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Justin Geisler
In clinic a lady has been coming in for R hip pain, she had labral surgery 2 years ago but she still has pain. This reminds me of the scenario if you do not address limitations then it will lead to the same poor mechanics and injury. My CI and I have been addressing a lot of glute med/max strengthening, hip mobilizations, quad stretching and t spine mobility. She also has tenderness in her R hip adductors which she received STM for to decrease pain combined with some adductor stretches. This patient is very active and has great body awareness in her movement which is great because she feels her body moving abnormally internally and she is able to describe it to us well which helps guide our reasoning and treatment interventions. Not all patients I have encountered, actually could count on one hand how many patients are that in tune to their body mechanics so it was greatly appreciated when she was able to provide us with the information. Hip mobilizations consisted of long axis distraction, lateral glides and posterior glides, grades 2-3 since she had pain throughout her range. I assessed her pain in FADIR/FABERs prior, post treatment those motions were more tolerable which was a good sign. Her TFL was also super tight as well so we did STM there as well as added sidelying clams to her HEP to target her posterior fibers of the glute med and emphasized firing of the glutes intially during bridges as well. This was a great reflection in realizing how body awareness, motivation and education a patient comes into clinic with can impact the treatment session. She was a great listener and I know she will demonstrate adherence to her HEP.
Rachel Lenz
This past week in clinic, I encountered a patient who cognitively was not alert. She had been given morphine and was diagnosed with dementia. This leads to garbled speech and made it very difficult to understand her. The reason she was in the hospital was that she had fallen at her home, in the dementia care unit, and broke her hip leading to a hemiarthroplasty of the hip to repair it. Due to her cognitive state, it was very hard to get any information out of her. I was able to get how much pain she was in, however, everything else was not discernable. The approach was anterolateral, however, this particular doctor has extra restrictions of no adduction compared to the typical restrictions associated with this surgery. This made not only myself but my CI nervous about trying to get her to the edge of the bed. She was not able to follow simple commands to wiggle her toes and did not seem to want to move either leg. This made it hard to implement interventions with her. We considered manually getting her to the edge of the bed, however, due to her mental state and the morphine in her system, we were unsure that this would be a safe position for her. Because of this, we chose to keep her in bed and perform some PROM of the LE bilaterally. This is where our treatment ended, however, I am wondering if we had sat her up, would she have become more coherent and be able to safely sit there. It is hard to tell as we were not able to measure her strength and although there were two of us in the room, it would have been difficult to maintain all of her precautions while sitting her up on the edge of the bed.Katie,
That is very cool that you were able to see something that we have talked so much about in class in a real life situation. I think in this pt’s case, it was really smart of you to consider being more aggressive to try to get results since being gentle did not seem to work. Sometimes its a guessing game, but when you find what works it is always nice to see the pt’s reaction. That is always really crazy that no one had told this pt about the connection between thyroid problems and her shoulder, I hope you were able to educate her a little on this so that she could have a better understanding of her body. Overall, great job!
-Ally Kuhn
Allyson Kuhn
Two weeks ago, My CI and I visited a pt who had a tumor removed from her C-spine earlier in the year and is now receiving home health PT following returning home from inpatient rehab. The surgery left the pt with increased weakness and balance problems which is where we came in. Prior to visiting the pt’s home, I looked over the pt’s files and my CI informed me that this pt was a hoarder and her house was very messy. This made me a little nervous honestly, now not only was I about to treat a spinal cord pt but I also had to some how treat her in a cluttered home. I had no idea what I was going to do, all I knew was that I was going to have to put on a happy face and try to ignore my surroundings. When we arrived at the pt’s home, there was a single walk way up to her front door and about the same inside as well with just enough space for the pt to walk from her bed at the front of her home to the wall at the other end of the room. I am not going to lie I was a little shocked at first but knew I had a job to do and that was to help the pt not to worry about the clutter in her home as long as she was safe. So, with that being said, we began by taking vitals and then started with some ambulation down her walkway with a front wheeled walker. For ambulation the pt was standby A and required some verbal and tactile cueing to lift her legs to walk rather than drag them and to avoid hyperextension of her right knee. After ambulation, we decided to practice stairs. At first the pt was very hesitant to work on stairs but with a little convincing she decided to give it a go. For this particular session we only practiced tapping as this was the first time practicing stairs again. The pt was able to perform this task while holding onto the railings and with min A with her left leg; however, her right side is much weaker and required mod A. During this session the pt was able to get just below the stair with her right foot but not fully up onto the step. She is a very motivated person so this was not easy for her to take in, all she wanted was to get her leg on that step. I could tell that she was starting to get down on herself so we provided her with some reassurance that she will get there with practice and decided to call it a day since she was beginning to fatigue as well. We provided her with a HEP that had the exercises we performed on it and then we were off.
Just yesterday, we went to visit the same pt again and not only was she now able to step her right leg up on the step and push herself all the way up onto the step, she has switched to a cane to walk and can now walk side ways with min A. It is incredible the strides that this pt had made in just one week. I was amazed and to see the smile on her face when she was able to do these things was great. Through this experience, I learned that we cannot judge a person right off the bat based on appearance or how cluttered their home is. Had my CI or myself been judgemental, I do not think this pt would have made the strides that she did. All she needed was someone to help her and because we were able to look over the clutter, we learned a lot about her and with her motivation we were able to help her reach her goals. I hope that I can be this way with all of my pts no matter who they are in order to provide the best treatment I can.
Katie Woelfel replying to Jesse
Ironic your patient seemed to be resistant to his HEP and PT when he reported to be eager about returning to his PLOF as soon as he could. Hopefully he sees improvement in his function and quality of gait after working with you guys and will be more bought into PT/what you can offer him. That’s awesome your CI is giving you autonomy over his HEP and making you an significantly active part of his treatment. Overall, good job!
Katie Woelfel
The past couple of weeks we have been seeing a 44 yo female patient presenting with s/s consistent with adhesive capsulitis. Based on length of symptoms, subjective reporting of pain, and objective measurements of ROM the patient seems to be at the cusp of freezing stage. Pt reported her pain with any movement is around 6/10 which was an improvement from the previous month where she felt it was consistently 9-10/10. The first time she saw my CI, she reported the other PT in the clinic she had been seeing was taking it pretty easy on her and she hadn’t seen improvements in her ROM yet. We decided to be more aggressive with grades of mobilizations, soft tissue mobs, and active ROM exercises.
We utilized many MWM techniques (i.e. posterior glide given with belt while also providing ER). Pts tissue was highly irritable when doing soft tissue mobilization to long head of biceps, pec minor, and pec major. Pt performed active assist pulley exercises in all direction. Pt also performed active assist utilizing TRX straps by holding on, facing away from straps, and while walking away moving her shoulders into either abduction or flexion.
This next session pt reported the day after her first time with us, she was in less pain and felt her shoulder had loosened up. When measuring ROM, she had maintained the ROM we gained at the end of last week.
An interesting side note to her story is that she reported having her thyroid removed many year ago, but had been having problems with her medication in the past year. As we had learned last year, there seems to be a correlation with thyroid disorders and the development of adhesive capsulitis (which her doctor failed to mention to her even when giving the script for PT). This was the first patient with a shoulder pathology I had seen in ICE 2, and it was awesome to be able to review MSK I.
Jesse Parsons
This past week in clinic I had the opportunity to eval a pt. 1 week s/p a L TKA. He is a very active 85 yo male who had not been performing any of his post-op exercises since the surgery. He is very motivated and wants to return to full function w/o pain as soon as possible. During our objective exam, we determined that he lacked 10 degrees of knee extension both passively and actively. He also had a compensatory trunk anterior lean during gait to make up for his lack of full knee extension. After further testing, we determined that his hamstrings and gastrocs were tight bilaterally and he had hypomobilities in his PF join on the left, specifically in his superior and lateral glides. As we neared the end of the session, my CI had me design a HEP for the pt. and take him through it. I then was able to explain the importance of performing his various stretches and exercises and how they would help him progress towards his goals. It was a great opportunity to work with a patient who wasn’t afraid to push the envelope post-op and get back to his PLOF. The hardest part with this pt. was having him actually perform his HEP, as he was very stubborn about the fact that he did not need any extra activities outside of his time in clinic. This was an important experience for me to work on my pt. education skills in an effort to change his mind and his stance towards physical therapy.
Uyen replying to Amy
Amy, your CI’s advice was awesome because I also wouldn’t know what to do if I encountered a highly irritable patient either. It was great that you realized during the subjective that there were other joints involved, and were able to gather more information about those. Even though it seemed like she had a lot going on, I’m glad you were able to narrow it down to those 3 impairments at the moment. It’s crazy to think about all the combos of impairments that we will see in clinic, but I think it goes to show that even if you don’t know what is going on, treating just the impairments can help the patient! I have also learned that about my patients this semester too!
Uyen Tran
Yesterday in clinic, I read a follow up note from a physical medicine doctor about one of the teenage patients we were treating. Reading that form, I saw so many deficits present, but I think about the patient we are treating and he’s so high functioning, that without special tests run, no one would know he had all these deficits. That taught me that with the pediatric setting, you can read a diagnosis and results from another doctor, but these kids could present in so many different ways. In this situation, I was glad that I had gotten to meet him a few weeks before reading this note, so I wasn’t biased, but I was still shocked when reading it. This patient presented with pes cavus external tibial torsion and decreased dorsiflexion ROM among other deficits. My CI knew we were just starting the ankle unit, but she showed me how to perform a talocrural posterior glide to help improve his ROM. I didn’t realize how hard that would be for me to perform since his feet are so huge and they were extra stiff. Then we worked on a few exercises I came up with that could help improve his medial longitudinal arch and tibial IR. I had him perform towel scrunches, holding a small ball between his arches while his legs were straight and lifting that up, and then I also had him perform heel walks. After the “therex” part of the session, we were able to take the patient to a punching bag that the clinic had and allowed him to perform punches while he stood on an decline to improve his dorsiflexion. He had alot of fun using the punching bag and I was glad we were able to have him exercise his whole body in a functional way. It was nice that during this session, I was able to apply things we’ve learned in class and learn something for the first time in clinic instead of in class. This made me realize that I need to start practicing on different people in the class more because there will be more situations where I will learn a skill for the first time on a patient who doesn’t present like a typical patient, so practicing on many different people will prepare me better for that next time.
Levi responding to Peter,
I remember when we first started the program, I think we were sitting in cool springs for professional issues, and they proposed the question: would you rather be an expert at mechanical manual skills, or an expert at psychosocial skills. And, at the time I was very much on the mechanical/manual skills…Think about a surgeon – it’s nice to have a surgeon with good bedside manner, but really you are more worried about their manual skills right? I think this still applies to PT, but the more time that goes on, the more I realize the importance of psychosocial skills. Obviously, manual/mechanical/therex skills are still very important (I hope), cause if they weren’t, then we would just be psychotherapists (and that would be depressing)!!!Amy Korcsmaros- Ankle Unit Post:
The other day I had my first foot/ankle initial evaluation. It was slightly daunting as I know that many foot pathologies can be related to other impairments found up the kinetic chain. To begin I took a detailed history that included PMH, aggs, eases and level of function. Due to their not being a clear MOI, it was going to be a challenge to determine the underlying factor causing her these pains. Initially I was very focused on the ankle, but quickly realized that there were many other things that were creating her pain. When asked to point to the most painful part of her foot, she was unable to even raise her entire leg to reach her foot. That is when I knew something more was going on. After observational analysis and many objective measures, we determined her three primary impairments were: pain in the medial calcaneal region, hip pain with limited hip ER, and tightness in the medial gastroc. Due to her irritability level, I was finding it difficult to create treatment options that would be conscious of her pain level. I was a little flustered, but then my CI was able to help guide me in the appropriate direction. He indicated that it might be beneficial to start away from the most painful regions to see if that makes a difference before moving to a region of higher irritability. This seems like a basic concept now, but it just goes to show you that when you are in the clinical setting, things might not seem as straight forward.
Next time in a situation like this I will be more cognizant of other joints prior to going into a more detailed exam of one joint. I will try and find a new flow that works for me and allows me to stay organized with my thoughts when multiple joints need to be looked at.
Amy Responding to Tori,
Wow that must have been so nice to be able to see that change in rapport with her. I recently had a patient with dementia and I had similar feelings. My CI had wanted me to take the lead, but I was a little nervous about how the patient might react to working with me for the first time. She previously had been very combative with other professionals. In that session I learned a lot. I picked up on that the patient used humor and so I tried to keep the mood very lighthearted in order to convince her to help me transfer her to the chair. I also found that by asking for a hug (to facilitate the transfer) was also in effective way to convince her to partake in therapy.
Thanks for your post, Levi! That reminds me of what all of our professors tell us about hypertension – most of the time, it is asymptomatic, which is why it is so important to check all patient’s blood pressures prior to treatment. Your post is a good reminder to be always on the alert for changes of patient status, and to stay calm in the midst.
-Victoria ApplerVictoria Appler Ankle Unit Post
About a month or so ago, I completed a patient’s initial examination. On my last day in clinic, my CI thought it would be neat for me to complete her progress note also to see how she had improved while I had been there. Initially, the patient presented with impairments relating to safety awareness, gait speed, balance, endurance, lower extremity weight bearing tolerance, and bilateral hip abductor strength. The factor that most impacted therapy for this patient, of her extensive PMH, was her diagnosis of dementia with agitation. During her initial evaluation, this patient required much coaxing and distraction in order to get her to do testing (the 6 Minute Walk Test, single limb stance, etc). Part of the reason she let us conduct all of our testing that day was the rapport my CI had already established with her prior to day 1. As she becomes fatigued, she becomes agitated, secondary to her diagnosis previously mentioned. The past week, prior to the progress note that was to be done, this patient had refused treatment over 3 times even with distraction techniques that had been implemented in the past to avoid her agitation. The day of the progress note, she let us into her room but as soon as we mentioned therapy, she verbalized that she would not be doing that today. My CI tried to convince her to do it to help me, as it was my last day, and it would be helpful for me to see her improvements. Slowly but surely we were able to get her to let me conduct MMTs of her lower extremity and test her standing balance and single limb stance on both sides. Throughout this testing, I felt I was walking on eggshells so as not to agitate the patient. After this testing, the patient became very firm in her assertion that she would not walk with us (we wanted to reassess her 6 MWT). She reported not being able to and she became very frustrated and clearly annoyed with us. We complied, saying we would only stay in her room a little longer to document what we had tested. While I was documenting I had a chance to ask the patient if she had Thanksgiving plans, and if she had any advice for me as what to make. We started talking about different cakes and the patient demonstrated an obvious shift in her response towards me. This patient has always intimidated me (in that I worry about how she will respond to me) so this was a very nice change of pace, as I never felt she was ever very trusting of me (I had only seen her for one or 2 other visits). After about 3 minutes of talking about nothing in particular, the patient turned to my CI and verbalized letting us walk with her to the activities room. Hoping she would let us complete the full 6 Minute Walk Test, we left her room. The patient even offered to go the opposite direction of the activity center for a little while since she knew we wanted to see her walk for longer. When we got to the activity room and to her puzzle, the patient made it clear she was done with us for the day. We had only walked for 3 minutes at this point but knew we could not get any more out of her today. Although we were not able to fully complete the patient’s progress note, her shift in attitude and motivation to help us do what we needed to do was crucial in getting even a little out of the patient. It will always amaze me what patients will do to make us happy, when there is a well-established rapport. For future clinical experiences, I hope to use this to grow in how intentional I am with creating good therapeutic alliances with my patients.Reply to Andrew’s Post:
I enjoyed reading about how you did not give up on the patient in this situation even when he might have seemed like he gave up on himself already. Bringing up something that he had interest in so you guys could connect was a smart move. I am curious to know though what you might have suggest or how you brought up the depression that you noticed. Did you ask him about if he was seeing any other health care professionals or talking with anyone about his depression? Keep this in mind because as health care professional I believe it is within our scope of practice to ask these question or at least document about it.