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My clinical experience is through contract services at Winchester Rehabilitation, meaning that we travel to different local inpatient and outpatient clinics filling in for other physical therapists. This Tuesday we spent the whole day at Winchester Medical Center covering for an inpatient PT. Our last patient was a 31 y.o. white female who was diagnosed with Lyme’s disease. I had heard of the detrimental effects of Lyme’s disease, but I had no idea really what to expect.
After we entered the room and went through our few subjective questions, my CI instructed me to take the pt through our regular “warm-up” exercises. I attempted to start with bending the hip and knee with heels slides, however it was quickly evident that this was a struggle for her. My CI then asked the pt to attempt ankle pumps. Even this was impossible for her. My CI pointed out that this was an example of a trace contraction, or a 1 on the MMT scale. We could see and palpate the tibialis anterior twitch while the patient was attempting to push against our hand into dorsiflexion. We tried to utilize a quick stretch in an elongated position in order to help facilitate more contractions. This was really interesting to be able to finally witness a trace contraction and be able to apply the quick stretch tactic that we were currently learning in adult neuro to increase contraction of the muscle.
During this process, I looked at the pt’s facial expression to see her in intense focus on the small task of trying to bring her toes toward her. Looking back, I think I should have given her more encouraging feedback, especially knowledge of results. I realized too late that she wasn’t able to tell if she was pushing against my hand into either DF or PF. We were eventually able to get her standing and ambulating with a front wheeled walker. Initially, we had to give her frequent knowledge of performance to help facilitate proper DF during her gait without her compensating with increase hip flexion. She was able to ambulate 175ft (100ft more than her last PT session). This experience was a very rewarding one with being able to see how much positive impact we had on the patient with just one session. This experience showed me the importance of giving appropriate feedback to help the patient gain self-esteem while relearning motor control. In the future I will attempt to be more aware of how and when I give extrinsic feedback to the pt.
Lindsey replying to Azita
I thought it was interesting that the patient stated that she already resting her foot on the stool automatically. It was also cool to hear that cueing her to do the posterior pelvic tilted helped decrease her pain. This shows how patient education can really have an impact.
Kyle,
In the outpatient setting last semester I had a similar experience with a patient. I ended up seeing this patient throughout the semester because my CI gave him exercises and stretching to do during the freezing phase. We then began more vigorous therapy during the thawing phase when we could make more progress. I agree with you in the aspect that it is one thing to learn it in class but then seeing it is very different because the end feel is empty and a quick catch-type feeling. Adhesive capsulitis is a very interesting pathology and seeing the progression of it in clinic is a positive experience to have.
Ali Cloutier
In clinic yesterday, I had an 85-year old woman with Alzheimers that fell in her home and consequently fractured her shoulder and her hip. She no longer has WB precautions in either and is very anxious when it comes to walking. In order to increase her confidence, my CI used to have someone trail behind her with a wheelchair but since this will not be feasible when she goes back to assistive living my CI was trying to wean her off of this technique. The patient then proceeded to get very upset and sit down and cry. This was my first experience in this sort of situation and it made me step back and realize the bigger picture. This elderly woman had come to visit her daughter in Virginia from New Jersey, fell, was in the hospital then inpatient rehab, and upon discharge is moving to Florida with her daughter. From all this information, you can see that she has had a lot of changes going on in her life. On top of all of this, she has Alzheimers which greatly complicated the situation because she is always thinking that her daughter is coming to visit her and she doesn’t have any clothes left in the inpatient rehab facility. My CI knew exactly how to handle this case and instead of letting this stop the therapy, she encouraged the patient to walk and talk about what was bothering her, even if it required extra cueing. After the walking we then proceeded to do simple therapeutic exercises including glute squeezes, ankle pumps, and adduction/abduction exercises. Overall from this experience, I learned that you need to be creative and quick-minded to quickly change your plan if a patient is having a difficult day. Also, being in physical therapy and the inpatient rehab setting you need to be patient with the patients because change affects them greatly.
Lindsey Rodriguez
I had a patient in a SNF who is 1-month s/p total hip replacement revision surgery after falling at home. He was back in the SNF due to infected blisters on his leg that were treated by IV steroids. This patient has a long list of co-morbidities, was a big fall risk, and has been in and out of the hospital three times over the past 6 months. He also has dementia, which made his case more complex. As I read his past medical history I started getting nervous and didn’t quite know what to expect. Although he was confused he was pleasant to work with. We started by simply transferring him from his bed to a wheelchair to get him to the gym. This activity required contact guard assist with a good number of verbal cues. I noticed my CI made sure to use the protocol and avoided IR/adducting his hip and flexing past 90 degs because his hip replacement was a posterior approach. It is important to think about how closed chained activities such as twisted with the foot planted could still bring him into IR rotation. I also noted that he might be at risk for decreased healing of the posterior incision due to his use of steroids for the infected blisters. His case was also more complicated because this was a revision surgery, therefore the surgeon had to go in twice in order to repair his hip, because he fell after his first TKA.
Before we began any exercise, we took his blood pressure and heart rate and asked what his pain level was on a scale of 1-10. He reported a 7/10, so we checked with the nurse to make sure he had received his pain medication before continuing with PT. He had sores up and down his leg and cuts on his ankle from the fall, which were contributing to his pain. My CI decided to give walking a try using a front wheeled walker and told him if his pain increased too much we could take a break. It appeared that his ankle was bothering him more than his hip, but he was still able to ambulate around the gym using his walker. We then had him practice on the 4” and 6” stairs, because he has stairs to enter his house. Although it took him awhile to complete them, he only required contact guard assistance. At the end of the session we did a few exercises with the patient supine on a bed. At the end of the session he reported his pain was a 6/10. Overall, I thought this session went well because we were able to get him up and moving and working on stairs to help him achieve his goal in order to go home. I felt that his therapeutic exercises were generic and would be more beneficial if we could have geared them towards a goal he had. It was also good because I was able to see what abilities a patient s/p total hip replacement revision surgery has and how to educate them on their protocol.John Orchard-Hays
This was the second week of clinic and my CI felt comfortable letting me take on more of his patients treatments. I worked with a 55y/o woman with chief complaints of general hip pain with a secondary complaint of ipsilateral ankle pain. Having looked over her subjective/objective history from the initial eval and speaking with my CI I was convinced her symptoms were consistent with gluteal tendinopathy and was able to rule out other possible pathologies such as FAI, athletic pubalgia, and OA. Since it was my first time working with her I decided to take her through a couple of her therapeutic exercises before I did any mobilizations so that I could see her functional status. After performing step ups, squats, and side stepping, I could see that she had signifiant trouble resisting dynamic valgus. I performed soft tissue mobilization/transverse friction massage to the gluteus medius tendon to increase blood flow and hopefully decrease sensitivity. I assessed her ankle next and found weakness and palpable pain/MTP’s along the distal musculotendinous junction of the fibularis longus. After speaking with my CI I decided to mobilize these tissues as well with transverse friction massage and myofascial release techniques. I wasn’t exactly sure of what was going on with her ankle purely because we haven’t covered that unit yet, but I did my best to make connections between her impairments along the full chain of the LE. It was interesting conversing with my CI regarding how the hip may be influencing the rest of her LE. I then had her perform exercises that target the gluteal muscles and minimize activation of the TFL such as side steps with a TB and bridging. For the ankle we focused on strengthening the arch of her foot and by balancing on compliant surfaces. I plan to ask my CI more about the rational with the Therex for her ankle next Tuesday.
Kyle Kohnen
In clinic this week I got the opportunity to work with a 60 y/o male patient with frozen shoulder. I was confident in my ability to evaluate and assess because we had gone over this particular pathology in class last semester. When checking the patient’s APRs, I was expecting to see limited range of motion in all planes but what really surprised me was the end range feeling. He got to about 45 degrees of abduction and it felt like I hit a wall. This was a cool case because understanding the pathology from an educational standpoint gave me a good idea of what to expect but actually seeing/feeling it first hand was a completely different experience. Next week I’ll get to work with the patient again and I’ll have a better idea of his limitations and how to tailor his intervention.
Caleb Baxter
14 y/o male came in with a referral for gluteal tendinopathy. Upon retrieving the patient from the waiting room, I had a feeling that activity modification (specifically reduction in activity) was not going to be an option. The patient plays for one of the high school football teams and is in the middle of his season. He presented with lateral thigh pain on the R after running or exercising for extended periods of time. Subjective history was consistent with a tendinopathy. During the objective exam, I was surprised to find no pain with abduction, even from an adduction position with the abductors on stretch. The patient was also able to maintain SLS without pain or compensation. Pain was provoked with resisted extension, IR, and ER. The lack of pain with abduction threw me off because I was thinking glute med/min, but the pain with extension may indicate that glute max is involved as well. My CI and I were both confident that treating the tendinopathy in aggravating positions was a good place to start. Since the patient was not very irritable, we completed 3 sets of eccentric IR (similar to derotation). Set length was dictated by patients subjective pain rating. With low irritability, we told the patient to continue managing participation in football and weightlifting by monitoring pain level. We instructed the patient to take a break if pain exceedes 4/10. The current action plan is to continue to increase load on the tendon using slow contractions while managing pain and hoping the patient heeds our advice and doesn’t just play through the pain.
Victoria Appler –
In the home health clinical setting, my CI and I saw a man diagnosed with Parkinson’s Disease. According to my CI, in the last few months he has been regressing (before that he had been doing really well therapy-wise). We had worked with him last week on endurance and transfers and had a productive therapy session. However, today he presented with orthostatic hypotension going from supine to standing. He exhibited symptoms of dizziness and discomfort, along with a rapid respiratory rate (>40 breaths per minute). We had the patient sit and attempt to increase his blood pressure by doing ankle pumps and drinking water. My CI told him we did not want him to work out his arms until his blood pressure was more normal (I had a conversation with her later that I was under the different impression any form of extremity movement could be beneficial to increase BP). Ultimately, we could not safely give this patient therapy today and before we left we gave the patient and his caretakers advice – don’t walk around too much today and if dizziness occurs, lay down and do ankle pumps. We also advised the patient to eat – he reported at the end of the session that he had not eaten all day and was stressed out about all of the things he has to do this week. During this visit, I was first confused and then was alarmed as soon as I realized what was happening. All I could think was that we could not treat this patient today and whether or not we should call someone (911, the doctor?). Coincidentally, I had a conversation with Daphne last week about how her CI said PD medications can cause orthostatic hypotension and that she had a patient with it and PD. This, along with the patient not eating could definitely have contributed to the blood pressure changes. Although I hope this does not happen again, if it does, I will feel more prepared in how to educate the patient and how to handle the situation – making sure the patient is safe is the primary objective.
in reply to Alex Gett,
I am also glad you got to see some hip action in your clinical. What I like about your post is the reality that it reminds me of Physical Therapy’s immediate results. At some point between our intensive study of pathologic prognosis and tendinopathic continuums I seem to have forgotten that some treatment have patients limping in and walking out pain free. It is quite unfortunate that I have let this important aspect of our profession slip my mind. I believe it should be among the forefront of my thoughts as I see patients. “Can I help them feel better right now?” should be one of my first questions to myself. It is not only our duty, but I believe if we were able to do this more often, we could facilitate a new popularity of the science and art of good Physical Therapy.
-PeteSamantha- answering to Austin
I agree with your thought process of the chemo possibly having an effect on your patients weakness as it seems in your post that this is a re-emergent thing since the start. I believe you have the right thought process on trying to see what works and where to go next. Monitor these signs and symptoms as you are working with her and see how they change throughout the session, not just on the re-eval days. Great reflection as I think you are on the right track with your thought process.
Pete,
This is another good example that speaks to the extent of our role as future clinicians. This case is very complex based on where we are in our careers, but it goes to show that through our MSK knowledge and understanding of systems, we can still provide quality care to the pt. I love the ability we have to be creative and devise our treatment parameters tailored to our pt’s functional ability and goals.Azita Nejaddehghan
Patient was a 32 y/o female patient returning for LBP (I hadn’t seen them before however. Pt states she has been doing HEP program daily. She reports no episode of intense pain in the last two weeks, but also has not had a full work shift in that time period either. Pt is a cashier, where shifts involve standing for long periods of time and occasionally bending over to lift objects. Pt states HEP has been helping reduce pain.
When returning from a position of lumbar flexion, the patient presented with aberrant motion and went into excessive lumbar hyperextension, at which point she reported pain. I educated her to go into a posterior pelvic tilt when returning from lumbar flexion in order to avoid excessive lumbar hyperextension. I then had her perform ten posterior pelvic tilts in standing. I re-assessed her active lumbar motions, and she reported less pain with L lat flexion and R lat flexion but stated there was a little more pain with R lat flexion compared to the L. She reported less pain with lumbar flexion, also demonstrating less lumbar hyperextension with return to a neutral lumbar position. Pt also exhibited increased AROM in lumbar flexion and side bend. To be honest I was surprised at how much of a difference ten posterior pelvic tilts made, and how quickly that change was seen.
We also provided Patient education was provided in regard to standing position when standing at the cash register and lifting mechanics. I informed her that resting one foot on a stool (of a typical step height) could help put her into a PPT while she’s at the register. She stated that she already did that… which was interesting to me because obviously she didn’t think “let me put my foot on this stool so I go into a PPT” … it was just something that her body led her to doing in order to be more comfortable.
Levi Perry
Disclaimer: this post contains exaggeration, cynicism, and naivety.
I am new to the acute care setting. My initial impression is that although PT serves a very important role, it seems to be very focused (too focused?). By this I mean that PT has the same goal for everyone: walking. Of course, some patients are unable to walk, but then the goal simply becomes whatever is highest on the continuum to walking that is achievable for that patient (sitting up in bed, transferring to a chair, etc.). When the patient is exhausted by their daily exercise of walking, or some stage of the progression, therapy finishes (even if the session only lasted 5 minutes) and documentation ensues. A patient that I saw entered the hospital due to a COPD exacerbation, but what about their back pain? Does oxycodone have a monopoly on this job in the hospital? Could the patient not benefit from, for example, PROM or a manual hip flexor stretch? If the patient is going to be lying in the hospital bed for another two days regardless, is there not more that we can do for them? Does it come down to the therapist’s time, and that it is not economical for the hospital to pay for the time spent performing these interventions? It felt odd to me saying to the patient “ok, I think we have done enough for today”. I imagine that my eyes will soon be opened, and I will soon see the silliness of my thinking, so I wanted to share my thoughts before this occurs.