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A couple weeks ago I was able to perform a PT screen with a patient in the acute care setting. It was an interesting experience and one that I had never heard of before. My CI explained to me that the “screen” we were to perform was simply to assess the patient’s chart to understand if this patient would require a PT evaluation or not. If we could not make a determination, we would speak to the patient to assess their typical baseline levels, but would not be allowed to touch the patient. So I went into each patient’s chart to assess if they might require an evaluation for PT, but was a bit in the dark about who would “require” it and who might not.
On the first patient I was looking through her chart and trying to decide if they would need an eval, but I wasn’t sure. My CI informed me that she had put in for an eval for the first patient screen. I was still quite unsure why she had decided to do this so I asked for her reasoning. She mentioned that through the patient’s previous notes, she was able to discern that her baseline levels prior to admission compared to her current level of function represents the need for PT to work back to those functional levels. This is where I began to understand what the screen was supposed to be used for.
Now that I understood the reasoning for the screen, she wanted me to take the lead on the next patient, who we were unable to determine if a screen was necessary simply looking nat the chart. We were speaking to him and he stated that he lived alone and was independent with all aspects of life, and then started becoming debilitated. He was unable to walk up the stairs and was crawling around the house. He then got a ride to the hospital and was found to have a blockage in his bowel, rendering him unable to care for himself. Therefore, we determined that he would need a PT consult as soon as he was strong enough to perform.
Jesse Parsons
Recently in clinic I evaluated a 14 yo girl who was complaining of anterior knee pain just below the apex of her patella. Originally, my CI believed that she most likely had patellar tendinopathy. As I listened to her subjective history, though, it became apparent that her pain was most likely stemming from other problems. She had sustained a fall in gym class where she landed on her patella on a wooden floor. While observing her standing posture and her walking form, it became apparent that she tended to stand with genu recurvatum and her knee went into excessive hyperextension during gait. She also had pain with end-range knee extension, but not with passive knee flexion or active knee extension. This led me to believe that patellar tendinopathy was less likely. I palpated the inferior pole of her patella where the patellar tendon attaches, and she said that it was not painful. She did have pain, however, when I palpated inferiorly along the tendon. I then remembered the fat pad that lies beneath the patellar tendon, because we had just learned about it in class that week. I palpated beneath the tendon and she reported a large increase in pain. This led me and my CI to believe that her pain was most likely stemming from her patella digging into her fat pad as she stands in knee hyperextension. It was really cool being able to apply knowledge from class in such a quick and relevant way.
Levi responding to Jacque,
That sounds super frustrating. As we are learning, there seems to be a lot that goes into a successful patient interaction, like patient rapport, and patient expectations. It’s unfortunate that the surgeon would start the patients off with this mindset and almost set them up for failure.I honestly don’t know how you go about winning over a patient like that. I guess the doc expects ROM and strength and all the rest to return in a self-limiting manner?
At this point in typing my response, I decided to do a quick literature search, and found a RCT “Formal physical therapy after total hip arthroplasty is not required: a randomized control trial”. This is from the journal of bone and joint surgery. The conclusion from the abstract states “This randomized trial suggests that unsupervised home exercise is both safe and efficacious for a majority of patients undergoing total hip arthroplasty, and formal physical therapy may not be required.”
Although this study is for the hip and not the knee, I guess this may provide some insight into the perspective that the surgeon takes?????Levi Perry
So I haven’t been in clinic since my surgery, but I did perform a hip exam on my Mom (Lol), so let me share:
She has been having bilateral hip pain (R>L) for upwards of a year to varying intensities. Subjectively, pain is on lateral aspect and some “deep down” in joint, as well as low back (she pointed to SI area). Pain is activity dependent and worsened by walking longer distances, standing, stairs, and some pivoting. No history of trauma or anything. When she told me this over the summer, I was thinking OA or lumbar, but after our hip unit, my primary hypothesis was glute med tendinopathy. Functional testing – DL squat had decreased depth, but was symmetrical and displayed no valgus or trunk lean and was only painful for both knees (she avoids squatting because of her knee pain…I left her knees for another exam due to time). Single leg stance displayed very poor balance, but no valgus, trendelenburg, or pain provocation. Active and passive ROM was normal. The only thing that reproduced her pain was inner flexion quadrant and FADIR (deep pain) and resisted IR (lateral pain)… she was not very irritable that day. At this point, I was confused by the presentation, but I was retaining my primary hypothesis of tendinopathy for a lack of a better replacement. The lack of ROM restriction largely ruled out OA, but I wasn’t really able to explain the deep pain from FADIR. I was also thinking that there was very likely not just one thing going on… maybe FAI or minor OA provoked by FADIR, tendinopathy provoke by resisted IR, and SI playing some role here? I skipped PAM because there was no ROM loss. Glute med MMT was about 4/5, but caused no pain (which really surprised me). FABER (-), Straight leg test (-), Scour (+ only in inner flexion quadrant), de-rotation (+). Palpation to glute med tendon painful, as well as glute med and TFL muscle bellies (glute > TFL), greater trochanter painful. Palpation to Right SI joint produced localized pain. I told her she would have to wait until I learned about the SI joint, but that there was likely something going on with it, and potentially strengthening glutes could help stabilize it. Easily the most provocative aspect of the exam was the palpation. I educated her on potential aggravations to a glute med tendinopathy (she sleeps on R side and doesn’t use a pillow between legs). I previously had given her the Myrtl hip routine and some stretches, but i told her to focus less on the stretches, which could potentially even aggravate things, and focus more on clamshells, SL abduction, and maybe a glute max exercise. I told her to do the exercises until fatigue or loss of form, and let me know if they aggravate her too much. I would really like to have her doing DL or SL squat stuff, but it bothers her knees too much. My plan is to progress the clamshell and abduction to something more functional, like step ups/downs (if knee can tolerate), and something in single leg to work the glutes and also her balance deficits.Matt Reis
I am currently with home health physical therapists doing my rotation. My CI and I showed up to this house where he asked me to take the history and figure out what we needed to do with this patient. I was informed that she was previously in the hospital for a fall, but that was the only thing I was informed of. Within the first few minutes of talking with the patient, it was clear that she suffered from some cognitive deficits. This lady is above the age of 90, lives in a two-story house, and was unable to directly tell me who lived with her in the house. She did, however, state that her husband worked at the power plant nearby, she hasn’t seen him a few days, but the plant gets really busy at this time of year so he would be home soon. After leaving the house, my CI informed that her husband passed away years ago.
I proceeded with my evaluation where I got the patient up and had her walk around the house. The first stop we made while walking was in the kitchen where I asked her if she had difficulties with preparing food. She stated that she didn’t, but when she opened the fridge to show me what she was eating, the fridge was essentially totally empty with maybe three or four items in the fridge which included the condiments. We left the kitchen and proceeded to the stairs as her bedroom is on the second floor. She is unable to use her FWW going up the stairs so she just simply leaves the walker at the bottom of the stairs. There is only one handrail on the left-hand side, and this is what she holds onto as she struggles to get up the 12 steps she has to the second floor. Once she reaches the top stair she has a dresser in the hallway, where she will let go of the handrail of the stairs and ever so cautiously staggers toward the dresser to use this to hold onto. She will scoot alongside the dresser to the door to her bedroom. Upon reaching the bedroom, she has dirty clothes laying all over the room, and as we walk around the house you can clearly smell that she has not bathed for multiple days and is unable to recall the last time she was bathed.
This lady had no one to check on her, lived on her own, and was one fall away from an extremely tragic accident that could possibly end up taking her life. My CI and I left the house and he discussed how she has a son, who lives out of town and cannot come back to care for her. My CI asked the son if he has looked into the getting a home care provider and the son stated, “No, every time I talk to her she says she is fine.”
My CI reached out to the adult protective services, and they essentially said that they can’t give out any information about the case or how long it would take to be resolved. So with all this being said, is there anything else we can do at this point and time to help this patient?Caleb,
Yeah I agree that getting good at completing a thorough subjective history can really give you 80% of what you need for diagnosis. I would imagine that any of the objective tests you performed matched up with what you thought it may have been after the subjective history. I know I am still trying to perfect histories and Im sure this experience probably helped you a lot with asking the right questions and teasing our important details for cases.
Andrew Lamont
Andrew Lamont
Last week in clinic, I was able to work with a patient who was 2 weeks s/p TKA. She was 82 which originally concerned me before arriving at her house because of the possibility of her healing capabilities and mobility. When we arrived to her home, she was in exceptional health and was ambulatory with limited AD use. We wanted to check her ROM and strength prior to discharge the following thursday to OP care. She demonstrated AROM knee ext at 7 degrees which was great considering her age and short period of recovery. Her AROM knee flex was at 104 degrees which was also exceptional at this point in her recovery. I performed some posterior tibial glides to her knee to try and gain a few degrees of flexion for a few minutes which ended up allowing her to passively reach 111 degrees by the end of the session. She was performing heel props as an exercise at home which had clearly been effective, however, i wanted to add something to gain those extra few degrees. She stated that she had been feeling stiff in the mornings especially and I wanted to target her limitations the best I could. I showed her a stretch in prone to hang her leg over the bed to encourage ext which would be easy for her to do in the mornings even before getting out of bed. She was extremely compliant with her HEP and I believe this is why she was progressing so well with her TKA. Its always great to see compliant patients and the outstanding outcomes that happen with them.
Above is from Jacque
Bri,
This is an interesting situation. I can see your frustration with this patient and I am puzzled myself with how to deal with this patient. I am interested if trying to address the issue would do anything? It would definitely depend on the type pf patient they are, but I wonder if asking them why their symptoms about driving and such would bring out some more information. Either way, it is definitely a difficult barrier to overcome, and you are right on with the importance of the patient’s participation. If they aren’t going to give optimal effort and reliable information, we unfortunately won’t be able to give them optimum treatment.Jacque Hemler
This past week in clinic I saw a TKA who was 3 weeks out. Before seeing the patient, my CI and I talked through the patient’s situation as this was the first time I was seeing her. My CI said that the patient was very pain oriented and had decreased knee flexion for her point in recovery. When we got the the house, the patient started out saying she wasn’t going to do much today because she was really hurting. She was having an MRI later that afternoon due to inspect the internal sutures because she was concerned that a muscle spasm in her leg may have ripped through them. The patient began to complain that her last outpatient PT had pushed her too hard and messed up her other knee. Her doctor advised her to stop going to PT due to this, so she isn’t too happy with therapy. I could tell my CI got very tense during this situation, but she proceeded with therapy. When we tested her flexion, she was still only achieving 58 degrees of active flexion with considerable pain. She seemed to exaggerate a lot of her pain and then seconds later she would be fine. After leaving, my CI explained to me that the surgeon she has often puts down physical therapy and tells the patients what they want to hear. This is very difficult to deal with as patients often look to surgeons for all their information, including the musculoskeletal aspects. While they obviously know what they are doing, if we are not working as a team in the health profession world, it makes the patient’s success in recovery much more difficult.
MJ,
Seems like you have a very interesting case in which you can begin to use the information you learned in MSK I. It is great that you were able to do a subjective and make some clinical decisions based on your findings. Excellent idea with the OP into flexion. It is important that he restores that flexion in order to be able complete ADL’s, correct? MJ, in this post you mentioned that he primarily uses shoulder movement to compensate for his elbow restrictions; with this in mind, do you suspect that improper/over use of his shoulder could lead to shoulder pathologies down the road if his elbow limitations are not addressed? Glad you had this opportunity and hope that he is able to make improvements as you continue to work with him.
-PetePeter Cradduck (second Post)
10/2/18
Let me tell you about how my CI and I helped a man with severe dementia to escape from the nursing home and run free into society. Okay, maybe not the last part about running free in society, but we did break a man out of the locked-down dementia unit and alter the trajectory of his day.
“Sun-downers” are patients with psychological illnesses that increase in symptoms during certain times; typically night time. Our fugitive patient (we’ll call him Mike) was characterized as one of the patients that had good times and bad times depending on the time of day. In the past few weeks, Mike had increased profanity and constant a disgruntled face (like Clint Eastwood from Gran Torino). I used my clinical reasoning to deduce that he was in his “sun-down” mode during our visits.
Mike is in pretty good shape for a 92 year old, especially in comparison to his fellow residents. If gait speed was the only vital sign, he would be healthier than my CI and I. Our exercises for Mike are designed for strengthening and getting him to slow down. Unlike all of the other patients we see during the day, his dementia truly is his biggest limiting factor. Exercise has helped him in the past and has seemed to be the most effective treatment for him in regard to his overall quality of life.
It was made clear to me that although patients with dementia may not remember a conversation from one minute to the next, the limbic system can perpetuate a negative/positive mood long after an experience. This mood can leave a patient angry or happy and not sure why. With this in mind, we decided to do our exercises in a way that might improve the patient’s mood and decrease profanity. My CI came up with the idea of taking Mike outside to do his exercises.
Once we got outside and sat down in a chair Mike’s Clint Eastwood face dissolved into a smile. As we did our exercises, instead of talking about how he can’t believe how his “Golf game has gone down the D*** pipes” he talked about how his wife would allow him to golf when he wanted and how he is proud of his son. He remembered our exercises more clearly. Mike’s dementia was not cleared, but he was more alert and optimistic this visit. When we walked Mike to his room an hour later, he was in great spirits and didn’t seem to know why. This was probably the most interesting part of my day, and whether he knows it or not, it was Mike’s highlight as well.
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.
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.
Daphne,
With regard to the stretching we mostly just stretched the shoulder in abduction and flexion, the elbow in extension and the wrist in extension 3 * 30s each then placed a split on her hand to help with positioning. As for her future abilities I do have faith that she will be able to be independent with a wheelchair as she was able to sit in her chair for a short period of time during our last visit; however, it may take a long time because she is still max A * 2. I predict hopefully by the end of the year she will be able to sit regularly in her wheelchair. Unfortunately, though we will not be able to see her success since she is no longer in need of hospice care they will not pay for our home health services and the patient’s insurance does not cover our services either so she will be switching to another home health service at the beginning of next week. I’m glad you enjoyed my post, it was a really great experience and one that I will care with me for a long time throughout my career.
Best,
Ally Kuhn