Forum Replies Created
-
Posts
-
MJ Erksine
My CI in the SNF recently had me lead the entirety of a patient’s treatment. The pt.’s goal was to walk with her cane. Since her last fall, she had progressed from the w/c to a walker so far. When I enquired as to her recent exercises, they were all seated strengthening exercises or walking with the walker. To assess her abilities I wanted her to do SLS for 30 sec but didn’t know yet if that was safe. So while guarding her I had her attempt to stand there without holding onto the walker for 1 minute. She was curious, willing, and completely able to do it to her surprise. Then I had her do weight shifts with the same parameters. She said no one had had her do either, but she could see how it could be a basis for walking. Then I had her do 30 sec SLS on each foot. This she did holding onto the walker. When trying to figure out her available hip motion after seeing Trendelenburg while on the left foot, I learned she had 2 hip replacements. I am constantly amazed at the information I am not able to easily find in the chart nor able to easily attain from the patient. I agreed with her that this probably had something to do with how she stood and moved her hips. :) I’m getting used to being in this kind of situation but I still have to remember how much info can be left out when my CI says I get to lead treatment. At least I made sure her vitals were good.
Pete,
Wow Pete, this sounds like a great experience! I just recently encountered working with a patient with dementia and I relate to many of the things you described. Given your patient’s mood change over the last several weeks, I think it was a great idea that your CI tried something different with this patient and it definitely showed improvements for them. This experience shows how we continuously have to change our plan, if the plan is not working for the patient, regardless of the treatment setting. Great job!
Sarah Roderick
Lori,
This sounds like a great experience! I think it’s awesome that the patient is able to give you good feedback on your manual skills and that you’re seeing improvements in your skills because of this feedback. It’s also awesome when we see a patient make progress and it sounds like both you and your CI have developed a great rapport with this patient. Great job!
Sarah Roderick
Sarah Roderick
My CI and I had the opportunity to work with a patient who had severe dementia and has been in the hospital due to an exacerbation of pre-existing cardiac and pulmonary conditions. The patient was consistently very resistant towards therapy. My CI and I were using every trick or idea we had to attempt to get the patient to participate in therapy with us. I was initially nervous in how best to communicate with this patient and was afraid my CI and I were not going to be able to get her to participate. The hospital currently had decorations for Halloween and when my CI and I started asking her about her favorite candy, we asked her if she wanted to see the decorations and the pumpkin creation outside of her room. She smiled and agreed, as long as we would tuck her back into bed. I thought it was great we were able to get her to participate in therapy and felt very accomplished given how difficult it initially was. This was a great experience for me as I was really able to work on providing less instructions and making our session of walking approximately 30 feet, much simpler for this patient, given their cognitive status. In the future, I will continue to remember how important it is for this patient population to receive less verbal instruction and find the appropriate balance of cueing to maintain patient safety.
Lori Yeaman – Reflection #2
My CI and I have been working with a patient with bilateral knee pain to decrease pain, increase knee ROM, and increase hip strength. The pt had imaging done that showed chondral changes. Seated tibiofemoral distractions relieve the patient’s symptoms, and we have been working on anterior/posterior TF mobilizations and patellar mobilizations to address the lack of ROM, based on the limitations found in the initial evaluation. The patient gives me great feedback when I am doing manual therapy by describing how my manual therapy compares to my CI, which has allowed me to continue to improve my skills. We have been working on hip strengthening exercises, including mini squats, step ups, hip abduction and extension, etc. to ultimately help the pt ascend/descend stairs with no pain. The patient has made great progress in hip abduction and extension strength, as well as increased knee flexion ROM. On progress-note day, it was exciting to see the patient pleased with his improvement and he reported that my CI and I have the “magic touch.” This feedback made me realize that not only is the patient improving objectively, but he is feeling the benefits from physical therapy.
Brianna Virzi
This week my CI and I had an initial evaluation for low back pain/scoliosis. When the patient walked in, it was clear there were many complicating factors within this case. She used a walking stick for support, had significant lateral trunk shift to the right and her scoliosis was evident. As we began to interview the patient, she revealed that she has had a left knee replacement, left ankle fusion, and last year she also had the right ankle fused. After this right ankle fusion, she was non-weight bearing for 6 months. My CI and I were shocked at this length of time in which she reported minimal activity. As a result, she has had significant weight gain and difficulty returning to functional activities. Through a McKenzie examination, we established that she likely has a derangement classification. We gave her prone and standing extension exercises to perform at home since this centralized her symptoms during the examination. Due to the many complications noted, my CI had a request from the patient that I found interesting and have not seen done with other patients. He asked that when she gets home, she writes down 3 things she would like to be able to do 3 years down the line. When we ask patients about their goals, they typically respond with what they want to get back to as soon as possible (sports, ADLs, household chores, etc). However, for this patient, who still has ankle restrictions and now an onset of worsening back pain, it may be harder for her to realistically reach these goals in the near future. I felt this was a thoughtful technique to use with this patient because it keeps her goals reasonable yet allows us to begin working towards them to improve her quality of life. I hope she finds this exercise beneficial and I am interested to see her goals next week.
The above post is also by Tim Webb
The above post is by Tim Webb
Alex Argentieri replying to Aly Nierzwicki
This sounds like a great example of how a to adjust your treatment session based on the patient’s need. I know from being in the hospital setting last semester that treatment session can change quickly depending on the patient’s signs and symptoms, but I imagine this must have been more stressful given the nature of your patient’s injury. However, it sounds like you were able to respond quickly and promptly to the patient’s needs and hopefully created more patient buy in for future therapy sessions. Good job!
Alex Argentieri
This week in clinic I was able to continue treating a patient for knee OA. She had been coming to therapy for a few weeks, and while her strength and endurance has improved, she is still reporting pain with walking and ascending stairs. While this was expected early in her treatment program, my CI was concerned that pain was still a major concern of hers. To address this issue, my CI decided that it was best to get the patient walking without her cane to prove she could do it. While the patient was timid to do this at first, she soon found herself walking 600 feet with supervision and no increase in pain. Soon the patient’s entire mentality about the treatment session changed and she became more determined to work on stairs and increase her endurance. Additionally, she trusted herself to be more mobile without the use of her cane. She was sent home that day with a goal to practice walking around her house without the use of the cane so that she can become more independent. While this may seem like little gains at the moment, it could be a huge impact on the rest of her treatment session as she is more trusting of her current condition and less fearful of her diagnosis.
Lori Yeaman in response to Peter Cradduck:
Peter,
This is a great example of the importance of adapting the environment, exercises, situations, etc. to help your patient receive the most benefit possible from therapy. Based on your patient’s presentation that day, you and your CI were able to come up with a way to positively influence the patient’s mood. It sounds like you are learning so much by working in this setting, great job!
-Lori
In response to John Orchard-Hays:
Wow bilaterally patellar tendon ruptures that sounds super painful! Great job comforting the patient and letting him know that his PLOF is definitely within arms reach. I can imagine that his quads were very atrophied as you mentioned due to muscular disuse. Awesome job relating his overall PLOF and current level of function to prognosis, and being realistic about it possibly being a lengthy recovery. I know he will receive great care and I hope he does not run down any more mountains soon in the near future. Great post!
Justin Geisler
Last week at clinic a patient came with L hip flexion pain and weak BLE glute med/max weakness with trendelenburg during gait. MOI involved a MVA, patient received surgery and had screws and a plate put in at lower thoracic and upper lumbar levels. Patient reporting hip pain to feel “like an impingement” during flexion in supine and with gait activities. MY CI let my take the ropes for this individual and I first assessed his hip mobility PAM/PPMs, decreased mobility was found due to soft tissue and capsular restrictions. I continued to treat the patient performing LLE long axis distraction, hip lateral glides, inferior and posterior glides grade 3, 3 sets of 30 second bursts. Combined with glute/piriformis and TFL stretches patient experienced immediate relief of pain. I then did STM of the L hip deep external rotators around greater trochanter (PGOGOQs) to decrease tightness. MY CI then suggested me to choose 3 glute max/med exercises to do to improve his decreased strength. I went with BLE prone hip extension with knee flexed for glute max 3 x 10, standing hip abduction 3 x 10 and side lying clams with TB 3 x 15. I also assessed his SLS bilaterally after ther ex his hip drop decreased due to improved firing of his glutes. I could have tested with a flamingo test to check for glute inhibition prior but likely patient had both decreased strength and inhibition of glute med and over firing of TFL. Overall this was a great experience for me to practice my manual skills combined with ther ex, and was able to have a positive response from the patient with decreased reports of pain and him being very thankful for my work.
Andrea,
Thanks for sharing! It sounds like this was quite a difficult evaluation. I am sure it was frustrating that the patient was so easily distracted during the session, but great job sticking with it and gaining some valuable information that will help you move forward with the patient’s impairments. I agree that you will likely have to come up with some creative ways to keep the patient engaged during the session. Have you thought of any ways you might do so? Keep up the good work!
Patrick Dumais
Patrick Dumais
Post 2During my clinical experience this semester at a SNF, my CI and I have not had many patients who were able to perform high-level exercises. Since this has seemed to be the norm at the SNF, I began to expect that most patients would be unable to complete more advanced exercises. This was the case until I had the opportunity to work with a patient who had some impressive balance skills. The patient and I had just finished gait training. My CI then asked me to work on some balance exercises with him. My CI informed me that our patient had done balance training on a bosu ball last week, and she wanted him to try it again. I was a bit surprised by this, but I went ahead and set up the exercise. I made sure the gait belt was snug on the patient, and we went ahead and began balancing on the bosu ball with a railing in front for extra support. To my surprise, not only was the patient able to complete a full 30 seconds on the bosu ball, but he did so with ease. After a quick rest break, we tried another round with similar results. To make it more challenging I had the patient close his eyes while on the bosu ball, and again he was able to complete the task successfully. This patient encounter was a great reminder to me that no matter what setting you are in, you should never expect less of a patient based on experiences with patients who had similar impairments. Each patient is unique in their abilities and may be capable of more than you expect. I will be sure to keep this in mind next time I treat a patient at the SNF.