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Post your patient encounter reflections
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Dominique Norris
In clinic this week, my CI and I saw a middle-aged male with a complicated case. Long story short, the man had received a total knee replacement that was successful, but months later developed an infection in the knee that led him to be hospitalized and NWB for several months. Ultimately, the infection caused a weakened quadriceps tendon and resulting severe lateral patella shift, especially during knee extension.
My CI has been seeing him for a few weeks and has been able to increase the medial availability and decrease the lateral movement. When we got to the room to feel the patella available movement on both knees, I began to feel unsure about my palpation skills. The involved knee still had some swelling and a lot of extra skin which made it difficult to see where the patella was.
Fortunately, I felt comfortable enough to share with my CI my confusion and he helped me understand, see, and feel the patella tracking by both showing me with his hands and then letting me put my hands on as well.
Having one clinical experience already, and thus knowing the value of getting clarification when I’m confused definitely helped to motivate me to ask for help in this situation. In future weeks, I will remember this and find appropriate ways to get clarification, even if it may be embarrassing for me to admit.
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Victoria Appler responding to Justin:
I think it is so neat that you get to experience so much about the spine/ribcage already! Like you, I have been looking forward to learning more about it and how to address impairments next semester (I think that is when we will learn). It will help you to see these patients now so that next semester seems that much more applicable. I hope you will share your thoughts next semester in how you could use certain interventions we use on a past patient experience! Right now I am working with many patients with Parkinson’s Disease and dementia, which is neat because we are learning a little about how to manage it in neuro now. It adds a new element in addition to learning it in class.
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John Knowlton
In clinic we were treating a 65 y.o white female who was sent to PT for trigger finger of the left thumb. The pt was a librarian at the local university. Pt c/o pain and inability to move her thumb. My initial thoughts were this doesn’t look like trigger finger because her PIP was not in a flexed position, but maybe a neurological issue because she could not initiate movement at the PIP of her thumb. The patient had arthritis of her 1st MCP joint. Pt had pain at the dorsal aspect of her PIP of the 1st digit when passively moving into flexion. She had active motion at her 1st CMC and MCP. She had 4/5 MMT of her thenar muscle and no other abnormalities at the hand or elbow. We thought this was an issue with the innervation of the FPL, so we tried e- stim to try to facilitate movement but we couldn’t isolate the FPL. We found no other impairments of muscles innervated by the anterior interosseous nerve. We recommended the patient look into a NCV test. We worked on passive motion of the MCP, CMC, IP joints of the 1st digit to maintain available motion. We instructed the patient to continue to work on this at home. Our plan is to search the literature for similar patient cases or methods of treatment.
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From what I’ve seen in my own experience even the most skillful interviewers aren’t going to be able to get all the necessary information needed to treat a patient in the initial exam. You all did a great job of not getting too hung up on what it looks like/doesn’t look like with regards to a specific medical diagnosis and proceeded to identify hopefully treatable impairments. It will be interesting and telling to see her responses to the EBP you provide her after having reviewed relevant literature.
-John Orchard-Hays
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Jesse Parsons
The patient was a 20 y.o. Hispanic female with back pain in two locations. Her pain was in her upper trap/suprascapular area on the left and the right, as well as in her lumbar spine. She described the pain as a dull ache after standing or sitting for long periods of time (over 3 hours). My thought was that it may be a postural issue, as we could see she had poor posture sitting in the chair during our evaluation. We went through repeated flexion/extension with her, with only the repeated extension causing pain in her lumbar spine. All AROM directions of the cervical spine caused an increase in pain in the suprascapular region. When observing the patient’s spine, it was clear to see that she had a flat lumbar curvature (no lordosis), along with some slight scoliosis. After the evaluation of the patient, the rest of the session was used to instruct the patient on proper sitting, standing, and lifting mechanics as well as. We also gave her a lumbar roll to use during sitting to improve her posture. After trying the lumbar roll in the chair, she immediately felt a decrease in symptoms in her lumbar spine as well as in her upper back. The plan is to have her work on her posture come back in within two weeks to see if the symptoms have improved. If she is still having pain, we may work on hamstring flexibility as that was minimally limited.
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Samantha Schambach
Today was the first day of clinic and also my first day in an inpatient acute care setting. I was nervous to be in an environment that I had not been before, but was ready and willing to take on any challenges that came my way. For the most part it was a easy day as my CI was planning on showing me the ropes before throwing me to the wolves, so to speak.
One patient did stand out to me though. I had the opportunity to work with an 89 y.o. WF who had severe dementia. The goal was to get her up and out of bed so we could assess the appropriate discharge planning. I was not sure what to expect as I have heard many stories about people with dementia or Alzheimer’s not being the most friendly people to work with, which is understandable as they can become frightened. My intention was to let the PT handle the conversation and I would be there where ever she needed, as to many people talking can get very confusing for the patient. I was surprised to see that this patient was non-verbal and very calm upon arrival. She was willingly to do what the PT asked, but did not understand commands fully, especially when asked to stand. After some brainstorming on how we could get this patient up and walking we decided to put the walker in front of her and see if there would be an automatic response to get up. She seemed to do better with the walker as we got her to lift her bottom off the bed, but still was not understanding our requests and therefore would not put pressure through her feet.
Next time we suggested having visual cues for the patient, like having a chair in sight so she can see where she is going and might have motivation, or take a small portion of the fear away as she can see the end plan in sight. I think we had some good strategies that we used that day that we can build upon for future experiences. Although being in the acute care setting, we may not get to see this patient again, I will be able to use this experience to know better for the next patient that comes along.
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Peter Cradduck
In an in-patient setting I learned from a patient in “memory care”. It was our first patient of the day. The 72 y/o male patient was in a wheel chair. PMH included OA, Parkinson’s, DM and dementia. The kyphotic man far the most complex case I’ve ever seen on paper. His Parkinson’s only manifested itself by making his movements slow, no tremors or inability to initiate movement. This man’s cognitive levels seemed to be rather keen despite his diagnosis, he demonstrated the ability to follow verbal commands and keep count. He was oriented and aware and his demeanor was cheerful. The man had severe contractures in his hamstrings that were a result of years in a wheelchair. His trunk flexion was severely limited which inhibited his ability to stand on his own volition. My CI made it clear that it was not out of the question for him to be able to be more mobile independently despite his comorbidities, this was a surprising revelation. What I learned most from this first experience in a dementia ward, was that creativity was essential to the process of physical therapy in this setting. It occurred to me that perhaps with lengthened/stretched hamstrings and increased trunk flexion, this individual would be able to stand and transfer by his self. He was able to stand while holding on to the railing for nearly two minutes by his self before his bent arthritic knees gave up and he sat back down. This creativity in care is not like the creativity found in the OP setting. It is my goal to recognize potential impairments and become a more creative therapist in order to assist in the mobility of those that have already lost so much.
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Pete,
This is another good example that speaks to the extent of our role as future clinicians. This case is very complex based on where we are in our careers, but it goes to show that through our MSK knowledge and understanding of systems, we can still provide quality care to the pt. I love the ability we have to be creative and devise our treatment parameters tailored to our pt’s functional ability and goals.
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Sabrina Harbaugh
My first day at clinic was relatively straight forward. We encountered numerous fracture patients, both upper and lower extremity, along with a handful of joint replacement patients. I was impressed to see that the therex portion of the patients treatment sessions were very individualized, however the biggest struggle I am current facing would be how to broach the ultra-sound discussion. Although we have not covered modalities officially in PT school, I have learned modalities through PTA school, the AT program and continuing education and I personally have found the research to be lacking, significantly. I also realize that my CI has YEARS of experience that is making them a fantastic clinician and that prior to heavy emphasis on researched based practice that modalities were thought to be a great help to our patients, thus I do not believe it is “just utilized for extra billing” but rather a lack of updated information/justification for our interventions that is causing the continued use of this modality.
Given this perspective that I formed over the years, I am looking for feedback on discussing the use of ultra-sound on 80% of patient case load.
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This is an interesting topic, I’m also looking forward to the consensus on ultra-sound
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Rachel Lenz
My CI and I were working with a lumbar fusion patient within the hospital, trying to get her to stand and walk to the chair. She would then stay there for an hour or so before going back to the bed. She was very anxious about walking and creating more pain by moving. We allowed her to take her time, as she was in pain while sitting on the side of the bed, but we tried to make her understand that standing would most likely be less painful then her current position. Once in the chair she was sweating, nauseous, blood pressure had dropped, and pulse was very fast. Luckily she did not throw up and we were able to stabilize her and make her comfortable in the chair. The encounter made me very nervous and I did not want a pt to throw up on me the first day of clinic. The good part was that I stayed calm the whole time. The not so good is that I was at a loss of how to handle the situation, so I needed to be told what to do every step. I think that if I was not so overwhelmed by the patient’s status, I would have been able to better anticipate what should have been done. We could have taken her BP prior to standing and left it on her arm so that it could have been evaluated while standing or directly after sitting down. The next time I encounter this, I will suggest putting the BP cuff on prior to standing and I will be more prepared on how to help decrease the pt. anxiety that created the situation.
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MJ Erskine
I’m following my CI, PG, through the rehab gym at a SNF and I notice someone who may be trying to get his attention. I get his attention and we detour to ask what she needs. She softly says, “my oxygen isn’t working.” ! After replacing the tank, making sure that the lines were fine and that the nasal cannula was placed properly, and trying multiple fingers because the pulse ox wasn’t getting a reading, the O2 reading was 99. She was reassured, another therapist was nearby, and we went on our way.
Later, we saw her as our 2nd to last patient. We found her slumped forward in a long sit position on the bed. Each time PG spoke to her to get her attention and start PT, she gave a nonsensical but audible response. He spoke loudly, tapped her on the shoulder and still got the same lack of response. Off we went to check with the nurse, who, understanding us to say that the patient was unresponsive, jumped out of her chair and raced off. Upon all of us entering her room and the nurse speaking to her, the patient, woke up.
I’m thrilled that everything went well. I even got to do her exercises with her, though I was perhaps overly cautious. But after thinking and writing about this, I realize maybe I should ask a few more questions about worst-case scenarios the next time I converse with my CI.
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Alex Gett
pt is 58 yo female c/o lumbar pain and bilateral anterior hip pain. Pt reports the pain is worst when she takes her first few steps after being seated for long periods of time; she has a desk job. Pt reports pain as aching and localized to the regions mentioned. Upon standing/walking observation, it was noted that pt has bilateral genu valgum, slight kyphotic posture of t spine, and decreased lumbar extension. I was thinking OA due to pt demographic, gait observation, and her chart, but after talking to the pt, her symptoms were not severe enough to justify my original thought. My CI has been treating this pt for a few weeks, so I did not get to see a detailed exam performed on her. My CI informed me that he believes both illiopsoas mm are the culprit and he has been working on calming them down through repetitive standing lumbar extensions, movement in prone, and lumbar mobs. Upon ambulation reassessment, pt had a more rhythmic gait and reported her pain went from a 3 upon arrival to a 0 by the end of her session. PT informed her to continue HEP. I’ve seen the psoas mm act as the culprit for lumbar pain in the past, so I am not surprised here. I’m glad I got to see hip pain on my first day since we are working on that unit in MSK.
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in reply to Alex Gett,
I am also glad you got to see some hip action in your clinical. What I like about your post is the reality that it reminds me of Physical Therapy’s immediate results. At some point between our intensive study of pathologic prognosis and tendinopathic continuums I seem to have forgotten that some treatment have patients limping in and walking out pain free. It is quite unfortunate that I have let this important aspect of our profession slip my mind. I believe it should be among the forefront of my thoughts as I see patients. “Can I help them feel better right now?” should be one of my first questions to myself. It is not only our duty, but I believe if we were able to do this more often, we could facilitate a new popularity of the science and art of good Physical Therapy.
-Pete
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Austin Wernecke-Home Health setting
Evaluation of new patient. Pt is a white female of 59 years old, undergoing chemo treatment as well as two years out of a right hemispheric stroke. Upon talking to the patient, observing how she sat, her attitude and body cues, I was confused as to why she was in home health and not outpatient. She seemed strong and strong-willed. I felt optimistic that she would advance in treatment quickly. Upon testing her muscular endurance, 2-minute walk, and standing march test, my mind changed. The pt’s left leg would get weaker and give way early on in the 2-minute walk test, as well as she had to take breaks during the march test. Seeing that she was much weaker than I thought. In conclusion, I am wondering if this is stemming from her stroke since her left is weaker, and is now resurfacing with her fatigue from chemo. The plan is to administer general strengthening and endurance exercises and using a cane with ambulation. Exercises include marching while standing and single leg standing. -
Mary Davern
The patient was a 38 year old WM who was severely overweight despite having lost 280lb over the last two years. He had difficulty ambulating and required a walker. His cardiovascular endurance was poor but he displayed a moderate amount of strength in the upper extremities. He had arthritis, lymphedema in both legs and a large lobule on this right leg with considerable knee pain. I felt a little overwhelmed because he was so big. Every part of his treatment required more forethought. If we wanted to use a piece of equipment, we had to make sure he would fit around it. We used a pulse ox to check his HR and oxygen levels after each set of exercises to ensure that his vitals stayed within normal ranges, We also asked him to report how he was feeling using an RPE chart. My CI asked me to think of new exercises to add to his program. The main goal was simple: to improve overall strength and cardiovascular capacity. However I found it difficult to come up with exercises that he could manage but were still sufficiently challenging. We did a lot of seated exercises with weights and seated dynamic exercises with a medicine ball. I was really impressed with his levels of motivation. He had lost his job due to his weight and has a full time caregiver at the age of 38 but he was turning his life around. I could tell he had been working hard lose weight and was continuing to do so. He took breaks but always completed the exercise without any complaints. I also thought my CI handled the situation beautifully. She was encouraging but not overly peppy. The patient felt totally comfortable and trusted her. Next time, we plan on transitioning to standing exercises using the cable machine and decreasing his rest time so his heart rate stays elevated for longer periods of time to increase his cardiovascular endurance.
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Jacque Hemler
During my first day at clinic, I was able to see a patient who had undergone multiple surgeries due to buccal cancer. This was an interesting case to me because I haven’t encountered a cancer patient before in the clinic. The patient had recently undergone surgery where they took part of the inferior border of the scapula to replace part of her mandible due to the cancer spreading to bone. They also took a skin graft from her back to place over her cheek where the mandible was rebuilt. The pt had reported having a headache when we first got there, so my CI performed a suboccipital release which helped relieve some tension. Next we got to do some scar mobilization on the skin graft on her cheek and the scar on her neck from the exploratory surgery. Next we did some exercises for her shoulder to help gain back some ROM due to the surgery from removing part of the scapula and skin. We also did some strengthening of the quads, hip abductors, and glutes from her general weakness after having to go through chemotherapy. I liked how we were able to focus on multiple parts of the body, not just one specific area. We plan on continuing to strengthen her legs and working on mobilizing her scar tissue.
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Lori Yeaman in response to Jacque Hemler,
Jacque,
This is an interesting case and it really demonstrates how important it is to consider the entire patient, rather than focusing too narrowly on one impairment. It also speaks to the importance of a thorough evaluation to determine goals of treatment, but also the importance of flexibility during each session to address unexpected pain/impairments, such as providing relief for the patient’s headache. Great job!
-Lori Yeaman
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Levi Perry
Disclaimer: this post contains exaggeration, cynicism, and naivety.
I am new to the acute care setting. My initial impression is that although PT serves a very important role, it seems to be very focused (too focused?). By this I mean that PT has the same goal for everyone: walking. Of course, some patients are unable to walk, but then the goal simply becomes whatever is highest on the continuum to walking that is achievable for that patient (sitting up in bed, transferring to a chair, etc.). When the patient is exhausted by their daily exercise of walking, or some stage of the progression, therapy finishes (even if the session only lasted 5 minutes) and documentation ensues. A patient that I saw entered the hospital due to a COPD exacerbation, but what about their back pain? Does oxycodone have a monopoly on this job in the hospital? Could the patient not benefit from, for example, PROM or a manual hip flexor stretch? If the patient is going to be lying in the hospital bed for another two days regardless, is there not more that we can do for them? Does it come down to the therapist’s time, and that it is not economical for the hospital to pay for the time spent performing these interventions? It felt odd to me saying to the patient “ok, I think we have done enough for today”. I imagine that my eyes will soon be opened, and I will soon see the silliness of my thinking, so I wanted to share my thoughts before this occurs. -
Azita Nejaddehghan
Patient was a 32 y/o female patient returning for LBP (I hadn’t seen them before however. Pt states she has been doing HEP program daily. She reports no episode of intense pain in the last two weeks, but also has not had a full work shift in that time period either. Pt is a cashier, where shifts involve standing for long periods of time and occasionally bending over to lift objects. Pt states HEP has been helping reduce pain.
When returning from a position of lumbar flexion, the patient presented with aberrant motion and went into excessive lumbar hyperextension, at which point she reported pain. I educated her to go into a posterior pelvic tilt when returning from lumbar flexion in order to avoid excessive lumbar hyperextension. I then had her perform ten posterior pelvic tilts in standing. I re-assessed her active lumbar motions, and she reported less pain with L lat flexion and R lat flexion but stated there was a little more pain with R lat flexion compared to the L. She reported less pain with lumbar flexion, also demonstrating less lumbar hyperextension with return to a neutral lumbar position. Pt also exhibited increased AROM in lumbar flexion and side bend. To be honest I was surprised at how much of a difference ten posterior pelvic tilts made, and how quickly that change was seen.
We also provided Patient education was provided in regard to standing position when standing at the cash register and lifting mechanics. I informed her that resting one foot on a stool (of a typical step height) could help put her into a PPT while she’s at the register. She stated that she already did that… which was interesting to me because obviously she didn’t think “let me put my foot on this stool so I go into a PPT” … it was just something that her body led her to doing in order to be more comfortable.
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Lindsey replying to Azita
I thought it was interesting that the patient stated that she already resting her foot on the stool automatically. It was also cool to hear that cueing her to do the posterior pelvic tilted helped decrease her pain. This shows how patient education can really have an impact.
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Samantha- answering to Austin
I agree with your thought process of the chemo possibly having an effect on your patients weakness as it seems in your post that this is a re-emergent thing since the start. I believe you have the right thought process on trying to see what works and where to go next. Monitor these signs and symptoms as you are working with her and see how they change throughout the session, not just on the re-eval days. Great reflection as I think you are on the right track with your thought process.
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Victoria Appler –
In the home health clinical setting, my CI and I saw a man diagnosed with Parkinson’s Disease. According to my CI, in the last few months he has been regressing (before that he had been doing really well therapy-wise). We had worked with him last week on endurance and transfers and had a productive therapy session. However, today he presented with orthostatic hypotension going from supine to standing. He exhibited symptoms of dizziness and discomfort, along with a rapid respiratory rate (>40 breaths per minute). We had the patient sit and attempt to increase his blood pressure by doing ankle pumps and drinking water. My CI told him we did not want him to work out his arms until his blood pressure was more normal (I had a conversation with her later that I was under the different impression any form of extremity movement could be beneficial to increase BP). Ultimately, we could not safely give this patient therapy today and before we left we gave the patient and his caretakers advice – don’t walk around too much today and if dizziness occurs, lay down and do ankle pumps. We also advised the patient to eat – he reported at the end of the session that he had not eaten all day and was stressed out about all of the things he has to do this week. During this visit, I was first confused and then was alarmed as soon as I realized what was happening. All I could think was that we could not treat this patient today and whether or not we should call someone (911, the doctor?). Coincidentally, I had a conversation with Daphne last week about how her CI said PD medications can cause orthostatic hypotension and that she had a patient with it and PD. This, along with the patient not eating could definitely have contributed to the blood pressure changes. Although I hope this does not happen again, if it does, I will feel more prepared in how to educate the patient and how to handle the situation – making sure the patient is safe is the primary objective.
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Caleb Baxter
14 y/o male came in with a referral for gluteal tendinopathy. Upon retrieving the patient from the waiting room, I had a feeling that activity modification (specifically reduction in activity) was not going to be an option. The patient plays for one of the high school football teams and is in the middle of his season. He presented with lateral thigh pain on the R after running or exercising for extended periods of time. Subjective history was consistent with a tendinopathy. During the objective exam, I was surprised to find no pain with abduction, even from an adduction position with the abductors on stretch. The patient was also able to maintain SLS without pain or compensation. Pain was provoked with resisted extension, IR, and ER. The lack of pain with abduction threw me off because I was thinking glute med/min, but the pain with extension may indicate that glute max is involved as well. My CI and I were both confident that treating the tendinopathy in aggravating positions was a good place to start. Since the patient was not very irritable, we completed 3 sets of eccentric IR (similar to derotation). Set length was dictated by patients subjective pain rating. With low irritability, we told the patient to continue managing participation in football and weightlifting by monitoring pain level. We instructed the patient to take a break if pain exceedes 4/10. The current action plan is to continue to increase load on the tendon using slow contractions while managing pain and hoping the patient heeds our advice and doesn’t just play through the pain.
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Caleb, this is great to experience this type of patient after we just learned about this pathology. I can understand some of your confusion to outcomes of some of the testing didn’t match what you expected. I think early on in our learning we expect the patient to be highly irritable and have most of the symptoms we learned, while this is often not the case, especially with someone so young and at a high activity level. It sounds like you handled it really well though and gave him appropriate advice! This was a good reminder to me to cast a wide net!
-Jacque -
Justin Geisler responding to Caleb Baxter
Caleb,
Great post! Your encounter with this patient sounds tricky because I too would of been confused why resisted abduction did not elicit pain due to the presentation of gluteal tendinopathy. I think you and your CI went a good route in having the patient perform ther ex in the aggravating positions to work up until the patient has pain then hold off. I am curious to see how the patient continues to respond to treatment and if treatment will be able to provide some relief/healing for this patient. Great post and relating it to the hip and how not all patients will not have text book like presentations.
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Kyle Kohnen
In clinic this week I got the opportunity to work with a 60 y/o male patient with frozen shoulder. I was confident in my ability to evaluate and assess because we had gone over this particular pathology in class last semester. When checking the patient’s APRs, I was expecting to see limited range of motion in all planes but what really surprised me was the end range feeling. He got to about 45 degrees of abduction and it felt like I hit a wall. This was a cool case because understanding the pathology from an educational standpoint gave me a good idea of what to expect but actually seeing/feeling it first hand was a completely different experience. Next week I’ll get to work with the patient again and I’ll have a better idea of his limitations and how to tailor his intervention.
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Kyle,
In the outpatient setting last semester I had a similar experience with a patient. I ended up seeing this patient throughout the semester because my CI gave him exercises and stretching to do during the freezing phase. We then began more vigorous therapy during the thawing phase when we could make more progress. I agree with you in the aspect that it is one thing to learn it in class but then seeing it is very different because the end feel is empty and a quick catch-type feeling. Adhesive capsulitis is a very interesting pathology and seeing the progression of it in clinic is a positive experience to have.
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John Orchard-Hays
This was the second week of clinic and my CI felt comfortable letting me take on more of his patients treatments. I worked with a 55y/o woman with chief complaints of general hip pain with a secondary complaint of ipsilateral ankle pain. Having looked over her subjective/objective history from the initial eval and speaking with my CI I was convinced her symptoms were consistent with gluteal tendinopathy and was able to rule out other possible pathologies such as FAI, athletic pubalgia, and OA. Since it was my first time working with her I decided to take her through a couple of her therapeutic exercises before I did any mobilizations so that I could see her functional status. After performing step ups, squats, and side stepping, I could see that she had signifiant trouble resisting dynamic valgus. I performed soft tissue mobilization/transverse friction massage to the gluteus medius tendon to increase blood flow and hopefully decrease sensitivity. I assessed her ankle next and found weakness and palpable pain/MTP’s along the distal musculotendinous junction of the fibularis longus. After speaking with my CI I decided to mobilize these tissues as well with transverse friction massage and myofascial release techniques. I wasn’t exactly sure of what was going on with her ankle purely because we haven’t covered that unit yet, but I did my best to make connections between her impairments along the full chain of the LE. It was interesting conversing with my CI regarding how the hip may be influencing the rest of her LE. I then had her perform exercises that target the gluteal muscles and minimize activation of the TFL such as side steps with a TB and bridging. For the ankle we focused on strengthening the arch of her foot and by balancing on compliant surfaces. I plan to ask my CI more about the rational with the Therex for her ankle next Tuesday.
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Lindsey Rodriguez
I had a patient in a SNF who is 1-month s/p total hip replacement revision surgery after falling at home. He was back in the SNF due to infected blisters on his leg that were treated by IV steroids. This patient has a long list of co-morbidities, was a big fall risk, and has been in and out of the hospital three times over the past 6 months. He also has dementia, which made his case more complex. As I read his past medical history I started getting nervous and didn’t quite know what to expect. Although he was confused he was pleasant to work with. We started by simply transferring him from his bed to a wheelchair to get him to the gym. This activity required contact guard assist with a good number of verbal cues. I noticed my CI made sure to use the protocol and avoided IR/adducting his hip and flexing past 90 degs because his hip replacement was a posterior approach. It is important to think about how closed chained activities such as twisted with the foot planted could still bring him into IR rotation. I also noted that he might be at risk for decreased healing of the posterior incision due to his use of steroids for the infected blisters. His case was also more complicated because this was a revision surgery, therefore the surgeon had to go in twice in order to repair his hip, because he fell after his first TKA.
Before we began any exercise, we took his blood pressure and heart rate and asked what his pain level was on a scale of 1-10. He reported a 7/10, so we checked with the nurse to make sure he had received his pain medication before continuing with PT. He had sores up and down his leg and cuts on his ankle from the fall, which were contributing to his pain. My CI decided to give walking a try using a front wheeled walker and told him if his pain increased too much we could take a break. It appeared that his ankle was bothering him more than his hip, but he was still able to ambulate around the gym using his walker. We then had him practice on the 4” and 6” stairs, because he has stairs to enter his house. Although it took him awhile to complete them, he only required contact guard assistance. At the end of the session we did a few exercises with the patient supine on a bed. At the end of the session he reported his pain was a 6/10. Overall, I thought this session went well because we were able to get him up and moving and working on stairs to help him achieve his goal in order to go home. I felt that his therapeutic exercises were generic and would be more beneficial if we could have geared them towards a goal he had. It was also good because I was able to see what abilities a patient s/p total hip replacement revision surgery has and how to educate them on their protocol.-
Lindsey,
That’s great that you were able to get some experience working with a patient who had a hip replacement. It sounds like your patient’s case was a bit more complex than a typical total hip due to the infected blisters. I’m sure your CI was glad that you were aware of the precautions for a posterior approach. Maybe you could think of some different exercises that are more geared towards your patient’s goals for the next time you see that patient. You could suggest them to your CI and see if they would be willing to let your patient try them.
Patrick D.
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Ali Cloutier
In clinic yesterday, I had an 85-year old woman with Alzheimers that fell in her home and consequently fractured her shoulder and her hip. She no longer has WB precautions in either and is very anxious when it comes to walking. In order to increase her confidence, my CI used to have someone trail behind her with a wheelchair but since this will not be feasible when she goes back to assistive living my CI was trying to wean her off of this technique. The patient then proceeded to get very upset and sit down and cry. This was my first experience in this sort of situation and it made me step back and realize the bigger picture. This elderly woman had come to visit her daughter in Virginia from New Jersey, fell, was in the hospital then inpatient rehab, and upon discharge is moving to Florida with her daughter. From all this information, you can see that she has had a lot of changes going on in her life. On top of all of this, she has Alzheimers which greatly complicated the situation because she is always thinking that her daughter is coming to visit her and she doesn’t have any clothes left in the inpatient rehab facility. My CI knew exactly how to handle this case and instead of letting this stop the therapy, she encouraged the patient to walk and talk about what was bothering her, even if it required extra cueing. After the walking we then proceeded to do simple therapeutic exercises including glute squeezes, ankle pumps, and adduction/abduction exercises. Overall from this experience, I learned that you need to be creative and quick-minded to quickly change your plan if a patient is having a difficult day. Also, being in physical therapy and the inpatient rehab setting you need to be patient with the patients because change affects them greatly.
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Ali –
I’m glad that your CI was able to handle and adapt to this situation so well! To me, it’s really encouraging to see how second nature showing compassion and genuine caring is for so many CIs in our profession. It gives me added motivation and reassurance of the positive impact that we will be able to have on the many pts that we come into contact with. I think it is easy to forget how many obstacles, including physical, mental, and social, that our patients are dealing with. I think this experience really highlights how important a holistic approach is and knowing how to have a productive PT session in the face of all other obstacles.
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Justin Geisler responding to Ali C.
Ali,
Your experience sounds very interesting, I think it is a great idea to start weening the patient off of relying on the wheelchair during ambulation. When patients start crying due to neurologic reasons it gets tricky. Positive conversation and patience is key, and at times I try funneling the patient out of the negative thoughts that they are having by talking about their hobbies or places they have visited. You also have to been consciously aware to not bring up subjects that will start the process all over again like asking about their family members etc. Treating individuals that have dementia and Alzheimer’s have been some of the most difficult patients to work with because they can be very easily distracted and need consistent verbal cues to stay on task but it has made me a better therapist and has helped improve my communication skills. Your experience sounds wonderful and I know you will get a lot out of it, great post!
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Ali,
I like that you talked about the patient’s feelings rather than just focusing on the PT side of things. Not a lot of people like change especially in your patient’s particular situation. She has so much going in her life that she may not have a normal routine anymore which can be hard on them so it was nice of you and your CI to step back and encouraged the patient by letting her talk about her feeling as well. I think that is great that you guys were able to quickly think on your toes and come up with a solution. I too recently had an encounter with a patient that got emotional due to her physical abilities so I will have to keep your ideas in mind in case it ever happens again so that I can be better prepared.
Great job,
Ally K
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My clinical experience is through contract services at Winchester Rehabilitation, meaning that we travel to different local inpatient and outpatient clinics filling in for other physical therapists. This Tuesday we spent the whole day at Winchester Medical Center covering for an inpatient PT. Our last patient was a 31 y.o. white female who was diagnosed with Lyme’s disease. I had heard of the detrimental effects of Lyme’s disease, but I had no idea really what to expect.
After we entered the room and went through our few subjective questions, my CI instructed me to take the pt through our regular “warm-up” exercises. I attempted to start with bending the hip and knee with heels slides, however it was quickly evident that this was a struggle for her. My CI then asked the pt to attempt ankle pumps. Even this was impossible for her. My CI pointed out that this was an example of a trace contraction, or a 1 on the MMT scale. We could see and palpate the tibialis anterior twitch while the patient was attempting to push against our hand into dorsiflexion. We tried to utilize a quick stretch in an elongated position in order to help facilitate more contractions. This was really interesting to be able to finally witness a trace contraction and be able to apply the quick stretch tactic that we were currently learning in adult neuro to increase contraction of the muscle.
During this process, I looked at the pt’s facial expression to see her in intense focus on the small task of trying to bring her toes toward her. Looking back, I think I should have given her more encouraging feedback, especially knowledge of results. I realized too late that she wasn’t able to tell if she was pushing against my hand into either DF or PF. We were eventually able to get her standing and ambulating with a front wheeled walker. Initially, we had to give her frequent knowledge of performance to help facilitate proper DF during her gait without her compensating with increase hip flexion. She was able to ambulate 175ft (100ft more than her last PT session). This experience was a very rewarding one with being able to see how much positive impact we had on the patient with just one session. This experience showed me the importance of giving appropriate feedback to help the patient gain self-esteem while relearning motor control. In the future I will attempt to be more aware of how and when I give extrinsic feedback to the pt.
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oops – the above post (about Lymes disease and inability to DF) is by Bailey Long.
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Uyen Tran
Yesterday in clinic, I was able to work with a patient that has has a delay in her gross motor development. She is currently 23 months old, but based on her gross motor function, she is functioning at the level of around 17 months. Before I left clinic last week, my CI assigned me to study the Peabody motor development scale so that I can administer the test on her this week in order for us to see her progress.
Before we worked with her, we had a patient that is one month younger than her that my CI was going to discharge that day. She pointed out to me to pay attention to his gross motor function and how it differs from our upcoming patient. Upon her discharge process, my CI performed a series of tests on the patient and I could see that as a 22 moth old, he was able to confidently walk up and down the stairs, catch himself if he falls, maintain his balance when sitting and standing, and run pretty fast. After successfully demonstrating his ability to function at his age level, the patient was happily discharged.
After he left, our 23 month old patient came in. I started administering the Peabody Scale on our patient and I was naive enough to think that asking a 2 year old to follow commands (such as “walk backwards with me” or “walk on this line”) would be all that I needed. The test was harder to administer than I had imagined and during the test, I was scrambling to find ways that I could modify my instructions and modify the environment so that I could possibly see her perform the tasks that I needed to see.
During the process of administering this test I realized 2 things- 1, that I needed to pull out all of the creativity in my brain when working with children and 2, that as a 23 month old, her motor skills were not even close to where the 22 month old patient was. Even through observing her, I could see her lack of confidence in her balance with her wide base of support and her hesitation in making moves with her legs. I realized that even though there is a scale to measure gross motor function, you can see clearly the differences in motor function through watching them play and move around the clinic. My CI stepped in at times to offer other ways that we could have the patient perform the activities and some of the ways worked and others didn’t. After the session was over, my CI helped me score the test. I was glad that my CI was confident in me enough to allow me to administer this test and only stepped in when she saw that I really needed help. I could tell she was allowing me to gain some discovery learning and I know that my struggles during that session has already taught me so much about pediatric PT. Next time that I work with this patient or another pediatric patient again, I know I won’t just won’t have one plan of how the session would go, I need to come up with several back up plans beforehand. I will also study up and observe how PTs can communicate with this population and practice the communication skills with my CI’s patients while I am in clinic. -
Emily Blum
Last Tuesday was my first day working in an inpatient rehabilitation hospital. I was very nervous going into it because while I have shadowed in a setting like this before, I’ve never really been hands on with an inpatient patient before. I am very interested in working with people with amputations, so I was very excited when my CI told me immediately that our first patient of the day was a woman with a left above the knee amputation.
This was the patient’s 4th time being admitted to this particular facility, and most recently she just spent 5 weeks in the hospital, with almost 2 weeks of those being in the ICU for complications from blood clots in her right leg. My CI informed me that when she first met this patient about 6 months ago, this woman had incredible upper body strength and could stand on one leg while doing her hair and makeup only a few weeks post amputation. The 5 weeks in the hospital recently had really set her back. We went in, I introduced myself and after she agreed to let us interrupt her doing her makeup, I took her vitals and we had her slideboard transfer into her wheelchair. She required min assist with this. We then took her into the facility’s rehab gym and began practicing car transfers, stairs, and ambulating using the parallel bars. On the parallel bars, she had difficulty walking backwards, as she would overshoot her right leg each time and her knee would buckle. She was having obvious motor control difficulties, but also lacked the strength to hold herself up, with mod assist required. She was also constantly in a lot of pain. It made me think about if this was due to pain inhibition of the muscles around the hip and knee, since she had such significant strength loss in such a short period of time. I know that you lose a lot of muscle in the hospital, but it was interesting watching her motor control patterns, and there wasn’t much activation of the stabilizing muscles of the hip occurring.
I saw her again in clinic this past Tuesday and she had made significant improvements, now able to WB on her right leg and stand with contact guard. This makes me think even more that it was pain inhibition of the muscle last week. Reflecting back, I wish I had taken the opportunity to talk to her more and try and unravel some of the biopsychosocial aspects of the situation, because clearly being admitted 4 times to this facility in a short amount of time can take a toll on someone’s mental health. In the future, I will not forgot to do this because I think it would have opened up a whole new layer of the patient and I could have understood better her life at home.
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Laura D’Costa
In clinic, I saw a 78-year-old male with multiple lower extremity impairments that were affecting his mobility. He previously had a right hip replacement and a gluteus medius tear on the same side. More recently, the patient had a left knee replacement. He could ambulate short distances with a walker but sometimes needed to use a wheelchair. To make things even more complex, he was recently diagnosed with a neurologic disorder that causes transient ischemic attacks. This disorder causes fluctuations in the patient’s function and has a poor prognosis. Although the patient is in denial of his diagnosis, he is very motivated to leave skilled nursing and move to independent living.
During our therapy session, the patient kept talking about how he wanted to go home soon. My CI had to have a difficult conversation with the patient about the severity of his condition and that the goal was not currently feasible. The patient got teary-eyed and seemed very upset. During the rest of the time we were working with him, he kept mentioning how he is getting better and will be in independent living soon. I kept thinking about how the nature of his condition will prevent him from achieving his goal. I was upset because it was evident how bad the patient wanted to live in his own home. This situation was difficult because despite the efforts of my CI the patient was not understanding or accepting his medical condition. I think my CI handled the situation well by telling him the truth as well as being sensitive towards his feelings. This experience highlights the importance of me creating functional goals and assisting patients in making their goals challenging yet attainable.-
Emily Blum responding to Laura D’Costa
Laura,
I’m sure that was incredibly difficult to have that conversation with the patient. I feel like that is a conversation that can never gets easier for a PT, even with years of experience. I like how you mentioned how important functional goals are and being honest with the patient upfront about their prognosis. It made me reflect about how honest and empathetic we must be with our patients, no matter how hard they might try and convince us otherwise we have to keep a level head and make realistic, appropriate functional goals.
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Laura D’Costa responding to Caleb
It is interesting that the patient did not experience pain with abduction especially from a lengthened position! It just goes to show that there are deviations from the stereotypical presentation. In terms of the patient being an athlete, it is was good of you and your CI to recognize that the patient would not stop activity and how to best approach participating in football.
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Uyen responding to Laura D’Costa
Laura, I’ve never worked with a patient that is in denial of their condition, but I see from reading what you wrote how difficult that situation can be. I’ve heard many PTs talk about how important having knowledge of the biopsychosocial aspects of PT is and this is such a great example of why we need that knowledge. I’m glad you are making functional goals for your patient so that staying in skilled nursing is more bearable for him.
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Jesse Parsons responding to Ali,
That is a great story and a good example of how our patients have so much more going on in their lives than just therapy. Your CI sounds like they are doing a great job treating the whole patient, and not just their impairments. The personal and social factors of patients are aspects that will have a huge impact on their attitude towards therapy, self-efficacy, and prognosis. It is always helpful to take a step back and examine their situation from their unique perspective.
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Amy Korcsmaros
Currently I am in the acute care center where I had the opportunity to treat a 75 y/o male who had sustained both a proximal humeral and pelvic fracture. My CI mentioned how the patient had been discharged last week, spent some time in in-patient rehab, but did not fair well and was ultimately sent back to acute care. Prior to his fall, this patient was completely independent. He was able to walk long distances without the use of an assistive device and even was able to descend a flight of stairs to reach his laundry room in his basement. Unfortunately, this patient currently needed moderate assistance to even sit up at the side of the bed. I remember feeling a mixture of emotions as I realized how much of a decline the patient really had.
Due to the communication deficits from the lack of his hearing aids, it was pertinent to demonstrate the marching and long arch quad sets that we wanted him to perform. Unfortunately, a lot of his LE exercises were cut short do to his complications with clearing his lungs. From the amount of “gunk” that he was coughing up while sitting on the side of the bed, we determined that this required further investigation. As I began to work on thoracic extension and deep breathing exercises, my CI discussed the care this patient received over the weekend. To our dismay, this patient had not been out of bed for the entire weekend (this was a Tuesday). If you recall, this patient was fully independent prior to his injury and it was frustrating to hear that he might be coming down with pneumonia (preventable) because he was not assisted in standing throughout the weekend.
Although this experience was highly frustrating, it showed me the impact that we as PTs can have on patients. Even though we spent the majority of time assisting in deep breathing exercises, these smaller exercises made a dramatic difference in his appearance. Once he was back in bed after our session, he was visibly more comfortable. This experience also allowed me to reflect on the role we play in a patient’s entire care given in the acute care setting. Through our documentation skills and knowledge of what movement can do for the human body, we can change the course of care given. This was shown by discussing with the nurses how to maneuver transfers with his fractures and how often he should be mobilized.
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Amy K. responding to Jesse,
I liked how you were able to combine both impairments that you found with your patient into one treatment session. I often find that people will focus on one impairment rather than looking at the entire picture. I am curious as to how the roll behind her lumbar spine would decrease her cervical pain as well. Would she get both areas of pain at the same, where one might initially realize that they are connected impairments? Or, did you find that each pain was from a separate source?
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Justin Geisler
In the outpatient setting my CI and I were treating an individual who had a recent fall from a ladder about 5-6 ft high. Luckily he did not have any fractures/broken bones and has been receiving PT services for thoracic pain. Overall this individual’s mobility was good and the fall just seemed like a accident, not due to muscle weakness or impaired balance. The patient had one rib on the left side elevated which was treated by a MET and then PA glides grade 4 mobilizations were done while the patient was prone due to one of the ribs being more prominent than the other while in prone. Patient received a MHP with estem post manual therapy to help decrease pain and to loosen the soft tissue in the upper back area. This was a spine day at the clinic, all the patients treated had a variety of different reasons for receiving PT services. My CI did a lot of MET’s and manual treatment today which was very interesting to watch and learn about, treatment for left on left sacral torsion, left on right sacral torsion, elevated ribs and right facet closing restriction at T10. Observing and learning about patient position and palpation was great to learn about today, it makes me even more excited to for next semester to start learning about the spine. It showed me different things to observe for during treatment and how important our palpation skills need to be to assess the misalignments during treatment of the spine. I felt that this day was very productive, all the patients responded well with treatment and I will continue to learn as much as I can during this experience.
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Victoria Appler responding to Justin:
I think it is so neat that you get to experience so much about the spine/ribcage already! Like you, I have been looking forward to learning more about it and how to address impairments next semester (I think that is when we will learn). It will help you to see these patients now so that next semester seems that much more applicable. I hope you will share your thoughts next semester in how you could use certain interventions we use on a past patient experience! Right now I am working with many patients with Parkinson’s Disease and dementia, which is neat because we are learning a little about how to manage it in neuro now. It adds a new element in addition to learning it in class. -
(Levi responding to Justin)
Hi Justin,
I’m interested in what you were talking about in regards to the patient with the rib issues. I’m curious what the MET for the rib looks like, because i’ve never seen that before. I actually was looking up rib things the other day, because I thought I had a subluxed rib (turns out it was actually referred pain from my gallbladder… misdiagnosed by myself and an urgent care doc… good lesson in differential diagnosing!!). Anyway, so I was doing research on “subluxed ribs”. The term is thrown around everywhere, with many treatments offered by PTs, chiropractors, DOs, and more. I came across an article written in 2015 by a PT, who essentially was saying that ribs don’t sublux. It’s kind of a big misconception. He did a thorough literature search and found only one case report about a confirmed out of place rib (you can type in “subluxed rib” or “dislocated rib” into pubmed and one case study comes up). Ribs get fractured from trauma all the time, and they get xrays all the time, and essentially never does the radiologic report describe a rib being out of place. One would think that if the trauma was great enough to fracture the rib, it would be great enough to sublux the rib… but nope. Now this is all what this PT was saying, but he did offer an explanation to what the anatomical cause of discomfort is, and why manipulations and the such bring relief to patients: sprained ligaments. He also postulated that the “bump” or “elevated” rib that many people call out of place could be due to spasming or guarding muscles, and when the treatment helps, the bump goes away. So he was saying that it’s not that treatment doesn’t help, it’s just that we might be treating something different than we thought. Anyway, just something that I’ve been interested in, so I thought I would share. I’ll attach the pdf article. -
Katie Woelfel responding to Justin Geisler:
Thank goodness your patient has minimal injury after their fall and that they’re able to get into clinic to see you guys! That’s awesome you’re getting so much experience already with spine and ribcage. Sounds like you guys are making a positive impact on your patients. I’m excited to hear more about your experience this semester and your application to our didactic material next semester in MSK III. Awesome job!
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Justin,
Sounds like you have a good jumpstart for MSK III. I am also looking forward to learning about spine treatment next semester. That is great you were able to observe multiple techniques that we have not learned yet. It sounds like you have a good CI who is knowledgeable about manual therapy and different techniques. Was there a particular manual technique that your CI used that yielded better results compared to other techniques used?
Patrick D.
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Christie Freund
Last week in clinic, we had an evaluation of a 68 year old female who was having debilitating pain in her hip. She reported missing a step several months prior and had no symptoms until a month after the incident. She had been to see an orthopedist and had imaging done revealing what she described as a compressive fracture of the femoral head. Her orthopedist referred her to my CI to see if PT might be able to improve her symptoms before considering surgery. She rated her pain as a 7/10 when resting completely, but it escalated to 10/10 with any movement at all. She was very tense and afraid to move and did not seem to think that PT would be able to help her at all.
Earlier in the day, when I saw a hip eval on our schedule, I was very excited to practice the skills and techniques we were learning in MSK. However, this patient had gotten herself so worked up that my CI handled what little of an objective exam that we were able to do with her. After quickly realizing that her high irritability level was going to prohibit an extensive examination that day, my CI decided to start off with a long axis distraction. Her symptoms immediately diminished, and within a few minutes, her pain was 0/10 for the first time in months. Watching the look on her face and on her husband’s face when she realized that PT could help her symptoms was very encouraging. It was impressive to witness the therapeutic alliance that my CI was able to develop with such a simple technique. Once he had earned her trust and her pain level was reduced, he was able to move her hip through a few other motions and begin to assess her limitations. However, he still did not put her through a full battery of tests and measures since he decided he could get more of that information the next visit.
I know sometimes we get so caught up in wanting to collect all of the objective data that we can as quickly as possible, especially as students who are still learning how to put the pieces together. However, I learned how important it is to not lose focus on the patient and what is in the best interest of the patient. As my CI and I reflected on later, it was more important to earn the trust of that patient and relieve her pain during that first visit so that she will come back for a second visit. If he had put her through a more vigorous exam the first day, she might never come back. Going forward, I will carefully assess my patients’ irritability level when determining what level of examination is appropriate so that their best interest always comes first.
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Christie responding to Amy
I can only imagine how frustrating it must have been for you and your CI to discover that your patient had not been out of bad in 3-4 days. We learned the first week of PT school how important it is to get people out of bed in the hospital setting in order to prevent the exact complications your patient appeared to be experiencing. Do you know why PT was not able to work with the patient over the weekend or on Monday? Did your CI seem to think this was an unusual occurrence for WMC or is it something that happens frequently? How can we as physical therapists advocate to the rest of the medical team in the hospital setting the importance of early mobility?
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Allyson Kuhn
This semester I am in home health for my ICE 2. Last Tuesday my CI and I started our day at our first patient’s house who has been a bedbound patient since May. In early May, the patient was placed with hospice with a predicted 2 weeks to live due to bilateral lymphoma and a R CVA that left her severely disabled. With that being said, they pretty much let her go, allowing her to rest in bed until she passed; however, during those two weeks her health started to improve to the point where she was no longer in need of hospice care, in other words she was no longer dying. This was great news, however because of her bedbound status and previous life expectancy, her functional status was now deteriorating and fast. Now bedbound for 4 months, she was in great need of home health PT. With a R CVA she has left sided weakness and with the extended time in bed she has allowed her arm to curl up leaving her elbow and wrist in a flexed position that has now developed a severe amount of tone. Before arriving, my CI caught me up on all of her information and informed me that she does have a hoyer lift at her house and from that, we decided that our goal for the visit was going to be to get her out of bed. We have talked a lot about hoyer lifts in class but I have never seen one in action so I was pretty excited.
We arrived at her house at 8:30 Tuesday morning to find her in her bed in the living room with her husband sitting next to her. We started off by getting her subjective for the day and taking her vitals then proceed to tell her our goals for the day. She was not too enthused; however, she was willing to try. Before getting her up, I worked on her left arm a little bit and for the first time was able to feel what an increased amount of tone feels like which was really cool to me. After working on some stretching with her it was hoyer lifting time. In a hospital setting most hoyer lifts are electric making it a little easier to manipulate; however, the one that we used was a hand pump hoyer lift that required a little bit more work. No worries though because we were determined to get her out of that bed. After some maneuvering and assisted bed mobility, we were able to get her all set up and ready to go. From there, we picked her up out of bed and moved her to a recliner chair. To see a hoyer lift in action for the first time was really cool to me to be able to bring what we have learned in E & I into real life situations. At this point, it was already a great success for her to be sitting up for the first time since May but we wanted more! So, after a little while of sitting in the recliner and performing some trunk leans we decided to stand. With two-person max A between my CI and I, we were able to stand her up from the recliner with a little help from her with trunk leans. While it was max A, it was still a huge success for her to stand. At this point I was sweating, it is not easy working performing a max assist and since it was my first time I was still trying to figure out the best foot and hand placements for myself to ensure patient safety. Even with all the sweat though I was still overwhelmed with excitement to have been a part of this, to see a bedbound patient stand for the first time in 4 months and we didn’t just do it once, we got her to stand twice letting her stand to see her husband at eye level again (her husband has back problems and is unable to bend over to help much when she is in her bed). In this moment, it made all the craziness of PT school worth it! To remind this patient of what she is able to do with hard work was amazing.
At the end of our visit, we returned her to her bed and were on our way. Afterwards, my CI informed me that this patient will most likely be a patient that we will start to see regularly on Tuesdays when I am with her which means that I will get to be a part of her treatment moving forward and will be able to see the progress she makes. With that being said, our goal for next week is to get her standing again and hopefully, sitting in her recliner chair more often for at least 30 minutes to one hour each day by teaching her family how to use to hoyer lift so she can sit in her chair even when we are not there. For next time, I plan to personally work on my foot and hand positioning a little more to figure out the safest position for my patient as well as the most comfortable for myself so that neither of us get hurt.
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Daphne Batista Replying to Ally Kuhn:
Ally,
What an incredible experience! I literally got goosebumps reading your patient encounter!
I can only imagine what was going on through the patient’s head. To essentially be put on a “death sentence” as you will and then miraculously improve to the point she was no longer requiring hospice care. What a turn of events!
Very cool that you got to experience what abnormal tone feels like and got to see a Hoyer lift in action, all in the same session too. What type of stretching did you do on her left arm?
How exciting that you’ll have the opportunity to be a part of her rehab process. I can’t imagine the gains you and your CI will have made with her by the end of the semester after all you two completed by the end of one session. Do you foresee her eventually being able to regain her independence, especially with transfers and ambulating, after being being in the bed since May? If so, how long do you think the process will take? I’m sure you can implement plenty of neuro principles with this specific patient.
Great job Ally!
-Daphne Batista
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Daphne,
With regard to the stretching we mostly just stretched the shoulder in abduction and flexion, the elbow in extension and the wrist in extension 3 * 30s each then placed a split on her hand to help with positioning. As for her future abilities I do have faith that she will be able to be independent with a wheelchair as she was able to sit in her chair for a short period of time during our last visit; however, it may take a long time because she is still max A * 2. I predict hopefully by the end of the year she will be able to sit regularly in her wheelchair. Unfortunately, though we will not be able to see her success since she is no longer in need of hospice care they will not pay for our home health services and the patient’s insurance does not cover our services either so she will be switching to another home health service at the beginning of next week. I’m glad you enjoyed my post, it was a really great experience and one that I will care with me for a long time throughout my career.
Best,
Ally Kuhn
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I am currently working in the critical care unit at Sentara RMH in Harrisonburg, VA working on the critical care floor. This past Tuesday, my CI and myself worked with a woman who, unfortunately, was in the hospital for heart failure. She had been on a breathing tube, but she pulled it out and then she was placed on a trach. My CI asked me to look at her chart to see what I might be dealing with when we began. Something that stuck out to me before we started was that she had a BMI of 63, which was something that my CI wanted me to note before we visited her room. This was important because with her having such an elevated BMI, paired with her LOS in the hospital (almost 3 weeks), and her dx of congestive heart failure, there were going to be a lot of things to take into account with her treatment.
When we arrived in her room the pt. was in bed and she had numerous lines and tubes that I needed to be aware of before attempting to begin my history. Once I assessed the scene and determined we could continue, my CI told me to be sure that she was alert and oriented to person, place and time. This was particularly difficult for me because it was well outside of my comfort zone since I was only able to ask yes or no questions that could be anything under the sun. For example, I needed to know what her home was like, so I asked if her home was a single story. My CI had to prompt me that she may not live in a house, so I first needed to ask if she lived in a house. I needed to phrase all of my questions that could be answered as a yes or no. Fortunately we got most of the information we needed to complete the evaluation and could move onto the rest of the exam.
Considering this patient was on a trach, had an extreme BMI, and had been on prolonged bedrest, we needed to get see what movement she had and wanted to see how much exercise we could get with her legs so that when she was able to get out of bed she would have enough strength to get up. We assessed her knee ROM, ankle ROM and the associated strength at the knee.
I think this patient stuck out in my mind because my previous experiences in clinic had been fairly successful, which my CI warned was outside of the norm on the critical care floor. It was an eye opener to the things that you can see and how crucial PT is in every setting, and not just the outpatient setting. Patients tell us all the time in the clinic how important we are to helping them feel better since we get them up and walk when they’ve been in bed at the CCU.
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The above post is by Tim Webb
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Daphne Batista
Patient was an 81 y/o WM who presented to the SNF one week ago s/p L tibial plateau fracture. The first day he was admitted, my CI and I conducted an evaluation on him. He was able to do his bed mobility with min assist and transferred supine to sit with min assist, where his static sitting balance was good. We asked him to do a sit to stand transfer with a front wheel walker in order to assess his dynamic standing balance. He was able to follow my CI’s instructions to not weight bear on his L leg, thus following his precautions, however he was shaky and was only able to maintain standing balance between 5-10 seconds with mod Ax2. At this point, I was thinking to myself how he’s done so well up until this point, but quickly lost momentum. His PMH includes COPD as he’s a smoker, and unfortunately it affected his endurance. Just standing for that brief time left him winded and I realized how much of an impact smoking can have on your body. We attempted the transfer one more time, but he insisted he was very tired and wanted to go back to bed. At this point, we were only halfway through the examination. My CI coaxed him into attempting a sliding board transfer into his wheelchair, to which he reluctantly agreed. My CI and I got him situated and when we cued him to transfer, he simply couldn’t execute the task due to fatigue. Earlier in the exam a quick scan of his UE demonstrated everything was WNL and strength was documented as 4/5 B/L. Watching him struggle with the sliding board transfer, was not expected as he had the appropriate UE strength to facilitate the task. He attempted no more than 2-3 scoots and called it quits. He insisted that he was done with PT for the day and that all he wanted was some Coca-Cola and coffee. I found this to be an unusual request as someone who recently out of the hospital should be drinking water to hydrate him. Given that he was drinking so much caffeine, I was under the impression that he would have lots of energy, but simply put, this was not the case. As a result, his cardiovascular endurance was an impairment that was limiting how much he could participate in the session. Given how much his COPD affects him, I debriefed with my CI after the encounter and tried to brainstorm ideas to not exhaust him as quickly as we did, in order to get the most benefit out of PT. I asked my CI if breathing exercises should be implemented in order to increase his respiration to allow him to further progress him for future visits.
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Daphne,
Wow, this was such an interesting case to read. I think it is very important that you addressed how fatigue due to his COPD was the primary impairment effecting his PT session. When we are in class and learn/ practice having these impairments, we do not realize how debilitating it really can be. I am in an outpatient clinic so I have not experienced situations like this yet, but I can see how challenging it would be to figure out ways to not fatigue a patient so quickly with this type of pathology. Great job!
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This past Tuesday in clinic I saw an 18 year-old patient who was first complaining of left posterior thigh. She is an avid, elite dancer who has won three national championships in dancing. This was the first time I was meeting this patient since I have been in clinic, so I asked my CI if I could have a quick run through of her prognosis, since she has been here before. My CI explained that a months ago (I am forgetting the exact timeframe), this patient was receiving PT for hamstring pain. Through weeks of PT, she was able to be discharged and continue dancing. Although, just recently, the patient remembers practicing on a surface that was like carpet and feeling immediate pain once again in her posterior thigh. The patient is now being treated again for the same issue, but it is really affecting her dancing performance. While my CI was explaining this patient’s case to me I could not help but think that this was a “classic” tendinopathy case. The patient also has weak hip ER’s compared to her hip IR’s. So, we are not only treating the hamstring tendinopathy, but also addressing her weak hip ER’s.
Before taking the patient through some exercises, I watched her receive dry needling beforehand. Dry needling is always very interesting to observe, and I was surprised that as soon as it was done, my patient went into a position four pose (dancer pose) and was not feeling any pain like she usually does. After she was done dry needling, my CI challenged me to think of exercise that would focus on her weak ER’s and hamstrings. I decided to take her through some eccentric exercise in regard to the hamstring since literature has shown that, that is one of the best methods. Another thing I wanted to focus on was stabilizing her core more. I decided to take her through a side plank with banded hip ER. This would target both her core and hip ER’s. I was surprised at myself that I was able to come up with about 4-5 exercises to really fit my patients’ current level of function and was in conjunction with what my CI wanted out of her. Even though I was not able to perform any manual therapy on this patient, I was pleased with myself for coming up with the exercises and adjusting the patient accordingly to target specific muscles.
At the end of the treatment session, my patient said that the side of her thighs (lateral thigh in PT terms) had never felt so worked. Personally, sometimes in clinic I can get really unsure of my abilities, knowledge, and skill sets. Experiences like this prove to me that I am learning and I am able to apply it.
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Replying to 6723 – no name
Mekayla SteckelSo awesome that you got a chance to observe some dry needling! I haven’t had the opportunity to do that yet and I’d really like to. It’s also interesting to hear how fast the effects come on. I’m looking forward to learning more about that soon.
It sounds like your critical thinking skills were put to the test when asked to choose some exercises specific to the patient’s impairments. I know that’s always a little intimidating. But it sounds like you were spot on! I really hope that did raise your confidence. We are very overwhelmed with all things school related and sometimes I think we forget how much we actually know. I’m glad you were able to apply what we’re learning in class to help you come up with some specific exercises for your patient! I’m also happy to hear your patient felt like she got a lot out of it! I think we’re all definitely getting better at brainstorming meaningful interventions for our patients the more we go through cases and practice in class. I’m sure it’ll only get easier from here… Keep up the good work! &be confident in your ability!
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I forgot to put my name for this post! This was done by Cassie Rawa!
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Mekayla Steckel
Reflection Post #1The patient that I’ve been working with in clinic experienced a R CVA one year ago. He is presenting to the clinic with expected deficits on the left-hand side in both the UE & LE. He is very weak and lacks coordination and control. This patient ambulates independently with a single point cane on the right side but lacks the appropriate proximal trunk stability. He has just recently started attending Ability Fitness Center in Leesburg. This individual shared with my CI and I that he has been feeling very down and depressed lately due to not seeing the improvements he’s been hoping for. I immediately felt a rush of sadness rush over me and wondered how my CI was going to respond to his concerns… I was wondering how I would’ve responded if it were just me… I was curious as to how much this encounter comes about and how to balance this with the utmost respect and empathy but also the most practical, realistic answer. My C.I. handled it gracefully. I’m sure she’s had to have this tough conversation many times before. She told this patient that she wasn’t going to promise him anything because she/nor he have complete control over their outcome. However, she did explain the importance of setting tangible, measurable goals. As well as explaining to this patient that reaching goals that he may think are insignificant are really monumental in the “neuro world” for gaining back that motor control he’s looking for. She explained the idea behind the time frame of improvements for patients post stroke. As hard as it may be, having to learn to accept that progressions will take longer and forcing yourself to focus on the fact that they’ve improved from this time last month on X, Y, Z rather than I’ve progressed from my last session, or last week. She continued to explain the idea of neuroplasticity and having to re-teach his brain these tasks will take some time, so to stay positive because his small gains are truly much greater than he believes. This patient still seemed down after this discussion, and she ended it with, “I don’t need you to agree with me…I just need you to hear me.” I was taken aback with how she handled the situation. I can only hope that one day when I am faced with that tough question, that I too will be able to have a response that’s well versed. It really made me reflect on the importance of patient education- even more so on how we as therapists deal with these psycho-social aspects of care. It is essential to be realistic and practical in these circumstances, and not tell patients what they may or may not accomplish. But to “be real” and honest with them. We’ve seen miracles happen with patients who have SCI, TBIs, CVAs etc. but one must be extremely careful in choosing the right words as to not get a patient’s hopes up. It truly is a day by day process with these patients. Some have great mindsets and are full of positivity. But others struggle immensely with that… understandably. We are there to help guide them and motivate them but never to give them a false reality. After this day in clinic, I’ve reflected on how I would handle this encounter personally and I challenge all of you to do the same. It’s a powerful situation to envision and I also think it has a way of humbling us as future clinicians in the field.
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Kayla Sweeney
This semester I am in early intervention PT for infants and toddlers under the age of 3. This past week in clinic I worked with a child with downs syndrome. One common thing seen in individuals with downs syndrome is decreased tone. This child had very low motor control in her legs and had difficulty standing for long periods of time because her muscles would easily fatigue. After getting an update from her mother and watching the patient crawl around and pull herself up to stand, my CI had me look at her range of motion because she wanted me to see what low tone would look like. We looked at all lower extremity range of motion, but when looking at the ankle, she had so much dorsiflexion that the superior aspect of her foot could almost touch the anterior aspect of her shin. I was very nervous when looking at this motion because I was afraid I was going to hurt the patient, so I didn’t take her through the full range at first. My CI reassured me that I was not going to cause pain, showed me and encouraged me try to find the end range. I was shocked at how much motion was there, however my CI told me that this was less motion than was seen in the previous session the week prior. When standing and taking steps, you could see the patient was having difficulties because of the hypermobility and lack of strength. Because of this, we came up with some functional goals the patient’s mom can be working on with her daughter to help increase strength.
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Kayla,
It is so interesting to learn how this patient’s hypermobility and low tone is affecting her stability and overall gait. My experience with people with Down’s Syndrome is limited to adults, and while I noticed general low tone in the individuals I worked with, I did not take a close look at how their tone may affect their ambulation and overall stability. I am very curious to hear more about this case, as I wonder how physical therapy will help sustainably build this patient’s stability and strength. It sounds like the primary goal will be to strengthen the patient’s musculature to make up for the low tone and provide some more stability in a system of hypermobility. Would love to hear more about what this looks like for a child under three!– Sarah Strong
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Katie Woelfel
In clinic, my CI has been consistently seeing a pelvic floor patient for quite some time now. The patient is a female in her mid-twenties with severe intermittent pain and hypertonicity of the pelvic floor. Many exercises she has tried, especially lower quarter, are aggravators of her symptoms which has given her some fear avoidance with most exercises we ask her to perform.
She has been seeing a personal trainer outside of PT for her fitness and weight loss goals, but she has expressed that squats and bridges are the most aggravating movements for her even after all this time coming to PT. This session I decided to encourage her to push past her fear of recreating her pain and try some new modifications with me. Instead of normal body weight bridges, I advanced them by adding a band around her knees to facilitate more hip abduction. My hypothesis was that most of her pain is linked to more psychosocial factors than somatic pain and this exercise is will introduce something new to focus on rather than getting into the same motor patterns. The band turned out to be a great success with her, and she said her pain wasn’t provoked even after 3 sets. Along with bridges, I had her perform squats on a pilates reformer machine. She expressed she feels more comfortable doing squats in a wider stance because she has noticed when doing conventional squats at shoulder width, her symptoms are almost always provoked. I gave her instructions to do whatever made her feel comfortable as long we she had good form and was getting reps in efficiently. I wandered off a bit to allow her to self adjust and play with different stances and what she felt comfortable with. At the end of the session, she was performing squats in the conventional shoulder width stance with almost double the resistance of what she was used to doing. I was thrilled that not only our patient did not elicit any pain during our treatment that day, but she expressed how exciting it is for her that these exercises are now starting to work for her.
Reflecting on this experience, I think this is a perfect example of the importance of allowing your patient to be an active participant in deciding their treatment in order to build self confidence and self efficacy. Not only did she feel great about her performance, but this was a huge win for our relationship with her. I’m excited to see if she has implemented these and even more exercises into her daily workouts and what progress she has made.
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Alex Argentieri Responding to Amy K.
It really is amazing how much of a role physical therapy can have in preventing other pathologies in an acute care setting. This must have been a very frustrating experience for you and your CI, but I like how you used it as an opportunity to educate the nurses about the importance of moving. It is easy to forget with all of the education that we get about moving that not everyone has the same mindset when it comes to patient care and intervention. Great job with advocating the benefits of our profession!
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Alex Argentieri
This semester I am in a typical outpatient setting that has a variety of patients come in ranging in age from teenagers to the older geriatric population. Last week I was able to work with a 70-year-old patient that was referred to physical therapy for OA in her knee. Additionally, the patient was highly irritable and weak in the involved side and just wanted to not be in pain anymore. My CI and I talked briefly beforehand about the exercises that we were going to start with her and the plan was for me to lead the treatment session. While I was excited to take the lead and start instructing the patient on how to perform some basic exercises, it soon became clear that her tolerance to exercise was very low. I tried think of different variations of the exercises that would make them more tolerable for the patient, but I soon found myself looking toward my CI for help. My CI then mentioned that I can try some patellar mobilizations to help relieve some pain. Of course we talk all the time in our MSK class about how grade 1-2 mobilizations can be used for pain relief, but this was the first time that I was able to use them intermittently with exercise. As soon as I began to move her patellar she instantly began to feel better. I was then able to instruct her through some exercises and when the pain became too much, I provided some more mobilizations in all directions before continuing. This was great way to get patient to buy-in and by the end of the session she was hopeful that this would actually get rid of her pain.
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Alyse Nierzwicki Response to Alex Argentieri:
It is incredible that you were able to see immediate results with your patient using patellar mobilizations. Although we simulate highly irritable patients during MSK lab or mock clinic, we don’t always get the opportunity to witness the effects of our treatment. I like how you used patellar mobilizations between exercises – this not only decreases the patient’s immediate pain, but also provides her with a strategy to increase her activity endurance. What kind of exercises did you give your patient to promote carryover effects of the patellar mobilizations?
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Alex Gett response to Alex A.
This is a great example of how we can use our knowledge of anatomy/MSK to use a quick modification without deviating from the treatment plan. Had you not thought to mobilize the patella in an attempt to relieve pain, you most likely would have made a regression to programming that the pt did not need. I’m continuing to learn to exhaust all options before regressing, as this should be a last option (in my mind). We need to treat impairments to achieve goals and we will usually see our best outcomes when we can continually to move forward. Additionally, I imagine this helps with pt buy-in, as symptom alleviation is confirmation that we have hunted down at least a part of the problem.
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Sarah Strong
In the inpatient acute care setting, I saw a 95 year old patient who received a L posterolateral approach Total Hip Arthroplasty. She lives alone in a condo for individuals over 55 and has a caregiver visit her throughout the day to assist her with ADLs. She was sharp-minded, but seemed to experience minor short term memory loss, or, she may have repeated questions such as “how long do I have to sit in this big chair for” until we might eventually tell her something she wanted to hear instead of the 30 min-1 hour, which she did not prefer. Anxiety about mobility seemed to be a significant limiting factor for her, especially in sit to stand with a rolling walker. Her walker at home has locks on it, and she is used to pulling herself up by pulling on her locked walker. She has PMH of peripheral neuropathy, which we suspect contributed to the fall that led to her hip replacement. This patient successfully transferred from the bed to a reclining chair with moderate assistance and use of the rolling walker.
In this moment, I reflected carefully on two aspects of this patient’s care. First, I visualized how well this patient might manage the precautions associated with the posterolateral approach THA. She required a verbal repetition of her precautions at each moment that she expressed wanting to move in ways that are contraindicated. For example, she asked to sit in a regular chair with arm rests, which would place her already at 90 degrees, or slightly more, of hip flexion and would not provide the support she needs to maintain a stable seated alignment, as the reclined larger chair did. She also expressed interest in dressing herself, which would require bending at the hip to put on her socks well past 90 degrees. Second, I am curious to know more about which considerations were made in determining that a THA was the best solution for her. At age 95, she may have low bone mineral density, and is at higher risk for surgical complications. I wonder if there might be a less invasive approach for elderly patients who sustain hip fractures? Some information I could have sought out would be to view her x-ray scans, and look closely at the emergency department note from when she was admitted.
I spoke with my CI following this clinical experience and we discussed that the patient’s anxiety likely limited her understanding of precautions, more so than any short-term memory loss. Additionally, based on watching her attempted sit to stand and knowing that caregivers frequently assist her with ADLs, she is unlikely to be left to her own devices for activities that may lead to her breaking her hip precautions. She is also planned to be discharged to a skilled nursing facility where she will receive more therapy before returning home. I am looking forward to learning more about specialized techniques for caring for post-surgical patients who are in this age range and mobility level, and how to navigate the challenging nuances specific to this population.
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Patrick Dumais
My clinical experience thus far has been very eye-opening. I am at a SNF this semester, and I have had very limited exposure to the inpatient side of PT prior to school. The evaluations were among the many things I noticed that differed from the outpatient setting. It was interesting to see my CI obtain most of the subjective history information needed from the computer via the patient’s medical chart. We were supposed to evaluate a patient who had an extensive medical history which included cancer that had metastasized to the brain. He also had cogitative deficits and expressive aphasia. Prior to going in to do the evaluation, an OT walked by and informed us that the patient had refused OT earlier that morning. I figured there was a good chance we would experience something similar when we went in to do our evaluation. When we arrived at our patient’s room his family told us that he had to leave for radiation therapy. I assumed that this meant we would have to do our evaluation at another time, but my CI used this as a chance to see how the patient got to the car and got into the car. She later explained to me that she was able to obtain a lot of valuable information simply from observing him get to the car. I thought this was clever of my CI since more than likely he would have declined to have a traditional PT evaluation done. I plan to try my best to think more creatively in terms of evaluating patients in this setting. There is a lot of valuable information that can be used to help the patient that can easily be missed if you are not looking for it.
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Andrea Choo replying to Pat
Pat,
I found it interesting that your CI utilized less traditional means of obtaining information about your patient. I’ve also noticed that it’s pretty similar in the pediatric population as well, since the majority of the patients are unable to speak for themselves or even follow basic commands. Even when there is a parent in the room to answer questions, we tend to take with a grain of salt because the information is not always the most accurate. We spend a lot of time observing how a patient motor plans and performs various functional tasks, rather than a more formal exam as we use in MSK class. At the beginning of ICE II, I didn’t really feel like I knew what to look for when I was observing patients. However, I do feel like I’m slowly beginning to become more observant and gain a better understanding of what to look for. I hope that you find that it gets easier too!
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Andrea Choo
A couple weeks ago, my CI and I performed an evaluation on a 20 mo year old boy with a referral due to problems with his L leg. As my CI and I performed a chart review that morning, we noticed that he had a significant family history. The patient’s biological mother had a history of gross motor and cognitive deficits due to fetal alcohol syndrome during her mom’s pregnancy and drug abuse (marijuana and heroin), which continued throughout her pregnancy with the patient. Additionally, the biological father had a history of CP. The patient was currently living with his mom’s adoptive parents (his grandparents) due to his parents’ inability to care for him and continued domestic abuse. We didn’t have a lot of information on his past medical history, however, there was a note that his pediatrician and neurologist had not found anything medically wrong with him. As we got the subjective history from his grandmother, the patient seemed like a normal toddler running around the room and playing with toys. The grandmother denied any observable cognitive or motor delays, but reported that the patient tended to drag his L foot and tremor exhibit a tremor throughout the day. Additionally, she was concerned that he may be experiencing grandma seizures but stated that neurology and the pediatrician had both cleared him. Instead of performing a structured objective assessment, the majority of our evaluation involved the patient playing games and participating in activities (ex. Sit on the floor, sit to stand from floor, kneeling, stairs, jumping, kick/throw a ball), as we observed his movements and motor planning. Some of our observations included walking/running toed out on various surfaces, preferential initiation of sit to stand with L, several motor plans to go up/down stairs but preferentially initiation with R (L required facilitation from PT), SLS could be achieved on both legs to kick a ball and jump off bottom stair with min A. His cognition and ability to follow commands seemed to be appropriate for his age. We did not observe any tremor or dragging of his L foot during our session, so we asked the grandmother when she tended to observe it. She reported that she tended to notice the tremor towards the end of the day but was not confident that it didn’t also occur earlier in the day. As my CI and I discussed potential causes for the tremor, we began to consider weakness leading to the tremor. We tried to elicit the tremor by trying to fatigue the patient by having him go up and down the stairs for 10 minutes. Despite our best efforts, we were not able to reproduce the tremor during our session, however, we did start to observe the patient begin drag his L foot as our session progressed. The fact that the tremor was not constant throughout the day, decreased our suspicion that this was a neurological issue, however, the patient’s family/past medical history prevented us from ruling it off our differential list completely. As we were going through the patient’s chart, I was initially thinking that the patient may present with CP. However, my CI told me that CP is not necessarily inheritable and is often not diagnosed in children until they’re at least 2 years old. We were also able to rule out hip dysplasia by performing Craig’s test and assessing his leg length. By the end of the session, we were leaning towards global LE weakness in the patient’s left leg, which was causing him to fatigue and tremor. We were not able to perform any standardized objective measures during our first session due to time restrictions, however during our next appointment that will be our priority. Overall, I found this patient’s case very interesting due to his complicated history and inconsistent symptoms. Additionally, it was exciting to see how things we learn MSK can be adapted for the pediatric population. I think that my observation and creativity have definitely improved since starting ICE II. I look forward to working with this patient again because this is the most confident I have been treating a patient in the pediatric population so far.
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Lori Yeaman
I have had the opportunity to work with a patient with gluteal tendinopathy over the past few weeks of clinic. She is a great patient to work with and has progressed well with her exercises in therapy. She has improved strength, decreased pain, and the patient reports that she can now sleep on the involved hip at night, whereas before therapy her hip was too irritable to sleep in sidelying. However, last week, she reported that her hip was more painful that day because she had rested in sidelying on the involved side for hours during the daytime. After asking further questions, my CI was able to offer the patient activity modifications such as sitting up in a chair to read a book or watch TV during the day, sitting at a table to do a puzzle, or going for walks. She educated that patient on how those activities would decrease the compression on the gluteal tendon and relieve pain. We learn about activity modification and patient education in class, so this experience demonstrated a real example of the importance of asking questions about a patient’s life outside of clinic, as well as being prepared and creative to respond constructively. I learned from watching my CI in this situation, that activity modifications should be feasible, functional, and meaningful to the patient in order to help the patient continue to progress through rehabilitation.
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Tiffany Reynolds
I am in an inpatient acute care setting where many of our patients that we see have chronic debilitation. Typically in the acute care setting as a part time student you will only see each patient one time, maybe twice. I have seen one patient 3 weeks in a row which is particularly rare in this setting. It is an unfortunate situation as she has hopes of going to inpatient rehab but was denied the first time around, the PT and case manager resubmitted and it is currently under review for the second time to see if she can get approved for inpatient rehab. I am not sure what her other option would be at this point in time as her husband works full time and she cannot stand on her own. She is mod assist in most activities and it would not be safe for her to be discharged home.
We have tried to help her as much as we can in acute care to decrease the level of assist. However, this has been very difficult as she has many fear avoidance behaviors. When speaking with the patient she seems very motivated and has a go getter attitude but when she has to perform her attitude becomes more negative and she does not believe that she can progress. We have continued to work with her performing bed mobility and sit to stands. We would like to progress to ambulation but she can stand at this time for more than a couple seconds. There is definitely a weight and lifestyle factors component to this patient’s state as well. While she has hopes to be discharged to inpatient rehab I think that this may not be the best option for her especially when considering her mental state as I do not think she would be able to tolerate the amount of rehab required. I hope to see her get approved for at least a SNF because she is not safe for discharge home at this time.-
Tiffany, that’s interesting that a patient would be held in an acute care setting for up to 3 weeks. I’m curious as to what her conditions are or what she in rehab for in the first place. I also get what you’re saying when you mentioned patient attitude and behavior changes from talking about doing PT to actually getting it done; I’ve had many patients in my clinical experience who come in very enthusiastic or almost overly energetic, but seem very hesitant and rigid once the session of treatment and evaluation actually begins. I am also curious as to how much her mental status is affecting this patient’s stay in acute care.
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Sarah Roderick
In the inpatient acute setting, I am currently in the cardiac and ICU units. My CI and I co-treated a patient who was originally having a cardiac catheterization performed. However, during the surgery the patient’s R coronary artery was nicked and caused the patient to go into cardiac arrest. The team was able to revive the patient with bouts of CPR. However, the patient was admitted to the ICU and remained there for approximately 3 weeks due to additional complications that arose after the catheterization.
I was originally nervous to work with this patient given the patient’s recent history and level of immobility. Given my CI’s description of the patient’s current status, I was not sure what we would be able to accomplish during our session. My CI and I were surprisingly able to do several AAROM activities and some isometric strength training, which the patient was not able to do the day before, according to my CI. Therefore, my CI and I felt that we were able to safely get the patient to the edge of the bed, and standing with mod A x 2. Throughout the entire session, the patient was very confused, but also very eager to get moving as the patient repeatedly stated that they were going home in a couple of days. This statement likely came from a severe state of severe confusion, and is a hinderance to the patient’s prognosis as this patient is very unaware of their limitations in strength and balance.
It was very eye opening for me to see a patient who had a high PLOF and within three weeks has declined tremendously. I think this speaks to the negative effects of immobility, as well as how quickly muscles atrophy and strength declines when we are immobilized for so long. Further, being in the ICU and immobile for so long can cause this state of severe confusion or delirium, which is often not an affect of immobility that many would think about; but the lack of awareness is a huge hinderance and obstacle to overcome in one’s recovery. Though the patient had made extreme amounts of progress in 24 hours, it is important to recognize how long it will take before the patient returns to their PLOF. It did not take much time (3 weeks) for the patient to lose so much mobility and muscle tissue. This also emphasizes the importance of a variety of rehab specialists that will be a part of this patient’s care and return to function, for an extended period of time.
I felt that my CI and I did the appropriate amount of activity and challenged the patient within their limitations, but also attempted to provide a sense of reality in directing the patient that additional rehab may be beneficial by pointing out their current functional status. In the future, I would like to continue to improve my comfort level with these types of patients who have undergone severe trauma, and continually think of the most appropriate activities to challenge the patient within their limitations as they are returning to their previous level of activity.
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Alex Gett
I performed an eval on a pt that came in with knee pain due to mild trauma. He was working on his trailer when one of the jacks holding it up malfunctioned and part of the trailer was on top of him. He was forced to rely on his R LE to push himself out from under a part of the trailer. He reported minimal pain at the time of the incident, but woke up at 3am that morning with “unbearable pain.” He got an image roughly 2-3 weeks later that was negative, and he managed his pain in the meantime with ice, rest, and NSAID’s. By the time he came to the clinic, it was roughly 6 weeks past initial injury; a decent amount of healing has been done at this point. His PCP advised him to come to PT “to make sure nothing sever is going on” –> no red flags, mild discomfort with active knee ext, no other measures reproduced symptoms; this was a rather quick screen before functional testing. pt had the “why am I here” attitude, but I was determined he walked into the office for a reason. We went into the main part of the clinic where I asked him to perform eccentric step-downs; pt presented with dynamic valgus, pain in knee, and arm strategy compensation. pt reported he uses stairs often, but he was not aware of his compensation and was able to see his impairments until asked to slowly lower himself. DL squat did not necessarily reproduce pain, but other ROM limitations hindered normal movement. Upon further STT, no other measures reproduced significant pain; slight weakness in ABD. This was a great experience, as I watched pt buy-in happen with one functional test. It was also a great experience because it showed me that a pt may look relatively normal during STT, but functional testing is a whole different story that has the ability to expose impairments.
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Alex,
That’s interesting, because we talk a lot about focusing on patients’ specific functional limitations and participation restrictions and their specific self-generated goals, but in this scenario you seem to have discovered limitations for the patient. Nice way to give the patient something meaningful to improve upon and at the same time give yourself a job.
-Levi -
Today in clinic I saw a female patient in her 50s who was in for R LE pain and weakness. She had been seen a few years prior in the clinic because of a total knee replacement in her L knee, but at that time she had already had arthritic symptoms in her R knee. In her words, she “got into it with a dog”, and fell on her left knee injuring it. After follow up with her doctor, that side then became the top priority. Me and my CI saw her today to measure her progress in pain and ambulatory status, and she then expanded on how much this therapy meant for her, and how much was riding on it. She works at a factory where she stands on her feet for 8 hours a day lifting heavy packages and stacking them, sometimes up to 50 lbs in weight. Because the pain in her right knee is due to arthritic changes and her leg weakness was also “self derived” in nature, and not on company ground, her employers essentially told her that if she did not get better in the allotted time, she would be fired. She was very emotional at the time, and my CI took over in calming her down and then taking her through some basic exercises to gain an understanding of her baseline strength. We did the 30 second sit to stands test, lateral step ups and overs, forward step ups and overs, and a plethora of other strengthening movements to help move her towards her goal. It resonated with me how profound an impact such little tasks, however functional they may be, can have on an individual; for us students, these are simple exercises we learn about in class and are tested on for a grade. For our patient, they were the keys to keeping her employment and being able to support herself.
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Marielle Giardini
In the outpatient ortho setting, I had the opportunity to work with a 30 y.o. male who presented with a SLAP III and a partial tear (1 cm) of supraspinatus. At the start of the session, my CI took him through PROM where he had pain and catching with flexion and aBduction. My CI and the patient let me take him through these, as well. We then moved on to AAROM with a broom and isometrics against the wall, with aBduction being the most painful. With scapular stabilization, we did scapular retraction in prone and the patient stated he felt like his arm was going to dislocate and that it was very painful. My CI decided we should try scapular retraction seated which seemed to not be as painful compared to being in prone. This was the patients third visit with my CI and her main concern was to make sure the patient didn’t lose him ROM and to work on scapular stabilization. However, the patient could tell he wasn’t getting any better (possibly worse) and he did not seem as motivated; he mentioned a few times during the session that he knew surgery was going to be his only option.
I found this experience very beneficial for me as a PT student because this was my first time moving a pathological shoulder. It is one thing to practice these skills on classmates who are healthy and have more range and are pain free, but to have the experience to feel what it is like and to feel and hear the “catching” in the shoulder. I also found it helpful talking with my CI through the different exercises and why we were doing them. I was able to see why she first chose these exercises (already established in the POC before I saw this patient) and seeing her problem solving when the patient experienced pain in one position, but not another.
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Alyse Nierzwicki
Over the past few weeks, I have treated a patient with a complete C4 spinal cord injury (IP acute setting). Our sessions thus far have targeted patient-led bed mobility, proper wheelchair positioning, independent pressure relief, and caregiver training. Given the patient’s injury level, he is unable to successfully execute a volitional cough; this leads to a significant increase in fluid build-up and subsequent decreased O2 sats. Recently, he has been refusing his cough assist from nursing and respiratory therapy.
This past Tuesday, my CI and I initially planned to implement the bed ladder to initiate self-rolling. He, however, described a significant increase in shortness of breath and fatigue. We altered our treatment plan to include chest percussions and postural drainage to decrease the fluid build-up. We placed the patient in multiple positions that isolated the lobes of the lung – progressing fluid from the lower lobes to the upper lobes and eventually out of the body. We also provided abdominal/chest compression to help the patient force a cough.
In effort to improve our patient’s cardiovascular function and overall participation in physical therapy, we performed rapid chest physical therapy. This was a beneficial learning experience because it introduced an alternative treatment technique necessary for patients with high-level spinal cord injuries. It also helped widen my perspective of in-patient physical therapy beyond the musculoskeletal and therapeutic exercise components.
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Alyse –
Thank you for sharing! I have not had the opportunity to work in a hospital setting so this aspect of PT is completely new to me. It’s so cool to see how our interventions seem to expand beyond the realm of just musculoskeletal treatment. The closest I’ve seen to this kind of intervention was in an outpatient ortho clinic where the PT used coughing as a form of exercise (I was a tech at the time so am not 100% sure of her reasoning for it but I can only imagine it had to do with decreased diaphragm function). Thinking of it, the diaphragm is still technically a muscle. Regardless, it seems to both overwhelm me and excite me the options we have as far as treatment goes in physical therapy.
-Victoria Appler
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Alex Argentieri replying to Aly Nierzwicki
This sounds like a great example of how a to adjust your treatment session based on the patient’s need. I know from being in the hospital setting last semester that treatment session can change quickly depending on the patient’s signs and symptoms, but I imagine this must have been more stressful given the nature of your patient’s injury. However, it sounds like you were able to respond quickly and promptly to the patient’s needs and hopefully created more patient buy in for future therapy sessions. Good job!
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Victoria Appler –
Today I saw an 85 year-old patient who suffers from L hip OA. This is a patient I’ve seen a few times now. Although she is motivated to do exercises in physical therapy to help her with her walking, today when I told her we would be working on bed exercises to help strengthen her hip (bridges, supine clams, etc) she voiced to me, frustrated (as she often tends to present as), something along the lines of: “I have OA – exercises can’t do anything about that.” When she verbalized this opinion, it occurred to me how common this misconception is for many patient’s conditions. I responded to her with something to the effect of “the exercises will make your hip stronger and take the pressure off your joint” to try and simplify the explanation as to why PT would be helpful. What makes these conversations difficult for me is trying to educate patients in Layman’s terms while still addressing their concerns. Sometimes the simplified version, to them, does not make sense, and may even add confusion. In this case, I don’t really think I changed my patient’s mind. Next time, I will be more prepared for a conversation like this. I will continue to work on patient education and getting my point across without being overzealous or overly analytical. -
Brianna Virzi
My CI has been treating a 47 y/o female patient with left shoulder pain for about 4 weeks via direct access. I have seen her on two separate occasions, and it has become a very frustrating case. This patient’s chief complaint during the initial evaluation was deltoid insertional pain specifically when turning her wheel while driving and lifting her arm overhead into abduction. Imaging has been negative, the capsule has normal mobility, and there is not a consistent pattern for symptom provocation. Although we are unsure of this patient’s medical diagnosis, we have been treating the impairments that were found in the objective exam such as PROM/AROM limitations and rotator cuff weakness. However, this patient’s symptoms seem to change between sessions and sometimes even within sessions. In the same day, active assisted abduction with the pulleys can be completely painless, and then active assisted abduction with the cane is suddenly so painful that she cannot perform the exercise. Even though fatigue may play a factor, you would not expect such a drastic change when performing essentially the same movement. She also reported that driving was much easier during one session, and then the following session claimed driving is still difficult and there hasn’t been any improvement.
The inconsistent findings with this patient are plentiful, and they have been challenging to comprehend. My CI and I feel like there is an underlying issue, especially since this patient takes Lithium yet did not report any past medical history. It feels like regardless of our many efforts, the patient’s story is always changing. Nonetheless, this experience has highlighted the importance of the patient’s role during treatment. We heavily rely on patient subjective and objective information to guide our clinical decisions, and this can be difficult when there are so many discrepancies. I would be interested to hear if anyone has any suggestions about how to manage patients similar to this.
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Bri,
That sounds like a very frustrating and challenging case. I haven’t experienced a patient like that but it is probably more common than most of us think. I do like that through this complicated case with changing stories, that you have found how important it is to make the patient involved in the treatment guiding what impairments you treat. Although the story changes, you still keep the patient first and do the best you can. While I have not experienced this before and do not have any advice to offer, I have learned one way that I could treat a patient like this. It is very important to keep the patient first and treat the impairments they have at that point in time!
Marielle
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Bri,
This sounds like a very frustrating case. I agree that there is probably something underlying going on. I saw a patient last semester who liked PT so much that they were constantly changing their pain so they wouldn’t get discharged. While this seems a different situation, we ended up watching the patients facial expression when they were doing things to help get a “more accurate” description of pain and relied less on the subjective reporting. We had to be careful about not letting the patient know this was what we were doing too. I hope you are able to find more consistency or different way to help this patient get better.
Kayla Sweeney
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Bri,
This is an interesting situation. I can see your frustration with this patient and I am puzzled myself with how to deal with this patient. I am interested if trying to address the issue would do anything? It would definitely depend on the type pf patient they are, but I wonder if asking them why their symptoms about driving and such would bring out some more information. Either way, it is definitely a difficult barrier to overcome, and you are right on with the importance of the patient’s participation. If they aren’t going to give optimal effort and reliable information, we unfortunately won’t be able to give them optimum treatment.-
Above is from Jacque
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Caleb Baxter
In clinic yesterday, I was involved with an eval of a patient who had just completed a bout of rehab with a different PT. I performed the subjective eval, while my CI took the lead on the objective portion since this patient was suffering from neck pain. Initially, the patient made it seem like the pain was new as of 4/5 months ago without a clear MOI. By asking a few more questions, I was able tease out that the pain was in a similar location to a surgery that was performed on the patient in 2007. The surgery was serious and focused on CN V. While the current neck pain feels new, it is likely that this patient had low levels of neck pain all along, the pain just was not enough to impact function. The patient seems like he is self-sufficient and deals with pain well, supporting the hypothesis that this may not actually be a completely new pain. I think this case supports the notion that we need to be specific with our subjective examination, as most of the relevant information can be gathered with a proper, accurate subjective. This can help us tailor our objective examination so we are not completing every test in the book. A strong subjective history also helps develop an accurate prognosis and give insight into the level of education that is necessary.
Patients that are not good at accurately describing their chief complaint, current level of function, and PMH provide a huge challenge to the interviewer. We need to be clear and concise with our questioning and clarify responses to make sure that we are getting an accurate picture of our patient. The most skillful interviewers are able to get this information quickly and effortlessly, and this is a skill I want to develop further throughout the second half of this clinical experience.
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Caleb,
Yeah I agree that getting good at completing a thorough subjective history can really give you 80% of what you need for diagnosis. I would imagine that any of the objective tests you performed matched up with what you thought it may have been after the subjective history. I know I am still trying to perfect histories and Im sure this experience probably helped you a lot with asking the right questions and teasing our important details for cases.
Andrew Lamont
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Melissa Murillo Jankus
In clinic this past week, I had the opportunity to perform an evaluation on a patient who had a motorcycle accident back in May of 2018, and who fractured his right ulna as a result of that accident. The patient underwent one surgery to repair the fracture with pins, however, he also underwent a few more surgeries throughout the summer, due to recurring infections of the surgical site. When this patient came into the clinic, he reported that his last surgery was 3 weeks ago. Through my subjective evaluation, I learned that he is a full-time mechanic, and is having weakness and pain with lifting heavy objects and twisting tools, such as a wrench, while performing his job. He also reported pain with using a knife to cut his food with the affected arm and he said that he used more shoulder motion than elbow motion to get his hand to his mouth. His mobility in the elbow was surprising, in a good way. His elbow extension was only limited by ten degrees, and he reported that he was happy with how much extension he had. His elbow flexion was more limited, with it only being 105 degrees. Resisted testing revealed that elbow flexion was strong and painful, and his elbow extension was weak and painful. A screen of his shoulder and wrist was unremarkable. With the help of my CI, I was able to come up with a few treatment ideas, one of which was providing passive overpressure into elbow flexion, up to the point of pain, and holding for approximately 25-30 seconds. After my CI performed some other treatment techniques, my CI asked me to come up with a few therapeutic exercises to give the patient to do at home. I chose to turn the manual therapy I had done into an exercise. Using his left arm, I had the patient passively move his right elbow into flexion, to the point of pain, and had him hold it there for 25-30 seconds. I also instructed the patient to remember to keep the right arm relaxed while doing this. I also decided to prescribe resisted elbow extension with a yellow TheraBand. I instructed the patient to go as far as possible without pain, and then control the movement back to neutral. After watching him perform these two exercises, I was confident that he would be able to complete them at home.
This evaluation was a huge learning experience for me, because I was able to do a majority of the evaluation, and my CI encouraged me to think on my feet about manual therapy techniques and therapeutic exercises. I am looking forward to seeing this patient again, and I am looking forward to being able to progress his therapy and exercises as he progresses.
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MJ,
Seems like you have a very interesting case in which you can begin to use the information you learned in MSK I. It is great that you were able to do a subjective and make some clinical decisions based on your findings. Excellent idea with the OP into flexion. It is important that he restores that flexion in order to be able complete ADL’s, correct? MJ, in this post you mentioned that he primarily uses shoulder movement to compensate for his elbow restrictions; with this in mind, do you suspect that improper/over use of his shoulder could lead to shoulder pathologies down the road if his elbow limitations are not addressed? Glad you had this opportunity and hope that he is able to make improvements as you continue to work with him.
-Pete
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Samantha Schambach (2nd post)
The other day in clinic I had the opportunity to work with a patient who had wernicke’s encephalopathy. This was due to his recurrent alcohol abuse. Before entering the patients room my CI told me that I would be taking control of this treatment and we reviewed the chart together. According to the chart this particular patient need max assist more bed mobility X2 and transfers. Ambulation was not attempted last treatment session due to safety and the patient agitation. After reviewing this I knew that it was going to be a difficult treatment, but I was up for the challenge. When arriving to the room I noticed the patient overall looked very frail and as though he was staring off into space. I tried to get his patient identifiers, but unfortunately he did not know his name or even where he was. When asked his name, the patients stated” the boat sank.”
Although this made me nervous as I was not sure how I was going to communicate with a patient that could not understand what I was asking or communicate how he was feeling, both my CI and I decided to continue with treatment. While performing bed mobility and getting the patient up to a sitting position he grabbed my pants and started pulling on them hard. I tried to loosen his grip and place his hand on the bed. Meanwhile my CI was holding onto his other arm as he was trying to bear hug me. After a few inappropriate hand placements by the patient, both my CI and I agreed that this was about all we were going to get done that day and ambulation was not an option.
I think it was a good learning experience for me to see that you can have 2 sides of the spectrum with all patients as before I was typically working with patients who were higher functioning or mainly cognitively there. I asked my CI if there was anything that I did wrong that might have provoked the patient and she stated that I ensured the safety of the patient and this is just what happens sometimes. I am glad I was able to review the chart because if not then I might have gone in there as a solo therapist if I was a full time PT and that would have not been a smart decision for my patient or my own safety. This will be a good reminder for future endeavors.
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Peter Cradduck (second Post)
10/2/18
Let me tell you about how my CI and I helped a man with severe dementia to escape from the nursing home and run free into society. Okay, maybe not the last part about running free in society, but we did break a man out of the locked-down dementia unit and alter the trajectory of his day.
“Sun-downers” are patients with psychological illnesses that increase in symptoms during certain times; typically night time. Our fugitive patient (we’ll call him Mike) was characterized as one of the patients that had good times and bad times depending on the time of day. In the past few weeks, Mike had increased profanity and constant a disgruntled face (like Clint Eastwood from Gran Torino). I used my clinical reasoning to deduce that he was in his “sun-down” mode during our visits.
Mike is in pretty good shape for a 92 year old, especially in comparison to his fellow residents. If gait speed was the only vital sign, he would be healthier than my CI and I. Our exercises for Mike are designed for strengthening and getting him to slow down. Unlike all of the other patients we see during the day, his dementia truly is his biggest limiting factor. Exercise has helped him in the past and has seemed to be the most effective treatment for him in regard to his overall quality of life.
It was made clear to me that although patients with dementia may not remember a conversation from one minute to the next, the limbic system can perpetuate a negative/positive mood long after an experience. This mood can leave a patient angry or happy and not sure why. With this in mind, we decided to do our exercises in a way that might improve the patient’s mood and decrease profanity. My CI came up with the idea of taking Mike outside to do his exercises.
Once we got outside and sat down in a chair Mike’s Clint Eastwood face dissolved into a smile. As we did our exercises, instead of talking about how he can’t believe how his “Golf game has gone down the D*** pipes” he talked about how his wife would allow him to golf when he wanted and how he is proud of his son. He remembered our exercises more clearly. Mike’s dementia was not cleared, but he was more alert and optimistic this visit. When we walked Mike to his room an hour later, he was in great spirits and didn’t seem to know why. This was probably the most interesting part of my day, and whether he knows it or not, it was Mike’s highlight as well.
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Lori Yeaman in response to Peter Cradduck:
Peter,
This is a great example of the importance of adapting the environment, exercises, situations, etc. to help your patient receive the most benefit possible from therapy. Based on your patient’s presentation that day, you and your CI were able to come up with a way to positively influence the patient’s mood. It sounds like you are learning so much by working in this setting, great job!
-Lori
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Pete,
Wow Pete, this sounds like a great experience! I just recently encountered working with a patient with dementia and I relate to many of the things you described. Given your patient’s mood change over the last several weeks, I think it was a great idea that your CI tried something different with this patient and it definitely showed improvements for them. This experience shows how we continuously have to change our plan, if the plan is not working for the patient, regardless of the treatment setting. Great job!
Sarah Roderick
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Jacque Hemler
This past week in clinic I saw a TKA who was 3 weeks out. Before seeing the patient, my CI and I talked through the patient’s situation as this was the first time I was seeing her. My CI said that the patient was very pain oriented and had decreased knee flexion for her point in recovery. When we got the the house, the patient started out saying she wasn’t going to do much today because she was really hurting. She was having an MRI later that afternoon due to inspect the internal sutures because she was concerned that a muscle spasm in her leg may have ripped through them. The patient began to complain that her last outpatient PT had pushed her too hard and messed up her other knee. Her doctor advised her to stop going to PT due to this, so she isn’t too happy with therapy. I could tell my CI got very tense during this situation, but she proceeded with therapy. When we tested her flexion, she was still only achieving 58 degrees of active flexion with considerable pain. She seemed to exaggerate a lot of her pain and then seconds later she would be fine. After leaving, my CI explained to me that the surgeon she has often puts down physical therapy and tells the patients what they want to hear. This is very difficult to deal with as patients often look to surgeons for all their information, including the musculoskeletal aspects. While they obviously know what they are doing, if we are not working as a team in the health profession world, it makes the patient’s success in recovery much more difficult.
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Levi responding to Jacque,
That sounds super frustrating. As we are learning, there seems to be a lot that goes into a successful patient interaction, like patient rapport, and patient expectations. It’s unfortunate that the surgeon would start the patients off with this mindset and almost set them up for failure.I honestly don’t know how you go about winning over a patient like that. I guess the doc expects ROM and strength and all the rest to return in a self-limiting manner?
At this point in typing my response, I decided to do a quick literature search, and found a RCT “Formal physical therapy after total hip arthroplasty is not required: a randomized control trial”. This is from the journal of bone and joint surgery. The conclusion from the abstract states “This randomized trial suggests that unsupervised home exercise is both safe and efficacious for a majority of patients undergoing total hip arthroplasty, and formal physical therapy may not be required.”
Although this study is for the hip and not the knee, I guess this may provide some insight into the perspective that the surgeon takes?????-
Levi,
Thank you for sharing your lit search and insight on the topic. That is a good point to consider about where the surgeon may be coming from. I think it is a good reminder that not everyone supports the physical therapy profession. As a professional, we need to learn how to address these situations and advocate for our services.
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Jaque,
This encounter most definitely seems frustrating. Although with recent years PT has become more established and most surgeon-PT relationships are positive, I think there is clearly still a disconnect in the health care world. But nonetheless, still frustrating. Especially because like you said, it’s “supposed” to be a team based approach for patient care and recovery. However, I think there is always going to be that now and again encounter like the one you’ve described here that pops up on our schedule. Unfortunately, I think at that point we just have to do our best to educate the patient on the benefits of physical therapy and the evidence behind pain. You can share some research with them or share some specific patient success examples/testimonials that have showed improvements (maybe on the company website). I know that more times than not this is easier said than done, and I know that most patients will be stuck in a certain mindset. However, we still need to try and if the patient is still adamant about not wanting to participate then ultimately that’s their decision. Hopefully, this patient will come to find out that PT could have really helped her in the long run. Maybe she’ll talk to some friends, or overhear a conversation about PT, or actually do some research if after re-visiting her surgeon she’s still not progressing. Has your CI talked to the director/manager of her company at all? I’d be curious to hear the advice they give for situations like this because I’m sure they’re more common than we may want to think.
Anyway, thank you for bring up this topic! I think this is something very important that we as students need to begin to think about and brainstorm how we would address it. I know that it can be awkward in that situation as a student as well, so I can appreciate the uneasiness you must’ve experienced. I hope her mindset can be changed. Even more reason to continue advocating for our profession!
Mekayla
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Mekayla, you are exactly right. It is a great reminder that we do still need to be actively participating for our profession. I know my CI has not contacted the physician personally about this topic, although that may be something to consider in the future if this keeps occurring!
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Andrew Lamont
Last week in clinic, I was able to work with a patient who was 2 weeks s/p TKA. She was 82 which originally concerned me before arriving at her house because of the possibility of her healing capabilities and mobility. When we arrived to her home, she was in exceptional health and was ambulatory with limited AD use. We wanted to check her ROM and strength prior to discharge the following thursday to OP care. She demonstrated AROM knee ext at 7 degrees which was great considering her age and short period of recovery. Her AROM knee flex was at 104 degrees which was also exceptional at this point in her recovery. I performed some posterior tibial glides to her knee to try and gain a few degrees of flexion for a few minutes which ended up allowing her to passively reach 111 degrees by the end of the session. She was performing heel props as an exercise at home which had clearly been effective, however, i wanted to add something to gain those extra few degrees. She stated that she had been feeling stiff in the mornings especially and I wanted to target her limitations the best I could. I showed her a stretch in prone to hang her leg over the bed to encourage ext which would be easy for her to do in the mornings even before getting out of bed. She was extremely compliant with her HEP and I believe this is why she was progressing so well with her TKA. Its always great to see compliant patients and the outstanding outcomes that happen with them.
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Matt Reis
I am currently with home health physical therapists doing my rotation. My CI and I showed up to this house where he asked me to take the history and figure out what we needed to do with this patient. I was informed that she was previously in the hospital for a fall, but that was the only thing I was informed of. Within the first few minutes of talking with the patient, it was clear that she suffered from some cognitive deficits. This lady is above the age of 90, lives in a two-story house, and was unable to directly tell me who lived with her in the house. She did, however, state that her husband worked at the power plant nearby, she hasn’t seen him a few days, but the plant gets really busy at this time of year so he would be home soon. After leaving the house, my CI informed that her husband passed away years ago.
I proceeded with my evaluation where I got the patient up and had her walk around the house. The first stop we made while walking was in the kitchen where I asked her if she had difficulties with preparing food. She stated that she didn’t, but when she opened the fridge to show me what she was eating, the fridge was essentially totally empty with maybe three or four items in the fridge which included the condiments. We left the kitchen and proceeded to the stairs as her bedroom is on the second floor. She is unable to use her FWW going up the stairs so she just simply leaves the walker at the bottom of the stairs. There is only one handrail on the left-hand side, and this is what she holds onto as she struggles to get up the 12 steps she has to the second floor. Once she reaches the top stair she has a dresser in the hallway, where she will let go of the handrail of the stairs and ever so cautiously staggers toward the dresser to use this to hold onto. She will scoot alongside the dresser to the door to her bedroom. Upon reaching the bedroom, she has dirty clothes laying all over the room, and as we walk around the house you can clearly smell that she has not bathed for multiple days and is unable to recall the last time she was bathed.
This lady had no one to check on her, lived on her own, and was one fall away from an extremely tragic accident that could possibly end up taking her life. My CI and I left the house and he discussed how she has a son, who lives out of town and cannot come back to care for her. My CI asked the son if he has looked into the getting a home care provider and the son stated, “No, every time I talk to her she says she is fine.”
My CI reached out to the adult protective services, and they essentially said that they can’t give out any information about the case or how long it would take to be resolved. So with all this being said, is there anything else we can do at this point and time to help this patient?-
Replying to Matt Reis:
This is such an incredibly sad event. I am astonished that the son is not more concerned about his mom and the conditions that she is living under. In regards to your question, I think the only thing we can do is make sure that adult protection services knows the severity of the case. In this situation, like any, we are advocates for the patient and especially in this case because the patient doesn’t seem capable of being an advocate for herself. Let us know if this gets taken care of. I would hate to see a critical fall occur due to negligence of the other healthcare professionals involved in this case.
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Levi Perry
So I haven’t been in clinic since my surgery, but I did perform a hip exam on my Mom (Lol), so let me share:
She has been having bilateral hip pain (R>L) for upwards of a year to varying intensities. Subjectively, pain is on lateral aspect and some “deep down” in joint, as well as low back (she pointed to SI area). Pain is activity dependent and worsened by walking longer distances, standing, stairs, and some pivoting. No history of trauma or anything. When she told me this over the summer, I was thinking OA or lumbar, but after our hip unit, my primary hypothesis was glute med tendinopathy. Functional testing – DL squat had decreased depth, but was symmetrical and displayed no valgus or trunk lean and was only painful for both knees (she avoids squatting because of her knee pain…I left her knees for another exam due to time). Single leg stance displayed very poor balance, but no valgus, trendelenburg, or pain provocation. Active and passive ROM was normal. The only thing that reproduced her pain was inner flexion quadrant and FADIR (deep pain) and resisted IR (lateral pain)… she was not very irritable that day. At this point, I was confused by the presentation, but I was retaining my primary hypothesis of tendinopathy for a lack of a better replacement. The lack of ROM restriction largely ruled out OA, but I wasn’t really able to explain the deep pain from FADIR. I was also thinking that there was very likely not just one thing going on… maybe FAI or minor OA provoked by FADIR, tendinopathy provoke by resisted IR, and SI playing some role here? I skipped PAM because there was no ROM loss. Glute med MMT was about 4/5, but caused no pain (which really surprised me). FABER (-), Straight leg test (-), Scour (+ only in inner flexion quadrant), de-rotation (+). Palpation to glute med tendon painful, as well as glute med and TFL muscle bellies (glute > TFL), greater trochanter painful. Palpation to Right SI joint produced localized pain. I told her she would have to wait until I learned about the SI joint, but that there was likely something going on with it, and potentially strengthening glutes could help stabilize it. Easily the most provocative aspect of the exam was the palpation. I educated her on potential aggravations to a glute med tendinopathy (she sleeps on R side and doesn’t use a pillow between legs). I previously had given her the Myrtl hip routine and some stretches, but i told her to focus less on the stretches, which could potentially even aggravate things, and focus more on clamshells, SL abduction, and maybe a glute max exercise. I told her to do the exercises until fatigue or loss of form, and let me know if they aggravate her too much. I would really like to have her doing DL or SL squat stuff, but it bothers her knees too much. My plan is to progress the clamshell and abduction to something more functional, like step ups/downs (if knee can tolerate), and something in single leg to work the glutes and also her balance deficits. -
Jesse Parsons
Recently in clinic I evaluated a 14 yo girl who was complaining of anterior knee pain just below the apex of her patella. Originally, my CI believed that she most likely had patellar tendinopathy. As I listened to her subjective history, though, it became apparent that her pain was most likely stemming from other problems. She had sustained a fall in gym class where she landed on her patella on a wooden floor. While observing her standing posture and her walking form, it became apparent that she tended to stand with genu recurvatum and her knee went into excessive hyperextension during gait. She also had pain with end-range knee extension, but not with passive knee flexion or active knee extension. This led me to believe that patellar tendinopathy was less likely. I palpated the inferior pole of her patella where the patellar tendon attaches, and she said that it was not painful. She did have pain, however, when I palpated inferiorly along the tendon. I then remembered the fat pad that lies beneath the patellar tendon, because we had just learned about it in class that week. I palpated beneath the tendon and she reported a large increase in pain. This led me and my CI to believe that her pain was most likely stemming from her patella digging into her fat pad as she stands in knee hyperextension. It was really cool being able to apply knowledge from class in such a quick and relevant way.
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Jesse,
That sounds like a great experience, especially since it really played out exactly how we learned in class. Its pretty cool that this scenario occured right after talking through these pathologies as well. Keep up the good work!
Andrew
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A couple weeks ago I was able to perform a PT screen with a patient in the acute care setting. It was an interesting experience and one that I had never heard of before. My CI explained to me that the “screen” we were to perform was simply to assess the patient’s chart to understand if this patient would require a PT evaluation or not. If we could not make a determination, we would speak to the patient to assess their typical baseline levels, but would not be allowed to touch the patient. So I went into each patient’s chart to assess if they might require an evaluation for PT, but was a bit in the dark about who would “require” it and who might not.
On the first patient I was looking through her chart and trying to decide if they would need an eval, but I wasn’t sure. My CI informed me that she had put in for an eval for the first patient screen. I was still quite unsure why she had decided to do this so I asked for her reasoning. She mentioned that through the patient’s previous notes, she was able to discern that her baseline levels prior to admission compared to her current level of function represents the need for PT to work back to those functional levels. This is where I began to understand what the screen was supposed to be used for.
Now that I understood the reasoning for the screen, she wanted me to take the lead on the next patient, who we were unable to determine if a screen was necessary simply looking nat the chart. We were speaking to him and he stated that he lived alone and was independent with all aspects of life, and then started becoming debilitated. He was unable to walk up the stairs and was crawling around the house. He then got a ride to the hospital and was found to have a blockage in his bowel, rendering him unable to care for himself. Therefore, we determined that he would need a PT consult as soon as he was strong enough to perform.
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The above post is also by Tim Webb
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Dominique Norris (Second post)
This past week, my CI told me that in the afternoon we would be doing a new eval on an ACL sprain (no surgery). During the morning, I prepared by trying to recall what we (just days before) learned about ACL. When it was time to go greet the new patient, our front office staff briefly stopped us to let us know that our patient was not in a very good mood. She had thought that her appointment was at 2, not 3 pm.
The patient was also clearly not excited about being at PT which made getting information from her challenging. We have learned to ask open ended questions and let the patient “lead” the conversation, but this patient would only answer a few words at a time. I was forced to take a step back and re-evaluate how I was going to get the information from her, while at the same time getting some patient buy-in, which would be critical with this patient given our rocky start.
Eventually, my CI and I were able to get some more detail out and she started to open up a little more. Near the end of the session, my CI and I walked her through a few exercises for ROM (inferior patella glides, seated heel slides). It took a few repetitions for the patient to warm up to the idea of having to work through some of her pain to get it better. My CI gave her a technique to relieve some weight on her leg during the slides (pull up on the ends of a towel wrapped around her thigh). This helped relieve some of the pain and got us some more patient buy-in. I was even able to lead her through resisted heel slides to strengthen her hamstrings and explain to her how that would help increase the stability in her knee.
While this was by no means the “typical” ACL (population, her capsule had tightened to protect the knee as opposed to having laxity), I was able to connect some of the treatments to the patient. More importantly, I was forced to re-think my strategy and really understand why patient buy-in is so important. I am more prepared for next time I see a patient that may not be fully sold on PT or may be having an off day. The eval took longer than typical, but it was worth it because we were able to convey to the patient why coming here will benefit her, and by the end of the session she was starting to understand and accept that.
How have you guys or your CIs negotiated evaluations (and even treatment sessions) with patients who are not motivated or not happy to be at therapy? And when your patient has a fairly negative outlook, how do you find a balance between being empathetic, motivating them, and being realistic about their prognosis? (especially for a patient who may not get back to 100%)
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From: John Orchard-Hays
To: Dominique (second post)In class we are so used to hearing of the increased laxity commonly associated with an ACL tear that it’s interesting hearing how a strain can cause increased capsular movement restrictions. As for the patient’s view towards PT, it seems to me that there was more going on regarding her attitude then having to just wait extra long for PT, which I’m sure you and your PT picked up on and addressed as best as possible. I’ve had similar experiences both during my internships and in my couple years as an aide in working with apprehensive patients. I think patient education is valuable but sometimes they won’t be receptive unless you show them specific techniques that will relieve their pain (much like your CI did). I had a similar experience the other week where I got caught up in trying to explain to an apprehensive patient how a back exercise was going to help their elbow. She had a hard time understanding and my CI stepped in and repositioned her scapula and then had her perform the same movement we were working on. She was able to compare the degree of pain felt with the movement from before and after the relocation of her scapula and reason that my CI’s position was better. She had an easier time attaining the value of the exercise through experiential learning and was more compliant with our treatment methods from then on.
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Andrew Lamont (second post)
This week I was able to work with a patient who is extremely obese and is continually lethargic about moving. She sits in her recliner almost all day with limited trips even to the bathroom. Our goal for treatment was going to be getting her up and walking, however, we also wanted to see how effectively she transferred from standing to supine in her bed and vice versa. With ambulation, I could tell that she was stuck in ER on her right side causing her to advance her leg using her adductors. As she laid down in bed, her mattress was extremely soft and caused her to almost fall off the bed on her right side. Upon asking her caretaker about it, she told us she comes in on a consistent basis in the mornings to the patient hanging her whole right side of her body out of the bed. This made sense with her whole pelvis being shifted to the right side as well and her hip in ER. I tested her hip ER and IR and found significant reduction in her ER being around 0 degrees. Taking into account my patient population being very sedentary, I wanted to find a way to passively bring her into IR. Her caretaker told me that she sits with her in bed sometimes to just read or talk and asked her if when shes in bed, if she could sit on the pts right side and just lean on her legs while bent to put her into a L leaning LTR. This was an easy solution to get her out of that constant ER position especially with her being “tired” and “not up for exercise” each and every session. I tried to get her to do seated IR (reverse clams on one side) but that did not go over well, as she only completed 3x on each side before “fatigue”. It was sad to see someone who believed she was gonna get better by just sitting there, but I tried my best to convince her and get her to buy into how she can help herself just by doing simple things. I will see her next week and hopefully hear she has been doing something that I instructed her on.
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Andrew,
I am also in a clinic were most of my patient population is sedentary and continuously talk about wanting to get better but don’t completely understand that in order to get better they will have to do some things that are going to be difficulty. Sometimes a session with a patient won’t consist of much because they are so resistant to exercise which can be very discouraging and hard to stay calm because I want to help them but they don’t want the help. Your idea to have the caregiver sit on the patients side to read to move her out of ER is really smart and super easy which is usually what these patient’s like most. I will have to keep that in mind for any future patients I have that may be similar to yours. Good job!
-Ally Kuhn
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Andrew,
You’re right it is sad to see patients who believe that they will get better by sitting in bed. It can be frustrating when they don’t buy into your advice for them. It makes us have to take a step back and think about how we can convince them that getting up and moving will actually make them feel better and have more energy than if they just sit in bed all day. It sounds like you did a good job by starting with lighter exercises but she was still fatiguing very early. I hope that next week she is able to do a little more with you. Sometimes we have to be really persuasive with patients who are less motivated and don’t really understand what physical therapy is.
-Lindsey Rodriguez
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Ali Cloutier
When arriving to clinic this week, my CI notified me that we had a patient that had a C3/C4 spinal cord tumor. I was super nervous because I had been working a lot with stroke patients but had yet to work with a patient with any sort of spinal cord injury. I was expecting this patient to not be able to walk, use his UE, etc. Turns out, I was completely wrong and the patient was able to do most things on his own. This man was 88-years old and had arrived at inpatient rehab 3 days before I saw him. This patient was particularly interesting because we discussed how he discovered the tumor. The patient discussed how he had been having dizzy spells and then he began to not be able to lift his R arm which prompted him to go see his physician. This is when his physician did scans and discovered that he had a tumor between his C3/C4 vertebrae. He got a 6hr long operation done at Johns Hopkins to remove the tumor and was able to be discharged to inpatient rehab about a week following surgery. Given that I am in an inpatient rehab facility, OT mainly focuses on rehabbing the UE and PT mainly focuses on rehabbing the LE. Therefore, my CI and I focused on working on his balance and walking while incorporating dual tasks that involved his R arm. Some of the activities we did included standing on a foam matt and putting clothes pins on a stand. This was particularly challenging given that he had a hard time getting to higher margins on the pole. We also had him go around the gym and collect different colored cones.
From this case, I learned that I should not get worked up about dealing with a patient population that I have not worked with before and rather take it as it comes. This patient was super interesting because the tumor only created deficits on his R side, whereas I expected it to create bilateral symptoms. This emphasized the fact that even though I can hypothesize how a patient will present, you never really know until they are in front of you and you do a subjective and objective exam. Next time when my CI presents the patients for the day, I will not get as nervous and focus on the positive learning experience I will have.-
Uyen replying to Ali
Wow that is such an interesting case. I think it’s cool that your CI presents patient cases for you before they come in, and as students in our second part-time clinical, I would also get nervous about seeing how the patient presents. It’s interesting to see that OT works mainly with UE and PT works with LE at your clinic. Do you know if they focus on fine motor only while PT can focus on gross motor or do they strictly work on everything with the UE? I liked how you were able to include dual task activities in the interventions as that is such great practice for things we can do with our patients in neuro!
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Ali,
Your patient does sound like a very interesting case which can be very nerve racking. I know that in home health where I am now, a lot of the patients have several diagnoses but they tend to vary in the functional ability so we never really know what we are walking into just like with SCIs. I have seen patients that seem like they have every diagnosis possible who are highly functioning and other individuals who have a minor diagnosis but are very low functioning. Overall, though it seems like you handled yourself very well. Good job!
-Ally Kuhn
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Uyen Tran
This week in clinic, I was able to perform a knee assessment on one of our patients. My CI had been working with fixing her ankle, knee, and hip mechanics, so she thought it was a great idea for me to assess her at this point to see her improvements. First, we watched her walk back and forth and noted that she has some valgus on her left knee and ER on her right knee. When looking at her posture, we noted that she stands with her L knee in extension and valgus and right knee in flexion with medial tibial torsion. Her femur was also noted to be ER and her ankles were noted to be in pronation. If you can imagine all of this- you would see a girl with a swaying posture towards the right side. Then I examined her patellae and I noted that they were frog-eyed patellae. I told that to my CI and the patient said, “my knees are not frogs!” and I had to reply with, “I’m sorry, I didn’t mean that! You know how frogs eyes face outward and they look like they are far apart?” and she replied, “yes” then I followed up with “I meant to describe your patellae as looking out like they are frog eyes, but that’s not a bad thing!” And so she agreed and I was able to move on to palpation. This moment made me realize how cognizant and careful I needed to be when examining a patient and talking to my CI about their impairments. I then palpated her patella location and structures around it and asked her if there was any pain, to which she always replied with, “nope!”
We moved on to having her perform a squat. Since she didn’t know what a squat was, I had to show her my squat, but I reminded her to do it the way she felt comfortable. When she squatted, we noticed forward leaning, valgus in her knees again, and pronation in both feet. We also noted her weight shifting to her left side during the squat. Then I had her perform some lunges, and those actually looked great! There was a little bit of genu valgus and femoral ER there, but my CI pointed out that she was proud of the patient because a few months ago, she was unable to do a lunge and now she looks more steady and stronger. Then I had her perform single leg hops and we also saw valgus and pronation of the hopping foot, on both sides. We also noted more force absorption on her left leg than the right because that is her stronger leg. Throughout the test, I made sure to ask if there was any pain with any motion and she always stated that she didn’t have any.
There were a lot of findings to take in. My CI asked me for 3 interventions I would recommend for this patient. I offered squatting with a TheraBand above the knee to facilitate hip abduction during squats and decrease in valgus, walking lunges with knee and ankle corrections to improve hip flexion ROM, strength, and control, and a calf stretch with each foot against a wall to improve dorsiflexion ROM. We taught her those exercises and she learned them quickly! It was really interesting for me to be able to see what actual limitations in the knee look and feel like. Talking with my CI, we agreed that her limitations began at her hips and go down the chain. So in addition to knee exercises, we taught her some hip exercises to work with and then allowed her to skate the rest of the session! -
Allyson Kuhn
Last week in clinic, my CI and I visited a patient with the intend of discharging him that day. Before arriving to his home, my CI caught me up on the patient’s original diagnosis, his treatment, his current status, and reason for discharge. The patient was a high functioning stroke patient who, from what I got from my CI, was back at baseline and ready for discharge. With that in mind, I was pretty excited for this visit because it seemed like it was going to be a fairly easy discharge, at least that was until my patient told me that she has discharged him multiple times and usually within a few days will have him back on her schedule. That immediately sparked my interest and made me nervous at the same time. At this point, I had a bunch of questions running through my head for instance, why is the patient being discharged if he isn’t ready? How is it that he is at baseline but still struggles once we discharge him? And lastly, is it okay to discharge him today, is he actually ready this time? I was at a loss and immediately became nervous for this discharge. When we arrived at the patient’s home and began our session, I checked his vitals and looked at his functional ability with ambulation, bed mobility, and asked if he was compliant with his HEP. Vitals were stable and the patient was able to perform all of the functional activities with ease so my CI and I decided that yes, the patient was ready for discharge. However, once we told the patient it was his discharge day his energy changed dramatically. This was very confusing to me because most patients are normally so excited to be discharged, but as we began filling out the appropriate paperwork for discharge everything started to become clear to me. This patient is a hypochondriac who believes in his head that he is in constant need of PT for all of his problems.
The patient was fearful of discharge and did not want to be done with PT because he believes that he still has severally problems that need to be addressed. While this answered all of my stirring questions, it did not relax my nerves much because I still wasn’t really sure how to convince this patient that he no longer needed PT. All that I could think of doing was patient education and allowing him to see for himself how he is doing. It ended up taking a lot of patient education to explain to him that he is at his baseline and no longer needs PT and even then, the patient still was not entirely convinced so we decided to have him perform a series of functionally activities on top of what he had already done to allow him to see how he is functioning for himself. Some of the functionally activities that we had him do included: SLS (eyes open and closed), ambulation outside in the grass, and the TUG test showing him the norms for his age and his scores which were just about the same. After all of these activities and a little more patient education, we were finally able to convince the patient that he was ready for discharge. While he still was not entirely enthused he was starting to understand that he is physically doing better than what he had thought. At the end of our visit we were finally able to successfully discharge him and told him to continue with his HEP and other activities similar to what we did with him to allow him to continue to work on getting even better than his baseline. This experience was definitely a first for me that I hadn’t really ever thought about until it happened but overall, I learned that sometimes a patient’s fear can play a huge impact in their treatment and discharge. In cases like this, it may take a little extra convincing to show a patient what they are capable of doing and not to be afraid of the activities but with the right education and allowing them to see for themselves, it is possible to change their mind. -
Chris Miller
So due to my wrist injury I have not been in ICE 2 since the first week. I have had some experience in my AT clinic rotation that has given me some solid learning opportunities this semester. In fact, during a football event that I was helping cover we had a defensive linemen get rolled up on and went down. He was in immediate pain and did not attempt to even get up. I was the first to reach him on the field and completed his on field evaluation which is very abbreviated just to make sure it is not a medical emergency. So I started by asking a few questions about where his pain was located which he stated, “my whole knee hurts and I felt a pop.” Unfortunately having seen the mechanism of an external valgus force I already had an idea of what I thought it could be. Just like we do in clinic I started to think of my differential diagnosis that could be possible. On this list I had ACL at the top of list along with MCL, Meniscus, Patellar Subluxation, and Fracture. First thing I did was see if he was able to still move his foot as he was unwilling to move his knee at all. I did a quick palpation for fracture screen of the patella, fibula and tibia. With no signs that led me to believe a fracture was present I was able to cross this off my list. I did a quick neurovascular screen and all this checked out as well. So my next step was to test out the ligaments of the knee. I did a lachman’s test first and thought felt some joint laxity compared to contralateral side. I was able to passively flex his knee so I wanted to do a anterior drawer as well since I feel a little more comfortable with this test. When completing this test on the first try I felt significant laxity and could feel a clunking sensation along with this. As we stated in class usually you have one or two tries to get it on the field. On my second time applying pressure with anterior drawer he already started to muscle guard and I really could not feel much laxity with this. With thinking his ACL was torn my goal was to get him to the sideline to test things further.
On the sideline he already started to experience some swelling and he was in a great deal of pain and was already emotionally affected by the results I found on the field. Honestly it was the hardest thing for me to tell him what I thought was going on. Of course I checked with my preceptor first. I remember telling him “I really hope that I am wrong but unfortunately I believe you may have tore your ACL. The good news is that there is no way for me to be 100 percent sure about this but we want you see our ortho.” At this point further testing was not really completed because I believed I found the pathology that occured. We continued to monitor and control pain for the rest of the event and had him ambulate with crutches until he was able to see the team orthopedic.
In that situation it is crazy just how much we actually know and our abilities to think when put in a stressful situation. Also something I don’t really think about much is the psychosocial aspect of communicating to patients what we found. It is harder than I thought it would be especially for an athlete in his senior year who just ended his season.
Also looking back I should have assessed more things at the time because when they went in for the operation they discovered he had also torn his MCL and his medial meniscus. I have not had much time treating this athlete because I switched sports but I do know he had all three repaired and was NWB for a few weeks and is just now getting to the point of weight bearing and is still working on ROM and light strengthening. I hope to check in with him soon and see how he is doing. Overall this was a great learning experience and confidence builder in my evaluation skills. It sucks that he suffered that injury but for me to come to the correct diagnosis in high stress situation of being on the field feels good.
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Mekayla Steckel
Post #2
This week in clinic, I had the opportunity to work with a patient who has a complete C5 spinal cord injury. He has been attending Ability Fitness Center for the last year and comes to the clinic three times per week. My CI asked me to work with him on the mat in high kneeling. Most of the patients I’ve been working with have had strokes, but I haven’t worked with many SCI pts, and especially one with a higher complete injury. So needless to say… I was very nervous. My CI walked me through transferring him out of his power WC onto the mat (max A). From there we worked on rolling into prone. This patient is able to use momentum to get his lower body turned over as long as you flex the knee opposite the side he’s rolling to. This patient has also been working on activating his abdominal and oblique muscles in order to help him roll all the way over. Once we got him into prone, it took 2 of us to safely get him into high kneeling. I stood behind him and had my hands holding up his upper body at his ribcage. My knees and shins were supporting his lower body. Once in this position, I had ALL of his weight. One wrong move, and the two of us were both falling to the mat. (It’s difficult to explain the significance of this encounter over writing and is something I hope all students have an opportunity to experience). So needless to say… again terrified, knowing I was the only thing keeping him up and every move I made mattered. However, I was able to make it work and we got to stay in that position for about 10 minutes. We worked on weight shifting side to side with activation of the glutes, while simultaneously addressing trunk control by firing the trunk musculature to get some active elongation. Let me tell you, it is HARD to hold someone’s weight up while facilitating weight shifting, while facilitating rib cage movement, all while in a squat because of how tall I am compared to the patient. Overall, this activity went fairly well being my very first time working with a SCI but my legs were shaking by the end of the ten minutes. I was able to appreciate how hard not only the patient was working but myself as well.
To conclude, this clinical experience has taught me again and again how much our body and hand placement matters!!! As well as timing. I have learned that the outcome or response I get from a patient is highly dependent on where/when my facilitation/cues are. I know I still need a lot of practice in this area but I know that the more patients I get to work with, the easier it will come. My plan is to force myself to practice these types of patient encounters. I need to practice with people of all shapes and sizes and learn how to best position my body and hands in order to facilitate the action I’m hoping to get from the patient. With the goal to come back to my CI and reassess my performance with that same patient as well as with other patients to see if I can adapt more instinctively. I am trying my best to try as many skills as I can while receiving feedback from my CI along with her expertise in the neuro scope of practice.
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Mekayla!
I can only imagine how scary the encounter must’ve been, considering that the patient had such a high complete injury. I have never worked with in individual with that diagnosis, until this yesterday, as my adult neuro patient has a C5 incomplete injury. With this patient population, every move matters, especially in the situation you were in, as the last thing we want is to drop the patient! Great application from class into your clinical setting, especially regarding having his use his momentum, addressing weight shifts, and active elongation. We will definitely have to chat about what you’ve done in clinic thus far with him and bounce off ideas as my group and I begin treating our patient for neuro. Great job!
-Daphne Batista
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Mekayla,
Wow, what an experience you had! I think the biggest problem I have is taking what we have learned in neuro and actually putting it to use in the clinic. I am in an OP setting, so I am not seeing a lot of stroke, SCI, and just general neurologic patients. It is awesome you get to take what we are learning and see it for yourself. Keep up the great work!
Cassie Rawa
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Daphne Batista: 2nd Reflection
The past few weeks at Ashby Ponds (SNF), I have been interacting with a 92 year old white male who is an absolute joy to work with. He is pleasantly confused and always seems eager to do physical therapy, even if he can’t remember me or my CI from session to session. Even though he’s typically one of the last patients of the day, he makes my day. Being in a SNF can be challenging as often times patients not only struggle with their physical limitations, but also battle with either a cognitive impairment, or an emotional aspect. After interacting with so many patients who have such a negative outlook on life and physical therapy, he is a breath of fresh air.
His PMH includes a left THA from years ago that left him with residual weakness. Unfortunately his weakness has deteriorated over the past few years that now he is living in the assisted living facility within Ashby Ponds. As a result, this has restricted his community ambulation. During gait training, he ambulates with a front wheel walker down a hallway for 150+ feet. Minimal verbal cues are provided in order for him to maintain upright posture in order to see where he’s going and reduce fall risk. He also requires additional minimal verbal cueing to modify his base of support in order to optimize his center of mass, as he has the habit of shifting his weight to his stronger side in order to offload his affected side. Due to his left sided weakness, he has developed compensations over the years in order to ambulate in a step-to pattern.
Noticing his weakness, I led him through a series of lower extremity strengthening exercises in order to help him be able to ambulate with a more normalized gait pattern. By this point, he mentioned that he was tired and I noticed that he was red in the face. I asked him if he was breathing and he sheepishly responded no he wasn’t because he was so focused on being able to move his feet. I educated him that it’s important to breathe as muscles need oxygen in order to do their job efficiently. With that piece of information, it reminded him of an exercise his primary care physician showed him, pursed lip breathing. With this technique he showed me how to breathe in with his nose, and then slowly exhale out through his mouth. I asked him to keep that in mind throughout the remainder of the session as we proceeded to do strengthening.
My CI instructed me to place two pound weights around his ankle as he did his exercises. however I noticed that he was having trouble with marching in place (hip flexion) on his involved side. He was grimacing through the exercise and turning red, so I immediately asked him to stop and do his breathing technique. I reassessed with my CI and asked her if it was appropriate to remove the weight on his involved side, to which she said yes. Once the weights were removed, he still had trouble getting that hip to actively flex. At this point I provided him with additional tactile cue and wrapped my gait belt around his thigh and helped guide him during hip flexion. I asked him why he didn’t verbally tell me that he was having trouble, and he mentioned that due to his prior military background he knows not to give up. While I appreciated the gesture, I explained to him that he needs to speak up because he may actually be doing more harm than good.
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Cassie Rawa: 2nd reflection
In clinic this past week, I was able to help treat a patient with right patella tendinopathy. The patient was a young, sophomore volley ball player that has been dealing with the pain for a few months. Therefore, I concluded from this information she was in the chronic stage of tendinopathy. This was the first time I have seen her, so I was unaware of her past exercises of PT sessions. Although, knowing her stage was enough for me to hypothesize different exercises or treatments to give her. After giving her a deep tissue friction massage, my CI and I decided to progressively load her tendon. Before we did that, we wanted to observe her squat. Her bilateral squat concluded that she had dynamic valgus. Even though we have not gone over the ankle and foot unit in depth yet, I know enough that over pronation of the foot can contribute to knee pain and can accompany dynamic valgus. Sure enough, as soon as the patient took off her shoes and performed a squat, her feet were pronated. By assessing her proximal segment and distal segment, we were able to address many aspects of this patient to try and improve her pain.
First, we decided to progressively load her tendon. The patient was instructed to perform single leg squats while picking up and putting down a kettle bell. The kettle bell would start on the ground and the patient would perform a single leg squat to pick up the kettle bell then squat to pick it back down. As far as addressing the proximal segment, I was instructed to give the patient her hip exercises. Since she is a high-level athlete, I decided to give her side planks with resisted hip abduction, yoga ball bridges with resisted hip abduction, side-walks, and resisted clamshells. I decided to dose each exercise around 2 to 3 sets with 20 repetitions for each. During each exercise I provided tactile cues if I believed any compensation was going on, such as making sure her hips were aligned appropriately. The patient reported no knee pain during each exercise.
Since we also wanted to address her distal segment, my CI decided to give my patient the option of wearing an orthotic. The orthotic provided more supination of the subtalar joint facilitating away from her normal pronation. The patient said the orthotic felt “weird” when she put them on first, but she was experiencing no knee pain. It was really cool putting everything I have learned thus far about the lower extremity into action. I have learned most knee pain stems from elsewhere and this case provided me that evidence to back it up. -
Lindsey Rodriguez
Reflection Post #2
In clinic the other day we had a 56 y/o male patient who was s/p ORIF of his great toe. I am currently in a SNF and this patient was very different compared to the patients we typically see. He was alert and oriented, as well as independent with pretty much all of the activities we had him perform, only requiring minimal verbal cues to maintain his non-weight bearing status. This was the first time I had worked with this patient. When I read his chart, I was confused as to why he was in a SNF because he is much younger than our other patients. As I read further, I saw that he has a long history of alcohol abuse. It turns out he injured himself while he was intoxicated and woke up with his toe completely deformed and the bone sticky out. He had no recollection of how he injured himself and was also in the process of healing from a previous injury to that same foot a few months prior that occurred during another blackout episode. This patient had been in the SNF for about 3 weeks and seemed to have met all of his goal but was not in the process of discharge planning. I noticed that he had worked with a different therapist for almost every session. I was confused by why he was still in therapy since he was independent with bed mobility, wheelchair mobility/management, and supervision/independent for transfers and gait. I think that it was more because he did not have a discharge plan. He spoke about trying to go to rehab for his alcoholism but didn’t have a set plan yet. This patient was very open about his alcohol problem with my CI and I and expressed how he really wanted to get better and get his life together. It was interesting working with him because he was at a much higher level of function than our typical patients, however he was quite impulsive and sometimes did not maintain his non-weight bearing status when going from sit to stand. He expressed that he was concerned that his foot wasn’t healing and that he could see the atrophy in his leg due to being immobilized. We were able to really challenge him with higher level exercises to help prevent further complications. We had him working in the parallel bars and doing single leg squats with his uninvolved leg. We also added an ankle weight to his affected leg had him work on hip flexion, hip abduction, and hip extension exercises. After our session my CI and I had a conversation about what to do moving forward with this patient. We were both concerned for him to go home because of the high possibility of relapse, but we also didn’t feel that he was a good candidate for therapy in the SNF. My CI decided to put in a 5 day until discharge for this patient and plans to speak with him in more detail next session about his discharge plan. This was a tricky case because we want what is best for the patient, but it didn’t seem like he was in the best setting. At the same time, this situation is better for him than him being home and going to outpatient PT because he has poor self-control with alcohol. I really hope that he is able to get into a rehab program and better manage his alcoholism. -
John Knowlton
Reflection Post 2Last week in clinic my CI and I were treating a 67 y.o WF whose c/o was back pain. My CI had been treating this patient for a while now and when asked how she had been doing she said her back is fine, but now she is having sharp hip pain and lateral knee pain with standing, walking, getting up from chairs, and other household chores. Due to the patient’s demographics and subjective reports I immediately thought this sounds like GTPS. She reported that her pain is in her lateral hip, then her knee starts hurting, then her ankle starts to hurt. From observing this patient, I noticed she seemed to stand in a valgus position and also was pronated at the ankle. To me this sounded like a kinetic chain issue stemming from the hip. I palpated the patients hip and she was tender on the superior aspect of the greater trochanter. When palpating the knee, she was tender on the lateral joint line. My CI started to explain to the patient how he thought she was dealing with greater trochanter bursitis. It felt good to be familiar with the joint we were working on, but I disagreed with my CI initial diagnosis. He asked me to roll out the patient’s lateral thigh and IT band. I asked my CI if he thought this could be more of a glute med tendinopathy. I discussed with him about the research we had been given and how more often than not this was the issue. I was concerned that if this was a compressive tendinopathy rolling out the patient’s leg could actually increase the patient’s symptoms. My CI thought that made sense and asked me what I thought our next step should be. I said that if this was a glute med tendinopathy she would likely benefit from progressive loading. Due to the patient’s presentation and irritability I recommended we start with isometrics into abduction and some clamshells. The patient tolerated these exercises well and after that we gave her a HEP. I have not seen this patient since, but I am hoping to hear she is doing better. I think we could have performed a more in depth objective examination but due to time we did not. Next time something like this happens I will voice my opinion sooner, so we can have more time to discuss what our next step should be.
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Kayla Sweeney
Reflection Post 2Because I am in early intervention, a lot of what we are doing is looking at children and looking for if they have a 25% delay in one or more area of development to see if they qualify for therapy. As a PT we are mostly looking at fine motor and gross motor function however we go through these evaluations with either a speech therapist or an educator who look at things like language both receptive and expressive. Together we also look at self-help and cognitive skills which are a combination of both language and motor skills. We don’t always see children with motor delays but even when we see a child with a speech delay we still look at their motor skills.
In each evaluation we get a subjective history and then we learn about the child’s skills through play. Afterwards, we document everything we see and then share it with the family. This week in clinic my CI challenged me to be more actively involved in the process and she had me write and present one of the sections to the parents. In previous weeks, I have just helped her write it and she presents it. I was very nervous to do this because the child was coming for a speech delay, yet he walked very heavy and had very low tone. His coordination was also a little off too. My CI read my section, added a few things and told me it was great to present. When it was my turn, I got very nervous because I knew it was the first time the mother was going to be hearing some of these things about his motor skills. Luckily, she took it very well and was very receptive to the information. She asked a lot of questions and together my CI and I were able to come up with some activities to get him a little stronger to help improve his gait. -
Kyle Kohnen,
I had the opportunity to work with a patient 3 months post patellar tendon rupture/repair. I was feeling confident about working with him because my CI had shown me the mobilizations the week prior. I also felt a little bit better that the knee anatomy and biomechanics information was so fresh in my head due to MSK and TherEx courses. The patient was lacking ROM near end-range knee flexion. He didn’t have any pain. I treated with tibial posterior glide at end range flexion and also patellar inferior glide. Technique wise, I did a great job with the interventions, but I forgot the most important thing: reassess to see if intervention worked. Luckily, my CI reminded me to reassess before the patient got off the table. I feel like little slip-ups like this are due to me overanalyzing what task I am doing rather than thinking big-picture (trying to increase flexion so reassess flexion!). I believe this is something that will improve with more clinical experience, practice, and confidence.
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Andrea Choo responding to Kyle
Kyle,
That’s awesome that you were able to apply the information we’re learning about the knee to a patient in clinic! Sometimes I also get caught up overanalyzing the specifics of a task and find myself forgetting simple things like re-assessing as well. As I practice and become more confident in my skills, I definitely feel more comfortable and everything seems to flow more seamlessly. Since your glides helped improve the patient’s flexion did you teach the patient a self-mobilization or implement a MWM? If so, how did the patient respond?
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John Orchard-Hays
This week I worked with an individual who had surgery to repair his patellar tendons in both knees. He was already 8 weeks into his rehabilitation and at this point the main focus of his therapy was to regain overall strength/function, especially in the quads that were significantly atrophied. I could see that he had overall LE weakness, likely due to healing restrictions post surgery and from decreased activity before. The pt was ex-military and now worked a typical desk job in sales. He ruptured his patellar tendons while running down a mountain. I could tell that his major frustration was his reduced level of activity. I knew that this would be a lengthy recovery in terms of getting back to his high level of function, but I was sure to let him know that he had a good prognosis for eventually being able to return to or near his prior level of function. I based this off of his medical history, motivation, surgical report, and knowledge of tissue healing. However, even beyond addressing the healing tissue in the knee, I was sure to address weakness in hip external rotators, hamstrings and ankle stabilizers in addition to his atrophied quads. He had a high level of understanding and was appreciative of how these seemingly unrelated exercises were going to help him in the long run, both in regards to function and in prevention of possible injury/complications down the road.-
In response to John Orchard-Hays:
Wow bilaterally patellar tendon ruptures that sounds super painful! Great job comforting the patient and letting him know that his PLOF is definitely within arms reach. I can imagine that his quads were very atrophied as you mentioned due to muscular disuse. Awesome job relating his overall PLOF and current level of function to prognosis, and being realistic about it possibly being a lengthy recovery. I know he will receive great care and I hope he does not run down any more mountains soon in the near future. Great post!
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Ahmad Rahman
Last week in clinic I saw a patient who was post surgery for a full thickness rotator cuff tear. He was actually one of the first patients I saw at my location this semester, and I remember his disposition from that visit about 6 weeks ago until now. At that point he was advised by his doctor to avoid all active movement until 12 weeks post surgery, being 6 weeks out with his arm was in a sling. He took it out occasionally and was able to do pendelums but not much else. We checked his grip strength with a dynamometer and were surprised to find out it was actually quite strong for his current level of function. His objective assessment was fine, and the protocol was being followed to a tee, but the patient’s attitude about PT was less than stellar. He was a mechanic before the injury and was out of work, so not being able to be functional with his arms and hands was taking a toll on his motivation. He was confined to being at home for most of the day, and had a lot of trouble with ADLs and relied on his wife extensively for even simple things like getting dressed. After telling the patient he would not be able to actively use his shoulder for ten weeks post op per protocol, we sent him off with his hep and activity modifications to make ADLs easier. A few weeks later he came back springy and full of life proclaiming that the past week had been amazing. He was spending less and less time in the sling and had regained some flexion motion, although straight abduction was still very hard for him. We were able to do some active ER exercises, with a band while standing and sidelying as well. He was eager to proceed with the session, and it was amazing the difference his mood made to the progress we saw in an hour.
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Andrea Choo
In the past couple of weeks, I haven’t really seen any patients with a lower extremity pathology. The majority of the patient’s I’ve worked with have been infants with Torticollis or gross motor delay and children with incontinence/pelvic floor dysfunction. The only patient I’ve seen recently with a lower quarter impairment, was a 15 month old girl who we evaluated for gross motor delay secondary to spastic diplegia. My CI had treated her previously, however, the family had stopped showing up because the commute was too long and they weren’t able to fit it in their schedule. Since my CI last saw her, the patient had undergone eye surgery to correct her strabismus. Now, the parents were bringing her back because she was still unable to walk on her own and they didn’t want her to fall even further behind.
As we started to evaluate the patient, it was difficult to get her to focus on the tasks that we wanted her to do. We tried getting her attention by using toys, however, the patient was completely content doing her own thing. This forced us to rely on our observations to gather information as she played around the room. For the most part, the patient mostly relied on crawling to move around the room. However, when we finally got her in standing, the patient was only able to maintain an independent standing posture for 20 seconds with an increased base of support in a toed-out position and forward trunk lean. After about 20 seconds, the patient would go into trunk flexion and put her hands on the ground to help stabilize herself, then sit down on the floor. Additionally, although the mom reported that the patient was independently cruising at home, the patient did not initiate any cruising during our session. Towards the end, the mom was able to hold the patient’s hands and encourage the patient to take 3 steps before she sat down. During those 3 steps, it was apparent that the patient had decreased balance strategies. We tried our best to assess the patient’s ROM, however she kept squirming and required 2 people to distract her and actually assess ROM. There was a slight increase in tone in her L LE compared to her R, however, my CI deemed that it was not significant enough to severely impair her function at this point.
Overall, we weren’t able to accomplish as much as we would’ve liked to during our initial evaluation. We were greatly limited by the patient’s lack of interest and temperament throughout our session. I think that this is a good example of how sessions don’t always go as planned and how it is often dictated by the patient, especially in pediatrics. Even though we weren’t able to accomplish everything that we wanted to, we were able to gain some valuable information and identify impairments to address in our future sessions. Although we are not able to change the patient’s spasticity, we can help her control it and find ways to increase her functional capacity. Additionally, balance is a big thing that we can work on in the upcoming weeks. I am suspecting that balance and lack of stability are the big limiting factors that are impeding the patient’s motor function. It was evident that as soon as the patient began to feel unstable, she would put her hands on the ground to stabilize herself, sit down, then revert back to crawling. In the upcoming weeks, I have a feeling my CI and I are going to have to be creative in order to engage our patient, in order to see any improvements.
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Andrea,
Thanks for sharing! It sounds like this was quite a difficult evaluation. I am sure it was frustrating that the patient was so easily distracted during the session, but great job sticking with it and gaining some valuable information that will help you move forward with the patient’s impairments. I agree that you will likely have to come up with some creative ways to keep the patient engaged during the session. Have you thought of any ways you might do so? Keep up the good work!
Patrick Dumais
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Patrick Dumais
Post 2During my clinical experience this semester at a SNF, my CI and I have not had many patients who were able to perform high-level exercises. Since this has seemed to be the norm at the SNF, I began to expect that most patients would be unable to complete more advanced exercises. This was the case until I had the opportunity to work with a patient who had some impressive balance skills. The patient and I had just finished gait training. My CI then asked me to work on some balance exercises with him. My CI informed me that our patient had done balance training on a bosu ball last week, and she wanted him to try it again. I was a bit surprised by this, but I went ahead and set up the exercise. I made sure the gait belt was snug on the patient, and we went ahead and began balancing on the bosu ball with a railing in front for extra support. To my surprise, not only was the patient able to complete a full 30 seconds on the bosu ball, but he did so with ease. After a quick rest break, we tried another round with similar results. To make it more challenging I had the patient close his eyes while on the bosu ball, and again he was able to complete the task successfully. This patient encounter was a great reminder to me that no matter what setting you are in, you should never expect less of a patient based on experiences with patients who had similar impairments. Each patient is unique in their abilities and may be capable of more than you expect. I will be sure to keep this in mind next time I treat a patient at the SNF.
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Justin Geisler
Last week at clinic a patient came with L hip flexion pain and weak BLE glute med/max weakness with trendelenburg during gait. MOI involved a MVA, patient received surgery and had screws and a plate put in at lower thoracic and upper lumbar levels. Patient reporting hip pain to feel “like an impingement” during flexion in supine and with gait activities. MY CI let my take the ropes for this individual and I first assessed his hip mobility PAM/PPMs, decreased mobility was found due to soft tissue and capsular restrictions. I continued to treat the patient performing LLE long axis distraction, hip lateral glides, inferior and posterior glides grade 3, 3 sets of 30 second bursts. Combined with glute/piriformis and TFL stretches patient experienced immediate relief of pain. I then did STM of the L hip deep external rotators around greater trochanter (PGOGOQs) to decrease tightness. MY CI then suggested me to choose 3 glute max/med exercises to do to improve his decreased strength. I went with BLE prone hip extension with knee flexed for glute max 3 x 10, standing hip abduction 3 x 10 and side lying clams with TB 3 x 15. I also assessed his SLS bilaterally after ther ex his hip drop decreased due to improved firing of his glutes. I could have tested with a flamingo test to check for glute inhibition prior but likely patient had both decreased strength and inhibition of glute med and over firing of TFL. Overall this was a great experience for me to practice my manual skills combined with ther ex, and was able to have a positive response from the patient with decreased reports of pain and him being very thankful for my work.
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Alex Argentieri
This week in clinic I was able to continue treating a patient for knee OA. She had been coming to therapy for a few weeks, and while her strength and endurance has improved, she is still reporting pain with walking and ascending stairs. While this was expected early in her treatment program, my CI was concerned that pain was still a major concern of hers. To address this issue, my CI decided that it was best to get the patient walking without her cane to prove she could do it. While the patient was timid to do this at first, she soon found herself walking 600 feet with supervision and no increase in pain. Soon the patient’s entire mentality about the treatment session changed and she became more determined to work on stairs and increase her endurance. Additionally, she trusted herself to be more mobile without the use of her cane. She was sent home that day with a goal to practice walking around her house without the use of the cane so that she can become more independent. While this may seem like little gains at the moment, it could be a huge impact on the rest of her treatment session as she is more trusting of her current condition and less fearful of her diagnosis.
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Brianna Virzi
This week my CI and I had an initial evaluation for low back pain/scoliosis. When the patient walked in, it was clear there were many complicating factors within this case. She used a walking stick for support, had significant lateral trunk shift to the right and her scoliosis was evident. As we began to interview the patient, she revealed that she has had a left knee replacement, left ankle fusion, and last year she also had the right ankle fused. After this right ankle fusion, she was non-weight bearing for 6 months. My CI and I were shocked at this length of time in which she reported minimal activity. As a result, she has had significant weight gain and difficulty returning to functional activities. Through a McKenzie examination, we established that she likely has a derangement classification. We gave her prone and standing extension exercises to perform at home since this centralized her symptoms during the examination. Due to the many complications noted, my CI had a request from the patient that I found interesting and have not seen done with other patients. He asked that when she gets home, she writes down 3 things she would like to be able to do 3 years down the line. When we ask patients about their goals, they typically respond with what they want to get back to as soon as possible (sports, ADLs, household chores, etc). However, for this patient, who still has ankle restrictions and now an onset of worsening back pain, it may be harder for her to realistically reach these goals in the near future. I felt this was a thoughtful technique to use with this patient because it keeps her goals reasonable yet allows us to begin working towards them to improve her quality of life. I hope she finds this exercise beneficial and I am interested to see her goals next week.
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Lori Yeaman – Reflection #2
My CI and I have been working with a patient with bilateral knee pain to decrease pain, increase knee ROM, and increase hip strength. The pt had imaging done that showed chondral changes. Seated tibiofemoral distractions relieve the patient’s symptoms, and we have been working on anterior/posterior TF mobilizations and patellar mobilizations to address the lack of ROM, based on the limitations found in the initial evaluation. The patient gives me great feedback when I am doing manual therapy by describing how my manual therapy compares to my CI, which has allowed me to continue to improve my skills. We have been working on hip strengthening exercises, including mini squats, step ups, hip abduction and extension, etc. to ultimately help the pt ascend/descend stairs with no pain. The patient has made great progress in hip abduction and extension strength, as well as increased knee flexion ROM. On progress-note day, it was exciting to see the patient pleased with his improvement and he reported that my CI and I have the “magic touch.” This feedback made me realize that not only is the patient improving objectively, but he is feeling the benefits from physical therapy.
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Lori,
This sounds like a great experience! I think it’s awesome that the patient is able to give you good feedback on your manual skills and that you’re seeing improvements in your skills because of this feedback. It’s also awesome when we see a patient make progress and it sounds like both you and your CI have developed a great rapport with this patient. Great job!
Sarah Roderick
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Sarah Roderick
My CI and I had the opportunity to work with a patient who had severe dementia and has been in the hospital due to an exacerbation of pre-existing cardiac and pulmonary conditions. The patient was consistently very resistant towards therapy. My CI and I were using every trick or idea we had to attempt to get the patient to participate in therapy with us. I was initially nervous in how best to communicate with this patient and was afraid my CI and I were not going to be able to get her to participate. The hospital currently had decorations for Halloween and when my CI and I started asking her about her favorite candy, we asked her if she wanted to see the decorations and the pumpkin creation outside of her room. She smiled and agreed, as long as we would tuck her back into bed. I thought it was great we were able to get her to participate in therapy and felt very accomplished given how difficult it initially was. This was a great experience for me as I was really able to work on providing less instructions and making our session of walking approximately 30 feet, much simpler for this patient, given their cognitive status. In the future, I will continue to remember how important it is for this patient population to receive less verbal instruction and find the appropriate balance of cueing to maintain patient safety.
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MJ Erksine
My CI in the SNF recently had me lead the entirety of a patient’s treatment. The pt.’s goal was to walk with her cane. Since her last fall, she had progressed from the w/c to a walker so far. When I enquired as to her recent exercises, they were all seated strengthening exercises or walking with the walker. To assess her abilities I wanted her to do SLS for 30 sec but didn’t know yet if that was safe. So while guarding her I had her attempt to stand there without holding onto the walker for 1 minute. She was curious, willing, and completely able to do it to her surprise. Then I had her do weight shifts with the same parameters. She said no one had had her do either, but she could see how it could be a basis for walking. Then I had her do 30 sec SLS on each foot. This she did holding onto the walker. When trying to figure out her available hip motion after seeing Trendelenburg while on the left foot, I learned she had 2 hip replacements. I am constantly amazed at the information I am not able to easily find in the chart nor able to easily attain from the patient. I agreed with her that this probably had something to do with how she stood and moved her hips. :) I’m getting used to being in this kind of situation but I still have to remember how much info can be left out when my CI says I get to lead treatment. At least I made sure her vitals were good.
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In response to MJ
I have not yet had the opportunity to work in a SNF, so these types of posts are always very interesting to me! Taking the helms and leading an entire treatment session is always very intimidating, so good job on going in confident, asking the right questions, and coming up with your own interventions to treat her walking ability. It must have been amazing to see the results of your own clinical application and thinking manifest itself in a patient in front of your own eyes. I agree that sometimes information not being readily available when you would imagine it would is frustrating, but you seemed to have handled that well. Props, and keep sharing more!Ahmad Rahman
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Marielle Giardini
Last week in clinic, we saw a 15 y.o. male who had the dx of chronic hip flexor tendinopathy. This was only his second visit to PT and my CI did not initially evaluate him. We started treatment off with 8 minutes on the recumbent bike and then moved into some more ther ex. We started him with streamboats with a theraband and we noticed he had excessive trunk movement during this exercise. We stopped the patient during the exercise to instruct him to not compensate with the trunk movement, however, he was not able to perform the exercise properly so we had him stop. My CI explained that the excessive trunk movement was indicative of a weak core. Because of that we wanted to see how he did with a plank, which he demonstrated improper alignment. For me, it was interesting to see another way that the whole kinetic chain comes together for proper biomechanics.
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Melissa Jankus – Reflection #2
This week in clinic, I was able to do a knee evaluation on a patient who came in with a script that said “bilateral PFPS and left plantar fasciitis”. This patient reported anterior knee pain (more in the left than in the right) that started approximately 2 years ago, due to a week long training exercise with excessive running. He reported that the pain was intermittent and sharp at times, and was aggravated with stairs, running and squatting. He reported that his pain only came about after a few minutes of activity (for example: walking up stairs are fine for the first few flights, and then towards the end, his knee would start to hurt). He also reported pain in his left heel with prolonged sitting, and said that if he sat for a long time, he would limp for the first 8-9 steps when he got up, until it “loosened up”. During functional testing, we observed pes planus, worse in the left than the right, as well as some dynamic valgus at the knee. His symptoms were not provoked with the functional tests. His biomechanical exam was unremarkable, with ROM and strength being within normal limits. The patellar tendon was not tender and he did not have pain with resisted knee extension. We also screened the ankle and the hip. We found that the patient’s glute med was relatively weak and that the patient’s gastroc was tight. We did manual therapy to help stretch and release the gastroc and gave stretches for the patient to start on. This case was a great learning experience, especially since we just finished the knee unit and I was able to put my knowledge of the knee together to help figure out what to do for this patient.
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Katie Woelfel replying to Melissa,
What an awesome case to have after finishing up the knee unit. That was great you could look proximally and distally to put the puzzle pieces together in order to better understand what the patient needed. I wonder if the patient would benefit from intrinsic foot strengthening giving his present pes planus. Can’t wait to hear more about his progress and response to the manual given.
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Amy Korcsmaros:
Recently, I was able to work with a patient who at the age of two, got meningitis. Now this individual is 30, but has been in the hospital and working with my CI for over six months. This prolonged stay is due to discharge complications and no facility willing to take this patient with a large amount of seizure activity. In prior months, my PT has worked with him on ambulation, as many other professions are not willing to walk him with a combative history. As my PT mentioned to me, ambulation without a reason for ambulation is not skilled PT. If he is only getting the 20 minutes of walking every couple of days, this brings the question of how can we keep seeing this patient if the interventions are not skilled?
I think this is often a question others may have when working with a patient that benefits from our interventions, but does not necessarily need skilled therapy. We know that it is beneficial for them both physically and mentally, but yet insurance or other parties say the patient no longer needs us. This makes me question, what can we do as a profession in order to be able to keep working with patients such as this patient in the acute care setting for over six months. Next time, I will suggest trying to implement more of a skill to the ambulation training. Unfortunately, he is very unwilling to try new activities, and this has been where he often becomes combative. I will discuss further with my CI different ways to try and “trick” him into doing functional gait activities, without him being aware of completing these other tasks. Throughout this patient encounter, I felt moments of frustration because everything I wanted to do, I was unable to due to his inability to cooperate and conduct the skilled interventions without getting angry. Hopefully, with more and more patient buy-in, we will be able to enhance his ability to conduct skilled interventions, therefore assisting his potential for discharge. -
Laura responding to Amy:
You post was very thought provoking! First of all, it must be frustrating for the patient to be stuck in the hospital for such an extended period of time due to other facilities not wanting to take complex patients.In clinic, I was able to see the other side of this. I sat in on a meeting where the staff of the SNF were deciding which patients would be admitted as residents from the hospital. There were two rooms available in the SNF and five potential patients that wanted to live there. The SNF did not take any of these patients due to them being too complex and requiring too many resources.
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Laura D’Costa:
This week at the SNF I got to attend a home visit to see if a patient post total hip replacement was safe to return home. The patient was able to navigate her home with little difficulty and did not need any additional devices to make her home more accessible. The medical professionals as well as the patient were surprised with how well she was able to safely perform ADLs within her home. Towards the end of the visit, the patient expressed the mixed emotions that she was experiencing. She was excited to return home but nervous to live by herself and not have the resources she currently has in the SNF. My CI recommended resources the patient can utilize including services that provide someone to assist you in your house or go with you into the community. This noticeably lessened the patient’s fear of returning home. This interaction made me realize the importance of a PT’s job in providing our patients with appropriate resources that will help them to increase their function. I will be able to transfer this to my first full-time clinical experience in home health by informing patients about resources that they might not be aware of that can help increase their quality of life. -
Azita
Recently I worked a 32 year old female patient who was in for pre-op ACL on her R, which she has previously had an ACL reconstruction on before as well. She has also had an ACL reconstruction on her L. Immediately my mind went to the research in terms of the fact that those who have a previous injury to an ACL are at increased risk of ipsilateral re-injury or contralateral injury, BOTH of which she has experienced at this point. Then I started to think about the research indicating that she now has a 3 fold increase in OA surgical knee vs control. This all almost frustrated me to a certain extend because as we’ve talked about there ARE modifiable risk factors that can be addressed. All of this to me just made me think that somewhere along the way, her coaches (she was an athlete), PTs, or other people misses these factors (weak hip ABD/ERs, upright postures, imbalance of Q:H, fatigue, pronation, etc.). From here on out the PT is focusing on hamstring strengthening, regaining ROM, reducing swelling, and then we will be seeing her again post-op!
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Emily responding to Azita:
I bet that must have been frustrating to know that this could have potentially been prevented! But it must make you feel good to know that we now have the knowledge to not make that mistake as clinicians. It just shows how important preventative programs are and how much they have progressed and become more popular in the last few years. I wonder if this woman ever had a chance to try coping, or if she immediately had the surgery done without trying the conservative management the first time.
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Emily Blum:
Last week was the first time working with a patient with a spinal cord injury. She had a C5 incomplete injury. The first day I saw her, she was in a lot of pain from spasticity and very emotional about everything that had occurred. She was having a difficult time moving her neck or arms, and grading movement was especially difficult. This week (1 week later) I saw her again, and I was shocked. We had an hour and a half to work with her, and when I walked into her room the first thing I noticed was movement from under her sheets. Her legs were getting quadriceps contractions, and her core was even starting to have some tone again! She was able to sit edge of bed with mod A (using biceps to stabilize herself) for 3 x 4 minutes each. Then, she was able to do 10 crunches in bed (mod A to sitting, min A eccentric control down). I was absolutely shocked at how much function she had gained in 1 week. We stopped the session multiple times to address the psychosocial factors that come with this injury as well, such as not wanting to be a burden on her family. I thought that I would have been a lot more uncomfortable discussing things like that, but it felt really good to talk to the patient about how much progress she has made. She was denying any progress, but to be able to show her by having her do certain things for increased amount of time really helped her mentally. This experience taught me to never doubt how much a patient can do and never say never to a patient about what they’re going to be able to do and not able to do. It is good to be realistic but patients will always surprise us.
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Christie Freund
In clinic I saw a 45 year old male who was having painful swelling in his left knee. My CI had been treating him following meniscal repair surgery in July, but he was doing better and coming less frequently as a result. My CI worked on lymphatic drainage of the entire left side of the patient’s body beginning with his chest and working all the way down to his ankle. This was the first lymphedema technique I had ever seen in clinic, so it was very interesting to watch and get to try a little myself. I was also very impressed with my CI’s patient education about the technique he was performing. He described it as clearing an accident off the highway so that traffic could start moving again, only the car accident was fluid. It made me think more about how we can use analogies to help patients understand what is going on with their body and the rationale behind the treatment techniques we select for them. While my CI was working on the patient, I asked him about the history of his meniscal injury, surgery, and recovery. It was really interesting to see hear about it from an actual patient instead of a made-up case scenario. I had trouble comprehending how the patient could not know whether he had his meniscus repaired or taken out. As PTs, I am learning that we should assume that our patients do not know anything about their problem from their physician or surgeon. We should explain things from the very beginning to make sure that our patients can be well-informed about their condition in a way that makes sense to them without alarming them. My other takeaway from this experience was that lymph drainage techniques can be used for more patients than I previously thought. I only ever thought about them for patients who had undergone lymph node removal or had swelling in the legs. This patient had swelling that was localized to the knee, but he still benefited from this technique. I will now think about this as a potential tool for reducing swelling at peripheral joints as well.
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Christie responding to Emily:
That sounds like a really powerful experience! How old was the patient and how did she sustain the spinal cord injury? I am sure that type of injury would be extremely challenging for anyone, but the exact psychosocial factors in play would probably be different for people of different ages. I love that you were able to address the patient’s physical and emotional needs throughout your session. The longer treatment sessions in the in-patient rehab setting seem really nice for making sure you have enough time to address everything that the patient needs. I would be very curious to see how regaining function helps the patient’s morale, especially when she reaches a plateau. You are definitely right that we should never underestimate people.
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Emily Blum
This semester at the inpatient rehab hospital I had my rotation in, I had the opportunity to treat a patient who had Multiple Sclerosis (hospitalized d/t infection). Thankfully, the session was first thing in the morning, so he was not too fatigued yet. We also made sure to have the session inside in the air conditioning so that he did not get too warm. The patient was very verbal about wanting to push himself and do as much physical activity as possible so that he would be less of a burden on his wife and kids. We had to educate him on while his motivation is great, it is important to not over-exert himself because that could set him back even further by having a more extreme exacerbation of symptoms. While observing the patient ambulate with his walker, I noticed he had foot drop. This made it more difficult to ambulate for him and to ascend and descend steps. This patient required moderate verbal cues to clear objects on the ground and steps enough so that he would not fall. The patient also lacked dorsiflexion bilaterally while I assessed his active and passive ROM of his feet. My CI and I talked about the potential reasons for this being true. Although I was not able to assess PAMs, this patient could have had a muscle length issue with gastroc/soleus complex (potentially due to recent increase immobility). The patient could also have a hypomobile posterior talocrural glide or posterior distal tibiofibular joint. It would also be good to assess the proximal tibiofibular joint (potential limitation in anterior glide), and calcaneocuboid joint (potentially limited dorsal glide), which could all possibly be limiting DF. This experience was great for me because I was able to make a musculoskeletal connection in a neuro setting. I had to opportunity to remind myself that all of these patients with neurological disorders do still have a musculoskeletal system and that they can benefit from manual therapy and therapeutic exercise to target these limitations just as much as they need to be able transfer, do bed mobility and walk safely. It was a great experience for me to put all of physical therapy together.
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Bailey Long
My current ICE placement with my CI has been a very new experience for me this semester. We come from very different styles of learning and perspectives when addressing patient care. My CI has over 40 years of physical therapy experience, where I am still really green when it comes to patient care. With his extensive experience in patient care, he relies less on new evidence. This is very different to the style of evidenced based therapy that is emphasized in Shenandoah University’s DPT program. In addition, my past CIs and current teachers all have pushed me to find answers in recent research, since I don’t have experience to fall back. Working with my current CI has been a beneficial experience with improving my interpersonal relationships. There have been a few times where my CI and I have “butt heads” over the best treatment approach for certain patients. I have taken these situations as opportunities to self-reflect on better ways to present new research and be better with “rolling with resistance” with patients and other potential colleagues that may be reluctant to hear new research.
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Alex Gett response to Bailey Long,
You have the best of both worlds, as you are learning the newest trends in PT where your CI has most likely seen more that I could forget. I encourage you to keep challenging yourself to lean on your CI to learn from their experience while also integrating what we are currently learning. As future PT’s, we must understand that there is more than one way to approach the job. If we can take pieces of info from everyone we come across, while integrating our own personalities and strengths, we will set ourselves up to be well-rounded clinicians.
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Sarah Strong
I am currently learning in the inpatient acute care setting, where we typically see TKA patients on the day of surgery to get them walking and assess their knee ROM. Due to the nerve blocks and otherwise anesthesia, these patients are in a knee immobilizer until they are determined safe to walk without any knee buckling, as my CI explained to me. There are a few aspects of these patients’ care that I have been especially curious about recently.
I understand the evidence for pre-habilitation is strong, suggesting that patients who received pre-habilitation before surgery have better outcomes than patients who did not complete any organized exercise program prior to surgery. My CI and I discussed this and unfortunately, it seems insurance does not typically reimburse for pre-habilitation treatment. I would be very interested to learn more about the dynamics that come in to play with advocating for access to this type of service, as the evidence is described as strong with regards to outcomes.
The patients that receive TKA surgery at the facility where I am in clinic undergo “joint camp” which is an educational course for about an hour or so a few weeks before their scheduled surgery. At joint camp, patients learn about the process of surgery, what to expect the day of, recommendations for home modification, and some exercises that they will be asked to do during their stay in the hospital. Because these patients are post-surgical and often still experiencing some lingering effects of anesthesia, we have kept these exercises very simple to ankle pumps, quad sets, and gluteus squeezes.
I am also curious to know more about what home health PT is like for these patients, as I understand a knee immobilizer is not typically used once they are at the level to be in outpatient care. My CI explained to me that usually the home-health PT will wean the patient off the knee immobilizer. I have a feeling that patient education on the reasons for the knee immobilizer are lacking, as it sounds to me like patients are instructed to have it on every time they are out of bed and this is contrary to what I have learned from outpatient PTs.I am excited to get more outpatient experience in order to gain a broader understanding of the continuum of care for patients who receive a TKA.
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Sarah Strong responding to Christie
Christie,
I, too, have not seen lymphedema techniques for patients other than for those who had a lymph node removed. I wonder which other post-surgical diagnoses benefit from this treatment. From what we are learning and from what I have seen in previous clinic experiences, it seems that scar management and reduction of swelling are important to implement early on to prevent limitations later on due to poor healing.
The analogy that your CI used to described the lymphedema technique to the patient sounds highly relatable to something that we all experience (those of us who drive), traffic. It seems to me that having an analogy that is relatable (and close to within context that the patient understands) is important in order to make that analogy effective.
Thank you for sharing!
– Sarah
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Alex Gett
I recently worked with a pt that is roughly 6 weeks post-TKA. She is coming along well but is lacking extension based on where she is in the treatment timeline. Like most pts, she remembers her goni measurements from previous weeks, and if she does not see improvement, she gets discouraged. I did my best to encourage her and let her know that she is doing everything right at home and that we are doing everything we can in the clinic. I did not say “your ROM will return if…” because nothing is guaranteed and I cannot make those assumptions. I share this because although both ends may be doing everything right, it does not necessarily mean we will always get the outcomes we want when we want them. I let the pt know that these things take time and that we will not stop working; we can only control our actions and we will not stop doing everything in our power to reach your goals. Her husbannd was present and he is very supportive. They both left the clinic thankful that we had the talk.
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Katie Woelfel
This semester I have the opportunity to be working with pelvic floor patients. Recently, we had an increase in male pelvic floor we’re seeing. I feel lucky to be able to advocate for this speciality / patient population. A specific patient that had me reflect on this was a mid 65 year old male patient that had been experiencing intermittent testicular pain since his teenage years. My CI decided to take a purely musculoskeletal approach for the initial evaluation rather than focusing on the medical diagnosis / suggestion of pelvic floor dysfunction. She made this decision based on his history of failed interventions from a multitude of different disciplines.
During the evaluation we observed his very obvious hypomobility in all directions of his spine, especially lumbar spine. We were able to replicate his exact pain L testicular pain with having him perform R lumbar rotation. We were then able to hypothesis that his pain was a referral from his pain and were able to treat accordingly to there.
The major significance of this was that when dealing with what seems like a complicated case to treat or something that might be out of our line of expertise, it’s always helpful to go back to the basics. Don’t get overwhelmed, and treat what you find.
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Reply to Katie Woelfel
Katie –
What a great experience! I was actually in women’s health last semester for ICE 1 and was also surprised to treat multiple male patients with urinary incontinence and testicular pain. Women’s health/pelvic floor is a specialty that is often marginalized, however, serves a population with significant quality of life changes.
It’s awesome that you were able to use referral patterns to treat this patient’s chronic pain. For a patient with a significant medical history, it is important to bring it back to the basics. Did your CI perform any spine manipulations to improve his hypo-mobility?
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Alyse Nierzwicki
For the past two weeks, I have had the opportunity to treat a 55 yo woman with a T8 SCI. This patient was diagnosed with stage 3 cancer and had a malignant tumor removed from her spinal cord, resulting in an acquired T8 incomplete spinal cord injury. Upon eval, her ASIA showed she did not have any sensation or motor function below T8. We thus, worked on improving her trunk control, sitting/dynamic balance, and w/c to mat transfers. This past week, however, she showed some motor return in her quads, hip flexors, and tibialis anterior (how exciting!). We utilized gravity-eliminated positions (i.e. powder board) to initiate strengthening and motor re-education of these muscles. She is, however, undergoing chemotherapy and consequently experiences a significant level of fatigue. It has been a challenge to try and implement multiple strengthening exercises, while catering her treatment around rest breaks.
This next coming week, we will incorporate the FES bike to improve muscle activation and prepare her for the standing frame. Depending on her level of fatigue, I plan to work on her static and dynamic standing balance, promoting carry over from her seated exercises. Due to her increased motor return, this patient has been extended for another four weeks. I am excited to see what improvements we make within the next month to increase her level of independence and possibly implement a home d/c.
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Mary Davern
I was working with a 17 year old girl who was 3 months post op from a surgery to treat patellar subluxation. She was focusing on increasing quad and hamstring strength.. I was feeling excited to work with a younger patient but when asked to think of new exercises to give her, I was having trouble being creative. After suggesting hamstring stool pulls and wall sits, I was running out of ideas so my CI suggested playing ‘crab soccer’. We set up goals on either side of the clinic and had to kick the ball while being in the reverse bridge/crab position. This exercise not only targeted her hamstrings and quads but also involved stabilizing the core especially when one leg lifted off the ground to kick the ball. This exercise kept the patient interested in therapy and demonstrated the importance of incorporating exciting exercises especially for younger patients. Next time I work with a young patient I will be sure to think of games or sport related activites to use as therex.
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Reply to Mary,
Mary, if I didn’t know your serious nature, I would have assumed you were kidding. This is interesting. Very cool though that this was utilized as a treatment. I am curious as to the specific utility and background behind this suggestion, I understand I am in no position to denounce this exercise/game as a treatment, but I am curious as to how this works. Nudge me in class sometime and explain.
Nice post!
-Pete
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Tiffany Reynolds
I worked with a patient in the hospital who has COPD. Upon discharge I was able to see how respiratory care normally assesses the patient to determine how much oxygen they need to be sent home with. They try to have the patient ambulate with as little oxygen coming from the tank as possible while still maintaining adequate perfusion. We were monitoring his O2 sats the whole time during ambulation. He ambulated about 100 feet and then we went to stairwell to practice stairs as he has 10 to get into his home so we did that many. Once he ascended the 10 stairs he said that he needed a break so we had him sit in a chair at the top. As he was seated his O2 sats dropped below 80 so we bumped up his O2 to 6L/min, then kept dropping until 65 at which point the nurse had her phone dialed to call the respiratory team but then it started to go up. That was the lowest oxygen saturation level I have seen thus far. This made us more hesitant about his discharge plans for home since he has the stairs. We decided to still say home with supervision as he has his wife at home and we instructed him on energy conservation techniques and taking appropriate rest breaks. We told him he will have to keep a chair at the top of his stairs and sit immediately for a few minutes once inside.
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Emily responding to Tiffany:
Hey Tiffany,
I had a similar thing happen multiple times in my ICE this semester. It made me reflect on how it’s one thing to learn about normal values in class and then a completely different thing to watch someone experience a life threatening low number right in front of you. That’s great you taught him about energy conservation. I think that’s as aspect of our profession that is bigger than I had ever imagined.
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Austin Wernecke
I was working with an individual who is currently going through dialysis in the home health setting, and today highlighted to me the importance of the physical therapist. He is an older male who is generally unmotivated, in pain because of his back or his headaches from dialysis and is known to cancel treatment sessions. This last visit was canceled because the pt had refused dialysis treatment and was in the hospital, my CI saying he was not sure that our pt would make it through. Fast forward to next week we are seeing him for a visit, after his hospitalization. Going into the visit I had mixed emotions, as I was not used to thinking that a patient I had seen that week may not be there the next. I was not sure what to think or how to think. Once in the visit, though I was able to put my mixed thoughts, feelings, and emotions aside and focus on the reason for the visit, the pt. It was in this visit that the pt expressed how no one is every helping with his exercises, he feels like he won’t get better and that even though he wanted to be better he did not know how to or even the belief he would. He was very negative about his standing, to say the least. I spent part of that visit not only providing therex but also working on the pt’s mindset. Talking him through that he may not get better right away, but if he kept working he could see progress in his strength. I talked to him about having a good mindset and doing his HEP as both those things would help determine where he ends up function wise. Looking back on this interaction what I took away is that we are physical therapists. Sometimes our emphasis is physical and sometimes its therapy and we have to be ready for both. We can give all the therex, manual therapy or modalities to help a patient, but if that pt is not onboard, positive and doing their HEP gains will be minimal. Going forward I plan to be positive and encouraging with the pt but also tough on his HEP. I want to stress that I am invested in him and that I can see an improvement in him even if he cannot see it himself. Maybe this way he can start to believe in himself and get better.
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Rachel Lenz
Post #2This week in clinic, I saw a patient who had just received an ORIF due to a fracture just below her greater trochanter on the L side. She was very nervous to get up and move however she wanted to move and knew that it was better if she was able to move more. We gave her some strategies to use AAROM (with the use of the contralateral leg or a sheet) to enable her to move the affected leg and reposition herself. She was very grateful for this. We also demonstrated and explained what her weight bearing restriction was. This was TTWB which I find to be difficult for a lot of patients to comprehend and abide by. She however did very well. At first, she struggled with the walker and how far to hop forward but after some practice she was able to ambulate with only slight difficulty.
Once she was seated in a chair, we were talking with her about how important it is for her to get up and walk with the nursing staff, however she got very nervous all of a sudden. It was obvious that she was much more apprehensive about the TTWB restriction than she had showed while working with us. This had surprised because of how well she did walking with us. Because of this we educated her on the process and asked what scared her the most, which was falling, and ensured her that as long as she walked with the nursing staff or us, that she would be safe and that she would not fall.
This showed me that even when someone performs and exercise well, that does not mean that they are comfortable doing so or that they will perform it the same way when you are not with them. Therefore it is really important to talk with your patients and make them feel safe to express concerns that they may have, otherwise you may miss some valuable information that may help the patient be more successful throughout the treatment process. -
Levi Perry
In the acute care setting, we were working with a lady that received a TKA the previous day. She was relatively young and healthy, headstrong, tough, and wasn’t going to let anything get in her way. Basically, not the type of patient you would normally worry about. However, she hadn’t had much sleep, was on pain medicine, had received some sleeping medicine the night before, hadn’t eaten breakfast yet, and just had major surgery. She had normal vitals, so we got her up and did some exercises, ambulation, visited the bathroom, did some more exercises – although unhappy, she was doing quite well with the activity. We checked her BP and it had dropped a bit. It was time to eat breakfast, and she wanted to sit in her chair and eat, so we transferred into the chair from bed. She complained of increasing dizziness and nausea. My CI quickly got her back into the bed and she practically collapsed into supine. Her BP had dropped even more. It was theorized that her BP was dropping in sitting and if she didn’t return to supine, then she would have crashed and passed out. After lying there for a bit her BP increased and she felt better. It was just a lesson that things can change quickly, and it’s not always the people that you would textbook think to have the issues.
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Thanks for your post, Levi! That reminds me of what all of our professors tell us about hypertension – most of the time, it is asymptomatic, which is why it is so important to check all patient’s blood pressures prior to treatment. Your post is a good reminder to be always on the alert for changes of patient status, and to stay calm in the midst.
-Victoria Appler
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11/12
Peter Cradduck
In the time since I last posted on here I have come to the conclusion that prerequisite, clear communication and patient rapport is foundational in administering effective treatment.
It was your typical tuesday in the Nursing home; loud TV’s, people sleeping in wheelchairs, a strange and inexplicable amalgam of smells… The patient was a 96 y/o woman who refuses to get out of bed on her own despite her adequate strength and ability. She had limited knee flexion, she had some balance issues when walking… I talked to her for the first 10 minutes about how great getting up might feel as we performed a “warm up” including ankle pumps, heel slides and SLR. I then told her about my ability to help her knee bend more without pain if she would allow me to help her. She allowed it. I did a condylar MWM. I emphasized the increase in flexion she got exclaiming “Would ya look at that? I think that might be just what you need to get up!” All this excitement worked for this individual. Through trial and error I recognize that each communicative tactic must be in the right time and right place with the right spirit. Luckily, this was all three.
To my surprise she swung her legs off the bed and prepared herself to stand up. She was still apprehensive, but she was willing to get up now as opposed to when we first arrived to her room and she recoiled at the mention of getting out of bed… Now let me be clear, I don’t believe I have magic hands that sweat essential-oils and permeate rays of divine healing, but as long as the patient believes they do (thus helping them be well), I won’t say anything.
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Pete,
I think this encounter was very similar to mine, and its so important to connect on a level thats not necessarily all about PT. You did a great job explaining to her what you can do for her, however, knowing you im sure you made her laugh or even told her a story which made her much more comfortable working with you. PT is so much more than just glides and mobs, but its a personal connection that you make with patients on a daily basis. You did a great job at that, keep doing you!
Andrew
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Levi responding to Peter,
I remember when we first started the program, I think we were sitting in cool springs for professional issues, and they proposed the question: would you rather be an expert at mechanical manual skills, or an expert at psychosocial skills. And, at the time I was very much on the mechanical/manual skills…Think about a surgeon – it’s nice to have a surgeon with good bedside manner, but really you are more worried about their manual skills right? I think this still applies to PT, but the more time that goes on, the more I realize the importance of psychosocial skills. Obviously, manual/mechanical/therex skills are still very important (I hope), cause if they weren’t, then we would just be psychotherapists (and that would be depressing)!!!
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Andrew Lamont (Third Post)
The other week in clinic, we arrived at the last patient of the days house, which was a beaten down, tiny house in the outskirts of Winchester. A man and a woman are sitting on the porch as we pull up. What ive learned from Home health is to never judge a book by its cover, and its been a valuable lesson to me throughout this semester. We walked up to the porch where we were greeted with nothing less than top notch treatment. After getting a quick history on this patient, I could tell that not only was he losing hope in himself, but showed a variety of depressive symptoms when talking about his family life. He mentioned being an alcoholic for about 10 years, drinking upwards of a fifth of a handle of vodka each day. I felt as though this person may need our services more than ever, however, may also need other types of therapy as well. Taking that into consideration, I wanted to bring up a lighter topic that may get him in a better mood to get up and move with us. I noticed him wearing a RealTree hat and asked him about hunting. This sparked about a 10 minute conversation about hunting and his past encounters with deer, however, he seemed to become much happier and more open to our treatment. We ended up working on crutch training since he was s/p femoral endarterectomy, which he picked up quite easily. He has a loss of sensation on his left and right feet from his diabetes which had left a sore on his left toe from dragging it on the ground. We talked about the importance of moving his feet consistently throughout the day, even when sitting. There was very little PT that I felt like we did, other than education, but what I feel like we did do was allow him an hour or so of an escape from reality. He kept talking to us to the point where we almost could not leave, but it felt so good to make an impact on this guy the way I felt like we did. I spoke to my CI who claimed that he had never opened up to anything before this treatment and also asked me how I knew he hunted. PT is not all about the physical aspect, but many times the emotional connection you can make with someone, that can ultimately lead to them getting better. This is one of the biggest reasons I chose PT, and it played out perfectly in this scenario.
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Reply to Andrew’s Post:
I enjoyed reading about how you did not give up on the patient in this situation even when he might have seemed like he gave up on himself already. Bringing up something that he had interest in so you guys could connect was a smart move. I am curious to know though what you might have suggest or how you brought up the depression that you noticed. Did you ask him about if he was seeing any other health care professionals or talking with anyone about his depression? Keep this in mind because as health care professional I believe it is within our scope of practice to ask these question or at least document about it.
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Samantha Schambach Ankle Unit Post
This past week during clinic I was able to do a full treatment session on my own. From start to finish. I was not fully aware of this before going into it because my CI was very sneaky about breaking it down step by step and saying look over this patients chart and tell me some key concepts about it and then what you would do before we go in. As she was saying this I figured it would be a treatment like we always do where I am the facilitator but she is there right beside me in case I need anything or if I forget a step/leave something out. During this treatment I walked into the patient’s room and per usual my CI was right behind me. In between getting the patients permission to work with them and me setting up the room, my CI had stepped outside. Later I found out she was keeping an eye on me from afar but where I could not see her. After talking a couple minutes with the patient I felt it was time to get her up and walk her then do her therapeutic exercise one we got into bed as she had just seen OT and gotten up to the chair. I turned to get the go ahead like usual from my CI and I saw her sitting outside the room working on notes. This was slightly nerve racking as this would be the first time I was alone with a patient and doing the whole treatment by myself. The rest of the treatment went fantastic though. I was able to walk safely with the patient in the hallway. I remembered the gait belt and all the lines and tubes. And when we were done we did some bed exercises that I told her she could do on her own. These were all the things my CI and I had discussed doing prior to treatment. I enjoyed this learning tactic that my CI tried as in my midterm I stated that I tend to look for approval before doing things even though I know it is appropriate to do them and that I wanted to work on this. By her not being in the room with me, I did not have that “crutch” and had to be a big girl PT and make my own clinically/evidence based decisions. Now that I know I can do this, I look forward to working with more challenging patients with more co-morbidities and seeing where my confidence levels can go. Overall I am greatly for this scary yet very rewarding experience.
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Victoria Appler Ankle Unit Post
About a month or so ago, I completed a patient’s initial examination. On my last day in clinic, my CI thought it would be neat for me to complete her progress note also to see how she had improved while I had been there. Initially, the patient presented with impairments relating to safety awareness, gait speed, balance, endurance, lower extremity weight bearing tolerance, and bilateral hip abductor strength. The factor that most impacted therapy for this patient, of her extensive PMH, was her diagnosis of dementia with agitation. During her initial evaluation, this patient required much coaxing and distraction in order to get her to do testing (the 6 Minute Walk Test, single limb stance, etc). Part of the reason she let us conduct all of our testing that day was the rapport my CI had already established with her prior to day 1. As she becomes fatigued, she becomes agitated, secondary to her diagnosis previously mentioned. The past week, prior to the progress note that was to be done, this patient had refused treatment over 3 times even with distraction techniques that had been implemented in the past to avoid her agitation. The day of the progress note, she let us into her room but as soon as we mentioned therapy, she verbalized that she would not be doing that today. My CI tried to convince her to do it to help me, as it was my last day, and it would be helpful for me to see her improvements. Slowly but surely we were able to get her to let me conduct MMTs of her lower extremity and test her standing balance and single limb stance on both sides. Throughout this testing, I felt I was walking on eggshells so as not to agitate the patient. After this testing, the patient became very firm in her assertion that she would not walk with us (we wanted to reassess her 6 MWT). She reported not being able to and she became very frustrated and clearly annoyed with us. We complied, saying we would only stay in her room a little longer to document what we had tested. While I was documenting I had a chance to ask the patient if she had Thanksgiving plans, and if she had any advice for me as what to make. We started talking about different cakes and the patient demonstrated an obvious shift in her response towards me. This patient has always intimidated me (in that I worry about how she will respond to me) so this was a very nice change of pace, as I never felt she was ever very trusting of me (I had only seen her for one or 2 other visits). After about 3 minutes of talking about nothing in particular, the patient turned to my CI and verbalized letting us walk with her to the activities room. Hoping she would let us complete the full 6 Minute Walk Test, we left her room. The patient even offered to go the opposite direction of the activity center for a little while since she knew we wanted to see her walk for longer. When we got to the activity room and to her puzzle, the patient made it clear she was done with us for the day. We had only walked for 3 minutes at this point but knew we could not get any more out of her today. Although we were not able to fully complete the patient’s progress note, her shift in attitude and motivation to help us do what we needed to do was crucial in getting even a little out of the patient. It will always amaze me what patients will do to make us happy, when there is a well-established rapport. For future clinical experiences, I hope to use this to grow in how intentional I am with creating good therapeutic alliances with my patients. -
Amy Responding to Tori,
Wow that must have been so nice to be able to see that change in rapport with her. I recently had a patient with dementia and I had similar feelings. My CI had wanted me to take the lead, but I was a little nervous about how the patient might react to working with me for the first time. She previously had been very combative with other professionals. In that session I learned a lot. I picked up on that the patient used humor and so I tried to keep the mood very lighthearted in order to convince her to help me transfer her to the chair. I also found that by asking for a hug (to facilitate the transfer) was also in effective way to convince her to partake in therapy.
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Amy Korcsmaros- Ankle Unit Post:
The other day I had my first foot/ankle initial evaluation. It was slightly daunting as I know that many foot pathologies can be related to other impairments found up the kinetic chain. To begin I took a detailed history that included PMH, aggs, eases and level of function. Due to their not being a clear MOI, it was going to be a challenge to determine the underlying factor causing her these pains. Initially I was very focused on the ankle, but quickly realized that there were many other things that were creating her pain. When asked to point to the most painful part of her foot, she was unable to even raise her entire leg to reach her foot. That is when I knew something more was going on. After observational analysis and many objective measures, we determined her three primary impairments were: pain in the medial calcaneal region, hip pain with limited hip ER, and tightness in the medial gastroc. Due to her irritability level, I was finding it difficult to create treatment options that would be conscious of her pain level. I was a little flustered, but then my CI was able to help guide me in the appropriate direction. He indicated that it might be beneficial to start away from the most painful regions to see if that makes a difference before moving to a region of higher irritability. This seems like a basic concept now, but it just goes to show you that when you are in the clinical setting, things might not seem as straight forward.
Next time in a situation like this I will be more cognizant of other joints prior to going into a more detailed exam of one joint. I will try and find a new flow that works for me and allows me to stay organized with my thoughts when multiple joints need to be looked at.
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Uyen replying to Amy
Amy, your CI’s advice was awesome because I also wouldn’t know what to do if I encountered a highly irritable patient either. It was great that you realized during the subjective that there were other joints involved, and were able to gather more information about those. Even though it seemed like she had a lot going on, I’m glad you were able to narrow it down to those 3 impairments at the moment. It’s crazy to think about all the combos of impairments that we will see in clinic, but I think it goes to show that even if you don’t know what is going on, treating just the impairments can help the patient! I have also learned that about my patients this semester too!
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Uyen Tran
Yesterday in clinic, I read a follow up note from a physical medicine doctor about one of the teenage patients we were treating. Reading that form, I saw so many deficits present, but I think about the patient we are treating and he’s so high functioning, that without special tests run, no one would know he had all these deficits. That taught me that with the pediatric setting, you can read a diagnosis and results from another doctor, but these kids could present in so many different ways. In this situation, I was glad that I had gotten to meet him a few weeks before reading this note, so I wasn’t biased, but I was still shocked when reading it. This patient presented with pes cavus external tibial torsion and decreased dorsiflexion ROM among other deficits. My CI knew we were just starting the ankle unit, but she showed me how to perform a talocrural posterior glide to help improve his ROM. I didn’t realize how hard that would be for me to perform since his feet are so huge and they were extra stiff. Then we worked on a few exercises I came up with that could help improve his medial longitudinal arch and tibial IR. I had him perform towel scrunches, holding a small ball between his arches while his legs were straight and lifting that up, and then I also had him perform heel walks. After the “therex” part of the session, we were able to take the patient to a punching bag that the clinic had and allowed him to perform punches while he stood on an decline to improve his dorsiflexion. He had alot of fun using the punching bag and I was glad we were able to have him exercise his whole body in a functional way. It was nice that during this session, I was able to apply things we’ve learned in class and learn something for the first time in clinic instead of in class. This made me realize that I need to start practicing on different people in the class more because there will be more situations where I will learn a skill for the first time on a patient who doesn’t present like a typical patient, so practicing on many different people will prepare me better for that next time.
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Jesse Parsons
This past week in clinic I had the opportunity to eval a pt. 1 week s/p a L TKA. He is a very active 85 yo male who had not been performing any of his post-op exercises since the surgery. He is very motivated and wants to return to full function w/o pain as soon as possible. During our objective exam, we determined that he lacked 10 degrees of knee extension both passively and actively. He also had a compensatory trunk anterior lean during gait to make up for his lack of full knee extension. After further testing, we determined that his hamstrings and gastrocs were tight bilaterally and he had hypomobilities in his PF join on the left, specifically in his superior and lateral glides. As we neared the end of the session, my CI had me design a HEP for the pt. and take him through it. I then was able to explain the importance of performing his various stretches and exercises and how they would help him progress towards his goals. It was a great opportunity to work with a patient who wasn’t afraid to push the envelope post-op and get back to his PLOF. The hardest part with this pt. was having him actually perform his HEP, as he was very stubborn about the fact that he did not need any extra activities outside of his time in clinic. This was an important experience for me to work on my pt. education skills in an effort to change his mind and his stance towards physical therapy.
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Katie Woelfel replying to Jesse
Ironic your patient seemed to be resistant to his HEP and PT when he reported to be eager about returning to his PLOF as soon as he could. Hopefully he sees improvement in his function and quality of gait after working with you guys and will be more bought into PT/what you can offer him. That’s awesome your CI is giving you autonomy over his HEP and making you an significantly active part of his treatment. Overall, good job!
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Katie Woelfel
The past couple of weeks we have been seeing a 44 yo female patient presenting with s/s consistent with adhesive capsulitis. Based on length of symptoms, subjective reporting of pain, and objective measurements of ROM the patient seems to be at the cusp of freezing stage. Pt reported her pain with any movement is around 6/10 which was an improvement from the previous month where she felt it was consistently 9-10/10. The first time she saw my CI, she reported the other PT in the clinic she had been seeing was taking it pretty easy on her and she hadn’t seen improvements in her ROM yet. We decided to be more aggressive with grades of mobilizations, soft tissue mobs, and active ROM exercises.
We utilized many MWM techniques (i.e. posterior glide given with belt while also providing ER). Pts tissue was highly irritable when doing soft tissue mobilization to long head of biceps, pec minor, and pec major. Pt performed active assist pulley exercises in all direction. Pt also performed active assist utilizing TRX straps by holding on, facing away from straps, and while walking away moving her shoulders into either abduction or flexion.
This next session pt reported the day after her first time with us, she was in less pain and felt her shoulder had loosened up. When measuring ROM, she had maintained the ROM we gained at the end of last week.
An interesting side note to her story is that she reported having her thyroid removed many year ago, but had been having problems with her medication in the past year. As we had learned last year, there seems to be a correlation with thyroid disorders and the development of adhesive capsulitis (which her doctor failed to mention to her even when giving the script for PT). This was the first patient with a shoulder pathology I had seen in ICE 2, and it was awesome to be able to review MSK I.
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Katie,
That is very cool that you were able to see something that we have talked so much about in class in a real life situation. I think in this pt’s case, it was really smart of you to consider being more aggressive to try to get results since being gentle did not seem to work. Sometimes its a guessing game, but when you find what works it is always nice to see the pt’s reaction. That is always really crazy that no one had told this pt about the connection between thyroid problems and her shoulder, I hope you were able to educate her a little on this so that she could have a better understanding of her body. Overall, great job!
-Ally Kuhn
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Allyson Kuhn
Two weeks ago, My CI and I visited a pt who had a tumor removed from her C-spine earlier in the year and is now receiving home health PT following returning home from inpatient rehab. The surgery left the pt with increased weakness and balance problems which is where we came in. Prior to visiting the pt’s home, I looked over the pt’s files and my CI informed me that this pt was a hoarder and her house was very messy. This made me a little nervous honestly, now not only was I about to treat a spinal cord pt but I also had to some how treat her in a cluttered home. I had no idea what I was going to do, all I knew was that I was going to have to put on a happy face and try to ignore my surroundings. When we arrived at the pt’s home, there was a single walk way up to her front door and about the same inside as well with just enough space for the pt to walk from her bed at the front of her home to the wall at the other end of the room. I am not going to lie I was a little shocked at first but knew I had a job to do and that was to help the pt not to worry about the clutter in her home as long as she was safe. So, with that being said, we began by taking vitals and then started with some ambulation down her walkway with a front wheeled walker. For ambulation the pt was standby A and required some verbal and tactile cueing to lift her legs to walk rather than drag them and to avoid hyperextension of her right knee. After ambulation, we decided to practice stairs. At first the pt was very hesitant to work on stairs but with a little convincing she decided to give it a go. For this particular session we only practiced tapping as this was the first time practicing stairs again. The pt was able to perform this task while holding onto the railings and with min A with her left leg; however, her right side is much weaker and required mod A. During this session the pt was able to get just below the stair with her right foot but not fully up onto the step. She is a very motivated person so this was not easy for her to take in, all she wanted was to get her leg on that step. I could tell that she was starting to get down on herself so we provided her with some reassurance that she will get there with practice and decided to call it a day since she was beginning to fatigue as well. We provided her with a HEP that had the exercises we performed on it and then we were off.
Just yesterday, we went to visit the same pt again and not only was she now able to step her right leg up on the step and push herself all the way up onto the step, she has switched to a cane to walk and can now walk side ways with min A. It is incredible the strides that this pt had made in just one week. I was amazed and to see the smile on her face when she was able to do these things was great. Through this experience, I learned that we cannot judge a person right off the bat based on appearance or how cluttered their home is. Had my CI or myself been judgemental, I do not think this pt would have made the strides that she did. All she needed was someone to help her and because we were able to look over the clutter, we learned a lot about her and with her motivation we were able to help her reach her goals. I hope that I can be this way with all of my pts no matter who they are in order to provide the best treatment I can.
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Rachel Lenz
This past week in clinic, I encountered a patient who cognitively was not alert. She had been given morphine and was diagnosed with dementia. This leads to garbled speech and made it very difficult to understand her. The reason she was in the hospital was that she had fallen at her home, in the dementia care unit, and broke her hip leading to a hemiarthroplasty of the hip to repair it. Due to her cognitive state, it was very hard to get any information out of her. I was able to get how much pain she was in, however, everything else was not discernable. The approach was anterolateral, however, this particular doctor has extra restrictions of no adduction compared to the typical restrictions associated with this surgery. This made not only myself but my CI nervous about trying to get her to the edge of the bed. She was not able to follow simple commands to wiggle her toes and did not seem to want to move either leg. This made it hard to implement interventions with her. We considered manually getting her to the edge of the bed, however, due to her mental state and the morphine in her system, we were unsure that this would be a safe position for her. Because of this, we chose to keep her in bed and perform some PROM of the LE bilaterally. This is where our treatment ended, however, I am wondering if we had sat her up, would she have become more coherent and be able to safely sit there. It is hard to tell as we were not able to measure her strength and although there were two of us in the room, it would have been difficult to maintain all of her precautions while sitting her up on the edge of the bed.-
Rachel,
Wow, this sounds like a tough, but good experience to have! I think you and your CI evaluated the different options you had for mobility and decided on the safest approach for this patient that would still provide them with some benefit. I think it’s important to highlight how difficult this patient’s long-term rehab will be. However, it’s also important that we implement individualized techniques that will work for this patient’s cognitive level throughout their rehab. Thanks for sharing!
Sarah Roderick
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Justin Geisler
In clinic a lady has been coming in for R hip pain, she had labral surgery 2 years ago but she still has pain. This reminds me of the scenario if you do not address limitations then it will lead to the same poor mechanics and injury. My CI and I have been addressing a lot of glute med/max strengthening, hip mobilizations, quad stretching and t spine mobility. She also has tenderness in her R hip adductors which she received STM for to decrease pain combined with some adductor stretches. This patient is very active and has great body awareness in her movement which is great because she feels her body moving abnormally internally and she is able to describe it to us well which helps guide our reasoning and treatment interventions. Not all patients I have encountered, actually could count on one hand how many patients are that in tune to their body mechanics so it was greatly appreciated when she was able to provide us with the information. Hip mobilizations consisted of long axis distraction, lateral glides and posterior glides, grades 2-3 since she had pain throughout her range. I assessed her pain in FADIR/FABERs prior, post treatment those motions were more tolerable which was a good sign. Her TFL was also super tight as well so we did STM there as well as added sidelying clams to her HEP to target her posterior fibers of the glute med and emphasized firing of the glutes intially during bridges as well. This was a great reflection in realizing how body awareness, motivation and education a patient comes into clinic with can impact the treatment session. She was a great listener and I know she will demonstrate adherence to her HEP.
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Justin in replying to Jesse,
This sounds like a great opportunity to be able to practice your patient education skills. I too have treated individuals who report subjectively that they want to get back to their PLOF and are motivated but when you ask if they have been completing their HEP you get a honest “no”. We appreciate the honesty but the importance of tying those two aspects of therapy together is essential. As PTs we can only do but so much, a lot relies on what the patient is doing when they return home and how they are moving forward in their treatment without us being there since we only see them a couple times a week in the outpatient setting usually. It goes along with being a good PT, making the patient believe in our interventions and how it truly will move them forward in their POC.
Great post
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Azita Nejaddehghan (foot/ankle unit post)
To make a long story short, I’m seeing a Pt at free clinic who has MAJOR psychological issues. I’ve written about her before (not sure if it was here or on TherEx), but this is a woman who is constantly with headphones in/listening to music to calm her self down. She presented a significant fear of falling and pain essentially all over her body.
Last tuesday I saw her for now the third time (second treatment session), and she is now able to walk without about 90% of the gait deviations she presented with gone! To put it in perspective, her gait at initial eval was so unsafe, even with me holding her hand, we had to have a conversation with her about a cane. Last Tuesday, the Pt told me that she now has her husband park farther back in the lot when they go to the grocery store so that she can walk farther, and that she doesn’t hold onto the cart for help when she’s shopping. I have to say this is one of the most rewarding experiences I’ve had so far. I have NEVER seen such a psychologically influenced case as with this scenario (she’s also reported that her anxiety and depression has been much better lately!)
I think this was an incredibly useful experience for me to have early on because I think it will help me when I experience patient’s like this in the future. -
Azita replying to Rachel,
Rachel that’s a tough situation, but I think you guys did what was best in that scenario! With a pt that “fragile” I think it’s best to walk on the safer side since they’re cognitively unaware… better safe than sorry. I can recall a similar situation when I was at Warrem memorial where we chose to do the same thing. It’s good that you guys chose to be anticipatory instead of reactive. It’s always great to walk pt’s in inpatient, but safety comes first!
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Azita replying to Katie,
Like you said, that’s awesome that you got to go back to MSK I. A little confused about the time table, how long have you been seeing her? I actually saw my first pt with frozen shoulder a couple weeks ago, and like you said it’s awesome to be able to apply our knowledge. Yours definitely fits the profile like you said! It’s interesting b/c my patient is a middle aged woman who fell, and apparently “developed frozen shoulder” after this.. I mean she truly is limited in all ROMs, with ER> abd. With her arm at her side (0 degrees), she has MINIMAL external rotation. I’ve seen improvements in ROM with the few treatment sessions I’ve had with her though. I’ve been using distraction glides due to her level of irritability, with PPMs in b/w bouts. Interesting to see where we’re both at in terms of stage of FS, with similar pt’s!
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Sarah Roderick
In the acute setting, my CI and I treated a patient who had suffered a fracture of his lateral malleolus and a subsequent talar subluxation. My CI and I chart reviewed this patient, and we discovered the patient weighed 575 lbs. With this information, I became nervous about our ability to perform several mobility interventions such as transfers and ambulation.
My CI and I evaluated this patient, and he had a very difficult time moving either of his legs, which made me nervous about how we would transfer the patient from supine to sitting. My CI and I were able to assist the patient to sit EOB. We tried to educate the patient on how important it was for him to attempt standing interventions, as he is non-weight bearing on his R LE and will need to master stand pivot transfers in order to safely go home. The patient did not want to attempt any standing interventions and stated he would try at a later time.
I recognized that the patient will likely not be in the hospital for very long, if he remains medically stable. It is very important for this patient to master his transfers independently, as it will likely be much harder for someone to assist him with a stand pivot transfer to a bedside commode, given his weight and prior limited level of mobility. Additionally, this patient needs to practice as many of these transfers in PT sessions while in the hospital, in order to prevent a SNF discharge recommendation.
It was great that my CI and I were able to encourage this patient to participate in PT and sit up EOB, as even this amount of mobility took some coaxing and encouragement. However, it would have been better if we had been able to get the patient standing, as he may not have many more opportunities to participate in PT in the acute setting. Though my CI and I provided this patient with this information, he still refused standing. In the future, I hope I continue to find the balance of encouraging a patient to participate in the most appropriate interventions for their treatment session that day.
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Brianna Virzi
While in clinic, we had a 65 y/o male come in for an initial evaluation s/p SLAP repair with a LH biceps tenotomy. He began conservative PT treatment in July shortly after his shoulder pain started. After 4 weeks of therapy, he admitted his shoulder was feeling a lot better and he wasn’t limited lifting overhead. However, imaging revealed that his labrum and LH biceps were torn. At this point, the patient claims that “the orthopedist made the decision” for him to have surgery. Currently, this patient’s complaints and restrictions post-surgery are more substantial than his complaints prior to surgery.
After this initial evaluation, my CI and I discussed this case. This patient is older, not very active, did not feel limited in his daily life, and felt like PT was helping. We both agreed that this patient may not have needed surgery despite what the imaging showed. This case made me wonder why the imaging and orthopedist’s opinion held more weight in his decision for surgery compared to the PT’s opinion, when therapy was proving to help manage his pain. This patient encounter made me realize how important it is to advocate for physical therapy. Patient’s should never feel like they are forced to have surgery, especially when conservative treatment is a viable option.
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Kyle Kohnen
During my last week in clinic I worked with a 50 y/o female with frozen shoulder. I was feeling confident about working with her because this was the 5th case of frozen shoulder I had seen in clinic and they all presented more or less the same. The patient was lacking ROM in all directions, with abduction being the most limited. Movement was very painful for the patient, so I started treatment with distraction for pain relief and then followed up with inferior and posterior glides. After treatment, her ROM was still the same, however her pain had decreased so the intervention was a success. Working with frozen shoulder multiple times was really helpful because It’s nice to finally feel comfortable and confident during treatment. Looking forward, I want to zone in on one particular pathology per month to get an in depth understanding of the different kinds of presentation and treatment. I think this will help me become a more well-balanced PT.
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Patrick replying to Kyle
Thanks for sharing! That’s great that you were able to help decrease your patient’s pain. It sounds like you had a lot of exposure to this pathology during your clinical. This will definitely be a huge confidence booster when you see a patient with frozen shoulder during your full-time clinics. You mentioned your plan moving forward, I hope to do something similar to increase my knowledge of different pathologies and reinforce what we’ve learned. Keep up the good work!
– Patrick
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Kyle,
That’s great you’re still getting experience with frozen shoulder and other shoulder pathologies. Sounds like she was pretty irritable and you did a great job adjusting your goal to pain management. I’m curious what stage she was in based off her time of onset and how that matched up with her presentation. Also, did she receive any other therapies such as injections in the short term for pain relief? I like you’re idea of dedicating a pathology per month. Could be a useful tactic in reviewing what we’ve already learned thus far in the program. Thanks for your post!
– John Orchard-Hays
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Patrick Dumais
Post #3My last week of clinic I had the opportunity to work with a patient I had not seen for several weeks because they were not on my CI’s schedule. It was a great chance to see the patient’s progress over the past several weeks. The patient had suffered from hydrocephalus which had left him with what my CI referred to as “stroke-like” impairments. The first time I had seen the patient he was doing all of his exercises in seated. He worked on some mirror therapy but had very little muscle activation on his entire R side. This time, however, the patient was able to stand up with Mod assist and CGA once standing. It was really nice to see how far the patient had progressed over the past several weeks. The patient’s son was also there during the therapy session, and he helped motivate the patient to push himself. Unfortunately, the patient did not really think that he was making much progress but I tried to remind him of how far he had come since I had last seen him. I was glad I had the opportunity on the last day to observe his progression first-hand.
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John Orchard-Hays
In my last week of clinic I worked with a patient who had a L CVA. I was unclear if the patient was to work with me or not and it turned out that he was on a different therapist’s schedule, even though my CI had been primarily working with him. After reading over his initial eval and previous daily note I asked if I was to work with him and my CI gave me the option. I had never worked with a patient who had a CVA as an SPT so I seized the opportunity. He was about a year out from his CVA. Overall, he was very functional and at a first glance you wouldn’t be able to recognize he had a CVA. Upon analyzing his gait however, I could tell he still favored his left leg due to hypertonicity in his RLE. I was instructed to perform some PNF patterns with his R UE and differed to another therapist to perform his LE PNF since I had never done it before and we had not covered it in class yet. As for his TE, we worked to normalize his gait and did a few exercises that encouraged trunk dissociation. I definitely got myself out of my comfort zone by working with this patient. I feel I gained some further insight into working with the CVA population by being able to apply what I’ve learned in my courses thus far at SU to a live case.
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Reply to John O-H,
I’m glad you had the opportunity to work with a patient post CVA! The clinic that I was in this past fall was a non-profit outpatient neuro facility. So I was able to work with lots of patients following stroke. I can appreciate the scariness of working with a new patient population. But it sounds like you did great! We also did A TON of PNF treatments in clinic. They are super helpful with these patients so I’m glad you were able to practice on a real patient! Additionally, with my experience this fall, gait is another huge component of their treatment. It is very interesting to do a gait assessment with patients following neurological injuries. There are many things I picked up on after working with more and more patients.Many stroke patients present with very similar deviations. …And I’m glad you picked an intervention tailored to the trunk! My CI always told me “Trunk is always the answer! (well ,almost).” But in all seriousness, for this patient population, their trunk control plays a tremendous effect on their quality of ambulation. I hope you enjoyed this day! Sounds like you had an awesome learning experience.
Mekayla Steckel
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Mekayla Steckel
As we all know, patients with neurologic disorders often present with an equinus positioning at the ankle. During my time at the AFC clinic, I was able to observe a lot of different feet! Equinus was present in almost everyone. At this clinic, I also did a lot of gait training. I saw many compensations including genu recurvatum, hip ER, decreased step length, premature heel rise, etc. Working with patients with these ankles can be scary! Obviously some cases were worse than others, but this increases their fall risk and risk for secondary complications. It is interesting to see the change from supine to standing. Their tone most definitely increases once they’re on their feet. I wish we would’ve gotten to the ankle sooner so I would’ve known a little more about working with these patients and what ankle treatments I could’ve done to benefit them. In addition, I wish I would’ve asked them more about the use of night splints and heel lifts, other MSK dysfunctions and whether or not they’d had a previous surgery on their LE. I am fortunate I was able to see patient’s with these deformities on a daily basis and I look forward to now applying what I’ve learned throughout the ankle unit to future patients that I’ll be working with.
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Ali responding to Mekayala,
This seems like an awesome experience! I saw a lot of equinovarus positioning as well in many of the patients we had. My CI showed me several techniques to help with this including using an ace wrap to get them into a more DF position so that we could gait train. It was interesting to see their gait without assistance into ankle DF because as discussed in class, they hyperextend their knee each step and had severe lack of pelvic control. Great to see concepts in class presented in clinic!
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John Knowlton (Third Post)
A couple weeks ago I treated a 68 y/o male about 5 weeks post TKE. I was taking the lead with this patient that day. The patient walked in with a walk and first thing I noticed was that he didn’t have full knee extension. After I read his chart I learned that the patient actually had about 30-40 deg of total motion this knee. He was not responding well to therapy and had developed arthofibrosis from his surgery. I performed about 30 mins of manual therapy including (STM to the quadriceps and hamstrings, anterior/posterior TF glides, all directions with patellar mobility, posterior glide of the femur on the tibia, and transverse plan glides). All mobilizations were grade 4 as this patient had severely limited motion and was painful. I was actually exhausted after this session and this patients knee felt like it was moving at all. After all of the manual treatment we had gained a few more degrees in each direction. Then we performed LLLD stretching to the hamstrings while the patient was in supine to increase knee extension. Then performed therapeutic exercises. The patient was actually going back in for a manipulation under anesthesia in the following weeks so I am interested to hear what the outcome was. Overall this was a great learning experience for me.
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Laura D’Costa
In the SNF setting, I worked with a patient that had balance deficits. My CI and I picked him up from his room due to his cognitive deficits. Before going to the therapy room, the patient locked his door. He did so with the key on a lanyard around his neck. Watching the patient lock the door in this manner did not seem safe especially if he was by himself. During the therapy session, I kept trying to think of a better way for him to lock the door. I targeted the session to reaching outside of his base of support to improve his balance specifically to for locking his door. After we dropped the patient back at his room (and watched him unlock his door), I asked my CI if there was a way for his key to be on his wrist or on a retractible clip. This would prevent the patient from bending over and reaching to go into and out of his apartment. The next week in clinic I saw that the patient had a retractible clip for his key. When he locked the door, he was more stable and had better body mechanics.
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Christie responding to Laura
That must have been really cool to see your suggestion implemented with this patient from one week to the next! I like how you were observing your patient in his daily life, even though it wasn’t part of your official treatment session in the gym and were able to guide your plan of care based on those observations. Your recommendation seems like it is in the best interest of that patient’s safety, so I’m glad you felt comfortable enough to speak up and mention it to your CI. Way to treat the whole person!
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Lindsey Responding to Laura,
This is such a great idea! I am so happy to hear that they implemented this with your patient so he was able to lock and unlock his door more safely. Great thinking!
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Christie Freund
Over the course of the semester, I had the opportunity to work several times with a patient with spinal stenosis. When my CI first starting seeing her (a few weeks before I started), she had symptoms starting in her back that extended all the way down into her foot. Over the course of time, her back and hip symptoms resolved, as did her leg symptoms. She got to the point where her only symptoms were in her foot. However, we had trouble determining exactly what was causing her foot symptoms and had to go through a series of differential diagnoses and were constantly reassessing to see if our treatments were affecting her symptoms. We had to use a lot of funneling with this patient to figure out what information was relevant to her problem, but we determined that there were likely two different problems contributing to her foot symptoms. She had some tingling in her foot that appeared to be associated with tightness, trigger points, and weakness in her calf muscles, so we treated proximally. She also had more of an ache over her metatarsals that appeared to be due to a lack of cushioning on the pad of her foot. We recommended a metatarsal pad shoe insert that seemed to help with those symptoms as of the last time I saw her. I really enjoyed working with this patient because I really had to think about what might be causing her non-traditional symptoms and go through trial and error. It was a great example of the importance of constantly assessing and reassessing to ensure we are heading down the right path with treatment.
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Lindsey Rodriguez Post 3
In clinic we had a patient who was 97 years old with a long list of co-morbidities, diabetes included. He was in the SNF post-op forefoot amputation due to complications with an infected sore on his foot. He had previously had his big toe removed due to infection, however it had now spread into his forefoot. When we saw him on eval, I wasn’t expecting him to be able to do much but to my surprise he was able to hop about 20 feet with a FWW. He was non-weight bearing in his surgical foot, however, was still able to SLS and hop on the non-involved side. Although we weren’t directly treating his amputated foot in the SNF, this case was interesting because I was able to see the side effects of diabetes and how it relates to the foot. I am curious to know what his gait pattern would look like once he is able to weight bear through the foot, since he is now missing his entire forefoot. -
Ali Cloutier- Post 3
During my final week at the inpatient rehab facility I was at, I had an 85 y/o male patient that had a R CVA and was also undergoing treatment for lung cancer. This patient had severe cognitive deficits and was unaware of his disability. His active lung cancer also made him have a severely limited endurance and would often experience coughing fits. My CI and I came up with multiple tasks for this patient including balance, gait, and therapeutic exercise activities. We also tried to incorporate cognitive elements into each task to increase his practice with memory. My CI had me come up with the exercises and since he does not safely stand, we did all the exercises in seated. I then explained to him what exercises we would be doing and how I wanted him to count to 12 while doing the exercises. Given that this patient had increased cognitive deficits and wasn’t fluent in English, I decided I would do the exercises with him so he could use me as a model as well as assist him with timing and coordination of the movements, especially on his L side. In about the middle of the set, I proceeded to put my hands on my hips out of habit and given that I advised him to copy me earlier, he immediately mimicked me. My CI immediately started laughing at this fact. This demonstrated to me quite how literally patients take your cues to “copy me.” It made me realize that I need to be more conscious of what I am doing while doing a task with a patient because I didn’t think he would take it so literally. Overall, this experience taught me to be mindful of my body position when demonstrating a task as many patients mimic your exact movements down to where your hands are even if you told them to place their hands in their lap or on their chair previously.
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Sarah Strong – Post 3
During my last week in the inpatient acute care setting this semester, we saw a patient who had surgery for an achilles tendon rupture. This patient has multiple co-morbidities including Parkinson’s Disease and LE muscle spasms. This patient was to be NWB for several weeks following this elective surgery. Usually when we saw patients who were receiving elective surgeries, they had a plan for following the surgery such as where they might go after their hospital stay including altered home set up or an anticipation that they might go to a Skilled Nursing Facility. This patient did not seem to have a plan in place. She reported that she was still ambulating a flight of stairs to enter her home, even right before the surgery. She stated that she could hardly put any weight on the affected limb at that point (which led to the surgery). She also stated that she had terrible pain in her other limb, due to muscle spasms. I got the feeling from my CI that the patient’s report of muscle spasms may not actually be spasticity of the muscle, but something else entirely. I was not sure, myself, how my CI came to this conclusion, however.
The patient’s medical presentation and her subjective report of prior level of function did not seem to add up. Following the treatment session, my CI and I discussed our confusion on how she could have possibly been ascending and descending stairs, why she elected to have this surgery without a post-hospital stay plan in place, and why it seemed as though her muscle spasms were not being medically monitored or treated. The patient did state that she sees a neurologist. It seemed to me that the surgeon or physician involved with her surgery did not educate her such that she understood what to expect following surgery. It also seemed to me that her co-morbidities were not taken into account.
What I learned most from this encounter was once again the value of a thorough chart review and ability to be flexible. We entered the room thinking we would try to get the patient up out of bed and see how she did with using the walker and following her post-surgical precautions. We left the room after giving her some in-bed therapeutic exercise activities that she can do on her own such as ankle pumps, straight leg raises, quad sets, glut sets etc., some of which seemed to exacerbate her muscle spasm which caused her pain in the unaffected limb. Due to the patient’s pain, we did not get her out of the chair that she was seated in at the start of the session. This patient also had plenty of psychosocial aspects to her medical status; she teared up during the session while speaking about how her husband helps her and how grateful she is for him; she also stated that she wouldn’t wish “this” (meaning her medical conditions) on anyone. It was a really difficult moment. We reassured her that we, along with nursing staff, would do our best to keep her comfortable and mobile during her stay in the hospital. We also encouraged her to speak with her neurologist about her muscle spasms.
I left this treatment session wishing there was more that I could do for this patient to decrease her pain and increase her access to providers who could help her manage her pain and various medical conditions. It turned out that her achilles rupture seemed to be the least relevant piece of her current medical status, as the muscle spasm pain that she described seem to be the main factor that limited her mobility at that moment.
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Hi Sarah,
What an interesting case, especially given that she had elective surgery for an Achilles tendon rupture. How unfortunate that she did not have a discharge plan in place either. Great job though focusing on the whole person instead of placing emphasis on the initial impairment itself, which sometimes we get caught up in. Especially in this type of setting, open communication between health professionals is critical as they impact a patient’s care. I’m curious as to what was the dosing that you gave her for therapeutic exercises and how frequently you had to modify activities based on her exasperating spasms.
-Daphne Batista
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Dominique Norris
While on my clinical, I had the opportunity to treat a patient with PF and PTTD that stemmed from a fracture she had sustained months earlier. The patient spent her entire work day on her feet on concrete floors, as she was a chef at a local restaurant. In addition to strengthening the patient’s feet and legs, and addressing more proximal biomechanical causes, we spent a fair amount of time working on STM and de-sensitization techniques. We also discussed shoe options with the patient, to try to make the long hours less severe. The patient was able to utilize the STM and de-sensitization techniques at home as well, which will help decrease her reliance on us and put her more in charge of her health. While the patient was still experiencing a fair amount of pain after a day of work, she told us that the techniques that we gave her both for while at work and once she was home, were helpful and made her work day less unpleasant. I was disappointed that we weren’t able to completely resolve her pain, but knowing that the patient felt a dramatic improvement showed me that we can still make a difference even if we cannot completely fix the problem.
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Daphne Batista
During my time at Ashby Ponds & Erickson Living, I had the opportunity to interact with an 89 year old female. Due to her poor vision, she tripped and ended up fracturing her ankle. Subsequently she underwent an ORIF of her RLE, unfortunately I do not know where the fracture took place. During my time at the SNF, her fracture was technically healed, however she was still in a boot due to a wound ulceration. She was full weight bearing in the boot and ambulated with a front wheel walker with a step through gait pattern. During treatment sessions, gait training was a big component. She was able to navigate long level hallways with supervision, however required more cueing when navigating corners or tight areas, such as her bathroom. Given that she was at the supervision level, I felt more at ease during her gait training sessions compared to other patients who required more assistance. Though her gait pattern was fairly normal while she was in her boot, patient education was provided to ensure that she always carried the walker with her, as she had never used one prior to the injury and often would forget to bring it with her. This would decrease potential fall risk if she accidently tripped due to the boot thus causing further injuries.
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Andrea Choo responding to Daphne
Hi Daphne,
Thanks for sharing! Was the wound ulceration due to the immobilization after the surgery or a separate complication? If it was due to the surgery do you know if it the surgeon instructed the patient to immobilize it for a certain amount of time or was it more related to the patient’s fear of moving/using her foot? Either way I think that it could be a good opportunity to provide patient education to try and minimize complications and promote mobility as appropriate.
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Andrea Choo
During my ICE II rotation, I got to assist with serial casting on a 6 yo girl who had decreased DF ROM. Unfortunately, I did not get a lot of information regarding her background or medical diagnosis. However, I do know that she had been casted a couple times before and had made great gains in the past. Before we could put on the new cast, my CI asked the patient and her mom about any complications with the existing cast and the patient’s reaction to the cast. The mom reported that the patient only noted mild discomfort at night, however it was tolerable and non-painful. After cutting off the pre-existing cast, my CI measured the patient’s DF ROM and cleaned the patient’s leg. After that was done, she found subtalar neutral, dorsiflexed the patient’s foot into a stretch, then asked me to hold the patient’s foot in that position as she casted. In MSK lecture, we learned that DF is important because it’s necessary for normal gait. Additionally, I got to witness this first hand when we serial casted in neuro lab and a good portion of the casts were not positioned in enough DF to allow for safe ambulation due to hyperextension of the knee. One difference between how my CI casted and what we learned in neuro lab was that my CI preferred casting in a prone position compared to supine because she found it easier for children to stay still in that position. Additionally, I found it easier to hold the foot in DF, since gravity was able to help me. Overall, it was interesting to see serial casting performed on a patient that actually lacked DF in clinic. After watching my CI, I realize that I still need a lot more practice with serial casting to make it cleaner and more efficient.
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Lori Yeaman responding to Andrea Choo:
Andrea,
This sounds like a great learning experience and really reinforces what we learned in class. With this case, and even speaking more generally, it is always interesting to compare and collect different techniques for similar treatments as we progress through our PT education. Great reflection!
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MJ Erskine
During my time in the SNF, there was a patient with whom I interacted 2 times. His primary language was Spanish (which I don’t speak), he had cognitive impairments, and I never did find out from my CI what his diagnosis was. He appeared to love soccer! The first time I saw this was an intervention for coordination where my CI would kick a balloon back and forth with the patient – my job was to keep the balloon in play. The patient had more fun with that than anything. The second time I saw this patient, my CI had just finished a similar intervention and asked me to sit with the patient while he stepped slightly away to do something. Every time the balloon would come near the patient, he would attempt to kick it. So I continued playing with him. I got the impression that as long as someone was willing to kick a ball/balloon/etc. with him, the patient would continue to play. This really pointed out to me how picking an activity that the patient enjoys can have a huge impact on the effort put forth by the patient and on adherence to programs. I hope I can carry this forward to future patient care and find interventions that both address the impairments and engage the patient.
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Ahmad Rahman
In my time at my internship there was a particular patient who showed up just once (although I’m sure she was seen regularly outside of my days there). She was a 26 year old white female who had recently suffered a stroke, and I figured that this would be a pretty straightforward case. It threw me off that she was as young as she was, seeing as I had just turned 26 as well, but that didn’t deter me from using the fresh knowledge about stroke rehab I had gotten in adult neuro to work with her. When she came in, it was apparent she had several cognitive defects on top of her stroke diagnosis as well; I don’t recall which sided stroke it was, but she was showing signs of learned non-use with her UE, and had an abnormal shuffling gait pattern with lack of pelvic dissociation. While doing her initial eval we noticed several of her limbs had increased spasticity, particularly in her upper arm and finger flexors, and we worked on these for a majority of the treat. It was eye opening for me to see someone so close to me in age be in the circumstances she found herself in, and it almost reinvigorated my desire to get the most bang for the buck out of the session as I could.
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Kayla Sweeney
In clinic this semester, I worked with a 2-year-old girl with a chromosomal deletion. She was unable to sit up without support and was unable to clear secretions on her own. I learned this semester that sometimes in early intervention you spend the hour educating the parent rather than putting hands on the patient. The patient’s mother was trying to decide if it was worth getting a supportive standing device the doctor had recommended. My CI spent the entire treatment educating the mother on the importance of weight bearing at a young age for proper development of the hips and acetabulum. While I was not able to actively participate in the moment, It was interesting to see how my CI handled the situation and changed the parent’s point of view. She focused on education and gave the parent the power to make the decision but made sure the parent had enough information for an informed decision.
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Kayla,
This is such a valuable experience you had. I think as future clinicians, we need to provide our knowledge not only manually, but with education. This is a great learning experiences for advocating for our patients. Great job!
Cassie
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Austin Wernecke
There was never a time in clinic that I saw a patient who had an ankle or foot pathology. However, there was one stroke patient that had neuropathy in his foot. He presented with decreased balance as well as increased postural sway with ambulation. These were both things that were caused by the neuropathy. When looking to treat this, I did not directly do anything to the foot or ankle per se. Instead, I focused on functional tasks with this patient. As we would walk, I had him reach out intermittently and touch a football that my CI was holding. This made my pt look up and not focus on his foot. This lead to an increase in his balance with gait as well as decreased postural sway. I feel as if this could be due to the fact the pt’s center of mass was brought more posteriorly and his eyes were focused straight ahead and not at his foot. I am wondering, even though he has neuropathy if this could potentially increase his proprioception as well. Not with the foot but possibly the ankle. Since I was forcing him to ambulate without visual cues for his foot in space. However, He did see improvements with this activity. -
Caleb Baxter
Over the course of ICE 2, I saw multiple patients with plantar fasciitis. This was before we covered the topic in MSK, so I wasn’t very familiar with the diagnosis and proper treatment. All i knew was that plantar fasciitis involved plantar heel pain and that a common treatment was stretching. I did not see these patients for many sessions, but it’s interesting to reflect and compare how my CI and I developed a plan and how I would develop a plan now. I was not involved in any of the evals but I’m almost positive my CI did not look at whether the patient had a pes planus or pes cavus foot to dictate treatment. One of the patient’s had a bone spur, which I assumed was certainly contributing to the pain and making things worse at the time. Now, I’m not so sure. We’ve learned that about 1/3 of people have a heel spur and many of these individuals are asymptomatic. All the patients with plantar fasciitis received noxious stim. I discussed this treatment in the therex discussion board for an achilles tendinopathy patient. It is essentially e-stim with the goal of pain desensitization. In order to be effective, the patient should experience a 6/7 out of 10 pain when the electric stimulus is on. In the CPG for plantar heel pain, electrotherapy receives a D and manual therapy with therex and foot orthoses are recommended instead. I wish I had looked more into the CPG while I was seeing these patients. I plan to treat plantar fasciitis more effectively the next time I see it in clinic as I know better now.
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Melissa Jankus
During one of my days in clinic, my CI and I performed an evaluation on a middle-aged woman 4 weeks post-lateral ankle sprain. The patient reported twisting her ankle while wearing heels with a narrow base of support. The patient reported minimal pain, just on the lateral side of the ankle. She reported that walking for a long time aggravates the ankle and resting and icing makes it feel better. The patient’s goals included getting back to walking and exercising at prior level of function. The patient’s ankle range of motion was almost all within normal limits, with only active and passive dorsiflexion being slightly limited. All resisted testing was strong and painless. Passive range of motion into dorsiflexion along with a posterior talocrural glide were done to help increase dorsiflexion range of motion. The exercises prescribed included ankle alphabets (active range of motion), 4-way ankle active range of motion with a Theraband, bilateral mini squats and backwards walking. The session was ended with ice and e-stim for 15 minutes. Overall, this was an interesting evaluation because the patient came in 4 weeks after the initial injury, so she was almost back to full function. She just needed PT for the common residual deficits involved with a lateral ankle sprain. My CI and I expected that she would not need many visits to PT in order to get her back to full function.
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MJ responding to Melissa Jankus re “evaluation on a middle-aged woman 4 weeks post-lateral ankle sprain”.
As I have seen 0 foot or ankle cases this semester, this was fun to read. From your description, it sounds as though this was a one-time event and she was not prone to repetitive sprains, do you know if that was the case? I’m always interested in seeing what the prescribed exercises are but we get so much more information when we can ask the PT why those since mini squats and backward walking could benefit AROM, balance and proprioception or strength depending on patient presentation. Thanks for sharing and proving an application case before exams!
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Post 3: Cassie Rawa
On my last day in clinic, I was able to evaluate a patient with an acute patella subluxation.The patient was holding her new born child and was twisting to get something and subluxed her patella, a week prior. When she presented to clinic, she had no range of motion deficits and no limited PAMs. The only issue was her fear of moving her knee into end ranges, considering when she did she subluxed her patella. There was minimal pain and swelling, again just reiterating the fact that this patient was just scared of just subluxing her patella again. The only impairment that was noted, was during ambulation she was hanging out in extreme inversion on her right leg (the same leg she subluxed her patella). We offered her orthotics in the future considering this could lead to issues. This case was interesting to see minimal deficits with the patient, the main problem was her fear of reinjury and her ankle. For the future, it is important to assess proximal and distal segments with the LQ as they related very much.
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Sarah responding to Cassie Post 3:
Cassie,
Thank you for sharing this patient case with us! It is so interesting that she was in PT for her knee, but did not have any mechanical deficits, aside from her fear of re-injury. I wonder if the orthotic, along with some lateral strengthening proximally and distally might help her in the long-run. It sounds like she is pretty young, so it seems as though there may be high potential for recovery and to help improve qualities of her biomechanics!
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Marielle Giardini
One week in clinic, we saw a 45 y.o. female with lumbar pain. My CI had been seeing her for a couple treatment sessions already and explained to me that the patient also had hip pain. My CI let me do back mobs and the patient was great about giving me feedback on if it felt similar to how my CI does it. After working on her back, I was able to perform inferior and lateral distraction with a belt. While doing this, I realized how much work and effort it takes to do treatment in those positions. After doing bouts of this, we reassessed her painful positions and the patient’s pain was decreased. It was great to see first hand how these treatments help the patients and to see the impact you made on their day.
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I saw a patient in clinic who had a broken down, planus foot, but also had fractured her big toe (dropped a weight on it). I joined in mid way through the session so all I really saw was her TherEx. She was doing a lot of toe yoga, short foot exercises, etc. At this point she was doing pretty well with therapy and she didn’t really have much else going on. It’s interesting that the patient at one point said “this is the most disabled I’ve ever had.” it’s interesting to see how degree of disability is so subjective. In her mind, she was severely limited in her life, where as right before I had seen a patient who had an above the knee amputation and used the phrase “I mean it’s whatever.” So this made me realize that as PT’s we tailor our approach to a patient not only based on their impairments, but how they perceive their impairments as well.
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Lori Yeaman – Reflection #3
Before we covered the ankle unit in our MSK course, I saw a patient in clinic who was several months s/p distal fibula fracture. The patient’s ankle was stiff in all directions secondary to being casted for 8 weeks. Some of the treatments that my CI selected to improve ROM were A-P TCJ mobilization, P-A TCJ mobilization, A-P fib mobilizations at the distal tib-fib joint (fib had healed appropriately), and mobilization with movement at the TCJ. After covering the ankle in class, I now have a better understanding of the arthrokinematics involved in ankle motion, as well as my CI’s treatment rationale. Upon reflection, it is interesting how such small quantitative gains in ankle ROM can lead to such large functional improvements, such as normalizing gait and stair ambulation.
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Mary Davern
I was working with a 40 year old white male who had a disc protrusion of L2 and was also complaining of pain in the anterior hip. My CI suggested that I do a lateral distraction with a belt. I had never done this technique on a real patient before so I was excited to try it. I was worried about handling his leg because this patient was over six feet tall and overweight. I was also feeling a little nervous because I found the distraction very uncomfortable when my lab partner did it on me and did not want to increase my patient’s pain. After I did the distraction for a couple of minutes, he did a lap walking around the clinic. My CI suggested doing some lumbar extension exercises next but he looked at me and said: “Could you do that belt thing again? It really seemed to work”. As I was getting the belt set up again, he said: “wow you PTs are pretty smart” and started telling me how he had thought about coming a PT but now teaches people to ride motorcycles instead! This was a really positive experience for me. I helped relieve some of his pain and achieved “patient buy in”. My initial skepticism about my ability to perform the technique was the only negative aspect. Next time an opportunity arises to practice joint glides, I will have more trust in the technique and will also give the patient a self mobilization technique to do at home
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