Letter from the Editor

Welcome to the Spring 2009 issue of the Therapeutic Word blog! It's time again to hear from the brilliant minds of Queen's University School of Rehabilitation Therapy.

Read below for contributions from Physical Therapy students, and updates from members of the Rehab Council. Check out the side-bar for upcoming events, and new links.

Good luck to all students with upcoming placements and classes, and CONGRATS to all the 2nd year soon-to-be grads (we're almost there)!!

The TW will return in Fall 2009, so until then, have a wonderful spring and summer, and thanks for reading!

Alisa Doell - MSc (OT) Candidate (2009), Therapeutic Word editor (2008-09)

What Hit Me in the Eye: One PT student’s humble lessons learned during initial placement

After 3 months of listening, absorbing, memorizing and being tested on our newly-gained knowledge in rehabilitation, we bid adieu to our classroom seats and set off to experience our first clinical placement as physical therapy students. For some there was excitement, nerves and tears, while others endured grueling 8 hour drives to new and remote towns, armed with nothing more than clothes, textbooks and a trusty goniometer.

Being the naïve optimist that I am, I spent the Sunday evening prior to my first day of placement raiding my closest for professional attire, setting out the lunch bag and skimming through my Magee textbook briefly before settling in with a cup of tea and a the last few chapters of Twilight. All we need to do for the next six weeks is run around the clinic, attempt to show our deepest empathy for our clients’ pain, and bask in the glow of our well-educated, well-dressed and all knowing Clinical Instructor. How hard could it be, right?

Three weeks since that lovely, relaxing Sunday evening already feels like a long lost life. No one told me that running around the clinic actually meant that I had to know where I was going, and what I was doing. Showing empathy for one client is easy enough, but try ten in one day? And as for the all knowing CI – how could anyone that “all knowing” ask so many questions, to a student none the less! Something is seriously not right here.

By the end of week one, I was ready to bust out the muscle relaxant and sleep the week-end away. By the end of week 2, My frustrations over recalling ultrasound parameters were beginning to show. By week 3 I managed to mobilize a client’s ankle correctly, only to find out that they were really coming in to get their low back treated instead.

Just another typical day for a PT student.

Now, the final weeks of placement are already here. I thought I would take the chance to reflect on my hectic experience at the clinic, and assure myself that in the midst of the uncertainty, the lack of confidence and overwhelming desire to throw my Magee textbook across the room, I am growing and learning. Certain skills are now coming along more easily, yet there is still so much more to learn.

I thought I would take a moment to share 4 lessons that I felt really hit me in the eye, and opened up my perspective to this challenging but exciting career.

Lesson 1: Always be on the radar for the latest Naturlizer and Feet First shoe sales.
Walking in the same shoes for 11 hours at a time is already an open invitation for blisters to come pay a visit. Having to that on top of balancing on a bosu, mobilizing a foot while walking, picking up dropped gel packs and negotiating tight corners in the hallway is a pretty foot’s worst nightmare. Not to mention a painful evening of slathering on Polysporin and band-aids.

Lesson 2: It is ok to look like a deer caught in headlights…once in a while.
Week 1, Monday morning, first client. My CI turns to me and asks “If Ms. Smith is complaining of back pain, why would it be a good idea to test her hip strength?” I nervously rack my brain, I let out an “em…” and when my memory fails me, I simply stand and stare. Sure, it may look like I slept through my lectures in class, but better to give no answer than a wrong one, right? I have no trouble admitting that the first week found me being caught in a fair number of “headlights”. The good news is that those headlights appear less often as the weeks go by. Whew.

Lesson 3: Charting treatment reports are NOT meant to be mini novels.
Yet I still cannot comprehend how to make them any shorter. While charting, I enviously look over my shoulder to see the other Physiotherapists scribble their way through a treatment report in less than 5 lines. Will having the initials RPT after my last name somehow magically transform my charting skills to be more efficient, precise and inclusive? I sure hope so, otherwise my writer’s cramp will soon need to get treated and charted about as well.

Lesson 4: Magee and Kisner/Colby texts double as excellent work-out equipment.
Sometimes, as students, we simply just don’t know the answer. We either haven’t gotten to that unit in our studies yet, or have way too much information in our brains to filter out the information that we need. What does it result in? Stress. Best way to deal with it? Pump some iron, or a pile of books in this case. Nothing beats a super set workout than walking back and forth at the clinic, each time with a larger textbook, in order to find the answer to your CI’s question.

As I prepare to write a big, satisfying checkmark next to the PT881 on my to-do list, I think about the nervousness, uneasiness and lack of confidence during my first few weeks on placement. Realizing that I am now a little less nervous, a little more at ease, and feel a glimmer of confidence starting to sprout, I look forward to tackling the next placement block with excitement…

…and a new pair of Soft Moc shoes.

Natalia Monka - MSc (PT) Candidate (2010)

Changes to OHIP Coverage

On April 1, 2005, changes were made to OHIP coverage for physiotherapy services to “improve access to those most in need.” While PT services provided in hospitals, by CCACs and WSIB were still covered, those who don’t qualify in any of those categories are left to find their own resources to cover PT services, whether it be from private insurance or out of pocket.

This reality didn’t really hit home for me until I was on a placement in a small, mostly rural, community north-west of Belleville. There are no OHIP funded clinics in the area, and for many people the clinic I was in was the closest clinic, and it could still be at least 30 minute drive away. I had an 83 year old female client who was quite active – she had jumped off of the back of a pick-up truck and fractured her wrist. She was coming to physiotherapy to regain range of motion and strength in her hand and wrist that she’d lost while the joint was fixated. I walked her to the front desk one day after her appointment to make sure she rebooked and was taken aback when the receptionist told her the cost of the treatment. Of course I knew that the clients paid for their appointments, but for some reason it really struck home that day. This 83 year old woman, without a job and with probably only a very modest income, was having to pay out of pocket for care in order to be able to use her hand properly again. I just couldn’t believe it. If she could not have afforded to pay would she lose the proper use of that hand? It made me wonder how many people in that small community were living with deficits that physiotherapists could help with because they couldn’t afford care.

I’m not sure how the government believes that cuts in physiotherapy care will improve access. To be treated at an OHIP covered clinic you need to have a doctor’s referral – does that not only slow down access? There are not even any OHIP covered clinics in a city as big as Mississauga! I think as students we need to become more aware of healthcare issues. As future physiotherapists and occupational therapists we need to become advocates for our patients and clients and make it known to the government that our services are useful, cost effective and are greatly needed to ensure quality of life!

For more information visit:

Ontario Physiotherapy Association http://www.opa.on.ca/policy_ohip.shtml

Ontario Ministry of Health and Long Term Care http://health.gov.on.ca/english/public/pub/ohip/physiotherapy.html

Shauna D’Amboise – MSc (PT) Candidate (2010)

UPDATE: Notes from the Senate

On February 26 before the Meeting of the Senate, Principle Tom Williams presented his “Principal’s February Financial Report to the Community.” He provided an outline of the finances at Queen’s and how we relate to other universities across the continent. Considering the financial environment in the world as well as the constantly increasing tuition fees, this address provided many answers and a good picture of these issues from the point of view of the administration.

It is understood that Queen’s does not have enough money to run and is under strain of debt and unfinished construction work. When the budget from the Federal government was announced a significant portion was allotted for universities’ infrastructure costs. Queen’s is awaiting information about how much money will be available and what restrictions will be placed on it, though it is clear this money is for infrastructure – which presents a problem. Queen’s budget is divided up into infrastructure and operating costs. Queen’s operating costs are deficient and so the federal money received for infrastructure will not accommodate these difficulties. The only choice the administration faces is balancing the operating budget.

The operating budget receives its income from donations and endowments, but both of these sources have dropped significantly as a result of the recession. The administration is therefore looking to reduce costs, appointing a task force to do so. Preliminary recommendations have already been made, some of which will be enforced as early as this July. They are recommending an increase in enrollment, more income generating over the summer, consolidating some degrees and other “creative thinking”. They are even engaging in “self-reflection”!

In addition, the university has enacted a three year plan in which they will be reducing spending by 15%. This is hitting departments the hardest, who are trying to limit their operating costs and are not filling vacant positions. This will likely negatively impact working conditions which will not go unnoticed by the administration.

The other option that would not decrease working conditions would be to decrease salaries. Other universities across the continent are looking at salary freezes as a solution to their income woes, but Principle Williams has emphasized that any salary modifications would only be negotiated through the appropriate channels and all contracts signed in good faith would be honoured.

The operating budget showed no other option with 9% being spent on Student Assistance, 21% on Departmental Budget (which has already been significantly cut) and 70% on Salaries and Benefits. Principle Williams closed comments by formally inviting the various unions to work with him towards their common goals.

If you have any further questions, please visit the Principal’s website (http://www.queensu.ca/principal/news.html) where you can access his presentation as well as ask any questions that have not been answered.

Liz Baird - MSc (OT) Candidate (2009), Secretary/Senator Rehab Society (2008/09)

My Experience – Out of the ZONE

I am a physical therapy student who loves kids, new experiences, traveling the world, and learning new things. These passions led a colleague and me to sign up for an international placement in the rural south of India last fall.

An overwhelming flood of warm emotions began the moment we embarked on our first village visit. A community-based rehabilitation (CBR) worker gave my colleagues and me a thorough introduction to village life in the Koppal District. We visited the homes of the beautifully decorated Lambani tribal women who were making clothing in bright colours of pink, red, purple, and blue, as well as traditional dessert for the Diwali festival (pronounced Divaly). Before I knew it, the entire village’s population had surrounded us. From infants held by their pre-school siblings, to old tribal men—everyone’s attention was focused on the “foreigners.”

I was caught off-guard by a little girl dressed in pink, wearing jingling glass bangles and orange flowers in her hair. Every time I looked at her, she would giggle. She followed me for the rest of the day. Although we had no language in common, I did eventually get her to smile and even wave for a photo. I will never forget the utter happiness she displayed despite her impoverished lifestyle. I quickly learned, however, that the lifestyle to which my hosts and clients were accustomed was in fact very functional.

After each morning’s traditional South Indian breakfast of rice with nuts and chilis or oput (a cream-of-wheat-like savory dish with onions and more chilis!), we left the compound on motor bikes or jeeps to visit our village clients with the local CBR workers. Our clients had myriad disabilities, including cerebral palsy, spina bifida, spinal cord injury, stroke, and intellectual disabilities. Our role was to work on difficult caseloads with the CBR workers and together establish a functional treatment plan that catered to our clients’ beliefs and lifestyles. Most of our treatments consisted of education, exercises as well as designing functional assistive devices such as ankle and foot orthotics, forearm crutches and wheelchairs using local resources and craftsmen. After our midday lunch break, we would sit in the shade, avoiding the excruciating heat as much as we could before embarking on more evening appointments.

I experienced some unforgettable and rewarding moments, gaining some deep insight and valuable lessons. Here are the three most important lessons I learned on this journey.

Be in the moment. No amount of preparation or advice can prepare you for something that is outside of your comfort zone. Embark on your journey, but make sure to leave expectations behind. The smallest things, such as a woman beading a flower necklace, children playing with old tire tubing and sticks, and even the sight of a cow crossing the road, can turn out to be unforgettable memories. You can easily overlook these exceptional events if you focus on certain expectations and outcomes.

Take every opportunity. Calculate the risks and before you start analyzing them too much, go ahead and take them. I quickly adopted the popular mantra, “have no regrets,” when debating whether to visit a local ashram and city markets solo, following the Mumbai terrorist attacks that occurred while I was abroad. Although most things are better when shared, some journeys and adventures can be experienced on a deeper level on your own.

Finally, the world is not a small place. It is huge, with so much to do and see that is different from your everyday world. It is fascinating how mankind has developed an avenue through technology and resources that provide the opportunity to go out there and visit, communicate and see how similar we as humans really are. We all feel love, pain, hot, cold, sad, happy, hungry, and sick. We all have different abilities and disabilities. We all have the capacity to learn languages and find a way to communicate with each other in order to share what we can.

On that note, if not to have stirred up some interest, reactions good or bad, I am happy to have had a chance to reflect on an experience that was completely out of my zone, and share it with the world, for this I thank you for reading my story.

Thank you to the wonderful and generous NGO that hosted us, SAMUHA, our supportive clinical instructor, Hilary Crowley, and my colleague Faraley VanderSchilden whose patience and support made this experience an unforgettable one. If anyone is interested in international placement feel free to contact me for some tips and information, especially if interested in a placement in India. 7hfa@queensu.ca

Hana Alazem – MSc (PT) Candidate (2009), PT Professional Rep, Rehab Society (2008/09)

Evidence-Based Practice: Hip fractures, fixation devices, and post-operative mobility

There are more than 40 000 new hip fractures occurring in people over the age of 65 each year in Canada. The increasing average life expectancy of people in our society also means that they have an increased chance of developing osteoporosis. This combined with an enhanced risk of falls due to reductions in neurological and musculoskeletal functioning indicates an increased risk of hip fractures; specifically proximal femur fractures. The surgical intervention chosen for management of proximal femur fractures in an elderly patient plays a crucial role in deciding a successful return to safe mobility and pre-operative functioning. The type of implant to achieve this must meet specific criteria including: 1) It can be inserted via a minimally invasive operation technique, 2) It has a post-operative indication of close to full body weight bearing capacity, and 3) It has a low peri and post-operative complication rate.

The dynamic hip screw (DHS) is an extramedullary device used in the treatment of proximal femur fractures. It consists of a large cannulated screw inserted through a side-plate that is fixated on the lateral aspect of the femoral shaft. The DHS has been the most popular implant choice for the treatment of proximal femur fractures over the past two decades, due to a fracture union rate of >95%. However, in the treatment of unstable fractures, mechanical failure occurs in 6-28% of the cases due to large bending moments on the implant. Intramedullary devices such as the gamma nail, and the proximal femur nail, were designed to overcome the high rate of mechanical failure associated with the DHS. These devices consist of a long nail inserted into the diaphysis of the femur, and a stabilizing locking screw advanced through the lateral femoral cortex into the head of the femur.

The insertion of the gamma nail indicates a smaller incision and requires less soft tissue disruption than with the insertion of the DHS. Estimated blood loss is also significantly less for the gamma nail than for the DHS. Thus, a smaller incision, less soft tissue disruption and a decrease in blood loss is indicative of less post-operative pain and earlier mobility. Nonetheless, a post-operative complication rate of 18% with the gamma nail has been reported, with the major complication encountered being the cutting out of the screws in the femoral head leading to instability of the fracture.

To combat the complications associated with the gamma nail the trochanteric fixation nail (TFN) was designed, and it was released for use in several US test markets in 2002. Changes made include a helical blade design, which upon insertion allows for a greater compaction of the cancellous bone in the head of the femur. The retention and compaction of cancellous bone in the femoral head indicates less of a chance of screw migration and the resulting fracture instability associated with it. For the most part, selection of the TFN in the treatment of proximal femur fractures indicates a post-operative, full body weight bearing status.

From a physiotherapy perspective, advancements in the design of the surgical implants used to fixate proximal femur fractures in the elderly, specifically the TFN, have resulted in earlier post-operative mobility which indicates a higher level of post-operative functioning and independence in patients.

Allison Burns – MSc (PT) Candidate (2010)

19th Annual Winter Adapted Games – Another Great Year!

This January, Queen’s University hosted its 19th annual Winter Adapted Games (WAG). WAG is a fun-filled day for children and youth with disabilities from the Kingston community. Both the schools of Kinesiology and Health Studies and Rehabilitation take part in organizing this event. WAG provides an opportunity for children and youth who have a disability to be involved in an exciting day of non-competitive games and activities at Queen’s. WAG emphasizes the importance of social interaction and physical activity in an environment that promotes success in children’s abilities to participate.

This year, 60 children from the Kingston community swung through the jungles of the PEC at WAG with the help of 104 student volunteers from the Schools of Phys-Ed/Kin and Rehab. The day was full of jungle themed games, movies, a scavenger hunt, swimming, a sleigh ride, tobogganing, and of course pizza!

WAG is a non-profit initiative; participants attend at no cost. This year’s event was run through the generosity of the Rehab Therapy Society, PHEKSA, community businesses and fundraising activities.

Want to be a part of the 20th annual Winter Adapted Games in January 2010? Get involved as a member of the planning committee by submitting applications in the early fall. In order for WAG to run so smoothly every year, many students are needed to be buddies, team leaders, and event facilitators. As a buddy, you will be paired up with a participant with whom you get to spend the entire day as you participate in all the activities that WAG has to offer. As a team leader, you will be in charge of a small group of buddy-participant pairs and you will lead the group to the different activities over the course of the day. As an event facilitator, you will be responsible for running one of the activity stations. It will be your job to explain the particular activity and get everyone involved as each new group arrives at your station. Watch for information about how to get involved in next year’s games coming in the fall of 2010!


Jeanette McNalty – MSc (OT) Candidate (2009), Vice President Internal, Rehab Society (2009/09)