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John Knowlton (Third Post)
A couple weeks ago I treated a 68 y/o male about 5 weeks post TKE. I was taking the lead with this patient that day. The patient walked in with a walk and first thing I noticed was that he didn’t have full knee extension. After I read his chart I learned that the patient actually had about 30-40 deg of total motion this knee. He was not responding well to therapy and had developed arthofibrosis from his surgery. I performed about 30 mins of manual therapy including (STM to the quadriceps and hamstrings, anterior/posterior TF glides, all directions with patellar mobility, posterior glide of the femur on the tibia, and transverse plan glides). All mobilizations were grade 4 as this patient had severely limited motion and was painful. I was actually exhausted after this session and this patients knee felt like it was moving at all. After all of the manual treatment we had gained a few more degrees in each direction. Then we performed LLLD stretching to the hamstrings while the patient was in supine to increase knee extension. Then performed therapeutic exercises. The patient was actually going back in for a manipulation under anesthesia in the following weeks so I am interested to hear what the outcome was. Overall this was a great learning experience for me.
Emily Blum
This semester at the inpatient rehab hospital I had my rotation in, I had the opportunity to treat a patient who had Multiple Sclerosis (hospitalized d/t infection). Thankfully, the session was first thing in the morning, so he was not too fatigued yet. We also made sure to have the session inside in the air conditioning so that he did not get too warm. The patient was very verbal about wanting to push himself and do as much physical activity as possible so that he would be less of a burden on his wife and kids. We had to educate him on while his motivation is great, it is important to not over-exert himself because that could set him back even further by having a more extreme exacerbation of symptoms. While observing the patient ambulate with his walker, I noticed he had foot drop. This made it more difficult to ambulate for him and to ascend and descend steps. This patient required moderate verbal cues to clear objects on the ground and steps enough so that he would not fall. The patient also lacked dorsiflexion bilaterally while I assessed his active and passive ROM of his feet. My CI and I talked about the potential reasons for this being true. Although I was not able to assess PAMs, this patient could have had a muscle length issue with gastroc/soleus complex (potentially due to recent increase immobility). The patient could also have a hypomobile posterior talocrural glide or posterior distal tibiofibular joint. It would also be good to assess the proximal tibiofibular joint (potential limitation in anterior glide), and calcaneocuboid joint (potentially limited dorsal glide), which could all possibly be limiting DF. This experience was great for me because I was able to make a musculoskeletal connection in a neuro setting. I had to opportunity to remind myself that all of these patients with neurological disorders do still have a musculoskeletal system and that they can benefit from manual therapy and therapeutic exercise to target these limitations just as much as they need to be able transfer, do bed mobility and walk safely. It was a great experience for me to put all of physical therapy together.
Reply to John O-H,
I’m glad you had the opportunity to work with a patient post CVA! The clinic that I was in this past fall was a non-profit outpatient neuro facility. So I was able to work with lots of patients following stroke. I can appreciate the scariness of working with a new patient population. But it sounds like you did great! We also did A TON of PNF treatments in clinic. They are super helpful with these patients so I’m glad you were able to practice on a real patient! Additionally, with my experience this fall, gait is another huge component of their treatment. It is very interesting to do a gait assessment with patients following neurological injuries. There are many things I picked up on after working with more and more patients.Many stroke patients present with very similar deviations. …And I’m glad you picked an intervention tailored to the trunk! My CI always told me “Trunk is always the answer! (well ,almost).” But in all seriousness, for this patient population, their trunk control plays a tremendous effect on their quality of ambulation. I hope you enjoyed this day! Sounds like you had an awesome learning experience.
Mekayla Steckel
Mekayla Steckel
As we all know, patients with neurologic disorders often present with an equinus positioning at the ankle. During my time at the AFC clinic, I was able to observe a lot of different feet! Equinus was present in almost everyone. At this clinic, I also did a lot of gait training. I saw many compensations including genu recurvatum, hip ER, decreased step length, premature heel rise, etc. Working with patients with these ankles can be scary! Obviously some cases were worse than others, but this increases their fall risk and risk for secondary complications. It is interesting to see the change from supine to standing. Their tone most definitely increases once they’re on their feet. I wish we would’ve gotten to the ankle sooner so I would’ve known a little more about working with these patients and what ankle treatments I could’ve done to benefit them. In addition, I wish I would’ve asked them more about the use of night splints and heel lifts, other MSK dysfunctions and whether or not they’d had a previous surgery on their LE. I am fortunate I was able to see patient’s with these deformities on a daily basis and I look forward to now applying what I’ve learned throughout the ankle unit to future patients that I’ll be working with.
Patrick replying to Kyle
Thanks for sharing! That’s great that you were able to help decrease your patient’s pain. It sounds like you had a lot of exposure to this pathology during your clinical. This will definitely be a huge confidence booster when you see a patient with frozen shoulder during your full-time clinics. You mentioned your plan moving forward, I hope to do something similar to increase my knowledge of different pathologies and reinforce what we’ve learned. Keep up the good work!
– Patrick
John Orchard-Hays
In my last week of clinic I worked with a patient who had a L CVA. I was unclear if the patient was to work with me or not and it turned out that he was on a different therapist’s schedule, even though my CI had been primarily working with him. After reading over his initial eval and previous daily note I asked if I was to work with him and my CI gave me the option. I had never worked with a patient who had a CVA as an SPT so I seized the opportunity. He was about a year out from his CVA. Overall, he was very functional and at a first glance you wouldn’t be able to recognize he had a CVA. Upon analyzing his gait however, I could tell he still favored his left leg due to hypertonicity in his RLE. I was instructed to perform some PNF patterns with his R UE and differed to another therapist to perform his LE PNF since I had never done it before and we had not covered it in class yet. As for his TE, we worked to normalize his gait and did a few exercises that encouraged trunk dissociation. I definitely got myself out of my comfort zone by working with this patient. I feel I gained some further insight into working with the CVA population by being able to apply what I’ve learned in my courses thus far at SU to a live case.
Patrick Dumais
Post #3My last week of clinic I had the opportunity to work with a patient I had not seen for several weeks because they were not on my CI’s schedule. It was a great chance to see the patient’s progress over the past several weeks. The patient had suffered from hydrocephalus which had left him with what my CI referred to as “stroke-like” impairments. The first time I had seen the patient he was doing all of his exercises in seated. He worked on some mirror therapy but had very little muscle activation on his entire R side. This time, however, the patient was able to stand up with Mod assist and CGA once standing. It was really nice to see how far the patient had progressed over the past several weeks. The patient’s son was also there during the therapy session, and he helped motivate the patient to push himself. Unfortunately, the patient did not really think that he was making much progress but I tried to remind him of how far he had come since I had last seen him. I was glad I had the opportunity on the last day to observe his progression first-hand.
Kyle Kohnen
During my last week in clinic I worked with a 50 y/o female with frozen shoulder. I was feeling confident about working with her because this was the 5th case of frozen shoulder I had seen in clinic and they all presented more or less the same. The patient was lacking ROM in all directions, with abduction being the most limited. Movement was very painful for the patient, so I started treatment with distraction for pain relief and then followed up with inferior and posterior glides. After treatment, her ROM was still the same, however her pain had decreased so the intervention was a success. Working with frozen shoulder multiple times was really helpful because It’s nice to finally feel comfortable and confident during treatment. Looking forward, I want to zone in on one particular pathology per month to get an in depth understanding of the different kinds of presentation and treatment. I think this will help me become a more well-balanced PT.
Brianna Virzi
While in clinic, we had a 65 y/o male come in for an initial evaluation s/p SLAP repair with a LH biceps tenotomy. He began conservative PT treatment in July shortly after his shoulder pain started. After 4 weeks of therapy, he admitted his shoulder was feeling a lot better and he wasn’t limited lifting overhead. However, imaging revealed that his labrum and LH biceps were torn. At this point, the patient claims that “the orthopedist made the decision” for him to have surgery. Currently, this patient’s complaints and restrictions post-surgery are more substantial than his complaints prior to surgery.
After this initial evaluation, my CI and I discussed this case. This patient is older, not very active, did not feel limited in his daily life, and felt like PT was helping. We both agreed that this patient may not have needed surgery despite what the imaging showed. This case made me wonder why the imaging and orthopedist’s opinion held more weight in his decision for surgery compared to the PT’s opinion, when therapy was proving to help manage his pain. This patient encounter made me realize how important it is to advocate for physical therapy. Patient’s should never feel like they are forced to have surgery, especially when conservative treatment is a viable option.
Rachel,
Wow, this sounds like a tough, but good experience to have! I think you and your CI evaluated the different options you had for mobility and decided on the safest approach for this patient that would still provide them with some benefit. I think it’s important to highlight how difficult this patient’s long-term rehab will be. However, it’s also important that we implement individualized techniques that will work for this patient’s cognitive level throughout their rehab. Thanks for sharing!
Sarah Roderick
Sarah Roderick
In the acute setting, my CI and I treated a patient who had suffered a fracture of his lateral malleolus and a subsequent talar subluxation. My CI and I chart reviewed this patient, and we discovered the patient weighed 575 lbs. With this information, I became nervous about our ability to perform several mobility interventions such as transfers and ambulation.
My CI and I evaluated this patient, and he had a very difficult time moving either of his legs, which made me nervous about how we would transfer the patient from supine to sitting. My CI and I were able to assist the patient to sit EOB. We tried to educate the patient on how important it was for him to attempt standing interventions, as he is non-weight bearing on his R LE and will need to master stand pivot transfers in order to safely go home. The patient did not want to attempt any standing interventions and stated he would try at a later time.
I recognized that the patient will likely not be in the hospital for very long, if he remains medically stable. It is very important for this patient to master his transfers independently, as it will likely be much harder for someone to assist him with a stand pivot transfer to a bedside commode, given his weight and prior limited level of mobility. Additionally, this patient needs to practice as many of these transfers in PT sessions while in the hospital, in order to prevent a SNF discharge recommendation.
It was great that my CI and I were able to encourage this patient to participate in PT and sit up EOB, as even this amount of mobility took some coaxing and encouragement. However, it would have been better if we had been able to get the patient standing, as he may not have many more opportunities to participate in PT in the acute setting. Though my CI and I provided this patient with this information, he still refused standing. In the future, I hope I continue to find the balance of encouraging a patient to participate in the most appropriate interventions for their treatment session that day.
Azita replying to Katie,
Like you said, that’s awesome that you got to go back to MSK I. A little confused about the time table, how long have you been seeing her? I actually saw my first pt with frozen shoulder a couple weeks ago, and like you said it’s awesome to be able to apply our knowledge. Yours definitely fits the profile like you said! It’s interesting b/c my patient is a middle aged woman who fell, and apparently “developed frozen shoulder” after this.. I mean she truly is limited in all ROMs, with ER> abd. With her arm at her side (0 degrees), she has MINIMAL external rotation. I’ve seen improvements in ROM with the few treatment sessions I’ve had with her though. I’ve been using distraction glides due to her level of irritability, with PPMs in b/w bouts. Interesting to see where we’re both at in terms of stage of FS, with similar pt’s!
Azita replying to Rachel,
Rachel that’s a tough situation, but I think you guys did what was best in that scenario! With a pt that “fragile” I think it’s best to walk on the safer side since they’re cognitively unaware… better safe than sorry. I can recall a similar situation when I was at Warrem memorial where we chose to do the same thing. It’s good that you guys chose to be anticipatory instead of reactive. It’s always great to walk pt’s in inpatient, but safety comes first!
Azita Nejaddehghan (foot/ankle unit post)
To make a long story short, I’m seeing a Pt at free clinic who has MAJOR psychological issues. I’ve written about her before (not sure if it was here or on TherEx), but this is a woman who is constantly with headphones in/listening to music to calm her self down. She presented a significant fear of falling and pain essentially all over her body.
Last tuesday I saw her for now the third time (second treatment session), and she is now able to walk without about 90% of the gait deviations she presented with gone! To put it in perspective, her gait at initial eval was so unsafe, even with me holding her hand, we had to have a conversation with her about a cane. Last Tuesday, the Pt told me that she now has her husband park farther back in the lot when they go to the grocery store so that she can walk farther, and that she doesn’t hold onto the cart for help when she’s shopping. I have to say this is one of the most rewarding experiences I’ve had so far. I have NEVER seen such a psychologically influenced case as with this scenario (she’s also reported that her anxiety and depression has been much better lately!)
I think this was an incredibly useful experience for me to have early on because I think it will help me when I experience patient’s like this in the future.Justin in replying to Jesse,
This sounds like a great opportunity to be able to practice your patient education skills. I too have treated individuals who report subjectively that they want to get back to their PLOF and are motivated but when you ask if they have been completing their HEP you get a honest “no”. We appreciate the honesty but the importance of tying those two aspects of therapy together is essential. As PTs we can only do but so much, a lot relies on what the patient is doing when they return home and how they are moving forward in their treatment without us being there since we only see them a couple times a week in the outpatient setting usually. It goes along with being a good PT, making the patient believe in our interventions and how it truly will move them forward in their POC.
Great post