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Mary Davern
I was working with a 40 year old white male who had a disc protrusion of L2 and was also complaining of pain in the anterior hip. My CI suggested that I do a lateral distraction with a belt. I had never done this technique on a real patient before so I was excited to try it. I was worried about handling his leg because this patient was over six feet tall and overweight. I was also feeling a little nervous because I found the distraction very uncomfortable when my lab partner did it on me and did not want to increase my patient’s pain. After I did the distraction for a couple of minutes, he did a lap walking around the clinic. My CI suggested doing some lumbar extension exercises next but he looked at me and said: “Could you do that belt thing again? It really seemed to work”. As I was getting the belt set up again, he said: “wow you PTs are pretty smart” and started telling me how he had thought about coming a PT but now teaches people to ride motorcycles instead! This was a really positive experience for me. I helped relieve some of his pain and achieved “patient buy in”. My initial skepticism about my ability to perform the technique was the only negative aspect. Next time an opportunity arises to practice joint glides, I will have more trust in the technique and will also give the patient a self mobilization technique to do at home
Lori Yeaman – Reflection #3
Before we covered the ankle unit in our MSK course, I saw a patient in clinic who was several months s/p distal fibula fracture. The patient’s ankle was stiff in all directions secondary to being casted for 8 weeks. Some of the treatments that my CI selected to improve ROM were A-P TCJ mobilization, P-A TCJ mobilization, A-P fib mobilizations at the distal tib-fib joint (fib had healed appropriately), and mobilization with movement at the TCJ. After covering the ankle in class, I now have a better understanding of the arthrokinematics involved in ankle motion, as well as my CI’s treatment rationale. Upon reflection, it is interesting how such small quantitative gains in ankle ROM can lead to such large functional improvements, such as normalizing gait and stair ambulation.
Lori Yeaman responding to Andrea Choo:
Andrea,
This sounds like a great learning experience and really reinforces what we learned in class. With this case, and even speaking more generally, it is always interesting to compare and collect different techniques for similar treatments as we progress through our PT education. Great reflection!
I saw a patient in clinic who had a broken down, planus foot, but also had fractured her big toe (dropped a weight on it). I joined in mid way through the session so all I really saw was her TherEx. She was doing a lot of toe yoga, short foot exercises, etc. At this point she was doing pretty well with therapy and she didn’t really have much else going on. It’s interesting that the patient at one point said “this is the most disabled I’ve ever had.” it’s interesting to see how degree of disability is so subjective. In her mind, she was severely limited in her life, where as right before I had seen a patient who had an above the knee amputation and used the phrase “I mean it’s whatever.” So this made me realize that as PT’s we tailor our approach to a patient not only based on their impairments, but how they perceive their impairments as well.
Marielle Giardini
One week in clinic, we saw a 45 y.o. female with lumbar pain. My CI had been seeing her for a couple treatment sessions already and explained to me that the patient also had hip pain. My CI let me do back mobs and the patient was great about giving me feedback on if it felt similar to how my CI does it. After working on her back, I was able to perform inferior and lateral distraction with a belt. While doing this, I realized how much work and effort it takes to do treatment in those positions. After doing bouts of this, we reassessed her painful positions and the patient’s pain was decreased. It was great to see first hand how these treatments help the patients and to see the impact you made on their day.
Emily responding to Tiffany:
Hey Tiffany,
I had a similar thing happen multiple times in my ICE this semester. It made me reflect on how it’s one thing to learn about normal values in class and then a completely different thing to watch someone experience a life threatening low number right in front of you. That’s great you taught him about energy conservation. I think that’s as aspect of our profession that is bigger than I had ever imagined.MJ responding to Melissa Jankus re “evaluation on a middle-aged woman 4 weeks post-lateral ankle sprain”.
As I have seen 0 foot or ankle cases this semester, this was fun to read. From your description, it sounds as though this was a one-time event and she was not prone to repetitive sprains, do you know if that was the case? I’m always interested in seeing what the prescribed exercises are but we get so much more information when we can ask the PT why those since mini squats and backward walking could benefit AROM, balance and proprioception or strength depending on patient presentation. Thanks for sharing and proving an application case before exams!Sarah responding to Cassie Post 3:
Cassie,
Thank you for sharing this patient case with us! It is so interesting that she was in PT for her knee, but did not have any mechanical deficits, aside from her fear of re-injury. I wonder if the orthotic, along with some lateral strengthening proximally and distally might help her in the long-run. It sounds like she is pretty young, so it seems as though there may be high potential for recovery and to help improve qualities of her biomechanics!
Kayla,
This is such a valuable experience you had. I think as future clinicians, we need to provide our knowledge not only manually, but with education. This is a great learning experiences for advocating for our patients. Great job!
Cassie
Post 3: Cassie Rawa
On my last day in clinic, I was able to evaluate a patient with an acute patella subluxation.The patient was holding her new born child and was twisting to get something and subluxed her patella, a week prior. When she presented to clinic, she had no range of motion deficits and no limited PAMs. The only issue was her fear of moving her knee into end ranges, considering when she did she subluxed her patella. There was minimal pain and swelling, again just reiterating the fact that this patient was just scared of just subluxing her patella again. The only impairment that was noted, was during ambulation she was hanging out in extreme inversion on her right leg (the same leg she subluxed her patella). We offered her orthotics in the future considering this could lead to issues. This case was interesting to see minimal deficits with the patient, the main problem was her fear of reinjury and her ankle. For the future, it is important to assess proximal and distal segments with the LQ as they related very much.
Melissa Jankus
During one of my days in clinic, my CI and I performed an evaluation on a middle-aged woman 4 weeks post-lateral ankle sprain. The patient reported twisting her ankle while wearing heels with a narrow base of support. The patient reported minimal pain, just on the lateral side of the ankle. She reported that walking for a long time aggravates the ankle and resting and icing makes it feel better. The patient’s goals included getting back to walking and exercising at prior level of function. The patient’s ankle range of motion was almost all within normal limits, with only active and passive dorsiflexion being slightly limited. All resisted testing was strong and painless. Passive range of motion into dorsiflexion along with a posterior talocrural glide were done to help increase dorsiflexion range of motion. The exercises prescribed included ankle alphabets (active range of motion), 4-way ankle active range of motion with a Theraband, bilateral mini squats and backwards walking. The session was ended with ice and e-stim for 15 minutes. Overall, this was an interesting evaluation because the patient came in 4 weeks after the initial injury, so she was almost back to full function. She just needed PT for the common residual deficits involved with a lateral ankle sprain. My CI and I expected that she would not need many visits to PT in order to get her back to full function.
Caleb Baxter
Over the course of ICE 2, I saw multiple patients with plantar fasciitis. This was before we covered the topic in MSK, so I wasn’t very familiar with the diagnosis and proper treatment. All i knew was that plantar fasciitis involved plantar heel pain and that a common treatment was stretching. I did not see these patients for many sessions, but it’s interesting to reflect and compare how my CI and I developed a plan and how I would develop a plan now. I was not involved in any of the evals but I’m almost positive my CI did not look at whether the patient had a pes planus or pes cavus foot to dictate treatment. One of the patient’s had a bone spur, which I assumed was certainly contributing to the pain and making things worse at the time. Now, I’m not so sure. We’ve learned that about 1/3 of people have a heel spur and many of these individuals are asymptomatic. All the patients with plantar fasciitis received noxious stim. I discussed this treatment in the therex discussion board for an achilles tendinopathy patient. It is essentially e-stim with the goal of pain desensitization. In order to be effective, the patient should experience a 6/7 out of 10 pain when the electric stimulus is on. In the CPG for plantar heel pain, electrotherapy receives a D and manual therapy with therex and foot orthoses are recommended instead. I wish I had looked more into the CPG while I was seeing these patients. I plan to treat plantar fasciitis more effectively the next time I see it in clinic as I know better now.
Austin Wernecke
There was never a time in clinic that I saw a patient who had an ankle or foot pathology. However, there was one stroke patient that had neuropathy in his foot. He presented with decreased balance as well as increased postural sway with ambulation. These were both things that were caused by the neuropathy. When looking to treat this, I did not directly do anything to the foot or ankle per se. Instead, I focused on functional tasks with this patient. As we would walk, I had him reach out intermittently and touch a football that my CI was holding. This made my pt look up and not focus on his foot. This lead to an increase in his balance with gait as well as decreased postural sway. I feel as if this could be due to the fact the pt’s center of mass was brought more posteriorly and his eyes were focused straight ahead and not at his foot. I am wondering, even though he has neuropathy if this could potentially increase his proprioception as well. Not with the foot but possibly the ankle. Since I was forcing him to ambulate without visual cues for his foot in space. However, He did see improvements with this activity.Kayla Sweeney
In clinic this semester, I worked with a 2-year-old girl with a chromosomal deletion. She was unable to sit up without support and was unable to clear secretions on her own. I learned this semester that sometimes in early intervention you spend the hour educating the parent rather than putting hands on the patient. The patient’s mother was trying to decide if it was worth getting a supportive standing device the doctor had recommended. My CI spent the entire treatment educating the mother on the importance of weight bearing at a young age for proper development of the hips and acetabulum. While I was not able to actively participate in the moment, It was interesting to see how my CI handled the situation and changed the parent’s point of view. She focused on education and gave the parent the power to make the decision but made sure the parent had enough information for an informed decision.
Ahmad Rahman
In my time at my internship there was a particular patient who showed up just once (although I’m sure she was seen regularly outside of my days there). She was a 26 year old white female who had recently suffered a stroke, and I figured that this would be a pretty straightforward case. It threw me off that she was as young as she was, seeing as I had just turned 26 as well, but that didn’t deter me from using the fresh knowledge about stroke rehab I had gotten in adult neuro to work with her. When she came in, it was apparent she had several cognitive defects on top of her stroke diagnosis as well; I don’t recall which sided stroke it was, but she was showing signs of learned non-use with her UE, and had an abnormal shuffling gait pattern with lack of pelvic dissociation. While doing her initial eval we noticed several of her limbs had increased spasticity, particularly in her upper arm and finger flexors, and we worked on these for a majority of the treat. It was eye opening for me to see someone so close to me in age be in the circumstances she found herself in, and it almost reinvigorated my desire to get the most bang for the buck out of the session as I could.