Politeness and face in digitally reconfigured e-learning spaces

This paper has two starting points. The first is a theorization about the way in which “rhetorical space” is reshaped in asynchronous, online, learning environments. In particular, an asynchronous bulletin- board (ABB) discussion offers both opportunities and constraints for teaching and learning. The learning that occurs will be affected by the affordances implicit in the design of the conversational space itself and the communicative practices engaged in by both teachers and students. The second starting point is a small case study, utilizing action research and discourse analytical strategies, whose research participants were the author and students involved in “delivering” and “receiving” an online education course at post-graduate level using asynchronous discussion. The course, taught in English, had a mix of Chinese students (for whom English was an additional language) and native English speakers. The paper will report on students’ perceptions of what worked for them and what didn’t in respect of this elearning environment. It will also use concepts such as politeness, face and positioning to analyse aspects of the participants’ communicative practices and will draw conclusions from these in respect of how successful learning can occur in elearning environments with multicultural and multilingual students. It will make connections between the findings of this case study and other research on asynchronous, web-based learning and will makes some suggestions about what is needed in respect of the future research agenda

How do counsellors and psychotherapists understand diet and nutrition as part of the therapy process? A heuristic study

Expert opinion and information in the public domain suggest that an individual's dietary and nutritional intake may be importance factors in both physical and mental health. However, at this tome in the counselling and psychotherapy field, it is not common for therapists to address issues of dietary intake and nutrition with clients. Further to quantiative studies exploring therapists' inclusion of such factors in their work, this qualitative heuristic study explores the perceptions and beliefs of six qualified counsellors and psychotherapists and how they understand dietary and nutritional information to be relevant as part of the therapeutic process with clients. Data was gathered with semi-structed telephone interviews and analysed using interpretative phenomenologcal analysis. Findings suggests that the personal history and lifestyle of the therapist may be significant in such an approach, as well as the professional maturity of the therapist. Maintaining the therapetic relationship, therapist self-awareness and professional competence were also discussed. Implications for practice include the consideration of multidisciplinary working and developing appropriate training for practitioners in this area

Case Presentation for Compartment Syndrome of Tibial Nerve

CASE HISTORY: The patient is an active 60-year-old male who was seen in the emergency room following an injury to the right lower extremity due to heavy impact with the ground during a lacrosse tournament. He stated that he felt a sharp pain in the knee and that he could not run the next day. His pain continued to get worse and he began feeling sharp pins and needles on plantar surface. The patient was put on Xarelto (an anticoagulant) for the next six months and continued to consult with different doctors to further evaluate the progression of the injury. The swelling and pain eventually resolved but the pins and needles on the plantar aspect of the foot was persistent. PHYSICAL EXAM: Examination of the right lower extremity showed right thigh girth at the vastus medialis obliques to be 46 cm in comparison to 48 cm at the left thigh. The girth of the right calf was 1 cm smaller than the left calf at 40 cm. Manual testing found that strength and reflexes remained throughout the extremity, except for a notable loss of toe flexion strength. Ankle inversion was 3/5 on the right and 5/5 on the left. The tibialis posterior tendon was not palpable on the right. A dull pinprick assessment found that sensation was absent on the plantar surface of the right foot. These results indicated that there was a considerable loss of right flexor digitorum and right flexor hallucis strength, with a decrease in tibialis posterior function. DIFFERENTIAL DIAGNOSES: Deep vein thrombosis; popliteal artery entrapment; fibula or tibia fracture; ischemic necrosis or gangrene; stress fracture, medial tibial stress syndrome. TESTS & RESULTS: Patient had an MRI of the right lower extremity performed, which found diffused edema involving the deep posterior compartment, especially within the posterior tibialis muscle below the knee and flexor digitorum longus muscle. With further exams, minimal edema was found in the medial head of the gastrocnemius. Prominence of the deep compartment veins of the right lower extremity along the neurovascular bundle extending through the course of the tibial nerve and posterior tibial artery was also discovered. Postsurgical changes from a right ACL reconstruction, severe lateral compartment degenerative changes with loss of articular cartilage and osteophytes were found as well. FINAL DIAGNOSIS: Compartment Syndrome of Right Tibial Nerve. DISCUSSION: Compartment syndrome occurs when the tissue pressure inside of a compartment exceeds perfusion pressure from the local arterial supply. This pressure can build up due to bleeding, edema, or soft tissue damage in a closed muscle compartment. Acute trauma and overuse syndrome are the most common causes of compartment syndrome. Men are ten times more likely to develop compartment syndrome in the lower extremities than women. Males younger than 35 years of age who are involved in a high energy trauma possess the highest risk. OUTCOME OF THE CASE: The most recent MRI showed an improvement of diffuse edema involving the deep posterior compartment of the right lower leg with minimal persistent edema within the tibialis posterior muscle. Right knee joint degenerative changes continued to progress, especially in the lateral compartment. Given this long injury-span, the active patient was given a chance to do exercise therapy in a whirlpool. He was also prescribed Capsaicin cream. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: The patient was given a physical therapy order for 1-2 times per week. He will also receive transcutaneous electrical nerve stimulation for 20 minutes to stimulate the tibial nerve, an electromyography to evaluate the health of motor units, and an ultrasonogram of the tibial nerve during his follow-up visit in 4 weeks

Acute Multiple Deep Vein Thrombosis

CASE HISTORY: The patient was a 49-year-old male who presented to the clinic for further evaluation right calf swelling and pain. He reported that the pain began approximately three weeks before the visit while in physical therapy for ACL knee surgery rehab. The patient recalls performing a lateral stepping exercise when he experienced a sharp pain in his groin that radiated down his leg to his toes on the right side. The pain in his groin eventually subsided but continued experiencing aching pains and swelling in the right calf. He initially had difficulty walking on his right leg but wearing a compression sleeve alleviated the pain and he was able to resume regular activities of daily living (ADLs). The swelling continued to persist, where at his physical therapy clinic they encouraged him to partake in rest, ice, compression, and elevation (RICE), but no improvement of swelling has occurred. He previously reported past family history of recurrent leg swelling and Congestive Heart Failure (CHF). PHYSICAL EXAM: Further investigation of patient reported pain and swelling of the right lower extremity found the right calf with firm edema and tenderness to palpation. Patient has full passive Range of Motion (ROM) of hips, knees and ankles. Thomas Test was negative bilaterally. Upon palpation of the right groin, an indirect hernia defect was confirmed. Strength of both right and left legs reported 5/5 on manual muscle testing with full ROM against gravity and maximal resistance. DIFFERENTIAL DIAGNOSES: Multiple Acute Deep Vein Thrombosis (DVT); Edema; Varicose Veins; Pulmonary Embolism (PE); Venous Ulcer. TESTS & RESULTS: Patient underwent an Extremity Venous Duplex test where seven acute DVT were found on the right femoral, popliteal, gastrocnemius, posterior tibial and peroneal veins. Multiple panels of blood work were analyzed and the patient had borderline low Blood Urea Nitrogen (BUN) and Creatine levels and Protime-International Normalized Ratio results of Prolonged Partial Thromboplastin Time noted. Rivaroxaban (Xarleto) 15 mg tablets were prescribed to patient twice a day for 21 days, then continue 20 mg with food daily. FINAL DIAGNOSIS: Multiple Acute Deep Vein Thrombosis. DISCUSSION: Deep Vein Thrombosis occurs when a blood clot (thrombus) forms in one or more deep veins, usually in the lower extremities. Blood clots can dislodge, travel to the lungs and cause Pulmonary Embolism. DVT is common in those who are overweight, smoke, have cancer, recently had lower extremity surgery, genetically predisposed, or spend long periods of time sitting. The incidence rate of DVT after knee surgery is 41.6%, after knee replacement surgery, 44-58% and after hip replacement surgery, 23-33%. Prevention and treatment vary per case, and can be managed with prescribed blood thinners, catheter-directed thrombolysis, inferior vena cava filter replacement and consistent exercise. OUTCOME OF THE CASE: The patient was prescribed Xarleto, a blood thinner, daily along with four weeks of supine/prone exercises focusing on upper body and abdominal movements. The patient will return after the allotted time to assess the DVT symptoms and reevaluate return to activity. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: Return to activity recommendations were made based on the anticoagulation initiation date as follow: 1-3 weeks gradual return to ADLs, at 4 weeks, perform non-weight bearing exercises, 5 weeks, perform non-impact loading exercises, and at 6 weeks, start low impact loading exercises. Follow-up with doctor in 3-4 weeks to reevaluate return to activity protocol

Clinical Case Study Abstract for Cervical Radiculopathy

ABSTRACT CASE HISTORY: The Patient was an 84-year-old male who presented with right arm tremors, right arm spasms, numbness and tingling. The patient stated that the numbness and tingling begun in the right fingers and radiated up to the right side of the neck. The pain is worse while driving and walking, especially over uneven surfaces. The pain did not inhibit his ADLs. He took Tylenol PM for the pain, though infrequently. The patient has benign prostatic hyperplasia (BPH), type 2 diabetes mellitus, foot pain, ankle pain, swelling of lower limb, hypertension, and hyperlipidemia. PHYSICAL EXAM: Patient presented with 5/5 strength in upper limbs bilaterally. He tested negative in Romberg’s, Adison’s, Babinski, Hoffman, Lhermitte’s, Phalen’s, Tinel’s, Neers, Hawkins, and empty can test. The patient had negative impingement and range of motion of shoulders was intact and symmetrical. He was nontender to palpation over anterior, lateral, medial, and posterior borders of the scapula. Examination included full neuro exam without any acute findings except horizontal nystagmus DIFFERENTIAL DIAGNOSES: peripheral nerve entrapment, rotator cuff impingement, parsonage turner syndrome, thoracic outlet syndrome, Cervical Radiculopathy, and Idiopathic brachial plexopathy. TESTS & RESULTS: Patient’s MRI showed cervical spine degeneration and stenosis of C4-C5 and C5-C6. EMG findings presented as normal with no significant evidence for a right upper extremity peripheral neuropathy, brachial plexus lesion, or cervical nerve root lesion. FINAL DIAGNOSIS: Cervical Radiculopathy. DISCUSSION: Cervical Radiculopathy most commonly involves the 6th and 7th cervical nerve roots and is caused by spondylosis of the C5-C6 and C6-C7 vertebrae. Vertebral body diameter, race, weight, and height are not significant risk factors for cervical radiculopathy. However, age, gender, and occupation were found to be significant risk factors. Prevalence is reportedly 3.5 out 1000 persons and gender preference vary. Individuals are commonly affected in the 5th and 6th decades of life. The intervertebral disc is accounted for 22% of cases, whereas the other 68% are caused by a combination of discogenic and spondylitis. Cervical Radiculopathy can be divided into three categories: acute, subacute, and chronic. Acute typical occurs in younger patients. While subacute radiculopathy occurs in patients with prior spondylosis. Subacute typically does not show many symptoms other than occasional neck pain. Chronic radiculopathy stems from untreated or non-response to treatment of acute and subacute radiculopathy. Common treatments of cervical radiculopathy include physical therapy (PT), specifically the use of cervical traction and manipulation, and medication such as oral analgesic, non-narcotic drugs, NSAID’s, and corticosteroid injections. Surgery is also an option for many with this condition. OUTCOME OF THE CASE: Through PT patient had reduction in symptoms. His pain level is 0/10 pain when at rest, 3/10 when doing activities. Radicular pain has improved and is only present in a patchy distribution. Patient was instructed to discontinue meloxicam and use an over-the-counter pain medication such as Tylenol. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: Patient was instructed to continue PT, ice the shoulder 1 to 3 times per day, as needed. Use Trekking poles for ambulation, cervical traction and was provided a handout for home exercise program, which included lateral pull and upright row exercises, 20 reps 7 days a week. Patient will continue PT and will follow up with physician to determine whether the epidural shot is necessary

Case Presentation for Polycystic Ovarian Syndrome

CASE HISTORY: The patient is a fourteen-year-old female who presented to the clinic for bilateral hip and lumbar back pain. She stated that the pain has been present for approximately seven months and described it as a deep ache in the low back and both hips anteriorly. The patient said she plays a variety of sports but denies any specific event that could contribute to her pain. She stated her pain is worse with prolonged walking, standing, and sitting. Additionally, the patient mentioned her first menstrual cycle lasted fifty-six days and she has since not had any following menses, indicating secondary amenorrhea. Secondary amenorrhea is characterized by the cessation of irregular menses for six months and is commonly caused by hormonal imbalances. PHYSICAL EXAM: Examination of the hip, abdomen, and back did not demonstrate any deformities. She had tenderness to palpation at the mid-abdomen and at the insertion of the hip flexors, at the ASIS and AIIS bilaterally. Her patellar reflex was normal and 5/5 strength in hip flexion, extension, and abduction was observed along with full range of motion of both hips. FABER and FADIR tests were conducted and resulted in a positive sign of pain for both tests. DIFFERENTIAL DIAGNOSES: Hip dysplasia, Slipped capital femoral epiphysis, Polycystic Ovarian Syndrome, Femoroacetabular impingement, and Snapping hip. TESTS & RESULTS: Patient had an x-ray of both hips that were negative for tissue abnormalities. A pelvic MRI suggested small areas of sub-chondral sclerosis and possible polycystic ovaries. FINAL DIAGNOSIS: Polycystic Ovarian Syndrome (PCOS). DISCUSSION: PCOS is a common endocrine disorder that effects an estimated 10% of women between the ages of fifteen to forty-four, though it is commonly diagnosed in adolescence to early twenties. PCOS is diagnosed when two of the following criteria are evident: menstrual irregularity, polycystic ovaries and/or symptoms of androgen excess. Though pain is not an indicator of PCOS, it is not uncommon, and presentation varies widely to include abdominal, anterior pelvic, and low back pain. PCOS is believed to be caused by genetics but is greatly influenced by lifestyle factors and is associated with many morbidities including obesity, insulin resistance, and depression. Management of PCOS consists of controlling the symptoms of androgen excess and/or the absence of ovulation, and to reduce the chances of long-term complications such as infertility, metabolic syndrome, and type two diabetes. Oral contraceptives are the most common treatment for menstrual irregularity in adolescents. Androgen excess is managed with a combination of cosmetic management, oral contraceptives, and anti-androgen therapy, such as cyproterone acetate. Prevention of long-term complications include diet and lifestyle changes to reduce the risk of developing type two diabetes. Metformin may also be an effective treatment for both type two diabetes and androgen excess. OUTCOME OF THE CASE: Patient was referred to physical therapy to include protective range of motion and exercise of hip flexors. She continued to take Diclofenac for pain. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: The patient will follow-up with endocrinology and gynecologist for questionable polycystic ovarian syndrome due to polycystic ovaries present on the hip MRI and elevated testosterone levels. An x-ray without contrast of bilateral hips will be obtained to evaluate bony anatomy and she will return to the clinic in 4-6 weeks to follow-up on symptoms and discuss the imaging findings

Case Presentation for Axillary Nerve Injury

CASE HISTORY: The patient is a 21-year-old male experiencing upper extremity numbness and tingling in the right deltoid. He began to experience these symptoms after a football injury and was seen by a doctor who referred him to a sports medicine specialist one month after the injury. The injury occurred during a football game, where he was struck by an opponent on the right inferior axillary region. The patient lost mobility of his right arm immediately following his injury, however, regain minimal mobility a week later. Right arm was checked for dislocation or any fractures, and none were found. The patient was referred to a specialist and received one follow-up visit after his initial evaluation. PHYSICAL EXAM: The patient received care from an Athletic Trainer who referred him to a doctor for further examination. The doctor tested the strength and reflexes of the upper body extremities and found a decreased in sensation at the right deltoid, compared to the left. DIFFERENTIAL DIAGNOSES: Shoulder dislocation, neuralgic amyotrophy, lymphoma, parsonage turner syndrome, cervical radiculopathy of C5-C6, quadrilateral space syndrome. TESTS & RESULTS: There was no spinal cord injury based on the Hoffman test. The Sensory Conducting Study found the right and left Antebrachial Cutaneous Nerves outside the normal range. The test displayed neuromuscular dysfunction in the Right Axillary Nerve, with very low amplitude; thus, the nerve signaling was not enough to allow movement. A Motor Nerve Conducting Study showed no significant abnormalities in six of the eight nerves but found irregularities in the Right Axillary and Right Radial Nerves. The EMG showed the Right Axillary Deltoid nerve to have a significant decrease in amplitude, 1.3 mV. An F Wave EMG showed a significant spike in the Right Median Nerve that controls the Abductor Pollicis Brevis muscle. The F wave test showed positive fibrillation, indicating the nerve was misfiring and continuing to provide signaling. There was no pattern or activation of neuromuscular response but misfiring of the Right Axillary Nerve indicated the patient has Right Axillary Neuropathy. The EMG tests were repeated during the one-month follow-up, and the results did not show a significant change. FINAL DIAGNOSIS: Right Axillary Nerve severe shock with partial laceration. DISCUSSION: Axillary Nerve damage is a common peripheral nerve injury involving the shoulder. The most common cause for Axillary Nerve damage is a dislocation of the glenohumeral joint, a fracture or a severe blow to the deltoid muscles. In extreme cases, nerve damage is caused by complications from shoulder surgery. In rare cases, Quadrilateral Space Syndrome, and Parsonage-Turner Syndrome causes unusual shoulder pain, numbness, motor weakness, and dysesthesia. In overhead athletes, subacromial impingement is common and affects the shoulder muscles\u27 functions. Other forms of sever shoulder pain can be cause by a hereditary phenomenon called Neuralgic Amyotrophy. Peripheral nerve lesions, which can range from lymphoma of a peripheral nerve to abnormalities, are uncommon but can affect the patient\u27s recovery. Diagnosis of injuries are confirmed by electrophysiological and electromyography testing, as well as nerve conduction studies. Treatment for this disorder should involve extensive rehabilitation focusing on passive and active range of motion with strengthening of the rotator cuff and deltoid muscles. OUTCOME OF THE CASE: Patient continued his care with the Athletic Trainer and gradually regained his mobility and did not return to football for the season. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: The patient will continue his care with the Athletic Trainer and is planning to return for next year season

Case Presentation for Lumbar Radiculopathy Consistent with Foraminal Stenosis and Herniated Nucleus Pulpous

CASE HISTORY: The patient was a 38-year-old male who presented with right lower extremity (LE) pain when performing lower back movements, with no specific low back pain. He stated that five months ago he felt an aching in his calves after performing a Romanian Deadlift, with shooting pain in his right lower extremity that radiated below the knee into the calf including paresthesia. The patient started a prednisone taper that helped relieve some of the symptoms, but after two weeks the symptoms resurfaced. The pain prevented him from exercising or performing certain ADLs. PHYSICAL EXAM: Examination of the right LE determined that reflexes at the patella and Achilles tendon are intact and strength remains present. Sensation decreased along the lateral right calf to the plantar surface of the right foot, but not along the lateral ankle or the foot dorsum. There was difference in sensation of plantar surface of the right and left sides. The straight leg raise test was negative. Increased tone of the quadratus lumborum on the right side was observed. Radiating pain down the right LE was reported while standing and extending the back. Forward flexion at the spine relieved the pain. DIFFERENTIAL DIAGNOSES: Disc bulge, low back pain, Lumbar radiculopathy, and Spondylolisthesis. TESTS & RESULTS: Patient had an MRI of the lumbar spine from the Anteroposterior (AP) and lateral view with flexion-extension. The AP view of the lumbar spine demonstrated no evidence of scoliosis, while the lateral view demonstrated a loss of lordosis that may be attributed to spasm of the back muscles. Further analysis showed that there appeared to be some degree of narrowing of the disc space at L5-S1, which is associated with facet joint disease extending from L3 to S1. FINAL DIAGNOSIS: L5 radiculopathy was consistent with L5-S1 foraminal stenosis on the right side with a disc protrusion. DISCUSSION: The prevalence of lumbar radiculopathy has been estimated to be about 3-5% of the population, affecting both males and females, with a male preponderance in the general population. Age is considered a primary risk factor, with symptoms typically beginning for males in their 40s, while females tend to be affected in their 50s and 60s. Current medical literature is at a consensus regarding the common causes of L5-S1 radiculopathy, intervertebral lumbar disc herniation. More than 90% of herniated discs occur at the L4-L5 or L5-S1 disc space. Compression of these spaces tend to produce a radiculopathy into the posterior leg and compromise or limit ADLs. Current guidelines suggest approaching lumbar radiculopathy in a conservative manner by educating patients, manual therapy, modifying exercises, staying active, and administration of a non-steroidal anti-inflammatory drug. OUTCOME OF THE CASE: Patient received one epidural steroid injection and is due for additional injection at L4-L5 or L5-S1. He was referred to physical therapy (PT) focusing on myofascial release and core stability exercises. Surgery was discussed but the patient stated that since he was improving, he would prefer to not proceed with surgical opinion at this time. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: Patient was instructed to perform his PT exercises along with light latissimus pull downs, chest supported back rows, and activities in the swimming pool. The patient will follow up over the next couple of weeks on his status post epidural steroid injection. Regarding disability, it has been determined that he will decide when he is ready to return to full administrative abilities. After his follow up, a program structured around his abilities for recovery and/or future need will be discussed

Case Presentation for Complex Regional Pain Syndrome

CASE HISTORY: The patient is a 54-year-old female who presented to the orthopedic clinic to evaluate a sharp burning pain in her left lower leg. She stated that the pain started eight months after an Open Reduction and Internal Fixation (ORIF) surgery of her left tibial plateau and had progressively gotten worse. She was prescribed gabapentin and oxycodone for pain and experienced minimal relief with gabapentin. Additionally, she applied analgesic gel which seems to have the most help along with the narcotic. She stated that stabbing and shooting pain radiated from her left lateral proximal tibia down to her foot, causing muscle spasm in her left big toe. PHYSICAL EXAM: Examination of lower leg demonstrated hyperesthesia and hypersensitivity over the anterolateral aspect of proximal tibia. Knee flexion and extension range of motion was between 3°-110° and symmetric bilaterally. There was no crepitus with range of motion. She was stable to valgus and varus stress testing. Edema in ankles was bilateral and chronic. There was an allodynia on the lateral aspect of the proximal tibia and fibula from light touch or pressure; gentle palpations cause extreme sharp pains over the anterolateral knee. There was no joint effusion or deformity, but minimal knee swelling presented. The patient walked with a noticeable limp. DIFFERENTIAL DIAGNOSES: Herniated disc, Peroneal neuropathy, Lumbar radiculopathy, Complex Regional Pain Syndrome, Peroneal compartment syndrome. TESTS & RESULTS: The patient had an EMG of left thigh and leg, a motor nerve conduction study (NCS) of Left Peroneal and Left Tibial, as well as a sensory NCS of Left Sural – Lateral Malleolus nerve and Left Superficial peroneal nerve. The studies were deemed abnormal based on evidence of a chronic left L4 vertebra radiculopathy and a possible mild left peroneal neuropathy because of a mildly low superficial peroneal amplitude and low-normal deep peroneal amplitudes. FINAL DIAGNOSIS: Complex Regional Pain Syndrome (CRPS) DISCUSSION: CRPS is characterized by constant regional neuropathic pain; usually associated with abnormal sensory, autonomic, and motor changes. It tends to develop after fracture, soft tissue injury, or surgical trauma; however, the pain is disproportionate in time or intensity to the usual cause of pain. CRPS should be suspected in patients reporting burning pain that lasts beyond usual healing time. Diagnosis requires clinical assessment, usually assessed using the Budapest criteria. Additionally, edema is the most specific clinical sign of CRPS. The syndrome is caused by a multifactorial process involving both peripheral and central mechanisms, but little is known experimentally about how these mechanisms might interact to produce CRPS. The upper limb is affected significantly more frequently than the lower limbs. In the general population, CRPS seems to occur more often after a fracture, having incidence of 3.8-7% within four months of fracture. It is three to four times more common in women than men; the average age is 50 to 70 yrs. OUTCOME OF THE CASE: A sympathetic ganglion block at the L4 level was performed as an intent to relieve the pain. The outcome was successful, and patient reported that pain was resolved besides a few aches posteriorly around the proximal calf. However, she does fear that pain may return. She is no longer on any pain medication. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: She will continue her physical therapy on tissue mobilization and gait stability. A follow-up in 2-3 months with a family medicine physician is scheduled. However, if pain returns before that, she will be sent to a pain clinic for consideration of repeat procedure versus nerve stimulator