[Shenandoah University Division of Physical Therapy]

From: John Orchard-Hays
To: Dominique (second post)

In class we are so used to hearing of the increased laxity commonly associated with an ACL tear that it’s interesting hearing how a strain can cause increased capsular movement restrictions. As for the patient’s view towards PT, it seems to me that there was more going on regarding her attitude then having to just wait extra long for PT, which I’m sure you and your PT picked up on and addressed as best as possible. I’ve had similar experiences both during my internships and in my couple years as an aide in working with apprehensive patients. I think patient education is valuable but sometimes they won’t be receptive unless you show them specific techniques that will relieve their pain (much like your CI did). I had a similar experience the other week where I got caught up in trying to explain to an apprehensive patient how a back exercise was going to help their elbow. She had a hard time understanding and my CI stepped in and repositioned her scapula and then had her perform the same movement we were working on. She was able to compare the degree of pain felt with the movement from before and after the relocation of her scapula and reason that my CI’s position was better. She had an easier time attaining the value of the exercise through experiential learning and was more compliant with our treatment methods from then on.

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

[Shenandoah University Division of Physical Therapy]

Andrea Choo responding to Kyle

Kyle,

That’s awesome that you were able to apply the information we’re learning about the knee to a patient in clinic! Sometimes I also get caught up overanalyzing the specifics of a task and find myself forgetting simple things like re-assessing as well. As I practice and become more confident in my skills, I definitely feel more comfortable and everything seems to flow more seamlessly. Since your glides helped improve the patient’s flexion did you teach the patient a self-mobilization or implement a MWM? If so, how did the patient respond?

[Shenandoah University Division of Physical Therapy]

Andrea Choo

In the past couple of weeks, I haven’t really seen any patients with a lower extremity pathology. The majority of the patient’s I’ve worked with have been infants with Torticollis or gross motor delay and children with incontinence/pelvic floor dysfunction. The only patient I’ve seen recently with a lower quarter impairment, was a 15 month old girl who we evaluated for gross motor delay secondary to spastic diplegia. My CI had treated her previously, however, the family had stopped showing up because the commute was too long and they weren’t able to fit it in their schedule. Since my CI last saw her, the patient had undergone eye surgery to correct her strabismus. Now, the parents were bringing her back because she was still unable to walk on her own and they didn’t want her to fall even further behind.

As we started to evaluate the patient, it was difficult to get her to focus on the tasks that we wanted her to do. We tried getting her attention by using toys, however, the patient was completely content doing her own thing. This forced us to rely on our observations to gather information as she played around the room. For the most part, the patient mostly relied on crawling to move around the room. However, when we finally got her in standing, the patient was only able to maintain an independent standing posture for 20 seconds with an increased base of support in a toed-out position and forward trunk lean. After about 20 seconds, the patient would go into trunk flexion and put her hands on the ground to help stabilize herself, then sit down on the floor. Additionally, although the mom reported that the patient was independently cruising at home, the patient did not initiate any cruising during our session. Towards the end, the mom was able to hold the patient’s hands and encourage the patient to take 3 steps before she sat down. During those 3 steps, it was apparent that the patient had decreased balance strategies. We tried our best to assess the patient’s ROM, however she kept squirming and required 2 people to distract her and actually assess ROM. There was a slight increase in tone in her L LE compared to her R, however, my CI deemed that it was not significant enough to severely impair her function at this point.

Overall, we weren’t able to accomplish as much as we would’ve liked to during our initial evaluation. We were greatly limited by the patient’s lack of interest and temperament throughout our session. I think that this is a good example of how sessions don’t always go as planned and how it is often dictated by the patient, especially in pediatrics. Even though we weren’t able to accomplish everything that we wanted to, we were able to gain some valuable information and identify impairments to address in our future sessions. Although we are not able to change the patient’s spasticity, we can help her control it and find ways to increase her functional capacity. Additionally, balance is a big thing that we can work on in the upcoming weeks. I am suspecting that balance and lack of stability are the big limiting factors that are impeding the patient’s motor function. It was evident that as soon as the patient began to feel unstable, she would put her hands on the ground to stabilize herself, sit down, then revert back to crawling. In the upcoming weeks, I have a feeling my CI and I are going to have to be creative in order to engage our patient, in order to see any improvements.

[Shenandoah University Division of Physical Therapy]

Ahmad Rahman

Last week in clinic I saw a patient who was post surgery for a full thickness rotator cuff tear. He was actually one of the first patients I saw at my location this semester, and I remember his disposition from that visit about 6 weeks ago until now. At that point he was advised by his doctor to avoid all active movement until 12 weeks post surgery, being 6 weeks out with his arm was in a sling. He took it out occasionally and was able to do pendelums but not much else. We checked his grip strength with a dynamometer and were surprised to find out it was actually quite strong for his current level of function. His objective assessment was fine, and the protocol was being followed to a tee, but the patient’s attitude about PT was less than stellar. He was a mechanic before the injury and was out of work, so not being able to be functional with his arms and hands was taking a toll on his motivation. He was confined to being at home for most of the day, and had a lot of trouble with ADLs and relied on his wife extensively for even simple things like getting dressed. After telling the patient he would not be able to actively use his shoulder for ten weeks post op per protocol, we sent him off with his hep and activity modifications to make ADLs easier. A few weeks later he came back springy and full of life proclaiming that the past week had been amazing. He was spending less and less time in the sling and had regained some flexion motion, although straight abduction was still very hard for him. We were able to do some active ER exercises, with a band while standing and sidelying as well. He was eager to proceed with the session, and it was amazing the difference his mood made to the progress we saw in an hour.

[Shenandoah University Division of Physical Therapy]

John Orchard-Hays
This week I worked with an individual who had surgery to repair his patellar tendons in both knees. He was already 8 weeks into his rehabilitation and at this point the main focus of his therapy was to regain overall strength/function, especially in the quads that were significantly atrophied. I could see that he had overall LE weakness, likely due to healing restrictions post surgery and from decreased activity before. The pt was ex-military and now worked a typical desk job in sales. He ruptured his patellar tendons while running down a mountain. I could tell that his major frustration was his reduced level of activity. I knew that this would be a lengthy recovery in terms of getting back to his high level of function, but I was sure to let him know that he had a good prognosis for eventually being able to return to or near his prior level of function. I based this off of his medical history, motivation, surgical report, and knowledge of tissue healing. However, even beyond addressing the healing tissue in the knee, I was sure to address weakness in hip external rotators, hamstrings and ankle stabilizers in addition to his atrophied quads. He had a high level of understanding and was appreciative of how these seemingly unrelated exercises were going to help him in the long run, both in regards to function and in prevention of possible injury/complications down the road.

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

[Shenandoah University Division of Physical Therapy]

Kyle Kohnen,

I had the opportunity to work with a patient 3 months post patellar tendon rupture/repair. I was feeling confident about working with him because my CI had shown me the mobilizations the week prior. I also felt a little bit better that the knee anatomy and biomechanics information was so fresh in my head due to MSK and TherEx courses. The patient was lacking ROM near end-range knee flexion. He didn’t have any pain. I treated with tibial posterior glide at end range flexion and also patellar inferior glide. Technique wise, I did a great job with the interventions, but I forgot the most important thing: reassess to see if intervention worked. Luckily, my CI reminded me to reassess before the patient got off the table. I feel like little slip-ups like this are due to me overanalyzing what task I am doing rather than thinking big-picture (trying to increase flexion so reassess flexion!). I believe this is something that will improve with more clinical experience, practice, and confidence.

[Shenandoah University Division of Physical Therapy]

Kayla Sweeney
Reflection Post 2

Because I am in early intervention, a lot of what we are doing is looking at children and looking for if they have a 25% delay in one or more area of development to see if they qualify for therapy. As a PT we are mostly looking at fine motor and gross motor function however we go through these evaluations with either a speech therapist or an educator who look at things like language both receptive and expressive. Together we also look at self-help and cognitive skills which are a combination of both language and motor skills. We don’t always see children with motor delays but even when we see a child with a speech delay we still look at their motor skills.
In each evaluation we get a subjective history and then we learn about the child’s skills through play. Afterwards, we document everything we see and then share it with the family. This week in clinic my CI challenged me to be more actively involved in the process and she had me write and present one of the sections to the parents. In previous weeks, I have just helped her write it and she presents it. I was very nervous to do this because the child was coming for a speech delay, yet he walked very heavy and had very low tone. His coordination was also a little off too. My CI read my section, added a few things and told me it was great to present. When it was my turn, I got very nervous because I knew it was the first time the mother was going to be hearing some of these things about his motor skills. Luckily, she took it very well and was very receptive to the information. She asked a lot of questions and together my CI and I were able to come up with some activities to get him a little stronger to help improve his gait.

[Shenandoah University Division of Physical Therapy]

John Knowlton
Reflection Post 2

Last week in clinic my CI and I were treating a 67 y.o WF whose c/o was back pain. My CI had been treating this patient for a while now and when asked how she had been doing she said her back is fine, but now she is having sharp hip pain and lateral knee pain with standing, walking, getting up from chairs, and other household chores. Due to the patient’s demographics and subjective reports I immediately thought this sounds like GTPS. She reported that her pain is in her lateral hip, then her knee starts hurting, then her ankle starts to hurt. From observing this patient, I noticed she seemed to stand in a valgus position and also was pronated at the ankle. To me this sounded like a kinetic chain issue stemming from the hip. I palpated the patients hip and she was tender on the superior aspect of the greater trochanter. When palpating the knee, she was tender on the lateral joint line. My CI started to explain to the patient how he thought she was dealing with greater trochanter bursitis. It felt good to be familiar with the joint we were working on, but I disagreed with my CI initial diagnosis. He asked me to roll out the patient’s lateral thigh and IT band. I asked my CI if he thought this could be more of a glute med tendinopathy. I discussed with him about the research we had been given and how more often than not this was the issue. I was concerned that if this was a compressive tendinopathy rolling out the patient’s leg could actually increase the patient’s symptoms. My CI thought that made sense and asked me what I thought our next step should be. I said that if this was a glute med tendinopathy she would likely benefit from progressive loading. Due to the patient’s presentation and irritability I recommended we start with isometrics into abduction and some clamshells. The patient tolerated these exercises well and after that we gave her a HEP. I have not seen this patient since, but I am hoping to hear she is doing better. I think we could have performed a more in depth objective examination but due to time we did not. Next time something like this happens I will voice my opinion sooner, so we can have more time to discuss what our next step should be.

[Shenandoah University Division of Physical Therapy]

Mekayla, you are exactly right. It is a great reminder that we do still need to be actively participating for our profession. I know my CI has not contacted the physician personally about this topic, although that may be something to consider in the future if this keeps occurring!

[Shenandoah University Division of Physical Therapy]

Levi,
Thank you for sharing your lit search and insight on the topic. That is a good point to consider about where the surgeon may be coming from. I think it is a good reminder that not everyone supports the physical therapy profession. As a professional, we need to learn how to address these situations and advocate for our services.

[Shenandoah University Division of Physical Therapy]

Andrew,

You’re right it is sad to see patients who believe that they will get better by sitting in bed. It can be frustrating when they don’t buy into your advice for them. It makes us have to take a step back and think about how we can convince them that getting up and moving will actually make them feel better and have more energy than if they just sit in bed all day. It sounds like you did a good job by starting with lighter exercises but she was still fatiguing very early. I hope that next week she is able to do a little more with you. Sometimes we have to be really persuasive with patients who are less motivated and don’t really understand what physical therapy is.

-Lindsey Rodriguez

[Shenandoah University Division of Physical Therapy]

Lindsey Rodriguez
Reflection Post #2
In clinic the other day we had a 56 y/o male patient who was s/p ORIF of his great toe. I am currently in a SNF and this patient was very different compared to the patients we typically see. He was alert and oriented, as well as independent with pretty much all of the activities we had him perform, only requiring minimal verbal cues to maintain his non-weight bearing status. This was the first time I had worked with this patient. When I read his chart, I was confused as to why he was in a SNF because he is much younger than our other patients. As I read further, I saw that he has a long history of alcohol abuse. It turns out he injured himself while he was intoxicated and woke up with his toe completely deformed and the bone sticky out. He had no recollection of how he injured himself and was also in the process of healing from a previous injury to that same foot a few months prior that occurred during another blackout episode. This patient had been in the SNF for about 3 weeks and seemed to have met all of his goal but was not in the process of discharge planning. I noticed that he had worked with a different therapist for almost every session. I was confused by why he was still in therapy since he was independent with bed mobility, wheelchair mobility/management, and supervision/independent for transfers and gait. I think that it was more because he did not have a discharge plan. He spoke about trying to go to rehab for his alcoholism but didn’t have a set plan yet. This patient was very open about his alcohol problem with my CI and I and expressed how he really wanted to get better and get his life together. It was interesting working with him because he was at a much higher level of function than our typical patients, however he was quite impulsive and sometimes did not maintain his non-weight bearing status when going from sit to stand. He expressed that he was concerned that his foot wasn’t healing and that he could see the atrophy in his leg due to being immobilized. We were able to really challenge him with higher level exercises to help prevent further complications. We had him working in the parallel bars and doing single leg squats with his uninvolved leg. We also added an ankle weight to his affected leg had him work on hip flexion, hip abduction, and hip extension exercises. After our session my CI and I had a conversation about what to do moving forward with this patient. We were both concerned for him to go home because of the high possibility of relapse, but we also didn’t feel that he was a good candidate for therapy in the SNF. My CI decided to put in a 5 day until discharge for this patient and plans to speak with him in more detail next session about his discharge plan. This was a tricky case because we want what is best for the patient, but it didn’t seem like he was in the best setting. At the same time, this situation is better for him than him being home and going to outpatient PT because he has poor self-control with alcohol. I really hope that he is able to get into a rehab program and better manage his alcoholism.

[Shenandoah University Division of Physical Therapy]

I forgot to put my name for this post! This was done by Cassie Rawa!

[Shenandoah University Division of Physical Therapy]

Mekayla,

Wow, what an experience you had! I think the biggest problem I have is taking what we have learned in neuro and actually putting it to use in the clinic. I am in an OP setting, so I am not seeing a lot of stroke, SCI, and just general neurologic patients. It is awesome you get to take what we are learning and see it for yourself. Keep up the great work!

Cassie Rawa

[Shenandoah University Division of Physical Therapy]

Cassie Rawa: 2nd reflection

In clinic this past week, I was able to help treat a patient with right patella tendinopathy. The patient was a young, sophomore volley ball player that has been dealing with the pain for a few months. Therefore, I concluded from this information she was in the chronic stage of tendinopathy. This was the first time I have seen her, so I was unaware of her past exercises of PT sessions. Although, knowing her stage was enough for me to hypothesize different exercises or treatments to give her. After giving her a deep tissue friction massage, my CI and I decided to progressively load her tendon. Before we did that, we wanted to observe her squat. Her bilateral squat concluded that she had dynamic valgus. Even though we have not gone over the ankle and foot unit in depth yet, I know enough that over pronation of the foot can contribute to knee pain and can accompany dynamic valgus. Sure enough, as soon as the patient took off her shoes and performed a squat, her feet were pronated. By assessing her proximal segment and distal segment, we were able to address many aspects of this patient to try and improve her pain.
First, we decided to progressively load her tendon. The patient was instructed to perform single leg squats while picking up and putting down a kettle bell. The kettle bell would start on the ground and the patient would perform a single leg squat to pick up the kettle bell then squat to pick it back down. As far as addressing the proximal segment, I was instructed to give the patient her hip exercises. Since she is a high-level athlete, I decided to give her side planks with resisted hip abduction, yoga ball bridges with resisted hip abduction, side-walks, and resisted clamshells. I decided to dose each exercise around 2 to 3 sets with 20 repetitions for each. During each exercise I provided tactile cues if I believed any compensation was going on, such as making sure her hips were aligned appropriately. The patient reported no knee pain during each exercise.
Since we also wanted to address her distal segment, my CI decided to give my patient the option of wearing an orthotic. The orthotic provided more supination of the subtalar joint facilitating away from her normal pronation. The patient said the orthotic felt “weird” when she put them on first, but she was experiencing no knee pain. It was really cool putting everything I have learned thus far about the lower extremity into action. I have learned most knee pain stems from elsewhere and this case provided me that evidence to back it up.

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

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