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MJ Erskine
During my time in the SNF, there was a patient with whom I interacted 2 times. His primary language was Spanish (which I don’t speak), he had cognitive impairments, and I never did find out from my CI what his diagnosis was. He appeared to love soccer! The first time I saw this was an intervention for coordination where my CI would kick a balloon back and forth with the patient – my job was to keep the balloon in play. The patient had more fun with that than anything. The second time I saw this patient, my CI had just finished a similar intervention and asked me to sit with the patient while he stepped slightly away to do something. Every time the balloon would come near the patient, he would attempt to kick it. So I continued playing with him. I got the impression that as long as someone was willing to kick a ball/balloon/etc. with him, the patient would continue to play. This really pointed out to me how picking an activity that the patient enjoys can have a huge impact on the effort put forth by the patient and on adherence to programs. I hope I can carry this forward to future patient care and find interventions that both address the impairments and engage the patient.
Andrea Choo responding to Daphne
Hi Daphne,
Thanks for sharing! Was the wound ulceration due to the immobilization after the surgery or a separate complication? If it was due to the surgery do you know if it the surgeon instructed the patient to immobilize it for a certain amount of time or was it more related to the patient’s fear of moving/using her foot? Either way I think that it could be a good opportunity to provide patient education to try and minimize complications and promote mobility as appropriate.
Andrea Choo
During my ICE II rotation, I got to assist with serial casting on a 6 yo girl who had decreased DF ROM. Unfortunately, I did not get a lot of information regarding her background or medical diagnosis. However, I do know that she had been casted a couple times before and had made great gains in the past. Before we could put on the new cast, my CI asked the patient and her mom about any complications with the existing cast and the patient’s reaction to the cast. The mom reported that the patient only noted mild discomfort at night, however it was tolerable and non-painful. After cutting off the pre-existing cast, my CI measured the patient’s DF ROM and cleaned the patient’s leg. After that was done, she found subtalar neutral, dorsiflexed the patient’s foot into a stretch, then asked me to hold the patient’s foot in that position as she casted. In MSK lecture, we learned that DF is important because it’s necessary for normal gait. Additionally, I got to witness this first hand when we serial casted in neuro lab and a good portion of the casts were not positioned in enough DF to allow for safe ambulation due to hyperextension of the knee. One difference between how my CI casted and what we learned in neuro lab was that my CI preferred casting in a prone position compared to supine because she found it easier for children to stay still in that position. Additionally, I found it easier to hold the foot in DF, since gravity was able to help me. Overall, it was interesting to see serial casting performed on a patient that actually lacked DF in clinic. After watching my CI, I realize that I still need a lot more practice with serial casting to make it cleaner and more efficient.
Hi Sarah,
What an interesting case, especially given that she had elective surgery for an Achilles tendon rupture. How unfortunate that she did not have a discharge plan in place either. Great job though focusing on the whole person instead of placing emphasis on the initial impairment itself, which sometimes we get caught up in. Especially in this type of setting, open communication between health professionals is critical as they impact a patient’s care. I’m curious as to what was the dosing that you gave her for therapeutic exercises and how frequently you had to modify activities based on her exasperating spasms.
-Daphne Batista
Daphne Batista
During my time at Ashby Ponds & Erickson Living, I had the opportunity to interact with an 89 year old female. Due to her poor vision, she tripped and ended up fracturing her ankle. Subsequently she underwent an ORIF of her RLE, unfortunately I do not know where the fracture took place. During my time at the SNF, her fracture was technically healed, however she was still in a boot due to a wound ulceration. She was full weight bearing in the boot and ambulated with a front wheel walker with a step through gait pattern. During treatment sessions, gait training was a big component. She was able to navigate long level hallways with supervision, however required more cueing when navigating corners or tight areas, such as her bathroom. Given that she was at the supervision level, I felt more at ease during her gait training sessions compared to other patients who required more assistance. Though her gait pattern was fairly normal while she was in her boot, patient education was provided to ensure that she always carried the walker with her, as she had never used one prior to the injury and often would forget to bring it with her. This would decrease potential fall risk if she accidently tripped due to the boot thus causing further injuries.
Dominique Norris
While on my clinical, I had the opportunity to treat a patient with PF and PTTD that stemmed from a fracture she had sustained months earlier. The patient spent her entire work day on her feet on concrete floors, as she was a chef at a local restaurant. In addition to strengthening the patient’s feet and legs, and addressing more proximal biomechanical causes, we spent a fair amount of time working on STM and de-sensitization techniques. We also discussed shoe options with the patient, to try to make the long hours less severe. The patient was able to utilize the STM and de-sensitization techniques at home as well, which will help decrease her reliance on us and put her more in charge of her health. While the patient was still experiencing a fair amount of pain after a day of work, she told us that the techniques that we gave her both for while at work and once she was home, were helpful and made her work day less unpleasant. I was disappointed that we weren’t able to completely resolve her pain, but knowing that the patient felt a dramatic improvement showed me that we can still make a difference even if we cannot completely fix the problem.
Sarah Strong – Post 3
During my last week in the inpatient acute care setting this semester, we saw a patient who had surgery for an achilles tendon rupture. This patient has multiple co-morbidities including Parkinson’s Disease and LE muscle spasms. This patient was to be NWB for several weeks following this elective surgery. Usually when we saw patients who were receiving elective surgeries, they had a plan for following the surgery such as where they might go after their hospital stay including altered home set up or an anticipation that they might go to a Skilled Nursing Facility. This patient did not seem to have a plan in place. She reported that she was still ambulating a flight of stairs to enter her home, even right before the surgery. She stated that she could hardly put any weight on the affected limb at that point (which led to the surgery). She also stated that she had terrible pain in her other limb, due to muscle spasms. I got the feeling from my CI that the patient’s report of muscle spasms may not actually be spasticity of the muscle, but something else entirely. I was not sure, myself, how my CI came to this conclusion, however.
The patient’s medical presentation and her subjective report of prior level of function did not seem to add up. Following the treatment session, my CI and I discussed our confusion on how she could have possibly been ascending and descending stairs, why she elected to have this surgery without a post-hospital stay plan in place, and why it seemed as though her muscle spasms were not being medically monitored or treated. The patient did state that she sees a neurologist. It seemed to me that the surgeon or physician involved with her surgery did not educate her such that she understood what to expect following surgery. It also seemed to me that her co-morbidities were not taken into account.
What I learned most from this encounter was once again the value of a thorough chart review and ability to be flexible. We entered the room thinking we would try to get the patient up out of bed and see how she did with using the walker and following her post-surgical precautions. We left the room after giving her some in-bed therapeutic exercise activities that she can do on her own such as ankle pumps, straight leg raises, quad sets, glut sets etc., some of which seemed to exacerbate her muscle spasm which caused her pain in the unaffected limb. Due to the patient’s pain, we did not get her out of the chair that she was seated in at the start of the session. This patient also had plenty of psychosocial aspects to her medical status; she teared up during the session while speaking about how her husband helps her and how grateful she is for him; she also stated that she wouldn’t wish “this” (meaning her medical conditions) on anyone. It was a really difficult moment. We reassured her that we, along with nursing staff, would do our best to keep her comfortable and mobile during her stay in the hospital. We also encouraged her to speak with her neurologist about her muscle spasms.
I left this treatment session wishing there was more that I could do for this patient to decrease her pain and increase her access to providers who could help her manage her pain and various medical conditions. It turned out that her achilles rupture seemed to be the least relevant piece of her current medical status, as the muscle spasm pain that she described seem to be the main factor that limited her mobility at that moment.
Ali responding to Mekayala,
This seems like an awesome experience! I saw a lot of equinovarus positioning as well in many of the patients we had. My CI showed me several techniques to help with this including using an ace wrap to get them into a more DF position so that we could gait train. It was interesting to see their gait without assistance into ankle DF because as discussed in class, they hyperextend their knee each step and had severe lack of pelvic control. Great to see concepts in class presented in clinic!
Ali Cloutier- Post 3
During my final week at the inpatient rehab facility I was at, I had an 85 y/o male patient that had a R CVA and was also undergoing treatment for lung cancer. This patient had severe cognitive deficits and was unaware of his disability. His active lung cancer also made him have a severely limited endurance and would often experience coughing fits. My CI and I came up with multiple tasks for this patient including balance, gait, and therapeutic exercise activities. We also tried to incorporate cognitive elements into each task to increase his practice with memory. My CI had me come up with the exercises and since he does not safely stand, we did all the exercises in seated. I then explained to him what exercises we would be doing and how I wanted him to count to 12 while doing the exercises. Given that this patient had increased cognitive deficits and wasn’t fluent in English, I decided I would do the exercises with him so he could use me as a model as well as assist him with timing and coordination of the movements, especially on his L side. In about the middle of the set, I proceeded to put my hands on my hips out of habit and given that I advised him to copy me earlier, he immediately mimicked me. My CI immediately started laughing at this fact. This demonstrated to me quite how literally patients take your cues to “copy me.” It made me realize that I need to be more conscious of what I am doing while doing a task with a patient because I didn’t think he would take it so literally. Overall, this experience taught me to be mindful of my body position when demonstrating a task as many patients mimic your exact movements down to where your hands are even if you told them to place their hands in their lap or on their chair previously.
Lindsey Rodriguez Post 3
In clinic we had a patient who was 97 years old with a long list of co-morbidities, diabetes included. He was in the SNF post-op forefoot amputation due to complications with an infected sore on his foot. He had previously had his big toe removed due to infection, however it had now spread into his forefoot. When we saw him on eval, I wasn’t expecting him to be able to do much but to my surprise he was able to hop about 20 feet with a FWW. He was non-weight bearing in his surgical foot, however, was still able to SLS and hop on the non-involved side. Although we weren’t directly treating his amputated foot in the SNF, this case was interesting because I was able to see the side effects of diabetes and how it relates to the foot. I am curious to know what his gait pattern would look like once he is able to weight bear through the foot, since he is now missing his entire forefoot.Christie responding to Laura
That must have been really cool to see your suggestion implemented with this patient from one week to the next! I like how you were observing your patient in his daily life, even though it wasn’t part of your official treatment session in the gym and were able to guide your plan of care based on those observations. Your recommendation seems like it is in the best interest of that patient’s safety, so I’m glad you felt comfortable enough to speak up and mention it to your CI. Way to treat the whole person!
Christie Freund
Over the course of the semester, I had the opportunity to work several times with a patient with spinal stenosis. When my CI first starting seeing her (a few weeks before I started), she had symptoms starting in her back that extended all the way down into her foot. Over the course of time, her back and hip symptoms resolved, as did her leg symptoms. She got to the point where her only symptoms were in her foot. However, we had trouble determining exactly what was causing her foot symptoms and had to go through a series of differential diagnoses and were constantly reassessing to see if our treatments were affecting her symptoms. We had to use a lot of funneling with this patient to figure out what information was relevant to her problem, but we determined that there were likely two different problems contributing to her foot symptoms. She had some tingling in her foot that appeared to be associated with tightness, trigger points, and weakness in her calf muscles, so we treated proximally. She also had more of an ache over her metatarsals that appeared to be due to a lack of cushioning on the pad of her foot. We recommended a metatarsal pad shoe insert that seemed to help with those symptoms as of the last time I saw her. I really enjoyed working with this patient because I really had to think about what might be causing her non-traditional symptoms and go through trial and error. It was a great example of the importance of constantly assessing and reassessing to ensure we are heading down the right path with treatment.
Laura D’Costa
In the SNF setting, I worked with a patient that had balance deficits. My CI and I picked him up from his room due to his cognitive deficits. Before going to the therapy room, the patient locked his door. He did so with the key on a lanyard around his neck. Watching the patient lock the door in this manner did not seem safe especially if he was by himself. During the therapy session, I kept trying to think of a better way for him to lock the door. I targeted the session to reaching outside of his base of support to improve his balance specifically to for locking his door. After we dropped the patient back at his room (and watched him unlock his door), I asked my CI if there was a way for his key to be on his wrist or on a retractible clip. This would prevent the patient from bending over and reaching to go into and out of his apartment. The next week in clinic I saw that the patient had a retractible clip for his key. When he locked the door, he was more stable and had better body mechanics.
Kyle,
That’s great you’re still getting experience with frozen shoulder and other shoulder pathologies. Sounds like she was pretty irritable and you did a great job adjusting your goal to pain management. I’m curious what stage she was in based off her time of onset and how that matched up with her presentation. Also, did she receive any other therapies such as injections in the short term for pain relief? I like you’re idea of dedicating a pathology per month. Could be a useful tactic in reviewing what we’ve already learned thus far in the program. Thanks for your post!
– John Orchard-Hays