[Shenandoah University Division of Physical Therapy]

Justin Geisler responding to Caleb Baxter

Caleb,

Great post! Your encounter with this patient sounds tricky because I too would of been confused why resisted abduction did not elicit pain due to the presentation of gluteal tendinopathy. I think you and your CI went a good route in having the patient perform ther ex in the aggravating positions to work up until the patient has pain then hold off. I am curious to see how the patient continues to respond to treatment and if treatment will be able to provide some relief/healing for this patient. Great post and relating it to the hip and how not all patients will not have text book like presentations.

[Shenandoah University Division of Physical Therapy]

Justin Geisler responding to Ali C.

Ali,

Your experience sounds very interesting, I think it is a great idea to start weening the patient off of relying on the wheelchair during ambulation. When patients start crying due to neurologic reasons it gets tricky. Positive conversation and patience is key, and at times I try funneling the patient out of the negative thoughts that they are having by talking about their hobbies or places they have visited. You also have to been consciously aware to not bring up subjects that will start the process all over again like asking about their family members etc. Treating individuals that have dementia and Alzheimer’s have been some of the most difficult patients to work with because they can be very easily distracted and need consistent verbal cues to stay on task but it has made me a better therapist and has helped improve my communication skills. Your experience sounds wonderful and I know you will get a lot out of it, great post!

[Shenandoah University Division of Physical Therapy]

Justin Geisler

In the outpatient setting my CI and I were treating an individual who had a recent fall from a ladder about 5-6 ft high. Luckily he did not have any fractures/broken bones and has been receiving PT services for thoracic pain. Overall this individual’s mobility was good and the fall just seemed like a accident, not due to muscle weakness or impaired balance. The patient had one rib on the left side elevated which was treated by a MET and then PA glides grade 4 mobilizations were done while the patient was prone due to one of the ribs being more prominent than the other while in prone. Patient received a MHP with estem post manual therapy to help decrease pain and to loosen the soft tissue in the upper back area. This was a spine day at the clinic, all the patients treated had a variety of different reasons for receiving PT services. My CI did a lot of MET’s and manual treatment today which was very interesting to watch and learn about, treatment for left on left sacral torsion, left on right sacral torsion, elevated ribs and right facet closing restriction at T10. Observing and learning about patient position and palpation was great to learn about today, it makes me even more excited to for next semester to start learning about the spine. It showed me different things to observe for during treatment and how important our palpation skills need to be to assess the misalignments during treatment of the spine. I felt that this day was very productive, all the patients responded well with treatment and I will continue to learn as much as I can during this experience.

[Shenandoah University Division of Physical Therapy]

Emily Blum responding to Laura D’Costa

Laura,
I’m sure that was incredibly difficult to have that conversation with the patient. I feel like that is a conversation that can never gets easier for a PT, even with years of experience. I like how you mentioned how important functional goals are and being honest with the patient upfront about their prognosis. It made me reflect about how honest and empathetic we must be with our patients, no matter how hard they might try and convince us otherwise we have to keep a level head and make realistic, appropriate functional goals.

[Shenandoah University Division of Physical Therapy]

Amy K. responding to Jesse,

I liked how you were able to combine both impairments that you found with your patient into one treatment session. I often find that people will focus on one impairment rather than looking at the entire picture. I am curious as to how the roll behind her lumbar spine would decrease her cervical pain as well. Would she get both areas of pain at the same, where one might initially realize that they are connected impairments? Or, did you find that each pain was from a separate source?

[Shenandoah University Division of Physical Therapy]

Amy Korcsmaros

Currently I am in the acute care center where I had the opportunity to treat a 75 y/o male who had sustained both a proximal humeral and pelvic fracture. My CI mentioned how the patient had been discharged last week, spent some time in in-patient rehab, but did not fair well and was ultimately sent back to acute care. Prior to his fall, this patient was completely independent. He was able to walk long distances without the use of an assistive device and even was able to descend a flight of stairs to reach his laundry room in his basement. Unfortunately, this patient currently needed moderate assistance to even sit up at the side of the bed. I remember feeling a mixture of emotions as I realized how much of a decline the patient really had.

Due to the communication deficits from the lack of his hearing aids, it was pertinent to demonstrate the marching and long arch quad sets that we wanted him to perform. Unfortunately, a lot of his LE exercises were cut short do to his complications with clearing his lungs. From the amount of “gunk” that he was coughing up while sitting on the side of the bed, we determined that this required further investigation. As I began to work on thoracic extension and deep breathing exercises, my CI discussed the care this patient received over the weekend. To our dismay, this patient had not been out of bed for the entire weekend (this was a Tuesday). If you recall, this patient was fully independent prior to his injury and it was frustrating to hear that he might be coming down with pneumonia (preventable) because he was not assisted in standing throughout the weekend.

Although this experience was highly frustrating, it showed me the impact that we as PTs can have on patients. Even though we spent the majority of time assisting in deep breathing exercises, these smaller exercises made a dramatic difference in his appearance. Once he was back in bed after our session, he was visibly more comfortable. This experience also allowed me to reflect on the role we play in a patient’s entire care given in the acute care setting. Through our documentation skills and knowledge of what movement can do for the human body, we can change the course of care given. This was shown by discussing with the nurses how to maneuver transfers with his fractures and how often he should be mobilized.

[Shenandoah University Division of Physical Therapy]

Caleb, this is great to experience this type of patient after we just learned about this pathology. I can understand some of your confusion to outcomes of some of the testing didn’t match what you expected. I think early on in our learning we expect the patient to be highly irritable and have most of the symptoms we learned, while this is often not the case, especially with someone so young and at a high activity level. It sounds like you handled it really well though and gave him appropriate advice! This was a good reminder to me to cast a wide net!
-Jacque

[Shenandoah University Division of Physical Therapy]

Jesse Parsons responding to Ali,

That is a great story and a good example of how our patients have so much more going on in their lives than just therapy. Your CI sounds like they are doing a great job treating the whole patient, and not just their impairments. The personal and social factors of patients are aspects that will have a huge impact on their attitude towards therapy, self-efficacy, and prognosis. It is always helpful to take a step back and examine their situation from their unique perspective.

[Shenandoah University Division of Physical Therapy]

Uyen responding to Laura D’Costa

Laura, I’ve never worked with a patient that is in denial of their condition, but I see from reading what you wrote how difficult that situation can be. I’ve heard many PTs talk about how important having knowledge of the biopsychosocial aspects of PT is and this is such a great example of why we need that knowledge. I’m glad you are making functional goals for your patient so that staying in skilled nursing is more bearable for him.

[Shenandoah University Division of Physical Therapy]

Laura D’Costa responding to Caleb

It is interesting that the patient did not experience pain with abduction especially from a lengthened position! It just goes to show that there are deviations from the stereotypical presentation. In terms of the patient being an athlete, it is was good of you and your CI to recognize that the patient would not stop activity and how to best approach participating in football.

[Shenandoah University Division of Physical Therapy]

Laura D’Costa
In clinic, I saw a 78-year-old male with multiple lower extremity impairments that were affecting his mobility. He previously had a right hip replacement and a gluteus medius tear on the same side. More recently, the patient had a left knee replacement. He could ambulate short distances with a walker but sometimes needed to use a wheelchair. To make things even more complex, he was recently diagnosed with a neurologic disorder that causes transient ischemic attacks. This disorder causes fluctuations in the patient’s function and has a poor prognosis. Although the patient is in denial of his diagnosis, he is very motivated to leave skilled nursing and move to independent living.
During our therapy session, the patient kept talking about how he wanted to go home soon. My CI had to have a difficult conversation with the patient about the severity of his condition and that the goal was not currently feasible. The patient got teary-eyed and seemed very upset. During the rest of the time we were working with him, he kept mentioning how he is getting better and will be in independent living soon. I kept thinking about how the nature of his condition will prevent him from achieving his goal. I was upset because it was evident how bad the patient wanted to live in his own home. This situation was difficult because despite the efforts of my CI the patient was not understanding or accepting his medical condition. I think my CI handled the situation well by telling him the truth as well as being sensitive towards his feelings. This experience highlights the importance of me creating functional goals and assisting patients in making their goals challenging yet attainable.

[Shenandoah University Division of Physical Therapy]

Emily Blum

Last Tuesday was my first day working in an inpatient rehabilitation hospital. I was very nervous going into it because while I have shadowed in a setting like this before, I’ve never really been hands on with an inpatient patient before. I am very interested in working with people with amputations, so I was very excited when my CI told me immediately that our first patient of the day was a woman with a left above the knee amputation.

This was the patient’s 4th time being admitted to this particular facility, and most recently she just spent 5 weeks in the hospital, with almost 2 weeks of those being in the ICU for complications from blood clots in her right leg. My CI informed me that when she first met this patient about 6 months ago, this woman had incredible upper body strength and could stand on one leg while doing her hair and makeup only a few weeks post amputation. The 5 weeks in the hospital recently had really set her back. We went in, I introduced myself and after she agreed to let us interrupt her doing her makeup, I took her vitals and we had her slideboard transfer into her wheelchair. She required min assist with this. We then took her into the facility’s rehab gym and began practicing car transfers, stairs, and ambulating using the parallel bars. On the parallel bars, she had difficulty walking backwards, as she would overshoot her right leg each time and her knee would buckle. She was having obvious motor control difficulties, but also lacked the strength to hold herself up, with mod assist required. She was also constantly in a lot of pain. It made me think about if this was due to pain inhibition of the muscles around the hip and knee, since she had such significant strength loss in such a short period of time. I know that you lose a lot of muscle in the hospital, but it was interesting watching her motor control patterns, and there wasn’t much activation of the stabilizing muscles of the hip occurring.

I saw her again in clinic this past Tuesday and she had made significant improvements, now able to WB on her right leg and stand with contact guard. This makes me think even more that it was pain inhibition of the muscle last week. Reflecting back, I wish I had taken the opportunity to talk to her more and try and unravel some of the biopsychosocial aspects of the situation, because clearly being admitted 4 times to this facility in a short amount of time can take a toll on someone’s mental health. In the future, I will not forgot to do this because I think it would have opened up a whole new layer of the patient and I could have understood better her life at home.

[Shenandoah University Division of Physical Therapy]

Uyen Tran

Yesterday in clinic, I was able to work with a patient that has has a delay in her gross motor development. She is currently 23 months old, but based on her gross motor function, she is functioning at the level of around 17 months. Before I left clinic last week, my CI assigned me to study the Peabody motor development scale so that I can administer the test on her this week in order for us to see her progress.
Before we worked with her, we had a patient that is one month younger than her that my CI was going to discharge that day. She pointed out to me to pay attention to his gross motor function and how it differs from our upcoming patient. Upon her discharge process, my CI performed a series of tests on the patient and I could see that as a 22 moth old, he was able to confidently walk up and down the stairs, catch himself if he falls, maintain his balance when sitting and standing, and run pretty fast. After successfully demonstrating his ability to function at his age level, the patient was happily discharged.
After he left, our 23 month old patient came in. I started administering the Peabody Scale on our patient and I was naive enough to think that asking a 2 year old to follow commands (such as “walk backwards with me” or “walk on this line”) would be all that I needed. The test was harder to administer than I had imagined and during the test, I was scrambling to find ways that I could modify my instructions and modify the environment so that I could possibly see her perform the tasks that I needed to see.
During the process of administering this test I realized 2 things- 1, that I needed to pull out all of the creativity in my brain when working with children and 2, that as a 23 month old, her motor skills were not even close to where the 22 month old patient was. Even through observing her, I could see her lack of confidence in her balance with her wide base of support and her hesitation in making moves with her legs. I realized that even though there is a scale to measure gross motor function, you can see clearly the differences in motor function through watching them play and move around the clinic. My CI stepped in at times to offer other ways that we could have the patient perform the activities and some of the ways worked and others didn’t. After the session was over, my CI helped me score the test. I was glad that my CI was confident in me enough to allow me to administer this test and only stepped in when she saw that I really needed help. I could tell she was allowing me to gain some discovery learning and I know that my struggles during that session has already taught me so much about pediatric PT. Next time that I work with this patient or another pediatric patient again, I know I won’t just won’t have one plan of how the session would go, I need to come up with several back up plans beforehand. I will also study up and observe how PTs can communicate with this population and practice the communication skills with my CI’s patients while I am in clinic.

[Shenandoah University Division of Physical Therapy]

Ali –

I’m glad that your CI was able to handle and adapt to this situation so well! To me, it’s really encouraging to see how second nature showing compassion and genuine caring is for so many CIs in our profession. It gives me added motivation and reassurance of the positive impact that we will be able to have on the many pts that we come into contact with. I think it is easy to forget how many obstacles, including physical, mental, and social, that our patients are dealing with. I think this experience really highlights how important a holistic approach is and knowing how to have a productive PT session in the face of all other obstacles.

[Shenandoah University Division of Physical Therapy]

oops – the above post (about Lymes disease and inability to DF) is by Bailey Long.

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