Last week one of my one o'clock patients cancelled, so I had an hour to spend tidying all the loose ends in my paperwork. Half way through I realized one of my office mates was doing the same. Casually I offered to let him practice dry needing on me if he ever needed, as he was recently certified in level 1 and needs to accrue practice hours before getting certified in level 2. I figured he was finishing an evaluation from later, which takes a good amount of time on our computer program. He jumped up. "Sure! Want to do it now?"
I paused as the reality of my offer set in. For me, that would mean needles in my butt - gluteus medius, glut minimus, piriformis, maybe even glut maximus. I have a tailbone that has been fractured twice and is now tilted to the left, rotated to the right, and the tip is bent and re-fused at a 90 degree angle; the larger muscles of my hips often develop the mysterious "trigger points" that are something of a controversy within therapy.
What are trigger points? They feel like knots in the muscle upon palpation with thready or stringy muscle fibers above and below that are supposedly held on tension from the knot. And yet when you press onto an area you are simultaneously pressing on hundreds of nerve endings, small blood vessels, and a significant amount of subcutaneous tissues and multiple fascial layers. Trigger points cannot be found during cadaver dissections. Who is to say you are palpating just muscle? Further, muscles do not sense pressure or pain - nerves send signals to the brain, which then decides what it is feeling and to what intensity. Pain and discomfort are interpretations.
This was my first time being needled. Not every state allows it - New York State does not so it never came up, but Colorado does. I've had my colleagues needle certain patients who had areas of chronic problems that didn't respond completely to other treatments. But this was my first time.
When the needle goes in you barely feel it. They are small needles, "dry" because there is no syringe attached. It looks more like acupuncture for those familiar (though the technique is not acupuncture as it is not eastern medicine, does not use meridians, etc). The size of the needle is determined by the tissues of the area being needled. Sometimes they place needles and attach a small electrical stimulation unit that the patient can control. Sometimes, like with me, they go for muscle twitching by pistoning or twisting the needle.
The sensation definitely increases to an intensity just beyond that of getting a tattoo. I had to tap my hand continuously on the therapy mat, since somehow this would prevent me from moving the area under treatment. There were also some mild verbalizations on my part amid laughing at myself. Laugh too hard and you'll move everything, so I had to stifle myself as well.
Then WHAMO. Your muscle twitches. That stringy line of taught muscle fiber is in repeated spasm and the sensation of a cramp feels like it takes up half your body. It isn't painful per say, but it is very peculiar and can be rather uncomfortable. I yelped more than a few times. The pistoning continues until the adequate muscle twitch is achieved, so the cramping goes on for what feels like five minutes but is probably about 10-15 seconds. I also started mild sweating all over, a tiny sympathetic response (as in sympathetic nervous system, or what many know as "fight or flight" physiological response) that luckily did not go any further than that. By now I was smacking the table with my eyes squeezed shut, probably sounding ridiculous to whoever was in the treatment room next door. "Whoa whoa whoa whoa...." My opposite knee was kicking, also feigning as help to hold still. My colleague had to use his elbow on my back to make sure I didn't buck. He needled three spots on my right hip/glut and two spots on the left. A mere twenty minutes.
At one point my colleague said "This is your ilium [hip bone]. Can you feel the tapping on your ilium?"
"Twitching! All I feel is TWITCHING!" Still smacking and kicking the table. But as awful the process probably sounds, we were both also laughing.
One of my colleague's patients previously said he was "screaming like a little girl" when his pectoralis muscles were needled. Those are super sensitive. I cannot even imagine. I planned to tell that patient that I was yelping most of the time, though I didn't go so far as to scream.
Afterward, the homunculus of my ass was gigantic. Every step felt like little rockets were pushing their way out through the skin. Flushing out the area with activity is recommended, so I hopped on a stationary bike and had the office staff send my next patient back to bike next to me once he arrived. I explained to my patient why I'd be dancing the wiggle worm and rubbing my bum throughout the session so he wouldn't think I was crazy. Supposedly the after effects wear off faster in those who are active. Since I'm more active that just about all our patients (aside from an occasional Adams State U athlete) they were very curious how it would go for me.
By the end of my second patient I stood up to walk her out of the clinic and realized I only felt the slightest, teeniest little pull on the lateral left hip. The right hip had been more pronounced before treatment, hence it receiving three needles. These spots have been there for years in fluctuating intensities that I try to keep under control by laying on a tennis ball or foam roller. It was weird to suddenly not feel them.
So what exactly does the twitching achieve? If nothing else, it gives a huge shot of sensation to the brain so that afterward the pesky little pulls probably don't even register anymore. Does the "knot" go away? It appears to. If the brain no longer interprets danger in an area then it won't tell that muscle to contract. Whatever the mechanism, I have not felt those areas on my two runs since.
Just after the treatment my colleague said, "If people didn't improve afterward then no one would come back."
Damn straight they wouldn't.
Showing posts with label nerdy stuff. Show all posts
Showing posts with label nerdy stuff. Show all posts
Sunday, August 10, 2014
Friday, June 6, 2014
"I get to set the pace. It's your job to keep up."
That was the response from a patient, who walked for the first time Wednesday since his stroke nine weeks ago, when I told him his head was moving forward twice as fast as his legs and thus twice as fast as me. His message came with a fist bump and a smile.
When told we would receive this patient directly after he spent four or five weeks in acute rehab and accomplished nothing more than hoyer lift and the occasional sliding board transfer, we all completely balked. We are not set up for high needs patients. We lack equipment. (How do we not have a single commode with a drop arm? How do we not have parallel bars?) We lack RN training for that level of mobility and the imperative of having the patient always doing as much work as they can. We lack the ability to schedule therapists to cover such high need patients due the complexity of set up, problem solving, the need for high repetition, and extensive family training. Our Swing program, meant to act as a short-stay pseudo rehab in an area where actual rehab facilities do not exist, is reserved for ambulatory patients who will definitely discharge home in no more than two weeks' time. So to take on a patient who was declared to be maximum assist/dependent for all basic activities seemed inappropriate, both for our facility and out of respect for the pt's needs.
We are now excessively happy to have been proven wrong.
Turns out that the therapist note from acute rehab did no justice whatsoever to the patient's presentation. They also seem to have done nothing with the patient during those weeks, wasting a very neuroplastic time frame with minimal to no functional training. Maybe they didn't know how to treat lateropulsion. Maybe they were kinda lazy and didn't want to do the work required for his level of need. Maybe they just didn't realize that the only way you get return into a flaccid limb is by progressive and supported weight bearing, and that you have to push the not-quite-ready activities in order for the previous steps to truly improve. Maybe they forgot that standing, someway somehow, is one of the most basic tenants of rehab.
Regardless, we received the patient with a still completely flaccid right arm and right leg, and his sense of balance and assistance during mobility was to strongly push himself over onto his flaccid side. After a mere two and a half weeks he has a good deal of functional tone in his leg, meaning when in a standing position his leg will accept weight even though it cannot control it and he cannot move his leg voluntarily, and he has walked with moderate assistance and the arm rails along the hallways of the hospital (which we cleared through maintenance prior to initiating). And he only pushes when he is tired or the activity gets set up funny and is extra challenging.
Yesterday morning, ambulation day #1, he/we did four repetitions of 12 feet. Yesterday afternoon was more of the same. This morning was two repetitions of 14 feet followed by transfer training with a freshly facilitated stand portion of a stand-pivot method.
Plus in outpatient I have recently acquired a slew of neurological patients: a spinal cord injury fresh out of Craig Hospital, a subdural hematoma, inclusion body myositis, what was assumed to be super severe diabetic neuropathy by the referring doctor but is more likely a spinal cyst....
Meaning? I'm totally geeking out. And even though I'm exhausted from the lack of infrastructure and lack of greater institutional support for providing an acute rehab do-over, I'm having a lot of fun.
As a neuro geek of a therapist who gave up a complex neuro caseload in NYC for a different extra-professional life (i.e. having a life outside of work), I though I had given up neuro by coming to such a small rural community that lacks a neurologist within two to three hours in any given direction. And until the last few weeks it has been 95% orthopedic.
Now I finally feel like my therapist self again.
When told we would receive this patient directly after he spent four or five weeks in acute rehab and accomplished nothing more than hoyer lift and the occasional sliding board transfer, we all completely balked. We are not set up for high needs patients. We lack equipment. (How do we not have a single commode with a drop arm? How do we not have parallel bars?) We lack RN training for that level of mobility and the imperative of having the patient always doing as much work as they can. We lack the ability to schedule therapists to cover such high need patients due the complexity of set up, problem solving, the need for high repetition, and extensive family training. Our Swing program, meant to act as a short-stay pseudo rehab in an area where actual rehab facilities do not exist, is reserved for ambulatory patients who will definitely discharge home in no more than two weeks' time. So to take on a patient who was declared to be maximum assist/dependent for all basic activities seemed inappropriate, both for our facility and out of respect for the pt's needs.
We are now excessively happy to have been proven wrong.
Turns out that the therapist note from acute rehab did no justice whatsoever to the patient's presentation. They also seem to have done nothing with the patient during those weeks, wasting a very neuroplastic time frame with minimal to no functional training. Maybe they didn't know how to treat lateropulsion. Maybe they were kinda lazy and didn't want to do the work required for his level of need. Maybe they just didn't realize that the only way you get return into a flaccid limb is by progressive and supported weight bearing, and that you have to push the not-quite-ready activities in order for the previous steps to truly improve. Maybe they forgot that standing, someway somehow, is one of the most basic tenants of rehab.
Regardless, we received the patient with a still completely flaccid right arm and right leg, and his sense of balance and assistance during mobility was to strongly push himself over onto his flaccid side. After a mere two and a half weeks he has a good deal of functional tone in his leg, meaning when in a standing position his leg will accept weight even though it cannot control it and he cannot move his leg voluntarily, and he has walked with moderate assistance and the arm rails along the hallways of the hospital (which we cleared through maintenance prior to initiating). And he only pushes when he is tired or the activity gets set up funny and is extra challenging.
Yesterday morning, ambulation day #1, he/we did four repetitions of 12 feet. Yesterday afternoon was more of the same. This morning was two repetitions of 14 feet followed by transfer training with a freshly facilitated stand portion of a stand-pivot method.
Plus in outpatient I have recently acquired a slew of neurological patients: a spinal cord injury fresh out of Craig Hospital, a subdural hematoma, inclusion body myositis, what was assumed to be super severe diabetic neuropathy by the referring doctor but is more likely a spinal cyst....
Meaning? I'm totally geeking out. And even though I'm exhausted from the lack of infrastructure and lack of greater institutional support for providing an acute rehab do-over, I'm having a lot of fun.
As a neuro geek of a therapist who gave up a complex neuro caseload in NYC for a different extra-professional life (i.e. having a life outside of work), I though I had given up neuro by coming to such a small rural community that lacks a neurologist within two to three hours in any given direction. And until the last few weeks it has been 95% orthopedic.
Now I finally feel like my therapist self again.
Wednesday, January 9, 2013
Two blunders to kick things off right
For John the Vicar's New Year's Eve celebration I made my Guinness stout gingerbread. Baking it starts out as a fun science adventure. The baking soda will hugely react with the Guinness - or is it with the molasses? Or both? Either way, you gotta get it to react fully and completely in a pot before making the rest of the gingerbread. Otherwise it will boil over while baking in the oven.
To do so, bring the Guinness and blackstrap molasses to a boil in a very large pot. Then, while stirringstirringstirring, add in 1/2 tablespoon of baking soda. It will froth up like you've never seen, and you gotta keep stirring to break the bubbles so it doesn't go over. Hence using a very large pot.
Now, I often eyeball ingredients and it usually is not a problem. Rather than suffer the tedium of measuring three 1/2 teaspoons in order to achieve 1/2 tablespoon, I instead grabbed the full tablespoon and eye-balled what looked as half way. And luckily I thought it would be fun to get the process on video....
Did you know I'm a genius? Because I am. My doctorate degree says so. *Cough* *Clear throat* *Cough-loser-cough* Luckily, as though more luck were possible in this situation, since the bulk of it was carbohydrate it cleaned up really easy with a little hot water and soap.
Now for the more serious stuff. I pulled up last year's similarly veined post to compare to 2011 stats and found, in true form, that last year's post describing 2011 data was instead labeled as 2012 in nice big bold print in the title.
Awesome sauce. Typo now fixed, one year later.
Anyways, things definitely bumped up a notch in the real 2012. Many months my walking mileage was about the same or higher than my running mileage from '11.
I like that my two week off season and the start of winter maintenance mileage is evident by the decrease in last year's November and December values.
2011 running total: 1583 miles
2012 running total: 1770 miles
2011 walking total: 535 miles *only recorded for 1/2 year
2012 walking total: 1605 miles
2012 grand total: 3375 miles
That's about the distance from Los Angeles to Maine. I'll take that. Better news with which to start the new year than a couple of blunders.
To do so, bring the Guinness and blackstrap molasses to a boil in a very large pot. Then, while stirringstirringstirring, add in 1/2 tablespoon of baking soda. It will froth up like you've never seen, and you gotta keep stirring to break the bubbles so it doesn't go over. Hence using a very large pot.
Now, I often eyeball ingredients and it usually is not a problem. Rather than suffer the tedium of measuring three 1/2 teaspoons in order to achieve 1/2 tablespoon, I instead grabbed the full tablespoon and eye-balled what looked as half way. And luckily I thought it would be fun to get the process on video....
Did you know I'm a genius? Because I am. My doctorate degree says so. *Cough* *Clear throat* *Cough-loser-cough* Luckily, as though more luck were possible in this situation, since the bulk of it was carbohydrate it cleaned up really easy with a little hot water and soap.
Now for the more serious stuff. I pulled up last year's similarly veined post to compare to 2011 stats and found, in true form, that last year's post describing 2011 data was instead labeled as 2012 in nice big bold print in the title.
Awesome sauce. Typo now fixed, one year later.
Anyways, things definitely bumped up a notch in the real 2012. Many months my walking mileage was about the same or higher than my running mileage from '11.
I like that my two week off season and the start of winter maintenance mileage is evident by the decrease in last year's November and December values.
 |
| Blue = 2011 run. Red = 2012 run. Green = 2012 walk. |
2012 running total: 1770 miles
2011 walking total: 535 miles *only recorded for 1/2 year
2012 walking total: 1605 miles
2012 grand total: 3375 miles
That's about the distance from Los Angeles to Maine. I'll take that. Better news with which to start the new year than a couple of blunders.
Monday, July 9, 2012
Ice spike!
I normally don't drink iced coffee unless in something close to a heat wave. We've had a lot of those lately. Nathan's four little ice cube trays have seen more use in the last month than they ever have before. In that time I have found an average of one ice spike per week. It's such a random phenomenon that I get really excited about it. I saw the first ice spike in summer of 2006, perhaps one or two since then. So to have this many popping up in a row is totally awesome. I had another one this morning:
Conversely, in winter I get super excited to show off the ice on my literally frozen ponytail after coming in from a run. Nathan has learned respond to each situation with "That's cool" and a pat on the head. He used to respond with "Okay...?" only to get my wide-eyed-speed-talk "Butit'ssoCOOLit'slikeanEXPLOSIONinyourfreezerbutcontainedtoanICECUBE!"
Nerd. Yes. Proudly so. Don't even need to carry a card because its so evident. Put me in a social situation like a party and I clam up like you wouldn't believe. Give me ice spikes in my freezer and I'm bouncing off the walls in excitement.
I always hopied it was a more ballistic occurrence, where the still-liquid but expanding inner portion of the ice breaks through the frozen surface like a rocket. Turns out its a much calmer process. The surface ice forms from the perimeter towards the center. The inner, still-liquid portion gets forced through a small remaining hole, though slowly. Instead of running down the sides of the ice cube it freezes on the perimeter of the hole and produces a tube. It continues to grow until the tube freezes over.
Apparently this mostly works with distilled water, since usually the particulate present in tap water is enough to sustain the surface shape and disallow the expansion of a tube. But lo! For whatever reason, our tap water and freezer temperature and ice cube tray size is perfect to grow a little stalagmite once a week. Hazzah!
For those of you who are not blatant nerds but do like silly cats, here are the worms as they tolerate the heat:
 |
| Merus, whose nickname has recently progressed to Ru Bear. (This is always followed with a ba-dum-dum in my head, as a pun for rubor (latin for redness, used as a descriptor for inflammation. Yes, I am easily entertained.) |
 |
| Sadie. |
 |
| For the record, the drawer was pushed back about 4 inches and Merus went in on her own. |
 |
| On a side note, this is how Nathan usually sleeps. "Why does my neck hurt?" Hmmm... |
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| Merus could teach Olympic divers a thing or two about their tuck. |
Friday, March 16, 2012
OH HAPPY DAY!
Remember, folks, writing in all caps means YELLING! Because today is A DAY TO YELL!
Only a few steps remaining. Pick up the two paper copies, get adviser and department chair signatures, get registrar signatures, and then make our official deposit. That will be next week. Luckily everything is ready and waiting for the trigger pull.
I now can reclaim my evenings, my weekends, my FREE TIME, my SANITY, my mental processing capacity... basically, I can reclaim my life. My last affiliation, the one I'm most excited about (traumatic brain injury!), will have no competition from the mentally and emotionally draining thesis. I am SO SO SO SO relieved.
You have no idea.
*bounce*bounce*bounce*bounce*
Oh right, its a day for YELLING!
*BOUNCE*BOUNCE*BOUNCE*BOUNCE*BOUNCE*
 |
| YEAAAAH! |
The last week, our so-called break between third and fourth affiliations went something like this:
type-type-type-swear-type-erase-erase-type-type-type-type-reformat-type-edit-edit-swear-curse-DAMN-YOU-FRIGGIN'-STATS-SOFTWARE-type-reformat-type-type-edit-type...
Monday's presentation was a success. Not nearly as intense and picky of feedback as I remembered from observing last year. I did not mind at all. Tuesday was a 13-hour marathon of re-running stats for improved accuracy, finishing the discussion section, and editing the entire dang-gone thing for APA style, grammar, and content. The APA style part took literally the entire time, with 10 hours of work by one group member (while the rest of us finished other sections) and a 3-hour group edit going from start to finish. Sixty four pages. Didn't get home until midnight. Oy...
Last night we received the final feedback from our primary adviser, which (THANKFULLY!) was a few minor grammar edits or dividing an epic 4-line sentence into two smaller sentences. I was so used to working on research every day in some capacity that I didn't know how to have a normal evening. Ended up creating the title page, approval signature page, and re-writing the abstract from 350 words to 150 words (as is the limit set by the Graduate Center).
Today was two-fold. Step one: the final final final edit. Scan the whole document a dozen times for formatting snafus. Get the damn tables and graphs to go where we want them to go (*grumble*). Attempt an appendix of documents used by the hospital. Can the appendix when, after an hour's worth of attempts, we realize that every attempt to put it in creates formatting problems elsewhere, and decide that it is simply not worth it. Get a table of contents, list of figures/tables, the document header and pagination to reflect two different sequences within one document (that was a first...). Sixty seven pages all in all.
 |
| The 67 page monstrosity. |
Step two: prep for submission. Run around the building getting signatures. Complete student loan exit counseling in the process. Meet with the dissertation clerk for approval of and notes for any corrections. Only one to be made: a copy/paste of the title page from a format example accidentally left in "Department of History" instead of physical therapy. Hah! Fix the error. Re-scan the document twice. Create PDF. Email PDF to advisers. Drop off flash drive of PDF at the printers (because the Graduate Center requires fancy paper). Printer does not have CDs, so go to a second printer to burn the PDF onto CD (it gets attached inside the back of the binding).
Only a few steps remaining. Pick up the two paper copies, get adviser and department chair signatures, get registrar signatures, and then make our official deposit. That will be next week. Luckily everything is ready and waiting for the trigger pull.
I now can reclaim my evenings, my weekends, my FREE TIME, my SANITY, my mental processing capacity... basically, I can reclaim my life. My last affiliation, the one I'm most excited about (traumatic brain injury!), will have no competition from the mentally and emotionally draining thesis. I am SO SO SO SO relieved.
You have no idea.
*bounce*bounce*bounce*bounce*
Oh right, its a day for YELLING!
*BOUNCE*BOUNCE*BOUNCE*BOUNCE*BOUNCE*
Friday, January 13, 2012
Olympic Trials tomorrow!
What would make me post twice in one day? Tomorrow are the Olympic Marathon Trials in Houston, TX!! I'm obviously not racing, and I can't actually watch the races take place, but I am nonetheless bouncing off the walls in excitement.
What I love about this year is that the women's race is getting LOTS of attention. Analysts have said in previous Trials the top three -- i.e. those going on to the Olympics -- were basically guaranteed before the race started based on qualifying times so long as everyone had a decent day. This further meant that any woman running a 2hr 30min or faster was basically guaranteed a spot so long as they continued to train. The Trials then became a race rather than a time trial; the group sets a comfortable pace and you duke it out in the end to set the spots. Then whoever gets to go on to the Olympics didn't waste a boatload of energy trying to get there for a certain time.
This year at eight women -- eight! -- have posted at or better than 2:30. So this year its a true race, and they all know it. I'm pulling with all my heart for my Lady Ds: Desiree Davila (interview) and Deena Kastor (interview). (Cue bouncing.)
Also of interest are top qualifiers Shalane Flanagan (interview), Amy Hastings, and Kara Goucher (interview). Then there's one of my local favorites, Kelly Chin, and the super awesome ultra runner Meghan Arbogast (she's over 50 years old -- hot stuff!). Another ultra runner, Kami Semick, qualified but is not running. I was also really hoping to cheer for Buzunesh Deba -- she placed a close second at the 2011 NYC Marathon and is also a home town hero hailing from the Bronx, but turns out she is Ethiopian. I hope her 2nd place finish earns her a spot on the undoubtedly competitive Ethiopian team for the London games.
On the men's side I'm following the awesome pro roadster Meb Keflezighi and the ultra runner Michael Wardian, who if you recall my race rundown from the TNF KC 50k is the pro who blasted through the course in just over 3 hours.
According to the New York Road Runners website, the Trials will be televised tomorrow afternoon from 3-5pm Eastern/2-4pm Central time on NBC.
What I love about this year is that the women's race is getting LOTS of attention. Analysts have said in previous Trials the top three -- i.e. those going on to the Olympics -- were basically guaranteed before the race started based on qualifying times so long as everyone had a decent day. This further meant that any woman running a 2hr 30min or faster was basically guaranteed a spot so long as they continued to train. The Trials then became a race rather than a time trial; the group sets a comfortable pace and you duke it out in the end to set the spots. Then whoever gets to go on to the Olympics didn't waste a boatload of energy trying to get there for a certain time.
This year at eight women -- eight! -- have posted at or better than 2:30. So this year its a true race, and they all know it. I'm pulling with all my heart for my Lady Ds: Desiree Davila (interview) and Deena Kastor (interview). (Cue bouncing.)
Also of interest are top qualifiers Shalane Flanagan (interview), Amy Hastings, and Kara Goucher (interview). Then there's one of my local favorites, Kelly Chin, and the super awesome ultra runner Meghan Arbogast (she's over 50 years old -- hot stuff!). Another ultra runner, Kami Semick, qualified but is not running. I was also really hoping to cheer for Buzunesh Deba -- she placed a close second at the 2011 NYC Marathon and is also a home town hero hailing from the Bronx, but turns out she is Ethiopian. I hope her 2nd place finish earns her a spot on the undoubtedly competitive Ethiopian team for the London games.
On the men's side I'm following the awesome pro roadster Meb Keflezighi and the ultra runner Michael Wardian, who if you recall my race rundown from the TNF KC 50k is the pro who blasted through the course in just over 3 hours.
According to the New York Road Runners website, the Trials will be televised tomorrow afternoon from 3-5pm Eastern/2-4pm Central time on NBC.
Tuesday, January 3, 2012
2011 Running stats
I decided to make a more formal running log for this year using Excel, so that I can track weekly mileage and accumulated shoe mileage on a daily basis to make it much less taxing to evaluate later. How do I know it would be taxing to wait to analyze? I first went through my calendar where everything was recorded very simply for each day (time, distance, workout type and location) but no cumulative values were created until now. None of the numbers are surprising to me so it likely will not influence the coming year by much, but it will be interesting to compare global stats of 2011 to 2012 at this point next year. Here's what I have found...
Total yearly distance running: 1583.2 mi
Walking distance for June 13 to Dec.: 535.5 mi
Latest pair of road shoes, worn Oct. 18 to today: 327.7 mi (totaling 43h 20m 20s)
Latest pair of walking shoes, worn Aug. 1 to today: 412.3 mi
And now for fancy mileage graphs. (Excel ain't got nothin' on me. Hazzah!) The dark lines indicate values for running, while the lighter lines indicate those for walking. You'll notice that the aforementioned walking distance only covered the latter half of the year -- I did not keep track until the middle of June, unfortunately.
Total yearly distance running: 1583.2 mi
Walking distance for June 13 to Dec.: 535.5 mi
Latest pair of road shoes, worn Oct. 18 to today: 327.7 mi (totaling 43h 20m 20s)
Latest pair of walking shoes, worn Aug. 1 to today: 412.3 mi
And now for fancy mileage graphs. (Excel ain't got nothin' on me. Hazzah!) The dark lines indicate values for running, while the lighter lines indicate those for walking. You'll notice that the aforementioned walking distance only covered the latter half of the year -- I did not keep track until the middle of June, unfortunately.
I laughed when I realized that my Jan, Feb, and Sept monthly running mileages ranged from 105 to 123, which is the same number of miles elite professionals will run per week. They also don't keep track of walking, because all their training occurs at a running pace.
But! When considering a) the absence of knee injury beyond normal upkeep and b) what I consider to be successful races, I have to say that training "like an old person" has treated me quite well. I use cutsie quotes because there are runners in their 60s who regularly knock out twice my weekly mileage while running a full minute per mile faster than me. They show up to each race, though I cannot pick them out of the crowd until looking at the race stats after the fact. I hope to join their club later in life, cause they are friggin' inspiring to me. The only trouble will be keeping up....
Wednesday, December 28, 2011
Reads.
My dance history professor from undergrad said graduate school taught her how to read. At this point in the game I whole heartedly agree. It shows in my fun reading -- I'm on my fourth book in a week and a half. But I probably must also credit my Nook since I can optimize the font style, font size and line spacing to my preference. Maybe its also all the time I had whilst without internet (which is up and running again -- whee!)....
1) Janet Evanovich, Smokin' Seventeen (2011).
Book eighteen came out in November, dropping the e-book price of Seventeen to what I consider a tolerable. Excellent humor. No required thought on my part. Perfect. Zoom.
2) Kathryn Stockett, The Help (2011).
I feared it would end up being a novel version of a chick flick. Boy, was I ever wrong! I am positive that anyone with even the teeneist smidgeon of awareness reads The Help with parallel examples running through their head, be they of personal experience or historical origin. The notion profoundly applies that those who act unto others and make the biggest public stink are often directly and/or indirectly addressing their own personal issues. Maybe its the overexposure to 17 Stephanie Plum novels since August, but I found myself wanting to text OMG to a few who have also read The Help when I vehemently never, never, never use such "acronyms." (For the record, I also use punctuation and form actual sentences when texting unless limited by space constraints.)
3) Oliver Sacks, Seeing Voices (1989).
Sacks is an incredibly sweet and humble doctor who is profoundly interested by both the pathological conditions and, more so, the patient themself. The man has only one fault: using four times as many commas as is appropriate, second only to the comma usage of some writers from The New Yorker. But for Sacks I am willing to forgive.
Seeing Voices is a discussion of prelingual deafness, meaning a child is born without the ability to hear or loses their hearing before having acquired any understanding of language. The deficit is larger than most would expect. The ability to form thoughts is dependent upon language, so much so that without it there is no of reasoning, no cause and effect, no concept of numbers, no concept of time, no concept of the ability to express ideas may exist without the brain having a basis for communication. This is different from those who acquired at least some language before losing their hearing, or postlingual deafness.
The process of learning is very intricate and relies on principles of neuroplasticity, how your brain adapts to new events. Spoken language is shown through research to be very left brain heavy, but the left side is a processor of the fine details of what is known. Exposure to a novel event (i.e. new event -- learning words, hearing a new usage of a known word, etc.) requires processing by the right brain, where global understanding predominates rather than fine details, which then sends the information to the left side for storage and future use. There are numerous fine details of the process, including whether long term potentiation is achieved through the limbic system (i.e. the process of an event becoming an actual part of your long term memory base), but we'll keep things simple for now.
Interestingly, American Sign Language (ASL) was only considered a true language within the last few decades. ASL was for many years assumed to be crude pantomime and/or a series of shapes strung together. In fact, as Sacks points out, ASL is its own language separate from signed english that has its own grammatical framework including word manipulations for tense/emotion/etc, it is highly spacial dependent for individual words and full thoughts alike, and has fluidity of thoughts and phrases.
The use of space while signing plays a huge roll. Spacial orientation is classically a right brain activity. It is acutely developed within signers significantly more so than in speakers, and yet because spacial orientation is linked so closely to "speaking" in ASL it becomes integrated into the left brain's language centers. Apparently signed english is much harder to convey thoughts than with ASL, and studies cited by Sacks demonstrate that over time many using signed english organically manipulate its use to where it begins to resemble ASL and its unique grammatical constructs.
4) Rebecca Skloot, The Immortal Life of Henrietta Lacks (2010).
Henrietta Lacks died in 1951 of an aggressive cervical cancer, but the cell sample (named HeLa) taken from the tumor growth is still alive today. Previously no human cells survived in culture past a few days. It was not for many, many years until scientists discovered the likely reason why her cells divided at a rate 20 times of other cells ad nauseum. The cells were then distributed across the world to anyone scientist who wanted to research using human cells for the first time, eventually leading to the polio vaccine, cancer and AIDS research, the effects of radiation and toxins, genetic mapping, drugs....
And yet a huge ethical construct exists. Many have heard of the Tuskegee Syphilis experiment, where blacks were used for research in a horribly unethical way. Henrietta Lacks was not infected with cancer by her doctors, but cells were removed and distributed into what became a multi-billion dollar industry while her family was left with nothing, including no knowledge that cells were harvested in the first place. Consent, disclosure, maleficence... you name it, the history of the HeLa cell line is wrought with it.
Next week will become a slow return to orthopedics. I'll be working my way through all three semesters' worth of manual therapy notes and through my textbooks (like my new gait book by Perry and interventions book by Magee -- ya!) to wrap my brain around treating a patient population filled with runners and triathletes instead of normal folk's usual pathologies. Hoping my memory is as robust as I *think* it is...
1) Janet Evanovich, Smokin' Seventeen (2011).
Book eighteen came out in November, dropping the e-book price of Seventeen to what I consider a tolerable. Excellent humor. No required thought on my part. Perfect. Zoom.
2) Kathryn Stockett, The Help (2011).
I feared it would end up being a novel version of a chick flick. Boy, was I ever wrong! I am positive that anyone with even the teeneist smidgeon of awareness reads The Help with parallel examples running through their head, be they of personal experience or historical origin. The notion profoundly applies that those who act unto others and make the biggest public stink are often directly and/or indirectly addressing their own personal issues. Maybe its the overexposure to 17 Stephanie Plum novels since August, but I found myself wanting to text OMG to a few who have also read The Help when I vehemently never, never, never use such "acronyms." (For the record, I also use punctuation and form actual sentences when texting unless limited by space constraints.)
3) Oliver Sacks, Seeing Voices (1989).
Sacks is an incredibly sweet and humble doctor who is profoundly interested by both the pathological conditions and, more so, the patient themself. The man has only one fault: using four times as many commas as is appropriate, second only to the comma usage of some writers from The New Yorker. But for Sacks I am willing to forgive.
Seeing Voices is a discussion of prelingual deafness, meaning a child is born without the ability to hear or loses their hearing before having acquired any understanding of language. The deficit is larger than most would expect. The ability to form thoughts is dependent upon language, so much so that without it there is no of reasoning, no cause and effect, no concept of numbers, no concept of time, no concept of the ability to express ideas may exist without the brain having a basis for communication. This is different from those who acquired at least some language before losing their hearing, or postlingual deafness.
The process of learning is very intricate and relies on principles of neuroplasticity, how your brain adapts to new events. Spoken language is shown through research to be very left brain heavy, but the left side is a processor of the fine details of what is known. Exposure to a novel event (i.e. new event -- learning words, hearing a new usage of a known word, etc.) requires processing by the right brain, where global understanding predominates rather than fine details, which then sends the information to the left side for storage and future use. There are numerous fine details of the process, including whether long term potentiation is achieved through the limbic system (i.e. the process of an event becoming an actual part of your long term memory base), but we'll keep things simple for now.
Interestingly, American Sign Language (ASL) was only considered a true language within the last few decades. ASL was for many years assumed to be crude pantomime and/or a series of shapes strung together. In fact, as Sacks points out, ASL is its own language separate from signed english that has its own grammatical framework including word manipulations for tense/emotion/etc, it is highly spacial dependent for individual words and full thoughts alike, and has fluidity of thoughts and phrases.
The use of space while signing plays a huge roll. Spacial orientation is classically a right brain activity. It is acutely developed within signers significantly more so than in speakers, and yet because spacial orientation is linked so closely to "speaking" in ASL it becomes integrated into the left brain's language centers. Apparently signed english is much harder to convey thoughts than with ASL, and studies cited by Sacks demonstrate that over time many using signed english organically manipulate its use to where it begins to resemble ASL and its unique grammatical constructs.
4) Rebecca Skloot, The Immortal Life of Henrietta Lacks (2010).
Henrietta Lacks died in 1951 of an aggressive cervical cancer, but the cell sample (named HeLa) taken from the tumor growth is still alive today. Previously no human cells survived in culture past a few days. It was not for many, many years until scientists discovered the likely reason why her cells divided at a rate 20 times of other cells ad nauseum. The cells were then distributed across the world to anyone scientist who wanted to research using human cells for the first time, eventually leading to the polio vaccine, cancer and AIDS research, the effects of radiation and toxins, genetic mapping, drugs....
And yet a huge ethical construct exists. Many have heard of the Tuskegee Syphilis experiment, where blacks were used for research in a horribly unethical way. Henrietta Lacks was not infected with cancer by her doctors, but cells were removed and distributed into what became a multi-billion dollar industry while her family was left with nothing, including no knowledge that cells were harvested in the first place. Consent, disclosure, maleficence... you name it, the history of the HeLa cell line is wrought with it.
Next week will become a slow return to orthopedics. I'll be working my way through all three semesters' worth of manual therapy notes and through my textbooks (like my new gait book by Perry and interventions book by Magee -- ya!) to wrap my brain around treating a patient population filled with runners and triathletes instead of normal folk's usual pathologies. Hoping my memory is as robust as I *think* it is...
Tuesday, June 21, 2011
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.
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.
Wednesday, June 15, 2011
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....
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....
Tuesday, June 7, 2011
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:
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:
Saturday, May 28, 2011
[An early] summertime in the city
This week NYC temperatures shot into the 80s. A handful of friends originally from CA commented that it finally felt like spring -- spring?? Pshaa! Spring was a month ago when the high was 60. I acclimate to cold very well, but to hot... yea, not so much. I don't sleep well (or very much at all), I sweat all the time, and I end up with light sensitive headaches because maintaining actual hydration becomes difficult while I continuously melt onto the floor. I ended up geeking out yesterday over hydration analysis.
An interesting take on hydration that seems physiologically grounded rather than assumption grounded appeared lately on Marathon Talk, a UK based weekly podcast. They've had a 3 part series with guest Dr. Mark Hetherington (BSc, PhD), a visiting senior research fellow at the Institute of Membrane and Systems Biology at the University of Leeds. The second part was of most interest regarding how fluid that is sweat out by the body correlates with appropriate fluid intake. That is, Hetherington describes how the common assumption that any loss of body weight after prolonged exercise means that exact amount of fluid must be replenished. I.e., if you end a run having lost 2 kg (or 4.4 pounds), then the assumption is that you lost 2 kg of blood volume and thus should drink back that same 2 kg (or 2 liters, since 1 kg = 1 liter) of water to regain proper hydration. According to Hetherington this is wrong on two counts, and this is why so many distance runners are in danger of hyponatremia, a state of abnormally low levels of salts/electrolytes in the blood.
The first point deals with the origination of sweat, which comes from two sources. One source is from the blood, like most would assume, which secretes the fluid through the skin in order to cool you down during/after such physical exertion. But apparently this only accounts for 50% of the sweat created by physical activity. The second source is is a byproduct of cellular metabolism of glycogen/glucose and fats. That means the sweating out of this byproduct water has no affect on blood volume -- your body creates the water as you burn fuel during exercise (same as it produces CO2), the water goes into the blood stream to then join in the fun as sweat (just as CO2 is transported by blood to then be exhaled through the lungs). Herherington breaks it down into three sub-categories: of the total fluid sweated out (including true blood volume fluid) 25% is produced by releasing glycogen (i.e. concentrated glucose stores) from storage in the muscles, 16.7% is produced by burning of glycogen (breaking it down into glucose) and fat, and 8.3% is from oxidizing glucose -- thus contributing to 50% of the fluid lost via sweat.
What does this mean? If this hypothetical runner lost 2 kg during the run, then only 1 kg was from blood volume, necessitating that only 1 kg of fluid be taken in. Otherwise you'd be taking in twice the fluid you need, and if this is straight water then you are at risk of essentially diluting yourself to death. This is Hetherington's second point -- that the composition of sweat is not pure water, it is an isotonic fluid. So if you drink plain water you'd have to consume food with the requisite electrolytes. Otherwise your blood will be diluted while cells will retain their normal isotonic properties, and this will cause osmotic flow and retention of water with cells. When this happens to your brain, this is when things get really bad really fast.
I also found an article described by exercise phys site called Sweat Science that publishes the results of current literature -- "Effect of exercise-induced dehydration on time-trial exercise performance: a meta-analysis" by Eric Goulet, published in April of this year in the British Journal of Sports Medicine. Comparison of 5 studies that met analysis criteria yielded that those who drank according to their thirst lost up to 4.0% of normal body mass (average 2.2%) , and yet these subjects performed better in a self-paced time trial than those who drank nothing or drank to maintain a near-perfect body mass (losing only an average of 0.44% of normal body mass). The premise is the latter category was over-hydrated despite maintaining "normal" body mass and thus hindered their performance.
So that means I don't need to freak out as much when comparing my fluid intake with others, or with temporarily dropping a few pounds after a really long run. I just wonder how I can apply this to non-running life in hopes of surviving the real summer once it gets here.
An interesting take on hydration that seems physiologically grounded rather than assumption grounded appeared lately on Marathon Talk, a UK based weekly podcast. They've had a 3 part series with guest Dr. Mark Hetherington (BSc, PhD), a visiting senior research fellow at the Institute of Membrane and Systems Biology at the University of Leeds. The second part was of most interest regarding how fluid that is sweat out by the body correlates with appropriate fluid intake. That is, Hetherington describes how the common assumption that any loss of body weight after prolonged exercise means that exact amount of fluid must be replenished. I.e., if you end a run having lost 2 kg (or 4.4 pounds), then the assumption is that you lost 2 kg of blood volume and thus should drink back that same 2 kg (or 2 liters, since 1 kg = 1 liter) of water to regain proper hydration. According to Hetherington this is wrong on two counts, and this is why so many distance runners are in danger of hyponatremia, a state of abnormally low levels of salts/electrolytes in the blood.
The first point deals with the origination of sweat, which comes from two sources. One source is from the blood, like most would assume, which secretes the fluid through the skin in order to cool you down during/after such physical exertion. But apparently this only accounts for 50% of the sweat created by physical activity. The second source is is a byproduct of cellular metabolism of glycogen/glucose and fats. That means the sweating out of this byproduct water has no affect on blood volume -- your body creates the water as you burn fuel during exercise (same as it produces CO2), the water goes into the blood stream to then join in the fun as sweat (just as CO2 is transported by blood to then be exhaled through the lungs). Herherington breaks it down into three sub-categories: of the total fluid sweated out (including true blood volume fluid) 25% is produced by releasing glycogen (i.e. concentrated glucose stores) from storage in the muscles, 16.7% is produced by burning of glycogen (breaking it down into glucose) and fat, and 8.3% is from oxidizing glucose -- thus contributing to 50% of the fluid lost via sweat.
What does this mean? If this hypothetical runner lost 2 kg during the run, then only 1 kg was from blood volume, necessitating that only 1 kg of fluid be taken in. Otherwise you'd be taking in twice the fluid you need, and if this is straight water then you are at risk of essentially diluting yourself to death. This is Hetherington's second point -- that the composition of sweat is not pure water, it is an isotonic fluid. So if you drink plain water you'd have to consume food with the requisite electrolytes. Otherwise your blood will be diluted while cells will retain their normal isotonic properties, and this will cause osmotic flow and retention of water with cells. When this happens to your brain, this is when things get really bad really fast.
I also found an article described by exercise phys site called Sweat Science that publishes the results of current literature -- "Effect of exercise-induced dehydration on time-trial exercise performance: a meta-analysis" by Eric Goulet, published in April of this year in the British Journal of Sports Medicine. Comparison of 5 studies that met analysis criteria yielded that those who drank according to their thirst lost up to 4.0% of normal body mass (average 2.2%) , and yet these subjects performed better in a self-paced time trial than those who drank nothing or drank to maintain a near-perfect body mass (losing only an average of 0.44% of normal body mass). The premise is the latter category was over-hydrated despite maintaining "normal" body mass and thus hindered their performance.
So that means I don't need to freak out as much when comparing my fluid intake with others, or with temporarily dropping a few pounds after a really long run. I just wonder how I can apply this to non-running life in hopes of surviving the real summer once it gets here.
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