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Kayla Sweeney
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.
Replying to 6723 – no name
Mekayla SteckelSo 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!
Mekayla Steckel
Reflection Post #1The 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.
Daphne,
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!
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.
Daphne Batista Replying to Ally Kuhn:
Ally,
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!
-Daphne Batista
Daphne Batista
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.
(Levi responding to Justin)
Hi 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.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.
Ali,
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.
Great job,
Ally K
Allyson Kuhn
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.
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.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.
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?
Christie Freund
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.