source of symptoms.

At the Otago sports injury clinic I saw a few new conditions including a middle aged male with a complete rupture of the long head of bicep brachialis and a young male with Sever's  disease.
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Wednesday, 29 April 2015

Y3S1W9: Ding

The 2nd and 3rd year physio students were once again involved in promoting the School of Physiotherapy during the Health Science First Year information evening, and the secondary school open day. I gave up two hours on Tuesday to get amongst the high school students whom were buzzing around looking at their career options. A common concern for many students was the common year, HSFY where they are lumped with medicine, dentistry, pharmacy and medical laboratory science hopefuls. The idea that they had to battle for their place was put to ease when we told them that the entry criteria was now 'should they meet the minimum requirements of a B- average, AND only select physiotherapy as their preferred professional programme then they will almost certainly be guaranteed a place in the professional programme'. So with that worry now abolished, they were then concerned about achieving grades in papers they really had not prepared for at high school such as chemistry or physics. Unfortunately that's something they will have to really study hard to ensure they pass with a good grade. Fortunately, all that first year health science study will be worth it, for they will be on track to becoming physiotherapists!! 

I participated in a Masters student's research project at the School of Physiotherapy on Wednesday morning. The data collection was undertaken in the biomechanics lab with a movement tracking system (UV, 3D-motion analysis) and advanced EMG setup. Researchers are generally more than happy to give you an insight as to how the equipment works, or to use it to showcase how your own body works. I got to see my shoulder muscles activation patterns with shoulder movement - the changes in EMG with movement reflect the dynamic role of each muscle group with specific movements (agonists/antagonists/stabilisers/neutralisers).... and as there was a lot of muscles measured, it was quite entertaining. It is an experience not to pass up, should you have an opportunity to participate in or conduct your own research using these devices. On this occasion the researchers were comparing a practitioner applied mobilisation with movement (MWM) technique of the glenohumeral joint with a self-mobilisation technique. I wish them well over the next few months as they analyse the data.

Biomechanics Lab, School of Physio.

 The setup: EMG and 3D Motion Analysis

 
Self-mobilisation with movement

 Physiotherapist applied mobilisation with movement

On Wednesday night we had our terms test for pathology. It was a 120 MCQ exam. The exam questions were played on a powerpoint show, with one minute per question before "Ding" the next slide/question was shown. There were plenty of images (histology, gross anatomy, tables and graphs) with arrows pointing, H&S stains highlighting, letters denoting and people with conditions displaying etc. "Ding". One minute per question was easily manageable (it was MCQ after all), however two hours of sitting there (most of which we were day dreaming or wishing for the previous slide to be replayed) was a struggle. "Ding". We had a joke before the exam about finishing early, knowing full well that if they did then they obviously had not seen all the questions (but the answer is always 'B' anyway, right??!). "Ding". In momentary discussions after the exam finished, I found that the general consensus was that the test wasn't as bad as we all had earlier perceived... yet, we were pleased to have been scared in to studying hard before hand. "Ding". Thank goodness for the "ding" after each slide changed, as this sound brought us back on task... but we're now very tied of hearing "DING!!" There was a lab group BYO (or in the case of our lab group, it was a flat pizza night) immediately following the exam for combined 2nd and 3rd year groups.

MSK is slowly bringing everything we have learnt together. The lab was split 50:50 between practical and theory. We started with clearing tests for the shoulder, thoracic and cervical regions. This fine-tuned our manual handling skills. There was a joke about "soft end feel" with horizontal flexion with overpressure for the shoulder joint on females... obviously that's something to avoid at all times! The second half was followed by a case study. We were tasked with coming up with a few hypotheses of the underlying structures at fault based on the subjective assessment. After stating our hypotheses, we had to explain what we would do in the objective test. Often our specific orthopaedic tests are based on functional limitations and reproduction of symptoms in the clearing tests. We were then given the objective assessment for the case and had to describe which structures were at fault and how we knew this. It feels like we're almost practitioners!

Our physical agents lab was about safely and effectively using ultrasound. There were a few machines (of varying ages) that we had to be confident using (once you've used one, you've used them all.... sort of). There are a few different ways to apply ultrasound e.g. through water, gel, balloons - so long as there was a contact medium. Apparently the ultrasound head is fairly easy to brake (and quite expensive). Our lab books also listed condoms as a good contact medium... but I wonder how well that would go in real clinical situations. Ultrasound is reported to be a useful therapeutic modality, and it is easy to use. There are a few parameters we need to think about: depth of penetration (1MHz vs 3MHz), duration of treatment, intensity (W/cm2) and whether it is continuous or pulsed (and the ratio of the pulse).

The week ended with an infections prevention and control lab. We were reminded about the 'five moments of hand hygiene', personal protective equipment (gowns/gloves/shields/masks) and protocols for people with or suspected to have a viral illness. There were a few 'what should you do in this situation' case studies and then we all practised putting on and safely removing the personal protective equipment... yes there is an order to removing the gear so as to contain any bacteria or virus that may have been sneezed on you, rubbed on you, or virus passed onto you by exposure to vomit. We didn't get to see an Ebola suit (although I'm sure the DHB will have one somewhere). When we were all dressed up, there was a suggestion that we should all run through the main street yelling "it got out!!" - that would be entertaining (and have many unintended consequences).

Vodafone was giving free passes to the rugby on Friday!! These opportunities don't come around too often. In the end the Highlanders were too strong for the Sharks, beating them 48-15!


With pathology terms test done, we can focus on other things... some productive, others for pure entertainment. If you're into a quiet evening reading physio blogs - here are a few worth browsing over. (I'm linking them here to save bookmarking them elsewhere):
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