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Sarah Roderick
In the inpatient acute setting, I am currently in the cardiac and ICU units. My CI and I co-treated a patient who was originally having a cardiac catheterization performed. However, during the surgery the patient’s R coronary artery was nicked and caused the patient to go into cardiac arrest. The team was able to revive the patient with bouts of CPR. However, the patient was admitted to the ICU and remained there for approximately 3 weeks due to additional complications that arose after the catheterization.
I was originally nervous to work with this patient given the patient’s recent history and level of immobility. Given my CI’s description of the patient’s current status, I was not sure what we would be able to accomplish during our session. My CI and I were surprisingly able to do several AAROM activities and some isometric strength training, which the patient was not able to do the day before, according to my CI. Therefore, my CI and I felt that we were able to safely get the patient to the edge of the bed, and standing with mod A x 2. Throughout the entire session, the patient was very confused, but also very eager to get moving as the patient repeatedly stated that they were going home in a couple of days. This statement likely came from a severe state of severe confusion, and is a hinderance to the patient’s prognosis as this patient is very unaware of their limitations in strength and balance.
It was very eye opening for me to see a patient who had a high PLOF and within three weeks has declined tremendously. I think this speaks to the negative effects of immobility, as well as how quickly muscles atrophy and strength declines when we are immobilized for so long. Further, being in the ICU and immobile for so long can cause this state of severe confusion or delirium, which is often not an affect of immobility that many would think about; but the lack of awareness is a huge hinderance and obstacle to overcome in one’s recovery. Though the patient had made extreme amounts of progress in 24 hours, it is important to recognize how long it will take before the patient returns to their PLOF. It did not take much time (3 weeks) for the patient to lose so much mobility and muscle tissue. This also emphasizes the importance of a variety of rehab specialists that will be a part of this patient’s care and return to function, for an extended period of time.
I felt that my CI and I did the appropriate amount of activity and challenged the patient within their limitations, but also attempted to provide a sense of reality in directing the patient that additional rehab may be beneficial by pointing out their current functional status. In the future, I would like to continue to improve my comfort level with these types of patients who have undergone severe trauma, and continually think of the most appropriate activities to challenge the patient within their limitations as they are returning to their previous level of activity.
Tiffany Reynolds
I am in an inpatient acute care setting where many of our patients that we see have chronic debilitation. Typically in the acute care setting as a part time student you will only see each patient one time, maybe twice. I have seen one patient 3 weeks in a row which is particularly rare in this setting. It is an unfortunate situation as she has hopes of going to inpatient rehab but was denied the first time around, the PT and case manager resubmitted and it is currently under review for the second time to see if she can get approved for inpatient rehab. I am not sure what her other option would be at this point in time as her husband works full time and she cannot stand on her own. She is mod assist in most activities and it would not be safe for her to be discharged home.
We have tried to help her as much as we can in acute care to decrease the level of assist. However, this has been very difficult as she has many fear avoidance behaviors. When speaking with the patient she seems very motivated and has a go getter attitude but when she has to perform her attitude becomes more negative and she does not believe that she can progress. We have continued to work with her performing bed mobility and sit to stands. We would like to progress to ambulation but she can stand at this time for more than a couple seconds. There is definitely a weight and lifestyle factors component to this patient’s state as well. While she has hopes to be discharged to inpatient rehab I think that this may not be the best option for her especially when considering her mental state as I do not think she would be able to tolerate the amount of rehab required. I hope to see her get approved for at least a SNF because she is not safe for discharge home at this time.Lori Yeaman
I have had the opportunity to work with a patient with gluteal tendinopathy over the past few weeks of clinic. She is a great patient to work with and has progressed well with her exercises in therapy. She has improved strength, decreased pain, and the patient reports that she can now sleep on the involved hip at night, whereas before therapy her hip was too irritable to sleep in sidelying. However, last week, she reported that her hip was more painful that day because she had rested in sidelying on the involved side for hours during the daytime. After asking further questions, my CI was able to offer the patient activity modifications such as sitting up in a chair to read a book or watch TV during the day, sitting at a table to do a puzzle, or going for walks. She educated that patient on how those activities would decrease the compression on the gluteal tendon and relieve pain. We learn about activity modification and patient education in class, so this experience demonstrated a real example of the importance of asking questions about a patient’s life outside of clinic, as well as being prepared and creative to respond constructively. I learned from watching my CI in this situation, that activity modifications should be feasible, functional, and meaningful to the patient in order to help the patient continue to progress through rehabilitation.
Andrea Choo replying to Pat
Pat,
I found it interesting that your CI utilized less traditional means of obtaining information about your patient. I’ve also noticed that it’s pretty similar in the pediatric population as well, since the majority of the patients are unable to speak for themselves or even follow basic commands. Even when there is a parent in the room to answer questions, we tend to take with a grain of salt because the information is not always the most accurate. We spend a lot of time observing how a patient motor plans and performs various functional tasks, rather than a more formal exam as we use in MSK class. At the beginning of ICE II, I didn’t really feel like I knew what to look for when I was observing patients. However, I do feel like I’m slowly beginning to become more observant and gain a better understanding of what to look for. I hope that you find that it gets easier too!
Andrea Choo
A couple weeks ago, my CI and I performed an evaluation on a 20 mo year old boy with a referral due to problems with his L leg. As my CI and I performed a chart review that morning, we noticed that he had a significant family history. The patient’s biological mother had a history of gross motor and cognitive deficits due to fetal alcohol syndrome during her mom’s pregnancy and drug abuse (marijuana and heroin), which continued throughout her pregnancy with the patient. Additionally, the biological father had a history of CP. The patient was currently living with his mom’s adoptive parents (his grandparents) due to his parents’ inability to care for him and continued domestic abuse. We didn’t have a lot of information on his past medical history, however, there was a note that his pediatrician and neurologist had not found anything medically wrong with him. As we got the subjective history from his grandmother, the patient seemed like a normal toddler running around the room and playing with toys. The grandmother denied any observable cognitive or motor delays, but reported that the patient tended to drag his L foot and tremor exhibit a tremor throughout the day. Additionally, she was concerned that he may be experiencing grandma seizures but stated that neurology and the pediatrician had both cleared him. Instead of performing a structured objective assessment, the majority of our evaluation involved the patient playing games and participating in activities (ex. Sit on the floor, sit to stand from floor, kneeling, stairs, jumping, kick/throw a ball), as we observed his movements and motor planning. Some of our observations included walking/running toed out on various surfaces, preferential initiation of sit to stand with L, several motor plans to go up/down stairs but preferentially initiation with R (L required facilitation from PT), SLS could be achieved on both legs to kick a ball and jump off bottom stair with min A. His cognition and ability to follow commands seemed to be appropriate for his age. We did not observe any tremor or dragging of his L foot during our session, so we asked the grandmother when she tended to observe it. She reported that she tended to notice the tremor towards the end of the day but was not confident that it didn’t also occur earlier in the day. As my CI and I discussed potential causes for the tremor, we began to consider weakness leading to the tremor. We tried to elicit the tremor by trying to fatigue the patient by having him go up and down the stairs for 10 minutes. Despite our best efforts, we were not able to reproduce the tremor during our session, however, we did start to observe the patient begin drag his L foot as our session progressed. The fact that the tremor was not constant throughout the day, decreased our suspicion that this was a neurological issue, however, the patient’s family/past medical history prevented us from ruling it off our differential list completely. As we were going through the patient’s chart, I was initially thinking that the patient may present with CP. However, my CI told me that CP is not necessarily inheritable and is often not diagnosed in children until they’re at least 2 years old. We were also able to rule out hip dysplasia by performing Craig’s test and assessing his leg length. By the end of the session, we were leaning towards global LE weakness in the patient’s left leg, which was causing him to fatigue and tremor. We were not able to perform any standardized objective measures during our first session due to time restrictions, however during our next appointment that will be our priority. Overall, I found this patient’s case very interesting due to his complicated history and inconsistent symptoms. Additionally, it was exciting to see how things we learn MSK can be adapted for the pediatric population. I think that my observation and creativity have definitely improved since starting ICE II. I look forward to working with this patient again because this is the most confident I have been treating a patient in the pediatric population so far.
Kayla,
It is so interesting to learn how this patient’s hypermobility and low tone is affecting her stability and overall gait. My experience with people with Down’s Syndrome is limited to adults, and while I noticed general low tone in the individuals I worked with, I did not take a close look at how their tone may affect their ambulation and overall stability. I am very curious to hear more about this case, as I wonder how physical therapy will help sustainably build this patient’s stability and strength. It sounds like the primary goal will be to strengthen the patient’s musculature to make up for the low tone and provide some more stability in a system of hypermobility. Would love to hear more about what this looks like for a child under three!– Sarah Strong
Lindsey,
That’s great that you were able to get some experience working with a patient who had a hip replacement. It sounds like your patient’s case was a bit more complex than a typical total hip due to the infected blisters. I’m sure your CI was glad that you were aware of the precautions for a posterior approach. Maybe you could think of some different exercises that are more geared towards your patient’s goals for the next time you see that patient. You could suggest them to your CI and see if they would be willing to let your patient try them.
Patrick D.
Justin,
Sounds like you have a good jumpstart for MSK III. I am also looking forward to learning about spine treatment next semester. That is great you were able to observe multiple techniques that we have not learned yet. It sounds like you have a good CI who is knowledgeable about manual therapy and different techniques. Was there a particular manual technique that your CI used that yielded better results compared to other techniques used?
Patrick D.
Patrick Dumais
My clinical experience thus far has been very eye-opening. I am at a SNF this semester, and I have had very limited exposure to the inpatient side of PT prior to school. The evaluations were among the many things I noticed that differed from the outpatient setting. It was interesting to see my CI obtain most of the subjective history information needed from the computer via the patient’s medical chart. We were supposed to evaluate a patient who had an extensive medical history which included cancer that had metastasized to the brain. He also had cogitative deficits and expressive aphasia. Prior to going in to do the evaluation, an OT walked by and informed us that the patient had refused OT earlier that morning. I figured there was a good chance we would experience something similar when we went in to do our evaluation. When we arrived at our patient’s room his family told us that he had to leave for radiation therapy. I assumed that this meant we would have to do our evaluation at another time, but my CI used this as a chance to see how the patient got to the car and got into the car. She later explained to me that she was able to obtain a lot of valuable information simply from observing him get to the car. I thought this was clever of my CI since more than likely he would have declined to have a traditional PT evaluation done. I plan to try my best to think more creatively in terms of evaluating patients in this setting. There is a lot of valuable information that can be used to help the patient that can easily be missed if you are not looking for it.
Sarah Strong
In the inpatient acute care setting, I saw a 95 year old patient who received a L posterolateral approach Total Hip Arthroplasty. She lives alone in a condo for individuals over 55 and has a caregiver visit her throughout the day to assist her with ADLs. She was sharp-minded, but seemed to experience minor short term memory loss, or, she may have repeated questions such as “how long do I have to sit in this big chair for” until we might eventually tell her something she wanted to hear instead of the 30 min-1 hour, which she did not prefer. Anxiety about mobility seemed to be a significant limiting factor for her, especially in sit to stand with a rolling walker. Her walker at home has locks on it, and she is used to pulling herself up by pulling on her locked walker. She has PMH of peripheral neuropathy, which we suspect contributed to the fall that led to her hip replacement. This patient successfully transferred from the bed to a reclining chair with moderate assistance and use of the rolling walker.
In this moment, I reflected carefully on two aspects of this patient’s care. First, I visualized how well this patient might manage the precautions associated with the posterolateral approach THA. She required a verbal repetition of her precautions at each moment that she expressed wanting to move in ways that are contraindicated. For example, she asked to sit in a regular chair with arm rests, which would place her already at 90 degrees, or slightly more, of hip flexion and would not provide the support she needs to maintain a stable seated alignment, as the reclined larger chair did. She also expressed interest in dressing herself, which would require bending at the hip to put on her socks well past 90 degrees. Second, I am curious to know more about which considerations were made in determining that a THA was the best solution for her. At age 95, she may have low bone mineral density, and is at higher risk for surgical complications. I wonder if there might be a less invasive approach for elderly patients who sustain hip fractures? Some information I could have sought out would be to view her x-ray scans, and look closely at the emergency department note from when she was admitted.
I spoke with my CI following this clinical experience and we discussed that the patient’s anxiety likely limited her understanding of precautions, more so than any short-term memory loss. Additionally, based on watching her attempted sit to stand and knowing that caregivers frequently assist her with ADLs, she is unlikely to be left to her own devices for activities that may lead to her breaking her hip precautions. She is also planned to be discharged to a skilled nursing facility where she will receive more therapy before returning home. I am looking forward to learning more about specialized techniques for caring for post-surgical patients who are in this age range and mobility level, and how to navigate the challenging nuances specific to this population.
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!
Alex Argentieri
This semester I am in a typical outpatient setting that has a variety of patients come in ranging in age from teenagers to the older geriatric population. Last week I was able to work with a 70-year-old patient that was referred to physical therapy for OA in her knee. Additionally, the patient was highly irritable and weak in the involved side and just wanted to not be in pain anymore. My CI and I talked briefly beforehand about the exercises that we were going to start with her and the plan was for me to lead the treatment session. While I was excited to take the lead and start instructing the patient on how to perform some basic exercises, it soon became clear that her tolerance to exercise was very low. I tried think of different variations of the exercises that would make them more tolerable for the patient, but I soon found myself looking toward my CI for help. My CI then mentioned that I can try some patellar mobilizations to help relieve some pain. Of course we talk all the time in our MSK class about how grade 1-2 mobilizations can be used for pain relief, but this was the first time that I was able to use them intermittently with exercise. As soon as I began to move her patellar she instantly began to feel better. I was then able to instruct her through some exercises and when the pain became too much, I provided some more mobilizations in all directions before continuing. This was great way to get patient to buy-in and by the end of the session she was hopeful that this would actually get rid of her pain.
Lori Yeaman in response to Jacque Hemler,
Jacque,
This is an interesting case and it really demonstrates how important it is to consider the entire patient, rather than focusing too narrowly on one impairment. It also speaks to the importance of a thorough evaluation to determine goals of treatment, but also the importance of flexibility during each session to address unexpected pain/impairments, such as providing relief for the patient’s headache. Great job!
-Lori Yeaman
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!
Katie Woelfel
In clinic, my CI has been consistently seeing a pelvic floor patient for quite some time now. The patient is a female in her mid-twenties with severe intermittent pain and hypertonicity of the pelvic floor. Many exercises she has tried, especially lower quarter, are aggravators of her symptoms which has given her some fear avoidance with most exercises we ask her to perform.
She has been seeing a personal trainer outside of PT for her fitness and weight loss goals, but she has expressed that squats and bridges are the most aggravating movements for her even after all this time coming to PT. This session I decided to encourage her to push past her fear of recreating her pain and try some new modifications with me. Instead of normal body weight bridges, I advanced them by adding a band around her knees to facilitate more hip abduction. My hypothesis was that most of her pain is linked to more psychosocial factors than somatic pain and this exercise is will introduce something new to focus on rather than getting into the same motor patterns. The band turned out to be a great success with her, and she said her pain wasn’t provoked even after 3 sets. Along with bridges, I had her perform squats on a pilates reformer machine. She expressed she feels more comfortable doing squats in a wider stance because she has noticed when doing conventional squats at shoulder width, her symptoms are almost always provoked. I gave her instructions to do whatever made her feel comfortable as long we she had good form and was getting reps in efficiently. I wandered off a bit to allow her to self adjust and play with different stances and what she felt comfortable with. At the end of the session, she was performing squats in the conventional shoulder width stance with almost double the resistance of what she was used to doing. I was thrilled that not only our patient did not elicit any pain during our treatment that day, but she expressed how exciting it is for her that these exercises are now starting to work for her.
Reflecting on this experience, I think this is a perfect example of the importance of allowing your patient to be an active participant in deciding their treatment in order to build self confidence and self efficacy. Not only did she feel great about her performance, but this was a huge win for our relationship with her. I’m excited to see if she has implemented these and even more exercises into her daily workouts and what progress she has made.