[Shenandoah University Division of Physical Therapy]

Alex Gett

I recently worked with a pt that is roughly 6 weeks post-TKA. She is coming along well but is lacking extension based on where she is in the treatment timeline. Like most pts, she remembers her goni measurements from previous weeks, and if she does not see improvement, she gets discouraged. I did my best to encourage her and let her know that she is doing everything right at home and that we are doing everything we can in the clinic. I did not say “your ROM will return if…” because nothing is guaranteed and I cannot make those assumptions. I share this because although both ends may be doing everything right, it does not necessarily mean we will always get the outcomes we want when we want them. I let the pt know that these things take time and that we will not stop working; we can only control our actions and we will not stop doing everything in our power to reach your goals. Her husbannd was present and he is very supportive. They both left the clinic thankful that we had the talk.

• This reply was modified 5 years, 8 months ago by Shenandoah University Division of Physical Therapy.

[Shenandoah University Division of Physical Therapy]

Sarah Strong responding to Christie

Christie,

I, too, have not seen lymphedema techniques for patients other than for those who had a lymph node removed. I wonder which other post-surgical diagnoses benefit from this treatment. From what we are learning and from what I have seen in previous clinic experiences, it seems that scar management and reduction of swelling are important to implement early on to prevent limitations later on due to poor healing.

The analogy that your CI used to described the lymphedema technique to the patient sounds highly relatable to something that we all experience (those of us who drive), traffic. It seems to me that having an analogy that is relatable (and close to within context that the patient understands) is important in order to make that analogy effective.

Thank you for sharing!

– Sarah

[Shenandoah University Division of Physical Therapy]

Sarah Strong

I am currently learning in the inpatient acute care setting, where we typically see TKA patients on the day of surgery to get them walking and assess their knee ROM. Due to the nerve blocks and otherwise anesthesia, these patients are in a knee immobilizer until they are determined safe to walk without any knee buckling, as my CI explained to me. There are a few aspects of these patients’ care that I have been especially curious about recently.

I understand the evidence for pre-habilitation is strong, suggesting that patients who received pre-habilitation before surgery have better outcomes than patients who did not complete any organized exercise program prior to surgery. My CI and I discussed this and unfortunately, it seems insurance does not typically reimburse for pre-habilitation treatment. I would be very interested to learn more about the dynamics that come in to play with advocating for access to this type of service, as the evidence is described as strong with regards to outcomes.

The patients that receive TKA surgery at the facility where I am in clinic undergo “joint camp” which is an educational course for about an hour or so a few weeks before their scheduled surgery. At joint camp, patients learn about the process of surgery, what to expect the day of, recommendations for home modification, and some exercises that they will be asked to do during their stay in the hospital. Because these patients are post-surgical and often still experiencing some lingering effects of anesthesia, we have kept these exercises very simple to ankle pumps, quad sets, and gluteus squeezes.
I am also curious to know more about what home health PT is like for these patients, as I understand a knee immobilizer is not typically used once they are at the level to be in outpatient care. My CI explained to me that usually the home-health PT will wean the patient off the knee immobilizer. I have a feeling that patient education on the reasons for the knee immobilizer are lacking, as it sounds to me like patients are instructed to have it on every time they are out of bed and this is contrary to what I have learned from outpatient PTs.

I am excited to get more outpatient experience in order to gain a broader understanding of the continuum of care for patients who receive a TKA.

[Shenandoah University Division of Physical Therapy]

Bailey Long

My current ICE placement with my CI has been a very new experience for me this semester. We come from very different styles of learning and perspectives when addressing patient care. My CI has over 40 years of physical therapy experience, where I am still really green when it comes to patient care. With his extensive experience in patient care, he relies less on new evidence. This is very different to the style of evidenced based therapy that is emphasized in Shenandoah University’s DPT program. In addition, my past CIs and current teachers all have pushed me to find answers in recent research, since I don’t have experience to fall back. Working with my current CI has been a beneficial experience with improving my interpersonal relationships. There have been a few times where my CI and I have “butt heads” over the best treatment approach for certain patients. I have taken these situations as opportunities to self-reflect on better ways to present new research and be better with “rolling with resistance” with patients and other potential colleagues that may be reluctant to hear new research.

[Shenandoah University Division of Physical Therapy]

Christie responding to Emily:

That sounds like a really powerful experience! How old was the patient and how did she sustain the spinal cord injury? I am sure that type of injury would be extremely challenging for anyone, but the exact psychosocial factors in play would probably be different for people of different ages. I love that you were able to address the patient’s physical and emotional needs throughout your session. The longer treatment sessions in the in-patient rehab setting seem really nice for making sure you have enough time to address everything that the patient needs. I would be very curious to see how regaining function helps the patient’s morale, especially when she reaches a plateau. You are definitely right that we should never underestimate people.

[Shenandoah University Division of Physical Therapy]

Christie Freund

In clinic I saw a 45 year old male who was having painful swelling in his left knee. My CI had been treating him following meniscal repair surgery in July, but he was doing better and coming less frequently as a result. My CI worked on lymphatic drainage of the entire left side of the patient’s body beginning with his chest and working all the way down to his ankle. This was the first lymphedema technique I had ever seen in clinic, so it was very interesting to watch and get to try a little myself. I was also very impressed with my CI’s patient education about the technique he was performing. He described it as clearing an accident off the highway so that traffic could start moving again, only the car accident was fluid. It made me think more about how we can use analogies to help patients understand what is going on with their body and the rationale behind the treatment techniques we select for them. While my CI was working on the patient, I asked him about the history of his meniscal injury, surgery, and recovery. It was really interesting to see hear about it from an actual patient instead of a made-up case scenario. I had trouble comprehending how the patient could not know whether he had his meniscus repaired or taken out. As PTs, I am learning that we should assume that our patients do not know anything about their problem from their physician or surgeon. We should explain things from the very beginning to make sure that our patients can be well-informed about their condition in a way that makes sense to them without alarming them. My other takeaway from this experience was that lymph drainage techniques can be used for more patients than I previously thought. I only ever thought about them for patients who had undergone lymph node removal or had swelling in the legs. This patient had swelling that was localized to the knee, but he still benefited from this technique. I will now think about this as a potential tool for reducing swelling at peripheral joints as well.

[Shenandoah University Division of Physical Therapy]

Emily Blum:

Last week was the first time working with a patient with a spinal cord injury. She had a C5 incomplete injury. The first day I saw her, she was in a lot of pain from spasticity and very emotional about everything that had occurred. She was having a difficult time moving her neck or arms, and grading movement was especially difficult. This week (1 week later) I saw her again, and I was shocked. We had an hour and a half to work with her, and when I walked into her room the first thing I noticed was movement from under her sheets. Her legs were getting quadriceps contractions, and her core was even starting to have some tone again! She was able to sit edge of bed with mod A (using biceps to stabilize herself) for 3 x 4 minutes each. Then, she was able to do 10 crunches in bed (mod A to sitting, min A eccentric control down). I was absolutely shocked at how much function she had gained in 1 week. We stopped the session multiple times to address the psychosocial factors that come with this injury as well, such as not wanting to be a burden on her family. I thought that I would have been a lot more uncomfortable discussing things like that, but it felt really good to talk to the patient about how much progress she has made. She was denying any progress, but to be able to show her by having her do certain things for increased amount of time really helped her mentally. This experience taught me to never doubt how much a patient can do and never say never to a patient about what they’re going to be able to do and not able to do. It is good to be realistic but patients will always surprise us.

[Shenandoah University Division of Physical Therapy]

Emily responding to Azita:
I bet that must have been frustrating to know that this could have potentially been prevented! But it must make you feel good to know that we now have the knowledge to not make that mistake as clinicians. It just shows how important preventative programs are and how much they have progressed and become more popular in the last few years. I wonder if this woman ever had a chance to try coping, or if she immediately had the surgery done without trying the conservative management the first time.

[Shenandoah University Division of Physical Therapy]

Azita

Recently I worked a 32 year old female patient who was in for pre-op ACL on her R, which she has previously had an ACL reconstruction on before as well. She has also had an ACL reconstruction on her L. Immediately my mind went to the research in terms of the fact that those who have a previous injury to an ACL are at increased risk of ipsilateral re-injury or contralateral injury, BOTH of which she has experienced at this point. Then I started to think about the research indicating that she now has a 3 fold increase in OA surgical knee vs control. This all almost frustrated me to a certain extend because as we’ve talked about there ARE modifiable risk factors that can be addressed. All of this to me just made me think that somewhere along the way, her coaches (she was an athlete), PTs, or other people misses these factors (weak hip ABD/ERs, upright postures, imbalance of Q:H, fatigue, pronation, etc.). From here on out the PT is focusing on hamstring strengthening, regaining ROM, reducing swelling, and then we will be seeing her again post-op!

[Shenandoah University Division of Physical Therapy]

Laura D’Costa:
This week at the SNF I got to attend a home visit to see if a patient post total hip replacement was safe to return home. The patient was able to navigate her home with little difficulty and did not need any additional devices to make her home more accessible. The medical professionals as well as the patient were surprised with how well she was able to safely perform ADLs within her home. Towards the end of the visit, the patient expressed the mixed emotions that she was experiencing. She was excited to return home but nervous to live by herself and not have the resources she currently has in the SNF. My CI recommended resources the patient can utilize including services that provide someone to assist you in your house or go with you into the community. This noticeably lessened the patient’s fear of returning home. This interaction made me realize the importance of a PT’s job in providing our patients with appropriate resources that will help them to increase their function. I will be able to transfer this to my first full-time clinical experience in home health by informing patients about resources that they might not be aware of that can help increase their quality of life.

[Shenandoah University Division of Physical Therapy]

Laura responding to Amy:

You post was very thought provoking! First of all, it must be frustrating for the patient to be stuck in the hospital for such an extended period of time due to other facilities not wanting to take complex patients.In clinic, I was able to see the other side of this. I sat in on a meeting where the staff of the SNF were deciding which patients would be admitted as residents from the hospital. There were two rooms available in the SNF and five potential patients that wanted to live there. The SNF did not take any of these patients due to them being too complex and requiring too many resources.

[Shenandoah University Division of Physical Therapy]

Amy Korcsmaros:

Recently, I was able to work with a patient who at the age of two, got meningitis. Now this individual is 30, but has been in the hospital and working with my CI for over six months. This prolonged stay is due to discharge complications and no facility willing to take this patient with a large amount of seizure activity. In prior months, my PT has worked with him on ambulation, as many other professions are not willing to walk him with a combative history. As my PT mentioned to me, ambulation without a reason for ambulation is not skilled PT. If he is only getting the 20 minutes of walking every couple of days, this brings the question of how can we keep seeing this patient if the interventions are not skilled?
I think this is often a question others may have when working with a patient that benefits from our interventions, but does not necessarily need skilled therapy. We know that it is beneficial for them both physically and mentally, but yet insurance or other parties say the patient no longer needs us. This makes me question, what can we do as a profession in order to be able to keep working with patients such as this patient in the acute care setting for over six months. Next time, I will suggest trying to implement more of a skill to the ambulation training. Unfortunately, he is very unwilling to try new activities, and this has been where he often becomes combative. I will discuss further with my CI different ways to try and “trick” him into doing functional gait activities, without him being aware of completing these other tasks. Throughout this patient encounter, I felt moments of frustration because everything I wanted to do, I was unable to due to his inability to cooperate and conduct the skilled interventions without getting angry. Hopefully, with more and more patient buy-in, we will be able to enhance his ability to conduct skilled interventions, therefore assisting his potential for discharge.

[Shenandoah University Division of Physical Therapy]

Melissa Jankus – Reflection #2

This week in clinic, I was able to do a knee evaluation on a patient who came in with a script that said “bilateral PFPS and left plantar fasciitis”. This patient reported anterior knee pain (more in the left than in the right) that started approximately 2 years ago, due to a week long training exercise with excessive running. He reported that the pain was intermittent and sharp at times, and was aggravated with stairs, running and squatting. He reported that his pain only came about after a few minutes of activity (for example: walking up stairs are fine for the first few flights, and then towards the end, his knee would start to hurt). He also reported pain in his left heel with prolonged sitting, and said that if he sat for a long time, he would limp for the first 8-9 steps when he got up, until it “loosened up”. During functional testing, we observed pes planus, worse in the left than the right, as well as some dynamic valgus at the knee. His symptoms were not provoked with the functional tests. His biomechanical exam was unremarkable, with ROM and strength being within normal limits. The patellar tendon was not tender and he did not have pain with resisted knee extension. We also screened the ankle and the hip. We found that the patient’s glute med was relatively weak and that the patient’s gastroc was tight. We did manual therapy to help stretch and release the gastroc and gave stretches for the patient to start on. This case was a great learning experience, especially since we just finished the knee unit and I was able to put my knowledge of the knee together to help figure out what to do for this patient.

[Shenandoah University Division of Physical Therapy]

Marielle Giardini

Last week in clinic, we saw a 15 y.o. male who had the dx of chronic hip flexor tendinopathy. This was only his second visit to PT and my CI did not initially evaluate him. We started treatment off with 8 minutes on the recumbent bike and then moved into some more ther ex. We started him with streamboats with a theraband and we noticed he had excessive trunk movement during this exercise. We stopped the patient during the exercise to instruct him to not compensate with the trunk movement, however, he was not able to perform the exercise properly so we had him stop. My CI explained that the excessive trunk movement was indicative of a weak core. Because of that we wanted to see how he did with a plank, which he demonstrated improper alignment. For me, it was interesting to see another way that the whole kinetic chain comes together for proper biomechanics.

[Shenandoah University Division of Physical Therapy]

In response to MJ
I have not yet had the opportunity to work in a SNF, so these types of posts are always very interesting to me! Taking the helms and leading an entire treatment session is always very intimidating, so good job on going in confident, asking the right questions, and coming up with your own interventions to treat her walking ability. It must have been amazing to see the results of your own clinical application and thinking manifest itself in a patient in front of your own eyes. I agree that sometimes information not being readily available when you would imagine it would is frustrating, but you seemed to have handled that well. Props, and keep sharing more!

Ahmad Rahman

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