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Mekayla!
I can only imagine how scary the encounter must’ve been, considering that the patient had such a high complete injury. I have never worked with in individual with that diagnosis, until this yesterday, as my adult neuro patient has a C5 incomplete injury. With this patient population, every move matters, especially in the situation you were in, as the last thing we want is to drop the patient! Great application from class into your clinical setting, especially regarding having his use his momentum, addressing weight shifts, and active elongation. We will definitely have to chat about what you’ve done in clinic thus far with him and bounce off ideas as my group and I begin treating our patient for neuro. Great job!
-Daphne Batista
Daphne Batista: 2nd Reflection
The past few weeks at Ashby Ponds (SNF), I have been interacting with a 92 year old white male who is an absolute joy to work with. He is pleasantly confused and always seems eager to do physical therapy, even if he can’t remember me or my CI from session to session. Even though he’s typically one of the last patients of the day, he makes my day. Being in a SNF can be challenging as often times patients not only struggle with their physical limitations, but also battle with either a cognitive impairment, or an emotional aspect. After interacting with so many patients who have such a negative outlook on life and physical therapy, he is a breath of fresh air.
His PMH includes a left THA from years ago that left him with residual weakness. Unfortunately his weakness has deteriorated over the past few years that now he is living in the assisted living facility within Ashby Ponds. As a result, this has restricted his community ambulation. During gait training, he ambulates with a front wheel walker down a hallway for 150+ feet. Minimal verbal cues are provided in order for him to maintain upright posture in order to see where he’s going and reduce fall risk. He also requires additional minimal verbal cueing to modify his base of support in order to optimize his center of mass, as he has the habit of shifting his weight to his stronger side in order to offload his affected side. Due to his left sided weakness, he has developed compensations over the years in order to ambulate in a step-to pattern.
Noticing his weakness, I led him through a series of lower extremity strengthening exercises in order to help him be able to ambulate with a more normalized gait pattern. By this point, he mentioned that he was tired and I noticed that he was red in the face. I asked him if he was breathing and he sheepishly responded no he wasn’t because he was so focused on being able to move his feet. I educated him that it’s important to breathe as muscles need oxygen in order to do their job efficiently. With that piece of information, it reminded him of an exercise his primary care physician showed him, pursed lip breathing. With this technique he showed me how to breathe in with his nose, and then slowly exhale out through his mouth. I asked him to keep that in mind throughout the remainder of the session as we proceeded to do strengthening.
My CI instructed me to place two pound weights around his ankle as he did his exercises. however I noticed that he was having trouble with marching in place (hip flexion) on his involved side. He was grimacing through the exercise and turning red, so I immediately asked him to stop and do his breathing technique. I reassessed with my CI and asked her if it was appropriate to remove the weight on his involved side, to which she said yes. Once the weights were removed, he still had trouble getting that hip to actively flex. At this point I provided him with additional tactile cue and wrapped my gait belt around his thigh and helped guide him during hip flexion. I asked him why he didn’t verbally tell me that he was having trouble, and he mentioned that due to his prior military background he knows not to give up. While I appreciated the gesture, I explained to him that he needs to speak up because he may actually be doing more harm than good.
Jaque,
This encounter most definitely seems frustrating. Although with recent years PT has become more established and most surgeon-PT relationships are positive, I think there is clearly still a disconnect in the health care world. But nonetheless, still frustrating. Especially because like you said, it’s “supposed” to be a team based approach for patient care and recovery. However, I think there is always going to be that now and again encounter like the one you’ve described here that pops up on our schedule. Unfortunately, I think at that point we just have to do our best to educate the patient on the benefits of physical therapy and the evidence behind pain. You can share some research with them or share some specific patient success examples/testimonials that have showed improvements (maybe on the company website). I know that more times than not this is easier said than done, and I know that most patients will be stuck in a certain mindset. However, we still need to try and if the patient is still adamant about not wanting to participate then ultimately that’s their decision. Hopefully, this patient will come to find out that PT could have really helped her in the long run. Maybe she’ll talk to some friends, or overhear a conversation about PT, or actually do some research if after re-visiting her surgeon she’s still not progressing. Has your CI talked to the director/manager of her company at all? I’d be curious to hear the advice they give for situations like this because I’m sure they’re more common than we may want to think.
Anyway, thank you for bring up this topic! I think this is something very important that we as students need to begin to think about and brainstorm how we would address it. I know that it can be awkward in that situation as a student as well, so I can appreciate the uneasiness you must’ve experienced. I hope her mindset can be changed. Even more reason to continue advocating for our profession!
Mekayla
Mekayla Steckel
Post #2
This week in clinic, I had the opportunity to work with a patient who has a complete C5 spinal cord injury. He has been attending Ability Fitness Center for the last year and comes to the clinic three times per week. My CI asked me to work with him on the mat in high kneeling. Most of the patients I’ve been working with have had strokes, but I haven’t worked with many SCI pts, and especially one with a higher complete injury. So needless to say… I was very nervous. My CI walked me through transferring him out of his power WC onto the mat (max A). From there we worked on rolling into prone. This patient is able to use momentum to get his lower body turned over as long as you flex the knee opposite the side he’s rolling to. This patient has also been working on activating his abdominal and oblique muscles in order to help him roll all the way over. Once we got him into prone, it took 2 of us to safely get him into high kneeling. I stood behind him and had my hands holding up his upper body at his ribcage. My knees and shins were supporting his lower body. Once in this position, I had ALL of his weight. One wrong move, and the two of us were both falling to the mat. (It’s difficult to explain the significance of this encounter over writing and is something I hope all students have an opportunity to experience). So needless to say… again terrified, knowing I was the only thing keeping him up and every move I made mattered. However, I was able to make it work and we got to stay in that position for about 10 minutes. We worked on weight shifting side to side with activation of the glutes, while simultaneously addressing trunk control by firing the trunk musculature to get some active elongation. Let me tell you, it is HARD to hold someone’s weight up while facilitating weight shifting, while facilitating rib cage movement, all while in a squat because of how tall I am compared to the patient. Overall, this activity went fairly well being my very first time working with a SCI but my legs were shaking by the end of the ten minutes. I was able to appreciate how hard not only the patient was working but myself as well.
To conclude, this clinical experience has taught me again and again how much our body and hand placement matters!!! As well as timing. I have learned that the outcome or response I get from a patient is highly dependent on where/when my facilitation/cues are. I know I still need a lot of practice in this area but I know that the more patients I get to work with, the easier it will come. My plan is to force myself to practice these types of patient encounters. I need to practice with people of all shapes and sizes and learn how to best position my body and hands in order to facilitate the action I’m hoping to get from the patient. With the goal to come back to my CI and reassess my performance with that same patient as well as with other patients to see if I can adapt more instinctively. I am trying my best to try as many skills as I can while receiving feedback from my CI along with her expertise in the neuro scope of practice.
Chris Miller
So due to my wrist injury I have not been in ICE 2 since the first week. I have had some experience in my AT clinic rotation that has given me some solid learning opportunities this semester. In fact, during a football event that I was helping cover we had a defensive linemen get rolled up on and went down. He was in immediate pain and did not attempt to even get up. I was the first to reach him on the field and completed his on field evaluation which is very abbreviated just to make sure it is not a medical emergency. So I started by asking a few questions about where his pain was located which he stated, “my whole knee hurts and I felt a pop.” Unfortunately having seen the mechanism of an external valgus force I already had an idea of what I thought it could be. Just like we do in clinic I started to think of my differential diagnosis that could be possible. On this list I had ACL at the top of list along with MCL, Meniscus, Patellar Subluxation, and Fracture. First thing I did was see if he was able to still move his foot as he was unwilling to move his knee at all. I did a quick palpation for fracture screen of the patella, fibula and tibia. With no signs that led me to believe a fracture was present I was able to cross this off my list. I did a quick neurovascular screen and all this checked out as well. So my next step was to test out the ligaments of the knee. I did a lachman’s test first and thought felt some joint laxity compared to contralateral side. I was able to passively flex his knee so I wanted to do a anterior drawer as well since I feel a little more comfortable with this test. When completing this test on the first try I felt significant laxity and could feel a clunking sensation along with this. As we stated in class usually you have one or two tries to get it on the field. On my second time applying pressure with anterior drawer he already started to muscle guard and I really could not feel much laxity with this. With thinking his ACL was torn my goal was to get him to the sideline to test things further.
On the sideline he already started to experience some swelling and he was in a great deal of pain and was already emotionally affected by the results I found on the field. Honestly it was the hardest thing for me to tell him what I thought was going on. Of course I checked with my preceptor first. I remember telling him “I really hope that I am wrong but unfortunately I believe you may have tore your ACL. The good news is that there is no way for me to be 100 percent sure about this but we want you see our ortho.” At this point further testing was not really completed because I believed I found the pathology that occured. We continued to monitor and control pain for the rest of the event and had him ambulate with crutches until he was able to see the team orthopedic.
In that situation it is crazy just how much we actually know and our abilities to think when put in a stressful situation. Also something I don’t really think about much is the psychosocial aspect of communicating to patients what we found. It is harder than I thought it would be especially for an athlete in his senior year who just ended his season.
Also looking back I should have assessed more things at the time because when they went in for the operation they discovered he had also torn his MCL and his medial meniscus. I have not had much time treating this athlete because I switched sports but I do know he had all three repaired and was NWB for a few weeks and is just now getting to the point of weight bearing and is still working on ROM and light strengthening. I hope to check in with him soon and see how he is doing. Overall this was a great learning experience and confidence builder in my evaluation skills. It sucks that he suffered that injury but for me to come to the correct diagnosis in high stress situation of being on the field feels good.
Andrew,
I am also in a clinic were most of my patient population is sedentary and continuously talk about wanting to get better but don’t completely understand that in order to get better they will have to do some things that are going to be difficulty. Sometimes a session with a patient won’t consist of much because they are so resistant to exercise which can be very discouraging and hard to stay calm because I want to help them but they don’t want the help. Your idea to have the caregiver sit on the patients side to read to move her out of ER is really smart and super easy which is usually what these patient’s like most. I will have to keep that in mind for any future patients I have that may be similar to yours. Good job!
-Ally Kuhn
Ali,
Your patient does sound like a very interesting case which can be very nerve racking. I know that in home health where I am now, a lot of the patients have several diagnoses but they tend to vary in the functional ability so we never really know what we are walking into just like with SCIs. I have seen patients that seem like they have every diagnosis possible who are highly functioning and other individuals who have a minor diagnosis but are very low functioning. Overall, though it seems like you handled yourself very well. Good job!
-Ally Kuhn
Allyson Kuhn
Last week in clinic, my CI and I visited a patient with the intend of discharging him that day. Before arriving to his home, my CI caught me up on the patient’s original diagnosis, his treatment, his current status, and reason for discharge. The patient was a high functioning stroke patient who, from what I got from my CI, was back at baseline and ready for discharge. With that in mind, I was pretty excited for this visit because it seemed like it was going to be a fairly easy discharge, at least that was until my patient told me that she has discharged him multiple times and usually within a few days will have him back on her schedule. That immediately sparked my interest and made me nervous at the same time. At this point, I had a bunch of questions running through my head for instance, why is the patient being discharged if he isn’t ready? How is it that he is at baseline but still struggles once we discharge him? And lastly, is it okay to discharge him today, is he actually ready this time? I was at a loss and immediately became nervous for this discharge. When we arrived at the patient’s home and began our session, I checked his vitals and looked at his functional ability with ambulation, bed mobility, and asked if he was compliant with his HEP. Vitals were stable and the patient was able to perform all of the functional activities with ease so my CI and I decided that yes, the patient was ready for discharge. However, once we told the patient it was his discharge day his energy changed dramatically. This was very confusing to me because most patients are normally so excited to be discharged, but as we began filling out the appropriate paperwork for discharge everything started to become clear to me. This patient is a hypochondriac who believes in his head that he is in constant need of PT for all of his problems.
The patient was fearful of discharge and did not want to be done with PT because he believes that he still has severally problems that need to be addressed. While this answered all of my stirring questions, it did not relax my nerves much because I still wasn’t really sure how to convince this patient that he no longer needed PT. All that I could think of doing was patient education and allowing him to see for himself how he is doing. It ended up taking a lot of patient education to explain to him that he is at his baseline and no longer needs PT and even then, the patient still was not entirely convinced so we decided to have him perform a series of functionally activities on top of what he had already done to allow him to see how he is functioning for himself. Some of the functionally activities that we had him do included: SLS (eyes open and closed), ambulation outside in the grass, and the TUG test showing him the norms for his age and his scores which were just about the same. After all of these activities and a little more patient education, we were finally able to convince the patient that he was ready for discharge. While he still was not entirely enthused he was starting to understand that he is physically doing better than what he had thought. At the end of our visit we were finally able to successfully discharge him and told him to continue with his HEP and other activities similar to what we did with him to allow him to continue to work on getting even better than his baseline. This experience was definitely a first for me that I hadn’t really ever thought about until it happened but overall, I learned that sometimes a patient’s fear can play a huge impact in their treatment and discharge. In cases like this, it may take a little extra convincing to show a patient what they are capable of doing and not to be afraid of the activities but with the right education and allowing them to see for themselves, it is possible to change their mind.Uyen replying to Ali
Wow that is such an interesting case. I think it’s cool that your CI presents patient cases for you before they come in, and as students in our second part-time clinical, I would also get nervous about seeing how the patient presents. It’s interesting to see that OT works mainly with UE and PT works with LE at your clinic. Do you know if they focus on fine motor only while PT can focus on gross motor or do they strictly work on everything with the UE? I liked how you were able to include dual task activities in the interventions as that is such great practice for things we can do with our patients in neuro!
Replying to Matt Reis:
This is such an incredibly sad event. I am astonished that the son is not more concerned about his mom and the conditions that she is living under. In regards to your question, I think the only thing we can do is make sure that adult protection services knows the severity of the case. In this situation, like any, we are advocates for the patient and especially in this case because the patient doesn’t seem capable of being an advocate for herself. Let us know if this gets taken care of. I would hate to see a critical fall occur due to negligence of the other healthcare professionals involved in this case.
Uyen Tran
This week in clinic, I was able to perform a knee assessment on one of our patients. My CI had been working with fixing her ankle, knee, and hip mechanics, so she thought it was a great idea for me to assess her at this point to see her improvements. First, we watched her walk back and forth and noted that she has some valgus on her left knee and ER on her right knee. When looking at her posture, we noted that she stands with her L knee in extension and valgus and right knee in flexion with medial tibial torsion. Her femur was also noted to be ER and her ankles were noted to be in pronation. If you can imagine all of this- you would see a girl with a swaying posture towards the right side. Then I examined her patellae and I noted that they were frog-eyed patellae. I told that to my CI and the patient said, “my knees are not frogs!” and I had to reply with, “I’m sorry, I didn’t mean that! You know how frogs eyes face outward and they look like they are far apart?” and she replied, “yes” then I followed up with “I meant to describe your patellae as looking out like they are frog eyes, but that’s not a bad thing!” And so she agreed and I was able to move on to palpation. This moment made me realize how cognizant and careful I needed to be when examining a patient and talking to my CI about their impairments. I then palpated her patella location and structures around it and asked her if there was any pain, to which she always replied with, “nope!”
We moved on to having her perform a squat. Since she didn’t know what a squat was, I had to show her my squat, but I reminded her to do it the way she felt comfortable. When she squatted, we noticed forward leaning, valgus in her knees again, and pronation in both feet. We also noted her weight shifting to her left side during the squat. Then I had her perform some lunges, and those actually looked great! There was a little bit of genu valgus and femoral ER there, but my CI pointed out that she was proud of the patient because a few months ago, she was unable to do a lunge and now she looks more steady and stronger. Then I had her perform single leg hops and we also saw valgus and pronation of the hopping foot, on both sides. We also noted more force absorption on her left leg than the right because that is her stronger leg. Throughout the test, I made sure to ask if there was any pain with any motion and she always stated that she didn’t have any.
There were a lot of findings to take in. My CI asked me for 3 interventions I would recommend for this patient. I offered squatting with a TheraBand above the knee to facilitate hip abduction during squats and decrease in valgus, walking lunges with knee and ankle corrections to improve hip flexion ROM, strength, and control, and a calf stretch with each foot against a wall to improve dorsiflexion ROM. We taught her those exercises and she learned them quickly! It was really interesting for me to be able to see what actual limitations in the knee look and feel like. Talking with my CI, we agreed that her limitations began at her hips and go down the chain. So in addition to knee exercises, we taught her some hip exercises to work with and then allowed her to skate the rest of the session!Ali Cloutier
When arriving to clinic this week, my CI notified me that we had a patient that had a C3/C4 spinal cord tumor. I was super nervous because I had been working a lot with stroke patients but had yet to work with a patient with any sort of spinal cord injury. I was expecting this patient to not be able to walk, use his UE, etc. Turns out, I was completely wrong and the patient was able to do most things on his own. This man was 88-years old and had arrived at inpatient rehab 3 days before I saw him. This patient was particularly interesting because we discussed how he discovered the tumor. The patient discussed how he had been having dizzy spells and then he began to not be able to lift his R arm which prompted him to go see his physician. This is when his physician did scans and discovered that he had a tumor between his C3/C4 vertebrae. He got a 6hr long operation done at Johns Hopkins to remove the tumor and was able to be discharged to inpatient rehab about a week following surgery. Given that I am in an inpatient rehab facility, OT mainly focuses on rehabbing the UE and PT mainly focuses on rehabbing the LE. Therefore, my CI and I focused on working on his balance and walking while incorporating dual tasks that involved his R arm. Some of the activities we did included standing on a foam matt and putting clothes pins on a stand. This was particularly challenging given that he had a hard time getting to higher margins on the pole. We also had him go around the gym and collect different colored cones.
From this case, I learned that I should not get worked up about dealing with a patient population that I have not worked with before and rather take it as it comes. This patient was super interesting because the tumor only created deficits on his R side, whereas I expected it to create bilateral symptoms. This emphasized the fact that even though I can hypothesize how a patient will present, you never really know until they are in front of you and you do a subjective and objective exam. Next time when my CI presents the patients for the day, I will not get as nervous and focus on the positive learning experience I will have.Jesse,
That sounds like a great experience, especially since it really played out exactly how we learned in class. Its pretty cool that this scenario occured right after talking through these pathologies as well. Keep up the good work!
Andrew
Andrew Lamont (second post)
This week I was able to work with a patient who is extremely obese and is continually lethargic about moving. She sits in her recliner almost all day with limited trips even to the bathroom. Our goal for treatment was going to be getting her up and walking, however, we also wanted to see how effectively she transferred from standing to supine in her bed and vice versa. With ambulation, I could tell that she was stuck in ER on her right side causing her to advance her leg using her adductors. As she laid down in bed, her mattress was extremely soft and caused her to almost fall off the bed on her right side. Upon asking her caretaker about it, she told us she comes in on a consistent basis in the mornings to the patient hanging her whole right side of her body out of the bed. This made sense with her whole pelvis being shifted to the right side as well and her hip in ER. I tested her hip ER and IR and found significant reduction in her ER being around 0 degrees. Taking into account my patient population being very sedentary, I wanted to find a way to passively bring her into IR. Her caretaker told me that she sits with her in bed sometimes to just read or talk and asked her if when shes in bed, if she could sit on the pts right side and just lean on her legs while bent to put her into a L leaning LTR. This was an easy solution to get her out of that constant ER position especially with her being “tired” and “not up for exercise” each and every session. I tried to get her to do seated IR (reverse clams on one side) but that did not go over well, as she only completed 3x on each side before “fatigue”. It was sad to see someone who believed she was gonna get better by just sitting there, but I tried my best to convince her and get her to buy into how she can help herself just by doing simple things. I will see her next week and hopefully hear she has been doing something that I instructed her on.
Dominique Norris (Second post)
This past week, my CI told me that in the afternoon we would be doing a new eval on an ACL sprain (no surgery). During the morning, I prepared by trying to recall what we (just days before) learned about ACL. When it was time to go greet the new patient, our front office staff briefly stopped us to let us know that our patient was not in a very good mood. She had thought that her appointment was at 2, not 3 pm.
The patient was also clearly not excited about being at PT which made getting information from her challenging. We have learned to ask open ended questions and let the patient “lead” the conversation, but this patient would only answer a few words at a time. I was forced to take a step back and re-evaluate how I was going to get the information from her, while at the same time getting some patient buy-in, which would be critical with this patient given our rocky start.
Eventually, my CI and I were able to get some more detail out and she started to open up a little more. Near the end of the session, my CI and I walked her through a few exercises for ROM (inferior patella glides, seated heel slides). It took a few repetitions for the patient to warm up to the idea of having to work through some of her pain to get it better. My CI gave her a technique to relieve some weight on her leg during the slides (pull up on the ends of a towel wrapped around her thigh). This helped relieve some of the pain and got us some more patient buy-in. I was even able to lead her through resisted heel slides to strengthen her hamstrings and explain to her how that would help increase the stability in her knee.
While this was by no means the “typical” ACL (population, her capsule had tightened to protect the knee as opposed to having laxity), I was able to connect some of the treatments to the patient. More importantly, I was forced to re-think my strategy and really understand why patient buy-in is so important. I am more prepared for next time I see a patient that may not be fully sold on PT or may be having an off day. The eval took longer than typical, but it was worth it because we were able to convey to the patient why coming here will benefit her, and by the end of the session she was starting to understand and accept that.
How have you guys or your CIs negotiated evaluations (and even treatment sessions) with patients who are not motivated or not happy to be at therapy? And when your patient has a fairly negative outlook, how do you find a balance between being empathetic, motivating them, and being realistic about their prognosis? (especially for a patient who may not get back to 100%)