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From what I’ve seen in my own experience even the most skillful interviewers aren’t going to be able to get all the necessary information needed to treat a patient in the initial exam. You all did a great job of not getting too hung up on what it looks like/doesn’t look like with regards to a specific medical diagnosis and proceeded to identify hopefully treatable impairments. It will be interesting and telling to see her responses to the EBP you provide her after having reviewed relevant literature.
-John Orchard-Hays
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.
Bri,
This sounds like a very frustrating case. I agree that there is probably something underlying going on. I saw a patient last semester who liked PT so much that they were constantly changing their pain so they wouldn’t get discharged. While this seems a different situation, we ended up watching the patients facial expression when they were doing things to help get a “more accurate” description of pain and relied less on the subjective reporting. We had to be careful about not letting the patient know this was what we were doing too. I hope you are able to find more consistency or different way to help this patient get better.
Kayla Sweeney
Bri,
That sounds like a very frustrating and challenging case. I haven’t experienced a patient like that but it is probably more common than most of us think. I do like that through this complicated case with changing stories, that you have found how important it is to make the patient involved in the treatment guiding what impairments you treat. Although the story changes, you still keep the patient first and do the best you can. While I have not experienced this before and do not have any advice to offer, I have learned one way that I could treat a patient like this. It is very important to keep the patient first and treat the impairments they have at that point in time!
Marielle
Caleb Baxter
In clinic yesterday, I was involved with an eval of a patient who had just completed a bout of rehab with a different PT. I performed the subjective eval, while my CI took the lead on the objective portion since this patient was suffering from neck pain. Initially, the patient made it seem like the pain was new as of 4/5 months ago without a clear MOI. By asking a few more questions, I was able tease out that the pain was in a similar location to a surgery that was performed on the patient in 2007. The surgery was serious and focused on CN V. While the current neck pain feels new, it is likely that this patient had low levels of neck pain all along, the pain just was not enough to impact function. The patient seems like he is self-sufficient and deals with pain well, supporting the hypothesis that this may not actually be a completely new pain. I think this case supports the notion that we need to be specific with our subjective examination, as most of the relevant information can be gathered with a proper, accurate subjective. This can help us tailor our objective examination so we are not completing every test in the book. A strong subjective history also helps develop an accurate prognosis and give insight into the level of education that is necessary.
Patients that are not good at accurately describing their chief complaint, current level of function, and PMH provide a huge challenge to the interviewer. We need to be clear and concise with our questioning and clarify responses to make sure that we are getting an accurate picture of our patient. The most skillful interviewers are able to get this information quickly and effortlessly, and this is a skill I want to develop further throughout the second half of this clinical experience.
Brianna Virzi
My CI has been treating a 47 y/o female patient with left shoulder pain for about 4 weeks via direct access. I have seen her on two separate occasions, and it has become a very frustrating case. This patient’s chief complaint during the initial evaluation was deltoid insertional pain specifically when turning her wheel while driving and lifting her arm overhead into abduction. Imaging has been negative, the capsule has normal mobility, and there is not a consistent pattern for symptom provocation. Although we are unsure of this patient’s medical diagnosis, we have been treating the impairments that were found in the objective exam such as PROM/AROM limitations and rotator cuff weakness. However, this patient’s symptoms seem to change between sessions and sometimes even within sessions. In the same day, active assisted abduction with the pulleys can be completely painless, and then active assisted abduction with the cane is suddenly so painful that she cannot perform the exercise. Even though fatigue may play a factor, you would not expect such a drastic change when performing essentially the same movement. She also reported that driving was much easier during one session, and then the following session claimed driving is still difficult and there hasn’t been any improvement.
The inconsistent findings with this patient are plentiful, and they have been challenging to comprehend. My CI and I feel like there is an underlying issue, especially since this patient takes Lithium yet did not report any past medical history. It feels like regardless of our many efforts, the patient’s story is always changing. Nonetheless, this experience has highlighted the importance of the patient’s role during treatment. We heavily rely on patient subjective and objective information to guide our clinical decisions, and this can be difficult when there are so many discrepancies. I would be interested to hear if anyone has any suggestions about how to manage patients similar to this.
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.
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.
Alyse –
Thank you for sharing! I have not had the opportunity to work in a hospital setting so this aspect of PT is completely new to me. It’s so cool to see how our interventions seem to expand beyond the realm of just musculoskeletal treatment. The closest I’ve seen to this kind of intervention was in an outpatient ortho clinic where the PT used coughing as a form of exercise (I was a tech at the time so am not 100% sure of her reasoning for it but I can only imagine it had to do with decreased diaphragm function). Thinking of it, the diaphragm is still technically a muscle. Regardless, it seems to both overwhelm me and excite me the options we have as far as treatment goes in physical therapy.
-Victoria Appler
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.Alex,
That’s interesting, because we talk a lot about focusing on patients’ specific functional limitations and participation restrictions and their specific self-generated goals, but in this scenario you seem to have discovered limitations for the patient. Nice way to give the patient something meaningful to improve upon and at the same time give yourself a job.
-LeviAlyse 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?
Alyse Nierzwicki
Over the past few weeks, I have treated a patient with a complete C4 spinal cord injury (IP acute setting). Our sessions thus far have targeted patient-led bed mobility, proper wheelchair positioning, independent pressure relief, and caregiver training. Given the patient’s injury level, he is unable to successfully execute a volitional cough; this leads to a significant increase in fluid build-up and subsequent decreased O2 sats. Recently, he has been refusing his cough assist from nursing and respiratory therapy.
This past Tuesday, my CI and I initially planned to implement the bed ladder to initiate self-rolling. He, however, described a significant increase in shortness of breath and fatigue. We altered our treatment plan to include chest percussions and postural drainage to decrease the fluid build-up. We placed the patient in multiple positions that isolated the lobes of the lung – progressing fluid from the lower lobes to the upper lobes and eventually out of the body. We also provided abdominal/chest compression to help the patient force a cough.
In effort to improve our patient’s cardiovascular function and overall participation in physical therapy, we performed rapid chest physical therapy. This was a beneficial learning experience because it introduced an alternative treatment technique necessary for patients with high-level spinal cord injuries. It also helped widen my perspective of in-patient physical therapy beyond the musculoskeletal and therapeutic exercise components.
Marielle Giardini
In the outpatient ortho setting, I had the opportunity to work with a 30 y.o. male who presented with a SLAP III and a partial tear (1 cm) of supraspinatus. At the start of the session, my CI took him through PROM where he had pain and catching with flexion and aBduction. My CI and the patient let me take him through these, as well. We then moved on to AAROM with a broom and isometrics against the wall, with aBduction being the most painful. With scapular stabilization, we did scapular retraction in prone and the patient stated he felt like his arm was going to dislocate and that it was very painful. My CI decided we should try scapular retraction seated which seemed to not be as painful compared to being in prone. This was the patients third visit with my CI and her main concern was to make sure the patient didn’t lose him ROM and to work on scapular stabilization. However, the patient could tell he wasn’t getting any better (possibly worse) and he did not seem as motivated; he mentioned a few times during the session that he knew surgery was going to be his only option.
I found this experience very beneficial for me as a PT student because this was my first time moving a pathological shoulder. It is one thing to practice these skills on classmates who are healthy and have more range and are pain free, but to have the experience to feel what it is like and to feel and hear the “catching” in the shoulder. I also found it helpful talking with my CI through the different exercises and why we were doing them. I was able to see why she first chose these exercises (already established in the POC before I saw this patient) and seeing her problem solving when the patient experienced pain in one position, but not another.
Alex Gett
I performed an eval on a pt that came in with knee pain due to mild trauma. He was working on his trailer when one of the jacks holding it up malfunctioned and part of the trailer was on top of him. He was forced to rely on his R LE to push himself out from under a part of the trailer. He reported minimal pain at the time of the incident, but woke up at 3am that morning with “unbearable pain.” He got an image roughly 2-3 weeks later that was negative, and he managed his pain in the meantime with ice, rest, and NSAID’s. By the time he came to the clinic, it was roughly 6 weeks past initial injury; a decent amount of healing has been done at this point. His PCP advised him to come to PT “to make sure nothing sever is going on” –> no red flags, mild discomfort with active knee ext, no other measures reproduced symptoms; this was a rather quick screen before functional testing. pt had the “why am I here” attitude, but I was determined he walked into the office for a reason. We went into the main part of the clinic where I asked him to perform eccentric step-downs; pt presented with dynamic valgus, pain in knee, and arm strategy compensation. pt reported he uses stairs often, but he was not aware of his compensation and was able to see his impairments until asked to slowly lower himself. DL squat did not necessarily reproduce pain, but other ROM limitations hindered normal movement. Upon further STT, no other measures reproduced significant pain; slight weakness in ABD. This was a great experience, as I watched pt buy-in happen with one functional test. It was also a great experience because it showed me that a pt may look relatively normal during STT, but functional testing is a whole different story that has the ability to expose impairments.