Final grade: histogram
Mean: 85.6%
Std Dev: 6.8%

Have a great break and a super clinical experience!
Evan

Q. Can you differentiate between the PAP (positive airway pressure) and the PEP (positive expiratory pressure) and the devices of each? The only devices through my notes I am finding are the acapella and flutter (both PEP's).

A.  In working with patients who have thick secretions and an ineffective cough we need to:

• train in effective coughing technique
• instruct the patient to assume specific postural drainage positions to help clear airways
• provide percussion, or instruct a family member in how to assist by using a mechanical vibrator (a back massager works fine)
• instruct in ACBT, or Autogenic Drainage
• instruct in the use of PEP devices, e.g. Acapella, Flutter, and PEP valve devices.

PAP can refer to either PEP or PIP (Positive Inspiratory Pressure)
As physical therapists we are directly involved only with PEP devices.
Respiratory Therapists will adjust both PEP and PIP levels for the patient on mechanical ventilation.  You are not responsible for this info, but if you are interested in the parameters, see Hillegass p.521-523.

Fun history fact:
Q.  Is Negative airway pressure every used?
A. Yes, Negative Airway Pressure is the principal used in the Iron Lung (see photo in Hillegass p.524)
Archive photo of a polio ward in the 1950s
The newly forming profession of physical therapy was greatly expanded to meet the demand for rehabilitation for polio survivors during this era.

Q.  Are inspiratory muscle trainers used for RLD? 
The acapella and PEP, are those both for obstructive airway diseases? 

A.  Yes, an inspiratory muscle trainer, IMT (looks like a kazoo) can be useful for non-progressive RLD patients, e.g.  a person with C5 quadriplegia.  But it would probably be inappropriate for the person with progressive RLD, e.g. ALS. 
Also, someone without any lung disease (trauma) that has been ventilator dependent could benefit from an IMT.

I suggest you ignore any evidence you might have come across about use of IMT for COPD or for CHF. This is based on the clinical judgement of Sharon Coffman and several RTs.

Don’t get the IMT confused with an Incentive Spirometer (device to increase inspiratory flow), given to nearly all patients after major surgery. 

Yes, PEP devices are designed to help with COPD patients who also have secretion problems (though other populations might benefit from their use also)

Remember, the Final is at 8:00 (not the usual starting time for Friday class).

Q. On the final concerning drugs and their classes/effects, are the matching questions going to be separated into cardiac, pulmonary and rheumatic? Or will they all be bunched together in the same question?

A. They will be separate, not bunched

Q.  Could you please clear up the following: consolidation lung sounds- do you hear distant/ rales and crackles/ or nothing?  I have all three listed in different parts of my notes?

A. The information in Hillegass, DeTurk (a previous text for this class), and Coffman are not completely consistent.  So we will keep it simple, and here are the points you need to know:

1. Left Heart Failure can cause Pulmonary Edema, resulting in auscultated rales/crackles.   This is from a buildup of fluid/serum/transudate OUTSIDE the alveolae/airways. 

2. Secretions INSIDE the airways will also result in auscultated rales/crackles.  Consolidated lung segments are filled with exudate and will have rales/crackles.

3. Distant breath sounds occur with hyperinflated lungs, e.g. emphysema and the increased A-P diameter of a “barrel chest”.  There is very little air actually being exchanged, so it sounds far off in the distance.

I know some people can’t resist having more detail, so it is given below.  But the concise info you need for the test are the points above, OK?

Atelectasis is defined as airlessness, and the “purest” example of this would perhaps be unilateral phrenic nerve paralysis (RLD).  However, in some conditions, a segment of the lungs may be under ventilated (but not completely airless), as well as having some secretions (but not all the way to being consolidated).  Under those circumstances, you might also expect to hear rales/crackles.

Q. Several sources I have read define benign tumors as non-cancerous.  I think you said in class a benign tumor is still considered cancer, and I just wanted to clarify before the exam. 

A.  A benign tumor is not cancerous.  If that’s what I said it’s wrong!
Here goes:

• Tumors can be benign or malignant. 
• Tumor are also called neoplasms. 
• Neoplasms can be benign (contained, encapsulated) or malignant (infiltrative and/or metastatic). 
• Benign tumors/neoplasms can be harmless, or they can be harmful if they press on vital organs, vessels, etc.
• A malignant neoplasm is called cancer.   
• Cancer is always malignant.

Q. Herb identification

A. Imagine walking into a health food store and looking at a display shelf of arthritis remedies.   All herbs compiled in the AF guide have research indicating efficacy, therefore with the help of the AF Guide you should be able to identify the ones on the shelf that could be helpful for an arthritic / musculoskeletal condition.

Final Exam Review sheet

Final: types of questions

• Multiple Choice: 107
• Matching: 6
• Short Answer: 10

Final: content proportions

1. Wound/Vascular: 10
2. Pulmonary: 17
3. Cardiac: 23
4. Burn: 16
5. Oncology: 27
6. Rheumatology: 30
   

The email message below was sent 3:46 PM, Thursday.

Dear Class, there WILL BE CLASS ON FRIDAY MAY 8, 9:00

At 3:23 PM, right after I walked upstairs, the Vice Chancellor emailed and said that it was OK to have class on Stop Day.

"As a block schedule class, based on input from the Registrar, your course operates with a different academic calendar."

1. Facilitators - don't worry, you don't have to present as usual.
   However, if possible, could you please show up 10 minutes early. I have a plan for an activity that you can help me with.
2. We will start class with the quiz
3. Evan and Dr. Hargrove will lecture.

Sorry for the chaos! Evan

Dear Class,
I am waiting to hear from the Vice Chancellor, and will let everyone know as soon as I do.
Until then, plan on class Friday (and having the facilitators’ meeting Thursday).
Objectives Coordinators will meet as usual.

More PCM advice: if your group has been in the habit of submitting apendices for the intervention component of the POC ...
... that will NOT be appropriate for Bonnie Carman.
Remember: The HEP must be integrated, concise, brief, and realistic for a working mom coping with variable pain and fatique.

The Final exam Review session next week could be held on either:

1. Monday morning
2. Monday afternoon
3. Tuesday afternoon

Please check your email for a message regarding Stop Day.
Dr. Minor will speak to the class at the end of class on Tuesday.

Eric and Brian have given permission to post their interview (for Med Testing) of Bret Derrick PT, about Industrial Physical Therapy

After reading this description, the point should be very clearly made that Bonnie Carman is NOT a candidate for typical work hardening or FCE, since she is not recovering from an injury. Her disease is chronic, variable, and progressive.
So the best role for the Industrial PT for this population would be to modify and accommodate the work environment, and prescribe joint protection measures for the specific work tasks.

... reposted from the Wound unit: Footwear Modifications
Note the sections relevant to rheumatoid arthritis.

Arthritis Foundation

Fibromyalgia Syndrome
1. ARHP p.103-107
2. Evan has a video of Manual Tender Point Survery, in his office, (13 minutes long).
3. Screening tool for FMS (Goodman - appendix B-14)
"Researchers have been unable to develop a reliable screening questionnaire for FMS because of the wide-ranging symptoms associated with this condition. This type of screening tool may help the therapist identify potential cases of FMS but should not be relied on as the only evaluation instrument."

Two Quizzes this week (details below)

Rheumatology Quiz #1 on Tuesday - short answer
O’Sullivan C.26: Arthritis, Appendix B, p.1087-1089
Sections:

1. Joint protection (introduction)
2. Joint protection principals
3. Additional reminders for the protection of the Rheumatoid Hand
4. Getting additional rest
5. Energy conservation to reduce fatigue

Hints for a successful PCM POC:

1. Be thinking of how the Industrial PT might apply these principals (from O'Sullivan) for Bonnie Carman in the workplace. 
2. A well-written POC will make clear the link between each principal with the specific modification / accommodation / activity that you are recommending.
3. The HEP must be PRECISE and brief. She is a busy woman! She does not have time to come to OPPT. The HEP must fit with her life.

Rheumatology Quiz #2 on Friday - short answer, matching

Hint: O'Sullivan p.1087-1089: Appendix B: Joint Protection, Rest, and Energy Conservation, is an important source.

Oncology handouts for Friday morning presentations:

• Group 1: Metastatic Endometrial CA
• Group 2: Paraneoplastic Syndrome
• Group 3: Glioblastoma
• Group 4: Non Hodgkins Lymphoma
• Group 5: Acute Lymphoblastic Leukemia (ALL)
• Group 6: Squamous Cell Carcinoma with Radical Neck Dissection

The Case of Bonnie Carman: part 2

Because this is an 8 week course instead of a 16 week course, there will be class as usual on Friday, May 8th (the traditional Stop Day).

Rheumatology Objectives

Friday Quiz (short answer) over the following article:
Minor, M. (2001). Rest & Exercise.
Clinical Care in the Rheumatic Diseases. (2nd ed.). Association of Rheumatology Health Professionals. 26;179-184.

... be thinking about how these principals might be applied to Mrs. Carman, in the last PBL case.

Come on Tuesday 10:00, to Lewis 3, before class, to look at your graded Midterm.
There will be some questions on the Midterm that will be repeated on the comprehensive Final.

Timeline for Oncology project:

1. Monday 10PM: submit ppt to Evan AND to your Tutor (using protocol).
   Purpose: it's not necessary to have all 20 slides done or content finalized. It will give tutors and Evan a look at what you have thus far.
2. Thursday 2PM:
   • Submit final ppt electronically (using protocol)
   • Submit Word document of handout electronically (using protocol)
   • Facilitators will come to rm. 125 to give Evan their hard copy of the Word document handout and receive any final feedback
     

Regarding oncology objective #11: Abdominal surgery precautions and management

Precautions after abdominal surgery (generally for 6 weeks):
Make cough more effective and less painful by splinting with a pillow.
Avoid lifting more than 15 pounds; avoid situps or crunches, instead teach to log roll; avoid valsalva (isometrics).
Stoma present? Be sure to not place gait belt over pouch. May work to put under axilla.

Midterm grades: histogram
Mean: 89%
SD: 9%

... for the PBL group whose patient is Dan (diagnosed with NH Lymphoma): helpful links

Related to oncology Obj #6
Fatigue (chemotherapy & radiation)
Also see Bottomley p.97, EB citation for PT journal article on fatigue.

... for the PBL group whose patient is Julie (diagnosed with glioblastoma)
Related to oncology Obj #13
Hill CI, Brain tumors. Phys Ther. 2002;82: 496–502.

Related to oncology Obj #17 & 18
Resources on Death and Dying

Related to oncology Obj #19
Advance Directive - information
Advance Directive - form

Related to oncology Obj #20
Do Not Resuscitate (DNR) - form

Related to oncology Obj #22 & #17
Cancer Pain Management; Acute vs. Chronic; Opiods

... for the PBL group whose patient is Sam (s/p radical neck dissection)
Related to objective #23: Radical Neck Dissection
Exercise protocol for post Neck Dissection - from Mary Ann Dougherty RN, University Hospital

Your oncology presentation is being judged not only on the content, but also on the formatting and the presentation technique.
Below is the same document that I presented to you all at the start of Peds-Neuro last fall. Follow it for a succesful presentation.
Guidelines for creating and presenting professional and effective PowerPoint ® presentations
For your 10 minute presentation, you will only have 20 slides.
Don't overcrowd the slides!

Typo in Juli Olmsted's lecture notes (corrected in red font, here)

"Heterotopic Ossification is found most commonly in patients with > 20% full thickness burn and in those whose wounds were ungrafted for prolonged period of time."

Oncology case:
No TOEs are required, however, include all your references on the last slide of your ppt.
Also, be sure to site those references within the text of the relevant ppt slide.

Come on Tuesday 28th at 10:00, to Lewis 3, before class, to look at your graded Midterm.
There will be some questions on the Midterm that will be repeated on the comprehensive Final.

For your review, and to assist with objectives and the PBL case:

1. PT Role in Oncology ... important lecture notes from Karen.
2. Consult your notes from Differential Diagnosis, Fall 2008:
   1. Teresa's lecture notes
   2. Karen's guest lecture notes

The APTA Section on Oncology has compiled a very comprehensive list of Cancer Web Links
with the following sub categories:

• Cancer Organizations
• Specific Cancers
• Cancer Treatment
• Cancer Treatment Side Effects
• Edema
• Hospice and Palliative Care

Oncology content objectives

Tuesday handouts posted in Week 5 calendar

Dutcher K. (1992). Rehabilitation Therapy in Pain Management in the Burn Patient
A Workshop Review. The Medicine Group USA. Yardley, PA. p.28-31

Optional: Rocky Mountain Model System for Burn Injury Rehabilitation    54-page pdf file

Optional: online case study of a pediatric burn patient, with Q&A.

In case you didn't get this handout when you did your observation, her is the Fit for Life Phase II Cardica Rehab Protocol.

Example of a good LTG from the Mary Long case.

If it makes it easier to prepare for the Midterm, the Friday 9AM due date for the Burn unit PCM can be postponed.

On Monday, Evan has more pamphlets and patient education material that will help with your burn case (and objectives).

Burn PBL Cases, Part 2

Lund & Browder Total Burn Surface Area (TBSA) diagrams for Johnnie, Barbara, and George

Student Performance Eval: weeks 5-7

Review sheet for the Midterm

Objectives for the Burn Unit (due Thurs, 4/23)

We will be taking walking pulses, so wear a watch that you can EASILY use to time seconds.

Documents for Wed. lab and lecture posted in calendar, below

Below is an email I just received from an alum.
It should help you picture what your role as a PT could be as you were working with a patient like Mrs. Long.

Evan, feel free to tell the students what I said about cardiac rehab and PBL. I'm working a mix of inpatient (cardiac rehab and ortho) and outpatient---spines, sports med, and women's health. We work with all post-op patients (CABG, valve replacements, MI), so all that info you taught has been incredibly helpful! I was more than ready to work safely with cardiac patients. If students think cardiopulmonary class is hard, it is WELL WORTH IT!

Stephanie (Burstin) Powell, MU PT Class of 2006

Information regarding Obj #6: Distress and Emergency Measures

Well-written Goals for the Pulmonary Unit, Mr. Carter.

Early warning signs of a heart attack

24 hour Holter (ambulatory) monitor (inpatient or outpatient use): tallies the abnormal events occurring in a 24 hour period

O'Sullivan p.633 has a helpful table that compares therapeutic issues for the full range of patients that would be recovering from an adverse cardiac event.

Teresa has given permission to re-post her excellent outlines from Diff. Diagnosis: Cardiac, Unit 5

Sternotomy precautions s/p CABG: A discussion excerpted from an APTA section listserv

American Heart Association
National Heart Lung and Blood Institute

Related to objective # 26:
Sexual activity after heart attack
Return to sexual activity following a heart attack  from the University of Michigan

Related to objective # 20: Sex-based biology (particulary as related to women's cardiac health)

Discussion of Rate Pressure Product (RPP) (Hillegass p.97)

Read two articles on clinical management of Heart Transplant / Denervated Heart patients:
Clough, P: The Denervated Heart
Fink, A.W: Exercise Responses in the Transplant Population
Then take the Blackboard online quiz, titled "Cardiac 1" which is available until Wednesday, 4-15, 12:30 PM (5 pts.)

There will be a short quiz at the start of Wednesday lab over vital signs.
To help you prepare there are the following files on Blackboard:

1. Answer the 6 questions on Blackboard (it is NOT for a grade). The title is "BP & HR - prep for exam"
2. Listen to this audio file: How to assess BP

PCM and TOEs for Mary Long due Friday 9AM

The Case of Mary Long, part 2
The Case of Mary Long, part 3

Blackboard quiz over PFTs is available until Friday, midnight. 3 points.

Objectives for cardiac unit -- to be covered on Thursday the 16th

Suctioning procedures - a handout for the Monday pulmonary check out.
Note: All the skills EXCEPT suctioning skills are being evaluated at a mastery level (as typical in a check out)

Here's more clarification about referencing in the PCM

Check the calendar for what you need for Wednesday.

Information about the Lab Check Out: Pulmonary Rehabilitation on Monday, April 15

Optional: Flow Volume Loops ... Linda Davis, RT referred to these briefly
Try staring at the various examples, and it will probably start to make sense.  Compare normal and pathological.
1. COPD is scooped out
2. RLD is shrunk
Also see Hillegass p.438 for explanation and examples of normal vs. obstructive vs. restrictive.

Pulmonary PCM & TOEs are due Friday April 10th, 9:00 (digital and paper)

Examples of well written goals, selected from the Wound PCMs. 

American Lung Association

Optional (eligible for a TOE): Dechman,G. Wilson, C. (2004). Evidence Underlying Breathing Retraining in People With Stable Chronic Obstructive Pulmonary Disease. Physical Therapy, 84(12), 1189-1197.
This is a review of 22 studies on Pursed Lip Breathing (PLB) and Diaphragmatic Breathing (DB)
Important Conclusion: PLB helps COPD, DB doesn't help COPD.

To make it easier for those reporting on evidence found in:

1. Systematic Reviews (SR) and Meta Analyses (MA), from Cochrane
2. Clinical Practice Guidelines (CPG), from the NIH National Guidelines Clearinghouse, etc.

... a new blank template for SR and CPG has been created that will make it easier to summarize the information. It can be found under "Templates" along with the TOE template for clinical trials.

Email question sent by Evan to Victoria Gilpin:

How many hours a day should the paient with venous insufficiency wear their compression garment? My assumption is that they should be worn during the day, taken off at night (while they are supine and edema is somewhat relieved), and then reapplied in the morning (when edema is at its lowest from being supine all night). If a person had co morbid CHF, I would think that it might even be contraindicated to wear them at night, potentially causing volume overload/orthopnea in supine.
Thanks for your expertise!
Evan

Your assumptions are correct about wearing stockings. Don’t want to wear at night for medical conditions as well as for skin health.
Victoria Gilpin
FNP-BC Vascular Surgery Division University Health Care System

From Evan's Friday presentation:
Illustrations of abnormal fluid conditions of the lung and of the pleura

MOVED TO BLACKBOARD !!!

Listen to this audio file explaining ABG and Acid-Base Balance.
Remember:

• In Respiratory Acidosis there is an INVERSE relationship between the pH and the PaCO2
• In Metabolic Acidosis there is a DIRECT relationship between the pH and the PaCO2

Oxyhemoglobin Dissociation Curve (Also see Hillegass p.64-65)

PBL case #2: Mr. Nathan Carter - Pulmonary, part 2

National Heart Lung and Blood Institute

Teresa has given permission to re-post her excellent outlines from Differential Diagnosis:
Pulmonary, Unit 6

FYI: the PCM for Nathan Carter will be due Friday April 10, 9AM

Sorry for the errors with the Kisner & Colby old 4th edition, instead of the 5th edition that you are using.
I am on the trail to find the stray citations, but if you spot any I missed, please let me know!

Here's what to have for Wednesday lab and lecture ... see the Week 2 calendar below

PBL case #2: Mr. Nathan Carter - Pulmonary, part 1

Pulmonary unit: content objectives (due in week 3).
On this Thursday, April 2nd, the Objectives Coordinators will polish off the remaining Wound/Vascular objectives.

Dr. Hargrove is soliciting volunteers to perform scoliosis screening for sixth grade girls and boys on Tuesday April 7 or Tuesday, April 28

Announcement: Each group's facilitator will submit ALL the TOEs for their group, at the same time that they submit the PCM.
Therefore the group members need to send their TOE on to the Facilitator (not to Evan).

Let's push back the due date on the PCM to Friday, 9AM.

Footwear Modifications (regarding wound objective #18)

Blackboard Pulmonary Quiz Instructions: there is a deadline to finish:11PM Wednesday, April 1st, but there is not a time limit while you are taking the test.
As long as you remember to SAVE YOUR ANSWERS, you can log off, and later log back on and continue taking the test.

If you don't have your Pierson's handy, here are pages about elastic bandaging that we will be reviewing on Tuesday:
Guidelines for applying bandages

How to wrap elastic bandages

... and more helpful discussion about TOEs and Cochrane, courtesy of Jen.

Maggie gave permission to share her first TOE attempt, along with some corrections. Here are some pointers on submitting a well-written TOE.
Remember: I want to be able to read in plain English which outcomes were statistically significant (along with the p values, if given).

Total contact casting & off loading footwear - [5 MB]
Kloth, L.C., McCulloch, J.M. (2002). Wound Healing, Alternatives in Management (3rd ed.) p.396-399

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BROCHURE: MPTA 60th Anniversary Spring Conference, April 17-19, The Lodge of Four Seasons, Lake of the Ozarks

PBL Case #1, Mrs. Sarah West - Wounds, Part 3
PCM and TOEs will be due Tues 31st (or Wed April 1st).
PCM and TOEs are to be submitted both electronically (by email attachment) and also as a printed hard copy in Evan’s mailbox. Use the submission protocol.

Directions to Fit for Life Cardiac and Pulmonary Rehab at University Hospital:
Fit for Life is right next to the University Hospital Physical Therapy Department, which is on the basement level, on the east end of the hospital.

Bring on Friday morning: Wound Management Adjuncts: Compression; Pressure Off-loading

Another handout from Victoria Gilpin about Venous mgmt.
1. Selecting compression (Circ-Aid should be included in this table)
2. Selecting dressing

Become familiar in the use of Well's Clinical Decision Rule for DVT. Resources can be found by starting in the left navigation bar,
clicking on Exam Tool Kit ... Cardiovascular Examination Tool Kit ... DVT
Would you use this for Sarah West? Why or why not?

MOVED TO BLACKBOARD !!!

Karla Malaney's full ppt with images: Assessing Wounds with Focus on Pressure Ulcers (100 slides, 12 MB)

Objective #8: regarding "Over classification"
Overclassification is the improper disposal of solid wastes that do not meet the definition of infectious “isolation” medical waste, as if they were infectious. Recognize that over classification greatly increases disposal costs as well as increasing the release of carcinogens from incineration.

Infectious Medical Waste is defined as medical waste capable of producing an infectious disease. Waste is considered infectious when it is:
• Contaminated by an organism that is pathogenic to healthy humans
• The organism is not routinely available in the environment
• The organism is in significant quantity and virulence to transmit disease
Source: West Virginia Department of Health and Human Resources, Bureau for Public Health, Office of Environmental Health Services. Accessed 5-22-2006.

Wed morning Lab Handouts:
1. Tarbot - order forms for Jobskin vascular compression garments
2. Semmes Weinstein Monofilament (SWM) protocol

Wednesday afternoon lecture handout:
Assessing Wounds with Focus on Pressure Ulcers -- Karla Malaney, RN, CNS-BE

FYI: regarding PEDro:
1. distribution of rating scores
2. growth of physical therapy research literature in the last 40 years
Maher CG, et al (2008). A description of the trials, reviews, and practice guidelines indexed in the PEDro database. Phys Ther.88(9):1068-77.

Electrical Stimulation for the Treatment of Wounds is covered by Medicare.
Read about the Indications and Limitations of Coverage

PBL Case #1, Mrs. Sarah West - Wounds, Part 2
There are 3 parts all together, so the intervention will be set in the third part.

Sharp debridement: the role of PTs & PTA - opinions

National Pressure Ulcer Advisory Panel
See description of "Suspected Deep Tissue Injury" which is a NEW category as of 2007 (therefore not in our text books) that Karla Malaney will address in her lecture on Wednesday. It is EARLIER than the Stage 1 ulcer (non-blanching erythema) that your text books talk about..

Bring the following texts to each PBL sessions:

1. The Guide
2. Bottomley
3. Hillegass
4. Goodman
5. O’Sullivan
6. ACSM

Bring your Guide Tuesday morning.

Phases of wound healing - diagram (notice how they overlap)
Kloth, L.C., McCulloch, J.M. (2002). Wound Healing, Alternatives in Management (3rd ed.).
Philadelphia: F. A. Davis Company. p.4.

Mrs. Sarah West's ulcer might have looked something like this photo

Denise Boyce PTA, CWS has given permission to re-post her notes on Wound Management from last spring in Pathophysiology, for you to review (in case you can't lay your hands on them).

Tuesday lecture handout: Principles of Venous Insufficiency Wound Care: Victoria Gilpin, FNP-BC

Examples of how to do referencing in the PCM

8 week Schedule

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Questions? email Evan