Catching up from the last week.

Nearing midterm for the affiliation means filling out (by hand, as Hunter is one of very few school who have no converted to the electronic version) 27 pages of a 40 page packet that painstakingly dissects all theoretical elements of a student therapist's performance and abilities.  My Clinical Instructor also fills out one of her own.  The midterm takes place when we compare views of my performance.  If your mind's response is to call the process laborious, then you've hit the thumb that is holding the nail meant to go into the coffin.  I have five pages to go and have already spent about 6 hours filling it out.  Waa waa, boo hiss.  Whatever.  There are a few things frustrating me about this affiliation, but they are not appropriate to discuss online.  In reality they are probably very similar frustrations that many students experience due to the nature of the affiliation process.  But I will say that the good things by far outweigh the frustrations, for which I feel lucky since not all student can say this.

I've found the key to keeping my joints happy in the summer is to ice immediately after every run and possibly every night as prophylaxis.  I'm starting to think I need to get two more ice packs so that with four in total I can ice both knees and both ankle/foot simultaneously.  I am, quite thankfully, acclimating to summer heat.  This morning I was able to run without any sensation of suffocation or burning from the inside out.  Not that I'm fully comfortable, but its just better.  Now if only running with ice packs on my knees were realistic for tendon function and wouldn't cause me to run like a penguin....

This past weekend's run was again over the George Washington Bridge and onto the Palisades Road, totaling 20 miles in about 2 hours 50 minutes.  The fun is that you are always either climbing or descending, and while this may sound counter intuitive to some it actually makes my legs much happier.  Running on flat road bums out my mind and my body.  Hence why I rarely stay on flat land, usually for very rehab oriented runs that I have not needed in quite some time *knock on wood*.  Last year I ran the Brooklyn 1/2 Marathon, which included a little over two laps in Prospect Park followed by a straight shot south on Ocean Parkway with a quick finish on the Coney Island boardwalk.  The portion on Ocean Parkway is 5.5-ish miles of nearly flat road with a minimum of 3 lanes in each direction and trees/houses/etc very far back set from the road.  The thing feels like a friggin highway leading to nowhere, and heat waves radiating from the road are the only block to seeing the next mile marker sign awaiting you dead straight ahead.  Can you tell I was thrilled?  Hence why I wasn't all that troubled with debating running it again this year versus running Bear Mountain.  Give me two and a half times the distance but on a much more interesting and technical course any day.  Granted retrospection alters your memory of events, but my mind places equal mental taxation to each of the Brooklyn 13.1 miles and the Bear Mountain 31 miles.  Goes to show what flat roads do to me. 

This weekend was extremely social.  I had friends over on Friday night who I hadn't seen in some time.  I needed to exchange stories, and I got exactly that and then some.  Sadie decided to show off for some of the guys.  In the background you can hear fellow students discussing their affils, Al Green offering sound scape, and some attempts to cheer on Sadie (like the fella in the background).  She was at it for a good minute before I got my camera out.

Saturday marked the arrival of Tim (my brother), Jenny (sister-in-law), and their friends Morgan and Jaime.  I met them in the Upper West Side near their hotel for lunch that ended up with more of a brunch menu.  I'm so anti-fabulous about the city these days that I forgot that my missing breakfast that morning would be fulfilled by restaurants' brunch menus that last as long as through four in the afternoon.  They went for a walk, I ran some errands on the way home, including a chat about possible non-chafing gear from my friend Mike who works at Patagonia UWS and who joined me for RAGBRAI and other cycling adventures in previous years.  That was a bust, but a few other errands were successful on the way home.

A few hours later the group joined me at my apartment to hang out, see where I lived and to meet the kittehs, who put on a good show of synchronous yodeling once it came to feeding time.  When asked where they'd like to find dinner, no one cared until I mentioned that Nathan's job is located in Hell's Kitchen.  Tim found the neighborhood name quaint, so south we headed.  Once resurfaced at 59th street we turned south to scope out restaurants on the way to say hi to Nathan.  Then we parked ourselves at El Centro, and Nathan met us once off work. 

Sunday started with my aforementioned long run, after which I quickly iced, showered, and joined the group at the NYC Pride March.  I mentioned that marriage equality was on the cusp between approval or failure.  Last Friday the bill was approved at something like 11 or 11:30pm.  Meant it was an extra exuberant celebration this weekend to finish off Pride Week.  Governor Cuomo, who introduced the bill in the first place, marched along with Mayor Bloomberg and City Council Speaker Christine Quinn.  I am impressed that Cuomo got the legislature to actually act on things this time around.

But I hear the Senate republican, who have the majority and thus decide what bills come to the floor, decided to vote on a state vegetable before attending to the equality of marriage bill.  Was this to produce more grand effect, or was this a version of stalling while the needed votes were still sought?  Likely something much less meaningful.  Regardless, the newly designated state vegetable: corn!  Nice.  So much for distinction from all those other states that are covered in corn.  I hear there is a lot of corn upstate between the stereotyped apple orchards, but I still don't find that impressive.  To have corn as your vegetable then you have to LOVE corn.  Take Iowa, where corn festivals are serious and frequent endeavors.  Then again, the runner up was an onion. 

Back to Tim and Jenny's visit.  I was grateful for the consensus of simply hanging out with no grand plans.  The parade was a hoot, but we happily left once the crowds got the best of us.  It started at noon, I met the group at 1, by 1:30 people needed to sit and rest away from the crowd.  We attempted a pizza joint Tim dutifully found via his smartphone that had good ratings, though unbeknownst to us (or the web) it was closed and vacated.  So we walked around the corner and took the first place we found, a thin crust pizza joint.  How thin?  Well, thinner than just about any cracker I've had before.  They offered a "nine-grain organic crust" for $2 extra per large pizza.  But if the crust is such that eating an entire pizza would accumulate the quantity of one normal slice's worth of crust, how much nutritional benefit would you actual yield from a few slices of the multigrain? 

I think the crowd wore us down much more than expected.  When I met up with them, they actually had crossed to the east side of the street before heading south to the parade, so that meant after eating and being done with the crowd we had to either traverse one of few streets allowing cross-throughs in sardine/cattle run form or we had to walk nearly a mile north just to then head west and south again to Morgan and Jaime's bus home.  We opted to traverse.  After surviving the 15 minutes that required we went for ice cream at the Ben & Jerry's near the needed bus stop and a quick stopover at a drug store.  Back to Philly for Morgan and Jaime, back uptown for me, Tim and Jenny.  We said our goodbyes on the subway, as I had a pile of paperwork awaiting me that I so dutifully sidelined in lieu of family time.  Nicely, the weekend left me feeling refreshed when waking up on Monday morning.

Now it is Wednesday.  I survived my birthday on Monday, managed to keep it relatively quiet (by preference).  This morning Nathan left for a vacation to see family upstate.  After putting seeing him off to his bus I walked a different route to work and ran into a friend of a friend who I have a knack of running into every 4 months nearly to the date.  After work I walked a little extra rather than getting on the nearest train, and ran into a former co-worker I hadn't seen since September of last year who was attending an acting workshop in midtown.  Sometimes NYC is not as big as it seems, but that does not preclude its intensity....

A little ditty about MS and an accordion finish

Today I worked again with Ms. E who has multiple sclerosis (MS), though I'm not sure which type she has.  For those who are not familiar, MS is a disease of demyelination within the central nervous system.  In simpler terms, most nerves are covered in myelin, a succession of fatty insulating blobs that allow electrical impulses to travel faster along said nerve.  The exact origin of MS is unknown, though it is postulated to be an autoimmune disease where the body "attacks" itself and removes this insulation layer (demyelination), but only within nerves inside the spinal cord and/or in the brain.  There is no pattern to what areas of the spinal cord and/or brain are affected in the way that Parkinson's is always a disorder of the extrapyramidal system (the substantia nigra portion of basal ganglia).  Symptoms thus occur according to the nerves that are involved.  These "lesions" can progress slowly over time so that more and more nerves are affected, they could be affected in bursts of lesion development called exacerbations that are intermixed with remission, or they could develop one lesion and rarely be affected by it in the future.  All depends on what type you have and what areas are affected.

What happens when nerves are demyelinated?  The electrical impulse does not travel the way it is supposed to.  If a motor nerve is involved there could be weakness or paralysis of a muscle.  If sensory is involved, there could be paresthesia (abnormal and/or painful sensation) or anesthesia (absence of sensation).  Why are lesions limited to the central nervous system?  Good question.  If it is known, it is above my level of knowledge.  But one big common theme with MS is fatigue.  The absence of myelin means electrical impulses travel slower, but this is heightened with increased body temperature regardless of whether this is due to hot weather or due to raised body heat from exercise.  Activity must then be modified so that the patient does not hit that level of effort that may trigger their fatigue.  Otherwise you will see those muscles progressively weaken until they seem paralyzed minutes later.  With rest this improves, and this does not preclude them from exercise in general -- on the contrary, preventing disuse atrophy is one of the best ways to prepare a patient with MS for any exacerbation of their disease.

So back to Ms. E.  Her MS at this point has developed into paralysis of both lower extremities, a very weak trunk, and partial use of her arms with the right more functional than the left.  Paralysis in the case of a central nervous system disease means that signals still reach muscles, but they are not normal.  School prepared us for all the motoric involvement with patients, such as with Ms. E.  But we never really discussed the sensory involvement aside from stating that "it can be quite painful."  Okay, bub, that sure helps me out.

Turns out that Ms. E has specific sensory involvement that can be pinpointed in a way I had not expected.  Different types of sensation travel by their own types of nerves grouped together in the spinal cord.  Light touch (think of a tickle from a cotton ball), proprioception (knowing where your body is in space) and vibration all travel through the dorsal column/medial lemniscus.  Separately, crude touch (a hand grabbing your arm), pain and temperature travel through the spinothalamic tract.  It is her dorsal column which is affected, and you can easily tell the difference.  Any light touch, such as a gentle hand resting on her knee while waiting for the aides to get set up for a multi-person transfer, is incredibly painful.  However if you go for it and grab her knee like you would a bat, using crude touch, then everything is fine.  Similarly she has no idea where her legs are in space, and thus will fuss over whether her leg is straight or whether her foot is fully supported on the footrest of the tilt table when everything is already set in a very fine position.  Vibration, well, I'm pretty sure that this is not testable due to the pain associated with light touch.  And she definitely feels pain and temperature differences, which are in the spinothalamic tract.

This type of differential involvement was taught to us assuming we'd need it for our spinal cord patients.  I have 5 spinal cord patients, and I haven't needed to differentiate any of this with them, likely because I'm in an outpatient clinic instead of rehab, but whatever.  But to get to see this in any patient is incredibly interesting.  Realizing what I was looking at was one of those "aha!" moments where you see for the first time the anatomy play out just like the textbooks say it could.  It is rarely so clean cut and distinct as with Ms. E's case.  Yet another moment of maintaining a facade of professionalism while inside I'm jumping up and down like a 5 year old screaming "WHOA!  Did you SEE THAT?  Duuuuude...."  And, yea, I'm that much of a nerd and that classy deep down inside....

How do accordions fit in with this?  Well, they don't.  This morning's run was pleasantly supplied a mental soundtrack by Beirut's song "Nantes."  Thought y'all might enjoy too.  Again, a better quality video may be seen by following the link to the original YouTube video.

 
Lastly, I leave you with Sadie's first experience with a laser.  I imagine that a kitteh rave would look something like this.  You can also see Merus's flapper attack here.

A mixture of thoughts

Now is when I wish I could project the thoughts/sounds/images from my head so that someone else can help me figure out what the heck I'm thinking.  Two songs alternated throughout my long run, but I can only identify one of them.  I could have sworn that song A was from Billy Joel, particularly because he is ubiquitous to all iPod playlists played at work.  But I have scoured all of his preview-able songs on iTunes and searched on Google for the fraction of lyrics that looped over and over again, and I still come up short.  It's teasing me now.  The second song, well, I'm not sure where this one came from - Madonna's "What it feels like for a girl." Go figure. 

Went back to the Long Path today.  About a mile in the trail becomes what I'd call half single track, since the normal single track width (only enough for one person) is half obscured by the overgrowing foliage, so you end up running with your arms out in front of you to avoid getting swat in the face unknowingly.  As I neared the end of this section I encountered a deer trotting straight towards me.  I didn't want to scare it, so I stopped about 15 feet shy and said "Hi, deer.  I don't want to startle you.  Want to run together?"  It just stared back at me with a little tilt of the head.  I repeated "So, wanna run together?" and started to walk towards it.  It turned and did a rather good impression of a scoffing teenager since I was seemingly forcing it to go the other way from its original route.  In about 50 feet it found a hole in the trees and scampered off on a tangent.  On the way back to the George Washington Bridge I looked up at the underside of my hat brim to see a caterpillar crawling upside down towards my face.  How long had it been there?  And did it start on top of my head and work its way under?  It might have been on there for as much as 7 miles.  I returned it to what I assumed might be somewhat yummy leaves and kept on. 

Speaking of bugs, saw my first firefly of the season!  It's always random when I see the first one, because in NYC I am rarely near grassy areas at night.  A few days ago Nathan and I went to grab some pizza.  Next door is a small church set some 20 feet back from the sidewalk, enclosed with a gate and with a full lawn and shrubbery.  I saw it in the corner where the yard and sidewalk met the pizza establishment.  After seeing the glow, I pulled a hard 180 and tried to catch it.  Nathan, carrying our dinner, laughed and kept walking.  I think he called me something just shy of ridiculous.  The firefly made me happy enough to skip to catch back up with him.

Around town it is nearing the end of the school year.  NYC schools run by far longer on the calendar than my school district growing up.  Many graduations have taken place this last week.  And yet yesterday as I was walking to the clinic I saw a young boy in Midtown West all decked out in a blue cap and gown with a yellow ribbon/sash/thing.  This fella was maybe in 2nd grade at the oldest.  I repressed the desire to glare at the kid.  I mean, I've never had a full graduation ceremony, and I've completed both high school and an undergraduate degree.  I had to leave my high school ceremony early thanks to the school scheduling it for the same day as track sectionals again, and Iowa did away with summer graduations the year I finished and I missed the message about either walking in the spring (oops, too late) or at the end of the fall (you expect me to come back for that??).  I'm looking forward to graduation next year because it will be the first degree that is truly meaningful to me, and I'll get to stay for the whole friggin thing.  And yet this little bugger gets a full Pomp & Circumstance just because he could color enough inside the lines and can write his ABCs?  Boo hiss.  New Yorkers annoy me to no end.

State officials in Albany are also making asses of themselves, but what else is new.  NYC and surrounding boroughs send scads of tax money to Albany, only for them to shun many of the approvals needed by the city in order to accomplish major projects.  I worry that it is going to happen again this week.  One previous example of this is congestion pricing.  It's based off of the success of London's similar plan and would have been absolutely amazing.  Yet Albany decided that they simply wouldn't even bring it to the floor for a vote.  Every so often locals joke about seceding from greater New York State.  The difference would be huge - NY State would be the fiscal equivalent of Arkansas.  I forget if that includes Long Island seceding with us.  Regardless, that's how much impact the NYC area has.

The next big ticket item is a third? fourth? attempt to pass marriage equality legislation.  At this point NY recognizes marriages performed elsewhere but does not allow them to be created within the state.  It's been a big battle between those living upstate and those in the city.  A few weeks ago Sen. Ruben Diaz held an anti-gay rally in the Bronx on the same day as the AIDS Walk in Central Park, supported by former Rep. Anthony Weiner and Assemblyman Richard Gottfried.  Sen. Diaz even has a gay daughter or granddaughter, and I forget if she was counter-protesting the Bronx rally or if she was vocally attending the AIDS Walk.  Either way, 40,000 showed up in Central Park while only a mere 1,000 showed in the Bronx.  Too many people in the NYC area support marriage equality as a civil right.  Our neighbors in Connecticut, Massachusetts and Vermont have approved it, with CT offering very articulate legislation as to why.  The hearsay goes back and forth depending on which news source you follow as to whether the last needed republican vote is likely or not.  It has to pass soon, because I think the session is nearing an end.  I'm hoping it doesn't end the same way many other meaningful bills die once when go upstate.  I know too many good people whose lives could be improved for the better by the passing of this bill.  It has a little to do with what the term is called ("union" versus "marriage"), but more so deals with legal rights like taking care of your family in case of unexpected sickness/death, insurance coverage and getting to ride in the ambulance when your partner is being whisked away to the emergency room. 

One last lighter note.  On Nathan's suggestion, I picked up a $5 laser at a pet store.  Amazing.  Here's Sadie showing off her rave dancing skills.  If you follow the link to YouTube then you can watch it in proper HD.

Start of week 3

Today marks the start of week 3 of my outpatient affiliation.  The time warp of school persists, though now the days go by fast and pleasantly.  I cannot remember which author in which I first read of the "whoosh effect," wherein good times strum along almost faster than you can keep up while rough times become strung out.  For some reason I want to say Douglas Adams or John Irving or Kurt Vonnegut, but usually such a lapse in memory recall gives a clue 3 stages away from how I think they present.  Meaning, my mind will say "their name starts with an F!" where in actuality there in an f-sounding ph in part of the book's title and their name actually has a T in it somewhere (as in some letter that gets crossed).  This may sound familiar to those whom I have described my astronomical difficulty with extemporaneous writing assignments.  Regardless, I may not ever know the date or day of the week correctly, but I am pleased by the greater state of whoosh-ness.  [Oh yes, I went there with my suffix.  Credit owed to performance theorists like bell hooks and Judith Butler.]

The outpatient setting is fun, but has its drawbacks.  Patients are only seen in 30 minute blocks, and that is assuming that transportation outlets for these neurological patients works like its supposed to (har har, good luck with that one...).  Patients are in chronic states of injury at this point, but long-term disuse and negative neuroplasticity create replicable patterns from patient to patient.  Furthermore most patients did not receive proper care during any stage of their injury, including chronic stages for as much as 18 years before coming to this facility.  Not that we are doing anything ground breaking, we just try to give whatever level of actual care we can rather than just a hot pack and ultrasound modalities before sending them on their way.  I previously described Mr. B, a chronic stroke patient with Parkinsonism characteristics.  His family didn't realize he had continual low-dose strokes until they had accumulated over a year and he was resultantly bed-ridden, and once given medical care nothing was done for his paretic and high-tone arm except a hot pack and elbow range of motion.

I have treated Mr. B a couple times now, which has been a very interesting process.  He is cognitively affected, so that he'll answer any question agreeably and doesn't understand verbal cues.  Thankfully he does follow gestures well, which I discovered today, so pointing while saying "lift up!" will yield actual results.  His tone is hard to decipher because you cannot use any patient descriptions within your assessment because the patient has none to offer.  The feel of his tone and range of motion could indicate any of three things: rigidity, massive muscle guarding against pain, or stage 1 of adhesive capsulitis (the "freezing stage" of a frozen shoulder).  I worried about the latter during my first assessment of him, particularly since I found restriction in a capsular pattern including nil external and internal rotation.  Mentally I was freaking out about whether my assignment to perform range of motion exercises on his shoulder would exacerbate symptoms.  Thankfully, it turns out to be an initiation block that correlates more with the premise of rigidity, where his body resists movement internally or externally initiated until some axonal threshold is crossed and he can finally move.  The tricks to cross that threshold -- that is the task at hand.  Mr. B is a patient from which I will continue to learn boat loads (metric sh*t tons!).

Ms. C is a bariatric patient with joint pain and major loss of functional independence.  She is incredibly motivated, and is quite practical with her personal goals of cleaning herself independently after using the bathroom and getting out of bed independently.  Seems like an acute bedside type of goal set, but her main limiting factor is her morbid obesity; she is over 500 pounds, but by how much is beyond my knowledge.  My first two sessions with her were performed in her wheelchair, as the clinic does not have a Hoyer Lift to transfer her to a mat and at the time the clinic had a bariatric walker (i.e. rate for patients up to 700 pounds) on order.  Lots of upper extremity motions with an emphasis on endurance, very reminiscent of the upper extremity class held daily by the occupational therapists on the spinal cord injury rehabilitation floor at Mount Sinai Hospital.  Then the walker arrived.

Thankfully, Ms. C is stable on her feet.  I still have to guard her when she walks, but the impending doom is much, much less than when I was first presented with the task.  For those who don't know, falls are NEVER okay during therapy.  Any falls at home are taken very seriously, a risk of falling can be the primary block for a patient who wants to regain independence, and every precaution is taken during session so that patients never hit the floor.  It is rare for such an opportunity to strike in outpatient, but sometimes knees give out or fatigue overtakes the patient's control.  If so, as the therapist (with a license and with malpractice insurance) you guard them, you catch them and you get them safely onto a seat or a table mat.  What do you do when the patient is >500 lbs?  You assess their ability before the attempt, if needed have a wheelchair follow (still dangerous, as she can and has nearly tipped her 300+ pound power wheelchair by accident before), and if she goes then you have to let her fall.  Otherwise you sacrifice your own health and your ability to treat the rest of your patients.  It is a unique case, where even if you had four people giving contact guard it still would not be appropriate to catch her during a fall.  I am happy to say that in the three sessions that we have walked, she has improved every time.  The distance remains the same -- 60 feet -- but she can speak a word or two mid-ambulation now.  That's a huge jump in stamina.

Then comes Mr. D, who has bilateral knee osteoarthritis and a script for therapy twice weekly, yet never reports pain, has no functional limitations and practically skips into and out of each session.  After so many patients, even the orthopedic cases, who need genuine help to restore normal life it can be difficult to respect his need for services.  Mr. D is super sweet, never argues, is more motivated to participate than 80% of the other patients, and yet I continually must remind myself that it is not my place to judge patients -- that any level of discomfort deserves a full course of treatment.  Perhaps his initial prescription was intended to jump start a home exercise program for long-term self-administered conservative care.  I was not yet at the clinic when he was evaluated, so cannot say for sure.  If we are given a script then we do our best to show a need for care within initial evaluation documentation and sometimes hyperbole can help our case.  I recently spoke with a classmate about the differences between her outpatient sports/orthopedic affiliation and my outpatient neuro/ortho affiliation.  She wonders the same thing regarding need of care, having spent her first affiliation in acute rehabilitation and now working with weekend warriors who have a slightly tender ankle.  I would and do have the same initial reaction as she does, but, again, must remind myself that any pain or limitation equates with some difference in how a person spends their time and thus affects quality of life.  We are not there to judge whose case is of more need; we are there to help resolve any and all limitations to a patient's normal life as best we can.

On that note, time for some whoosh sleep....

Note to self, need to shoot some legitimate film soon... [REVISED]

Comma M, Comma S

I had a picture of the two of them holding down an orthopedic textbook by Mark Dutton that is as thick as my thumb is long while I was trying to research spondylolysthesis interventions, but I think this video better illustrates their current state.  Namely, Sadie goes on exploring in her dainty ways like that of any kitteh with finness.  Merus once again proves herself to be, well, a bit of a simpler kitteh.  This latter point may also be witnessed in (the also recently posted) video of Merus and the bouncing ball.

Crappers and devil's dreams.

The Queens Half Marathon (1/2M) is full!  Crappers.

[Betcha thought a title of "crappers" would implicate something entirely different, didn'cha??]

I remember back in January or February that the Brooklyn 1/2M, set for late May, filled all its spots in a ridiculously small amount of time.  Brooklyn is the most popular of the borough affiliated 1/2M series (go figure), and while it usually hits max capacity 2 months ahead of time this year it was full some 4-5 months ahead.  Here's the deal: New York Road Runners this year started guaranteed entry to the NYC 1/2M if you run all the other borough 1/2Ms.  Its not like the NYC full M where you run any 9 races and volunteer once -- you can only get in by running the other 1/2Ms.

What does that mean?  Last year the Queens, Bronx and Staten Island 1/2Ms each had thousands of entrants but never hit max capacity.  I had been debating a few races (Bronx 1/2M or a 50k in KC, since they are the same weekend) with the intention of signing up for them all at once so as to avoid multiple processing fees.  But a few days ago when I'd finally decided on my late summer/early fall race lineup... lo and behold, the Queens 1/2M is full.  It's probably the scuzziest of them all, stuck in concrete-laden Queens with late July heat and lots of icky traffic pollution, and yet its full solely because of the guaranteed entry deal.  So this year it'll be claustrophobic on top of its regular hot sticky icky cement-y grossness.  Maybe its better that I miss it.  But I will need a different mid-summer race to keep me going.

[On a side note, "scuzziest" never developed a red squiggle line beneath it indicating that either I had misspelled or I had made up the word.  Awesome.  I'll add that one to my supporting list next time Nathan makes fun of me for my term "warbly-warb."]

Continuing the theme of running, I've realized that grad school and a youth spent in the sun have aged my eyes so that I wear my glasses all the time and need protection from the sun when running or outdoors.  I don't run with my glasses because there's no way they'd stay on my face.  Maybe they would, but somehow their small, subtle prescription never seemed to require it when I'm merely putting one foot in front of the other at a quicker pace.  Turns out, I realized as of late, that I focus on the road about 10 feet in front of me because its more in focus than the surrounding scene.  My eyesight is only so nearsighted as the 8th and 9th (or so) lightest lenses of the eye doc's assessment box -- you know, those lenses the eye doc uses when they ask "is this better, or that?"  Yet it is significant enough that I don't keep a good head/neck posture.  The dream solution is a pair of Julbo brand sunglasses called, ironically, Run that fit most excellently, stay in place, are NOT polarized, and can come with what they call Zebra lenses that morph from light to dark depending on the environment.  For the other gear geeks, these lenses allow a visible light transmission rate of 7% if super bright to 51% if in shade or mid-range light.  Downside: they cost $160 before adding prescription lenses.  I've drooled over them for the last two year, and the cost has been the main hindering factor.  Debating what the solution should be.

Aside from realizing that parts of my body are getting older, this week was the first full week where every run felt good.  I wondered how long full recovery would take following a major race like the Bear Mountain trail 50k, and it seems about a month is a good estimate.  My running total was 34.3 miles over 4 hours and 36 minutes, and walking totaled at least 25 miles but was probably more.

I've mentioned before that songs will pop into my head during a run.  I've become very disconnected from music since I started listening to NPR in Iowa.  The shift was partly because I didn't want to suffer through some of the experimental hipster stuff on college radio while waiting for songs/styles that I enjoyed.  Then, once I re-entered academia, I realized that I cannot study if I hear different words from what I am reading and thinking.  Classical music works, but NYC's classical station can be rather hit or miss.  Honestly, I forget that having music on is an option.  That's partially because some song is usually playing in my head, and that keeps me musically occupied for much longer than one might expect.  I don't play a song just before a run unless the devil's dream was a decidedly foul move by my deejay-ing subconscious.  Sometimes a bodega (aka NYC corner deli) or store will be playing stuff that pops up a few days later, or Nathan will usually keep music on at his apartment.  Or every once in a while I put something on while I cook.  The subconscious deejay has ten times its usual options thanks to the outpatient clinic at which I'm currently posted.  It's funny how most of these pop-up songs reflect the needs of the run or of that day's mental needs quite well. 

Sunday 6/05:  17.3 mile long run out-and-back on across the George Washington Bridge and onto the Long Path.  Song: The Beatles, "Get Back." 

Tuesday 6/07:  8 miles loop in Central Park, 5x8-minute intervals.  Song, which I definitely blame on the clinic: Journey, "Any Way Your Want It."  Made me laugh, but I'm glad that one didn't play for very long after my run was finished....

Thursday 6/09:  9 mile out-and-back on the Hudson greenway to Dykeman St. and back, 8x5-minute intervals.  Song:  U2, "With or Without You."

Now time to catch up on this week's Wait, Wait, Don't Tell Me episode, and possibly another shot of Radiolab.  Yes, I am the nerd that will list NPR shows when originally asked what TV shows I watch.  Also, for those who noticed and were left wondering, I opted for the 50k road race in KC in lieu of the Bronx 1/2M.  This way I get to see some of my family before the fall semester starts, although I do shed a tear for missing the Bronx, since in my opinion it is by far a more interesting race than most other NYRR races.

Mr. A and Mr. B

Working is astronomically better than being in school.  The difference is startling.  I am in an outpatient neurological facility that also sees some orthopedic cases.  Ron, a classmate of mine, is also at the same facility.  It's been fun to see him working with a completely different patient set than my own.  We have the good fortune of actually liking our CIs (Clinical Instructors).  Mine seems a little ADD at times, but I've realized that so long as I precede each patient session with the right questions then I will be prepared for what is needed.  My CI gives me a lot of autonomy so long as we've seen the patient together once before.  Yesterday that meant I saw 80% of the patients on my own while she worked on internal documentation in the next room over (which, since the wall to the office is glass, would be considered "distant supervision.")  Today was less on my own, but most patients were new to me.

In terms of my own case load, I have at least 4 patients with spinal cord injury (SCI).  Three cases are mid- to low-thoracic injuries, so these patients have full use of their arms and at least the top half of their trunk if not most of their trunk.  One interesting case is concomitant with a gun shot wound to the head and thus traumatic brain injury (TBI) on top of an incomplete lesion somewhere around C1-C4 (meaning cervical nerves in the upper neck).  Neurologically, patients are assigned one designation according to the highest spinal nerve level that is intact for both motor and sensory.  I keep wishing they would include full ASIA assessment scales, just because that's easy to look at to get an initial idea of the patient.  But I suppose it doesn't matter too much since we complete a full evaluation and treat their deficits accordingly.  Some patients know their level whereas others have the dual TBI that may or may not be evident, so the only concrete indication may be the ICD-9 codes that give a range like C1-C4.

This latter patient, the C1-C4 with concomitant TBI, I will call Mr. A.  He is an interesting case.  This morning went fast since every patient showed up, and they were all on time to boot.  That meant I had to suffice with a verbal run-down of what they've been working on lately instead of checking the plan of care listed in the notes.  My CI included all the functional information, but I didn't realize til part way through that she didn't say his diagnosis.  From his facial expressions, motoric patterns of speech and sharp wit I at first thought cerebral palsy.  From his left arm and leg I'd have though stroke.  Then I noticed a very faint line of absent hair indicative of a craniotomy suture scar, so wondered TBI.  The SCI is incomplete, but the TBI was much more impactful.  And yet he is super uber fun and quite capable aside from tone limitations.  He called me "Laura the explorah" while working with the OT before our session, and he couldn't stop talking about his 2 year old granddaughter who gets to stay with him and his wife for 2 months this summer.  Mr. A is the kind of patient that you wish were duplicated throughout your schedule -- motivated, excited, full of life and interest, genuine with every laugh.

There is another patient I described to a school colleague who I've realized is interesting enough to post, and this patient was the main impetus of wanting to talk PT today.  I'll call him Mr. B.  He is, unfortunately, not my patient but Ron's.  Guess you could say I'm jealous he got this case.  Mr. B had a a long succession of very small strokes some time ago, and no one knew until months had passed and the subsequent accumulation of small strokes had taken a huge chunk of out his independence.  Now he is attending PT for chronic issues.  The interesting part of Mr. B's stroke presentation a very particular and isolated manifestation of Parkinsonism.  And for those who may not know, Parkinsonism means "characteristics of" rather than actual, primary Basal Ganglia/Substantia Nigra/extrapyramidal disease.  Mr. B only experiences difficulty with initiation for sit-to-stand the beginning few feet of ambulation.  His feet festinate like crazy, there's no arm movement to assist anything, you can see his left leg starting to pick up but not being able to cross the threshold.  Check here for a visual of what a Parkinsonian gate looks like.  The festinations experienced by the man in the video when turning are similar to what Mr. B experiences when he tries to start walking.

On my first day in this affiliation one of the aides (who are AMAZING, by the way) was helping him stand and them walk over to the stationary arm bike, but he got completely stuck once standing and spent at least 2 minutes festinating in place by the time the aides realized he was "stuck" much more severely than before.  Another aide got my CI to help.  They tried having him step over a line marked on the floor, step over their foot, move as big as he can, tgo around objects....  These were all attempts to trigger the external cueing needed to "unlock" a patient.  They aren't weak or unable, they just need something outside of them, such as stepping over an object, to make the motor patterns fire.  None of these worked for another 2 minutes.  So Mr. B was getting quick the jitterbug workout for at least 4 minutes in total until finally they got him to turn (still in his festinating pattern) slightly to the left to go around an orange cone placed in front of him.  He took a few quick shuffles, each moving perhaps an inch forward, and then BOOOOM!  Just like that, he walked as though he had no ailments at all.  He walked perfectly to the arm bike, side stepped to get around an object, took the cane that he suddenly had taken for a walk (rather than use) and hung it off a nearby, unused machine, and mounted the bike seat without any problem.  Each stride was smooth as a whistle, weight shift from foot to foot was marvelous, and any decreased arm swing during gait seemed a mild remnant of the stroke.  It's as though the Parkinsonism just washed away and disappeared.  Amazing.  Absolutely amazing.  

This is why I am so interested in neurological physical therapy.  There's nothing clear cut, all patients present differently even if they have similar diagnoses, and you never know what is going to come out along the way.

On another note, I've been posting kitteh [sic] videos on YouTube.  I'm turning into a cat lady.  But take heart that after another year or two, once I complete school and leave NYC, I will have a dog dog [sic] to compliment my kittehs.  Imagine a boxer, pitbull, husky, or great dane kind of dog dog all snuggled up with the kittehs!  Gee, its not obvious at all that I'm ready to move on with live.  Not obvious at all... *cough*ahem*  Here's one video of Merus to get you started, with Nathan's Civil War show contributing the sound score:

First weekend without studying

She picked a killer pair, but I wouldn't have supposed that dirt from Bear Mtn. would taste so nice.

Merus and Sadie are settling in (in their own ways...), and last night I was able to sleep nearly the whole way through.  I got them a cardboard scratcher, since the lobular multi-level furniture things are a bit more than I can stand and yet the only other choices available in most NYC stores.  They make a fantastic sound when they go sliding across a wooden floor in the middle of the night.  Not sure which of them turned it into a sleigh.

Replaced some shoes just before this affiliation started.  Figured I should show up with a fresh clean pair since sneakers *technically* are not considered "professional dress."  I refuse to play the NYC fashion game, I DESPISE shopping, and I highly doubt such "professional dress" appropriate shoes would ever accommodate the alien toenail babies coexisting within my wide runner's feet that are shaped more like ducks than like classic homosapien females.  These particular sneakers, Brooks' mostly minimalist Green Silence, are men's/unisex (I wear men's 9) with a very rounded toe box.  They also remind me of my track spikes from high school. 

Anyways, I always get some satisfaction in looking at the wear patterns of the old pain as compared to the fresh new pair.  The old pair has been going strong since August.  I left the new pair at work so that they won't get soiled by NYC streets, and on days that I walk to work I'll still walk in the old pair and change once I arrive.  (For those who don't know, NYC can turn a pair of shoes into a gray version of themselves in about a month.  Check anyone who loves to walk in flip flops -- their feet are always equally as soiled.)

First few days of the rotation went well.  Patient diagnoses included peroneal/fibularis tendonitis, osteoarthritis, low back pain, cerebral palsy, multiple sclerosis, spinal cord injury, stroke, spina bifida, amyotrophic lateral sclerosis (Lou Gehig's disease).  My CI is very laid back and allows a decent amount of autonomy while at the same time indulging all my questions and curiosities.  There'll be a lot to learn this summer.

Today I returned to the Long Path in New Jersey for my long run, which turned out to be 17.3 miles.  The weather finally cooled off to expected levels, which made for a much more pleasant run than any of the last two weeks.  All the foliage on the Long Path was also thriving.  Many stretches seemed more like bushwhacking, or occasionally like I was running through the backwoods of Iowa City during college.  Best part was feeling at ease -- no exams to study for, no papers to write, no school politics, no stress!  A girl could get used to this regular schedule and free weekend stuff....

Watch where you sit

This week has been filled with transitions.   Tuesday was the comprehensive exam, Wednesday kicked off our summer affiliations (to describe via simile, affiliations : PT school :: rotations : med school), and Thursday two kittehs [sic] became a part of the family.   Merus is the larger of the two, with a solid tabby coloring on her back, and Sadie is the smaller one and has half a white stripe transversing half her waist.  For the first hour they made haste to sniff every corner and scurry across every possible area regardless of height.  Sadie then started asking for attention while Merus started looking out the window during calmer moments or snuggling away under my bed comforter if things picked up, as is each of their normal personality.  They were still a bit out of sorts, but I expected them to hide for at least a day or two.  Instead they kept me up until 1:30 this morning by knocking things onto the floor.

Miss Sadie

Where did the names come from?  The origins are rather nerdy, to be honest (but what else is new...).  Merus is taken from the latter half of Brontomerus, a dinosaur whose name stands for "thunder thighs" and has a particularly good kick.  Sadie is from the latter half of Palisades, my local forested refuge just across the Hudson River where I often take my long runs.

I found out their back story -- their mom was feral when they were born 3 years ago, and Anjellicle Cats adopted out the litter while spaying and releasing the mom.  A woman gave them a good home for two and a half years, but then got a boyfriend who was allergic enough that she gave them back to the shelter.

Merus (the blob beneath the covers on the left) and Sadie, as they are often found.

The volunteer in charge of their account at the shelter is going to email me a copy of their medical records.  They got a full medical workup and have been spayed.  Tests have shown nothing is wrong with their eyes except for frequent tearing, hence the slight discoloration extending from the nasal portion of their eyes.  But I wonder, because there is a reddish tint to the tears, as you can tell by the little bit of tear goop on Merus (see below).  I'm cleaning them as needed, and I'm keeping an eye on their progress, but I'm going to look into vets to make sure there's no greater reason.  Not sure if it started before or after they entered the shelter, so not sure if its a byproduct of stress.

Better watch where you sit.... (photo taken by Nathan)

They are acclimating rather well.  Just need to figure out what kind of toys they like.  Kittehs!  Yea!