Monday Memo 6/12/2017

The Monday Memo

June 12, 2017                                                                           PITT DPT STUDENTS

Patient Adherence

 

As is typical with most physical therapy students, I had a very active and healthy lifestyle growing up. I was a competitive swimmer in high school and spent nearly 20 hours a week in the pool training. I got into triathlon, weightlifting, and played intramurals throughout my academic career at Virginia Tech. My personal interests always revolved around physical activity and training, so naturally pursuing a career in health care made sense.

Like many, I figured I would apply to medical school upon graduating, but I slowly started to realize that physical therapy was much better suited for me. This profession gives you the opportunity to analyze a patient’s movement system, determine the best course of treatment, and help initiate their path to recovery. This path may include some passive methods, such as employing the RICE method or prescribing orthotics, but these typically lead us to the more effective and vitally important method that we utilize: active therapeutic exercise.

Your TherEx protocol is the “meat and potatoes” of your therapeutic protocol. This is what will provide true adaptation to your patient’s issue. At least for me, it’s also the aspect of PT that as a clinician you are most excited about. You’re creating an exercise regimen that will help the patient grow stronger, safer, and more resilient, and all they have to do is follow your instructions! What could go wrong?

The answer: A lot.
For instance, the patient may not do it. Unless you have the opportunity to work with the elite athletic population whose paychecks are on the line, you’ll be fighting the constant battle of patient adherence. Your patients are busy. They have jobs. They had kids. They have other interests and other priorities, and completing your 3×10 sit-to-stand protocol is likely very low on the totem pole.

We know how important exercise is. We understand the consequences of working a desk job 50-60 hours a week and coming home to eat a microwaveable meal and sit on the couch for the remainder of the evening. It is up to us to create patient buy-in; and to educate the public on the importance of regular physical activity and adherence to our therapeutic protocols.

This concept applies to all therapeutic settings: in-patient neuro, outpatient ortho, pediatrics, etc. We must work everyday to connect with our patients and show them how improving their functional deficiencies will lead to improved participation in the activities that they truly care about. Our goals and protocols must be patient-centered. They must be dedicated to helping the patient get back to the activities of their choice. This will not only enhance patient adherence, but also result in improved outcomes and reduced healthcare costs further down the road.

 

  • Charles Badawy, SPT, CSCS, USAW,

            Pitt DPT Class of 2019

June 12, 2017 |

Monday Memo 5/22/17

The Monday Memo

May 22, 2017                                                                           PITT DPT STUDENTS

Below is a hypothetical case study: The patient is representative of an impairment/functional deficit that is common in an outpatient physical therapy clinic. Leave a comment with the next steps that you would take if you were the primary clinician: Would you continue with the physical exam? Redirect your focus? Do you feel comfortable prescribing treatment from the given information? What other questions might you ask this patient? Is this a situation where referral may be needed? Why or why not?

 

Patient: 26 y.o Female Graduate Student

Chief Complaint:

  • Right shoulder pain with elevation affecting the ability to perform overhead activities and reach across to grab her seatbelt.

Onset:

  • Over 1 month ago — Occurred while performing dumbbell presses in a strength training group class. Immediate limitations included putting on a shirt and reaching across her body. Pain at the AC joint area.
  • Seemed to get better on its own over the next week or two… Then got worse after a poor night’s sleep. This worsening presented as more of a “constant” pain and stiffness with the patient feeling as though she needed to pop it back into place. Reports “cracking” with movement.
  • Seemed to get better again with time, but 2 days ago the patient was leaning on her elbows and pain flared back up after standing back up and unweighting the shoulder. New onset of pain is in a different place: More lateral to the AC Joint. Pain has decreased over the past 48 hours.
  • Worst: 5-7/10 , Best: 1/10

PMHx:

  • No prior history of shoulder injuries besides bilateral broken clavicles at a young age.
  • Pt has been dealing with headaches since teenage years. Two main types: First is typical with a cervicogenic left-sided “Ram’s Horn” presentation and also has referral to the supraorbital area over the R. eye. She also complains of tension-type headaches that she correlates with dehydration, stress, and posture. Reports that the tension-type headaches are helped with postural exercises (chin tucks).

Exam:

  • Patient appears to be in good health. Slender frame with average or slightly below average muscle mass. Slight forward head posture. Depressed R shoulder relative to L.
  • Full ROM with slight pain at end-range FLEX/ABD; 4/5 on MMT with most movements, but painful with resisted FLEX/ABD/ER.
  • Abnormal scapular mechanics noted with ABD. R side seems to get hung up, especially on descent. Flexion mechanics appear normal, but a “click” or “pop” is felt and heard with both movements on elevation and descent.
  • Special Tests:
    • No signs of instability or apprehension with testing.
    • Clicking felt with Load and Shift to assess anterior capsule/labrum
    • (+) Neers, (+) Jerk for anterior pain, (+) Crank w/ clicking, (+) Hawkins Kennedy
    • (-) RTC cluster, (-) Sulcus Sign, (-) Biceps load test

May 22, 2017 |

Monday Memo: 2/20/2017

The Monday Memo

February 20, 2017                                                                           PITT DPT STUDENTS

 The Three Stages of Rehabilitation

 

A successful rehab outcome is fostered using both an artistic and a scientific mindset. The exact percentage of each will depend on the education, preferences, and bias of the practicing clinician, and that’s what makes this profession both exciting and frustrating. There are no “cookbook” formulas in rehab, which demands years of “trial and error” from entry-level clinicians. Luckily, we have guidelines and the experience of our mentors to help guide us early on in our professional careers.

 

One of the most important concepts that has surfaced for me in my education thus far is the concept of “Staging” a patient. This process guides our clinical decision-making and helps us create an effective and efficient plan of attack. It can be applied to anyone, in both inpatient and outpatient settings, and for every kind of injury or disease. It must be done on Day 1, but must also be continually reevaluated throughout the course of care. Below are brief descriptions of the stages:

  • Stage 1: Symptom Modulation: This patient is most likely in the “acute” stage of their injury, and their medical status could be either volatile or stable. The hallmark of this stage is that symptoms predominate and are highly volatile. The focus should be on alleviating pain and working towards “calming” the condition down in order to open the door for more long-lasting treatment methods.

 

  • Stage 2: Movement Control: This patient will oftentimes still be in pain, but the pain will simply not be as limiting. The functional impairments present can be more accurately attributed to the neurological and/or neuromuscular impairments, so our treatment methods can consist of relatively more “aggressive” techniques aimed at increasing tissue length, strength, or neuromuscular control of the joints in question.
  • Stage 3: Functional Optimization: If you find your patients consistently reaching this stage in their rehabilitation process, you’re clearly doing something right. The patient will likely be in little or perhaps no pain at all, and the focus of your rehab can be on optimizing the patient’s movement patterns, preparing them for return to normal function, and strengthening/reconditioning the physical attributes of the patient.

 

Make no mistake, as much as we would love for this to be a linear process, reality tells us otherwise. Oftentimes, your patient will experience setbacks. They will have pushed their shoulder repair too far playing with their kids over the weekend and show up to clinic on Monday morning with highly volatile symptoms. You will need to adapt and revisit the symptom modulation phase to temper their symptoms. This is what makes our profession so unique and so individual. This is why we as professionals need to be ever vigilant with our clients and constantly monitoring their status. This adaptability is where the “art” of rehab comes into play, guided by these “scientific” principles.

 

Are you using the “Staging” process with your patients? Why or why not? Has it helped improve your patient outcomes? Comment below or reach out to Pitt PT to share your story!

 

  • Charlie Badawy, President: DPT Class of 2019
Social Media Updates
  • #DPTstudent –  WEDNESDAYS , 9-10pm EST!   Check out #DPTstudent page for details!
  • Unite Physical Therapy Students – If you haven’t yet, please check out the “Doctor of Physical Therapy Students” Facebook page. More than 9,500 students have already joined!
  • Our own page! Pitt Physical Therapy, thanks to the Social Media Team, has created an official PittPT Facebook page!
  • #SolvePT (meets on Tuesdays Twitter from 9-10pm EST)
  • Follow @Pitt_PT on Instagram!
February 20, 2017 |

Monday Memo: 2/6/2017

The Monday Memo

February 2, 2017                                                                           PITT DPT STUDENTS

Optimal Care vs. Acceptable Care

 

If you’re a clinician, you probably want to provide your patients with the absolute best possible care in order to help them regain control over their bodies and lives. This is exactly why the research arm of the physical therapy profession exists — to bring us the most relevant evidence that will help guide our treatment and equip us with the most effective therapeutic strategies to reach our goals. In an ideal world, every method we use would be backed with Grade-A research, but is this always possible?

 

Oftentimes, a skilled therapist has devised a comprehensive plan for their patient that has been guided by the initial evaluation. It’s inevitable that we will encounter resistance from our patients, either as a result of their busy lives or from their preconceived notions. There are more than a few barriers that may prevent us from giving our patients what can be considered “optimal care,” including jam-packed work schedules, varying patient values, lack of equipment, and more. The challenge for us is to consider how we can navigate these barriers and adjust our plan in order to provide the patient with the most effective strategies available at the time.

 

An expert clinician must be able to skillfully develop alternative therapeutic exercise options, educate the patient to help change or guide their beliefs, and create a therapeutic environment where the patient feels comfortable and cared for. No two patients will present the same, so you must equip yourself with the skills to manage a variety of personalities and belief systems. This is your challenge as a therapist — How well can you adjust on the fly and deviate from your plan, while still providing care that will improve the status of your patient?

-Charlie Badawy
Post if you have a story to share!

Social Media Updates
  • #DPTstudent –  WEDNESDAYS , 9-10pm EST!   Check out #DPTstudent page for details!
  • Unite Physical Therapy Students – If you haven’t yet, please check out the “Doctor of Physical Therapy Students” Facebook page. More than 9,500 students have already joined!
  • Our own page! Pitt Physical Therapy, thanks to the Social Media Team, has created an official PittPT Facebook page!
  • #SolvePT (meets on Tuesdays Twitter from 9-10pm EST)
  • Follow @Pitt_PT on Instagram!
February 6, 2017 |

The Monday Memo: 1/9/2017

The Monday Memo

January 9, 2017                                                                           PITT DPT STUDENTS

Psychology and Physical Therapy

 

Physical therapy is a profession that relies heavily on relationships. The psychology behind human interaction and health care plays a critical role in the success of our interventions. Today we’ll touch on two incredibly important relationships: The patient /therapist relationship, and the relationship between the patient and their own self-image.

 

Patient / Therapist

Obviously, patient/therapist interactions play a major role in the effectiveness of therapeutic interventions. It’s imperative that the therapist fosters a therapeutic environment where the patient feels comfortable and cared for, encouraged, and empowered to take an active role in their treatment. The psychosocial aspects of healing are undeniable: There is plenty of research that shows the psychological state of the patient will dictate how effective evidence-based protocols will be. This is one of the reasons why a risk factor for becoming a chronic pain patient is a high Fear Avoidance Belief Questionnaire score. Our mind matters.

 

As therapists, we often focus too heavily on selecting the “correct” protocol and interventions. Remember that there are always multiple paths to a given destination and it can often be more useful to choose a protocol that the patient believes in to foster a psychologically supportive environment rather than solely the therapist’s choice. This is a tactful way to generate patient buy-in and trust, and may open the door for you to sample your more desirable protocols later on in the process. This is not a call to use unscientific methods, but instead encouragement to use your clinical judgment in deciding which interventions will work best for the individual patient in front of you.
Patient / Self-Image

This relationship is one where the therapist may have the least control, but a proactive approach to assisting the patient in this capacity can go a long way. I’m not advocating the therapist plays the role of counselor, but I am suggesting that the environment you create, the words you choose, and the actions that you take will affect the way the patient feels and the therapeutic benefits of your session.

 

One of the reasons I chose to pursue a career in physical therapy is that I wanted to play an active role in providing patients with the tools to fix themselves. Patients need to understand that what they do away from therapy is, in many cases, more important than what they do while in your office. We give them the strategies. We provide them with activity modifications. We provide the framework for the patients to take control of their condition and actively “fix” themselves. If we can also foster a psychological environment of self-belief and positive thinking, our patient compliance and intervention success will be greatly improved.

 

This post simply scrapes the surface when it comes to the psychological influences of our profession. It’s an aspect of therapy that we need to contemplate every single day with every single one of the patients we see. It’s our job to achieve a grasp of our patient from a pathoanatomic perspective and a psychological perspective, and design our interactions and interventions tailored towards the patient in front of us. Each patient will present differently and the mark of an expert clinician is the ability to adapt and adjust in order to achieve positive outcomes for all of our patients.

 

-Charlie Badawy, Class of 2019

 

Check the Calendar for Class Schedules and Events

Social Media Updates
  • #DPTstudent –  WEDNESDAYS , 9-10pm EST!   Check out #DPTstudent page for details!
  • Unite Physical Therapy Students – If you haven’t yet, please check out the “Doctor of Physical Therapy Students” Facebook page. More than 9,500 students have already joined!
  • Our own page! Pitt Physical Therapy, thanks to the Social Media Team, has created an official PittPT Facebook page!
  • #SolvePT (meets on Tuesdays Twitter from 9-10pm EST)
January 9, 2017 |