This topic contains 98 replies, has 2 voices, and was last updated by Shenandoah University Division of Physical Therapy 1 week ago.
September 12, 2018 at 10:21 am #6623
Post your patient encounter reflections
September 12, 2018 at 10:50 am #6624
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.
- This reply was modified 1 month ago by Shenandoah University Division of Physical Therapy.
September 27, 2018 at 2:30 pm #6713
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.
September 12, 2018 at 10:56 am #6625
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.
October 3, 2018 at 6:29 pm #6795
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.
- This reply was modified 1 week, 4 days ago by Shenandoah University Division of Physical Therapy.
September 12, 2018 at 11:04 am #6626
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.
September 12, 2018 at 12:48 pm #6628
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.
September 12, 2018 at 2:21 pm #6631
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.
September 17, 2018 at 8:20 am #6646
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.
September 12, 2018 at 2:31 pm #6632
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.
September 17, 2018 at 8:18 am #6645
This is an interesting topic, I’m also looking forward to the consensus on ultra-sound
- This reply was modified 4 weeks ago by Shenandoah University Division of Physical Therapy.
- This reply was modified 4 weeks ago by Shenandoah University Division of Physical Therapy.
September 12, 2018 at 2:51 pm #6633
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.
September 12, 2018 at 2:57 pm #6634
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.
September 12, 2018 at 5:13 pm #6635
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.
September 17, 2018 at 10:20 pm #6658
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.
- This reply was modified 3 weeks, 6 days ago by Shenandoah University Division of Physical Therapy.
September 12, 2018 at 5:36 pm #6636
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.
- This reply was modified 1 month ago by Shenandoah University Division of Physical Therapy.
September 12, 2018 at 6:29 pm #6638
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.
September 12, 2018 at 7:46 pm #6639
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.
September 29, 2018 at 11:04 am #6743
Lori Yeaman in response to Jacque Hemler,
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!
September 12, 2018 at 8:28 pm #6640
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.
September 14, 2018 at 11:39 am #6641
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.
September 19, 2018 at 4:08 pm #6676
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.
September 17, 2018 at 11:59 am #6650
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.
September 18, 2018 at 6:22 pm #6660
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.
September 19, 2018 at 11:17 am #6667
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.
September 22, 2018 at 3:35 pm #6687
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!
September 23, 2018 at 2:52 pm #6693
Justin Geisler responding to Caleb Baxter
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.
September 19, 2018 at 12:34 pm #6670
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.
September 19, 2018 at 3:44 pm #6675
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.
September 19, 2018 at 1:59 pm #6671
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.
September 19, 2018 at 3:21 pm #6672
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.
September 30, 2018 at 6:21 pm #6751
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.
September 19, 2018 at 3:33 pm #6673
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.
- This reply was modified 3 weeks, 4 days ago by Shenandoah University Division of Physical Therapy.
September 19, 2018 at 9:19 pm #6679
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.
September 23, 2018 at 2:36 pm #6692
Justin Geisler responding to Ali C.
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!
September 27, 2018 at 6:33 pm #6717
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.
September 19, 2018 at 9:06 pm #6677
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.
September 19, 2018 at 9:07 pm #6678
oops – the above post (about Lymes disease and inability to DF) is by Bailey Long.
September 19, 2018 at 9:37 pm #6680
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.
September 20, 2018 at 8:04 am #6681
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.
September 20, 2018 at 11:55 pm #6683
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.
September 22, 2018 at 10:09 pm #6690
Emily Blum responding to Laura D’Costa
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.
September 21, 2018 at 11:58 am #6684
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.
September 21, 2018 at 12:55 pm #6685
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.
September 21, 2018 at 8:57 pm #6686
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.
September 22, 2018 at 6:53 pm #6688
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.
September 22, 2018 at 8:26 pm #6689
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?
September 23, 2018 at 2:11 pm #6691
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.
September 27, 2018 at 3:42 pm #6714
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.
September 27, 2018 at 7:48 pm #6719
(Levi responding to 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.
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September 28, 2018 at 11:08 pm #6740
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!
September 30, 2018 at 6:17 pm #6750
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?
September 27, 2018 at 1:14 am #6705
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.
September 27, 2018 at 10:16 am #6710
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?
September 27, 2018 at 6:19 pm #6716
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.
September 27, 2018 at 8:51 pm #6722
Daphne Batista Replying to Ally Kuhn:
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!
October 3, 2018 at 6:33 pm #6797
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.
September 27, 2018 at 7:39 pm #6718
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.
September 27, 2018 at 8:25 pm #6721
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.
September 27, 2018 at 9:51 pm #6724
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!
September 27, 2018 at 9:39 pm #6723
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.
September 28, 2018 at 6:44 pm #6737
Replying to 6723 – no name
So 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!
September 28, 2018 at 6:25 pm #6736
Reflection Post #1
The 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.
September 28, 2018 at 8:38 pm #6738
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.
September 30, 2018 at 7:25 pm #6752
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
September 28, 2018 at 10:46 pm #6739
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.
September 29, 2018 at 3:50 pm #6745
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!
September 29, 2018 at 3:36 pm #6744
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.
October 1, 2018 at 11:37 pm #6763
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?
October 3, 2018 at 10:57 am #6790
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.
September 29, 2018 at 8:31 pm #6746
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.
September 30, 2018 at 5:59 pm #6749
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.
September 30, 2018 at 10:14 pm #6754
Andrea Choo replying to 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!
September 30, 2018 at 10:01 pm #6753
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.
October 1, 2018 at 7:17 am #6755
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.
October 1, 2018 at 3:15 pm #6756
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.
October 2, 2018 at 10:10 pm #6769
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.
October 1, 2018 at 4:22 pm #6757
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.
October 1, 2018 at 5:17 pm #6758
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.
- This reply was modified 1 week, 6 days ago by Shenandoah University Division of Physical Therapy.
October 2, 2018 at 6:40 pm #6764
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.
October 2, 2018 at 10:02 pm #6768
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.
October 1, 2018 at 7:45 pm #6760
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.
October 1, 2018 at 10:57 pm #6762
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.
October 2, 2018 at 7:00 pm #6767
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.
October 2, 2018 at 6:52 pm #6765
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.
- This reply was modified 1 week, 5 days ago by Shenandoah University Division of Physical Therapy.
October 2, 2018 at 11:29 pm #6770
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.
October 3, 2018 at 10:21 am #6788
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!
October 3, 2018 at 10:27 am #6789
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.
October 4, 2018 at 6:50 pm #6805
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.
October 4, 2018 at 6:50 pm #6806
Above is from Jacque
October 3, 2018 at 9:44 am #6787
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.
October 7, 2018 at 5:32 pm #6838
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.
October 3, 2018 at 8:57 pm #6798
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.
October 4, 2018 at 1:20 pm #6803
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.
October 4, 2018 at 10:19 am #6801
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.
October 4, 2018 at 11:46 am #6802
Peter Cradduck (second Post)
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.
October 4, 2018 at 2:28 pm #6804
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.
October 7, 2018 at 5:27 pm #6836
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.
- This reply was modified 1 week ago by Shenandoah University Division of Physical Therapy.
October 8, 2018 at 12:14 pm #6841
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?
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