Lebanon Valley College Study Abroad

PT Clinical Week #8

Our last week has come to a close, and it didn’t disappoint! I was able to increase my caseload and try new things with patients!

LOKOMAT

For two afternoons, I learned how to operate and use the Lokomat (a body weight support system combined with a machine that moves the lower legs on a treadmill). It is so complicated! There are so many things that you have to do before you even get the patient! During the examination, you have to get measurements of the legs and enter it into the computer. Then every time that patient comes, you have to manually set the machine to those measurements so it fits the patient perfectly. Each patient does it for 20-30 minutes depending on how much they can tolerate. The type of patients that can use the Lokomat varies. Some patients have some movement in their legs, so the level of assistance that the Lokomat provides is less and vice versa. Even though most patients will probably never walk again, it can be good for maintaining passive range of motion and reducing spasticity. Also, if the patient has some weight-bearing on the treadmill, that is good for maintaining bone strength.

There was a big screen set up in front of the patient that they could play games. Many of the games had an avatar who performed the same movements as them. The object of the game was to catch different items on the screen. In order to turn, the patient could use what little movement they had to change directions on the screen. There were graphs on the computer monitor that showed how much assistance the patient needed, and if their movement was corresponding with the machine or not. If the patient were cognitively aware, they would be able to adjust.

INDEGO:

One of the coolest things I saw was the “Indego”.  It was invented in Germany, but Italy is the first nation in the WORLD to get it approved and use it in their clinics. It is like the Exo-skeleton (which is also a body movement walking system) but much smaller and lighter weight. All you need to be able to use it is passive movement of your legs. The level of assistance the machine gives can vary from patient to patient. There is a computer in the hip and the knee and the total weight is 12lbs.

Indego

Our hospital/clinic was on the news because there was a patient who was getting married, and he was to use the Indego to walk down the aisle!!!! It’s amazing what technology can do. The ultimate goal is that because it’s so compact, lightweight, and easy to use, that patients will be able to use it at home. It costs about $80,000 so those who can afford it can purchase it; otherwise,  the hope is that as the price goes down, they will become more affordable.

One of the Indego patients was a 47-year-old woman who also had surgery on her spine and no longer has use of her legs. She uses the Indego almost every day. I also saw an Indego examination of an anesthesiologist who fell from a small ladder and injured C3-C5. He regained use of his arms and trunk, but not his legs.

INSERVICE:

On Wednesday, Kristin and I presented our inservice, “Mobilization with movement” (Mulligan Concept). We spoke in English incorporating some Italian, but our Powerpoint was ENTIRELY in Italian. It went awesome, and all the therapists were really impressed. We even included two demonstrations of the techniques. Normally in the US we bring in food for the inservices we present, but here they had a spread of pizza, paninis, and dessert!

MY FAVORITE PATIENT:

My favorite patient was always treated in her room because she had a trach and an NG tube. In the last two weeks, we progressed to standing and walking! Her hair was always crazy when we started getting her out of bed, so I would comb it for her (one of my favorite things). The last week my therapist and I would tell her I was leaving and traveling Europe and then heading back to America. On Friday, I told her “ e stato un piacere” (It was nice to meet you), buona fortuna (good luck), and even asked her to come back to my house! After all this, she looked up at my CI and says “ill see her Monday??” We had to explain I was leaving…forever. ;(

BUONA VITA

Before leaving, one of the CI’s told us, “Buona Vita”, meaning have a “good life”. Contrary to belief, it’s a term used instead of goodbye, in the possibility of reuniting in the future even though we are a world apart. I love it, and I will be back. I promise.

~Jordan

PS: Next post from Vienna, Austria!

A Sunday in Retiro Park

The Parque del Buen Retiro is Madrid´s proverbial oasis in the midst of the captial´s overpopulated and semi-polluted streets. The Museo del Prado and a number of the city´s other famous monuments overlook the park, designed by felipe IV in the 17th century as a refuge for kings, queens, and the many members of their courts. Opened to the public in 1868, today the park serves as a harbor for madrileños and tourists alike. Particularly popular on Sundays, the park´s main pathways are nearly as populated as the city´s streets. Despite this, a stroll through the park provides the odd sensation of being surrounded by a flurry of activity as well as a sense of complete relaxation, calm, and peace.

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The life of the park centers around its artificial lake and the adjacent El Monumento a Alfonso XII de España, a massive bronze and marble commemorative statue to the king who laid the groundwork for a stable, constitutional monarchy in Spain. An equestrian sculpture of the king, flanked by four leonian guards, stands tall among weary travelers that rest at his feet.

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At periodic intervals throughout the  park, grandiose sculptures and palatial buildings sit eclipsed by the ever-present greenery. One such masterpiece is the Palacio de Velazquez.

Named for its architect, Ricardo Velazquez Bosco, el Palacio is the only surviving building of the pavilions built between 1881 and 1883 for Spain´s National Exhibition of mining, metallurgy, ceramics, and glass-making industries. The historical influence of muslo-romano culture is evident in the structural elements and the intricate tiles that adorn the front facade of the building.

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Crest one of the Park’s subtle hills and catch a glimpse of a glistening luminescence; walk towards it and the trees open on one of the park’s crowning achievements, the Palacio de Cristal. Nothing matches the sight of the trees parting on the reflection of a thousand small, glittering suns–a collection of daytime stars, trapped on the earth in panes of glass. Originally built to exhibit exotic flora and fauna from the Philippines, the Palace now houses contemporary art exhibitions. Hundreds of dinosaur-like bones hang suspended from the ceiling as part of the current piece, only adding to the building’s ethereal atmosphere.

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Tucked away in a one of the corners of the Park and hidden behind an unassuming brick wall sits a series of gardens reminiscence of a scene from Alice in Wonderland  with its marbled floors and whimsical gazebos.  The large trees that dominate the park center abruptly cease at the wall’s opening, flooding the symmetrical gardens with a partial illusion of expansive spaciousness and amplifying the intensity of its contrasting colors. The numerous peacocks that freely roam the gardens contribute to the fanciful environment.

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Many are familiar with American writer Ernest Hemingway’s infamous quote on the frenetic energy of Madrid after-hours: “Nobody goes to bed in Madrid until they have killed the night.” Let it be said that no one should leave Madrid without spending a leisurely afternoon exploring the wonders of Buen Retiro Park.

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A visit to the “City of Three Cultures”

The “City of Three Cultures,” also known as Toledo, is a smaller city about an hour south of Madrid by train. Despite having already travelled to Madrid we stopped there first, on our second weekend excursion with our university. We arrived in Toledo around noon on Saturday in the picturesque train station, with ornate stained glass windows and colorful tiled walls. Alberto, our professor and guide for the weekend, suggested we take taxis in order to get closer to the city, to avoid walking up the steep hill the city is located on top of. So Olivia and I hopped in the first taxi we found and headed to La Puerta de Bisagra to begin our ascent of the ancient city. Located high above the neighboring cities, Toledo was constructed here for its geographic and military advantage. Fortified with a substantial surrounding wall and a large castle, called Alcázar, Toledo was a military stronghold for ages. As we slowly climbed higher and higher, closer to the city center, we admired the impressive view of the landscape.

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Finally reaching the city, we wandered around the tight streets until we came to the cathedral, called Catedral Primada. Construction on this impressive gothic structure began in 1226 and wasn’t completed until over 200 years later in 1493. Alisha, Olivia, and I put on our headsets and enjoyed the commentary explaining each intricate part of the cathedral. Meandering through the many alcoves and small chapels located within the church, we finally came across the sacristy. We entered in complete awe. The sacristy is a huge hall adorned with religious portraits, 15 of them done by the famous El Greco who completed the majority of his paintings in Toledo during his lifetime. Even more breathtaking was the fresco that ran the entire length of the ceiling.

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The pictures taken cannot do this beautiful cathedral justice, I guess you may just have to visit for yourself! Our bellies started growling as we finished up our tour of the cathedral so we headed to a small Spanish restaurant for lunch. Most restaurants offer a daily deal called “el menu del día” which generally offers two dishes, a dessert, and a drink for one flat price. It is the best way to get a generous portion of delicious food for a decent price. We each ordered something different and tried traditional Spanish food, which we are now all fairly accustomed to. I ordered paella (a classic rice and seafood dish), pisto de verduras (similar to ratatouille which is mixed vegetables in a tomato sauce), and flan (a creamy custard-like dessert). Everything was delicious and we waddled our way out of the restaurant to Alcázar and the Jewish Quarter. Unfortunately, we couldn’t spend much time in either space because we had to catch our train back to Madrid. Nonetheless, we were fortunate to see both sites and learn a little more about the history behind Toledo. Renowned for its religious tolerance, Toledo maintained a population of Christians, Jews, and Muslims for hundreds of years, a notable fact considering Spain’s tumultuous history. The influence of all three distinct religions and cultures is still quite evident today in the architecture and layout of the city. The Jewish Quarter is characterized by amazingly tight streets and a few remaining synagogues.

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Additionally, Toledo has been famous for producing items of metal, specifically steel, for centuries. There is a shop on nearly every corner selling metal items made in Toledo, including swords, knives, and jewelry. I, along with the rest of the gals, could not resist the beautiful (and affordable) jewelry sold here.

As the time of our departing train loomed closer, we had to head down from the charming city, passing la Puerta de Bisagra one last time before heading back to the train station.

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Visiting Toledo and Madrid once again solidified my love for Spanish cities and the deep-rooted history behind them. Thursday, after class, marks the beginning our spring break, which is about 10 days long. Rachel and I are headed for Amsterdam, Berlin, and Copenhagen on Friday to enjoy our break! I look forward to sharing our adventures with you all when we return!

Adios y gracias para leer,

McKenna

Cinque Terre & Pisa (Round 2)

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This was our last weekend trip in Italy, and it was by far the best experience I have ever had. The other girls had not seen Cinque Terre, so I decided to go back with them, and I am sure glad I did. The 5 towns are nothing too spectacular individually, but we did the hike between the towns along the coast, which is a MUST DO.  It was the most amazing/beautiful hike I haven ever done. The weather was perfect, and I wore a sleeveless shirt the entire time! The views were absolutely breathtaking. Here’s a glimpse of just how much physical activity was involved:

  • 33,000 steps
  • 232 flights of stairs
  • 14 miles

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We didn’t make it to all 5 towns because we wanted to stop in the second to last one to watch the sunset. Everyone was standing around just waiting for it on the cliffs and taking pictures. There is nothing more to say…the pictures say it all.

~Jordan

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PS:  The tower is still leanin’…

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PT Clinical Week#7

Another week down, only one more week to go! This week flew by especially because I was sick on Wednesday so I only worked 4 days.

On Monday, I completed a home exercise program for a patient who was discharged home. I included 5 exercises with pictures, descriptions, and prescriptions. Because the computer wasn’t working in time to print before he left, it will be mailed to him. And because I was in a time crunch, I used Google translator to translate from English to Italian (hehe).

The older gentleman with the stroke (that I mentioned in an earlier post) was discharged on Wednesday. On Monday, I was working with him alone, and he said something to me in Italian. I responded with, “yes” even though I didn’t fully understand what he said (never do that). The next thing I knew he was trying to go from lying down to sitting up on his own and his face was bright red! I was able to help him up, but I was not ready for that unexpected transfer. The language barrier has been tolerable thus far, but it can become really scary when you are alone and something unexpected happens. Sometimes when I am transferring this patient, he begins before I am ready. So later in the week, I tried to instruct him in terms of steps that I wanted him to complete first like “viene avanti” which means “come forward” in his chair. Then I count to three (uno, due, tre) before he begins. This method has gone a lot smoother.

We had 3 new patients this week:

  • 41 y/o incomplete SCI patient C3-T1 (motorcycle crash) also sustained 2 broken elbows & nose
  • 40 y/o TBI (fall at work) hemiplegic L side, frontal lobe signs, and has a 17 month old son
  • 77 y/o stroke patient who gets very emotional and cries several times each session.

DIFFERENCES:

Most therapists transfer a lot differently than we would. They transfer with their arms under the patient’s armpits instead of their hands under the patient’s butt, and it seems very unsafe.

All the therapists, nurses, and health assistants wear scrubs, but the doctors wear business casual and even some wear jeans (nicer jeans of course). I find that really cool.

PT’s go to school for a total of 3 years after HS and receive a bachelor’s degree. Nurses also go to school for 3 years after HS. The HS system is a lot better in Italy so a lot of our general education courses that are taught in undergrad in college are actually taught in HS here. They feel that PTs in the US actually have two bachelor’s degrees (undergrad and then PT) because of how the 6 years is divided by different subject matter.

~Jordan

Orvieto

Orvieto Cathedral

Facade of Orvieto Cathedral

Facade of Orvieto Cathedral

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The second place we traveled to this past Saturday was Orvieto. The parking garage was located underground below the city, and we wanted to take the escalators to the top but they were broken! So we walked up 100s of stairs! After that workout, we explored some of the city, and then three of us took a 3 mile walking path that encompassed the city parameters. Because of the location of the city (see below),  the trail was extremely difficult and we were sweating by the end.

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The girls wanted to get gelati following the hike, but every gelati place was either closed or the open restaurants didn’t serve it. The season for gelato must be coming to an end until spring?? I hope not.  Before leaving the town, we headed to some underground caves. They were really cool and not what I was expecting when I thought of the word “cave”. The one we went into was founded in 1984 by people who were working on their trattoria. They began excavating the cave in that year, and the excavation still continues today!

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We were going to eat dinner in Orvieto because there were a lot of great restaurants recommended, but because most Italian restaurants don’t open until 7:30, we decided to call our landlord Paolo, who makes the best italian food known to man, and he prepared dinner for us to have when we got back.

Only one more weekend of Italian travels!

Inside the caves

Inside the caves

Caves

Caves

Caves

Caves

FACTS:

Situated on the flat summit of a large butte of volanic tuff. The site of the city is among the most dramatic in Europe, rising above the almost vertical faces of tuff cliffs completed by defensive walls built of the same stone called Tufa.

A major center of Entruscan civilization

Orvieto was annexed by Rome in the third century BC and was last conquered by Julius Caesar.

The city of Orvieto has long kept the secret of its labyrinth of caves and tunnels that lie underground. The underground city holds more than 1200 tunnels, galleries, wells, cellars, etc. Many of the homes of noble families used these tunnels as a means to escape times of siege. The tunnels would lead from the city of palazzo to a safe exit point some distance from the city walls.

~Jordan

Civita di Bagnoregio

This past weekend we decided to do two places on Saturday and spend Sunday at home in Umbertide. The first place we went to on Saturday morning was Civita di Bagnoregio. This town perched high on a small cliff surrounded by a valley. There is literally only one road/bridge that you can take to get there. You park at the edge of the bridge and then walk up to the town. The entire walk across the bridge was absolutely incredible and filled with great views.IMG_3543
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It was supposed to rain all day, but that morning when we checked the weather, it said it was going to be clear all day! We really lucked out. We walked the city and did a tour of a small house that was built into the side of the mountain. Shortly after we were informed that it was used in the film “Pinocchio” here in Italy.  We also went through a tunnel that cut through the mountain (it was off limits to tourists, but the fence was kicked over, so we went through anyway. It was a rather large tunnel, but centuries ago it was just big enough for women to hold their water jugs on their head to transport place to place. It was one of the only tunnels used to go from one side of town to the other…and later they widened it so farmers could go through with their equipment.   
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Cliff house

Cliff house

Cliff house

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FACTS:

Civita was founded by Etruscans more than 2,500 years ago

At the end of the 17th century, the bishop and the municipal gov’t were forced to move to Bagnoregio (former suburb) because of the major earthquake that accelerated the old town’s decline.

In the 19th century, Civita’s location was turning into an island (as seen in pictures), and the pace of the erosion quickenend as the layer of clay below the stone was reached in the area where today’as bridge is situated (the only way to get into the city from the mainland).

Civita became known in Italian as “il paese che muore” (the town that is dying).

 

~Jordan

Rainy Saturday in Segovia

This Saturday was our first excursion with our university to a small, but beautiful city about an hour southeast of Valladolid called Segovia. As we approached, we could spot the city, protected by brick walls and situated above all the neighboring towns. Upon arrival we could not miss the massive aqueduct that straddled what used to be the road to enter the city (cars are no longer able to drive under it).IMG_3342

This impressive landmark was most likely constructed in the first century by the Romans; however the exact year of construction remains a mystery. The huge granite blocks that comprise the aqueduct are unmortared, meaning this entire structure is held together solely by the weight and placement of the blocks! While a few spots have been restored, the majority of the aqueduct is original and it is considered one of the best preserved structures in Europe.

After climbing to the top of the aqueduct, we took a walk around the city guided by our professor, Patricia. She explained the many legends associated with Segovia; it seems every place in the city has an entertaining story behind it!

Additionally, Segovia haIMG_3375s a colorful religious history with a few remaining Jewish neighborhoods and synagogues (notable because almost all Jews were expelled from Spain during the 15th and 16th centuries). As we walked around the city, we admired the the tight streets, old brick buildings, and quaint shops. As lunch time appraoched, we were granted free time to eat and explore the city on our own before moving onto our final tour of the day.

 

After eating and, of course, doing a little shopping, Rachel, Sam and I decided to check out the massive cathedral, located right off of Plaza Mayor. Beginning in the 16th century, the construction of Segovia’s cathedral continued for over 200 years until it was finally completed and consecrated in 1768. This Gothic cathedral is breathtaking, not only for its sheer size but also for its grandeur visible in every detail. Difficult to put into words or capture in a picture, the cathedral silenced us all upon entering. It was astonishing.

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After about an hour in the cathedral, we met up with the rest of our group to move onto our final tour of the day: Alcázar. Originally built by the Moors, this castle exemplifies mudéjar architecture characterized by the use of brick, elaborate tile and IMG_3460woodwork, geometric shapes, and vegetal images. Interestingly, images of humans or animals are never used in this style. The massive castle, with its many tall spires, felt a bit familiar upon first glance. As it turns out, Alcázar was the inspiration for the castle in Walt Disney’s Cinderella. Completed in the 13th century, this castle is yet another spectacular historical structure of Segovia. Unfortunately, part of the castle is currently under renovation so we were unable to get a good view of the castle in its entirety or climb the tower. Nonetheless, visiting Alcázar was a great exerience! Despite the unpredictable rain and chilly wind, Saturday’s trip to Segovia was another enjoyable and eye-opening day in Spain.

¡Hasta luego!

McKenna

Valladolid Portraits II

The mornings are late, the coffee is hot, and the company is good–it’s Sunday in Valladolid.

Even the city itself slumbers, relaxed and recharging for the hectic week ahead. The vast majority of shops and cafés are closed, leaving the sidewalks and streets free of cars and open to the occasional runner or dog-walker. An array of exercise clothing guards against the cold, a refreshing break from the inherent perfectionism of Spanish fashion. Sunglasses protect tired eyes, rimmed in red from lack of sleep and masking hungover headaches. Were this America, each passerby would desperately clutch a paper coffee cup, purchased from Starbucks, Dunkin’ Donuts, or corner coffee shop, but this is Spain, and take-away coffee cups are a nonexistent convenience.

Just as the city pauses, so do its people. Any shopping or errands forgotten Friday and Saturday must remain incomplete until Monday, an institutional reinforcement of human intermission, allowing the day to truly be one of rest and not guilty procrastination.

Sunday is a day to re-center the mind and spirit by attending religious services or focusing on family–a reaffirmation of core values buried in the distraction and desperation of daily life. Instead of lifting weights and running miles, dedicated gym enthusiasts hoist their children onto their shoulders for a family walk in the park. Refreshed after sleeping in, the committed architect gets down on hands and knees with his daughter to construct Lego cities instead of heading to the office to meet the latest deadline. Even the public libraries are closed, forcing stressed students to remain at home with their biological families or collegiate equivalent.

In many Spanish families, such as mine, the importance of family is a tradition that has withstood the aggressive onslaught of cultural modernization. The stereotype of the extended family cohabiting together under one roof no longer holds true; however, my host father visits his parents almost every day, and he is not unique in his habits. The six, eight, or tend hour distances that separate American families are unheard of for the Spanish, an inconceivable disconnect on more than a geographic level.

Each Sunday morning, a few steps across the hall of the apartment building takes my host mother from her apartment of that of her sister. Over tea and coffee they enjoy one another’s company, often for over an hour. While they talk, the rest of their apartments gradually wake to eat breakfast and discuss the night’s adventures: a jumbled, verbal conglomeration of the names of friends, locations, and city streets. We break, only to converge over mid-day Sunday dinner.

Sunday dinners are the only chance to eat together as a family, and as such are a production: the table is set for a minimum of seven, often eight, and sometimes nine. The extra table sections and chairs necessary for that week’s meal are added with eager hands and open hearts–the more the merrier. My host father sings as he cooks with his wife, an indecipherable but melodic line repeated in a boisterous voice, a happy bellow that echoes throughout the apartment.

The accompanying dance to his tune: five people passing through a hallway made for one in order to set the table, ducking under plates passed overhead, whirling in and out of the hallway’s adjoining bedrooms as steaming plates of paella pass; juggling the proper number of tumblers for water, pan perched precariously on the glass tower. I press myself against the wall as one of my host sisters charge past with fistfuls of silverware, singing along with her father. Each addition to the table brings a slight shift to the items already present, continual change to assure that all have adequate space with minimal bumping of elbows and knocking of knees.

There is an art to Spanish dinner conversations, a hectic abstract painting layered in jubilant strokes of luminous yellows, brilliant reds, and striking blues: speak up or risk being spoken over. A topic from a single voice starts the conversation but fast multiples into layered interjections and exclamations, each voice rising to be heard and apply a messy splash of color to the canvas. Two or three conversations now occur at once across the table, from corner to corner and end to end–four, if neighbor converses with neighbor. An interwoven net of noise, statements and ideas spill across the table in waves, dripping off the sides and rolling underfoot.

The woman here have deep voices, a rumbling growl that allows projection throughout the room. Opinions are spoken with the tone of fact, strong and sure. An American conversation, notoriously loud and unruly, could not match the excited roar of sound that springs from the table. When things become too heated, my host father explains the discussion in simplifies words accompanied by a series of gestures and over-emphasized facial expressions. Good-natured ribbing instigates amusement from all, conversations often terminating in roaring guffaws and chortling laughter.

Delight in one another’s company carries the meal well into the afternoon–through the main course, a dessert of naranjas, platanos, and mandarinas, and after-dinner coffee–until it is time to part for siesta, with chipper goodbyes moving the house to quiet. As echoes of dinner fade the apartment settles, the mid-day sun drifting into the calming shade of early evening.

The food is delicious, the conversations are fulfilling, and the family is together–it’s Sunday in Valladolid, and the end of one of my favorite times of the week.

M. Gorman

PT Clinical Week #6

Week six has come to a close, which means Kristin and I only have 2 more weeks in the clinic before we start Part 3 of our journey.

This week I did a lot more hands on with patients than the previous week. But it was a mix of observing, helping, and then working independently, so I was able to learn in different ways.

The patient I am treating independently goes to occupational therapy following her morning treatment session with us. So I am allowed to follow and observe her there. At first I was just watching, but then no one was really telling her what to do or even watching her so my instructor told me to come up with exercises for her to do to work on the deficits I found in PT! Didn’t know I would become an OT on this journey too! I have her drawing, building block towers, and using a tiny peg board (fine motor skills). I work with coordination and proprioception of the UE but also endurance. It’s different from the US because a therapist would normally be 1v1 with a patient working or at least working with a group of patients.  But sometimes I am the only person in the room, and I am supposed to be with PT!

PT’s here are able to use the hoyer lift and don’t have to get the nurse to do it for them. I’ve never actually seen one used fully before, and the one they have is so easy to use! One of my patients has tetanus and has been bedridden for quite some time due to the infection. She is on an NG tube and isn’t able to go down to the gym for treatment; so we visit her room twice a day of which she shares with 2 other roommates. I was worried that Italians did not take tetanus shots as seriously as we do, but they do.  She just happened to be someone who didn’t get one.  Definitely a new diagnosis for me.

Friday, Saturday, and Sunday here there is a course going on Bobath NDT (Neuro-Developtment Treatment). A lot of the therapists are involved and are using some of my patients as participants. Italian therapists use a lot of Bobath concepts here, even though there isn’t a lot of evidence supporting it. We touch upon it briefly at LVC, but don’t harp on it because of the lack of evidence.

DIFFERENCES:

They have a break room where there are tons of goodies from patients or that the staff brings in. For instance, my patient is being discharged today, so he ordered a huge box of pastries for everyone. Not only do they have caffé and biscotti/pastries in the break room but they also have wine! Some of the therapists drink wine during lunch.

Apparently Italians don’t use hand sanitizers too much. It is not located in the clinic (to use after treating each patient) and it is actually really expensive for a tiny bottle in stores. So instead, therapists wear rubber gloves when treating, or they just be sure to wash their hands after each patient. They also don’t utilize spray sanitizer for the plinths like the US does after every patient. Here, they have the paper that they roll over the beds like you see in the doctors offices. Only if the bed is really dirty do they use the spray (I saw it for the first time today).

 

~Jordan